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    Implementing Low-Intensity Thrombolysis Monitoring for Patients with Acute Ischemic Stroke in Latin America: Insights from the OPTIMISTmain Process Evaluation
    (S. Karger AG, 2025-12-18) ; ;
    Craig S. Anderson
    ;
    Carlos Delfino
    ;
    Marilaura Nuñez
    <jats:p>Introduction: The Optimal Post-rtPA-IV Monitoring in Ischemic Stroke Trial (OPTIMISTmain) was an international, pragmatic, stepped-wedge, cluster-randomized, non-inferiority trial designed to compare a low-intensity protocol to standard high-intensity monitoring in patients with mild-to-moderate acute ischemic stroke treated with thrombolysis. The results showed the safety, feasibility, and non-inferiority efficacy of the low-intensity monitoring protocol, supporting hospitals to consider adopting this approach in stroke care depending on local resources and circumstances. An embedded process evaluation was undertaken to explore factors influencing implementation and impact of the intervention in Latin America. Methods: A convergent mixed-methods design was used to combine quantitative data and qualitative interviews with implementers and patients (or family members) at participating hospitals in Chile and Mexico. Purposive sampling ensured that a diverse range of experiences and discourses were captured, and normalization process theory (NPT) guided the identification of factors facilitating or hindering the incorporation of low-intensity monitoring. The analysis focused on key implementation outcomes. Results: Low-intensity monitoring was widely accepted by clinicians who found it efficient, straightforward to implement, and potentially cost saving for hospital services. Patients and families expressed acceptance, emphasizing the protocol’s potential to support continuous improvements in healthcare. Implementation challenges included staff turnover across shifts and hospital units, reliance on external contractors, and resistance to changing established care routines. Factors enabling successful implementation included strong team communication, dedicated stroke units, and ongoing feedback. Overall, the intervention demonstrated high acceptability, adoption and appropriateness, fidelity (median of 17 assessments in both countries), and sustainability. Feasibility outcomes were more variable, reflecting organizational challenges at the healthcare system level, such as initial resistance of nursing teams and high workloads in emergency services. Conclusions: Implementation of a novel low-intensity monitoring protocol was well accepted by healthcare staff and offers potential benefits to patients with mild-to-moderate acute ischemic stroke admitted to hospitals in Latin America. Embedding a process evaluation into the main trial provided valuable insights into the challenges of implementing a complex intervention. A comprehensive understanding of the factors influencing organization change is critical to improving health outcomes.</jats:p>
      1
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    Transcatheter Aortic Valve Implantation in Latin America: Lessons From Chile’s Limited Access
    (Elsevier BV, 2026-01)
    Gonzalo J. Martínez
    ;
    Marilaura Nuñez
    ;
    Olivia Sanhueza
    ;
    Pedro Villablanca
    ;
    Mario Araya
      1
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    Intracerebral haemorrhage management practices and adherence to the INTERACT3 care bundle in Latin America: Results from an international survey
    (Elsevier BV, 2025-10)
    Julieta Rosales
    ;
    Leonardo Augusto Carbonera
    ;
    Ana Cláudia De Souza
    ;
    Eva Rocha
    ;
    Vanessa Cano-Nigenda
      2
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    Scopus© Citations 1  3
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    Sex Differences in Profile and In‐Hospital Death for Acute Stroke in Chile: Data From a Nationwide Hospital Registry
    (2024)
    Marilaura Nuñez
    ;
    Ma.Ignacia Allende
    ;
    GONZALEZ MC CAWLEY, FRANCISCA
    ;
    Gabriel Cavada
    ;
    Craig S. Anderson
    <jats:sec xml:lang="en"> <jats:title>Background</jats:title> <jats:p xml:lang="en">Knowledge of local contextual sex differences in the profile and outcome for stroke can improve service delivery. We aimed to determine sex differences in the profile of patients with acute stroke and their associations with in‐hospital death in the national hospital database of Chile.</jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Methods and Results</jats:title> <jats:p xml:lang="en"> We present a retrospective cohort based on the analysis of the 2019 Chilean database of Diagnosis‐Related Groups, which represents 70% of the operational expenditure of the public health system. Random‐effects multiple logistic regression models were used to determine independent associations of acute stroke (defined by main diagnosis <jats:italic>International Classification of Diseases, Tenth Revision</jats:italic> [ <jats:italic>ICD‐10</jats:italic> ] codes) and in‐hospital death, and reported with odds ratios (ORs) and 95% CIs. Of 1 048 575 hospital discharges, 15 535 were for patients with acute stroke (7074 [45.5%] in women), and 2438 (15.6%) of them died during hospitalization. Differences by sex in sociodemographic and clinical characteristics were identified for stroke and main subtypes. After fully adjusted model, women with ischemic stroke had lower in‐hospital death (OR, 0.79 [95% CI, 0.69–0.91]) compared with men; other independent predictors included age per year increase (OR, 1.03 [95% CI, 1.03–1.04]), chronic kidney disease (OR, 1.47 [95% CI, 1.20–1.80]), atrial fibrillation (OR, 1.50 [95% CI, 1.26–1.80]), and other risk factors. Conversely, for intracerebral hemorrhage, women had a higher in‐hospital mortality rate than men (OR, 1.19 [95% CI, 1.02–1.40]); other independent predictors included age per year increase (OR, 1.009 [95% CI, 1.003–1.01]), chronic kidney disease (OR, 1.55 [95% CI, 1.23–1.97]), oral anticoagulant use (OR, 1.88 [95% CI, 1.37–2.58]), and other risk factors. </jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Conclusions</jats:title> <jats:p xml:lang="en">Sex differences in characteristics and in‐hospital death of hospitalized patients exist for acute stroke in Chile. In‐hospital death is higher for acute ischemic stroke in men and higher for intracerebral hemorrhage in women. Future research is needed to better identify contributing factors.</jats:p> </jats:sec>
      1Scopus© Citations 3
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    Disparities in Stroke Incidence Over Time by Sex and Age in Latin America and the Caribbean Region 1997 to 2021: A Systematic Review and Meta‐Analysis
    <jats:sec sec-type="background" xml:lang="en"> <jats:title>Background</jats:title> <jats:p xml:lang="en">High‐income country studies show unfavorable trends in stroke incidence (SI) in younger populations. We aimed to estimate temporal change in SI disaggregated by age and sex in Latin America and the Caribbean region.</jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Methods and Results</jats:title> <jats:p xml:lang="en"> A search strategy was used in MEDLINE, WOS, and LILACS databases from 1997 to 2021, including prospective population‐based observational studies with first‐ever stroke incidence in Latin America. Reports without data broken down by age and sex were excluded. Risk of bias was assessed with The Joanna Briggs Institute's guide. The main outcomes were incidence rate ratio and relative temporal trend ratio of SI, comparing time periods before 2010 with after 2010. Pooled relative temporal trend ratios considering only studies with 2 periods in the same population were calculated by random‐effects meta‐analysis. Meta‐regression analysis was used to evaluate incidence rate determinants. From 9242 records identified, 6 studies were selected including 4483 first‐ever stroke in 4 101 084 individuals. Crude incidence rate ratio in younger subjects (&lt;55 years) comparing before 2010:after 2010 periods showed an increase in SI in the past decade (incidence rate ratio, 1.37 [95% CI, 1.23–1.50]), in contrast to a decrease in older people during the same period (incidence rate ratio, 0.83 [95% CI, 0.76–0.89]). Overall relative temporal trend ratio (&lt;55:≥55 years) was 1.65 (95 CI%, 1.50–1.80), with higher increase in young women (pooled relative temporal trend ratio, 3.08 [95% CI, 1.18–4.97]; <jats:italic>P</jats:italic> for heterogeneity &lt;0.001). </jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Conclusions</jats:title> <jats:p xml:lang="en">An unfavorable change in SI in young people, especially in women, was detected in population‐based studies in the past decade in Latin America and the Caribbean. Further investigation of the explanatory variables is required to ameliorate stroke prevention and inform local decision‐makers.</jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Registration</jats:title> <jats:p xml:lang="en"> URL: <jats:ext-link xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="uri" xlink:href="https://www.crd.york.ac.uk/prospero/">https://www.crd.york.ac.uk/prospero/</jats:ext-link> Identifier: CRD42022332563. </jats:p> </jats:sec>
      7Scopus© Citations 5
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    Stroke in Latin America: Systematic review of incidence, prevalence, and case-fatality in 1997–2021
    (2023)
    Carlos Delfino Carvalho Pinheiro
    ;
    Marilaura Nuñez
    ;
    Claudia Asenjo-Lobos
    ;
    ;
    Amy Riviotta
    <jats:sec><jats:title>Background:</jats:title><jats:p> Stroke is a major global cause of death and disability. Most strokes occur in populations of low-middle-income country (LMIC); therefore, the subsequent disease burden is greater than in populations of high-income countries. Few epidemiological data exist for stroke in Latin America, composed primarily of LMIC. </jats:p></jats:sec><jats:sec><jats:title>Aims:</jats:title><jats:p> To determine epidemiological measures of incidence, prevalence, and 1-month case-fatality for stroke in Latin America/Caribbean (LAC) during 1997–2021. </jats:p></jats:sec><jats:sec><jats:title>Summary of review:</jats:title><jats:p> A structured search was conducted to identify relevant references from MEDLINE, WOS, and LILACS databases for prospective observational and cross-sectional studies in LAC populations from January 1997 to December 2021. A total of 9242 records were screened and 12 selected for analysis, seven incidence studies and five prevalence studies. Case-fatality was reported in six articles. Sub-group analysis by age, sex, and income countries was performed. A narrative synthesis of the findings was performed. Meta-analysis was performed using random-effect model to obtain pooled estimates with 95% confidence intervals (CIs). Studies quality was assessed according to the risk of bias criteria described in the Joanna Briggs Institute’s guide. The overall crude annual incidence rate of first-ever stroke in LAC was 119.0 (95% CI = 95.9–142.1)/100,000 people (with high heterogeneity between studies ( I<jats:sup>2</jats:sup> = 98.1%)). The overall crude prevalence was 3060 (95% CI: 95.9–142.1)/100,000 people (with high heterogeneity between studies ( I<jats:sup>2</jats:sup> = 98.8%)). The overall case-fatality at 1 month after the first stroke was 21.1% (95% CI = 18.6–23.7) ( I<jats:sup>2</jats:sup> = 49.40%). </jats:p></jats:sec><jats:sec><jats:title>Conclusion:</jats:title><jats:p> This review contributes to our understanding regarding the burden caused by stroke in LAC. More studies with comparable designs are needed to generate reliable data and should include both standardized criteria, such as the World Health Organization clinical criteria and updated standard methods of case assurance, data collection, and reporting. </jats:p></jats:sec>
    Scopus© Citations 11  9
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    Vancomycin Presoaking of the Graft Appears to Prevent Infection After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis
    <jats:p> Background: Vancomycin presoaking of the graft has been shown to decrease infection rates in some case series of anterior cruciate ligament (ACL) reconstruction. Purpose: We sought to substantiate the efficacy of vancomycin presoaked grafts for the prevention of infection after ACL reconstruction. Methods: We performed a systematic review of Medline and OVID to assess the incidence of postoperative infection in studies comparing patients undergoing ACL reconstruction with the use of vancomycin presoaked ACL grafts and a control group of patients undergoing ACL reconstruction without the use of presoaked grafts. The efficacy of vancomycin presoaking was calculated using the Agresti-Coull confidence interval. Relative risk (RR) was calculated for every study and the total sample. Results: The 11 studies that met inclusion criteria comprised 24,298 patients. In patients with vancomycin presoaking of the graft, 1 infection was reported in 8764 cases (0.01% rate). In the studies with control groups that did not have vancomycin presoaked grafts, there were 125 infections in 15,534 ACL reconstructions (0.8% rate). The efficacy of vancomycin presoaking in preventing infection after ACL reconstruction was 99.9% (0.999%–1.000% CI). The overall RR obtained was 0.07 (0.03–0.16 CI). All included studies were retrospective cohort studies (level III). Conclusions: Vancomycin presoaking of the graft has been shown to decrease infection rates after ACL reconstruction in studies of low evidence level. This suggests the need for prospective randomized controlled trials addressing this issue so that recommendations on the routine use of vancomycin presoaking of ACL grafts can be made with confidence. </jats:p>
      3Scopus© Citations 11