Introduction: Decompressive hemicraniectomy has been shown to reduce mortality in malignant middle cerebral artery (MCA) infarction. This procedure has been done for malignant MCA infarction at our institution, a tertiary referral centre, since 2011. We aimed to review the outcomes of patients receiving this procedure based on hospital of origin. Hypothesis: Patients originating outside of a tertiary centre would have worse outcomes and delays in obtaining decompressive hemicraniectomy for malignant MCA infarction. Methods: We retrospectively reviewed the medical records of all patients who underwent decompressive hemicraniectomy for malignant MCA infarction from March 2011 until March 2014. We compared 30-day mortality as well as time to surgery between patients presenting to the tertiary referral centre and patients presenting to peripheral hospitals. We compared 30-day mortality between those patients receiving surgery within 48 hours and those receiving surgery over 48 hours. We also compared the clinical characteristics of the patients in our cohort to data from published trials. Results: Eighteen patients underwent decompressive hemicraniectomy during this period of time. The 30-day mortality rate was 10/18 (55.6%). There was no difference in mortality between those presenting to the tertiary referral centre and those presenting to peripheral centres (3/6 [50%] vs 7/12 [58.3%], p=0.99). There was no difference in time to surgery between those presenting to the tertiary referral centre and those presenting to peripheral hospitals (median 44.2 vs 30.5 h, p=0.3933). There was weak evidence of reduced mortality for those undergoing the procedure within 48 hours of onset (6/14 [42.9%] vs 4/4 [100%], p=0.092). The patients in our cohort had no statistically significant difference in mortality compared to those in the hemicraniectomy trials but did have a longer time to surgery and a greater percentage of males. Conclusions: Mortality rates and time to surgery were comparable regardless of hospital of origin for decompressive hemicraniectomy after malignant MCA infarction.
OBJECTIVE:
To develop an electronic decision support tool for anticoagulation and stroke prevention in patients with atrial fibrillation (AF) and demonstrate its efficacy through a randomized cluster controlled trial.
BACKGROUND:
Despite good evidence of the benefits of anticoagulation in preventing stroke in patients with AF, doctors are often reluctant to prescribe anticoagulation citing fear of patient falls and risk of bleeding.
A recent audit of stroke care in New Zealand revealed that among patients presenting with an acute ischaemic stroke, 40[percnt] had a known history of AF, however, only 24[percnt] of patients with AF were on anti-coagulants. Two audits confirmed the low use of anticoagulation in patients presenting to Wellington Hospital.
While AF is considered a disease of the heart, the end organ damage of stroke falls in the domain of the neurologist. We plan to address the low rates of anticoagulation through an electronic decision support (EDS) tool in order to reduce the rate of stroke.
DESIGN/METHODS:
Medtech is a patient management system used by 95[percnt] of primary care practices in New Zealand. We partnered with Best Practice Advocacy Centre (bpacNZ) and created a fully integrated EDS tool for anticoagulation and AF management.
RESULTS:
The EDS tool delivers prompts, support and guidance to the primary care physician for establishing a patient on anticoagulation whenever AF is identified. We plan a randomised cluster controlled trial, randomising primary care practices to either the intervention arm (EDS tool) or a control arm (current best practice), to prove efficacy of the EDS tool for increasing anticoagulation rates.
CONCLUSIONS:
Given that the existing technology base is well established nationwide, it is expected that this could become a national model which would have significant benefits for patient care and healthcare costs across the country. Disclosure: Dr. Jolliffe has nothing to disclose. Dr. Rosemergy has nothing to disclose. Dr. Lanford has nothing to disclose. Dr. Abernethy has nothing to disclose. Dr. Ranta has nothing to disclose.
EpiNet was established to encourage epilepsy research. EpiNet is used for multicenter cohort studies and investigator-led trials. Physicians must be accredited to recruit patients into trials. Here, we describe the accreditation process for the EpiNet-First trials.Physicians with an interest in epilepsy were invited to assess 30 case scenarios to determine the following: whether patients have epilepsy; the nature of the seizures (generalized, focal); and the etiology. Information was presented in two steps for 23 cases. The EpiNet steering committee determined that 21 cases had epilepsy. The steering committee determined by consensus which responses were acceptable for each case. We chose a subset of 18 cases to accredit investigators for the EpiNet-First trials. We initially focused on 12 cases; to be accredited, investigators could not diagnose epilepsy in any case that the steering committee determined did not have epilepsy. If investigators were not accredited after assessing 12 cases, 6 further cases were considered. When assessing the 18 cases, investigators could be accredited if they diagnosed one of six nonepilepsy patients as having possible epilepsy but could make no other false-positive errors and could make only one error regarding seizure classification.Between December 2013 and December 2014, 189 physicians assessed the 30 cases. Agreement with the steering committee regarding the diagnosis at step 1 ranged from 47% to 100%, and improved when information regarding tests was provided at step 2. One hundred five of the 189 physicians (55%) were accredited for the EpiNet-First trials. The kappa value for diagnosis of epilepsy across all 30 cases for accredited physicians was 0.70.We have established criteria for accrediting physicians using EpiNet. New investigators can be accredited by assessing 18 case scenarios. We encourage physicians with an interest in epilepsy to become EpiNet-accredited and to participate in these investigator-led clinical trials.
Abstract Decompressive hemicraniectomy (DHC) has been shown to reduce mortality in malignant middle cerebral artery (MCA) infarction. Our primary objective was to compare 1‐year mortality between patients receiving DHC for malignant MCA infarction at our institution based on hospital of origin. We retrospectively reviewed the medical records of all patients treated for malignant MCA infarction with DHC at our institution over a 3‐year period. One‐year mortality rates and time to surgery were comparable regardless of whether the patient first attended the tertiary referral centre or a peripheral centre.
A 51-year-old woman with no significant medical history was found collapsed at work having sustained a head strike. She was evaluated at her local hospital. Glasgow Coma Scale was 12 (E3 V3 M6). Pupils were equal and reactive. Eye movements were normal. CT of the brain revealed a large left-sided
We wanted to determine whether adult patients presenting with a seizure to the emergency department (ED) of Wellington Hospital and Hutt Hospital, in the Wellington region, were equally likely to be referred for neurology input.A retrospective review was conducted of 250 consecutive patients presenting with a seizure to the ED of each hospital. Patient electronic records were examined to determine the proportion of patients discussed with the inpatient neurology team and referred to neurology outpatient clinic.Fifty-two per cent of the patients presenting to Wellington Hospital ED with a seizure were referred to neurology, compared to 13.4% of those presenting to Hutt Hospital ED. The proportion of 'first seizure' patients referred to neurology was 63.1% for Wellington Hospital and 9.8% for Hutt Hospital. The difference in referral rates was primarily attributable to the difference in inpatient referrals. Māori were over-represented in the patients presenting to ED with a seizure, compared to their population composition.This study demonstrated unequal referral practices and therefore provision of neurology care for adult seizure patients across the Wellington region, for patients with established epilepsy and those with a first seizure. There were a disproportionately high number of Māori accessing acute seizure care.
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