While Coid et al note that our psychotic experiences measure used a low severity cutoff in our published data (positive response to at least 1 of the 4 psychosis items), the associations between psychotic experiences and urbanicity were null regardless of how the psychosis variable was coded.Coid et al also note their finding from Sichuan Province, China, that the association between psychosis and urban upbringing only became significant after they had adjusted their analyses for depression. 2 Our article did not include data from China, a country experiencing very rapid urban development. However, we would advise caution when interpreting results that go from nonsignificant to significant following statistical adjustments for variables that are collinear; psychotic experiences and depressive symptoms are highly associated, 3 and adjusting for collinear variables can cause spurious statistical associations. In any case, in terms of the current study, including depression in our models did not change the associations for psychotic experiences (odds ratio, 1.00; 95% CI, 0.90-1.11) or for psychotic disorder (odds ratio, 0.90; 95% CI, 0.75-1.08).That said, there are factors that we could not explore owing to limitations in the data. Coid et al identify urban upbringing vs current urban living, duration of urban exposure, and migration history, all of which may explain some of the heterogeneity in findings but were not testable in these data. Other unmeasured factors include substance use, trauma exposure, and social isolation and cohesion, among others. Just as these factors may guide us to a better understanding of how high-income countries vary from low-and middle-income countries in terms of urbanicity and psychosis, they also may lead us to a better understanding of how urbanicity might affect increased (or decreased) risk for psychosis in certain individual countries.We agree that our study is just 1 piece of a very complicated puzzle and not a final word. We should not yet discard the urbanicity hypothesis. However, it is certainly time to rethink its broad generalizability.

Evidence-Based Medicine proposes a prescriptive model of physician decision-making in which “best evidence” is used to guide best practice. And yet, proponents of EBM acknowledge that EBM fails to offer a systematic theory of physician decision-making. In this paper, we explore how physicians from the neurology and emergency medicine communities have responded to an evolving body of evidence surrounding the acute treatment of patients with ischemic stroke. Through analysis of this case study, we argue that EBM’s vision of evidence-based medical decision-making fails to appreciate a process that we have termed epistemic evaluation. Namely, physicians are required to interpret and apply any knowledge — even what EBM would term “best evidence” — in light of their own knowledge, background and experience. This is consequential for EBM as understanding what physicians do and why they do it would appear to be essential to achieving optimal practice in accordance with best evidence.

BACKGROUND Monitoring stroke patients in critical-care units for 24 hours after thrombolysis or endovascular thrombectomy is considered standard of care but is not evidence-based. Due to the Covid-19 pandemic, our center modified its protocol in April 2021 with 24-hour critical-care monitoring no longer being guaranteed for stroke patients. We aim to compare the incidence and timing of complications over the first 24 hours post-reperfusion therapies and their association to hospital unit in 2019, 2020 and 2021. METHODS We conducted a single-center retrospective cohort study. We analyzed data from stroke patients treated with thrombolysis and/or endovascular thrombectomy at our center in 2019 (pre-Covid-19, standard of care), 2020 (during Covid-19, standard of care) and 2021 (during Covid-19, new protocol). Data extracted included demographics, the nature and timing of complications within the first 24 hours, and the unit at the time of any complication. Major complications included neurologic deterioration, symptomatic intracranial hemorrhage, recurrent stroke, myocardial infarction, systemic bleeding, rapid assessment of critical events call, and death. RESULTS Three hundred forty-nine patients were included in our study: 78 patients in 2019, 115 patients in 2020, and 156 patients in 2021. In 2021, 32% of patients experienced at least one complication within the first 24 hours compared to 34% in 2020 and 27% in 2019. In 2021, 33% of patients admitted to critical-care units had a complication compared to 31% in 2020 and 26% in 2019. In 2021, 70% of complications had occurred by hour eight compared to 49% in 2020 and 29% in 2019. CONCLUSIONS Despite the change of protocol in April 2021, the incidence and timing of complications did not significantly worsen compared to prior years and were not associated with hospital location. Further research is required to evaluate the necessity of critical care monitoring for 24 hours in this population.

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