NorthShore University HealthSystem (formerly Evanston Northwestern Healthcare or ENH) is an integrated healthcare delivery system serving patients throughout the Chicago metropolitan area.NorthShore encompasses six hospitals, as of late 2021 — Evanston, Glenbrook, Highland Park, Skokie, Swedish, and Northwest Community — as well as NorthShore Medical Group with more than 70 offices and more than 800 primary and specialty care physicians, the Research Institute and Foundation. In total, the health system employs more than 10,000 people.NorthShore has a teaching affiliation with the University of Chicago Pritzker School of Medicine.
BACKGROUND:Endovascular thrombectomy (EVT) has transformed acute ischemic stroke (AIS) care, with onset-to-puncture (OTP) time widely recognized as a critical determinant of outcome. However, emerging evidence suggests that in-hospital procedure time (PT)-from arterial puncture to final recanalization-may have an equally or more significant impact. This study examines the relative contribution of PT versus OTP to functional outcomes in patients with AIS undergoing EVT. METHODS:A retrospective analysis was conducted of 6644 patients with AIS treated at 44 international stroke centers from the Stroke Thrombectomy and Aneurysm Registry (STAR; 2016-2023). Multivariable regression, time-equivalence analysis, and marginal effects modeling were used to assess associations between PT, OTP, and 90-day modified Rankin Scale (mRS) outcomes. Centers were stratified by procedural efficiency and compared using propensity score matching (PSM). Mediation analysis evaluated whether PT accounted for inter-center differences. RESULTS:PT and OTP were independently associated with functional outcomes; however, PT had a significantly stronger effect (adjusted OR for mRS 0-2: PT=0.56 vs OTP=0.96 per hour). Each 5 min increase in PT was equivalent to 78-100 min of additional OTP in outcome impact. Centers with faster average PT had higher rates of functional independence (number needed to treat (NNT)=10), fewer complications, and lower symptomatic intracranial hemorrhage rates. PT significantly mediated the relationship between center tier and outcomes (Sobel's P<0.001). CONCLUSION:While minimizing OTP remains important, PT exerts a greater influence on outcomes after EVT. Procedural efficiency should be emphasized in stroke systems of care and included in center performance metrics to improve patient outcomes.
BACKGROUND:The contact aspiration (CA) technique is often used to perform endovascular thrombectomy (EVT) for acute ischemic stroke (AIS); however, rescue strategies are necessary if CA fails to achieve recanalization. This study investigates the outcomes of incorporating stent retriever (SR) thrombectomy in the rescue strategy following failed CA. METHODS:EVT patients with failed CA attempts were identified from a large multicenter registry and stratified by rescue technique: CA alone or incorporating SR in the rescue strategy. Outcomes included successful recanalization, 90-day functional outcomes (defined by the modified Rankin Scale (mRS) score), symptomatic intracranial hemorrhage (sICH), and 90-day mortality. RESULTS:Among 1885 patients with failed CA attempts, conversion to SR was associated with higher recanalization rates (85.2% vs 80.6%; p=0.03), higher rates of second-pass recanalization (31.2% vs 23.4%; p<0.001), and better 90-day outcomes (mRS 0-2: 35.2% vs 29.9%; p=0.04) when compared with repeated CA attempts. Trevo SRs showed higher odds of successful recanalization (adjusted odds ratio (aOR)=1.9; p=0.02), second-pass recanalization (aOR=1.7; p=0.01), and reduced odds of sICH (aOR=0.3; p=0.02). EmboTrap SRs were associated with higher odds of 90-day mortality (aOR=2.6; p=0.004) and sICH (aOR=2.9; p=0.04) and lower odds of recanalization (aOR=0.5; p=0.03). CONCLUSIONS:Incorporating SR in the rescue strategy after a failed CA improves recanalization rates and functional outcomes. Trevo SRs demonstrated superior efficacy and safety when incorporated into the rescue strategy.
Current health care strategies trend toward optimizing outcomes and improving cost; the shift from fee- for- service toward value- based care models has enhanced the delivery of medical care to our patients. Value- based care aims to align health care providers in coordinated patient- focused health care rather than an episodic problem- focused response. Meanwhile, episodic care has shifted from hospital- based to outpatient procedures. To achieve these goals, hospital systems and private practices have employed various strategies of cost containment. Prior literature has introduced the concept of specialist- led care. Although focused primarily on orthopedic surgery specialists, the concept of specialist- led care can be broadly applied, whereby surgical specialists, in conjunction with multidisciplinary teams, drive clinical decision- making. Prior literature supports a specialist- led care model that enhances patient outcomes and reduces overall health care costs and physician burnout while minimizing waste. The present article explores the feasibility of achieving a specialist- led care model in orthopedic surgery and in orthopedic or neurosurgical spine practices in the current health care climate. The shifting dynamics and pressures faced by private practitioners and employed physicians, bundled payment and cost containment strategies, and direct- to- employer contracting are examined. By building a collaborative network, a specialist- led care model will drive supply chain decisions, employ directto- employer contracts, improve care delivery, reduce health care costs, and assist specialists in maintaining clinical and financial independence.
BACKGROUND:Methyl Methanesulfonate-Sensitivity Protein 22-Like (MMS22L) plays a key role in homology-directed DNA repair, and experimental models have shown that its loss confers sensitivity to Poly (ADP-ribose) polymerase inhibitors (PARPi). A rare germline loss-of-function founder mutation in MMS22L, F722fs (c.2164_2168del), was recently identified as a prostate cancer risk factor among individuals of Ashkenazi Jewish ancestry. The impact of this mutation on the disease course following prostate cancer diagnosis remains unclear. Here, we report the longitudinal outcomes of seven MMS22L F722fs carriers diagnosed with different stages of prostate cancer identified at the Brady Urological Institute at Johns Hopkins University. METHODS:We investigated the longitudinal outcomes of seven MMS22L F722fs carriers diagnosed with different stages of prostate cancer identified at the Brady Urological Institute. RESULTS:With a follow-up time ranging from 5 to 27 years, five of the seven patients who were initially treated with radical prostatectomy remain alive and disease-free, including two patients who had adjuvant and salvage therapies, and one patient who was cured after developing metastatic disease post-surgery. For the remaining two patients with metastatic prostate cancer at diagnosis, one patient responded to ADT for 11 years, and the other died of unknown causes 5 years after diagnosis. None of these patients received PARPi. CONCLUSIONS:Although limited by its retrospective design and small cohort size, this series suggests the potential for exceptional outcomes in F722fs mutation carriers diagnosed with prostate cancer, despite the aggressive disease features and lack of treatment with PARPi. The findings also suggest that prostate cancer patients with this mutation may respond well to standard systemic treatments.
