Barriers to stroke treatment: The price of long-distance from thrombectomy centers.

BACKGROUND: Endovascular thrombectomy, the preferred treatment for acute large-vessel occlusion stroke, is highly time-dependent. Many patients live far from thrombectomy centers due to large geographical variations in stroke services. This study aimed to explore the consequences of long transport distance on the proportion of thrombectomy-eligible patients who underwent thrombectomy, the clinical outcomes with or without thrombectomy, the timelines for patients transported, and the diagnostic accuracy of large-vessel occlusion in primary stroke centers. METHODS: We conducted a retrospective observational study in a county with only primary stroke centers, ∼ 300 km from the nearest thrombectomy center. All stroke patients admitted over a year were retrieved from the Norwegian Stroke Registry. A neuroradiologist identified all computed tomography images with large-vessel occlusions. A panel determined whether these patients had a corresponding clinical indication for thrombectomy. RESULTS: A total of 50% of the eligible patients did not receive thrombectomy. These patients had a significantly higher risk of severe disability or death compared to the patients who underwent thrombectomy. The median time from computed tomography imaging at the primary stroke center to arrival at the thrombectomy center was over 3 hours. Additionally, 30% of the large-vessel occlusions were initially undiagnosed, and half of these patients had a corresponding clinical indication for thrombectomy. CONCLUSIONS: In a county with a long transport distance to a thrombectomy center, a high proportion of eligible patients did not undergo thrombectomy, negatively impacting clinical outcomes. The transport time was considerable. A high rate of large-vessel occlusions was initially not diagnosed.

Virtual reality simulation training in stroke thrombectomy centers with limited patient volume-Simulator performance and patient outcome.

BACKGROUND: Virtual reality simulation training may improve the technical skills of interventional radiologists when establishing endovascular thrombectomy at limited-volume stroke centers. The aim of this study was to investigate whether the technical thrombectomy performance of interventional radiologists improved after a defined virtual reality simulator training period. As part of the quality surveillance of clinical practice, we also assessed patient outcomes and thrombectomy quality indicators at the participating centers. METHODS: Interventional radiologists and radiology residents from three thrombectomy-capable stroke centers participated in a five months thrombectomy skill-training curriculum on a virtual reality simulator. The simulator automatically registered procedure time, the number of predefined steps that were correctly executed, handling errors, contrast volume, fluoroscopy time, and radiation dose exposure. The design was a before-after study. Two simulated thrombectomy cases were used as pretest and posttest cases, while seven other cases were used for training. Utilizing the Norwegian Stroke Register, we investigated clinical results in thrombectomy during the study period. RESULTS: Nineteen interventional radiologists and radiology residents participated in the study. The improvement between pretest and posttest cases was statistically significant for all outcome measures in both simulated cases, except for the contrast volume used in one case. Clinical patient outcomes in all three centers were well within the recommendations from multi-society consensus guidelines. CONCLUSION: Performance on the virtual reality simulator improved after training. Virtual reality simulation may improve the learning curve for interventional radiologists in limited-volume thrombectomy centers. No correlation alleged, the clinical data indicates that the centers studied performed thrombectomy in accordance with guideline-recommended standards.

Maintaining immobilization devices on trauma patients during chest and pelvic X-ray: a feasibility study.

BACKGROUND: Most trauma systems and traumatic spinal injury guidelines mandate spinal stabilization from the site of injury to a radiological confirmation or refutal of spinal injury. Vacuum mattresses have been advocated for patients in need of prehospital spinal stabilization. PURPOSE: To investigate the effect of different vacuum mattresses on standard resuscitation bay conventional radiography of chest and pelvis, especially regarding artefacts. MATERIAL AND METHODS: We used a mobile X-ray machine to perform chest and pelvic conventional radiography on an anthropomorphic whole-body phantom with a trauma transfer board, three different vacuum mattresses, and without any stabilization device. The vacuum mattresses were investigated in activated, deactivated, and stretched after deactivated states. Two radiologists assessed the artefacts independently. Agreement was measured using kappa coefficient. RESULTS: All radiographs were of good technical quality and fully diagnostic. With the exception of one disagreed occurrence, artefacts were seen to hamper clinical judgment exclusively with activated vacuum mattresses. There was substantial agreement on artefact assessment. The observed agreement was 0.82 with a kappa coefficient of 0.71. The first vacuum mattress caused no artefacts hampering with clinical judgment. CONCLUSION: Our study concludes that it is feasible to maintain some vacuum mattresses through resuscitation bay conventional radiography of chest and pelvis. They do not result in artefacts hampering with clinical judgment. Our vacuum mattress No. 1 is recommendable for this purpose. Together with our previous findings our present results indicate that some vacuum mattresses may be used throughout the initial resuscitation bay assessment and CT examination.

Maintaining immobilisation devices on trauma patients during CT: a feasibility study.

BACKGROUND: To reduce the possibility of secondary deterioration of spinal injuries, it is desirable to maintain the spinal immobilisation that is applied in the prehospital setting throughout computed tomography (CT) scanning. A previous study found that metallic components within the inflation valve of the vacuum mattresses caused CT artefacts. The aim of our study was to investigate the effect of vacuum mattresses with plastic valves on CT artefacts, the radiation dose, and noise compared to a trauma transfer board and the spine boards currently used in our trauma system. METHODS: We scanned an anthropomorphic whole body phantom with different immobilisation devices on a 128-slice CT scanner using the standard polytrauma CT-protocol at our institution. The phantom was scanned without any immobilisation device and with three different vacuum mattresses, two spine boards, and one trauma transfer board. Two radiologists independently assessed the artefacts. Agreement between the two radiologists was measured using the kappa coefficient. The radiation dose and noise were assessed. RESULTS: One spine board produced major artefacts due to its metal components. One of the vacuum mattresses resulted in artefacts that impaired clinical judgement. Otherwise, the artefacts predominantly did not impede clinical judgement and were mainly subtle. One of the vacuum mattresses resulted in no artefacts that affected clinical judgement. The overall inter-rater agreement was substantial (0.86, kappa 0.77). We did not observe any artefacts due to plastic valves. The mean CT radiation dose was slightly higher for two of the devices in the head series than that for the trauma transfer board, used as the standard in our system. Only marginal differences were noted for the other devices and series. Small differences in image noise were found between the devices. CONCLUSIONS: Our results indicate that it is feasible to maintain some vacuum mattresses with plastic valves on trauma patients during CT scanning. The tested mattresses did not result in a considerably increased radiation dose or artefacts that hampered clinical judgement. One of the tested vacuum mattresses produced no artefacts that hampered clinical judgement whatsoever.

[Surveillance after curative resection for colorectal cancer]. / Oppfølging etter kurativ kirurgi for kolorektal kreft.

BACKGROUND: Colorectal cancer is one of the most frequent cancers in the Western world. Systematic surveillance after curative resection is common practice in Norway. The article presents the scientific grounds for surveillance in general, and for the Norwegian guidelines in particular. MATERIAL AND METHOD: The basis for the study is literature on updated meta-analyses, randomized studies and reviews from 2002 to April 2007 (retrieved from Medline), and an evaluation of own experience with the national guidelines for follow-up. RESULTS AND INTERPRETATION: Meta-analyses indicate better overall survival with systematic surveillance after curative resection for colorectal cancer, but the scientific evidence remains uncertain. Clinical practice varies from the setup in randomized trials and direct comparison is difficult. The exact factors associated with better survival remain unclear. The Norwegian surveillance routines contribute to diagnosing about 10 % of all patients with recurrent disease while they are still asymptomatic and amenable to secondary curative surgery. Systematic surveillance after curative resection for colorectal cancer is time-consuming and costly, and secondary curative surgery is only possible in a small proportion of the patients. Realistic and adequate information on what the surveillance can offer is an important part of optimal care. Several large ongoing international studies will shed new light on the usefulness of systematic surveillance.

Diagnostic accuracy of serum-carcinoembryonic antigen in recurrent colorectal cancer: a receiver operating characteristic curve analysis.

BACKGROUND: Serial measurements of carcinoembryonic antigen (CEA) are frequently used in the follow-up after colorectal cancer (CRC), but its usefulness remains debatable. Choosing the appropriate cut-off point is crucial to the diagnostic accuracy (DA) of continuous test variables. Receiver operating characteristic curve (ROC) analysis is the appropriate statistical method for this purpose, but has not been applied in previous studies. METHODS: One hundred ninety-four consecutive patients surgically treated with curative intent for CRC between July 1996 and June 1999 had systematic follow-up for five years. Follow-up included imaging, coloscopy and serial CEA measurements. Complete data including CEA measurements were available from 153 patients. ROC analysis of CEA was done with regard to detection of recurrent disease. RESULTS: Depending on the chosen cut-off value of CEA, DA varied widely within the normal range (CEA 4 U/ml provided the highest sensitivity (0.78) and specificity (0.91), compared to a sensitivity and specificity at the upper normal range (CEA = 10 U/ml) of 0.51 and 0.99, respectively. Thirty-three patients (24%) developed recurrence. Among 11 (5%) asymptomatic patients diagnosed by elevated CEA levels, only two patients (1.5%) were amenable to secondary curative surgery. A threefold increase of CEA in an individual patient had the same DA as the best cut-off value (>4 U/ml). CONCLUSIONS: Diagnostic accuracy of CEA in follow-up after curative surgery for CRC is influenced by the chosen cut-off value. A threefold increase of CEA may indicate recurrent disease. The value of serial measurement of CEA was limited.