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The severe acute respiratory coronavirus virus 2 (SARS-CoV-2) delta variant is highly transmissible, and current vaccines may have reduced effectiveness in preventing symptomatic infection. Using epidemiological and genomic analyses, we investigated an outbreak of the variant in an acute-care setting among partially and fully vaccinated individuals. Effective outbreak control was achieved using standard measures.
Although intravenous thrombolysis increases the probability of a good
functional outcome in carefully selected patients with acute ischemic
stroke, a substantial proportion of patients who receive thrombolysis do not
have a good outcome. Several recent trials of mechanical thrombectomy appear
to indicate that this treatment may be superior to thrombolysis. We
therefore conducted a systematic review and meta-analysis to evaluate the
clinical effectiveness and safety of new-generation mechanical thrombectomy
devices with intravenous thrombolysis (if eligible) compared with
intravenous thrombolysis (if eligible) in patients with acute ischemic
stroke caused by a proximal intracranial occlusion. We systematically
searched seven databases for randomized controlled trials published between
January 2005 and March 2015 comparing stent retrievers or thromboaspiration
devices with best medical therapy (with or without intravenous thrombolysis)
in adults with acute ischemic stroke. We assessed risk of bias and overall
quality of the included trials. We combined the data using a fixed or random
effects meta-analysis, where appropriate. We identified 1579 studies; of
these, we evaluated 122 full-text papers and included five randomized
control trials (n=1287). Compared with patients treated medically, patients
who received mechanical thrombectomy were more likely to be functionally
independent as measured by a modified Rankin score of 0-2 (odds ratio, 2.39;
95% confidence interval, 1.88-3.04; I2=0%). This finding was
robust to subgroup analysis. Mortality and symptomatic intracerebral
hemorrhage were not significantly different between the two groups.
Mechanical thrombectomy significantly improves functional independence in
appropriately selected patients with acute ischemic stroke.
Background: Transient ischemic attack (TIA) and minor stroke are associated with
a substantial risk of subsequent stroke; however, there is uncertainty about
whether such patients require admission to hospital for their initial
management. We used data from a clinical stroke registry to determine the
frequency and predictors of hospitalization for TIA or minor stroke across
the province of Ontario, Canada. Methods: The Ontario Stroke Registry collects information on a
population-based sample of all patients seen in the emergency department
with acute stroke or TIA in Ontario. We identified patients with minor
ischemic stroke or TIA included in the registry between April 1, 2008, and
March 31, 2011, and used multivariable analyses to evaluate predictors of
hospitalization. Results: Our study sample included 8540 patients with minor ischemic stroke
or TIA, 47.2% of whom were admitted to hospital, with a range of 37.6% to
70.3% across Ontario’s 14 local health integration network regions. Key
predictors of admission were preadmission disability, vascular risk factors,
presentation with weakness, speech disturbance or prolonged/persistent
symptoms, arrival by ambulance, and presentation on a weekend or during
periods of emergency department overcrowding. Conclusions: More than one-half of patients with minor stroke or TIA were not
admitted to the hospital, and there were wide regional variations in
admission patterns. Additional work is needed to provide guidance to health
care workers around when to admit such patients and to determine whether
discharged patients are receiving appropriate follow-up care.
Background: There is strong evidence that clinical outcomes are improved for stroke patients admitted to specialized Stroke Units. The Toronto Western Hospital (TWH) created a Neurovascular Unit (NVU) using resources from General Internal Medicine, Neurology, and Neurosurgery for patients with stroke and acute neurovascular conditions. Under resource-constrained conditions, the operational and economic impacts of the Neurovascular Unit were unknown. Methods: Retrospective patient-level data was studied from two years prior and one year post NVU implementation. Descriptive statistical analysis and non-parametric testing were conducted on the acute length of stay (LOS), alternate level of care LOS, total cost per bed-day and per visit, and patient flow within each medical service and hospital wide. Results: The median acute LOS per hospitalization for NVU-eligible patients decreased significantly (p=0.001). For Neurology patients, mean acute LOS decreased from 9.1 days pre-Neurovascular Unit to 7.6 days post and median acute LOS decreased from 6 to 5 days (p=0.002); however, mean alternate level of care LOS per visit more than doubled (from 1.6 to 4.1 days, p=0.001). For the Neurology service, the mean cost per visit decreased by $945, representing a 5% reduction (p=0.042) and the mean cost per bed-day decreased by $233, or 12.5% (p=0.026). Hospital wide, a saving of over C$450 000 was achieved. Conclusions: During the first year of operation, the NVU at TWH achieved decreased acute LOS per visit and lowered the total hospitalization cost per year for NVU-eligible patients. Addressing the issue of increased alternate level of care LOS could result in additional efficiencies.
Hyperglycemia is noted in up to 60% of stroke patients. Practice guidelines recommend glucose monitoring following stroke but provide few management recommendations. We examined physician care practices for glucose management in stroke patients.
Emergency physicians, family physicians, general internists, intensive care specialists and neurologists in Ontario comprised the study population. A mailed, self-administered survey inquired about glucose management practices. Proportions of responses for survey questions were determined. Chi-square analysis was used for comparing physician groups.
Surveys were mailed to 2,280 physicians; 26.8% returned surveys. There were 278 respondents who reported providing stroke patient care. For physicians treating glucose in stroke patients, 16.6% targeted glucose 4.0-6.0 mmol/l, 52% targeted 6.1-8.0 mmol/l, 13.6% targeted 8.1-12.0 mmol/l, 0.8% targeted 12.1-15.0 mmol/l, and 7.5% were unsure. Comparing specialties, 32% of intensivists, 17.5% of neurologists, 13% of general internists, 14% of emergency physicians, and 0% of family physicians reported targeting 4.0-6.0 mmol/l (p=0.026). Overall, 44% reported aiming for target glucose within 12 hours and 77% within 24 hours from hospital presentation. Intensive care specialists treated glucose most aggressively, including 20% treating, with insulin infusion, patients with no diabetes and initial glucose 6.0-8.0 mmol/l. Emergency physicians were most conservative when treating glucose in stroke patients.
There is variability in the aggressiveness of glucose management in stroke patients by different physician specialty groups, reflecting the lack of evidence available to guide hyperglycemia management in this setting. These results highlight an important gap in knowledge and recommendations for stroke patient care that must be addressed to ensure optimal patient outcomes.