1
|
Michiwaki Y, Yamane F, Itokawa H, Tanaka T, Shimoji K, Matsuno A. Hands-on neuroendovascular practice for nonselective undergraduate medical students increases interest and aspirations in pursuing neurosurgery as a specialization. Surg Neurol Int 2023; 14:414. [PMID: 38213451 PMCID: PMC10783694 DOI: 10.25259/sni_778_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/03/2023] [Indexed: 01/13/2024] Open
Abstract
Background The number of medical students aspiring to become neurosurgeons has decreased worldwide, mainly due to poor work-life balance among neurosurgeons; therefore, recruiting students for neurosurgery is essential to ensure the availability and appropriate quality of neurosurgical treatment. This study aimed to evaluate the efficacy of hands-on neuroendovascular practice for nonselective undergraduate medical students to determine whether this increases their interest in neurosurgery and contributes to their aspirations of becoming neurosurgeons. Methods Hands-on neuroendovascular practice for mechanical thrombectomy was performed by undergraduate 5th-year medical students during their 2-week clinical rotation in the Department of neurosurgery at our university hospital between April 2021 and March 2023. After the neurosurgery practice, a questionnaire about their understanding of neurosurgery and aspirations for this specialization before and after the practice was anonymously completed by all students. Results Overall, 153 students completed the questionnaire. Of these, 140 (91.5 %) showed increased interest in neurosurgery after participating in the hands-on practice. Through this practice, the number of students who considered neurosurgery as their first choice or one of their specialty choices increased from 8 (5.2%) to 12 (7.8%) (P = 0.3534) and from 19 (12.4%) to 52 (34.0%) (P < 0.0001), respectively. Furthermore, the number of students with no aspiration to become neurosurgeons decreased from 95 (62.1%) to 43 (28.1%) (P < 0.0001). Conclusion Hands-on neuroendovascular practice for nonselective undergraduate medical students effectively increased their interest in neurosurgery specialization and their desire to become neurosurgeons. Therefore, this practice can help recruit medical students for neurosurgery specialization.
Collapse
Affiliation(s)
- Yuhei Michiwaki
- Department of Neurosurgery, International University of Health and Welfare, School of Medicine, Narita City, Chiba, Japan
| | | | | | | | | | | |
Collapse
|
2
|
Abdalla RN, Ansari SA, Hurley MC, Attarian H, Fargen KM, Hirsch JA, Cantrell DR, Curl PK, Daves PR, Shaibani A. Correlation of Call Burden and Sleep Deprivation with Physician Burnout, Driving Crashes, and Medical Errors among US Neurointerventionalists. AJNR Am J Neuroradiol 2022; 43:1286-1291. [PMID: 36007952 PMCID: PMC9451637 DOI: 10.3174/ajnr.a7606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/27/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE High call frequency can lead to inadequate sleep, fatigue, and burnout, resulting in detrimental effects on physicians and patients. We aimed to assess the correlation between the frequency and burden of neurointerventional surgery calls and sleep deprivation with physician burnout, physical and driving safety, and fatigue-related medical errors. MATERIALS AND METHODS We sent an online questionnaire to the members of the 2 neurointerventional surgery societies comprising 50 questions and spanning 3 main topics: 1) overnight/weekend call burden, 2) sleeping patterns, and 3) Copenhagen Burnout Inventory. RESULTS One hundred sixty-four surveys were completed. Most (54%) neurointerventional surgeons reported burnout. Call burden of ≥1 every 3 days and being in practice >10 years were independent predictors of burnout. Thirty-nine percent reported falling asleep at the wheel, 23% reported a motor vehicle crash/near-crash, and 34% reported medical errors they considered related to call/work fatigue. On multivariate logistic regression, high call burden (called-in >3 times/week) was an independent predictor of sleeping at the wheel and motor vehicle crashes. Reporting <4 hours of uninterrupted sleep was an independent predictor of motor vehicle crashes and medical errors. Most neurointerventional surgeons recommended a maximum call frequency of once every 3 days. CONCLUSIONS Call frequency and burden, number of years in practice, and sleep deprivation are associated with burnout of neurointerventional surgeons, sleeping at the wheel, motor vehicle crashes, and fatigue-related medical errors. These findings contribute to the increasing literature on physician burnout and may guide future societal recommendations related to call burden in neurointerventional surgery.
Collapse
Affiliation(s)
- R N Abdalla
- From the Departments of Radiology (R.N.A., S.A.A., D.R.C., A.S.)
- Neurological Surgery (R.N.A., S.A.A., A.S.)
- Department of Radiology (R.N.A.), Ain Shams University, Cairo, Egypt
| | - S A Ansari
- From the Departments of Radiology (R.N.A., S.A.A., D.R.C., A.S.)
- Neurology (S.A.A.)
- Neurological Surgery (R.N.A., S.A.A., A.S.)
| | - M C Hurley
- Department of Radiology (M.C.H.), University of Chicago, Chicago, Illinois
| | - H Attarian
- Sleep Medicine (H.A.), Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - K M Fargen
- Department of Neurosurgery (K.M.F.), Wake Forest University, Winston-Salem, North Carolina
| | - J A Hirsch
- Department of Radiology (J.A.H.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - D R Cantrell
- From the Departments of Radiology (R.N.A., S.A.A., D.R.C., A.S.)
| | - P K Curl
- Department of Radiology (P.K.C.), University of Washington, Seattle, Washington
| | - P R Daves
- Department of Finance (P.R.D.), University of Tennessee, Knoxville, Tennessee
| | - A Shaibani
- From the Departments of Radiology (R.N.A., S.A.A., D.R.C., A.S.)
- Neurological Surgery (R.N.A., S.A.A., A.S.)
| |
Collapse
|
3
|
Altersberger VL, Wright PR, Schaedelin SA, De Marchis GM, Gensicke H, Engelter ST, Psychogios M, Kahles T, Goeldlin M, Meinel TR, Mordasini P, Kaesmacher J, von Hessling A, Vehoff J, Weber J, Wegener S, Salmen S, Sturzenegger R, Medlin F, Berger C, Schelosky L, Renaud S, Niederhauser J, Bonvin C, Schaerer M, Mono ML, Rodic B, Schwegler G, Peters N, Bolognese M, Luft AR, Cereda CW, Kägi G, Michel P, Carrera E, Arnold M, Fischer U, Nedeltchev K, Bonati LH. Effect of admission time on provision of acute stroke treatment at stroke units and stroke centers—An analysis of the Swiss Stroke Registry. Eur Stroke J 2022; 7:117-125. [DOI: 10.1177/23969873221094408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/29/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction: Rapid treatment of acute ischemic stroke (AIS) depends on sufficient staffing which differs between Stroke Centers and Stroke Units in Switzerland. We studied the effect of admission time on performance measures of AIS treatment and related temporal trends over time. Patients and methods: We compared treatment rates, door-to-image-time, door-to-needle-time, and door-to-groin-puncture-time in stroke patients admitted during office hours (Monday–Friday 8:00–17:59) and non-office hours at all certified Stroke Centers and Stroke Units in Switzerland, as well as secular trends thereof between 2014 and 2019, using data from the Swiss Stroke Registry. Secondary outcomes were modified Rankin Scale and mortality at 3 months. Results: Data were eligible for analysis in 31,788 (90.2%) of 35,261 patients. Treatment rates for IVT/EVT were higher during non-office hours compared with office hours in Stroke Centers (40.8 vs 36.5%) and Stroke Units (21.8 vs 18.5%). Door-to-image-time and door-to-needle-time increased significantly during non-office hours. Median (IQR) door-to-groin-puncture-time at Stroke Centers was longer during non-office hours compared to office hours (84 (59–116) vs 95 (66–130) minutes). Admission during non-office hours was independently associated with worse functional outcome (1.11 [95%CI: 1.04–1.18]) and increased mortality (1.13 [95%CI: 1.01–1.27]). From 2014 to 2019, median door-to-groin-puncture-time improved and the treatment rate for wake-up strokes increased. Discussion and Conclusion: Despite differences in staffing, patient admission during non-office hours delayed IVT to a similar, modest degree at Stroke Centers and Stroke Units. A larger delay of EVT was observed during non-office hours, but Stroke Centers sped up delivery of EVT over time. Patients admitted during non-office hours had worse functional outcomes, which was not explained by treatment delays.
Collapse
Affiliation(s)
- Valerian L Altersberger
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Patrick R Wright
- Clinical Trial Unit, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sabine A Schaedelin
- Clinical Trial Unit, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurorehabilitation, University of Basel and University Department of Geriatic Medicine FELIX PLATTER, University of Basel, Switzerland
| | - Stefan T Engelter
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurorehabilitation, University of Basel and University Department of Geriatic Medicine FELIX PLATTER, University of Basel, Switzerland
| | - Marios Psychogios
- Department of Neuroradiology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Timo Kahles
- Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland
| | - Martina Goeldlin
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Thomas R Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology and University Institute of Diagnostic, Interventional and Paediatric Radiology, Inselspital, Bern University Hospital Inselspital Bern, and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology and University Institute of Diagnostic, Interventional and Paediatric Radiology, Inselspital, Bern University Hospital Inselspital Bern, and University of Bern, Bern, Switzerland
| | | | - Jochen Vehoff
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Johannes Weber
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Stephan Salmen
- Department of Neurology, Spitalzentrum Biel, Biel, Switzerland
| | | | - Friedrich Medlin
- Department of Internal Medicine, Stroke Unit and Division of Neurology, HFR Fribourg, Cantonal Hospital, Fribourg, Switzerland
| | | | | | - Susanne Renaud
- Stroke Unit and Division of Neurology, Neuchatel Hospital Network, Neuchatel, Switzerland
| | | | | | | | | | - Biljana Rodic
- Cantonal Hospital Winterthur, Winterthur, Switzerland
| | | | - Nils Peters
- Stroke Center, Hirslanden Hospital Zurich, Zurich, Switzerland
| | | | - Andreas R Luft
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Cereneo Center for Neurology and Rehabilitation, Weggis, Switzerland
| | - Carlo W Cereda
- Stroke Center and Department of Neurology, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Georg Kägi
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Patrick Michel
- Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | | | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | | | - Leo H Bonati
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| |
Collapse
|
4
|
Bulwa Z, Chen M. Stroke Center Designations, Neurointerventionalist Demand, and the Finances of Stroke Thrombectomy in the United States. Neurology 2021; 97:S17-S24. [PMID: 34785600 DOI: 10.1212/wnl.0000000000012780] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 11/24/2020] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW This article aims to provide an update on the designation of stroke centers, neurointerventionalist demand, and cost-effectiveness of stroke thrombectomy in the United States. RECENT FINDINGS There are now more than 1,660 stroke centers certified by national accrediting bodies in the United States, 306 of which are designated as thrombectomy-capable or comprehensive stroke centers. Considering the amount of nationally certified centers and the number of patients with acute stroke eligible for thrombectomy, each center would be responsible for 64 to 104 thrombectomies per year. As a result, there is a growing demand placed on neurointerventionalists, who have the ability to alter the trajectory of large vessel occlusive strokes. Numbers needed to achieve functional independence after stroke thrombectomy at 90 days range from 3.2 to 7.4 patients in the early time window and 2.8 to 3.6 patients in the extended time window in appropriately selected candidates. With the low number needed to treat, in a variety of valued-based calculations and cost-effectiveness analyses, stroke thrombectomy has proved to be both clinically effective and cost-effective. SUMMARY Advancements in the early recognition and treatment of stroke have been paralleled by a remodeling of health care systems to ensure best practices in a timely manner. Stroke center-accrediting bodies provide oversight to safeguard these standards. As successful trial data from high volume centers transform into real-world experience, we must continue to re-evaluate cost-effectiveness, strike a balance between sufficient case volumes to maintain clinical excellence vs the burden and burnout associated with call responsibilities, and improve access to care for all.
Collapse
Affiliation(s)
- Zachary Bulwa
- From the Departments of Neurology (Z.B.) and Neurosurgery (M.C.), Rush University Medical Center, Chicago, IL.
| | - Michael Chen
- From the Departments of Neurology (Z.B.) and Neurosurgery (M.C.), Rush University Medical Center, Chicago, IL
| |
Collapse
|
5
|
Oravec CS, Tschoe C, Fargen KM, Kittel CA, Spiotta A, Almallouhi E, Starke RM, McCarthy DJ, Simon S, Zyck S, Gould GC, De Leacy R, Mocco J, Siddiqui A, Vaziri S, Fox WC, Fraser JF, Chitale R, Zipfel G, Huguenard A, Wolfe SQ. Trends in mechanical thrombectomy and decompressive hemicraniectomy for stroke: A multicenter study. Neuroradiol J 2021; 35:170-176. [PMID: 34269121 DOI: 10.1177/19714009211030526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND PURPOSE Acute ischemic stroke has increasingly become a procedural disease following the demonstrated benefit of mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) on clinical outcomes and tissue salvage in randomized trials. Given these data and anecdotal experience of decreased numbers of decompressive hemicraniectomies (DHCs) performed for malignant cerebral edema, we sought to correlate the numbers of strokes, thrombectomies, and DHCs performed over the timeline of the 2013 failed thrombolysis/thrombectomy trials, to the 2015 modern randomized MT trials, to post-DAWN and DEFUSE 3. MATERIALS AND METHODS This is a multicenter retrospective compilation of patients who presented with ELVO in 11 US high-volume comprehensive stroke centers. Rates of tissue plasminogen activator (tPA), thrombectomy, and DHC were determined by current procedural terminology code, and specificity to acute ischemic stroke confirmed by each institution. Endpoints included the incidence of stroke, thrombectomy, and DHC and rates of change over time. RESULTS Between 2013 and 2018, there were 55,247 stroke admissions across 11 participating centers. Of these, 6145 received tPA, 4122 underwent thrombectomy, and 662 patients underwent hemicraniectomy. The trajectories of procedure rates over time were modeled and there was a significant change in MT rate (p = 0.002) without a concomitant change in the total number of stroke admissions, tPA administration rate, or rate of DHC. CONCLUSIONS This real-world study confirms an increase in thrombectomy performed for ELVO while demonstrating stable rates of stroke admission, tPA administration and DHC. Unlike prior studies, increasing thrombectomy rates were not associated with decreased utilization of hemicraniectomy.
Collapse
Affiliation(s)
- Chesney S Oravec
- Department of Neurosurgery, Wake Forest Baptist Medical Center, USA
| | - Christine Tschoe
- Department of Neurosurgery, Wake Forest Baptist Medical Center, USA
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forest Baptist Medical Center, USA
| | - Carol A Kittel
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | - Justin F Fraser
- Departments of Neurological Surgery, Neurology, Radiology, and Neuroscience, University of Kentucky, USA
| | | | | | | | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest Baptist Medical Center, USA
| |
Collapse
|
6
|
Zha M, Yang Q, Liu S, Huang K, Zhang X, Wu M, Cai H, Lv Q, Liu R, Yang D, Liu X. Off-hour effect is not significant in endovascular treatment for anterior circulation large vessel occlusion in a multicentre registry. Stroke Vasc Neurol 2021; 6:640-648. [PMID: 34244447 PMCID: PMC8717780 DOI: 10.1136/svn-2021-000949] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/22/2021] [Indexed: 11/17/2022] Open
Abstract
Background and purpose Whether the off-hour effect has an impact on workflow and outcomes of endovascular treatment (EVT) for anterior circulation large vessel occlusion (AC-LVO) remains uncertain. This study aimed to compare the characteristics and outcomes of patients who presented or were treated during off-hour versus on-hour in a multi-center registry. Methods AC-LVO patients from 21 centres were categorised into the off-hour group and the on-hour group. Off-hour (weekends, holidays, and 18:00–7:59 on weekdays) and on-hour (8:00–17:59 on weekdays except for holidays) were defined according to arrival and groin-puncture time points, respectively. Subgroup comparisons between patients both arrived and treated during off-hour (true off-hour) and on-hour (true on-hour) were performed. The primary outcome was the 90-day modified Rankin Scale (mRS) score. Secondary outcomes included favourable outcome (mRS 0–2 at 90 days), EVT-related time metrics, and other clinical outcomes. Ordinary and binary logistic regression and linear regression were taken to adjust for confounding factors. Results Of all 698 patients enrolled, 435 (62.3%) and 456 (65.3%) patients were categorised into the off-hour arrival and off-hour puncture group, respectively. Shorter onset to door time (adjusted ß coefficient: −21.56; 95% CI −39.96 to −3.16; p=0.022) was noted in the off-hour arrival group. Ordinal and dichotomous mRS scores at 90 days were comparable between the off-hour group and the on-hour group regardless of off-hour definitions. Other time metrics and outcomes were comparable between the two groups. Of 595 patients both presented and were treated during off-hour or on-hour, 394 patients were categorised into the true off-hour group and 201 into the true on-hour group. Time metrics and clinical outcomes were similar between the true off-hour and the true on-hour group. Conclusions The off-hour effect was not significant regarding clinical outcomes and in-hospital workflow in AC-LVO patients receiving EVT in this Chinese multicentre registry.
Collapse
Affiliation(s)
- Mingming Zha
- Department of Neurology, Southeast University, Nanjing, Jiangsu, China
| | - Qingwen Yang
- Department of Neurology, Southeast University, Nanjing, Jiangsu, China
| | - Shuo Liu
- Department of Internal Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Kangmo Huang
- Department of Neurology, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Xiaohao Zhang
- Department of Neurology, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Min Wu
- Department of Neurology, Southern Medical University, Guangzhou, Guangdong, China
| | - Haodi Cai
- Department of Neurology, Southeast University, Nanjing, Jiangsu, China
| | - Qiushi Lv
- Department of Neurology, Nanjing Jinling Hospital, Nanjing, Jiangsu, China
| | - Rui Liu
- Department of Neurology, Nanjing Jinling Hospital, Nanjing, Jiangsu, China
| | - Dong Yang
- Department of Neurology, Nanjing Jinling Hospital, Nanjing, Jiangsu, China
| | - Xinfeng Liu
- Department of Neurology, Southeast University, Nanjing, Jiangsu, China .,Department of Neurology, Nanjing Jinling Hospital, Nanjing, Jiangsu, China
| |
Collapse
|
7
|
Zha M, Yang Q, Liu S, Wu M, Huang K, Cai H, Zhang X, Lv Q, Liu R, Yang D, Liu X. Off-hour effect on time metrics and clinical outcomes in endovascular treatment for large vessel occlusion: A systematic review and meta-analysis. Int J Stroke 2021; 17:669-680. [PMID: 33877016 DOI: 10.1177/17474930211012545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is an ongoing debate on the off-hour effect on endovascular treatment (EVT) for acute large vessel occlusion (LVO). AIM This meta-analysis aimed to compare time metrics and clinical outcomes of acute LVO patients who presented/were treated during off-hour with those during working hours. SUMMARY OF REVIEW Structured searches on the PubMed, Embase, Web of Science, and Cochrane Library databases were conducted through 23 February 2021. The primary outcomes were onset to door (OTD), door to imaging, door to puncture (DTP), puncture to recanalization, procedural time, successful recanalization, symptomatic intracranial hemorrhage (SICH), mortality in hospital, good prognosis (90-day modified Rankin Scale (mRS) score 0-2), and 90-day mortality. The secondary outcomes were imaging to puncture (ITP), onset to puncture (OTP), onset to recanalization (OTR), door to recanalization (DTR) time, mRS 0-2 at discharge, and consecutive 90-day mRS score. The odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (CI) of the outcomes were calculated using random-effect models. Heterogenicity and publication bias were analyzed. Subgroup and sensitivity analyses were conducted as appropriate. Nineteen studies published between 2014 and 2021 with a total of 14,185 patients were eligible for quantitative synthesis. Patients in the off-hour group were significantly younger than those in the on-hour group and with comparable stroke severity and intravenous thrombolysis rate. The off-hour group had longer OTD (WMD [95% CI], 12.83 [1.84-23.82] min), DTP (WMD [95% CI], 11.45 [5.93-16.97] min), ITP (WMD [95% CI], 10.39 [4.61-16.17] min), OTP (WMD [95% CI], 25.30 [13.11-37.50] min), OTR (WMD [95% CI], 25.16 [10.28-40.04] min), and DTR (WMD [95% CI], 18.02 [10.01-26.03] min) time. Significantly lower successful recanalization rate (OR [95% CI], 0.85 [0.76-0.95]; p = 0.004; I2 = 0%) was detected in the off-hour group. No significant difference was noted regarding SICH and prognosis. But a trend toward lower OR of good prognosis was witnessed in the off-hour group (OR [95% CI], 0.92 [0.84-1.01]; p = 0.084; I2 = 0%). CONCLUSIONS Patients who presented/were treated during off-hour were associated with excessive delays before the initiation of EVT, lower successful reperfusion rate, and a trend toward worse prognosis when compared with working hours. Optimizing the workflows of EVT during off-hour is needed.
Collapse
Affiliation(s)
- Mingming Zha
- Department of Neurology, Jinling Hospital, Medical School of Southeast University, Nanjing, China
| | - Qingwen Yang
- Department of Neurology, Jinling Hospital, Medical School of Southeast University, Nanjing, China
| | - Shuo Liu
- Department of Internal Medicine, Medical School of Southeast University, Nanjing, China
| | - Min Wu
- Department of Neurology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China
| | - Kangmo Huang
- Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
| | - Haodi Cai
- Department of Neurology, Jinling Hospital, Medical School of Southeast University, Nanjing, China
| | - Xiaohao Zhang
- Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
| | - Qiushi Lv
- Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
| | - Rui Liu
- Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
| | - Dong Yang
- Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
| | - Xinfeng Liu
- Department of Neurology, Jinling Hospital, Medical School of Southeast University, Nanjing, China.,Department of Neurology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China.,Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
| |
Collapse
|
8
|
Potts MB, Abdalla RN, Golnari P, Sukumaran M, Palmer AH, Hurley MC, Shaibani A, Jahromi BS, Ansari SA. Analysis of Mechanical Thrombectomy for Acute Ischemic Stroke on Nights and Weekends Versus Weekdays at Comprehensive Stroke Centers. J Stroke Cerebrovasc Dis 2021; 30:105632. [PMID: 33517033 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105632] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/13/2021] [Accepted: 01/17/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The "weekend effect" has been shown to affect outcomes in acute ischemic stroke. We sought to compare metrics and outcomes of emergent stroke thrombectomy at three affiliated comprehensive stroke centers on weekdays versus nights/weekends for a three-year period beginning in 2015, when thrombectomy became common practice for large vessel occlusion acute ischemic stroke. METHODS We performed a retrospective analysis of all stroke thrombectomy patients treated from 2015 to 2018 to compare standard thrombectomy metrics and outcomes in patients presenting during weekdays or nights/weekends. RESULTS Two hundred-sixteen mechanical thrombectomy cases were evaluated, with 50.9% of patients presenting on weekdays and 49.1% presenting on nights/weekends. There were no statistical differences in baseline characteristics in demographics, stroke risk factors, or stroke severity, but patients presenting on nights/weekends had longer times from last known normal to presentation (130 versus 72.5 minutes, p=0.03). Door-to-groin times were delayed in patients presenting on nights/weekends compared to weekdays (median 104.5 versus 86 minutes, respectively; p=0.007) but groin-to-reperfusion times were similar (51.5 versus 48 minutes, respectively; p=0.4). Successful reperfusion was similar in both groups (90.6% nights/weekends versus 90% weekdays; p=1.0) as were the incidence of symptomatic intracerebral hemorrhage (10.4% nights/weekend versus 7.3% weekdays; p=0.48) and 90-day good functional outcomes based on the modified Rankin Scale did not differ between the two groups in a shift analysis (p=0.545). CONCLUSIONS Despite delays in door-to-groin puncture times in acute ischemic stroke patients presenting on nights/weekends compared to weekdays, we did not identify significant differences in successful reperfusion or functional outcomes in this cohort. Further studies are warranted to continue to evaluate differences in stroke care on nights/weekends versus weekdays.
Collapse
Affiliation(s)
- Matthew B Potts
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States; Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States.
| | - Ramez N Abdalla
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States; Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States.
| | - Pedram Golnari
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States.
| | - Madhav Sukumaran
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States.
| | - Aaron H Palmer
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States.
| | - Michael C Hurley
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States; Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States.
| | - Ali Shaibani
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States; Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States.
| | - Babak S Jahromi
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States; Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States.
| | - Sameer A Ansari
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States; Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States; Department of Neurology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States.
| |
Collapse
|
9
|
Felbaum DR, Dowlati E, Mai JC, Liu AH, Schuette AJ, Bell R, Armonda RA. Letter: Realistic Expectations for Incorporating Dual-Trained Neurosurgeons in a Call Schedule. Neurosurgery 2020; 87:E615-E616. [PMID: 32860029 DOI: 10.1093/neuros/nyaa375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023] Open
Affiliation(s)
- Daniel R Felbaum
- Department of Neurosurgery MedStar Georgetown University Hospital Washington, District of Columbia
- Department of Neurosurgery MedStar Washington Hospital Center Washington, District of Columbia
| | - Ehsan Dowlati
- Department of Neurosurgery MedStar Georgetown University Hospital Washington, District of Columbia
| | - Jeffrey C Mai
- Department of Neurosurgery MedStar Georgetown University Hospital Washington, District of Columbia
- Department of Neurosurgery MedStar Washington Hospital Center Washington, District of Columbia
| | - Ai-Hsi Liu
- Department of Radiology MedStar Washington Hospital Center Washington, District of Columbia
| | - A Jesse Schuette
- Division of Neurosurgery Walter Reed National Military Medical Center Bethesda, Maryland
| | - Randy Bell
- Division of Neurosurgery Walter Reed National Military Medical Center Bethesda, Maryland
| | - Rocco A Armonda
- Department of Neurosurgery MedStar Georgetown University Hospital Washington, District of Columbia
- Department of Neurosurgery MedStar Washington Hospital Center Washington, District of Columbia
| |
Collapse
|
10
|
Kastrup A, Brunner F, Roth C, Papanagiotou P. Frequency and Timing of Endovascular Therapy in Acute Stroke Patients: A Population-Based Analysis Using the Bremen Stroke Register. Neuroepidemiology 2020; 54:398-403. [PMID: 32906124 DOI: 10.1159/000509430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/14/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE In patients with large vessel occlusions (LVOs), endovascular treatment (ET) has become the standard of care, so that the potential number of these patients needs to be considered for the effective implementation of comprehensive stroke services. However, population-based data on the incidence of ET are scarce. METHODS Using our prospective stroke register, in which all endovascular procedures on the 557,464 inhabitants of the city of Bremen are included, we performed a population-based analysis on the frequency and timing of ET in acute stroke patients with LVOs in the year 2017. RESULTS Out of a total of 1,448 acute ischemic stroke patients, 173 patients (12%) had received ET (161 patients in the anterior circulation and 12 patients in the posterior circulation). Among these, 95 patients were inhabitants of Bremen. The population-based incidence thus was 17 (95% confidence interval [CI]: 14-21) ET cases per 100,000 person-years. The number of stroke procedures per month varied from 9 to 19 (median: 14.5; interquartile range [IQR]: 12-17). The number of stroke procedures per month and 100,000 inhabitants varied from 0.7 to 2.1 (median: 1.4; IQR: 0.9-1.7). Many procedures (53%) were performed during nonwork hours (between 17:00 h and 06:59 h or weekends). CONCLUSIONS Approximately 12% of all ischemic stroke patients received ET, and the incidence of ET was 17 (95% CI: 14-21) cases per 100,000 person-years. However, despite being a high-volume center, the absolute number of stroke procedures per month was low, and many patients were treated during nonwork hours.
Collapse
Affiliation(s)
- Andreas Kastrup
- Department of Neurology, Klinikum Bremen-Mitte, Bremen, Germany,
| | | | - Christian Roth
- Department of Neuroradiology, Klinikum Bremen-Mitte, Bremen, Germany
| | | |
Collapse
|
11
|
Tschoe C, Kittel C, Brown P, Hafeez M, Kan P, Alawieh A, Spiotta AM, Almallouhi E, Dumont TM, McCarthy DJ, Starke RM, De Leacy R, Wolfe SQ, Fargen KM. Impact of off-hour endovascular therapy on outcomes for acute ischemic stroke: insights from STAR. J Neurointerv Surg 2020; 13:693-696. [PMID: 32900909 DOI: 10.1136/neurintsurg-2020-016474] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/30/2020] [Accepted: 08/01/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND The off-hour effect has been observed in the medical care of acute ischemic stroke. However, it remains unclear if time of arrival affects revascularization rates and outcomes after endovascular therapy (EVT) for emergent large vessel occlusion (ELVO). We aimed to investigate the clinical outcomes of EVT between on-hour and off-hour admissions. METHODS Patients who underwent EVT for ELVO from January 2013 to June 2019 from the STAR Registry were included. Patients were grouped based on time of groin puncture: on-hour period (Monday through Friday, 7:00 am-4:59 pm) and off-hour period (overnight 5:00pm-6:59am and the weekends). Primary outcome was final modified Rankin Scale (mRS) at 90 days on mRS-shift analysis. RESULTS A total of 1919 patients were included in the study from six centers. The majority of patients (1169, 60.9%) of patients presented during the off-hour period. The mean age was 68.1 years and 50.5% were women. Successful reperfusion, as defined by a Thrombolysis In Cerebral Infarction (TICI) score of ≥2B, was achieved in 88.8% in the on-hour group and 88.0% in the off-hour group. Good clinical outcome (mRS 0-2) was obtained in 34.4% of off-hour patients and 37.7% of on-hour patients. On multivariable ordinal logistic regression analysis, time of presentation was not associated with worsened outcome (OR 1.150; 95% CI 0.96 to 1.37; P=0.122). Age, admission National Institutes of Health Stroke Scale (NIHSS), baseline mRS, and final TICI score were significantly associated with worse outcomes. CONCLUSION There is no statistical difference in functional outcome in acute ischemic stroke patients who underwent EVT during on-hours versus off-hours.
Collapse
Affiliation(s)
- Christine Tschoe
- Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Carol Kittel
- Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Patrick Brown
- Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Muhammad Hafeez
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Ali Alawieh
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eyad Almallouhi
- Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - David J McCarthy
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Reade De Leacy
- Radiology, Mount Sinai Health System, New York, New York, USA
| | - Stacey Q Wolfe
- Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Kyle M Fargen
- Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| |
Collapse
|
12
|
Weddell J, Parr E, Knight S, Muddegowda G, Natarajan I, Chembala J, Ferdinand P, Ahmad N, Pencz Z, Rana S, Warusevitane A, Jadun C, Nayak S, Hashim Z, Augustine A, Sim J, Roffe C. Mechanical thrombectomy: can it be safely delivered out of hours in the UK? BMC Neurol 2020; 20:326. [PMID: 32873250 PMCID: PMC7461259 DOI: 10.1186/s12883-020-01909-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 08/24/2020] [Indexed: 12/15/2022] Open
Abstract
Background Mechanical thrombectomy was approved by NICE as a treatment for stroke in 2016. However, most of the evidence is from studies conducted during working hours. Only few centres in the UK perform thrombectomies out-of-hours. The Royal Stoke University Hospital (RSUH) has offered thrombectomies over 24 h (24/7) since 2010. The aim of this service review is to compare the outcomes for patients treated in regular working hours to those treated outside normal working hours within this unit. Methods This retrospective service analysis includes all patients treated with mechanical thrombectomy at RSUH since the start of the service in January 2010 to June 2019. Data on key demographics, timings, procedural complications, and long-term outcomes including death and disability at 90 days were collected. In-hours was defined as the time between 8:00–17:00 h, Monday to Friday; out-of-hours was defined as any time outside this period. Results In total, 516 mechanical thrombectomies were performed in this time period; data were available on 501 of these. Successful recanalization (TICI 2b/3) was achieved in 86% of patients. By 90 days 96 (19%) had died and 234 (47%) were functionally independent (modified Rankin Scale score ≤ 2). 211 (42%) of the procedures were performed in-hours and 290 (58%) out-of-hours. Door-to-CT and door-to-groin times were significantly longer out-of-hours than in-hours, but thrombectomy duration was significantly shorter. There were no significant differences in complications and short- and long-term outcomes. Conclusion Mechanical thrombectomy was delivered safely and effectively 24/7 in this UK hospital, with no difference in clinical outcomes.
Collapse
Affiliation(s)
- Jake Weddell
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK.
| | - Emma Parr
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Stacey Knight
- School of Medicine, Keele University, Newcastle-under-Lyme, ST5 5BG, UK
| | - Girish Muddegowda
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Indira Natarajan
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Jayan Chembala
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Phillip Ferdinand
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Nasar Ahmad
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Zoltan Pencz
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Saad Rana
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Anushka Warusevitane
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Changez Jadun
- Department of Radiology, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Sanjeev Nayak
- Department of Radiology, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Zafar Hashim
- Department of Radiology, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Albin Augustine
- Department of Anaesthetics, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Julius Sim
- School of Medicine, Keele University, Newcastle-under-Lyme, ST5 5BG, UK
| | - Christine Roffe
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK.,School of Medicine, Keele University, Newcastle-under-Lyme, ST5 5BG, UK
| |
Collapse
|
13
|
Kaaouana O, Bricout N, Casolla B, Caparros F, Schiava LD, Mounier-Vehier F, Pasi M, Dequatre-Ponchelle N, Pruvo JP, Cordonnier C, Hénon H, Leys D. Mechanical thrombectomy for ischaemic stroke in the anterior circulation: off-hours effect. J Neurol 2020; 267:2910-2916. [DOI: 10.1007/s00415-020-09946-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/20/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
|
14
|
Fargen KM, Leslie-Mazwi TM, Chen M, Hirsch JA. Physician, know thyself: implicit and explicit decision-making for mechanical thrombectomy in stroke. J Neurointerv Surg 2020; 12:952-956. [DOI: 10.1136/neurintsurg-2020-015973] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 03/27/2020] [Accepted: 03/30/2020] [Indexed: 01/02/2023]
Abstract
Few clinical situations in medical practice are as time-sensitive and and have such profound ramifications as selection of patients with acute stroke for mechanical thrombectomy (MT). Emergent large vessel occlusion has become a treatable disease with minimal numbers needed to treat to achieve a functional, long-term neurologic outcome. However, MT carries risk and many patients who are appropriately reperfused continue to have significant neurologic deficits and disability despite a successful procedure. The decision to offer or withhold MT can be complex. Frequently decisions must be made based on incomplete information or emergently while the physician is awoken from sleep or distracted while performing other procedures. A growing number of studies have examined cognitive errors and biases as they pertain to patient diagnosis and treatment in medicine. Dual process theory identifies two decision-making processes as system 1 ('implicit') and system 2 ('explicit') and describes the patterns through which decisions are formulated. The implicit system is the default pathway as it requires little effort or focus, uses mental short cuts, and is rapid; however, this pathway is subject to considerable bias and error. This manuscript reviews the mechanisms underlying the way in which physician decisions about MT are made, specifically highlighting prominent biases that may affect judgment, and reviews other important principles, such as confidence in decisions, aggressiveness to pursue MT, and strategies to improve decisions.
Collapse
|
15
|
Radiology workload in clinical implementation of thrombectomy for acute ischemic stroke: experience from The Netherlands. Neuroradiology 2020; 62:877-882. [PMID: 32248269 DOI: 10.1007/s00234-020-02416-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/24/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To investigate the number of acute stroke patients undergoing CT angiography (CTA) for suspected large vessel occlusion (LVO) and those eligible for thrombectomy in relation to the population. METHODS Consecutive patients in a Western population who underwent CTA for suspected LVO of the proximal anterior circulation between January and August 2019 were included. The date and time of CTA and the number of patients eligible for thrombectomy were assessed. Our hospital's service area population was estimated using the Central Bureau for Statistics data. One-way analysis of variance with post-hoc tests and chi-squared tests were used for statistical analyses. RESULTS Of 520 patients (49% males, mean age of 72 years) undergoing CTA, 84 (16.2%) were eligible for thrombectomy. Our hospital's service area population was estimated at 420,000. Therefore, 3.6 CTA scans were performed and 0.6 patients were eligible for thrombectomy per 100,000 people per week. The number of patients undergoing CTA and the number of patients eligible for thrombectomy both did not significantly differ between any days of the week (P > 0.05). A total of 236 (45%) and 284 patients (55%) underwent CTA during office and on-call hours, respectively. The percentage of patients eligible for thrombectomy did not significantly differ between office and on-call hours (P = 0.834). CONCLUSION Our study estimated the number of stroke patients undergoing CTA for suspected LVO and those eligible for thrombectomy in relation to the population. Numbers were essentially the same throughout the week, and during office and on-call hours. Our data can be used to make adequate staffing plans.
Collapse
|
16
|
Dalsania AK, Kansagra AP. Strategies to reduce the impact of demand for concurrent endovascular thrombectomy. J Neurointerv Surg 2020; 12:1072-1075. [PMID: 32188761 DOI: 10.1136/neurintsurg-2020-015826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/23/2020] [Accepted: 02/25/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The rise in demand for endovascular thrombectomy (EVT) has increased the possibility that multiple patients with acute ischemic stroke may present concurrently and exceed local capacity to provide timely treatment. In this work, we quantitatively compared the efficacy of various strategies to mitigate demand in excess of capacity (DEC). METHODS Strategies evaluated included a backup neurointerventional team for 3 hours, 8 hours, or 24 hours per day; a separate pre-intervention imaging team; and a 30% decrease in procedure duration. For each strategy, empirical distributions were used to probabilistically generate arrival time and case duration for 16 000 independent trials repeated across a range of annual case volumes. DEC was calculated from time series representing the number of concurrent cases at each minute of the year for each trial at each case volume. RESULTS All strategies decreased DEC compared with baseline. At a representative volume of 250 cases per year, availability of a backup team for 3 hours, 8 hours, and 24 hours per day reduced DEC by 27.0%, 60.3%, and 97.2%, respectively, compared with baseline. Similarly, availability of a pre-intervention imaging team and a 30% decrease in procedure duration reduced DEC by 26.6% and 17.7%, respectively, compared with baseline. CONCLUSIONS A backup neurointerventional team, even if available only part time, was an effective strategy for decreasing DEC for EVT. Understanding the actual quantitative benefit of each strategy can facilitate rational cost-benefit analyses underlying the development of efficient and sustainable models of care.
Collapse
Affiliation(s)
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri, USA .,Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine, St Louis, Missouri, USA
| |
Collapse
|
17
|
Panesar SS, Volpi JJ, Lumsden A, Desai V, Kleiman NS, Sample TL, Elkins E, Britz GW. Telerobotic stroke intervention: a novel solution to the care dissemination dilemma. J Neurosurg 2020; 132:971-978. [PMID: 31783366 DOI: 10.3171/2019.8.jns191739] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Sandip S Panesar
- 1Department of Neurological Surgery and Neurological Institute, Houston Methodist Hospital
| | - John J Volpi
- 1Department of Neurological Surgery and Neurological Institute, Houston Methodist Hospital
| | - Alan Lumsden
- 2Department of Cardiovascular Surgery, Texas Medical Center
| | - Virendra Desai
- 1Department of Neurological Surgery and Neurological Institute, Houston Methodist Hospital
| | - Neal S Kleiman
- 3Department of Interventional Cardiology, Houston Methodist Hospital
| | | | - Eric Elkins
- 5Cardiac Catheterization Laboratory, Houston Methodist Hospital, Houston, Texas
| | - Gavin W Britz
- 1Department of Neurological Surgery and Neurological Institute, Houston Methodist Hospital
| |
Collapse
|
18
|
Williams MM, Leslie-Mazwi T, Hirsch JA, Kittel C, Spiotta A, De Leacy R, Mocco J, Albuquerque FC, Ducruet AF, Goyal N, Arthur AS, Kan P, Mokin M, Dumont TM, Reeves A, Wolfe SQ, Fargen K. Real-world effects of late window neurothrombectomy: procedure rates increase without night-time bias. J Neurointerv Surg 2019; 12:460-464. [PMID: 31723049 DOI: 10.1136/neurintsurg-2019-015223] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/23/2019] [Accepted: 10/01/2019] [Indexed: 01/13/2023]
Abstract
INTRODUCTION With the expansion of the interventional time window for stroke from emergent large vessel occlusion (ELVO), the rate of mechanical thrombectomy (MT) is expected to rise, potentially causing higher burnout rates and requiring hospitals to develop strategies for adequate coverage of these procedures. METHODS Neurointerventional physicians at 10 participating stroke centers prospectively recorded time requirements for all MT consultations over 30 consecutive 24-hour call periods, including both false positive consultations and MT procedures, during mid to late 2018. Consult start time, procedure start and end time, and data regarding commute to the hospital and delay in scheduled procedures were collected and compared with those from an identical prospective study performed in 2017. RESULTS Data were collected from a total of 300 days of call. A total of 166 procedures were performed (mean 0.55 per day), an increase from 0.32 per day in 2017. Overall mean MT direct time burden during each 24-hour call was 124 min (compared with 85 min in 2017). The percentage of consultations for thrombectomy varied based on time of day, with 87% of consults between the hours of midnight and 04:00 proceeding to thrombectomy compared with 37% between the hours of 16:00 and 20:00. CONCLUSIONS MT procedural volumes have increased from one every 5 days in 2016 to one every 2 days in 2018. The highest percentage of consults leading to thrombectomy occur in the early morning hours after midnight. Compared with similar data from 2016 and 2017, call demands continue to escalate, representing a significant demand on neurointerventional teams.
Collapse
Affiliation(s)
- Michelle Marie Williams
- Neurological Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Thabele Leslie-Mazwi
- Interventional Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua A Hirsch
- Interventional Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Carol Kittel
- Neurological Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Alejandro Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Reade De Leacy
- Neurosurgery, Mount Sinai Hospital, New York City, New York, USA
| | - J Mocco
- Neurosurgery, Mount Sinai Hospital, New York City, New York, USA
| | | | - Andrew F Ducruet
- Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Nitin Goyal
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
| | - Adam S Arthur
- UT Dept Neurosurgery/Semmes-Murphey Clinic, Memphis, Tennessee, USA
| | - Peter Kan
- Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Maxim Mokin
- Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Travis M Dumont
- Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Alan Reeves
- Neuroendovascular Division, Department of Radiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Stacey Q Wolfe
- Neurological Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Kyle Fargen
- Neurological Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| |
Collapse
|
19
|
Albuquerque FC. All for One. J Neurointerv Surg 2019; 11:1063-1064. [PMID: 31604841 DOI: 10.1136/neurintsurg-2019-015478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2019] [Indexed: 11/04/2022]
|
20
|
Stein L, Tuhrim S, Fifi J, Mocco J, Dhamoon M. National trends in endovascular therapy for acute ischemic stroke: utilization and outcomes. J Neurointerv Surg 2019; 12:356-362. [DOI: 10.1136/neurintsurg-2019-015019] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/23/2019] [Accepted: 07/29/2019] [Indexed: 11/03/2022]
Abstract
ObjectiveFollowing widespread acceptance of endovascular therapy (ET) for large vessel occlusion stroke in 2015, we assessed nationwide utilization of revascularization for acute ischemic stroke (AIS).MethodsWe utilized the 2013–2016 Healthcare Cost and Utilization Project Nationwide Readmissions Database. We identified AIS admissions, treatment with intravenous thrombolysis (IVT), ET, and vascular risk factors using International Classification of Disease Clinical Modification codes. Main predictor of outcome was the time period of index admission (‘pre-endovascular era (pre-EA)’ January 2013–January 2015 and ‘endovascular era (EA)’ February 2015– December 2016). We calculated the proportion of AIS admissions in which, first, VT and second, ET was performed. Among patients treated with ET, we examined the association between era and discharge disposition, in-hospital mortality during index admission, and 30-day readmission.ResultsThere were 925 363 index AIS admissions before the EA and 857 347 during. A higher proportion of AIS patients received IVT (8.4% vs 7.8%) and ET (2.6% vs 1.3%) in the EA. Although length of stay (LOS) was shorter in the EA (5.70 vs 6.80 days), total charges were greater ($56 691 vs $53 878), and admissions were more often to a metropolitan hospital (65.2% vs 57.2%). Among those treated with ET, a smaller proportion received IVT (29.7% vs 44.9%), LOS was substantively shorter (9.75 vs 12.76 days), and patients had a lower odds of discharge home.ConclusionsThe utilization of ET has doubled in the EA but ET remains underutilized. ET is predominantly provided at metropolitan teaching hospitals and associated with higher charges despite shorter LOS and unchanged in-hospital mortality.
Collapse
|
21
|
Chiu YC, Tang SC, Sun JT, Tsai LK, Hsieh MJ, Lee CW, Jeng JS, Lee YC, Chien YC, Wang YC, Chiang WC, Ma MHM. Using G-FAST to recognize emergent large vessel occlusion: a training program for a prehospital bypass strategy. J Neurointerv Surg 2019; 12:104-108. [PMID: 31337733 DOI: 10.1136/neurintsurg-2019-015171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 01/17/2023]
Abstract
INTRODUCTION The shorter the time between the onset of symptoms and reperfusion using endovascular thrombectomy, the better the functional outcome of patients. A training program was designed for emergency medical technicians (EMTs) to learn the gaze-face-arm-speech-time test (G-FAST) score for initiating a prehospital bypass strategy in an urban city. This study aimed to evaluate the effect of the training program on EMTs. METHODS All EMTs in the city were invited to join the training program. The program consisted of a 30 min lecture and a 20 min video which demonstrated the G-FAST evaluation. The participants underwent tests before and after the program. The tests included (1) a questionnaire of knowledge, attitudes, confidence, and behaviors towards stroke care; and (2) watching 10 different scenarios in a video and answering questions, including eight sub-questions of G-FAST parameters, and choosing a suitable receiving hospital. RESULTS In total, 1058 EMTs completed the training program. After the program, significant improvement was noted in knowledge, attitudes, and confidence, as well as scenario judgement. The performance of the EMTs in evaluating G-FAST criteria in comatose patients was relatively poor in the pre-test and improved significantly after the training course. Although the participants answered the G-FAST items correctly, they tended to overtriage the patients and refer them to higher-level hospitals. CONCLUSIONS A short training program can improve the ability to identify stroke patients and choose a suitable receiving hospital. A future training program could put further emphasis on how to evaluate comatose patients and choose a suitable receiving hospital.
Collapse
Affiliation(s)
- Yu-Chen Chiu
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jen-Tang Sun
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Ching Lee
- Department of Industrial Engineering and Engineering Management, National Tsing Hua University, Hsinchu, Taiwan
| | - Yu-Chun Chien
- Fire Department of the City of Taipei, Taipei, Taiwan
| | | | - Wen-Chu Chiang
- Department of Emergency Medicine, National Taiwan University Hospital YunlinBranch, Yunlin County, Taiwan
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital YunlinBranch, Yunlin County, Taiwan
| |
Collapse
|
22
|
Ospel JM, Kashani N, Goyal M, Menon BK, Campbell BCV, Fischer U, Turjman F, Mitchell P, Yoshimura S, Podlasek A, Rabinstein AA, Wilson AT, Kim BM, Baxter BW, Cherian MP, Heo JH, Foss M, Demchuk AM, Sylaja PN, Hill MD, Saposnik G, Almekhlafi MA. Time of day and endovascular treatment decision in acute stroke with relative endovascular treatment indication: insights from UNMASK EVT international survey. J Neurointerv Surg 2019; 12:122-126. [DOI: 10.1136/neurintsurg-2019-014976] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/29/2019] [Accepted: 05/30/2019] [Indexed: 11/03/2022]
Abstract
Background and purposeThe decision to proceed with endovascular thrombectomy should ideally be made independent of inconvenience factors, such as daytime. We assessed the influence of patient presentation time on endovascular therapy decision making under current local resources and assumed ideal conditions in acute ischemic stroke with level 2B evidence for endovascular treatment.Methods and materialsIn an international cross sectional survey, 607 stroke physicians from 38 countries were asked to give their treatment decisions to 10 out of 22 randomly assigned case scenarios. Eleven scenarios had level 2B evidence for endovascular treatment: 7 daytime scenarios (7:00 am–5:00 pm) and four night time cases (5:01 pm– 6:59 am). Participants provided their treatment approach assuming (A) there were no practice constraints and (B) under their current local resources. Endovascular treatment decisions in the 11 scenarios were analyzed according to presentation time with adjustment for patient and physician characteristics.ResultsParticipants selected endovascular therapy in 74.2% under assumed ideal conditions, and 70.7% under their current local resources of night time scenarios, and in 67.2% and 63.8% of daytime scenarios. Night time presentation did not increase the probability of a treatment decision against endovascular therapy under current local resources or assumed ideal conditions.ConclusionPresentation time did not influence endovascular treatment decision making in stroke patients in this international survey.
Collapse
|
23
|
Dalsania AK, Kansagra AP. Simultaneous patient presentation for endovascular thrombectomy in acute ischemic stroke. J Neurointerv Surg 2019; 11:1201-1204. [PMID: 31030186 DOI: 10.1136/neurintsurg-2019-014857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/02/2019] [Accepted: 04/08/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Increased demand for endovascular thrombectomy has increased the likelihood of simultaneous patient presentation leading to competing demand for time-critical treatment that could adversely impact patient outcomes. We aimed to quantify the occurrence of simultaneous patient presentation at different patient volumes. METHODS Empirical distributions for time of patient presentation and case duration were used to probabilistically generate arrival time and case duration for a set annual patient volume, ranging from 1 to 500 cases per year, for 16 000 independent trials at each volume. Time series were generated for each trial to represent the number of cases being performed at each minute of the year. Time series were used to calculate daily thrombectomy demand, annual concurrent demand, and hourly excess demand. RESULTS The patient volumes at which at least one annual occurrence of concurrent demand by two patients was 50% and 97.5% likely were 45 and 101, respectively. The volumes at which at least one annual occurrence of concurrent demand by three patients was 50% and 97.5% likely were 216 and 387, respectively. There was dramatic variation in the occurrence of excess demand by two or more patients throughout the day. CONCLUSIONS The occurrence of simultaneous presentation by multiple patients for endovascular thrombectomy varies with annual patient volume and time of day. Understanding these trends and the associated patient impact can inform intelligent strategies at regional and national levels for optimizing patient care within real-world financial and operational constraints.
Collapse
Affiliation(s)
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri, USA.,Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine, St Louis, Missouri, USA
| |
Collapse
|
24
|
Fargen KM, Arthur AS, Leslie-Mazwi T, Garner RM, Aschenbrenner CA, Wolfe SQ, Ansari SA, Dabus G, Spiotta A, Mokin M, Linfante I, Mocco J, Hirsch JA. A survey of burnout and professional satisfaction among United States neurointerventionalists. J Neurointerv Surg 2019; 11:1100-1104. [PMID: 30975735 DOI: 10.1136/neurintsurg-2019-014833] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/11/2019] [Accepted: 03/14/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND The toll of burnout on healthcare is significant and associated with physician depression and medical errors. OBJECTIVE To assess the prevalence and risk factors for burnout among neurointerventionalists. METHODS A 39-question online survey containing questions about neurointerventional practice and the Maslach Burnout Inventory-Human Services Survey for medical personnel was distributed to members of major US neurointerventional physician societies. RESULTS 320 responses were received. Median (interquartile range) composite scores for emotional exhaustion were 25 (16-35), depersonalization 7 (4-12), and personal accomplishment 39 (35-44). 164/293 respondents (56%) met established criteria for burnout. There was no significant relationship between training background, practice setting, call frequency, or presence of a senior partner on burnout prevalence. Multiple logistic regression analysis showed that feeling underappreciated by hospital leadership (OR=3.71; p<0.001) and covering more than one hospital on call (OR=1.96; p=0.01) were strongly associated with burnout. Receiving additional compensation for a call was independently protective against burnout (OR= 0.70; p=0.005). CONCLUSIONS This survey of United States neurointerventional physicians demonstrated a self-reported burnout prevalence of 56%, which is similar to the national average among physicians across other specialties. Additional compensation for a call was a significant protective factor against burnout. In addition, feeling underappreciated by departmental or hospital leadership and covering more than one hospital while on call were associated with greater odds of burnout.
Collapse
Affiliation(s)
- Kyle M Fargen
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Adam S Arthur
- UT Department of Neurosurgery/Semmes-Murphey Clinic, Memphis, Tennessee, USA
| | | | - Rebecca M Garner
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Carol A Aschenbrenner
- Biostatistics, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Sameer A Ansari
- Radiology, Neurology, and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Guilherme Dabus
- Interventional Neuroradiology and Neuroendovascular Surgery, Miami Cardiac & Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
| | - Alejandro Spiotta
- Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Maxim Mokin
- Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Italo Linfante
- Baptist Cardiac and Vascular Institute, Miami, Florida, USA
| | - J Mocco
- The Mount Sinai Health System, New York, New York, USA
| | - Joshua A Hirsch
- Interventional Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
25
|
The pincer movement of cost and quality in neurointerventional care: resource management as an imperative. J Neurointerv Surg 2019; 11:323-325. [DOI: 10.1136/neurintsurg-2019-014871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2019] [Indexed: 11/03/2022]
|
26
|
Ebashi R, Ogata A, Nishihara M, Inoue K, Yoshioka F, Takase Y, Masuoka J, Yakushiji Y, Irie H, Hara H, Abe T. Significance of simulated conventional images on dual energy CT after endovascular treatment for ischemic stroke. J Neurointerv Surg 2019; 11:898-902. [PMID: 30670626 DOI: 10.1136/neurintsurg-2018-014486] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 12/20/2018] [Accepted: 12/26/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE CT scans often reveal post-interventional cerebral hyperdensities (PCHDs) immediately after intra-arterial thrombectomy (IAT) for ischemic stroke. Dual energy CT (DE-CT) can indicate whether PCHDs are caused by hemorrhage or iodinated contrast. Hyperdense lesions, detected on DE-CT with the use of iodinated contrast, could be associated with delayed hemorrhagic transformation and poor outcome. However, the quantitative indicators in DE-CT for predicting delayed hemorrhagic transformation remain unclear. We assessed such indicators for predicting delayed hemorrhagic transformation. MATERIAL AND METHODS We retrospectively analyzed 52 consecutive acute ischemic stroke patients who underwent IAT. Simulated conventional CT (sCCT) images were obtained immediately after a DE-CT scan. Virtual, unenhanced, non-contrast (VNC) imaging was performed after reconstruction. Hounsfield units (HU) of the infarct areas observed on the sCCT were measured. The association of HU on sCCT with hemorrhage on VNC and delayed parenchymal hemorrhage (PH) was evaluated. RESULTS The HU of sCCT with hemorrhage on VNC was significantly higher than without it (377.9±385 HU vs 83.5±37.9 HU; P<0.0001). The cut-off index was 80 HU, which displayed 100% sensitivity, 63.8% specificity, 22.3% positive predictive value, and 100% negative predictive value (P=0.0001, area under the curve (AUC)=0.89). The HU with delayed PH was substantially higher than without it (250.8±382.2 HU vs 93.7±64.8 HU; P=0.01). The cut-off index was 78 HU, which showed 100% sensitivity, 61% specificity, 25% positive predictive value, and 100% negative predictive value (P=0.049, AUC=0.76). CONCLUSION sCCT images on DE-CT are useful for excluding intracerebral hemorrhage and delayed PH.
Collapse
Affiliation(s)
- Ryo Ebashi
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Atsushi Ogata
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Masashi Nishihara
- Department of Radiology, Faculty of Medicine, Saga University, Saga, Japan
| | - Kohei Inoue
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Fumitaka Yoshioka
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Yukinori Takase
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Jun Masuoka
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Hiroyuki Irie
- Department of Radiology, Faculty of Medicine, Saga University, Saga, Japan
| | - Hideo Hara
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Tatsuya Abe
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| |
Collapse
|
27
|
Hirsch JA, Leslie-Mazwi T, Nicola GN, Milburn J, Kirsch C, Rosman DA, Gilligan C, Manchikanti L. Storm rising! The Obamacare exchanges will catalyze change: why physicians need to pay attention to the weather. J Neurointerv Surg 2018; 11:101-106. [DOI: 10.1136/neurintsurg-2018-014412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2018] [Indexed: 11/03/2022]
|
28
|
Almallouhi E, Al Kasab S, Harvey JB, Reardon C, Alawieh A, Girotra T, Aysse P, Turner RD, Holmstedt CA. Impact of Treatment Time on the Long-Term Outcome of Stroke Patients Treated With Mechanical Thrombectomy. J Stroke Cerebrovasc Dis 2018; 28:185-190. [PMID: 30343988 DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 08/26/2018] [Accepted: 09/19/2018] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To assess the long-term functional outcome of stroke in patients treated with mechanical thrombectomy (MT) performed during work hours (on-hours) versus after-hours, weekends, and official holidays (off-hours). METHODS Data on all patients receiving MT at a comprehensive stroke center was collected between December 2014-December 2016. Our primary outcomes were the discharge and 90-day modified Rankin Scale (mRS). We developed propensity scores for off-hours treatment and used inverse probability of treatment weights to address confounding. We estimated logistic regression to assess the relationship between off-hours treatment and favorable patient outcomes. Independent variables include receiving thrombectomy during the off-hours, admission National Institute of Health Stroke Scale (NIHSS), door to groin time in minutes, age, and race. RESULTS During the study period, 80 (41%) patients underwent thrombectomy during on-hours and 116 (59%) during off-hours. Mean age was 69.1 years for the on-hours group and 64.1 years for the off-hours group (P = .02). There were no statistically significant differences in median admission NIHSS, rate of alteplase administration, mean time from last known well to thrombectomy, rate of revascularization, and rate of hemorrhagic transformation between the 2 groups. Logistic regression analysis showed the probability of a favorable outcome at discharge (mRS ≤ 2) is 12.6 % lower for off-hours patients (P = .038, [95%CI -.25 to -.01]). For patients with a 90-day mRS (n = 117), the probability of a favorable outcome was 18.7% lower for those treated during the off-hours (P = .029, [95%CI -.36 to -.02]). CONCLUSIONS There is a higher probability of a good functional outcome in acute ischemic stroke patients who receive MT when performed during regular work hours.
Collapse
Affiliation(s)
- Eyad Almallouhi
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina.
| | - Sami Al Kasab
- Department of Neurology, University of Iowa, Iowa City, Iowa.
| | - Jillian B Harvey
- Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina.
| | - Christopher Reardon
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina.
| | - Ali Alawieh
- Medical Scientist Training Program, Medical University of South Carolina, Charleston, South Carolina; Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina.
| | - Tarun Girotra
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina.
| | - Patricia Aysse
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina.
| | - Raymond D Turner
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina.
| | - Christine A Holmstedt
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina.
| |
Collapse
|
29
|
Fargen KM, Hirsch JA. Neurointerventionalists, stroke and burnout. J Neurointerv Surg 2018; 10:811-812. [DOI: 10.1136/neurintsurg-2018-014304] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2018] [Indexed: 11/04/2022]
|
30
|
Williams MM, Wilson TA, Leslie-Mazwi T, Hirsch JA, Kellogg RT, Spiotta AM, De Leacy R, Mocco J, Albuquerque FC, Ducruet AF, Arthur A, Srinivasan VM, Kan P, Mokin M, Dumont TM, Reeves A, Singh J, Wolfe SQ, Fargen KM. The burden of neurothrombectomy call: a multicenter prospective study. J Neurointerv Surg 2018; 10:1143-1148. [PMID: 29678885 DOI: 10.1136/neurintsurg-2018-013772] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/04/2018] [Accepted: 03/09/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Neurothrombectomy frequency is increasing, and a better understanding of the neurothrombectomy call burden is needed. METHODS Neurointerventional physicians at nine participating stroke centers prospectively recorded time requirements for all neurothrombectomy (NT) consultations over 30 consecutive 24 hour call periods. RESULTS Data were collected from a total of 270 days of call. 214 NT consultations were reported (mean 0.79 per day), including 130 'false positive' consultations that ultimately did not lead to thrombectomy (mean 0.48 per day). 84 NT procedures were performed at the nine centers (0.32 per day, or 1 every 3 days). Most (59.8%) consultations occurred between 5pm and 7am. 30% of thrombectomy procedures resulted in delays in scheduled cases; treating physicians had to emergently travel to the hospital for 51.2% of these cases. A median of 27 min was spent on each false positive consultation and 171 min on each thrombectomy. Overall, the median physician time spent on NT responsibilities per 24 hour call period was 69 min (mean 85 min; IQR 16-135 min). CONCLUSIONS NT consultations are frequent and often disrupt physician schedules, requiring physicians to commute in from home after hours in the majority of cases. As procedural and consultation volumes increase, it is crucial to understand the significant burden of call on neurointerventional physicians and develop strategies that reduce the potential for burnout. Importantly, this study was performed prior to the completion of the DAWN and DEFUSE3 trials; NT consultations are expected to continue to increase in the future.
Collapse
Affiliation(s)
- Michelle M Williams
- Department of Neurological Surgery, Wake Forest University, Winston Salem, North Carolina, USA
| | - Taylor A Wilson
- Department of Neurological Surgery, University of Arkansas, Little Rock, Arkansas, USA
| | - Thabele Leslie-Mazwi
- Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua A Hirsch
- Department of Interventional Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ryan T Kellogg
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Reade De Leacy
- Department of Neurosurgery, Mount Sinai Hospital, New York City, New York, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Hospital, New York City, New York, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Adam Arthur
- Department of Neurosurgery, University of Tennessee/Semmes-Murphy Clinic, Memphis, Tennessee, USA
| | | | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Travis M Dumont
- Department of Neurosurgery, University of Arizona, Tucson, Arizona, USA
| | - Alan Reeves
- Department of Radiology, Neuroendovascular Division, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jasmeet Singh
- Department of Neurological Surgery, Wake Forest University, Winston Salem, North Carolina, USA
| | - Stacey Q Wolfe
- Department of Neurological Surgery, Wake Forest University, Winston Salem, North Carolina, USA
| | - Kyle M Fargen
- Department of Neurological Surgery, Wake Forest University, Winston Salem, North Carolina, USA
| |
Collapse
|
31
|
Fargen KM, West JL, Mocco J. Lifting the veil on stroke outcomes: revisiting stroke centers' transparency through public reporting of metrics. J Neurointerv Surg 2018; 10:839-842. [PMID: 29627793 DOI: 10.1136/neurintsurg-2018-013866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 03/16/2018] [Accepted: 03/19/2018] [Indexed: 12/18/2022]
Abstract
Public reporting of healthcare metrics provides transparency that allows patients and emergency medical providers to make informed decisions about where patients should receive care. Most previous reports about public reporting of health metrics have demonstrated significant improvements in outcome metrics after implementation. However, no mechanism exists, voluntary or otherwise, for the public reporting of outcomes of stroke care. We review the components of public reporting of health outcomes data and its limited history in stroke outcomes. We summarize the literature on public reporting in cardiovascular interventions, particularly percutaneous coronary interventions, as a close corollary to mechanical neurothrombectomy. The benefits, limitations, and controversies associated with reporting of cardiovascular outcomes are reviewed with a focus on the development of risk-avoidant behaviors. This article serves as a primer for discussion of the potential benefits, limitations, and unintended consequences of public reporting of stroke data.
Collapse
Affiliation(s)
- Kyle M Fargen
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - James L West
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Hospital, New York City, New York, USA
| |
Collapse
|