Outcomes of late endovascular recanalization for symptomatic non-acute atherosclerotic intracranial large artery occlusion

OBJECTIVES

The optimal treatment of symptomatic non-acute atherosclerotic intracranial large artery occlusion (ILAO) beyond 24 h from onset remains uncertain. We investigate the outcomes of late endovascular recanalization for symptomatic non-acute atherosclerotic ILAO.

PATIENTS AND METHODS

From September 2013 to July 2018, with safety as the first principle, late endovascular recanalization for symptomatic non-acute atherosclerotic ILAO beyond 24 h from onset was attempted in 32 consecutive patients. Primary safety outcome was any stroke or death within 30 days. Primary efficacy outcome were functional independence at 90 days.

RESULTS

The median time from imaging-documented occlusion to treatment was 25.5 days (interquartile range: 10.5-36.5) for all patients. Technical success in recanalization was achieved in 17 patients (53.1%, 17/32). The 30-day rate of any stroke or death was 5.9% (1/17) in the recanalized group versus 6.7% (1/15) in the failure group (P = 0.927). The rate of functional independence at 90 days (70.5%, 12/17) was increased significantly as compared with that before operation (23.5%, 4/17) in the recanalized group (P = 0.015). The rate of functional independence at 90 days (66.7%, 10/15) was not different from that before operation (66.7%,10/15) in the failure group (P = 1.00). The median score reduction in mRS from baseline at 90 days was 1.0 (interquartile range: 1.0-2.0) in the recanalized group versus 0 (interquartile range: 0.0-0.0) in the failure group (P＜0.001).

CONCLUSION

For carefully selected patients with symptomatic non-acute atherosclerotic ILAO beyond 24 h from onset, late endovascular recanalization is technically feasible. The periprocedural safety of late endovascular recanalization is acceptable. Successful recanalization may effectively improve the degree of disability in such patients. However, it should be emphasized that revascularization of non-acute ILAO is a high risk procedure, which should only be performed by experienced operators with safety as the first principle.

A systematic review of team-building interventions in non-acute healthcare settings

Background

Healthcare is increasingly delivered in a team-based format emphasizing interdisciplinary coordination. While recent reviews have investigated team-building interventions primarily in acute healthcare settings (e.g. emergency or surgery departments), we aimed to systematically review the evidence base for team-building interventions in non-acute settings (e.g. primary care or rehabilitation clinics).

Methods

We conducted a systematic review in PubMed and Embase to identify team-building interventions, and conducted follow-up literature searches to identify articles describing empirical studies of those interventions. This process identified 14 team-building interventions for non-acute healthcare settings, and 25 manuscripts describing empirical studies of these interventions. We evaluated outcomes in four domains: trainee evaluations, teamwork attitudes/knowledge, team functioning, and patient impact.

Results

Trainee evaluations for team-building interventions were generally positive, but only one study associated team-building with statistically significant improvement in teamwork attitudes/knowledge. Similarly mixed results emerged for team functioning and patient impact.

Conclusions

The evidence base for healthcare team-building interventions in non-acute healthcare settings is much less developed than the parallel literature for short-term team function in acute care settings. Only one intervention we identified has been tested in multiple non-acute settings by distinct research teams. Positive findings regarding the utility of team-building interventions are tempered by a lack of control conditions, inconsistency in outcome measures, and high probability of bias. Considering these results alongside the well-recognized costs of poor healthcare teamwork suggests that additional research is sorely needed to develop the evidence base for team-building in non-acute settings.

Switching from oral atypical antipsychotic monotherapy to paliperidone palmitate once-monthly in non-acute patients with schizophrenia: A prospective, open-label, interventional study

RATIONALE

Long-acting injectable antipsychotic therapies may offer benefits over oral antipsychotics in patients with schizophrenia.

OBJECTIVE

This study aimed to explore the safety, tolerability, and treatment response of paliperidone palmitate once-monthly in non-acute but symptomatic adult patients switched from previously unsuccessful monotherapy with frequently used oral atypical antipsychotics.

METHODS

This was a post hoc analysis of a prospective, interventional, single-arm, international, multicenter, open-label, 6-month study.

RESULTS

The patients (N = 472) were switched to paliperidone palmitate once-monthly (PP1M) from daily oral treatment with either aripiprazole (n = 46), olanzapine (n = 87), paliperidone extended-release (n = 104), quetiapine (n = 44), or risperidone (n = 191). In all groups, mean Positive and Negative Syndrome Scale total (p < 0.0001) and Clinical Global Impression-Severity scores improved significantly (p = 0.0004 to p < 0.0001). An improvement of ≥50 % in the Positive and Negative Syndrome Scale total score was observed in 21.7 % (aripiprazole), 29.9 % (olanzapine), 29.8 % (paliperidone extended-release), 27.3 % (quetiapine), and 37.2 % (risperidone) of patients. The patients showed significant improvements in the Personal and Social Performance score (aripiprazole p = 0.0409, all others p ≤ 0.0015); Mini International Classification of Functionality, Disability and Health Rating for Activity and Participation Disorders in Psychological Illnesses total scores (all p < 0.01); and Treatment Satisfaction Questionnaire for Medication Global Satisfaction score (olanzapine and risperidone p < 0.0001, quetiapine p = 0.0465, paliperidone extended-release p = 0.0571, aripiprazole p = NS). Paliperidone palmitate once-monthly was well tolerated, presenting no new safety signals.

CONCLUSIONS

These data illustrate that stable, non-acute but symptomatic patients on oral antipsychotic monotherapy may show clinically meaningful improvement of symptoms, functioning, and treatment satisfaction after direct transition to PP1M. The findings are limited by the naturalistic study design; thus, further studies are required to confirm the current findings.

Paliperidone palmitate in non-acute patients with schizophrenia previously unsuccessfully treated with risperidone long-acting therapy or frequently used conventional depot antipsychotics

PALMFlexS, a prospective multicentre, open-label, 6-month, phase IIIb interventional study, explored tolerability, safety and treatment response in adults (n = 231) with non-acute but symptomatic schizophrenia switching to flexibly dosed paliperidone palmitate (PP) after unsuccessful treatment with risperidone long-acting injectable therapy (RLAT) or conventional depot antipsychotics (APs). Treatment response was measured by change in Positive and Negative Syndrome Scale (PANSS) total score from baseline (BL) to last-observation-carried-forward (LOCF) endpoint (EP). Safety and tolerability assessments included Extrapyramidal Symptom Rating Scale (ESRS) total score and treatment-emergent adverse events. Significant reductions in mean PANSS total score were observed for all groups (-7.5 to -10.6; p ⩽ 0.01 [BL to LOCF EP]). After switching to PP, more than 50% of all patients achieved ⩾20% and one-third of RLAT-treated patients even achieved ⩾50% improvement in PANSS total score. Across groups, there were significant improvements (p < 0.05) in symptom severity as measured by Clinical Global Impression-Severity (CGI-S; trend for improvement with RLAT; p = 0.0568), subjective well-being, medication satisfaction, and patient functioning with PP. PP was generally well tolerated. Clinically relevant benefits were observed in non-acute patients with schizophrenia switched from RLAT or conventional depot APs to PP.