Background Several studies have reported the overuse of spinal imaging, which, in Canada, led to several provincial pathways aimed at optimizing the use of imaging. We assessed temporal trends in spine imaging in two Canadian provinces. Methods We explored the use of X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) examinations of the cervical, thoracic, and lumbar spine regions among adults in Ontario (April 1, 2002, to March 31, 2019) and in Manitoba, Canada (April 1, 2001, to March 31, 2011) using linked Ontario Health Insurance Plan administrative databases and data from Manitoba Health. We calculated the age- and sex-adjusted rates of spinal X-ray, CT, and MRI examinations by dividing the number of imaging studies by the population of each province for each year and estimated the use of each imaging modality per 100,000 persons. Results The total cost of spine imaging in Ontario increased from $45.8 million in 2002/03 to $70.3 million in 2018/19 (a 54% increase), and in Manitoba from $2.2 million in 2001/02 to $5 million in 2010/11 (a 127% increase). In Ontario, rates of spine X-rays decreased by 12% and spine CT scans decreased by 28% over this time period, while in Manitoba, rates of spine X-rays and CT scans remained constant. Age- and sex-adjusted utilization of spinal MRI scans per 100,000 persons markedly increased over time in both Ontario (277%) and Manitoba (350%). Conclusion Despite efforts to reduce the use of inappropriate spinal imaging, both Ontario and Manitoba have greatly increased utilization of spine MRI in the past two decades.

Background and Objectives The clinical course and outcome of the Guillain-Barré syndrome (GBS) are diverse and vary among regions. The modified Erasmus GBS Outcome Score (mEGOS), developed with data from Dutch patients, is a clinical model that predicts the risk of walking inability in patients with GBS. The study objective was to validate the mEGOS in the International GBS Outcome Study (IGOS) cohort and to improve its performance and region specificity. Methods We used prospective data from the first 1,500 patients included in IGOS, aged ≥6 years and unable to walk independently. We evaluated whether the mEGOS at entry and week 1 could predict the inability to walk unaided at 4 and 26 weeks in the full cohort and in regional subgroups, using 2 measures for model performance: (1) discrimination: area under the receiver operating characteristic curve (AUC) and (2) calibration: observed vs predicted probability of being unable to walk independently. To improve the model predictions, we recalibrated the model containing the overall mEGOS score, without changing the individual predictive factors. Finally, we assessed the predictive ability of the individual factors. Results For validation of mEGOS at entry, 809 patients were eligible (Europe/North America [n = 677], Asia [n = 76], other [n = 56]), and 671 for validation of mEGOS at week 1 (Europe/North America [n = 563], Asia [n = 65], other [n = 43]). AUC values were >0.7 in all regional subgroups. In the Europe/North America subgroup, observed outcomes were worse than predicted; in Asia, observed outcomes were better than predicted. Recalibration improved model accuracy and enabled the development of a region-specific version for Europe/North America (mEGOS-Eu/NA). Similar to the original mEGOS, severe limb weakness and higher age were the predominant predictors of poor outcome in the IGOS cohort. Discussion mEGOS is a validated tool to predict the inability to walk unaided at 4 and 26 weeks in patients with GBS, also in countries outside the Netherlands. We developed a region-specific version of mEGOS for patients from Europe/North America. Classification of Evidence This study provides Class II evidence that the mEGOS accurately predicts the inability to walk unaided at 4 and 26 weeks in patients with GBS. Trial Registration Information NCT01582763.

Background and Objectives The clinical course and outcome of the Guillain-Barre syndrome (GBS) are diverse and vary among regions. The modified Erasmus GBS Outcome Score (mEGOS), developed with data from Dutch patients, is a clinical model that predicts the risk of walking inability in patients with GBS. The study objective was to validate the mEGOS in the International GBS Outcome Study (IGOS) cohort and to improve its performance and region specificity. Methods We used prospective data from the first 1,500 patients included in IGOS, aged >= 6 years and unable to walk independently. We evaluated whether the mEGOS at entry and week 1 could predict the inability to walk unaided at 4 and 26 weeks in the full cohort and in regional subgroups, using 2 measures for model performance: (1) discrimination: area under the receiver operating characteristic curve (AUC) and (2) calibration: observed vs predicted probability of being unable to walk independently. To improve the model predictions, we recalibrated the model containing the overall mEGOS score, without changing the individual predictive factors. Finally, we assessed the predictive ability of the individual factors. Results For validation of mEGOS at entry, 809 patients were eligible (Europe/North America [n = 677], Asia [n = 76], other [n = 56]), and 671 for validation of mEGOS at week 1 (Europe/North America [n = 563], Asia [n = 65], other [n = 43]). AUC values were >0.7 in all regional subgroups. In the Europe/North America subgroup, observed outcomes were worse than predicted; in Asia, observed outcomes were better than predicted. Recalibration improved model accuracy and enabled the development of a region-specific version for Europe/North America (mEGOS-Eu/NA). Similar to the original mEGOS, severe limb weakness and higher age were the predominant predictors of poor outcome in the IGOS cohort. Discussion mEGOS is a validated tool to predict the inability to walk unaided at 4 and 26 weeks in patients with GBS, also in countries outside the Netherlands. We developed a region-specific version of mEGOS for patients from Europe/North America. Classification of Evidence This study provides Class II evidence that the mEGOS accurately predicts the inability to walk unaided at 4 and 26 weeks in patients with GBS.

# Experiences in implementing the EOS radiographic system and SterEOS three-dimensional module {#article-title-2} The American Academy of Orthopaedic Surgeons, Scoliosis Research Society, Pediatric Orthopaedic Society of North America and American Academy of Pediatrics believe that the principles

# 0107: Nationwide quality assessment of the Canadian Spine Outcomes Research Network (CSORN) {#article-title-2} The Canadian Spine Outcomes and Research Network (CSORN) is an emergent, rapidly growing national spine registry. The utility of a medical database is dependent on the quality of the

INTRODUCTION:Parkinson's disease (PD) is neurodegenerative movement disorder affecting primarily the central nervous system with several recognized non-motor symptoms that can occur at various stages of the disease. Recently it has been shown that patients with PD may be prone to peripheral nervous system pathology in the form of a peripheral neuropathy (PN). It is unclear if PN is an inherent feature of PD or if it is an iatrogenic effect of the mainstay PD treatment Levodopa.METHODS:To determine if peripheral neuropathy occurs in early untreated PD we employed a case-control study design using gold standard tests for PN, including neurological examination according to the Utah Early Neuropathy Scale (UENS) and nerve conduction studies, as well as new, more sensitive and informative tests for PN including the skin biopsy and corneal confocal microscopy (CCM).RESULTS:We studied 26 patients with PD and 22 controls using the neurological examination and nerve conduction studies (NCS) and found no significant difference between groups except for some reduced vibration sense in the PD group. Epidermal nerve densities in the skin biopsies were similar between our cohorts. However, using CCM - a more sensitive test and a surrogate marker of small fiber damage in PN, we found that patients with PD had significantly reduced corneal nerve fiber densities and lengths as compared to controls.CONCLUSIONS:We conclude that our positive CCM results provide evidence of preclinical PN in newly diagnosed PD patients.

BACKGROUND:Routine imaging of patients with spine-related complaints referred for surgical assessment may represent an inefficient use of technological resources. Our objective was to explore Canadian spine surgeons' requirements with respect to imaging studies accompanying spine-related referrals.METHODS:We administered an 8-item survey to all 100 actively practising surgeon members of the Canadian Spine Society that inquired about demographic variables and imaging requirements for patients referred with spine-related complaints.RESULTS:Fifty-five spine surgeons completed our survey, for a response rate of 55%. Most respondents (43; 78%) required imaging studies to accompany all spine-related referrals. The type of imaging required was highly variable, with respondents endorsing 7 different combinations. Half (47%) required magnetic resonance imaging and 38% required plain radiographs either alone or in combination with other forms of imaging. Half of the respondents refused to see 20% or more of all patients referred for spine-related complaints.CONCLUSION:Most Canadian spine surgeons require imaging studies to accompany spine-related referrals; however, the type and combination of studies is highly variable, and many patients who are referred are never seen (for a consultation). Standardization and optimization of imaging practices for patients with spine-related complaints referred for surgical assessment may be an important area for cost savings.

HomeStrokeVol. 44, No. 4Why Calls for More Routine Carotid Stenting Are Currently Inappropriate Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBWhy Calls for More Routine Carotid Stenting Are Currently InappropriateAn International, Multispecialty, Expert Review and Position Statement Anne L. Abbott, MD, PhD, FRACP, Mark A. Adelman, MD, Andrei V. Alexandrov, MD, P. Alan Barber, PhD, MBChB, FRACP, Henry J.M. Barnett, CC, MD, Jonathan Beard, FRCS, ChM, MEd, Peter Bell, FRCS, MD, DSC, KBE, Martin Björck, MD, PhD, David Blacker, MD, FRACP, Leo H. Bonati, MD, Martin M. Brown, MD, FRCP, Clifford J. Buckley, MD, FACS, Richard P. Cambria, MD, John E. Castaldo, MD, Anthony J. Comerota, MD, FACS, RVT, E. Sander ConnollyJr, MD, Ronald L. Dalman, MD, FACS, Alun H. Davies, MA, DM, FRCS, FHEA, FEBVS, FACPh, Hans-Henning Eckstein, MD, PhD, Rishad Faruqi, MD, FRCS (Eng), FRCS (Ed), FACS, Thomas E. Feasby, MD, Gustav Fraedrich, MD, Peter Gloviczki, MD, Graeme J. Hankey, MD, FRACP, Robert E. Harbaugh, MD, FAANS, FACS, Eitan Heldenberg, MD, Michael G. Hennerici, MD, Michael D. Hill, MD, MSc, FRCPC, Timothy J. Kleinig, PhD FRACP, MBBS (Hons), BA, Dimitri P. Mikhailidis, BSc, MSc, MD, FRSPH, FCP, FFPM, FRCP, FRCPath, Wesley S. Moore, MD, Ross Naylor, MD, FRCS, Andrew Nicolaides, MS, FRCS, PhD (Hon), Kosmas I. Paraskevas, MD, PhD, David M. Pelz, MD, FRCPC, James W. Prichard, MD, Grant Purdie, MD, FRACP, Jean-Baptiste Ricco, MD, PhD, Peter A. Ringleb, MD, PhD, Thomas Riles, MD, Peter M. Rothwell, MD, PhD, FRCP, FMedSci, Peter Sandercock, MA, DM, FRCPE, FMedSci, Henrik Sillesen, MD, DMSc, J. David Spence, BA, MBA, MD, FRCPC, FCAHS, Francesco Spinelli, MD, Jonathon Sturm, MBChB, PhD, Aaron Tan, MD, FRACP, Ankur Thapar, BSc, MBBS, MRCS, Frank J. Veith, MD, Tissa Wijeratne, MD, FRACP and Wei Zhou, MD Anne L. AbbottAnne L. Abbott From the School of Public Health and Preventive Medicine, The Alfred Centre, Monash University, Melbourne, Australia (A.L.A.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (A.L.A.); Florey Institute of Neuroscience and Mental Health, Melbourne, Australia (A.L.A.); Division of Vascular and Endovascular Surgery, New York University Langone Medical Center, New York, NY (M.A.A.); Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL (A.V.A.); Department of Medicine, Centre for Brain Research, University of Auckland, Auckland, New Zealand (A.B.); Clinical Neurological Sciences, Division of Neurology, University of Western Ontario, London, Canada (H.J.M.B.); Sheffield Vascular Institute, Northern General Hospital, Sheffield, United Kingdom (J.B.); University of Leicester, University of Leicester Hospitals, Leicester, United Kingdom (P.B.); Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden (M.B.); Neurology Department, Sir Charles Gairdner Hospital, Perth, Australia (D.B.); Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (L.B.); UCL Institute of Neurology, The National Hospital, Queen Square, London, United Kingdom (M.M.B.); Texas A&M Health Sciences Center College of Medicine, Scott and White Health Care Systems, Central Texas Veterans Health Care System, Temple, TX (C.J.B.); Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.P.C.); Neurology Division, USF College of Medicine, Lehigh Valley Health Network, Allentown, PA (J.E.C.); Jobst Vascular Institute, The Toledo Hospital, Toledo, OH (A.J.C.); Department of Neurological Surgery, Columbia University, New York, NY (E.S.C.); Divisions of Vascular Surgery and Cardiovascular Health (Quality and Outcomes), Stanford University, Stanford, CA (R.L.D.); Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, United Kingdom (A.H.D.); Department for Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen, Universität München, München, Germany (H.-H.E.); Stanford University, Stanford, CA (R.F.); University of California, San Francisco, CA (R.F.); Department of Vascular and Endovascular Surgery, Kaiser Permanente Medical Center, Santa Clara, CA (R.F.); Department of Clinical Neurosciences Faculty of Medicine, University of Calgary, Calgary, Canada (T.E.F.); Department of Vascular Surgery, Medical University, Innsbruck, Austria (G.F.); Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN (P.G.); Neurology Department, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.); Penn State Institute of the Neurosciences, Penn State University, Hershey, PA (R.E.H.); Department of Vascular Surgery, Assaf Harofeh Medical Center, Zerifin, Israel (E.H.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.H.); Neurologische Universitätsklinik, Universitätsmedizin Mannheim, UMM; University of Heidelberg, Mannheim, Germany (M.G.H.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (M.D.H.); Neurology Department, Royal Adelaide and Lyell McEwin Hospitals, Adelaide, Australia (T.J.K.); Department of Medicine, University of Adelaide, Adelaide, Australia (T.J.K.); Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College London Medical School, University College London, London, United Kingdom (D.P.M.); Division of Vascular Surgery, UCLA, Los Angeles, CA (W.S.M.); Vascular Surgery Group, Division of Cardiovascular Sciences, Leicester Royal Infirmary, University of Leicester, Leicester, United Kingdom (R.N.); Department of Vascular Surgery, Imperial College, London, Vascular Non-invasive Diagnostic Centre, London, United Kingdom (A.N.); Red Cross Hospital, Athens, Greece (K.I.P.); Medical Imaging and Clinical Neurological Sciences, University of Western Ontario, London, ON, Canada (D.M.P.); Neurology Department, Yale Medical School, New Haven, CT (J.W.P.); Neurology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia (G.P., A.T.); Vascular Surgery Service, University of Poitiers, Poitiers, France (J-B.R.); Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.A.R.); Division of Vascular Surgery, New York University School of Medicine, New York, NY (T.R.); Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom (P.M.R.); Division of Clinical Neuroscience, University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom (P.S.); Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (H.S.); Neurology and Clinical Pharmacology, University of Western Ontario, London, ON, Canada (J.D.S.); Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, London, ON, Canada (J.D.S.); Department of Cardiovascular and Thoracic Sciences, University of Messina, Messina, Italy (F.S.); Neurology Department, Gosford and Wyong Hospitals, University of Newcastle, New South Wales, Australia (J.S.); Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College, London, London, United Kingdom (A.T.); Division of Vascular Surgery, New York University School of Medicine, Cleveland Clinic, Lerner School of Medicine of Case Western Reserve University, Edward Hebert School of Medicine, University of The Health Sciences, New York (F.J.V.); Neurology Department, Western Hospital, Western Clinical School, University of Melbourne, Melbourne, Australia (T.W.); and Vascular and Endovascular Surgery, Stanford University, Palo Alto VA Health Care System, Stanford, CA (W.Z.). Search for more papers by this author , Mark A. AdelmanMark A. Adelman From the School of Public Health and Preventive Medicine, The Alfred Centre, Monash University, Melbourne, Australia (A.L.A.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (A.L.A.); Florey Institute of Neuroscience and Mental Health, Melbourne, Australia (A.L.A.); Division of Vascular and Endovascular Surgery, New York University Langone Medical Center, New York, NY (M.A.A.); Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL (A.V.A.); Department of Medicine, Centre for Brain Research, University of Auckland, Auckland, New Zealand (A.B.); Clinical Neurological Sciences, Division of Neurology, University of Western Ontario, London, Canada (H.J.M.B.); Sheffield Vascular Institute, Northern General Hospital, Sheffield, United Kingdom (J.B.); University of Leicester, University of Leicester Hospitals, Leicester, United Kingdom (P.B.); Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden (M.B.); Neurology Department, Sir Charles Gairdner Hospital, Perth, Australia (D.B.); Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (L.B.); UCL Institute of Neurology, The National Hospital, Queen Square, London, United Kingdom (M.M.B.); Texas A&M Health Sciences Center College of Medicine, Scott and White Health Care Systems, Central Texas Veterans Health Care System, Temple, TX (C.J.B.); Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.P.C.); Neurology Division, USF College of Medicine, Lehigh Valley Health Network, Allentown, PA (J.E.C.); Jobst Vascular Institute, The Toledo Hospital, Toledo, OH (A.J.C.); Department of Neurological Surgery, Columbia University, New York, NY (E.S.C.); Divisions of Vascular Surgery and Cardiovascular Health (Quality and Outcomes), Stanford University, Stanford, CA (R.L.D.); Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, United Kingdom (A.H.D.); Department for Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen, Universität München, München, Germany (H.-H.E.); Stanford University, Stanford, CA (R.F.); University of California, San Francisco, CA (R.F.); Department of Vascular and Endovascular Surgery, Kaiser Permanente Medical Center, Santa Clara, CA (R.F.); Department of Clinical Neurosciences Faculty of Medicine, University of Calgary, Calgary, Canada (T.E.F.); Department of Vascular Surgery, Medical University, Innsbruck, Austria (G.F.); Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN (P.G.); Neurology Department, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.); Penn State Institute of the Neurosciences, Penn State University, Hershey, PA (R.E.H.); Department of Vascular Surgery, Assaf Harofeh Medical Center, Zerifin, Israel (E.H.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.H.); Neurologische Universitätsklinik, Universitätsmedizin Mannheim, UMM; University of Heidelberg, Mannheim, Germany (M.G.H.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (M.D.H.); Neurology Department, Royal Adelaide and Lyell McEwin Hospitals, Adelaide, Australia (T.J.K.); Department of Medicine, University of Adelaide, Adelaide, Australia (T.J.K.); Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College London Medical School, University College London, London, United Kingdom (D.P.M.); Division of Vascular Surgery, UCLA, Los Angeles, CA (W.S.M.); Vascular Surgery Group, Division of Cardiovascular Sciences, Leicester Royal Infirmary, University of Leicester, Leicester, United Kingdom (R.N.); Department of Vascular Surgery, Imperial College, London, Vascular Non-invasive Diagnostic Centre, London, United Kingdom (A.N.); Red Cross Hospital, Athens, Greece (K.I.P.); Medical Imaging and Clinical Neurological Sciences, University of Western Ontario, London, ON, Canada (D.M.P.); Neurology Department, Yale Medical School, New Haven, CT (J.W.P.); Neurology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia (G.P., A.T.); Vascular Surgery Service, University of Poitiers, Poitiers, France (J-B.R.); Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.A.R.); Division of Vascular Surgery, New York University School of Medicine, New York, NY (T.R.); Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom (P.M.R.); Division of Clinical Neuroscience, University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom (P.S.); Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (H.S.); Neurology and Clinical Pharmacology, University of Western Ontario, London, ON, Canada (J.D.S.); Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, London, ON, Canada (J.D.S.); Department of Cardiovascular and Thoracic Sciences, University of Messina, Messina, Italy (F.S.); Neurology Department, Gosford and Wyong Hospitals, University of Newcastle, New South Wales, Australia (J.S.); Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College, London, London, United Kingdom (A.T.); Division of Vascular Surgery, New York University School of Medicine, Cleveland Clinic, Lerner School of Medicine of Case Western Reserve University, Edward Hebert School of Medicine, University of The Health Sciences, New York (F.J.V.); Neurology Department, Western Hospital, Western Clinical School, University of Melbourne, Melbourne, Australia (T.W.); and Vascular and Endovascular Surgery, Stanford University, Palo Alto VA Health Care System, Stanford, CA (W.Z.). Search for more papers by this author , Andrei V. AlexandrovAndrei V. Alexandrov From the School of Public Health and Preventive Medicine, The Alfred Centre, Monash University, Melbourne, Australia (A.L.A.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (A.L.A.); Florey Institute of Neuroscience and Mental Health, Melbourne, Australia (A.L.A.); Division of Vascular and Endovascular Surgery, New York University Langone Medical Center, New York, NY (M.A.A.); Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL (A.V.A.); Department of Medicine, Centre for Brain Research, University of Auckland, Auckland, New Zealand (A.B.); Clinical Neurological Sciences, Division of Neurology, University of Western Ontario, London, Canada (H.J.M.B.); Sheffield Vascular Institute, Northern General Hospital, Sheffield, United Kingdom (J.B.); University of Leicester, University of Leicester Hospitals, Leicester, United Kingdom (P.B.); Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden (M.B.); Neurology Department, Sir Charles Gairdner Hospital, Perth, Australia (D.B.); Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (L.B.); UCL Institute of Neurology, The National Hospital, Queen Square, London, United Kingdom (M.M.B.); Texas A&M Health Sciences Center College of Medicine, Scott and White Health Care Systems, Central Texas Veterans Health Care System, Temple, TX (C.J.B.); Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.P.C.); Neurology Division, USF College of Medicine, Lehigh Valley Health Network, Allentown, PA (J.E.C.); Jobst Vascular Institute, The Toledo Hospital, Toledo, OH (A.J.C.); Department of Neurological Surgery, Columbia University, New York, NY (E.S.C.); Divisions of Vascular Surgery and Cardiovascular Health (Quality and Outcomes), Stanford University, Stanford, CA (R.L.D.); Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, United Kingdom (A.H.D.); Department for Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen, Universität München, München, Germany (H.-H.E.); Stanford University, Stanford, CA (R.F.); University of California, San Francisco, CA (R.F.); Department of Vascular and Endovascular Surgery, Kaiser Permanente Medical Center, Santa Clara, CA (R.F.); Department of Clinical Neurosciences Faculty of Medicine, University of Calgary, Calgary, Canada (T.E.F.); Department of Vascular Surgery, Medical University, Innsbruck, Austria (G.F.); Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN (P.G.); Neurology Department, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.); Penn State Institute of the Neurosciences, Penn State University, Hershey, PA (R.E.H.); Department of Vascular Surgery, Assaf Harofeh Medical Center, Zerifin, Israel (E.H.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.H.); Neurologische Universitätsklinik, Universitätsmedizin Mannheim, UMM; University of Heidelberg, Mannheim, Germany (M.G.H.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (M.D.H.); Neurology Department, Royal Adelaide and Lyell McEwin Hospitals, Adelaide, Australia (T.J.K.); Department of Medicine, University of Adelaide, Adelaide, Australia (T.J.K.); Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College London Medical School, University College London, London, United Kingdom (D.P.M.); Division of Vascular Surgery, UCLA, Los Angeles, CA (W.S.M.); Vascular Surgery Group, Division of Cardiovascular Sciences, Leicester Royal Infirmary, University of Leicester, Leicester, United Kingdom (R.N.); Department of Vascular Surgery, Imperial College, London, Vascular Non-invasive Diagnostic Centre, London, United Kingdom (A.N.); Red Cross Hospital, Athens, Greece (K.I.P.); Medical Imaging and Clinical Neurological Sciences, University of Western Ontario, London, ON, Canada (D.M.P.); Neurology Department, Yale Medical School, New Haven, CT (J.W.P.); Neurology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia (G.P., A.T.); Vascular Surgery Service, University of Poitiers, Poitiers, France (J-B.R.); Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.A.R.); Division of Vascular Surgery, New York University School of Medicine, New York, NY (T.R.); Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom (P.M.R.); Division of Clinical Neuroscience, University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom (P.S.); Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (H.S.); Neurology and Clinical Pharmacology, University of Western Ontario, London, ON, Canada (J.D.S.); Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, London, ON, Canada (J.D.S.); Department of Cardiovascular and Thoracic Sciences, University of Messina, Messina, Italy (F.S.); Neurology Department, Gosford and Wyong Hospitals, University of Newcastle, New South Wales, Australia (J.S.); Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College, London, London, United Kingdom (A.T.); Division of Vascular Surgery, New York University School of Medicine, Cleveland Clinic, Lerner School of Medicine of Case Western Reserve University, Edward Hebert School of Medicine, University of The Health Sciences, New York (F.J.V.); Neurology Department, Western Hospital, Western Clinical School, University of Melbourne, Melbourne, Australia (T.W.); and Vascular and Endovascular Surgery, Stanford University, Palo Alto VA Health Care System, Stanford, CA (W.Z.). Search for more papers by this author , P. Alan BarberP. Alan Barber From the School of Public Health and Preventive Medicine, The Alfred Centre, Monash University, Melbourne, Australia (A.L.A.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (A.L.A.); Florey Institute of Neuroscience and Mental Health, Melbourne, Australia (A.L.A.); Division of Vascular and Endovascular Surgery, New York University Langone Medical Center, New York, NY (M.A.A.); Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL (A.V.A.); Department of Medicine, Centre for Brain Research, University of Auckland, Auckland, New Zealand (A.B.); Clinical Neurological Sciences, Division of Neurology, University of Western Ontario, London, Canada (H.J.M.B.); Sheffield Vascular Institute, Northern General Hospital, Sheffield, United Kingdom (J.B.); University of Leicester, University of Leicester Hospitals, Leicester, United Kingdom (P.B.); Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden (M.B.); Neurology Department, Sir Charles Gairdner Hospital, Perth, Australia (D.B.); Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (L.B.); UCL Institute of Neurology, The National Hospital, Queen Square, London, United Kingdom (M.M.B.); Texas A&M Health Sciences Center College of Medicine, Scott and White Health Care Systems, Central Texas Veterans Health Care System, Temple, TX (C.J.B.); Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.P.C.); Neurology Division, USF College of Medicine, Lehigh Valley Health Network, Allentown, PA (J.E.C.); Jobst Vascular Institute, The Toledo Hospital, Toledo, OH (A.J.C.); Department of Neurological Surgery, Columbia University, New York, NY (E.S.C.); Divisions of Vascular Surgery and Cardiovascular Health (Quality and Outcomes), Stanford University, Stanford, CA (R.L.D.); Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, United Kingdom (A.H.D.); Department for Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen, Universität München, München, Germany (H.-H.E.); Stanford University, Stanford, CA (R.F.); University of California, San Francisco, CA (R.F.); Department of Vascular and Endovascular Surgery, Kaiser Permanente Medical Center, Santa Clara, CA (R.F.); Department of Clinical Neurosciences Faculty of Medicine, University of Calgary, Calgary, Canada (T.E.F.); Department of Vascular Surgery, Medical University, Innsbruck, Austria (G.F.); Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN (P.G.); Neurology Department, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.); Penn State Institute of the Neurosciences, Penn State University, Hershey, PA (R.E.H.); Department of Vascular Surgery, Assaf Harofeh Medical Center, Zerifin, Israel (E.H.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.H.); Neurologische Universitätsklinik, Universitätsmedizin Mannheim, UMM; University of Heidelberg, Mannheim, Germany (M.G.H.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (M.D.H.); Neurology Department, Royal Adelaide and Lyell McEwin Hospitals, Adelaide, Australia (T.J.K.); Department of Medicine, University of Adelaide, Adelaide, Australia (T.J.K.); Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College London Medical School, University College London, London, United Kingdom (D.P.M.); Division of Vascular Surgery, UCLA, Los Angeles, CA (W.S.M.); Vascular Surgery Group, Division of Cardiovascular Sciences, Leicester Royal Infirmary, University of Leicester, Leicester, United Kingdom (R.N.); Department of Vascular Surgery, Imperial College, London, Vascular Non-invasive Diagnostic Centre, London, United Kingdom (A.N.); Red Cross Hospital, Athens, Greece (K.I.P.); Medical Imaging and Clinical Neurological Sciences, University of Western Ontario, London, ON, Canada (D.M.P.); Neurology Department, Yale Medical School, New Haven, CT (J.W.P.); Neurology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia (G.P., A.T.); Vascular Surgery Service, University of Poitiers, Poitiers, France (J-B.R.); Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.A.R.); Division of Vascular Surgery, New York University School of Medicine, New York, NY (T.R.); Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom (P.M.R.); Division of Clinical Neuroscience, University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom (P.S.); Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (H.S.); Neurology and Clinical Pharmacology, University of Western Ontario, London, ON, Canada (J.D.S.); Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, London, ON, Canada (J.D.S.); Department of Cardiovascular and Thoracic Sciences, University of Messina, Messina, Italy (F.S.); Neurology Department, Gosford and Wyong Hospitals, University of Newcastle, New South Wales, Australia (J.S.); Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College, London, London, United Kingdom (A.T.); Division of Vascular Surgery, New York University School of Medicine, Cleveland Clinic, Lerner School of Medicine of Case Western Reserve University, Edward Hebert School of Medicine, University of The Health Sciences, New York (F.J.V.); Neurology Department, Western Hospital, Western Clinical School, University of Melbourne, Melbourne, Australia (T.W.); and Vascular and Endovascular Surgery, Stanford University, Palo Alto VA Health Care System, Stanford, CA (W.Z.). Search for more papers by this author , Henry J.M. BarnettHenry J.M. Barnett From the School of Public Health and Preventive Medicine, The Alfred Centre, Monash University, Melbourne, Australia (A.L.A.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (A.L.A.); Florey Institute of Neuroscience and Mental Health, Melbourne, Australia (A.L.A.); Division of Vascular and Endovascular Surgery, New York University Langone Medical Center, New York, NY (M.A.A.); Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL (A.V.A.); Department of Medicine, Centre for Brain Research, University of Auckland, Auckland, New Zealand (A.B.); Clinical Neurological Sciences, Division of Neurology, University of Western Ontario, London, Canada (H.J.M.B.); Sheffield Vascular Institute, Northern General Hospital, Sheffield, United Kingdom (J.B.); University of Leicester, University of Leicester Hospitals, Leicester, United Kingdom (P.B.); Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden (M.B.); Neurology Department, Sir Charles Gairdner Hospital, Perth, Australia (D.B.); Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (L.B.); UCL Institute of Neurology, The National Hospital, Queen Square, London, United Kingdom (M.M.B.); Texas A&M Health Sciences Center College of Medicine, Scott and White Health Care Systems, Central Texas Veterans Health Care System, Temple, TX (C.J.B.); Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.P.C.); Neurology Division, USF College of Medicine, Lehigh Valley Health Network, Allentown, PA (J.E.C.); Jobst Vascular Institute, The Toledo Hospital, Toledo, OH (A.J.C.); Department of Neurological Surgery, Columbia University, New York, NY (E.S.C.); Divisions of Vascular Surgery and Cardiovascular Health (Quality and Outcomes), Stanford University, Stanford, CA (R.L.D.); Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, United Kingdom (A.H.D.); Department for Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen, Universität München, München, Germany (H.-H.E.); Stanford University, Stanford, CA (R.F.); University of California, San Francisco, CA (R.F.); Department of Vascular and Endovascular Surgery, Kaiser Permanente Medical Center, Santa Clara, CA (R.F.); Department of Clinical Neurosciences Faculty of Medicine, University of Calgary, Calgary, Canada (T.E.F.); Department of Vascular Surgery, Medical University, Innsbruck, Austria (G.F.); Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN (P.G.); Neurology Department, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.); Penn State Institute of the Neurosciences, Penn State University, Hershey, PA (R.E.H.); Department of Vascular Surgery, Assaf Harofeh Medical Center, Zerifin, Israel (E.H.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.H.); Neurologische Universitätsklinik, Universitätsmedizin Mannheim, UMM; University of Heidelberg, Mannheim, Germany (M.G.H.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (M.D.H.); Neurology Department, Royal Adelaide and Lyell McEwin Hospitals, Adelaide, Australia (T.J.K.); Department of Medicine, University of Adelaide, Adelaide, Australia (T.J.K.); Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College London Medical School, University College London, London, United Kingdom (D.P.M.); Division of Vascular Surgery, UCLA, Los Angeles, CA (W.S.M.); Vascular Surgery Group, Division of Cardiovascular Sciences, Leicester Royal Infirmary, University of Leicester, Leicester, United Kingdom (R.N.); Department of Vascular Surgery, Imperial College, London, Vascular Non-invasive Diagnostic Centre, Lond

stable injury fatality rate over the decade; however, this is an open question requiring further study. Westphal addresses the use of fatality rates in the Poisson regression models to determine the relationship between firearm legislation and firearm-related fatalities. The regression models we used in our study accurately evaluated this relationship1; however, we repeated the analysis using Poisson models with counts of deaths rather than rates, adjusted for population. Using this methodology in our previous multivariable model, we found a similar effect of legislation (incident rate ratio for suicide, 0.41 in the fourth compared with the first quartile; 95% CI, 0.21-0.82). This effect persisted after correction for gun prevalence (incident rate ratio, 0.48; 95% CI, 0.23-0.98).

BACKGROUND:Intravenous immune globulin (IVIG) is an expensive and sometimes scarce blood product that carries some risk. It may often be used inappropriately. We evaluated the appropriateness of IVIG use before and after the introduction of an utilization control program to reduce inappropriate use.METHODS:We used the RAND/UCLA Appropriateness Method to measure the appropriateness of IVIG use in the province of British Columbia (BC) in 2001 and 2003, before and after the introduction of a utilization control program designed to reduce inappropriate use. For comparison, we measured the appropriateness of use during the same periods in the province of Alberta, which had no control program.RESULTS:Of 2256 instances of IVIG use, 54.1% were deemed to be appropriate, 17.4% were of uncertain benefit, and 28.5% were deemed inappropriate. The frequency of inappropriate use in BC after the introduction of the utilization control program did not differ significantly from the frequency before the program or the frequency in Alberta.INTERPRETATION:Almost half of IVIG use in BC and Alberta was judged to be inappropriate or of uncertain benefit, and the frequency of inappropriate use did not decrease after implementation of a utilization control program in BC. More effective utilization controls are necessary to prevent wasted resources and unnecessary risk to patients.

The validity of administrative data may be vulnerable to how well physicians document medical charts. The objective of this study is to determine the relationship between chart documentation quality and the validity of administrative data. The charts for patients who underwent carotid endarterectomy were re-abstracted and rated for the quality of documentation. Poorly and well-documented charts were compared by patient, physician, and hospital variables, as well as on agreement between the administrative and re-abstracted data. Of the 2061 charts reviewed, 42.6 per cent were rated well documented. The proportion of charts well documented varied from 14.6 to 87.5 per cent across 17 hospitals, but did not vary significantly by patient characteristics. The kappa statistic was generally higher for well-documented charts than for poorly documented charts, but varied across comorbidities. In conclusion, poorly documented hospital charts tend to be translated into invalid administrative data, which reduces the communication of clinical information among healthcare providers.

ACP Journal Club20 October 2009Contrast-enhanced magnetic resonance angiography is the most accurate noninvasive imaging technique for carotid stenosisThomas E. Feasby, MDThomas E. Feasby, MDUniversity of Calgary, Calgary, Alberta, Canada (T.E.F.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-151-8-200910200-02015 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Source CitationChappell FM, Wardlaw JM, Young GR, et al. Carotid artery stenosis: accuracy of noninvasive tests—individual patient data meta-analysis. Radiology. 2009;251:493-502. https://pubmed.ncbi.nlm.nih.gov/19276319Clinical Impact RatingsHospitalists: Neurology: Author, Article, and Disclosure InformationAffiliations: University of Calgary, Calgary, Alberta, Canada (T.E.F.)This article was published at Annals.org on 6 October 2009. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 20 October 2009Volume 151, Issue 8Page: JC4-15KeywordsAngiographyArteriesCarotid endarterectomyComputed axial tomographyImaging techniquesMagnetic resonance angiographySpecificityStenosisTransient ischemic attacksUltrasound imaging ePublished: 20 October 2009 Issue Published: 20 October 2009 Copyright & PermissionsCopyright © 2009 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

BACKGROUND:Studies suggest that the side of carotid endarterectomy (CE) may influence the rate of postoperative complications. We sought to clarify this by (1) analysis of individual-level data from 3 large studies and (2) systematic review and meta-analysis of additional published descriptions of outcomes by side. METHODS AND RESULTS:The Western Canada Carotid Endarterectomy (WCCE) study (n=3164) was analyzed for outcomes by side along with data from the North American Symptomatic Carotid Endarterectomy Trial (NASCET; n=1415), and the ASA [Acetylsalicylic Acid] in Carotid Endarterectomy Trial (ACE; n=2469). Pooled analysis of individual-level data from these three studies allowed calculation of rate ratios for stroke or death by side. Medline and EMBASE were searched to identify additional studies reporting CE outcomes by side, and an overall risk ratio for outcomes by side was determined with fixed-effects meta-analysis. The WCCE in-hospital stroke or death rates for left and right-sided CE were 3.72% and 3.07%, respectively (P=0.27). A pooled analysis of the NASCET and ACE trials also revealed higher stroke or death rates for left-sided CE (5.39% versus 2.96%; P<0.001). The corresponding risk-adjusted rate ratios for stroke or death for left- versus right-sided surgery were 1.22 (95% CI, 0.83 to 1.77) for WCCE and 1.82 (1.32 to 2.50) for the pooled NASCET and ACE trials. Systematic review of the literature identified 2 additional studies. Meta-analysis of all 5 available studies yielded a corresponding pooled rate ratio for stroke or death of 1.36 (1.18 to 1.56). CONCLUSIONS:Left-sided CE is consistently associated with higher postoperative adverse event rates. Research into potential mechanisms is required to explain and address this finding.

INTRODUCTION Adverse events (AEs) are poor outcomes caused by medical care. They occur in 20% of medical patients following hospital discharge. We designed an interactive voice response system (IVRS) with the intent of identifying patients who might be experiencing an AE following discharge or were at risk of developing one. OBJECTIVES We determined the proportion of post-discharge patients requiring an intervention after identifying potential problems using the IVRS, the relationship between IVRS responses and AE occurrence, and patients’ opinions of the IVRS call. METHODS We studied patients discharged from the general medical service of an academic hospital. The IVRS called patients 2 days post-discharge and asked three questions to determine the need for nurse follow-up. We contacted patients 30 days later to elicit AE status and perceptions of the IVRS. RESULTS Our cohort consisted of 270 elderly patients [median 64 years (IQR 50-76)] with multiple co-morbidities. Responses to the IVRS identified 57 patients (21%, 95% CI 17%-27%) for follow-up. When contacted by a nurse, 25 patients (9%, 95% CI 6%-13%) actually required an intervention. At 30-day follow-up, AEs occurred in 33 patients (12%, 95% CI 8%-17%). Only three AEs (9%) were identified by the IVRS; the remainder occurred before or after the IVRS call. Patients remembering the IVRS call found it easy to use (97%), and a minority would prefer a person to call (8%). CONCLUSION An IVRS-based method of monitoring was acceptable to patients and identified a significant proportion requiring changes in management. However, the method identified only a minority of AEs. To have a significant improvement in care, this method will need to be combined with other interventions.

Excessive wait times for magnetic resonance imaging (MRI) studies are a major problem in the Canadian healthcare system. To determine how requests for MRI studies are managed, the authors performed a survey of public MRI facilities in Canada. Ninety-six per cent had some method to triage MRI requests. However, only 42% had documented guidelines for prioritization, and none employed quality assurance methods to ensure that guidelines were followed. Target timelines for each prioritization category varied widely. Sixteen per cent of centres were not able to meet their target timelines for any prioritization category, and 45% of centres met target times only for some prioritization categories. Strategies for dealing with wait lists primarily involved attempts to increase capacity. No centres attempted to reduce wait times by decreasing inappropriate requests. There appears to be a need to standardize MRI wait list management given the variation in management practices and wait times observed.

OBJECTIVE To test the feasibility and utility of an interactive voice response system (IVRS) for monitoring patients after outpatient surgery. METHODS We studied consecutive patients undergoing gynecologic day surgery. The IVRS called patients on the first postoperative day and asked them if they were experiencing new problems. Feasibility was assessed in terms of call responses and acceptance by patients. Utility was measured in terms of the ability of the IVRS to identify adverse events (AEs), defined as procedure-related symptoms requiring a physician or hospital visit. We contacted patients 30 days later to elicit their perceptions of the IVRS and determine AE status. RESULTS Follow-up was complete for 249 of 270 enrolled patients (92%). The IVRS successfully contacted 130 patients (52%). Of the 22 patients (17%) who required a follow-up phone call, 9 had a new problem related to surgery, 7 had new or worsening symptoms, 6 wanted to speak with a nurse, and 1 had a medication-related problem. Patients remembering the automated call (n = 96) reported the system easy to use (82%) and comprehend (86%). Most patients (68%) preferred the IVRS to a personal follow-up call (probability greater than 50%, P <.001). AEs occurred in 40 patients (16%; 95% confidence interval = 12%, 21%). The IVRS did not identify any AEs because 90% of these occurred after the automated call. CONCLUSION An IVRS-based method of monitoring outpatient surgery patients is feasible. To improve utility, calls must occur later than first postoperative day.

Carotid endarterectomy (CE) has been used for stroke prevention since its introduction in 1954.1 It was embraced with great enthusiasm in the 1980s and rates soared.2 However, the lack of efficacy data from randomized controlled trials (RCTs) and doubts about its effectiveness had at least three effects. Rates began to drop, a major study of the appropriateness of CE was undertaken,3 and RCTs were conducted. The result today should be more appropriate and effective use of CE. The 1988 RAND study of the appropriateness of CE3 revealed a disturbing result; about a third of procedures were judged inappropriate, based upon the best evidence and expert opinion; a third were of uncertain value; and only a third were appropriate.3 This result tempered enthusiasm for CE and rates dropped.2 It also helped persuade the National Institute of Neurologic Disorders and Stroke to support the first major RCT of CE, the North American Symptomatic Carotid Endarterectomy Trial (NASCET).4 NASCET showed that CE substantially reduced the risk of stroke in symptomatic patients with ≥70% stenosis and to a lesser degree in those with 50 to 69% stenosis. A large European RCT substantiated these results for symptomatic patients.5 The Asymptomatic Carotid Stenosis Trial (ACAS)6 showed a more modest reduction of stroke in asymptomatic patients with ≥60% carotid stenosis. Significant …