Workload of on-call emergency room neurologists in a Spanish tertiary care centre. A one-year prospective study.

INTRODUCTION: Population ageing, the rising demand for healthcare, and the establishment of acute stroke treatment programs have given rise to increases in the number and complexity of neurological emergency cases. Nevertheless, many centres in Spain still lack on-call emergency neurologists. METHODS: We conducted a retrospective study to describe the role of on-call neurologists at Hospital General Universitario Gregorio Marañón, a tertiary care centre in Madrid, Spain. Sociodemographic characteristics, most common pathologies, diagnostic tests, and destination of the patients attended were recorded daily using a computer database. Results were compared with the general care data from the emergency department. RESULTS: The team attended 3234 patients (3.48% of the emergency department total). The mean number of patients seen per day was 11.15. The most frequent pathologies were stroke (34%), epilepsy (16%) and headache (8%). The mean stay in the emergency department was 7.17 hours. Hospital admission rate was 40% (7.38% of emergency hospital admissions). The main destinations for admitted patients were the stroke unit (39.5%) and the neurology department (33%). Endovascular or thrombolytic therapies were performed on 76 occasions. Doctors attended 70% of the patients during on-call hours. CONCLUSIONS: Emergency neurological care is varied, complex, and frequently necessary. Neurological cases account for a sizeable percentage of both patient visits to the emergency room and the total number of emergency admissions. The current data confirm that on-call neurologists available on a 24-hour basis are needed in emergency departments.

[Aetiological classification of ischaemic strokes: comparison of the new A-S-C-O classification and the classification by the Spanish Society of Neurology's Cerebrovascular Disease Study Group]. / Clasificación etiológica del ictus isquémico: comparación entre la nueva clasificación A-S-C-O y la clasificación del Grupo de Estudio de Enfermedades Cerebrovasculares de la Sociedad Española de Neurología.

INTRODUCTION: The A-S-C-O classification may be better than other methods for classifying ischaemic stroke by aetiology. Our aims are to describe A-S-C-O phenotype distribution (A: atherosclerosis, S: small vessel disease, C: cardiac source, O: other causes; 1: potential cause, 2: causality uncertain, 3: unlikely to be a direct cause although disease is present) and compare them to the Spanish Society of Neurology's Cerebrovascular Disease Study Group (GEECV/SEN) classification. We will also find the degree of concordance between these classification methods and determine whether using the A-S-C-O classification delivers a smaller percentage of strokes of undetermined cause. METHODS: We analysed those patients with ischaemic stroke admitted to our stroke unit in 2010 with strokes that were classified according to GEECV/SEN and A-S-C-O criteria. RESULTS: The study included 496 patients. The percentages of strokes caused by atherosclerosis and small vessel disease according to GEECV/SEN criteria were higher than the percentages for potential atherosclerotic stroke (A1) (14.1 vs. 11.9%; P=.16) and potential small vessel stroke (S1) (14.3 vs. 3%; P<.001). Cardioembolic stroke (C1) was more frequent (22.2 vs. 31%; P<.001). No differences between unusual cause of stroke and other potential causes (O1) were observed. Some degree of atherosclerosis was present in 53.5% of patients (A1, A2, or A3); 65.5% showed markers of small vessel disease (S1, S2, or S3), and 74.9% showed signs of cardioembolism (C1, C2, or C3). Fewer patients in the group without scores of 1 or 2 for any of the A-S-C-O phenotypes were identified as having a stroke of undetermined cause (46.6 vs. 29.2%; P<.001). The agreement between the 2 classifications ranged from κ<0.2 (small vessel and S1) to κ>0.8 (unusual causes and O1). CONCLUSION: Our results show that GEECV/SEN and A-S-C-O classifications are neither fully comparable nor consistent. Using the A-S-C-O classification provided additional information on co-morbidities and delivered a smaller percentage of strokes classified as having an undetermined cause.

Labor asistencial del equipo de guardia de neurología en un hospital terciario de Madrid: análisis prospectivo durante un año / Workload of on-call emergency room neurologists in a Spanish tertiary care centre. A one-year prospective study

Introducción: El envejecimiento poblacional, el aumento en la demanda asistencial y la instauración de tratamientos avanzados para el ictus agudo han originado que las urgencias neurológicas crezcan en número y complejidad. A pesar de esto, muchos centros hospitalarios de España carecen de guardias específicas de Neurología. Métodos: Estudio prospectivo durante un año (agosto 2010-julio 2011), que describe la labor asistencial del equipo de guardia de Neurología del Hospital terciario Gregorio Marañón de Madrid. Se recogieron las características sociodemográficas, las principales afecciones, las pruebas diagnósticas y el flujo de los pacientes atendidos, utilizando un registro diario mediante una base de datos informatizada. Los resultados fueron comparados con la asistencia médica general en urgencias. Resultados: Se atendió a 3.234 pacientes (3,48% del total de urgencias médicas), con una media de 11,15 pacientes/día. La edad media fue de 59 años. Las enfermedades más frecuentes fueron la cerebrovascular (34%), epilepsia (16%) y cefalea (8%). La estancia media en urgencias fue de 7,17 h. La tasa de ingreso hospitalario fue del 40% (7,38% del total de ingresos urgentes por afección médica). Los principales destinos de los pacientes hospitalizados fueron Unidad de Ictus (39,5%) y la planta de Neurología (33%). Se realizaron 76 procedimientos trombolíticos o intravasculares en ictus agudos. El 70% de los pacientes fue valorado fuera del horario laboral. Conclusiones: La atención neurológica es frecuente, variada y compleja, representando un alto porcentaje sobre el total de paciente atendidos o ingresados en urgencias. Nuestros resultados justifican la presencia física de un neurólogo de guardia 24 h en urgencias

Introduction: Population ageing, the rising demand for healthcare, and the establishment of acute stroke treatment programs have given rise to increases in the number and complexity of neurological emergency cases. Nevertheless, many centres in Spain still lack on-call emergency neurologists. Methods: We conducted a retrospective study to describe the role of on-call neurologists at Hospital General Universitario Gregorio Marañon, a tertiary care centre in Madrid, Spain. Sociodemographic characteristics, most common pathologies, diagnostic tests, and destination of the patients attended were recorded daily using a computer database. Results were compared with the general care data from the emergency department. Results: The team attended 3234 patients (3.48% of the emergency department total). The mean number of patients seen per day was 11.15. The most frequent pathologies were stroke (34%), epilepsy (16%) and headache (8%). The mean stay in the emergency department was 7.17 hours. Hospital admission rate was 40% (7.38% of emergency hospital admissions). The main destinations for admitted patients were the stroke unit (39.5%) and the neurology department (33%). Endovascular or thrombolytic therapies were performed on 76 occasions. Doctors attended 70% of the patients during on-call hours. Conclusions: Emergency neurological care is varied, complex, and frequently necessary. Neurological cases account for a sizeable percentage of both patient visits to the emergency room and the total number of emergency admissions. The current data confirm that on-call neurologists available on a 24-hour basis are needed in emergency departments

Clasificación etiológica del ictus isquémico: comparación entre la nueva clasificación A-S-C-O y la clasificación del Grupo de Estudio de Enfermedades Cerebrovasculares de la Sociedad Española de Neurología / Aetiological classification of ischaemic strokes: comparison of the new A-S-C-O classification and the classification by the Spanish Society of Neurology's Cerebrovascular Disease Study Group

Introducción: La nueva clasificación A-S-C-O puede suponer una mejora en la clasificación etiológica del ictus isquémico. Nuestros objetivos son describir la distribución de los fenotipos A-S-C-O (A: aterotrombótico, S: «small vessel» pequeño vaso, C: cardioembólico, O: otras causas; 1: causa probable, 2: causa posible, 3: enfermedad presente, pero causa improbable), compararlos con la clasificación del Grupo de Estudio de Enfermedades Cerebrovasculares de la Sociedad Española (GEECV/SEN), conocer la concordancia entre ambas clasificaciones y determinar si la clasificación A-S-C-O reduce la proporción de ictus de causa indeterminada. Métodos: Analizamos los pacientes con ictus isquémicos ingresados en nuestra unidad de ictus durante el 2010, clasificados según las clasificaciones GEECV/SEN y A-S-C-O. Resultados: Incluímos 496 pacientes. La proporción de ictus aterotrombóticos y por enfermedad de pequeño vaso según criterios GEECV/SEN fue mayor al porcentaje de ictus aterotrombótico probable (A1) (14,1 vs. 11,9%; p = 0,16) e ictus por enfermedad de pequeño vaso probable (S1) (14,3 vs. 3%; p < 0,001). Los ictus cardioembólicos probables (C1) fueron más frecuentes (22,2 vs. 31%; p < 0,001). No observamos diferencias entre los ictus de causa infrecuente y otras causas probables (O1). Un 53,5% presentó algún grado de ateromatosis (A1, A2 o A3), el 65,5% rasgos de pequeño vaso (S1, S2 o S3) y el 74,9% características cardioembólicas (C1, C2 o C3). Una menor proporción de pacientes se clasificaron como de origen indeterminado al considerar aquellos que no obtuvieron puntuación 1 o 2 en ninguno de los fenotipos A-S-C-O (46,6 vs. 29,2%; p < 0,001). La concordancia entre ambas clasificaciones osciló entre κ < 0,2 (pequeño vaso y S1) y κ > 0,8 (causa infrecuente y O1). Conclusión: Nuestros resultados muestran que las clasificaciones GEECV/SEN y A-S-C-O no son plenamente comparables ni concordantes. La clasificación A-S-C-O aportó información adicional sobre enfermedades coexistentes y permitió reducir la proporción de ictus clasificados como de causa indeterminada (AU)

Introduction: The A-S-C-O classification may be better than other methods for classifying ischaemic stroke by aetiology. Our aims are to describe A-S-C-O phenotype distribution (A: atherosclerosis, S: small vessel disease, C: cardiac source, O: other causes; 1: potential cause, 2: causality uncertain, 3: unlikely to be a direct cause although disease is present) and compare them to the Spanish Society of Neurology‘s Cerebrovascular Disease Study Group (GEECV/SEN) classification. We will also find the degree of concordance between these classification methods and determine whether using the A-S-C-O classification delivers a smaller percentage of strokes of undetermined cause. Methods: We analysed those patients with ischaemic stroke admitted to our stroke unit in 2010 with strokes that were classified according to GEECV/SEN and A-S-C-O criteria. Results: The study included 496 patients. The percentages of strokes caused by atherosclerosis and small vessel disease according to GEECV/SEN criteria were higher than the percentages for potential atherosclerotic stroke (A1) (14.1 vs. 11.9%; P=.16) and potential small vessel stroke (S1) (14.3 vs. 3%;P<.001). Cardioembolic stroke (C1) was more frequent (22.2 vs. 31%; P<.001). No differences between unusual cause of stroke and other potential causes (O1) were observed. Some degree of atherosclerosis was present in 53.5% of patients (A1, A2, or A3); 65.5% showed markers of small vessel disease (S1, S2, or S3), and 74.9% showed signs of cardioembolism (C1, C2, or C3). Fewer patients in the group without scores of 1 or 2 for any of the A-S-C-O phenotypes were identified as having a stroke of undetermined cause (46.6 vs. 29.2%; P<.001). The agreement between the 2 classifications ranged from κ<0.2 (small vessel and S1) to κ>0.8 (unusual causes and O1). Conclusion: Our results show that GEECV/SEN and A-S-C-O classifications are neither fully comparable nor consistent. Using the A-S-C-O classification provided additional information on co-morbidities and delivered a smaller percentage of strokes classified as having an undetermined cause (AU)