Perioperative smoking cessation seems to be an effective tool to reduce postoperative complications even if it is introduced as late as 4 weeks before surgery.

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BackgroundEarly identification and transfer of patients with acute stroke to a primary or comprehensive stroke center results in favorable outcomes.ObjectiveTo describe implementation and results of an emergency medical service (EMS)-driven stroke protocol in Lucas County, Ohio.MethodAll county EMS personnel (N=464) underwent training in the Rapid Arterial oCclusion Evaluation (RACE) score. The RACE Alert (RA) protocol, whereby patients with stroke and a RACE score ≥5 were taken to a facility that offered advanced therapy, was implemented in July 2015. During the 6-month study period, 109 RAs were activated. Time efficiencies, diagnostic accuracy, and mechanical thrombectomy (MT) outcomes were compared with standard ‘stroke-alert’ (N=142) patients from the preceding 6 months.ResultsAn increased treatment rate (25.6% vs 12.6%, p<0.05) and improved time efficiency (median door-to-CT 10 vs 28 min, p<0.05; door-to-needle 46 vs 75 min, p<0.05) of IV tissue plasminogen activator within the RA cohort was achieved. The rate of MT (20.1% vs 7.7%, p=0.06) increased and treatment times improved, including median arrival-to-puncture (68 vs 128 min, p=0.04) and arrival-to-recanalization times (101 vs 205 min, p=0.001) in favor of the RA cohort. A non-significant trend towards improved outcome (50% vs 36.4%, p=0.3) in the RA cohort was noted. The RA protocol also showed improved diagnostic specificity for ischemic stroke (52.3% vs 30.1%, p<0.05).ConclusionsOur results indicate that EMS adaptation of the RA protocol within Lucas County is feasible and effective for early triage and treatment of patients with stroke. Using this protocol, we can significantly improve treatment times for both systemic thrombolysis and MT.

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BackgroundData on the implementation of prehospital large vessel occlusion (LVO) scales to identify and triage patients with acute ischemic stroke (AIS) in the field are limited, with the majority of studies occurring outside the USA.ObjectiveTo report our long-term experience of a US countywide emergency medical services (EMS) acute stroke triage protocol using the Rapid Arterial oCclusion Evaluation (RACE) score.MethodsOur prospective database was used to identify all consecutive patients triaged within Lucas County, Ohio by the EMS with (1) a RACE score ≥5, taken directly to an endovascular capable center (ECC) as RACE-alerts (RA) and (2) a RACE score <5, taken to the nearest hospital as stroke-alerts (SA). Baseline demographics, RACE score, time metrics, final diagnosis, treatments, and clinical and angiographic outcomes were captured. The sensitivity and specificity for patients with a RACE score ≥5 with LVO, eligible for mechanical thrombectomy (MT), were calculated.ResultsBetween July 2015 and June 2018, 492 RA and 1147 SA were triaged within our five-hospital network. Of the RA, 37% had AIS secondary to LVOs. Of the 492 RA and 1147 SA, 125 (25.4%) and 38 (3.3%), respectively, underwent MT (OR=9.9; 95% CI 6.8 to 14.6; p<0.0001). Median times from onset-to-ECC arrival (74 vs 167 min, p=0.03) and dispatch-to-ECC arrival (31 vs 46 min, p=0.0002) were shorter in the RA-MT than in the SA-MT cohort. A RACE cut-off point ≥5 showed a sensitivity and specificity of 0.77 and 0.75 for detection of patients with LVO eligible for MT, respectively.ConclusionsWe have demonstrated the long-term feasibility of a countywide EMS-based prehospital triage protocol using the RACE Scale within our hospital network.

SummaryIt is known that smokers constitute an important risk group of patients undergoing surgery. It is unknown how smoking cessation intervention initiated 4 weeks prior to elective surgery affects the probability of permanent cessation. We randomly assigned 117 patients, scheduled to undergo elective orthopaedic and general surgery, to smoking cessation intervention and control group. The intervention group underwent a programme initiated, on average, 4 weeks prior to surgery with weekly meetings or telephone counselling and were provided with free nicotine replacement therapy (NRT). The control group received standard care. As a result, 20 ⁄ 55 (36%) patients the intervention group vs 1 ⁄ 62 (2%) in the control group became completely abstinent throughout the peri-operative period (p < 0.001). After 1 year, those in the intervention group was most likely to be abstinent (18 ⁄ 55 (33%) vs 9 ⁄ 62 (15%) of the controls (p = 0.03). Level of nicotine dependence and obesity seemed to be a predictor of long-term abstinence (p = 0.02). Smokers constitute an important risk group of patients prone to develop a range of postoperative complications including impaired wound and bone healing to lifethreatening pulmonary and cardiovascular complications [1][2][3][4][5][6][7]. For these reasons, it is particularly important to find feasible, financially attractive, and effective means of pre-operative smoking cessation.The success of an intervention programme is known to be affected by different patient-related factors. Low socio-economic status [8][9][10], high level of nicotine dependence [11][12][13], and having a partner who smokes [14,15] are known predictors of failed smoking cessation. It seems that older age [16,17] and a high body mass index [18,19] (BMI) increase the probability of achieving abstinence. The intensity of the intervention programme also affects the success in smoking cessation [20,21]. Some efforts have been aimed at optimising the pre-operative condition of smokers through smoking cessation intervention prior to planned surgery [22,23], but there is still uncertainty about how long such interventions should last in order to reduce the risk of postoperative complications [24,25].In this study, the main aim was to investigate the shortand long-term efficacy of a pre-operative smoking cessation programme initiated 4 weeks pre-operatively and lasting 4 weeks following surgery. The second aim was to study how different patient-related characteristics affect the probability of long-term abstinence.Patients and methods

CAS is not as safe as CEA from a national perspective but our results indicate that a single centre can achieve acceptable results with CAS.