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Background: Although geographical differences in treatment and outcomes after stroke have been described, we lack evidence on differences in the costs of treatment between urban and nonurban regions. Additionally, it is unclear whether greater costs in one setting are justified given the outcomes achieved. We aimed to compare costs and quality-adjusted life years in people with stroke admitted to urban and nonurban hospitals in New Zealand. Methods: Observational study of patients with stroke admitted to the 28 New Zealand acute stroke hospitals (10 in urban areas) recruited between May and October 2018. Data were collected up to 12 months poststroke including treatments in hospital, inpatient rehabilitation, other health service utilization, aged residential care, productivity, and health-related quality of life. Costs in New Zealand dollars were estimated from a societal perspective and assigned to the initial hospital that patients presented to. Unit prices for 2018 were obtained from government and hospital sources. Multivariable regression analyses were conducted when assessing differences between groups. Results: Of 1510 patients (median age 78 years, 48% female), 607 presented to nonurban and 903 to urban hospitals. Mean hospital costs were greater in urban than nonurban hospitals ($13 191 versus $11 635, P =0.002), as were total costs to 12 months ($22 381 versus $17 217, P P Conclusions: Better outcomes following initial presentation to urban hospitals were associated with greater costs compared to nonurban hospitals. These findings may inform greater targeted expenditure in some nonurban hospitals to improve access to treatment and optimize outcomes.

Background: Endovascular thrombectomy (EVT) access in remote areas is limited. Preliminary data suggest that long distance transfers for EVT may be beneficial; however, the magnitude and best imaging strategy at the referring center remains uncertain. We hypothesized that patients transferred >300 miles would benefit from EVT, achieving rates of functional independence (modified Rankin Scale [mRS] score of 0–2) at 3 months similar to those patients treated at the comprehensive stroke center in the randomized EVT extended window trials and that the selection of patients with computed tomography perfusion (CTP) at the referring site would be associated with ordinal shift toward better outcomes on the mRS. Methods: This is a retrospective analysis of patients transferred from 31 referring hospitals >300 miles (measured by the most direct road distance) to 9 comprehensive stroke centers in Australia and New Zealand for EVT consideration (April 2016 through May 2021). Results: There were 131 patients; the median age was 64 [53–74] years and the median baseline National Institutes of Health Stroke Scale score was 16 [12–22]. At baseline, 79 patients (60.3%) had noncontrast CT+CT angiography, 52 (39.7%) also had CTP. At the comprehensive stroke center, 114 (87%) patients underwent cerebral angiography, and 96 (73.3%) proceeded to EVT. At 3 months, 62 patients (48.4%) had an mRS score of 0 to 2 and 81 (63.3%) mRS score of 0 to 3. CTP selection at the referring site was not associated with better ordinal scores on the mRS at 3 months (mRS median of 2 [1–3] versus 3 [1–6] in the patients selected with noncontrast CT+CT angiography, P =0.1). Nevertheless, patients selected with CTP were less likely to have an mRS score of 5 to 6 (odds ratio 0.03 [0.01–0.19]; P Conclusions: In selected patients transferred >300 miles, there was a benefit for EVT, with outcomes similar to those treated in the comprehensive stroke center in the EVT extended window trials. Remote hospital CTP selection was not associated with ordinal mRS improvement, but was associated with fewer very poor 3-month outcomes.

Limited data guide the selection of patients with large vessel occlusion ischaemic stroke who may benefit from referral to a distant tertiary centre for mechanical thrombectomy (MT). We aimed to characterize this population, describe clinical outcomes and develop a screening system to identify patients most likely to benfit from delayed mechanical thrombectomy (MT).We undertook a retrospective cohort analysis enrolling patients transferred from regional sites to one of two MT comprehensive stroke units with a time from non-contrast computed tomography (NCCT) of the brain to reperfusion of 4 h or more. We describe Alberta Stroke Programme Early Computed Tomography Score (ASPECTS), National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) in our patients and compare these patients to those in extended-time-window trials. Lastly, we developed and validated a scoring model to help clinicians identify appropriate patients based on variables associated with poor outcomes.We included 563 patients, 46% of whom received thrombolysis; the median (interquartile range [IQR]) ASPECTS was 8 (7-10) and the median (IQR) NIHSS score was 16 (11-20). The median (IQR) symptom to mechanical reperfusion time was 390 (300-580) min. Eight patients (1%) had a symptomatic haemorrhage. We achieved good clinical outcome (defined as mRS score ≤2) in 299 patients (54%). Age, diabetes, NIHSS score and ASPECTS were used to create a weighted scoring system with a validated area under the curve of 0.83 (95% confidence interval 0.74-0.92).Our study shows, in highly selected patients, that delayed MT many hours after baseline NCCT is associated with good clinical outcomes. However, older patients with diabetes, high NIHSS score and low ASPECTS may not benefit from transfer to a hub centre many hours away for MT in this model of care.

A primary focus among colleges implementing student success reforms has been to increase overall rates of credential completion and to reduce racial and socioeconomic equity gaps in completion rates. The focus on general completion may overlook inequities in the type of program students complete, which is particularly significant given the wide variety of credentials offered at community colleges—from short-term certificates to transfer-oriented associate degrees that may lead to bachelor’s and graduate degree programs—and the resulting variation in labor market returns among completers. This study examines racial/ethnic stratification among community college students as they enter and progress through different programs leading to higher- and lower-paying jobs. The authors develop a discrete-time survival analysis using longitudinal enrollment and transcript data on first-time-in-college, credential-seeking community college students from a state with more than 20 community colleges. They track student enrollment, completion, and transfer for up to nine years and examine when equity gaps in completion emerge. They also measure the student achievement of academic milestones (such as levels of credit accrual) along educational pathways that are associated with higher rates of credential completion and transfer over the long term. Results suggest that a significant gap in the likelihood of bachelor’s degree completion between Black and White students emerges more episodically, while the gap between Hispanic and White students develops earlier and remains more consistent over time. Results also suggest that while all students generally benefit from the attainment of academic milestones, such as gaining credit momentum or completing pre-transfer associate degrees, doing so disproportionately benefits Black and Hispanic students.

The benefit of combined treatment with intravenous thrombolysis before endovascular thrombectomy in patients with acute ischaemic stroke caused by large vessel occlusion remains unclear. We hypothesised that the clinical outcomes of patients with stroke with large vessel occlusion treated with direct endovascular thrombectomy within 4·5 h would be non-inferior compared with the outcomes of those treated with standard bridging therapy (intravenous thrombolysis before endovascular thrombectomy).DIRECT-SAFE was an international, multicentre, prospective, randomised, open-label, blinded-endpoint trial. Adult patients with stroke and large vessel occlusion in the intracranial internal carotid artery, middle cerebral artery (M1 or M2), or basilar artery, confirmed by non-contrast CT and vascular imaging, and who presented within 4·5 h of stroke onset were recruited from 25 acute-care hospitals in Australia, New Zealand, China, and Vietnam. Eligible patients were randomly assigned (1:1) via a web-based, computer-generated randomisation procedure stratified by site of baseline arterial occlusion and by geographic region to direct endovascular thrombectomy or bridging therapy. Patients assigned to bridging therapy received intravenous thrombolytic (alteplase or tenecteplase) as per standard care at each site; endovascular thrombectomy was also per standard of care, using the Trevo device (Stryker Neurovascular, Fremont, CA, USA) as first-line intervention. Personnel assessing outcomes were masked to group allocation; patients and treating physicians were not. The primary efficacy endpoint was functional independence defined as modified Rankin Scale score 0-2 or return to baseline at 90 days, with a non-inferiority margin of -0·1, analysed by intention to treat (including all randomly assigned and consenting patients) and per protocol. The intention-to-treat population was included in the safety analyses. The trial is registered with ClinicalTrials.gov, NCT03494920, and is closed to new participants.Between June 2, 2018, and July 8, 2021, 295 patients were randomly assigned to direct endovascular thrombectomy (n=148) or bridging therapy (n=147). Functional independence occurred in 80 (55%) of 146 patients in the direct thrombectomy group and 89 (61%) of 147 patients in the bridging therapy group (intention-to-treat risk difference -0·051, two-sided 95% CI -0·160 to 0·059; per-protocol risk difference -0·062, two-sided 95% CI -0·173 to 0·049). Safety outcomes were similar between groups, with symptomatic intracerebral haemorrhage occurring in two (1%) of 146 patients in the direct group and one (1%) of 147 patients in the bridging group (adjusted odds ratio 1·70, 95% CI 0·22-13·04) and death in 22 (15%) of 146 patients in the direct group and 24 (16%) of 147 patients in the bridging group (adjusted odds ratio 0·92, 95% CI 0·46-1·84).We did not show non-inferiority of direct endovascular thrombectomy compared with bridging therapy. The additional information from our study should inform guidelines to recommend bridging therapy as standard treatment.Australian National Health and Medical Research Council and Stryker USA.

It is important to understand how consumers (person with stroke/family member/carer) and health workers perceive stroke care services.Consumers and health workers from across New Zealand were surveyed on perceptions of stroke care, access barriers, and views on service centralisation. Quantitative data were summarised using descriptive statistics whilst thematic analysis was used for free-text answers.Of 149 consumers and 79 health workers invited to complete a survey, 53 consumers (36.5%) and 41 health workers (51.8%) responded. Overall, 40/46 (87%) consumers rated stroke care as 'good/excellent' compared to 24/41 (58.6%) health workers. Approximately 72% of consumers preferred to transfer to a specialised hospital. We identified three major themes related to perceptions of stroke care: 1) 'variability in care by stage of treatment'; 2) 'impact of communication by health workers on care experience'; and 3) 'inadequate post-acute services for younger patients'. Four access barrier themes were identified: 1) 'geographic inequities'; 2) 'knowing what is available'; 3) 'knowledge about stroke and available services'; and 4) 'healthcare system factors'.Perceptions of stroke care differed between consumers and health workers, highlighting the importance of involving both in service co-design. Improving communication, post-hospital follow-up, and geographic equity are key areas for improvement.Implications for rehabilitationProvision of detailed information on stroke recovery and available services in the community is recommended.Improvements in the delivery of post-hospital stroke care are required to optimise stroke care, with options including routine phone follow up appointments and wider development of early supported discharge services.Stroke rehabilitation services should continue to be delivered 'close to home' to allow community integration.Telehealth is a likely enabler to allow specialist urban clinicians to support non-urban clinicians, as well as increasing the availability and access of community rehabilitation.

This article documents the patterns of White-Black and White-Hispanic enrollment gaps in Advanced Placement (AP) and Dual Enrollment (DE) programs across thousands of school districts in the United States by merging several data sources. We show that the vast majority of districts have racial enrollment gaps in both programs, with wider gaps in AP than DE. Results from fractional regression models indicate that geographic variations in these gaps can be explained by both local and state factors. We also find that district-level resources and state policies that provide greater access to AP and DE are also associated with wider racial enrollment gaps, implying that greater resources may engender racial disparity without adequate efforts to provide equitable access and support for minority students.

Cell and gene therapies are demonstrating clinical efficacy, but prohibitive product costs and operational complexity bottlenecks may limit expanded patient access to these innovative and transformative products. An initial survey and subsequent article published through the International Society for CellGene Therapy in 2017 presented a roadmap on how specific steps, from tissue procurement and material acquisition to facility operation and production, contribute to the high cost of cell and gene therapies. Herein the authors expanded the investigation to provide considerations to better understand how post-production procedures can impact a product's accessibility to patients. The administration of a drug product to and follow-up in a patient involve key decisions in several post-production process areas, such as product storage, distribution and handling logistics and compliance, across the value chain through integrated data management solutions. Understanding as well as carefully evaluating these specific components is not widely considered during early process development but is critical in developing a viable product life cycle.

To describe stroke services currently offered in New Zealand hospitals and compare service provision in urban and non-urban settings.An online questionnaire was sent to stroke lead clinicians at all New Zealand District Health Boards (DHBs). Questions covered number and location of stroke inpatients, stroke service configuration, use of guidelines/protocols, staffing mix, access to staff education, and culture appropriate care.There were responses from all 20 DHBs. Differences between urban and non-urban hospitals included: access to acute stroke units (55.6% non-urban vs 100% urban; p=0.013), stroke clinical nurse specialists (50% vs 90%; p=0.034), stroke clot retrieval (38.9% vs 80%; p=0.037) and Pacific support services (55.6% vs 100%; p=0.030). There were also differences in carer training (66.7% non-urban vs 100% urban; p=0.039) and goal-specific rehabilitation plans in the community (61.1% vs 100%; p=0.023). Access to TIA services, stroke rehabilitation units, early supported discharge, psychologists, continuing staff education, and culturally responsive stroke care were suboptimal irrespective of hospital location.Hospital location is associated with differences in stroke services provision across New Zealand and ongoing work is required to optimise consistent access to best practice care. These results, in conjunction with an ongoing (REGIONS Care) study, will be used to determine whether this affects patient outcomes.

Objective: This study develops an analytical framework for identifying effective partnerships between 2- and 4-year institutions that enable community college entrants to transfer to a 4-year institution and earn a bachelor’s degree in a timely fashion. Method: Using the individual term-by-term college enrollment and degree records from the National Student Clearinghouse for the entire 2007 fall cohort of first-time-in-college community college students nationwide, we use regressions to control for student and institutional characteristics in identifying effective partnerships in two steps: first, we identify community colleges with large residual values (better than expected outcomes); and second, we identify the 4-year partners of those community colleges with large residual values. Results: Descriptive results on the variation in transfer outcomes among the thousands of unique transfer partnerships nationally are presented alongside results from regressions used in the two-step effective transfer partnership identification. Contributions: Recommendations and considerations for using this framework to evaluate and benchmark institutional performance in supporting the academic success of vertical transfer students for baccalaureate attainment are also discussed.

Using detailed administrative data from Virginia, this paper examines whether community college “vertical transfer” students who resemble “native four-year” students in their accumulated college-level credits and performance at their point of entry into the four-year sector perform equally well in terms of both academic and labor market outcomes. We compare matching strategies typically used in existing literature to one where we match vertical transfer and native four-year students based on prior credits earned, accumulative GPA, and the destination four-year institution, and find substantial differences in estimates based on different matching strategies. We also examine potential mechanisms underlying vertical transfer students’ relative performance at the four-year institution and in the labor market. The results show that vertical transfer students’ probability of baccalaureate attainment is comparable to that of similar native students attending the same four-year institution. However, when ...

Objective: The objective of this study was to describe practices of 2- and 4-year institutional partnerships effective in supporting transfer student success. Method: Using student records from the National Student Clearinghouse (NSC) for the entire 2007 fall cohort of first-time-in-college community college students nationwide, researchers identified partnerships of 2- and 4-year institutions that were more effective than expected (controlling for student and institutional characteristics) in enabling community college entrants to transfer to a 4-year institution and earn a bachelor’s degree. Based on this methodology, and in partnership with the Aspen Institute’s College Excellence Program, researchers visited six pairs of 2- and 4-year college transfer partnerships identified as high performers, interviewing more than 350 faculty, student-facing and senior-level staff, and transfer students. Results: From these in-depth interviews, researchers identified a set of essential transfer practices common among these highly effective institutional partnerships. The practices were grouped under three broad strategies: (a) make transfer a priority, (b) create clear programmatic pathways with aligned high-quality instruction, and (c) provide tailored transfer advising. Contributions: This study offers a set of essential transfer practices culled from national fieldwork to 2- and 4-year institutional transfer partnerships identified using NSC data as highly effective in supporting transfer student success.

Outside offers, defined as comparable offers of employment at another organization, are means by which faculty determine their relative market worth and increase their salary at their home institution. Despite the career advantages associated with outside offers, little is known about the groups of faculty most likely to receive them. For example, given unexplained pay differences between men and women faculty at research universities, it is important to understand whether there are gender differences in who receives outside offers. This study used survey data from (n = 784) faculty respondents at a large, public university and exploratory logistic regression to examine the relationship between receiving outside offers and gender, partner status and having dependents, rank, and time in rank. Key findings suggested that rank was associated with outside offers, with those in higher ranks more likely to receive outside offers. Men were more likely to receive outside offers than women. We draw implications fr...

Introduction: The REGIONS Care project is a New Zealand (NZ) based nationwide project that aims to capture all stroke patients admitted to NZ hospitals exploring ethic and geographic inequities in stroke care access and patient outcomes. Findings from this study will advise the National Stroke Programme strategy. This project includes an organisational survey to assess current availability of interventions and general management approaches in each hospital. Methods: This is a prospective registry based study with up to one year follow-up. Patients are registered into a central database by hospital teams and follow-up is achieved primarily via telephone calls. The outcome data will be adjusted for baseline function and stroke severity among other factors. At this stage the main study is ongoing, but the organisational survey has been completed. Analysis has not yet been finalised. Final and validated results will be presented at the meeting. Results: All NZ hospitals were approached and 100% completed the online survey. Preliminary results found that of these hospitals 82% have an acute stroke unit, 86% have a TIA pathway, but only 57% offer rapid access specialist TIA services. 100% offer thrombolysis, 93% use an EMS pre-notification and rapid ED triage system, and 75% an in-hospital ‘code stroke’ alert. 11% offer onsite thrombectomy, and a further 41% access thrombectomy via rapid inter-hospital transfer. 82% offer inter-disciplinary team review within 24 hours of admission and while 100% have access to OT, PT, and SLT, only 27% have access to a psychologist. 100% offer inpatient and 92% community rehabilitation service while only 11% offer early supported discharge programmes. Only 31% of hospitals have a dedicated stroke rehab unit. While 88% routinely provide stroke patient education, only 52% provide individualised stroke care plans at discharge. Conclusion: These preliminary results show good access to thrombolysis and multi-disciplinary stroke care. However, improvements are needed in access to thrombectomy, rapid specialist TIA services, early supported discharge, dedicated stroke rehabilitation units, psychologists, and individualised patient care plans. Final and additional results will be presented at the conference.

Student affairs practitioners at a large, mid-Atlantic research university created a learning community directed by the student union to support community college transfer students. The authors examined qualitative data and pre/post surveys from 40 learning community participants in the program’s pilot year. Results suggested favorable effects of participation with regard to civic engagement and mental health and descriptions of major challenges and supports encountered among this group of community college transfer students.

Stroke endovascular clot retrieval (ECR) in patients with large proximal vessel occlusion improves clinical outcomes. We present the New Zealand ECR experience.All New Zealand patients treated with ECR since 2011 were included. Patients were considered eligible if they were independent prior to stroke and had proximal intracranial arterial occlusion.Three hundred and twelve patients [136 women, mean (SD) age of 64 (17) years] from 11 district health boards have been treated between March 2011 and April 2018. There were 260 (83%) patients with anterior and 52 (17%) with posterior circulation arterial occlusion. One hundred and ninety-three (62%) patients were pre-treated with intravenous alteplase. The median time from symptom onset to groin puncture was 210 (range 65-985) minutes. Complete or near-complete recanalisation (Thrombolysis in Cerebral Infarction scores of 3 or 2b) was achieved in 260 of 300 (87%) and the National Institutes of Health Stroke Scale score improved from a median of 18 at baseline to 7 at 24 hours. By day 90, 55% of the anterior circulation patients and 40% of the posterior circulation patients were living independently at home. Mortality rates were 20% for anterior circulation patients and 30% for the posterior circulation patients.This study has shown that stroke endovascular clot retrieval is being provided safely and effectively in New Zealand. However, there remain discrepancies in service provision, and ongoing regional, inter-regional and inter-sector collaboration is essential to implement comprehensive and equitable ECR services across the country.

To meet the demands of population health and value-based care, healthcare organizations may soon be compelled to take steps to rationalize their service and resource offerings.

Discovery of nearly 200 genes implicated in epilepsy and insights into the molecular and cellular pathways involved are transforming our knowledge of the causes, classifications, diagnosis, and in some cases, treatments for individuals with chronic seizure disorders. Numerous disorders once considered "idiopathic" are now recognized as genetic conditions. Despite these remarkable advances, the cause of epilepsy for most individuals is unknown. We present a clinical approach to patients with epilepsy, presenting an algorithm for clinical and genetic testing, and review genes implicated in epilepsy and their associated syndromes.

This chapter explores the practices of learning communities designed for specific, underserved student populations, highlighting on-campus examples and culminating with a synthesized list of core practices from these “inclusive” learning communities.

Cell therapy products are frequently developed and produced without incorporating cost considerations into process development, contributing to prohibitively costly products. Herein we contextualize individual process development decisions within a broad framework for cost-efficient therapeutic manufacturing. This roadmap guides the analysis of cost of goods (COG) arising from tissue procurement, material acquisition, facility operation, production, and storage. We present the specific COG considerations related to each of these elements as identified through a 2013 International Society for Cellular Therapy COG survey, highlighting the differences between autologous and allogeneic products. Planning and accounting for COG at each step in the production process could reduce costs, allowing for more affordable market pricing to improve the long-term viability of the cell therapy product and facilitate broader patient access to novel and transformative cell therapies.

Objective: To explore the predictive factors of student mental health within the college environment. Participants: Students enrolled at 7 unique universities during years 2008 (n = 1,161) and 2009 (n = 1,459). Methods: Participants completed survey measures of mental health, consequences of alcohol use, and engagement in the college environment. Results: In addition to replicating previous findings related to Keyes’ Mental Health Continuum, multiple regression analysis revealed several predictors of college student mental health, including supportive college environments, students’ sense of belonging, professional confidence, and civic engagement. However, multiple measures of engaged learning were not found to predict mental health. Conclusions: Results suggest that supportive college environments foster student flourishing. Implications for promoting mental health across campus are discussed. Future research should build on exploratory findings and test confirmatory models to better understand ...

Community colleges may represent an important component of strategies that aim to increase the quantity and diversity of computer science bachelor's degree earners. This study examines a national cohort of bachelor's recipients who began at community colleges, and finds limited evidence that these students can follow a “well-trodden pathway” in computer science. To entice more students to CS bachelor's degrees, 4-year colleges may need to work more closely with 2-year colleges to create structured pre-transfer pathways in CS.

The New Zealand National Stroke Network introduced a National Stroke Thrombolysis Register on the first of January 2015 to assist with quality assurance and continuous service improvement. In the first 6 months, there were 179 [75 women, mean (SD) age 69.9 (14) years] treated with stroke thrombolysis out of a total of 2,796 ischaemic stroke patients, giving a national thrombolysis rate of 6.4%. The median [Inter-quartile range (IQR)] onset-to-treatment time was 154 (125-190) minutes, and the median (IQR) door-to-needle time was 74.5 (55.7-105.0) minutes. The rate of symptomatic intracranial haemorrhage following thrombolysis was 4.4%. These results are similar to other international centres, and indicate an approximate doubling of the proportion of stroke patients treated with stroke thrombolysis since a 2009 national audit. However, there is need for on-going efforts to improve treatment rates and process efficiency, particularly door-toneedle times.

Succeeding under Medicare's enterprise Comprehensive Care for Joint Replacement Model will require collaboration among caregivers and financial arrangements to align incentives Priorities for most organization's transition to becoming a value-based hospitals will be care redesign, supply-purchasing strategy, and post-acute care provider partnering. Pursuing value for your joint replacement program will chart a path for other service lines and lead your organization's transition to becoming a value-based enterprise.

When effectively designed and implemented, regionalization allows a health system to coordinate care, eliminate redundancies, reduce costs, optimize resource utilization, and improve outcomes. The preferred model to manage service lines regionally will depend on each facility's capabilities and the willingness of physicians to accept changes in clinical delivery. Health systems can overcome physicians' objections to regionalization by implementing a hospital-physician alignment structure that gives a measure of shared control in the management of the organization.

The New Zealand Faculty of the Australasian College for Emergency Medicine (ACEM) is the professional body representing the specialist emergency medicine physicians who work in and lead emergency departments of New Zealand. The National Stroke Network Leadership Group represents New Zealand stroke clinicians including stroke physicians and neurologists who work within and lead district health board (DHB) stroke services. In an effort to promote their shared goal of ensuring patient safety while striving to achieve improved stroke outcomes, the two communities have set up a consensus group to develop this combined emergency physician and neurologist/stroke physician consensus statement on the use of intravenous alteplase in stroke ('stroke thrombolysis').

Urgent assessment and management of patients with transient ischaemic attack (TIA) reduces the early risk of stroke. In 2008 an audit was conducted of TIA services in New Zealand and a substantial discrepancy was found between clinical practice and recommendations in TIA guidelines. We aimed to re-evaluate the situation again in 2013 to determine if there had been any change in provision of TIA services.A brief written questionnaire, based on the 2008 survey, was sent to lead stroke clinicians at all district health boards. Questions were asked about the provision of services, including investigation and management of patients with TIA.The questionnaire was completed by all DHBs. The number of DHBs with a dedicated TIA clinic has increased from 3 in 2008 to 15 in 2013 and the number with a clinical pathway for assessment of patients with TIA has increased from 5 to 17. Brain and carotid imaging is usually available within 48h for patients assessed as having high stroke risk. Delays for other patients remain frequent for brain imaging in 14 DHBs and for carotid imaging in 16 DHBs. There was a decrease in the number of DHBs with a wait of more than a week for carotid endarterectomy when indicated from 16 in 2008 to 4 in 2013.There have been significant improvements in the provision of TIA services over the last 5 years. However in order to reduce the burden of stroke, DHBs need to consider further investments into adequately resourced TIA services as a priority.

A new single-crystal nickel-based superalloy has been developed as part of the GE Aviation strategy of “Rhenium Reduction” This new material provides second-generation properties while using significantly less rhenium. The new alloy development and introduction is part of the four-part strategy of “revert, recycle, recover, and reduce.”

Many independent hospitals and medical groups are pursuing affiliations with partner organizations to meet the challenges posed by healthcare reform and value-based payments. Before embarking on such a strategy, however, these organizations should: Clearly define their objectives of pursuing an affiliation; Assess potential affiliation options; Identify a preferred strategy based on evaluation of different affiliation scenarios.

To audit the care of a consecutive group of acute stroke patients admitted to all District Health Boards (DHBs) in New Zealand.A clinical audit involving a review of up to 40 consecutive stroke patients treated and discharged from each DHB between 1st of June 2008 and 31st of December 2008.The clinical care of 832 patients [400 men; median age 77 (interquartile range 67-84) years] admitted to 20 of 21 DHBs was audited. This represents approximately 20% of all stroke patients admitted to hospital in New Zealand over this 6 month period. Most of the audited patients were independent (66%, mRS=2) and 90% lived at home prior to their strokes. At stroke onset, 40% had a known diagnosis of atrial fibrillation (AF), of whom only 24% were taking anticoagulants. Thirty-eight percent of patients arrived in hospital within 4.5 hours of stroke onset but only 3% were treated with stroke thrombolysis. Only 28% of patients were managed in a stroke unit but these patients had higher rates of thrombolysis, more rapid access to multidisciplinary team assessments and a lower rate of stroke progression (8% vs 15%, p0.01). Only 21% of ischaemic stroke patients received aspirin within 48 hours and 35% of patients had a speech-language therapist assessment within 48 hours of admission.Access to stroke unit care and thrombolysis rates remain low in New Zealand and should be seen as the top priorities for acute stroke care improvement along with anticoagulation for stroke prevention in AF, acute aspirin use and increased speech language therapy assessments.

To characterise the nature of acute stroke services provided by District Health Boards (DHBs) in New Zealand.An audit of all 21 DHBs was carried out in 2009 via an online survey examining the structural and process elements of acute stroke service provision. A clinical audit involving a retrospective review of consecutive admitted stroke patients is reported separately.The organisational survey found that most patients (82%) are admitted to hospitals in the 13 large and medium DHBs. Only 8 DHBs had stroke units and 5 of the large and medium DHBs did not have stroke units. On audit day, only 39% of all New Zealand patients were being managed in a stroke unit, compared with 51% of all Australian patients. Even in the 8 DHBs with stroke units, only 64% of patients were actually being managed in the stroke unit on the day of the audit. New Zealand compared favourably with Australia in aspects of TIA management and in access to brain imaging.There is significant regional variation in the provision of organised stroke care and the level of stroke unit care is low by international standards. This audit provides a benchmark against which to compare future changes in the delivery of stroke care.

A 48-year-old woman with known epilepsy presented to the Emergency Department with a 1-day history of decreasing coordination, impaired speech, and recurrent falls. Phenytoin levels were measured and found to be grossly elevated at 170 mmol/L. A diagnosis of phenytoin toxicity was made and she was treated by withdrawing the medication. During admission she was found to be profoundly hypothyroid despite being on adequate thyroid replacement therapy. Normalisation of phenytoin levels was associated with return of euthyroidism. The interaction between phenytoin, thyroid function, and thyroid replacement therapy is discussed.

We conducted an audit of transient ischaemic attack (TIA) services in New Zealand to determine how current practice compares to best practice recommendations.A brief written questionnaire was sent to all district health boards (DHBs) concerning service provision, clinical management and clinical audit activity related to patients with TIA.Questionnaires were completed by all 21 DHBs. In 18 of 21 (71%) DHBs, most TIA patients were managed by acute services; 3 (14%) DHBs routinely admit most patients and 15 (72%) see most patients in hospital emergency departments or acute assessment units. Three (14%) DHBs see most TIA patients in outpatient clinics, with a usual wait to be seen of more than 1 week. Delays of more than a week were common for carotid ultrasound scans (10 DHBs, 48%) and carotid endarterectomy when indicated (16 DHBs, 76%). Only 4 (19%) DHBs had audited TIA management at a patient level and 3 (14%) at a service level.There are major discrepancies between current management of TIA patients and best practice recommendations in national and international guidelines. Significant regional variations in models of care and access to investigations exist. The provision of dedicated appropriately resourced TIA services within an organised stroke service should be seen as a priority.

To determine changes in the organisation of acute stroke management in New Zealand between 2001 and 2007.A questionnaire was sent to 58 New Zealand hospitals; it included questions about access to organised stroke care, the presence of designated areas for stroke patient management, guidelines for stroke management, and audit.Responses were received from all hospitals surveyed, with 46 admitting stroke patients either acutely or for stroke rehabilitation. Sixteen District Health Boards (DHBs) covering 88% of the population have a physician who provides overall leadership for stroke services. Seven of 46 hospitals, covering 48% of the population, had areas designated for acute management of stroke patients. Rehabilitation for patients older than 65 years was carried out in designated areas for patients with stroke in seven hospitals, covering 49% of the population. Only 13 hospitals (serving 60% of the population) had audited local inpatient stroke care at the patient level and 10 (45% of the population) at the service level.While there have been improvements in the development of an organised approach to acute inpatient acute stroke care in New Zealand there remain major variations between different centres. The training of general physicians, geriatricians, and neurologists in stroke medicine must be seen as a priority.