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A System-Based Intervention to Improve Access to Hyperacute Stroke Care
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- Richard H. Swartz, Elizabeth Linkewich, Shelley Sharp, Jacqueline Willems, Chris Olynyk, Nicola Tahair, Megan L. Cayley, Mark T. Bayley
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- Journal:
- Canadian Journal of Neurological Sciences / Volume 44 / Issue 5 / September 2017
- Published online by Cambridge University Press:
- 09 May 2017, pp. 475-482
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- Article
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Background: Hyperacute stroke is a time-sensitive emergency for which outcomes improve with faster treatment. When stroke systems are accessed via emergency medical services (EMS), patients are routed to hyperacute stroke centres and are treated faster. But over a third of patients with strokes do not come to the hospital by EMS, and may inadvertently arrive at centres that do not provide acute stroke services. We developed and studied the impact of protocols to quickly identify and move “walk-in” patients from non-hyperacute hospitals to regional stroke centres (RSCs). Methods and Results: Protocols were developed by a multi-disciplinary and multi-institutional working group and implemented across 14 acute hospital sites within the Greater Toronto Area in December of 2012. Key metrics were recorded 18 months pre- and post-implementation. The teams regularly reviewed incident reports of protocol non-adherence and patient flow data. Transports increased by 80% from 103 to 185. The number of patients receiving tissue plasminogen activator (tPA) increased by 68% from 34 to 57. Total EMS transport time decreased 17 minutes (mean time of 54.46 to 37.86 minutes, p<0.0001). Calls responded to within 9 minutes increased from 34 to 59%. Conclusions: A systems-based approach that included a multi-organizational collaboration and consensus-based protocols to move patients from non-hyperacute hospitals to RSCs resulted in more patients receiving hyperacute stroke interventions and improvements in EMS response and transport times. As hyperacute stroke care becomes more centralized and endovascular therapy becomes more broadly implemented, the protocols developed here can be employed by other regions organizing patient flow across systems of stroke care.
Chapter 7d - Molecular Cytogenetics
- from Chapter 7 - Tools of Molecular Medicine
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- By Pascale Willem, qualified as a medical doctor in Paris and specialised in human genetics (Grenobles- Marseille, France). Since 1990 she has run the Somatic Cell Genetics Unit in the Division of Molecular Medicine and Haematology, University of the Witwatersrand. She is involved in cancer research and diagnostics using both molecular genetics and cytogenetics techniques., Jacqueline Brown, MSc, has worked in the Somatic Cell Genetics Unit in the Division of Molecular Medicine and Haematology, University of the Witwatersrand, for more than five years. She is currently a medical scientist in the Division and is involved in diagnostics, research and development in the area of cancer molecular genetics.
- Edited by Barry Mendelow, University of the Witwatersrand, Johannesburg, Michèle Ramsay, University of the Witwatersrand, Johannesburg, Nanthakumarn Chetty, University of the Witwatersrand, Johannesburg, Wendy Stevens, University of the Witwatersrand, Johannesburg
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- Book:
- Molecular Medicine for Clinicians
- Published by:
- Wits University Press
- Published online:
- 04 June 2019
- Print publication:
- 01 October 2008, pp 102-112
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Summary
INTRODUCTION
Cytogenetics, the study of genetic material at the level of the chromosomes, is now a routine part of the investigation of many cancers as well as in the detection of inherited chromo - some disorders such as Down syndrome (trisomy 21). However, dramatic advances in molecular techniques over the past two decades have facilitated the extension of cytogenetic studies to probe deeper to the level of the genes themselves, for example by fluorescent in situ hybridisation (FISH) and comparative genomic hybridisation (CGH). This chapter will briefly review the principles of cell division and cell culture in the context of cytogenetic analysis, explore the principles and clinical applications of cytogenetics and molecular cytogenetics, and introduce CGH array concepts.
CONVENTIONAL CYTOGENETIC ANALYSIS
Cytogenetic analysis explores the full chromo - some complement in number and structure. There are two different kinds of cellular division in vivo: meiosis, the specialised division that occurs in germ cells, and mitosis, or somatic (non-reproductive) cell division.
A thorough understanding of the principles of the somatic cell cycle and mitotic cell division, as detailed in Chapter 4, is man - da tory for the understanding of cytogenetics. Between successive divisions, the cell cycle is characterised by four stages: G1 or gap 1 (in the mammalian cell cycle this lasts approxi mately 9 hours), S or synthesis of DNA (5 hours), G2 or gap 2 (3 hours) and M or mitosis (1 hour). Resting cells that are not dividing are said to be in G0. A full cell cycle spans about 18 hours.
Manipulating the cell cycle in vitro to ‘catch’ metaphases.
In order to visualise individual chromosomes the cell must be at the mitosis stage of the cell cycle and in metaphase. This is when chromosomes are the most compact and individualised. When cells do not divide they are said to be in interphase. During this stage the chromatin that forms the chromosomes unfolds to varying degrees, particularly within regions of active gene expression. The chromatin is loose and chromosomes are not visibly individualised. For cytogenetic analysis it is necessary to obtain a number of cells in meta phase, and cell culture is needed to achieve this in most cases.