Letters

Author Contributions: Dr Reames had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Finks, Bacal, Dimick. Acquisition, analysis, or interpretation of data: Reames, Carlin. Drafting of the manuscript: Reames, Bacal, Dimick. Critical revision of the manuscript for important intellectual content: Reames, Finks, Carlin, Dimick. Statistical analysis: Reames. Administrative, technical, or material support: Bacal. Study supervision: Finks, Bacal, Carlin, Dimick. Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Dimick reported serving as consultant and having an equity interest in ArborMetrix Inc, which provides software and analytics for measuring hospital quality and efficiency; however, the company had no role in the study. No other disclosures were reported. Funding/Support: Dr Reames is supported by grant 5T32CA009672-23 from the National Cancer Institute. Role of the Sponsor: The National Cancer Institute had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Disclaimer: The views expressed in this article do not necessarily represent those of the US government. 1. Hainer V, Toplak H, Mitrakou A. Treatment modalities of obesity: what fits whom? Diabetes Care. 2008;31(suppl 2):S269-S277. 2. Padwal R, Klarenbach S, Wiebe N, et al. Bariatric surgery: a systematic review of the clinical and economic evidence. J Gen Intern Med. 2011;26(10):1183-1194. 3. Nguyen NT, Masoomi H, Magno CP, Nguyen XM, Laugenour K, Lane J. Trends in use of bariatric surgery, 2003-2008. J Am Coll Surg. 2011;213(2):261-266. 4. Nguyen NT, Nguyen B, Gebhart A, Hohmann S. Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy. J Am Coll Surg. 2013;216(2):252-257. 5. Carlin AM, Zeni TM, English WJ, et al; Michigan Bariatric Surgery Collaborative. The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity. Ann Surg. 2013;257(5):791-797. 6. Lazzati A, Guy-Lachuer R, Delaunay V, Szwarcensztein K, Azoulay D. Bariatric surgery trends in France: 2005-2011. Surg Obes Relat Dis. 2014;10(2):328-334.

COMMENT & RESPONSE

Ambulance-Based Thrombolysis in Acute Ischemic Stroke To the Editor Dr Ebinger and colleagues1 reported that ambulance-based thrombolysis using the Stroke Emergency Mobile (STEMO) led to higher rates of tissue plasminogen activator (tPA) treatment and shorter alarm-to-treatment time in patients with acute ischemic stroke without increasing cerebral hemorrhage or mortality rate. Ebinger et al1 randomly assigned weeks to STEMO deployment or usual care during the study period. However, it is questionable whether the results during the STEMO weeks and the control weeks were comparable. Patients were more likely to receive tPA treatment and be transported to hospitals with a stroke unit even without STEMO deployment during the STEMO weeks than during the control weeks (24.1% vs 21.1% and 90.7% [estimated] vs 87.3%, respectively). There might have been more resources available or medical practitioners might have paid extra attention to the care of patients with possible stroke during the STEMO weeks. Therefore, it would be important to compare outcomes such as alarm-to-imaging time, alarm-to-laboratory time, and

imaging-to-treatment time without STEMO deployment during the STEMO weeks vs during the control weeks. In addition, STEMO was deployed for only 56% of patients during the STEMO weeks because STEMO was already in operation or under maintenance. The authors stated that they included patients for whom STEMO was initially deployed but later cancelled and those who received tPA later in the hospital in the STEMO group to minimize bias due to selective use of STEMO. However, Ebinger et al1 did not mention the possibility of selective deployment that might have occurred during the dispatch process. Additional analysis of stroke severity and onsetto-alarm time according to decision to deploy STEMO could clarify this question. Min Ji Kwak, MD Jongoh Kim, MD Author Affiliations: University of Texas Health Science Center, Houston (Kwak); Baylor College of Medicine, Houston, Texas (Kim). Corresponding Author: Jongoh Kim, MD, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Ebinger M, Winter B, Wendt M, et al; STEMO Consortium. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. JAMA. 2014;311(16):1622-1631.

In Reply As Drs Kwak and Kim note, the Prehospital Acute Neurological Treatment and Optimization of Medical Care in Stroke Study (PHANTOM-S) used randomization by weeks instead of at the patient level, and this was an acknowledged limitation of our study. However, independent of STEMO or control week and independent of actual STEMO availability during STEMO weeks, dispatchers at the dispatch center activated a stroke alarm if stroke was suspected during an emergency call. All patients for whom a stroke alarm was activated were eligible for the study. Apart from the 1 additional ambulance (ie, STEMO) that was available in addition to the approximately 30 ambulances in the catchment area during STEMO weeks, there were no other additional resources available during STEMO weeks compared with control weeks and no specific additional treatment was given to patients for whom a regular ambulance was deployed during STEMO weeks. Slightly more patients who received conventional treatment during STEMO weeks received tPA (24.1% vs 21.1%, P = .20) or were transported to a stroke unit during STEMO weeks compared with control weeks (90.9% vs 87.3%, P = .02) (Table). For both parameters, the differences between patients with and without STEMO deployment were more substantial. Comparing patients with conventional care during STEMO weeks with patients in control weeks with regard to the suggested parameters (Table), no other significant differences could be detected. We are not able to completely rule out selective deployment during the dispatch process. However, with similar num-

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Table. Outcomes in Patients With Ischemic Strokes Receiving Thrombolysis Comparing Stroke Emergency Mobile (STEMO) Groups With Control Weeks STEMO Weeks No STEMO Deployment (n = 650)

STEMO Deployment (n = 866) Delivery to hospitals with stroke unit (patients with cardiovascular disease), No. (%)

818 (94.5)

591 (90.9)

Ischemic stroke, No. (%)

614 (70.9)

456 (70.2)

Tissue plasminogen activator treatment, No. (%)

200 (32.6)

110 (24.1)

(n = 192)

(n = 107)

Time, mean (median) [IQR], min

1274 (87.3)

P Valueb .02

1041 (71.3) .003

220 (21.1)

.20

(n = 219)

49.9 (22) [9-70]

44.1 (25) [8-68]

.59

43.2 (23) [9-61]

.96

Alarm to imaging

37.7 (35) [30-42]

55.3 (54) [44-65]

Ambulance-based thrombolysis in acute ischemic stroke.

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