Impact of Direct Admission Versus Interfacility Transfer on Endovascular Treatment Outcomes for Acute Ischemic Stroke: Systematic Review and Meta-Analysis.

BACKGROUND: Mechanical thrombectomy is a proven treatment for large-vessel ischemic stroke with improved functional outcomes compared with intravenous thrombolytics. Access to thrombectomy-capable sites varies greatly by geography, often necessitating interhospital transfer of patients who first present to hospitals unable to provide thrombectomy. The purpose of this meta-analysis was to examine the impact of interhospital transportation on patient outcomes to better inform recommendations for prehospital protocols. METHODS: A meta-analysis was performed following systematic literature searches. Outcomes of interest included successful reperfusion, symptomatic intracranial hemorrhage, 90-day modified Rankin Scale score 0-2, 90-day mortality, onset-to-puncture times, and door-to-puncture times. RESULTS: Pooled analysis comprised >27,000 patients. Door-to-puncture time was 35.6 minutes shorter among transferred patients; however, symptom onset-to-puncture time was 91.6 minutes longer. Rate of reperfusion or symptomatic intracranial hemorrhage as well as 90-day mortality did not differ significantly between transferred and directly admitted patients. While the proportion of patients achieving good functional outcome at 90 days with modified Rankin Scale score 0-2 did not differ by admission type, when modified Rankin Scale score was narrowed to 0-1, direct transport showed 20% greater probability of achieving excellent functional outcome (P < 0.001). CONCLUSIONS: This meta-analysis represents the largest pooled population examined to date to assess how interfacility transportation to thrombectomy-capable sites affects patient outcomes. Our results indicate that direct admission is a significant predictor of excellent functional outcome. The findings presented here can be used to better inform quality improvement projects to streamline access to facilities providing endovascular mechanical thrombectomy capabilities.

Trends in Endovascular Mechanical Thrombectomy in Treatment of Acute Ischemic Stroke in the United States.

BACKGROUND: Numerous randomized controlled trials have shown that endovascular mechanical thrombectomy (MT) is an effective treatment for large vessel ischemic stroke. This study examines variation in rates of MT across the United States by geographic region and urban-rural areas to identify utilization disparities. METHODS: Data from the Global Burden of Disease Collaborative Network were used to determine acute ischemic stroke (AIS) incidence by state for 2016. The 2016 National Inpatient Sample was accessed to identify patients who underwent MT and patients who were diagnosed with cerebral infarct due to thrombosis or embolism of anterior circulation arteries representing the AIS population of interest. National Inpatient Sample data were used to create national weighted estimates of the size of subject populations, age at admission, length of stay, and discharge status. RESULTS: In the United States, approximately 13,010 mechanical thrombectomies were performed in 2016, representing 3.1% of the AIS population. Proportions of patients undergoing MT were highest in large central metropolitan areas and lowest in rural settings when compared with the national estimate. East North Central and West South Central regions had significantly lower proportions of patients treated with MT. Discharge destinations, a proxy for clinical outcome, differed significantly by region and urban-rural designation. CONCLUSIONS: The number of MTs performed in 2016 increased approximately 1.3 times from 2015. Considering that 10%-17% of patients with AIS may be MT-eligible, current rates of MT are low across all regions, but the most pronounced disparities and poorer clinical outcomes occur in rural areas, particularly in the Northeast/Southwest regions of the Midwest.

Modeling cystic fibrosis disease progression in patients with the rare CFTR mutation P67L.

BACKGROUND: The progression of cystic fibrosis (CF) in patients with the rare mutation P67L was examined to determine if it induced a milder form of CF compared to the common severe ΔF508 mutation. METHODS: Parameters of lung function, level of bacterial infection, nutritional status and hospitalization were used to represent CF progression. Age at diagnosis and pancreatic status were used to assess CF presentation. Analysis of data from the CF Canada Registry collected over a 15-year period included 266 ΔF508/ΔF508 homozygote patients from CF clinics in Atlantic Canada and 26 compound heterozygote patients with the rare P67L mutation from clinics across Canada. RESULTS: Late age at diagnosis, high incidence of pancreatic sufficiency, maintained Body Mass Index (BMI) with age, delayed life-threatening bacterial infection, and fewer days in hospital were observed for P67L heterozygote patients included in this study. Although the decline of lung function did not differ from ΔF508 homozygotes, the fact that a greater proportion of P67L heterozygotes live to an older age suggests that lung function is not the primary factor determining CF progression for P67L heterozygote patients. CONCLUSION: The P67L mutation is associated with a mild disease, even when combined with the severe ΔF508 mutation.