Association of Magnet Status With Hospitalization Outcomes for Ischemic Stroke Patients.

BACKGROUND: It is not clear whether Magnet recognition by the American Nurses Credentialing Center (nursing excellence program) is associated with improved patient outcomes. We investigated whether hospitalization in a Magnet hospital is associated with improved outcomes for patients with ischemic stroke. METHODS AND RESULTS: We performed a cohort study of patients with ischemic stroke from 2009 to 2013, who were registered in the New York Statewide Planning and Research Cooperative System database. Propensity-score-adjusted multivariable regression models were used to adjust for known confounders, with mixed effects methods to control for clustering at the facility level. An instrumental variable analysis was used to control for unmeasured confounding and simulate the effect of a randomized trial. During the study period, 176 557 patients were admitted for ischemic stroke, and met the inclusion criteria. Of these, 32 092 (18.2%) were hospitalized in Magnet hospitals, and 144 465 (81.8%) in non-Magnet institutions. Instrumental variable analysis demonstrated that hospitalization in Magnet hospitals was associated with lower case-fatality (adjusted difference, -23.9%; 95% CI, -29.0% to -18.7%), length of stay (adjusted difference, -0.4; 95% CI, -0.8 to -0.1), and rate of discharge to a facility (adjusted difference, -16.5%; 95% CI, -20.0% to -13.0%) in comparison to non-Magnet hospitals. The same associations were present in propensity-score-adjusted mixed effects models. CONCLUSIONS: Using a comprehensive all-payer cohort of patients with ischemic stroke in New York State, we identified an association of treatment in Magnet hospitals with lower case-fatality, discharge to a facility, and length of stay. Further research into the factors contributing to the superiority of Magnet hospitals in stroke care is warranted

New York State: Comparison of Treatment Outcomes for Unruptured Cerebral Aneurysms Using an Instrumental Variable Analysis

Background: There is wide regional variation in the predominant treatment for unruptured cerebral aneurysms. We investigated the association of elective surgical clipping and endovascular coiling with mortality, readmission rate, length of stay, and discharge to rehabilitation. Methods and Results: We performed a cohort study involving patients with unruptured cerebral aneurysms, who underwent surgical clipping or endovascular coiling from 2009 to 2013 and were registered in the Statewide Planning and Research Cooperative System database. An instrumental variable analysis was used to investigate the association of treatment technique with outcomes. Of the 4643 patients undergoing treatment, 3190 (68.7%) underwent coiling, and 1453 (31.3%) underwent clipping. Using an instrumental variable analysis, we did not identify a difference in inpatient mortality (marginal effect, 0.13; 95% CI, −0.30, 0.57), or the rate of 30‐day readmission (marginal effect, −1.84; 95% CI −4.06, −0.37) between the 2 treatment techniques for patients with unruptured cerebral aneurysms. Clipping was associated with a higher rate of discharge to rehabilitation (marginal effect, 2.31; 95% CI 0.21, 4.41), and longer length of stay (β, 2.01; 95% CI 0.85, 3.04). In sensitivity analysis, mixed‐effect regression, and propensity score, adjusted regression models demonstrated identical results. Conclusions: Using a comprehensive all‐payer cohort of patients in New York State with unruptured cerebral aneurysms, we did not identify an association of treatment method with mortality or 30‐day readmission. Clipping was associated with a higher rate of discharge to rehabilitation and longer length of stay

Ευπαθείς ομάδες και χώροι έκτακτων καταλυμάτων κατά τη διαχείριση κρίσης ή καταστροφής. Διαδικασίες, Καλές Πρακτικές.

Η συχνότητα των κρίσεων και καταστροφών που συμβαίνουν ανά τον κόσμο αυξάνεται τα τελευταία χρόνια, με μεγάλες επιπτώσεις στο κοινωνικό σύνολο, στις ανθρώπινες δομές και στο περιβάλλον, ενώ στα άτομα που ανήκουν σε ευπαθείς ομάδες οι επιπτώσεις είναι έτι περισσότερο δυσμενείς λόγω των προκλήσεων που αυτά εξ ορισμού αντιμετωπίζουν. Μεγάλο τμήμα της διαδικασίας αντιμετώπισης μιας καταστροφής, συχνά αποτελεί η καταφυγή και διαμονή του πληγέντος πληθυσμού σε έκτακτα καταλύματα, τα οποία όμως πολλές φορές δεν παρέχουν ένα βιώσιμο περιβάλλον για τα άτομα που ανήκουν σε ευπαθείς ομάδες, με αποτέλεσμα να τους δημιουργούνται περαιτέρω προβλήματα. Για να είναι ομαλή η διαβίωσή τους στα καταλύματα αυτά, απαιτείται είτε ο εξαρχής κατάλληλος σχεδιασμός είτε η εκτέλεση τροποποιήσεων ή βελτιώσεων στις υφιστάμενες δομές, καθώς επίσης και η σχετική εκπαίδευση αλλά και συνεργασία του αρμόδιου προσωπικού. Στο Κεφάλαιο 1 της παρούσας εργασίας γίνεται μια επεξήγηση των βασικών εννοιών και ορισμών που σχετίζονται με τη θεωρία της διαχείρισης κρίσεων και καταστροφών. Στο Κεφάλαιο 2 γίνεται αναφορά στις κατηγορίες των ευπαθών ομάδων, με τα ιδιαιτερότητες και τα χαρακτηριστικά έκαστης. Στο Κεφάλαιο 3 εξετάζονται τα είδη των έκτακτων καταλυμάτων ανά κατηγορίες, ενώ γίνεται επεξήγηση των βασικών τεχνικών προδιαγραφών τους καθώς και της οργάνωσης και του τρόπου λειτουργίας τους. Στο Κεφάλαιο 4 αναλύονται τα ζητήματα που αφορούν τη διαχείριση των ατόμων που ανήκουν σε ευπαθείς ομάδες σε σχέση με τα έκτακτα καταλύματα κατά την αντιμετώπιση κρίσης ή καταστροφής, ομαδοποιημένα ανά τύπο ευπαθούς ομάδας. Στο Κεφάλαιο 5 παρουσιάζονται ζωντανά παραδείγματα πρακτικών λειτουργίας έκτακτων καταλυμάτων ως προς την αντιμετώπιση των ευπαθών ομάδων. Τέλος, στο Κεφάλαιο 6 παρατίθενται κάποια γενικότερα συμπεράσματα και προτάσεις επί του ζητήματος των έκτακτων καταλυμάτων σε σχέση με τις ευπαθείς ομάδες.In recent years, natural and human related disasters have been escalating in scale and frequency, making a heavy impact on people, communities, infrastructures and the environment. People belonging in vulnerable groups are even more affected by the disasters, because of the extra challenges they have to face by definition. Evacuating to emergency shelters and having to live there for a time period, often occupies a large part in crisis or disaster management. The problem here is that in a number of cases these shelters are not suited for or accessible to people belonging in vulnerable groups, which in turn leads them to face even greater problems while also having to cope with the crisis or disaster aftermath. In order to become possible for vulnerable persons to live in accessible and barrier-free shelters, careful and thorough advance planning or alteration making to the current structures is required, as well as suitable personnel training and coordination. In Chapter 1 there is an explanation of the basic meanings related to Disaster and Crisis Management. In Chapter 2 the categories of vulnerable groups, with their special needs and characteristics are presented. The types of emergency shelters per category along with their basic technical specifications and their organization and mode of operation are expanded in Chapter 3. Chapter 4 examines and analyses the issues related to people belonging in vulnerable groups and emergency sheltering during a crisis or a disaster, per category of vulnerable groups. Chapter 5 features real cases and incidents which are presented with regard to people belonging in vulnerable groups and emergency sheltering. Finally, in Chapter 6 conclusions and recommendations that resulted from the analysis of the preceding chapters are suggested

Assessing a 600-mg Loading Dose of Clopidogrel 24 Hours Prior to Pipeline Embolization Device Treatment

Background: Clopidogrel/aspirin antiplatelet therapy routinely is administered 7-10 days before pipeline aneurysm treatment. Our study assessed the safety and efficacy of a 600-mg loading dose of clopidogrel 24 hours before Pipeline Embolization Device (PED) treatment. Methods: In this retrospective cohort study, we included patients treated with PED from October 2010 to May 2016. A total of 39.7% (n = 158) of patients were dispensed a loading dose of 650 mg of aspirin plus at least 600 mg of clopidogrel 24 hours preceding PED deployment, compared to 60.3% (n = 240) of patients who received 81-325 mg of aspirin daily for 10 days with 75 mg of clopidogrel daily preprocedurally. The mean follow-up was 15.8 months (standard deviation [SD] 12.4 months). modified Rankin Scale (mRS) was registered before the discharge and at each follow-up visit. To control confounding, we used multivariable logistic regression and propensity score conditioning. Results: Of 398 patients, the proportion of female patients was ~16.5% (41/240) in both groups and shared the same mean of age ~56.46 years. ~12.2% (mean = 0.09; SD = 0.30) had a subarachnoid hemorrhage. 92% (mean = 0.29; SD = 0.70) from the pretreatment group and 85.7% (mean = 0.44; SD = 0.91) of the bolus group had a mRS ≤2. In multivariate analysis, bolus did not affect the mRS score, P = 0.24. Seven patients had a long-term recurrence, 2 (0.83%; mean = 0.01; SD = 0.10) of which from the pretreatment group. In a multivariable logistic regression, bolus was not associated with a long-term recurrence rate (odds ratio [OR] 1.91; 95% confidence interval [CI] 0.27-13.50; P = 0.52) or with thromboembolic accidents (OR 0.99; 95% CI 0.96-1.03; P = 0.83) nor with hemorrhagic events (OR 1.00; 95% CI 0.97-1.03; P = 0.99). Three patients died: one who received a bolus had an acute subarachnoid hemorrhage. The mean mortality rate was parallel in both groups ~0.25 (SD = 0.16). Bolus was not associated with mortality (OR 1.11; 95% CI 0.26-4.65; P = 0.89). The same associations were present in propensity score-adjusted models. Conclusions: In a cohort receiving PED, a 600-mg loading dose of clopidogrel should be safe and efficacious in those off the standard protocol or showing \u3c30% platelet inhibition before treatment

The Use of Prasugrel and Ticagrelor in Pipeline Flow Diversion

Background: Despite the routine clopidogrel/aspirin anti-platelet therapy, complications like thromboembolism, continue to be encountered with PED. We studied the safety and the efficacy of prasugrel in the management of clopidogrel non-responders treated for intracranial aneurysms. Methods: 437 consecutive neurosurgery patients were identified between January 2011 and May 2016. Patients allergic or having \u3c30% platelet-inhibition with a daily 75mg of clopidogrel were dispensed 10mg of prasugrel daily (n=20) or 90mg of ticagrelor twice daily (n=2). The average follow-up was 15.8 months (SD=12.4 months). Patient clinical well being was evaluated with the modified Rankin Scale (mRS) registered before the discharge and at each follow-up visit. To control confounding we used multivariable mixed-effects logistic regression and propensity score conditioning. Results: 26 of 437(5.9%) patients (mean of age 56.3 years; 62 women [14,2%]) presented with a sub-arachnoid hemorrhage. 1 patient was allergic to clopidogrel and prasugrel simultaneously. All the patients receiving prasugrel (n=22) had a mRS\u3c2 on their latest follow-up visit (mean=0.67; SD=1.15). In a multivariate analysis, clopidogrel did not affect the mRS on last follow-up, p=0.14. Multivariable logistic regression showed that clopidogrel was not associated with an increased long-term recurrence rate (odds ratio[OR], 0.17; 95%Confidence Interval [CI95%], 0.01-2.70; p=0.21) neither with an increased thromboembolic accident rate (OR, 0.46; CI95%, 0.12-1.67; p=0.36) nor with an increased hemorrhagic event rate (OR, 0.39; CI95%,0.91-1.64; p=0.20). None of the patients receiving prasugrel deceased or had a long-term recurrence nor a hemorrhagic event, only 1 patient suffered from mild aphasia subsequent to a thromboembolic event. 3 patients on clopidogrel passed during the study: (2) from acute SAH and (1) from intra-parenchymal hemorrhage. Clopidogrel was not associated with an increased mortality rate (OR, 2.18; CI95%,0.11-43.27; p=0.61). The same associations were present in propensity score adjusted models. Conclusion: In a cohort of patients treated with PED for their intracranial aneurysms, prasugrel (10mg/day) is a safe alternative to clopidogrel resistant, allergic or non-responders

Consistency of Hemoglobin A1c Testing and Cardiovascular Outcomes in Medicare Patients With Diabetes

Background: Annual hemoglobin A1c testing is recommended for patients with diabetes mellitus. However, it is unknown how consistently patients with diabetes mellitus receive hemoglobin A1c testing over time, or whether testing consistency is associated with adverse cardiovascular outcomes. Methods and Results: We identified 1 574 415 Medicare patients (2002–2012) with diabetes mellitus over the age of 65. We followed each patient for a minimum of 3 years to determine their consistency in hemoglobin A1C testing, using 3 categories: low (testing in 0 or 1 of 3 years), medium (testing in 2 of 3 years), and high (testing in all 3 years). In unweighted and inverse propensity‐weighted cohorts, we examined associations between testing consistency and major adverse cardiovascular events, defined as death, myocardial infarction, stroke, amputation, or the need for leg revascularization. Overall, 70.2% of patients received high‐consistency testing, 17.6% of patients received medium‐consistency testing, and 12.2% of patients received low‐consistency testing. When compared to high‐consistency testing, low‐consistency testing was associated with a higher risk of adverse cardiovascular events or death in unweighted analyses (hazard ratio [HR]=1.21; 95% CI, 1.20–1.23; P\u3c0.001), inverse propensity‐weighted analyses (HR=1.16; 95% CI, 1.15–1.17; P\u3c0.001), and weighted analyses limited to patients who had at least 4 physician visits annually (HR=1.15; 95% CI, 1.15–1.16; P\u3c0.001). Less‐consistent testing was associated with worse results for each cardiovascular outcome and in analyses using all years as the exposure. Conclusions: Consistent annual hemoglobin A1c testing is associated with fewer adverse cardiovascular outcomes in this observational cohort of Medicare patients of diabetes mellitus

Sonographic Evaluation of Complications of Extracranial Carotid Artery Interventions

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/142556/1/jum14376_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142556/2/jum14376.pd