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Recent trials suggested immediate complete revascularization (ICR) as a safe alternative to staged complete revascularization (SCR), but the impact of the respective percutaneous coronary intervention strategies between on- versus off-hours is unclear. On-hours was defined as an index revascularization performed between 8:00 a.m. and 6:00 p.m., Monday to Friday, or else the procedure was defined as performed during off-hours. The primary end point consisted of a composite of all-cause mortality, myocardial infarction, unplanned ischemia-driven revascularization, and cerebrovascular events at 1-year follow-up. We used Cox regression models to relate randomized treatment with study end points. We evaluated multiplicative and additive interactions between on- versus off-hours and randomized treatment. The BIOVASC (Percutaneous Complete Revascularization Strategies Using Sirolimus Eluting Biodegradable Polymer Coated Stents in Patients Presenting With Acute Coronary Syndromes and Multivessel Disease) trial enrolled 1,097 and 428 patients during on- and off-hours, respectively. Patients randomized during off-hours were more likely to present with ST-segment elevation myocardial infarction (66.4% vs 29.5%, p <0.001). The composite primary outcome occurred in 8.4% and 10.1% of patients randomized to ICR and SCR, respectively, during on-hours (hazard ratio 0.80, 95% confidence interval 0.54 to 1.19). During off-hours, the primary composite outcome occurred in 5.4% and 7.7% in ICR and SCR (0.69, 95% confidence interval 0.32 to 1.46) with no evidence of a differential effect (interaction pmultiplicative = 0.70, padditive = 0.56). No differential effect was found between treatment allocation and on- versus off-hours in any of the secondary outcomes. In conclusion, no differential treatment effect was found when comparing ICR versus SCR in patients presenting with acute coronary syndrome and multivessel disease during on- or off-hours.

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BACKGROUND: We sought to determine the achievement of key performance indicators (KPIs) of initial trauma care at non-tertiary hospitals in Ghana during on-hours (8AM-5PM weekdays) compared to off-hours (nights, weekends, and holidays). We also sought to assess the effectiveness of a standardized trauma intake form (TIF) with built-in decision support prompts to improve care and to assess whether this effectiveness varied between on-hours and off-hours. METHODS: A stepped-wedge cluster randomized trial was performed with research assistants directly observing trauma care before and after introducing the TIF at emergency units of eight hospitals for 17.5 months. Differences in KPIs and mortality were assessed using multivariable logistic regression and generalized linear mixed regression. RESULTS: Management of 4,077 patients was observed; 1,126 (28 %) during on-hours and 2,951(72 %) during off-hours. At baseline, four of 20 KPIs were performed significantly more often during off-hours. TIF improved care during both on- and off-hours. Seventeen KPIs improved during on-hours and 18 KPIs improved during off-hours. After TIF, six KPIs were performed more often during on-hours, but differences, though significant, were small (1-5 %). Examples of KPIs which were performed more often during on-hours after TIF included: airway assessment (99 % for on-hours vs. 98 % for off-hours), evaluation for intra-abdominal bleeding (91 % vs. 87 %), and spine immobilization for blunt trauma (90 % vs. 85 %) (all p < 0.05). At baseline, mortality among seriously injured patients (Injury Severity Score >9) was higher during on-hours (27 %) compared to off-hours (17 %, p = 0.047). TIF lowered mortality for seriously injured patients during both on-hours (27 % before TIF, 8 % after, p = 0.027) and during off-hours (17 % before, 7 % after, p = 0.004). After TIF, mortality among seriously injured patients was equal between on- and off-hours (8 % vs. 7 %, NS). CONCLUSIONS: At baseline, KPIs of trauma care were slightly better during off-hours compared with on-hours, and mortality was lower among seriously injured patient during off-hours. A quality improvement initiative (the TIF) using built-in decision support prompts improved care strongly in both on- and off-hours and eliminated the mortality difference between on- and off-hours. Use of similar decision support prompts during initial trauma care should be promoted widely in other low- and middle-income countries.

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BACKGROUND: The spectrum of patients with cardiogenic shock (CS) has changed significantly over time. CS has become especially more common in the absence of acute myocardial infarction (AMI), while this subset of patients was typically excluded from recent studies. Furthermore the prognostic impact of onset time and onset place due to CS has rarely been investigated. RESEARCH QUESTION: Do the place of CS onset (out-of-hospital, ie, primary CS vs in-hospital, ie, secondary CS) and the onset time of out-of-hospital CS (ie, on-hours vs off-hours admission) affect the risk of all-cause mortality at 30 days? STUDY DESIGN AND METHODS: This prospective monocentric registry included consecutive patients with CS of any cause from 2019 until 2021. First, the prognostic impact of the place of CS onset (out-of-hospital, ie, primary CS vs during hospitalization, ie, secondary CS) was investigated. Thereafter, the prognostic impact of the onset time of out-of-hospital CS was investigated. Furthermore, the prognostic impact of causative AMI vs non-AMI was investigated. Statistical analyses included Kaplan-Meier analyses, and univariable and multivariable Cox regression analyses. RESULTS: Two hundred seventy-three patients with CS were included prospectively (64% with primary out-of-hospital CS). The place of CS onset was not associated with increased risk of all-cause mortality within the entire study cohort (secondary in-hospital CS: hazard ratio [HR], 1.532; 95% CI, 0.990-2.371; P = .06). However, increased risk of 30-day all-cause mortality was seen in patients with AMI related secondary in-hospital CS (HR, 2.087; 95% CI, 1.126-3.868; P = .02). Furthermore, primary out-of-hospital CS admitted during off-hours was associated with lower risk of all-cause mortality compared to primary CS admitted during on-hours (HR, 0.497; 95% CI, 0.302-0.817; P = .01), irrespective of the presence or absence of AMI. INTERPRETATION: Primary and secondary CS were associated with comparable, whereas primary out-of-hospital CS admitted during off-hours was associated with lower risk of all-cause mortality at 30 days. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT05575856; URL: www. CLINICALTRIALS: gov.

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BACKGROUND: There is an ongoing debate if weekend admissions of critically ill patients are associated with higher mortality rates. The current review aimed to specifically assess this effect in sepsis and septic shock patients by comparing mortality rates with weekend versus weekday admissions. METHODS: PubMed, CENTRAL, Scopus, Web of Science, and Embase were searched up to 20th February 2023 with an additional search of Google Scholar for gray literature. RESULTS: Nine studies were eligible. Meta-analysis of all nine studies with data from 1,134,417 patients demonstrated that sepsis or septic shock patients admitted on weekends don't have higher mortality as compared to those admitted on weekdays (OR: 1.04; 95% CI: 1.00, 1.09; p = 0.05; I2 = 93%). On subgroup analysis based on sample size (>2000 or <2000 patients) and timing of mortality, we noted no difference in the significance of the results. However, there was a small significant increased risk of mortality with weekend admission noted in studies on the Asian population and including septic shock patients. CONCLUSION: Weekend admission does not have an adverse impact on mortality rates of sepsis and septic shock patients. Results must be interpreted with caution owing to high interstudy heterogeneity and variation in confounders adjusted by individual studies.

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Promoting good primate welfare outside of daylight hours is an important task. The responsibility to provide a complex environment and environmental enrichment is an essential element of primate wellbeing programs that should be approached from a 24-h perspective and planned according to the species and individual needs, including giving animals the ability to interact with and control their environment during hours when animal care staff are not present. One must be aware, however, that their needs may differ at night-time from their care needs during the day when staff are present. Assessing welfare and providing enrichment during times when staff are not on hand can be achieved through the use of a variety of technologies, such as night-view cameras, animal-centred technologies, and data loggers. This paper will address the relevant topics concerning the care and welfare of primates during off-hours, and the use of related technologies to facilitate and assess wellbeing at these times.

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Door-to-balloon (DTB) time significantly affects the prognosis of patients with ST-segment elevation myocardial infarction (STEMI). The effects of temporal differences in emergency department (ED) arrival time on DTB time and on different segments of DTB time remain inconclusive. Therefore, we performed a retrospective study in a tertiary hospital between January 2013 and December 2021 and investigated the relationship between a patient's arrival time and both their DTB time and different segments of their DTB time. Of 732 STEMI patients, 327 arrived during the daytime (08:01-16:00), 268 during the evening (16:01-24:00), and 137 at night (00:01-08:00). Significantly higher odds of delay in DTB time were observed during the nighttime (adjusted odds ratio (aOR): 2.87; 95% confidence interval (CI): 1.50-5.51, p = 0.002) than during the daytime. This delay was mainly attributed to a delay in cardiac catheterization laboratory (cath lab) activation-to-arrival time (aOR: 6.25; 95% CI: 3.75-10.40, p < 0.001), particularly during the 00:00-04:00 time range. Age, sex, triage level, and whether patients arrived during the COVID-19 pandemic also had independent effects on different segments of DTB time. Further studies are required to investigate the root causes of delay in DTB time and to develop specific strategies for improvement.

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BACKGROUND: The "weekend effect" has been associated with worse clinical outcomes. Our aim was to compare off-hours vs. regular-hours peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) in cardiogenic shock patients. METHODS: We analyzed in-hospital and 90-day mortality among 147 consecutive patients treated with percutaneous VA-ECMO for medical reasons between July 1, 2013, and September 30, 2022, during regular-hours (weekdays 8:00 a.m.-10:00 p.m.) and off-hours (weekdays 10:01 p.m.-7:59 a.m., weekends, and holidays). RESULTS: The median patient age was 56 years (interquartile range [IQR] 49-64 years) and 112 (72.6%) were men. The median lactate level was 9.6 mmol/L (IQR 6.2-14.8 mmol/L) and 136 patients (92.5%) had a Society for Cardiovascular Angiography and Interventions (SCAI) stage D or E. Cannulation was performed off-hours in 67 patients (45.6%). In-hospital mortality was similar in off-hours and regular hours (55.2% vs. 56.3%, p = 0.901), as was the 90-day mortality (58.2% vs. 57.5%, p = 0.963), length of hospital stay (31 days [IQR 16-65.8 days] vs. 32 days [IQR 18-63 days], p = 0.979), and VA-ECMO related complications (77.6% vs. 70.0%, p = 0.305). CONCLUSIONS: Off-hours and regular-hours percutaneous VA-ECMO implantation in cardiogenic shock of medical cause have similar results. Our results support well-designed 24/7 VA-ECMO implantation programs for cardiogenic shock patients.

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OBJECTIVES: Presentation with ST-segment-elevation myocardial infarction (STEMI) during off-hours may impact timely reperfusion and clinical outcomes. We investigated the association between off-hours presentation, door-to-balloon time, and in-hospital mortality in patients with STEMI referred for primary percutaneous coronary intervention (PCI). METHODS: We included consecutive patients referred for primary PCI at the University of Ottawa Heart Institute between July 2004 and December 2017. The off-hours group included patients presenting on weekends, statutory holidays, or between 18:00 to 07:59 hours on weekdays. The on-hours group included patients presenting between 08:00 and 17:59 hours on weekdays. The primary clinical outcome was the adjusted in-hospital mortality. The primary quality-of-care indicator was door-to-balloon time. RESULTS: A total of 5132 patients were included, with 3152 (61.4%) in the off-hours group and 1980 (38.6%) in the on-hours group. The median door-to-balloon time was longer in the off-hours group compared with the on-hours group (102 minutes vs 77 minutes; P<.001), while the median onset-to-door time was similar (P=.40). There was no difference in the rates of in-hospital mortality (3.5% vs 3.0%; P=.32) or in the adjusted mortality (odds ratio, 1.2; 95% confidence interval, 0.8-1.8; P=.44) between off-hours and on-hours groups. However, door-to-balloon time was an independent predictor of in-hospital mortality (P<.01) and off-hours presentation was an independent predictor of longer door-to-balloon time (P<.001), with an excess of 22.1 minutes. CONCLUSION: Patients treated with primary PCI during off-hours had longer door-to-balloon times. Treatment during off-hours was an independent predictor of longer door-to-balloon time and longer door-to-balloon times were associated with higher mortality.

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Objective: Previous studies have reported the presence of a "weekend effect" with respect to mortality in serious emergency admissions, including cases of traumatic brain injury (TBI). However, the relationship between weekend hospitalization and TBI mortality has not been fully established. This study aimed to conduct a systematic review of available evidence and investigate differences in mortality among TBI patients between weekday and weekend admissions. Methods: Electronic databases including PubMed, Cochrane Library, and Embase were used to obtain relevant articles. Mortality, as the primary outcome of interest, encompassed in-hospital or 30-day mortality. Mortality rates were compared between the 2 groups, weekend and weekday admissions. Additionally, meta-regression analysis was performed on potential confounders to verify and provide comparative results. Results: A total of 7 studies involving 522,942 TBI patients were eligible for inclusion in the synthesis of the systematic review. Of these patients, 71.6% were admitted during weekdays, whereas 28.4% were hospitalized on weekends. The overall integrated mortality was 11.0% (57,286/522,942), with a mortality rate of 10.8% in the weekday group and 11.3% in the weekend group. Pooled analysis revealed no significant difference in mortality between the weekday and weekend groups (risk ratio, 0.99; 95% confidence interval, 0.90-1.09; p=0.78). Furthermore, the meta-regression analysis for sensitivity assessment showed no modifying effect on mortality (p=0.79). Conclusion: This study found no difference in mortality rates between weekday and weekend admissions among TBI patients. Additional sensitivity analyses also demonstrated no significant increase in the risk of mortality in the weekend group.

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Background: To investigate the effect of shift work on surgical outcomes at different times in patients with acute type A aortic dissection (ATAAD). Materials and methods: Patients with ATAAD who underwent total arch replacement at Qilu Hospital of Shandong University from January 2015 to March 2022 were retrospectively analyzed. All patients were managed according to the green channel emergency management strategy, and a professional cardiac team was arranged during off-hours. Based on surgery time and symptom onset to procedure time, the patients were divided into weekday, weekend and holiday groups; daytime and nighttime groups; intervention time ≤48 h and >48 h groups; working hours and off-hours groups. In-hospital mortality between these groups was compared. Results: In total, 499 ATAAD patients underwent surgery within 7 days of symptom onset, and the in-hospital mortality rate was 10% (n = 50/499). Among the 499 patients, 320 (64.13%), 128 (25.65%) and 51 (10.22%) underwent surgery on weekdays, weekends and holidays, respectively. In-hospital mortality and 7-day mortality showed no significant difference among the three groups. Two hundred twenty-seven (45.5%) underwent daytime surgery, and 272 (54.5%) underwent nighttime surgery. Durations of ICU stay and hospital stay were significantly different between the two groups (P < 0.05). There was no significant differences in in-hospital mortality (9.2% vs. 10.7%) and 7-day mortality (4.4% vs. 6.6%). 221 patients (44.3%) and 278 patients (55.7%) were included in the intervention time ≤48 h and >48 h groups, respectively. Acute renal injury, ICU stay and hospital stay were significantly different (P < 0.05) whereas 7-day mortality (5.0% vs. 6.1%) and in-hospital mortality (8.6% vs. 11.1%) were not. Furthermore, 7-day (1.9% vs. 6.6%) and in-hospital mortality (11.1% vs. 9.8%) showed no difference between working hours group (n = 108) and off-hours group (n = 391). Cox regression analysis showed that postoperative acute renal injury (HR = 2.423; 95% CI, 1.214-4.834; P = 0.012), pneumonia (HR = 2.542; 95% CI, 1.186-5450; P = 0.016) and multiple organ dysfunction (HR = 11.200; 95% CI, 5.549-22.605; P = 0.001) were the main factors affecting hospital death in ATAAD patients. Conclusion: Under the management of a professional cardiac surgery team with dedicated off-hours shifts, surgery time was not related to in-hospital mortality in ATAAD patients.

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OBJECTIVE: This meta-analysis assessed the impact of off-hour hospitalization (weekends, and evenings or nighttime on weekdays) on mortality and morbidity in patients with nontraumatic subarachnoid hemorrhage (SAH). METHODS: Electronic databases were systematically searched for studies comparing outcomes between patients with nontraumatic SAH hospitalized during off-hour and on-hour periods (daytime on weekdays). The primary outcome was mortality (in-hospital and at different follow-up periods after hospitalization). Secondary outcomes included delays in treatment, and complications. Sensitivity analysis including only studies in which adjusted multivariate analyses were performed for any of the outcomes, and meta-regression controlling for clinically important patient factors, were also performed. RESULTS: Sixteen studies were included. There was no significant difference in in-hospital mortality (adjusted odds ratio, 1.03; 95% confidence interval [CI], 0.97-1.09; P = 0.30) and at all follow-up periods (7/14 days and 1/3/6 months) after hospitalization between SAH patients who were admitted during off-hour compared with on-hour periods, despite adjusted multivariate meta-analysis being performed. However, patients who were admitted during off-hour periods experienced greater delays from their initial scan to treatment (mean difference, 42.7, 25.2-60.1 hours; P < 0.0001) and had higher rates of pneumonia (odds ratio, 1.65, 1.12-2.44; P = 0.011). CONCLUSIONS: This meta-analysis has not shown an increased risk of mortality in the short-term and long-term among patients with nontraumatic SAH who were hospitalized during off-hour compared with on-hour periods, despite adjusting for potentially confounding patient factors. The delays to treatment and higher observed rates of pneumonia highlight areas in which hospital services and resources should be targeted during these off-hour periods in patients presenting with nontraumatic SAH.

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We aimed to investigate whether there are differences in outcome for pediatric patients when extracorporeal life support (ECLS) is initiated on-hours compared with off-hours. DESIGN: Retrospective cohort study. SETTING: Ten-year period (2009-2018) in United States centers, from the Extracorporeal Life Support Organization registry. PATIENTS: Pediatric (>30 d and <18 yr old) patients undergoing venovenous and venoarterial ECLS. INTERVENTIONS: The primary predictor was on versus off-hours cannulation. On-hours were defined as 0700-1859 from Monday to Friday. Off-hours were defined as 1900-0659 from Monday to Thursday or 1900 Friday to 0659 Monday or any time during a United States national holiday. The primary outcome was inhospital mortality. The secondary outcomes were complications related to ECLS and length of hospital stay. MEASUREMENTS AND MAIN RESULTS: In a cohort of 9,400 patients, 4,331 (46.1%) were cannulated on-hours and 5,069 (53.9%) off-hours. In the off-hours group, 2,220/5,069 patients died (44.0%) versus 1,894/4,331 (44.1%) in the on-hours group (p = 0.93). Hemorrhagic complications were lower in the off-hours group versus the on-hours group (hemorrhagic 18.4% vs 21.0%; p = 0.002). After adjusting for patient complexity and other confounders, there were no differences between the groups in mortality (odds ratio [OR], 0.95; 95% CI, 0.85-1.07; p = 0.41) or any complications (OR, 1.02; 95% CI, 0.89-1.17; p = 0.75). CONCLUSIONS: Survival and complication rates are similar for pediatric patients when ECLS is initiated on-hours compared with off-hours. This finding suggests that, in aggregate, the current pediatric ECLS infrastructure in the United States provides adequate capabilities for the initiation of ECLS across all hours of the day.

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Aim: Different researches showed controversial results about the 'off-hours effect' in nonvariceal upper gastrointestinal bleeding (NVUGIB). Materials & methods: A total of 301 patients with NVUGIB were divided into regular-hours group and off-hours group based on when they received endoscopic hemostasis, and the relationship of the clinical outcomes with off-hours endoscopic hemostasis was evaluated. Results: Patients who received off-hours endoscopy were sicker and more likely to experience worse clinical outcomes. Off-hours endoscopic hemostasis was a significant predictor of the composite outcome in higher-risk patients (adjusted OR: 4.63; 95% CI: 1.35-15.90). However, it did not associate with the outcomes in lower-risk patients. Conclusion: Off-hours effect may affect outcomes of higher-risk NVUGIB patients receiving endoscopic hemostasis (GBS ≥12).

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This systematic review and meta-analysis aimed to evaluate patients with acute ST-segment elevation myocardial infarction (STEMI) who were admitted during off-hours and treated with primary angioplasty associated with an increased risk of mortality compared with those admitted during regular working hours. We performed a systematic literature search using PubMed, SCOPUS, Europe PMC, and Cochrane CENTRAL databases that was finalized on March 15, 2021. The primary outcome was mortality comprising early (in-hospital), midterm (30 days to 1 year), and long-term mortality (>1 year). A total of 384,452 patients from 56 studies were included. The overall mortality of acute STEMI patients admitted during off-hours and regular hours were 6.1 and 6.7%, respectively. Patients admitted during off-hours had similar risk of early, midterm, and long-term mortality compared to those admitted during regular working hours ([relative risk or RR = 1.07, 95% confidence interval or CI, 1.00-1.14, p = 0.06; I 2 = 45%, p = 0.0009], [RR = 1.00, 95% CI, 0.95-1.05, p = 0.92; I 2 = 13%, p = 0.26], and [RR = 0.95, 95% CI, 0.86-1.04, p = 0.26; I 2 = 0%, p = 0.76], respectively). Subgroup analyses indicated that the results were consistent across all subgroups ([women vs. men], [age >65 years vs. ≤65 years], and [Killip classification II to IV vs. Killip I]). Funnel plot was asymmetrical. However, Egger's test suggests no significance of small-study effects ( p = 0.19). This meta-analysis showed that patients with acute STEMI who were admitted during off-hours and treated with primary angioplasty had similar risk of early, midterm, and long-term mortality compared with those admitted during regular working hours.

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OBJECTIVES: The study aim is to determine whether invasive cardiac procedures following a 3-day (holiday) weekend have worse outcomes compared with procedures following a 2-day (normal) weekend. BACKGROUND: Catheterization laboratory schedules after 3-day holiday weekends tend to be overloaded with urgent procedures for patients who have waited up to 3 days. We hypothesized that this would be reflected by more procedural complications in patients undergoing procedures after a 3-day weekend. METHODS: Invasive cardiac procedures that occurred after a weekend at Geisinger Medical Center from July 2012 to December 2019 were included. Baseline characteristics, presentation, periprocedural variables, adverse events, and clinical outcomes were compared between catheterizations on the day following a 2-day weekend and catheterizations following a 3-day weekend. Independent correlates of adverse events were identified by logistic regression analysis. RESULTS: We identified 13,704 invasive cardiac procedures performed after a weekend, of which 722 occurred after a 3-day (holiday) weekend. Baseline demographics, presentation, and case volumes were similar between the 2 groups. Procedures after a 3-day weekend were not associated with any differences in in-hospital mortality, myocardial infarction, or stroke compared with those after a standard 2-day weekend. By univariate analysis, procedural complications were more frequent after a 3-day weekend (15.1% vs 12.3%; P=.03), but this difference was not significant on multivariate analysis (odds ratio, 1.22; P=.30). CONCLUSIONS: Cardiac catheterization procedures performed after a 3-day weekend were not associated with differences in in-patient mortality, myocardial infarction, stroke, or procedural complications.

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BACKGROUND: The potential relationship between intravascular catheter infections with their insertion during weekend or night-time (i.e., off-hours or not regular business hours) remains an open issue. Our primary aim was to describe differences between patients and catheters inserted during on- versus off-hours. Our secondary aim was to investigate whether insertions during off-hours influenced the intravascular catheter infectious risks. METHODS: We performed a post hoc analysis using the databases from four large randomized-controlled trials. Adult patients were recruited in French ICUs as soon as they required central venous catheters or peripheral arterial (AC) catheter insertion. Off-hours started at 6 P.M. until 8:30 A.M. during the week; at weekend, we defined off-hours from 1 P.M. on Saturday to 8.30 A.M. on Monday. We performed multivariable marginal Cox models to estimate the effect of off-hours (versus on-hours) on major catheter-related infections (MCRI) and catheter-related bloodstream infections (CRBSIs). RESULTS: We included 7241 patients in 25 different ICUs, and 15,208 catheters, including 7226 and 7982 catheters inserted during off- and on-hours, respectively. Catheters inserted during off-hours were removed after 4 days (IQR 2, 9) in median, whereas catheters inserted during on-hours remained in place for 6 days (IQR 3,10; p < 0.01) in median. Femoral insertion was more frequent during off-hours. Among central venous catheters and after adjusting for well-known risk factors for intravascular catheter infection, we found a similar risk between off- and on-hours for MCRI (HR 0.91, 95% CI 0.61-1.37, p = 0.65) and CRBSI (HR 1.05, 95% CI 0.65-1.68, p = 0.85). Among central venous catheters with a dwell-time > 4 or > 6 days, we found a similar risk for MCRI and CRBSI between off- and on-hours. Similar results were observed for ACs. CONCLUSIONS: Off-hours did not increase the risk of intravascular catheter infections compared to on-hours. Off-hours insertion is not a sufficient reason for early catheter removal, even if femoral route has been selected.

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Background: There may be a delay in or a poor outcome of endovascular treatment (EVT) among acute ischemic stroke (AIS) patients with large-vessel occlusion (LVO) during off-hours. By using a prospective, nationwide registry, we compared the workflow intervals and radiological/clinical outcomes between patients with acute LVO treated with EVT presenting during off- and on-hours. Methods: We analyzed prospectively collected Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke (ANGEL-ACT) data. Patients presenting during off-hours were defined as those presenting to the emergency department from Monday to Friday between 17:30 and 08:00, on weekends (from 17:30 on Friday to 08:00 on Monday), and on national holidays. We used logistic regression models with adjustment for potential confounders to determine independent associations between the time of presentation and outcomes. Results: Among 1,788 patients, 1,079 (60.3%) presented during off-hours. The median onset-to-door time and onset-to-reperfusion time were significantly longer during off-hours than during on-hours (165 vs. 125 min, P = 0.002 and 410 vs. 392 min, P = 0.027). The rates of successful reperfusion and symptomatic intracranial hemorrhage were similar in both groups. The adjusted odds ratio (OR) for the 90-day modified Rankin Scale score was 0.892 [95% confidence interval (CI), 0.748-1.064]. The adjusted OR for the occurrence of functional independence was 0.892 (95% CI, 0.724-1.098), and the adjusted OR for mortality was 1.214 (95% CI, 0.919-1.603). Conclusions: Off-hours presentation in the nationwide real-world registry was associated with a delay in the visit and reperfusion time of EVT in patients with AIS. However, this delay was not associated with worse functional outcomes or higher mortality rates. Clinical Trial Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03370939.

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OBJECTIVE: Several studies have reported inconsistent findings among countries on whether off-hour hospital presentation is associated with worse outcome in patients with acute stroke. However, its association is yet not clear and has not been thoroughly studied in Korea. We assessed nationwide administrative data to verify off-hour effect in different subtypes of acute stroke in Korea. METHODS: We respectively analyzed the nationwide administrative data of National Emergency Department Information System in Korea; 7144 of ischemic stroke (IS), 2424 of intracerebral hemorrhage (ICH), and 1482 of subarachnoid hemorrhage (SAH), respectively. "Off-hour hospital presentation" was defined as weekends, holidays, and any times except 8:00 AM to 6:00 PM on weekdays. The primary outcome measure was in-hospital mortality in different subtypes of acute stroke. We adjusted for covariates to influence the primary outcome using binary logistic regression model and Cox's proportional hazard model. RESULTS: In subjects with IS, off-hour hospital presentation was associated with unfavorable outcome (24.6% off hours vs. 20.9% working hours, p<0.001) and in-hospital mortality (5.3% off hours vs. 3.9% working hours, p=0.004), even after adjustment for compounding variables (hazard ratio [HR], 1.244; 95% confidence interval [CI], 1.106-1.400; HR, 1.402; 95% CI, 1.124-1.747, respectively). Off-hours had significantly more elderly ≥65 years (35.4% off hours vs. 32.1% working hours, p=0.029) and significantly more frequent intensive care unit admission (32.5% off hours vs. 29.9% working hours, p=0.017) than working hours. However, off-hour hospital presentation was not related to poor short-term outcome in subjects with ICH and SAH. CONCLUSION: This study indicates that off-hour hospital presentation may lead to poor short-term morbidity and mortality in patients with IS, but not in patients with ICH and SAH in Korea. Excessive death seems to be ascribed to old age or the higher severity of medical conditions apart from that of stroke during off hours.

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BACKGROUND: In Japan, even if physicians have not experienced surgical training, they face many instances in which they must provide initial surgical treatment, especially during off-hours. This study aimed to identify the frequency and fields of commonly encountered problems in a Japanese emergency department. METHODS: A retrospective review was performed to identify walk-in outpatients with exogenous problems visiting during off-hours in the Japanese educational hospital providing primary to tertiary emergency care between January 1 and December 31, 2014. Diseases were aggregated according to International Classification of Primary Care (Second Edition; ICPC-2). RESULTS: During the study period, 33 424 patients visited and 7476 were classified into the "exogenous" group. We analyzed the data of 7421 patients after excluding 55 who were deemed undiagnosable based on reviews of the charts. The median age of patients who visited the ED during off-hours was 29 years (range: 0-101 years, IQR: 8-60 years). Altogether, 226 types of problems included in ICPC-2 were identified during the study period. The majority fields of exogenous problems were 'skin,' 'Musculoskeletal,' and 'eye.' The 15 problems with the highest frequencies accounted for 50.2% of the total problems. CONCLUSIONS: We identified surgical problems with high treatment frequencies among patients visiting the ED during off-hours. Providing education focusing on these frequent surgical problems can help to improve the initial treatment quality and reduce the anxiety for those doctors who provide initial surgical treatment.

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OBJECTIVES: This study aimed to assess the effect of the admission time (on-hours versus off-hours) on in-hospital mortality in patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI) in a region without STEMI network. METHODS: We analysed in-hospital the mortality among 300 consecutive ST-segment elevation myocardial infarction (STEMI) patients treated with PPCI between March 2012 and February 2017. Patients were divided according to admission time into on-hours admission (08:00 AM until 08:00 PM on weekdays) versus off-hours admission (08:00 PM until 08:00 AM on weekdays and 24 h on weekends and holidays). Demographic and clinical data as well as in-hospital mortality were compared between the two groups. RESULTS: One hundred and seventy eight (59.3%) patients were admitted during on-hours, and 122 (40.7%) patients were presented in off-hours. The mean door-to-balloon time was 42.3 min in the off-hours group and 34.2 min in the on-hours group with no statistically significant difference (p = 0.39). The mortality rate was 3.9% at on-hours presentation versus 4.09% in off-hours admission (p = 0.58). Multivariate logistic regression analysis showed that off-hours presentation was not associated with in-hospital mortality. [odds ratio (OR) 0.74; 95% CI, 0.21-2.61, p = 0.64]. CONCLUSION: Despite no efficient STEMI network in present study, off-hour presentation had no significant impact on in-hospital prognosis in patients with STEMI treated with PPCI. Larger studies are warranted in order to determine the prognostic role of off-hour presentation in patients with STEMI undergoing PPCI.