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IntroductionNeurocritical care focuses on the care of critically ill patients with an acute neurologic disorder and has grown significantly in the past few years. However, there is a lack of data that describe the scope of practice of neurointensivists and epidemiological data on the types of patients and treatments used in neurocritical care units worldwide. To address these issues, we designed a multicenter, international, point-prevalence, cross-sectional, prospective, observational, non-interventional study in the setting of neurocritical care (PRINCE Study).MethodsIn this manuscript, we analyzed data from the initial phase of the study that included registration, hospital, and intensive care unit (ICU) organizations. We present here descriptive statistics to summarize data from the registration case report form. We performed the Kruskal-Wallis test followed by the Dunn procedure to test for differences in practices among world regions.ResultsWe analyzed information submitted by 257 participating sites from 47 countries. The majority of those sites, 119 (46.3%), were in North America, 44 (17.2%) in Europe, 34 (13.3%) in Asia, 9 (3.5%) in the Middle East, 34 (13.3%) in Latin America, and 14 (5.5%) in Oceania. Most ICUs are from academic institutions (73.4%) located in large urban centers (44% > 1 million inhabitants). We found significant differences in hospital and ICU organization, resource allocation, and use of patient management protocols. The highest nursing/patient ratio was in Oceania (100% 1:1). Dedicated Advanced Practiced Providers are mostly present in North America (73.7%) and are uncommon in Oceania (7.7%) and the Middle East (0%). The presence of dedicated respiratory therapist is common in North America (85%), Middle East (85%), and Latin America (84%) but less common in Europe (26%) and Oceania (7.7%). The presence of dedicated pharmacist is highest in North America (89%) and Oceania (85%) and least common in Latin America (38%). The majority of respondents reported having a dedicated neuro-ICU (67% overall; highest in North America: 82%; and lowest in Oceania: 14%).ConclusionThe PRINCE Study results suggest that there is significant variability in the delivery of neurocritical care. The study also shows it is feasible to undertake international collaborations to gather global data about the practice of neurocritical care.

PURPOSE Operational failures are system-level errors in the supply of information, equipment, and materials to health care personnel. We aimed to review and synthesize the research literature to determine how operational failures in primary care affect the work of primary care physicians. METHODS We conducted a critical interpretive synthesis. We searched 7 databases for papers published in English from database inception until October 2017 for primary research of any design that addressed problems interfering with primary care physicians' work. All potentially eligible titles/abstracts were screened by 1 reviewer; 30% were subject to second screening. We conducted an iterative critique, analysis, and synthesis of included studies. RESULTS Our search retrieved 8,544 unique citations. Though no paper explicitly referred to 'operational failures,' we identified 95 papers that conformed to our general definition. The included studies show a gap between what physicians perceived they should be doing and what they were doing, which was strongly linked to operational failures--including those relating to technology, information, and coordination--over which physicians often had limited control. Operational failures actively configured physicians' work by requiring significant compensatory labor to deliver the goals of care. This labor was typically unaccounted for in scheduling or reward systems and had adverse consequences for physician and patient experience. CONCLUSIONS Primary care physicians' efforts to compensate for suboptimal work systems are often concealed, risking an incomplete picture of the work they do and problems they routinely face. Future research must identify which operational failures are highest impact and tractable to improvement. Key words: primary care; organization and administration; organizational efficiency; operations research; review, INTRODUCTION High-quality health care depends on well-functioning operational systems that ensure that what is required to meet patient needs is in the right place at the right time. (1) Operational [...]

Windstorms affecting Europe are among the natural hazards with the largest socio-economic impacts. Therefore, many sectors like society, economy or the insurance industry are highly interested in reliable information on associated impacts and losses. There are different metrics to quantify windstorm-related losses, ranging from simple natural hazard databases over loss indices based on meteorological variables to more complex insurance loss (catastrophe) models. In this study, we compare estimated windstorm losses using the meteorological Loss Index (LI) with losses obtained from the European Windstorm Model of Aon Impact Forecasting. To test the sensitivity of LI to different meteorological input data, we furthermore contrast LI based on the reanalysis dataset ERA5 and its predecessor ERA-Interim. We focus on similarities and differences between the datasets in terms of loss values and storm rank for specific storm events in the common reanalysis period across 11 European countries. Our results reveal higher LI values for ERA5 than for ERA-Interim for all of Europe, coming mostly from a higher spatial resolution in ERA5. The storm ranking is comparable for Western and Central European countries for both reanalyses. Compared to Aon's Impact Forecasting model, LI ERA5 shows comparable storm ranks. However, LI seems to have difficulties in distinguishing between extreme windstorms with high losses and those with only moderate losses. The loss distribution in LI is thus not steep enough and the tail is probably on the short side, yet it is an effective index, precisely because of its simplicity, suitable for estimating the impacts and ranking storm events. [ABSTRACT FROM AUTHOR]

Background: Remote tele-proctoring has been conducted in neuro-endovascular surgery, however, evidence to support its use in the fellowship training is limited. We demonstrate a novel augmented reality tele-proctoring platform to enable a remote attending to guide a fellow. Methods: A consecutive series of neuro-endovascular cases were performed by a neuro-endovascular fellow with remote guidance from an attending surgeon. The fellow and attending were connected using a commercially available cloud-based platform designed to capture and stream up to four live video feeds from a clinical environment to a remote user. In this setting, two video streams were obtained directly from the anteroposterior and lateral cameras on the biplane. Additional video of the operator from a telescopic camera was streamed live to the remote attending surgeon. The attending could provide immediate vocal feedback and also deploy the platform's augmented reality tools to communicate with the fellow in the angiography suite. Results: A total of 10 cases were performed on eight patients utilizing the cloud-based tele-proctoring platform to facilitate instruction. The series included diagnostic angiograms and interventions such as intracranial balloon angioplasty, carotid stenting, and intracranial stenting. All cases were a technical success. No complications or deaths occurred. When compared to similar cohort of 10 cases prior to these which utilized a traditional instruction paradigm; we saw no differences in contrast use (p = 0.38), fluoroscopy time (p = 0.85), or technical success. Conclusions: This study demonstrates successful use of an augmented reality tele-proctoring platform to guide a neuro-endovascular fellow through complex neuro-interventional procedures from a remote setting. [ABSTRACT FROM AUTHOR]

To purchase or authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1552-6569.2007.00225.x Byline: Qaisar A. Shah (1), Alexandros L. Georgiadis (1), M. Fareed K. Suri (1), Gustavo J. Rodriguez (1), Adnan I. Qureshi (1) Keywords: Carotid artery; in-stent restenosis; cutting balloon angioplasty; transluminal angioplasty; carotid stent Abstract: ABSTRACT Percutaneous stenting techniques are becoming more commonly used for treatment of carotid artery disease. One outcome of particular concern is in-stent restenosis. Indications for treatment of in-stent restenosis are not clearly defined. Use of traditional balloon angioplasty with or without stent placement is still considered the first option. Cutting balloon angioplasty has recently been used as an alternative treatment option for revascularization of in-stent restenosis with higher procedural success rates and without the use of additional stents. We report our experience with cutting balloon angioplasty in treating 2 patients with carotid in-stent restonosis, and review previous cases reported in the literature. A total of 16 patients have been treated with cutting balloon angioplasty. Among 11 patients for whom the clinical and angiographic information were available, 63% of patients were asymptomatic at the time of treatment, and more than 90% of patients showed either complete angiographic resolution or residual stenosis of less than 30%. Additional stent placement or angioplasty was required in only half of the patients, and 1 patient had recurrent stenosis. The review suggests that the procedure is safe and effective. Author Affiliation: (1)From the Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, MN (QAS, ALG, MFKS, GJR, AIQ) Article History: Acceptance: Received September 27, 2007, and in revised form September 27, 2007. Accepted for publication November 9, 2007. Article note: Correspondence: Address correspondence to Qaisar A. Shah, MD, University of Minnesota, Department of Neurology, MMC 295, 420 Delaware Street SE Minneapolis, MN 55455. E-mail: qaisarshah@gmail.com

Background: Although problems that impair task completion - known as operational failures - are an important focus of concern in primary care, they have remained little studied.Aim: To quantify the time GPs spend on different activities during clinical sessions; to identify the number of operational failures they encounter; and to characterise the nature of operational failures and their impact for GPs.Design and Setting: Mixed-method triangulation study with 61 GPs in 28 NHS general practices in England from December 2018 to December 2019.Method: Time-motion methods, ethnographic observations, and interviews were used.Results: Time-motion data on 7679 GP tasks during 238 hours of practice in 61 clinical sessions suggested that operational failures were responsible for around 5.0% (95% confidence interval [CI] = 4.5% to 5.4%) of all tasks undertaken by GPs and accounted for 3.9% (95% CI = 3.2% to 4.5%) of clinical time. However, qualitative data showed that time-motion methods, which depend on pre-programmed categories, substantially underestimated operational failures. Qualitative data also enabled further characterisation of operational failures, extending beyond those measured directly in the time-motion data (for example, interruptions, deficits in equipment/supplies, and technology) to include problems linked to GPs' coordination role and weaknesses in work systems and processes. The impacts of operational failures were highly consequential for GPs' experiences of work.Conclusion: GPs experience frequent operational failures, disrupting patient care, impairing experiences of work, and imposing burden in an already pressurised system. This better understanding of the nature and impact of operational failures allows for identification of targets for improvement and indicates the need for coordinated action to support GPs. [ABSTRACT FROM AUTHOR]

Background: Neurocritical care is devoted to the care of critically ill patients with acute neurological or neurosurgical emergencies. There is limited information regarding epidemiological data, disease characteristics, variability of clinical care, and in-hospital mortality of neurocritically ill patients worldwide. We addressed these issues in the Point PRevalence In Neurocritical CarE (PRINCE) study, a prospective, cross-sectional, observational study.Methods: We recruited patients from various intensive care units (ICUs) admitted on a pre-specified date, and the investigators recorded specific clinical care activities they performed on the subjects during their first 7 days of admission or discharge (whichever came first) from their ICUs and at hospital discharge. In this manuscript, we analyzed the final data set of the study that included patient admission characteristics, disease type and severity, ICU resources, ICU and hospital length of stay, and in-hospital mortality. We present descriptive statistics to summarize data from the case report form. We tested differences between geographically grouped data using parametric and nonparametric testing as appropriate. We used a multivariable logistic regression model to evaluate factors associated with in-hospital mortality.Results: We analyzed data from 1545 patients admitted to 147 participating sites from 31 countries of which most were from North America (69%, N = 1063). Globally, there was variability in patient characteristics, admission diagnosis, ICU treatment team and resource allocation, and in-hospital mortality. Seventy-three percent of the participating centers were academic, and the most common admitting diagnosis was subarachnoid hemorrhage (13%). The majority of patients were male (59%), a half of whom had at least two comorbidities, and median Glasgow Coma Scale (GCS) of 13. Factors associated with in-hospital mortality included age (OR 1.03; 95% CI, 1.02 to 1.04); lower GCS (OR 1.20; 95% CI, 1.14 to 1.16 for every point reduction in GCS); pupillary reactivity (OR 1.8; 95% CI, 1.09 to 3.23 for bilateral unreactive pupils); admission source (emergency room versus direct admission [OR 2.2; 95% CI, 1.3 to 3.75]; admission from a general ward versus direct admission [OR 5.85; 95% CI, 2.75 to 12.45; and admission from another ICU versus direct admission [OR 3.34; 95% CI, 1.27 to 8.8]); and the absence of a dedicated neurocritical care unit (NCCU) (OR 1.7; 95% CI, 1.04 to 2.47).Conclusion: PRINCE is the first study to evaluate care patterns of neurocritical patients worldwide. The data suggest that there is a wide variability in clinical care resources and patient characteristics. Neurological severity of illness and the absence of a dedicated NCCU are independent predictors of in-patient mortality. [ABSTRACT FROM AUTHOR]

South America is a subcontinent with 393 million inhabitants with widely distinct countries and diverse ethnicities, cultures, political and societal organizations. The epidemiological transition that accompanied the technological and demographic evolution is happening in South America and leading to a rise in the incidence of neurodegenerative and cardiovascular diseases that now coexist with the still high burden of infectious diseases. South America is also quite heterogeneous regarding the existence of systems of care for the various neurological emergencies, with some countries having well-organized systems for some diseases, while others have no plan of action for the care of patients with acute neurological symptoms. In this article, we discuss the existing systems of care in different countries of South America for the treatment of neurological emergencies, mainly stroke, status epilepticus, and traumatic brain injury. We also will address existing gaps between the current systems and recommendations from the literature to improve the management of such emergencies, as well as strategies on how to solve these disparities. [ABSTRACT FROM AUTHOR]