Thrombolytic Refusal Over Telestroke.

BACKGROUND: Tissue plasminogen activator (tPA) refusal is 4%-6% for acute ischemic stroke (AIS) in the emergency department. Telestroke (TS) has increased the use of tPA for AIS but is accompanied by barriers in communication that can affect tPA consent. We characterized the incidence of tPA refusal in our TS network and its associated reasons. METHODS: Patients with AIS who were offered tPA within 4.5 hours from symptom onset according to American Heart Association guidelines were identified within our Lone Star Stroke Consortium Telestroke Registry from September 2015 to December 2018. We compared baseline characteristics and clinical outcomes between patients who refused tPA and patients who accepted tPA. RESULTS: Among the 1,242 patients who qualified for tPA and were offered treatment, 8% refused tPA. Female and non-Hispanic Black patients and patients with a prior history of stroke were more likely to decline tPA. Patients who refused tPA presented with a lower NIHSS and were associated with a final diagnosis of stroke mimic (odds ratio [OR] 0.23; 95% confidence interval [CI] 0.15-0.36). Good outcome (90-day modified Rankin Scale 0-2) was the same among patients who received tPA and those who refused (OR 0.80; 95% CI 0.42-1.54). The most common reasons for refusal were rapidly improving and mild/nondisabling symptoms and concern for potential side effects. CONCLUSION: tPA refusal over TS is comparable to previously reported rates; there was no difference in outcomes among patients who received tPA compared with those who refused. Sex and racial differences associated with an increased tPA refusal warrant further investigation in efforts to achieve equity/parity in tPA decisions.

Variability and Delay in Telestroke Physician Alert among Spokes in a Telestroke Network: A Need for Metric Benchmarks.

INTRODUCTION: Telestroke has increased access to acute management of ischemic stroke in areas that lack stroke care expertise, yet delays persist in evaluation and treatment. We describe variation in time to alert a telestroke physician of suspected acute ischemic stroke patients potentially eligible for acute stroke therapies among community hospitals in our telestroke network, and explore demographic and spoke-related characteristics associated with delays. METHODS: From our telestroke registry, we identified suspected acute ischemic stroke patients who arrived within 6 hours of symptom onset and underwent video consultation at 1 of 17 community hospitals in our hub-and-spoke network. We compared time between patient arrival to telestroke alert (door-to-page-time) and to tissue plasminogen activator (tPA) administration for eligible patients (door-to-needle-time). We identified factors associated with prolonged metrics. RESULTS: Of 1020 cases between 9/2015 and 3/2017, 47% received tPA. Sixty percent had door-to-page-time more than 15 minutes (median 19.5; IQR, 11-34). Door-to-page-time more than 15 minutes was associated with an 8-fold increase in likelihood of door-to-needle-time more than 60 minutes. Patients with severe stroke experienced faster door-to-page-times. Hospitals with more beds had prolonged door-to-page-time. Full time in-house neurology presence, even when not covering emergent consultations, was associated with faster door-to-page-time over telestroke. Seventy-one percent of patients underwent CT brain prior to the telestroke physician alert; this scenario delayed door-to-page and door-to-needle times. CONCLUSIONS: Door-to-page-time varied considerably among spokes. Awaiting CT scan prior to alerting the telestroke consultant of a stroke code delayed metrics. Telestroke physician alert standards are needed, as are educational initiatives on acute ischemic stroke management and workflow.

Benchmarking Telestroke Proficiency: Page-to-Needle Time Among Neurovascular Fellows and Attendings.

BACKGROUND AND PURPOSE: Formal telestroke training for neurovascular fellows (NVFs) is necessary because of growing use of telestroke technologies in the management of acute ischemic stroke; yet, educational approaches and training benchmarks are not formalized. Time between telestroke consultant page and tissue-type plasminogen activator administration (page-to-needle time, PTNT) can provide an objective measure of proficiency. We compared PTNT between NVFs and neurovascular attendings (NVAs) and evaluated changes in PTNT with experience. METHODS: We identified suspected acute ischemic stroke patients in our telestroke registry from July 2013 to December 2015 who received tissue-type plasminogen activator. Using multivariable quantile regression, we estimated the difference and 95% confidence interval in median PTNT between NVFs and NVAs. We also report the coefficient of change in PTNT over increasing number of telestroke consults. RESULTS: NVFs evaluated 53.7% of 618 tissue-type plasminogen activator cases over telestroke. NVAs had significantly shorter PTNT compared with NVFs, with a difference in median PTNT of -9 minutes (95% confidence interval, -12.3 to -5.7). This difference persisted when adjusted for relative tissue-type plasminogen activator contraindications. For each additional telestroke consult, PTNT decreased by 0.07 minutes for NVFs or NVAs (P=0.02 and <0.01, respectively). CONCLUSIONS: PTNT improves by ≈1 minute for every 14 consults for both NVFs and NVAs. Our findings support the importance of integrating telestroke training into supervised neurovascular fellowships to increase proficiency prior to independent practice and suggest that PTNT can be a benchmark for tracking proficiency.

Proximal Roux-en-y Gastrojejunal Anastomosis with Pyloric Ring Resection Improves Gastric Emptying After Pancreaticoduodenectomy.

BACKGROUND: Delayed gastric emptying (DGE) is a common complication of pancreaticoduodenectomy. We determined the efficiency of a new reconstruction technique, designed to preserve motilin-secreting cells and maximize the utility of their receptors, in reducing the incidence of DGE after pancreaticoduodenectomy. METHODS: From April 2005 to September 2014, 217 consecutive patients underwent pancreaticoduodenectomy at our institution. Nine patients who underwent total pancreatectomy were excluded. We compared outcomes between patients who underwent pancreaticoduodenectomy with resection of the pyloric ring followed by proximal Roux-en-y gastrojejunal anastomosis (group I, n = 90) and patients who underwent standard pancreaticoduodenectomy with the orthotopic reconstruction technique (group II, n = 118). RESULTS: Overall and clinically relevant rates of DGE were significantly lower in group I than in group II (10 and 2.2 % vs. 57 and 24 %, respectively; p < 0.05). Length of hospital stay as a result of DGE was shorter in group I than in group II. In univariate analysis, older age, comorbidities, ASA grade 4, operative time, preoperative diabetes, standard reconstruction technique, and postoperative complications were significant risk factors for DGE. In multivariate analysis, older age, standard technique, and postoperative complications were independent risk factors for DGE. CONCLUSION: Our new reconstruction technique reduces the occurrence of DGE after pancreaticoduodenectomy.

Different causes of referral to ophthalmology emergency room.

BACKGROUND: Eye-related complaints compose approximately 1-6% of complaints of patients referring to general emergency ward around the world. Eye injuries are the most common cause of referral to eye emergency ward. To understand the impact of eye injuries in Iran and to plan preventive strategies, it is important to understand the complete magnitude of the problem with regard to true population-based data and standard reproducible definitions. AIM: The main goal of this study was to identify the major causes of referrals to eye emergency ward in patients with eye-related complaints in an eye referral Hospital in Iran. SETTINGS AND DESIGN: In a cross-sectional study, 3150 patients who referred to Farabi Hospital emergency ward, Tehran, Iran, from January to December 2007 were included in the study and their detailed information were recorded. MATERIALS AND METHODS: The patients' demographic data, medical history and final diagnosis were recorded in a questionnaire. RESULTS: The mean age of patients was 33.2±16.8 years and 2380 patients (75.6%) were males. While 299 patients (9.5%) were referred for non-urgent reasons, work-related injuries were the most common cause of referral (955 patients; 30.3%). In patients referred due to trauma (1950 patients), work-related injuries occurred in 955 patients (49%) and occurred accidentally (by chance) in 819 patients (42%). The majority of patients referred with traumatic injuries were males (1708 patients; 87.6% versus 242 patients; 12.4%). The most common etiologies of eye trauma (1950 patients) were metal filings (814 patients; 41.8%), blunt trauma (338 patients; 17.3%), fireworks (236 patients; 12.1%) and sharp objects (222 patients; 11.4%). Globe injury was diagnosed in 1865 patients (95.7%) of trauma cases. In patients referred due to non-traumatic reason (1200 patients), eye infection occurred in 482 patients (40.2%) and 299 patients (24.9%) were referred for non-urgent reasons. There was little difference between the frequency of non-trauma-related problems among genders (672 male patients; 56% versus 528 female patients; 44%). CONCLUSIONS: This study identified multiple risk factors whose presence significantly increases severity of an eye injury. Male gender, youth and unprotected eyes during high-risk activities such as sports and certain jobs are risk factors for eye injuries. In patients referred due to non-traumatic reasons, males and females are similar. Considerable proportion of non-trauma-related problems was due to eye infection, that one of the most important reasons may be connected to the increasing use of contact lenses in our target population. Thereupon, we need for further educative and preventive interventions at the level of general population.

Epidemiology and sociodemographic aspects of ocular traumatic injuries in Iran.

Although the incidence of ocular trauma has been clearly described in developed countries, few published data are available on the epidemiology and the effects of parameters that can influence the incidence and severity of ocular injuries in Iran. The present study tried to determine epidemiological aspects of ocular traumatic injuries and evaluate their effects on different types of ocular injury. The case series included 1950 consecutive patients with acute ophthalmic trauma presented to the emergency ward of Farabi Hospital in Tehran. Information was collected by interviewing patients and having them fill in a questionnaire. The final diagnosis was made by a medical resident. If there was a difficulty or doubt in diagnosis or classification, confirmation of diagnosis was made by senior faculty. Ocular injuries were classified into globe and non-globe injuries according to the site of injury. Mechanical globe injuries were classified according to Birmingham Eye Trauma Terminology (BETT) into closed and open injuries. The mean age of patients was 28.8 ± 12.8 years; 87.6% were male. The most common causes of injury were work-related (49.0%) and chance events (42.0%). The most frequent ocular injury was globe injury (95.6%), including mechanical (77.6% closed and 5.9% open), chemical (7.6%), photic (2.3%) and thermal (2.2%) injuries. Non-globe injury also occurred in 10.8% of patients; both globe and non-globe injuries occurred in 6.5% of patients. The hospitalization rate in all patients was 8.8%. Previous history of eye trauma was significantly more common in the group with isolated globe injuries (P < 0.001). History of eye trauma is a risk factor for globe injuries and female gender is a risk factor only for non-globe injuries. These two factors may predict future eye injury and increase its risk by 5.2 and 1.6 times, respectively.