A Simplified One-Size-Fits-All Approach to Carotid Stenting.

BACKGROUND: Carotid artery stenosis causes up to 20% of ischemic strokes. Stenting is used as an alternative to endarterectomy in symptomatic patients. Each commercially available stent offers numerous stent diameters/lengths. Most centers thus carefully match each individual stenosis to a specific stent length/diameter stent size. However, this process can be time-consuming and costly while the relative benefit of a custom stent sizing versus one-size-fits-all approach has not been well evaluated yet. We hypothesized that a 'one-size-fits-all' default approach to carotid stenting results in comparable results to a customized approach. METHODS: We conducted a descriptive retrospective cohort study on 154 patients who presented to our academic carotid revascularization clinic with symptomatic carotid artery stenosis who underwent carotid artery stenting for peri- and postprocedural carotid artery stenting complications. The primary outcomes were periprocedural (within 24 hours of the procedure) or postprocedural (within 30 days of the procedure) TIA, stroke, or death. The secondary outcome was the estimated degree of stenosis on follow-up ultrasound performed within 6 months of the procedure. RESULTS: The complication rate within the first 24 hours was 4.5% while that during the first 30 days postprocedure was 6.5%. Age over 80 and degree of stenosis on postprocedural cerebral angiogram were associated with an increased risk of complications. Severe restenosis was reported in 16.8% of patients within 6 months postprocedure. CONCLUSION: Our study suggests that using a simplified, one-size-fits-all, approach to carotid stenting results in safe and effective outcomes, suggesting an alternative to simplify a complex medical procedure.

The Impact of Duty Hour Limits on Sleep Quality of Resident: A Cross-sectional Study.

Objectives: Resident physicians are particularly prone to sleep disturbance due to long shift hours and excessive workload. Despite the numerous measures undertaken to improve their wellbeing, it is still unknown if limiting the work shift duration would improve sleep quality. We sought to compare sleep quality, anxiety, and depression before and after implementing duty hour limits. We also aim to evaluate how satisfaction with life is related to sleep quality, anxiety, and depression. Methods: We used a self-reported questionnaire to obtain data about sleep quality, anxiety, and depression using the Pittsburgh Sleep Quality Index and Patient Health Questionnaire-4 (PHQ-4) scales, respectively. Using data from a previous study, we compared those parameters before and after implementing duty hour reduction across several specialties at King Abdullah University Hospital, Jordan. Furthermore, we investigated residents' life satisfaction using the Satisfaction with Life Scale. Results: One hundred and eighty residents filled the questionnaire (median age = 26.5 years). Males reported higher rates of poor sleep quality while females had higher rates of anxiety and depression. Decreasing the duration of on-call shifts from 32 to 24 hours decreased the prevalence of poor sleep quality from 91.5% to 83.2% (p = 0.038), and smoking rates decreased from 30.4% to 12.5% (p < 0.001). More than six on-calls per month were associated with poorer quality of sleep. Night float shifts significantly decreased rates of moderate and severe PHQ-4 scores (p < 0.001). In addition, 63.3% of residents were satisfied with life. Life satisfaction was associated with enhanced sleep quality and lower PHQ-4 scores (p = 0.007 and p < 0.001, respectively). Conclusions: Optimizing shift scheduling and duration can positively influence rates of sleep quality, anxiety, depression, and smoking. More interventions should be tackled along with duty hour limits to optimize residents' life satisfaction.

Sleep quality and health related problems of shift work among resident physicians: a cross-sectional study.

OBJECTIVES: Shift work is defined as any irregular work schedule that extends beyond the usual 9 am to 5 pm time frame. Evidence from outside medicine suggests that it may be related to detrimental health outcomes. Our objective from this study is to evaluate sleep quality, health risks, and chronic diseases among post-graduate resident physicians who work on rotating shifts at a large tertiary health care center. STUDY DESIGN: A self-reported questionnaire-based cross-sectional study. METHODS: Sleep quality was assessed by Pittsburgh Sleep Quality Index (PSQI) while anxiety and depression were estimated through the four-item patient health questionnaire for anxiety and depression (PHQ-4). Associations between sleep quality and the following: Gender, PHQ-4 stage, year of residency, number of on-calls per month and subjective fatigue; memory impairment; and lack of concentration was investigated. RESULTS: A total of 201 resident physicians participated in the study [60.7% males, median; IQR age: 27 years (26-29). More than one third of subjects were smokers, 41.3% were overweight, and 16.4% were obese. The majority (90%) reported poor sleep quality, 38.3% mild PHQ-4, 21.4% moderate PHQ-4, and 18.9% severe PHQ-4. Residents having six on-calls or more per month had significantly poorer sleep quality (p: 0.03), as well as higher anxiety and depression scores compared to their counterparts. Poor sleep quality was markedly associated with moderate PHQ-4, subjective fatigue, and lack of concentration (p: 0.026, 0.004 and 0.001, respectively). Subjective difficulty with concentration was reported in 86.6% of resident physicians and was significantly higher as the number of on-calls per month is 3 or more. Most residents report subjective fatigue (92.5%) while subjective memory impairment was prevalent in 68.7%. Irritable bowel syndrome was the most prevalent chronic disorder (13%), followed by heartburn or gastrointestinal ulcers and disc prolapse (6% and 3.5%, respectively). CONCLUSIONS: Resident physicians have considerable risk for developing severe diseases. Our findings suggest that several modifications should be undertaken to enhance work facilities, limit working hours, and raise awareness among post-graduate resident physicians.

Nosocomial Infections among Patients with Intracranial Hemorrhage: A Retrospective Data Analysis of Predictors and Outcomes.

OBJECTIVE: Intracranial hemorrhage is a critical medical emergency. Nosocomial infections may promote worse outcomes in these vulnerable patients. This study investigated microbial features, predictors, and clinical outcomes of nosocomial infections among patients with multiple subtypes of intracranial hemorrhage. PATIENTS AND METHODS: We conducted a retrospective cohort study of patients that were hospitalized with intracranial hemorrhage between January 2015 and October 2018, and divided them into two groups based on the development of nosocomial infection. Within the cohort of patients with nosocomial infections, microbiology and resistance patterns were established across multiple sites of infection. Moreover, consequences of nosocomial infection such as mortality and length of hospital stay were determined. RESULTS: A total of 233 cases were identified that met our inclusion and exclusion criteria out of which were 94 cases of nosocomial infection (40.3%) versus 139 cases with no nosocomial infection (59.7%). The most common infections were pneumonia, urinary tract infections, and bacteremia. Resistance accounted for 70.2% of cultures. Multivariable analysis revealed significant association of nosocomial infections with hypertension (OR: 2.62, 95% CI: 1.11-6.16, p = 0.027), hospital LOS (OR: 1.08, 95% CI: 1.05-1.12, p < 0.001), levetiracetam (OR: 3.6, 95% CI: 1.41-0.922, p = 0.007), and GCS category (OR: 5.42, 95% CI: 1.67-17.55, p = 0.005 and OR: 7.63, 95% CI: 2.44-23.87, p < 0.001 for moderate and severe, respectively). Patients with nosocomial infections witnessed a significant increase in the length of hospital stay (23 versus 8 hospital days, p < 0.001). This finding was significant across most types of brain hemorrhage. Mortality was significantly associated with GCS category (OR: 10.1, 95% CI: 4-25.7, p < 0.001) and percutaneous endoscopic gastrostomy tube insertion (OR: 19.6, 95% CI: 4.1-91, p < 0.001). CONCLUSIONS: Collectively, these findings suggest that nosocomial infections are common among patients with intracranial hemorrhage and can be predictable by considering certain risk factors. Future studies are warranted to evaluate the efficacy of implementing infection control strategies or protocols on these patients to achieve better therapeutic outcomes.