The association between use of ambient voice technology documentation during primary care patient encounters, documentation burden, and provider burnout.

BACKGROUND: The burden of documentation in the electronic medical record has been cited as a major factor in provider burnout. The aim of this study was to evaluate the association between ambient voice technology, coupled with natural language processing and artificial intelligence (DAX™), on primary care provider documentation burden and burnout. METHODS: An observational study of 110 primary care providers within a community teaching health system. The primary objectives were to determine the association between DAX™ usage and provider burnout scores on the Oldenburg Burnout Inventory (OLBI) as well as the effect on documentation time per patient encounter (minutes). RESULTS: The completion rate for the survey was 75% (83/110) and high DAX™ use (>60% of encounters) was seen in 28% of providers (23/83). High DAX™ use was associated with significantly less burnout on the OLBI disengagement sub-score (MD [Mean Difference] -2.1; 95% confidence interval [CI] -3.8 to -0.4) but not the OLBI disengagement sub-score (-1.0; 95% CI -2.9 to 1.0) or total score (MD -3.0; 95% CI -6.4 to 0.3). Nineteen providers with high implementation of DAX™ had pre and postimplementation data on documentation time per encounter. After DAX™ implementation average documentation time in notes per encounter was significantly reduced by 28.8% (1.8 min; 95% CI 1.4-2.2). CONCLUSIONS: The use of ambient voice technology during patient encounters was associated with significantly reduced documentation burden and primary care provider disengagement but not total provider burnout scores.

Changes in Therapeutic Intensity Level Following Airway Pressure Release Ventilation in Severe Traumatic Brain Injury.

PURPOSE: Airway pressure release ventilation (APRV) utilizes high levels of airway pressure coupled with brief expiratory release to facilitate open lung ventilation. The aim of our study was to evaluate the effects of APRV-induced elevated airway pressure mean in patients with severe traumatic brain injury. MATERIALS AND METHODS: This was a retrospective cohort study at a 424-bed Level I trauma center. Linear mixed effects models were developed to assess the difference in therapeutic intensity level (TIL), intracranial pressure (ICP), and cerebral perfusion pressure (CPP) over time following the application of APRV. RESULTS: The study included 21 epochs of APRV in 21 patients. In the 6-hour epoch following the application of APRV, the TIL was significantly increased ( P = .002) and the ICP significantly decreased ( P = .041) compared to that before 6 hours. There was no significant change in CPP ( P = .42) over time. The baseline static compliance and time interaction was not significant for TIL (χ2 = 0.2 [ df 1], P = .655), CPP (χ2 = 0 [ df 1], P = 1), or ICP (χ2 = 0.1 [ df 1], P = .752). CONCLUSIONS: Application of APRV in patients with severe traumatic brain injury was associated with significantly, but not clinically meaningful, increased TIL and decreased ICP. No significant change in CPP was observed. No difference was observed based on the baseline pulmonary static compliance.

Multilevel and kin selection in a connected world.

Wild et al. argue that the evolution of reduced virulence can be understood from the perspective of inclusive fitness, obviating the need to evoke group selection as a contributing causal factor. Although they acknowledge the mathematical equivalence of the inclusive fitness and multilevel selection approaches, they conclude that reduced virulence can be viewed entirely as an individual-level adaptation by the parasite. Here we show that their model is a well-known special case of the more general theory of multilevel selection, and that the cause of reduced virulence resides in the opposition of two processes: within-group and among-group selection. This distinction is important in light of the current controversy among evolutionary biologists in which some continue to affirm that natural selection centres only and always at the level of the individual organism or gene, despite mathematical demonstrations that evolutionary dynamics must be described by selection at various levels in the hierarchy of biological organization.

A Randomized Trial of Central Venous Catheter Type and Thrombosis in Critically Ill Neurologic Patients.

BACKGROUND: Observational studies suggest peripherally inserted central venous catheters (PICCs) are associated with a high risk of catheter-related large vein thrombosis (CRLVT) in critically ill neurologic patients. We evaluated the difference in thrombosis risk between PICCs and centrally inserted central venous catheters (CICVCs). METHODS: We conducted a pragmatic, randomized controlled trial of critically ill adult neurologic patients admitted to neurological and trauma critical care units at two level I trauma centers. Patients were randomized to receive either a PICC or CICVC and undergo active surveillance for CRLVT or death within 15 days of catheter placement. RESULTS: In total, 39 subjects received a PICC and 41 received a CICVC between February 2012 and July 2015. The trial was stopped after enrollment of 80 subjects due to feasibility affected by slow enrollment and funding. In the primary intention-to-treat analysis, 17 (43.6 %) subjects that received a PICC compared to 9 (22.0 %) that received a CICVC experienced the composite of CRLVT or death, with a risk difference of 21.6 % (95 % CI 1.57-41.71 %). Adjusted common odds ratio of CRLVT/death was significantly higher among subjects randomized to receive a PICC (adjusted OR 3.08; 95 % CI 1.1-8.65). The higher adjusted odds ratio was driven by risk of CRLVT, which was higher in those randomized to PICC compared to CICVC (adjusted OR 4.66; 95 % CI 1.3-16.76) due to increased large vein thrombosis without a reduction in proximal deep venous thrombosis. CONCLUSIONS: Our trial demonstrates that critically ill neurologic patients who require a central venous catheter have significantly lower odds of ultrasound-diagnosed CRLVT with placement of a CICVC as compared to a PICC.

Cost-effectiveness of transfers to centers with neurological intensive care units after intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Our aim was to estimate the cost-effectiveness of transferring patients with intracerebral hemorrhage from centers without specialized neurological intensive care units (neuro-ICUs) to centers with neuro-ICUs. METHODS: Decision analytic models were developed for the lifetime horizons. Model inputs were derived from the best available data, informed by a variety of previous cost-effectiveness models of stroke. The effect of neuro-ICU care on functional outcomes was modeled in 3 scenarios. A favorable outcomes scenario was modeled based on the best observational data and compared with moderately favorable and least-favorable outcomes scenarios. Health benefits were measured in quality-adjusted life years (QALYs), and costs were estimated from a societal perspective. Costs were combined with QALYs gained to generate incremental cost-effectiveness ratios. One-way sensitivity analysis and Monte Carlo simulations were performed to test robustness of the model assumptions. RESULTS: Transferring patients to centers with neuro-ICUs yielded an incremental cost-effectiveness ratio for the lifetime horizon of $47,431 per QALY, $91,674 per QALY, and $380,358 per QALY for favorable, moderately favorable, and least-favorable scenarios, respectively. Models were robust at a willingness-to-pay threshold of $100,000 per QALY, with 95.5%, 75.0%, and 2.1% of simulations below the threshold for favorable, moderately favorable, and least-favorable scenarios, respectively. CONCLUSIONS: Transferring patients with intracerebral hemorrhage to centers with specialized neuro-ICUs is cost-effective if observational estimates of the neuro-ICU-based functional outcome distribution are accurate. If future work confirms these functional outcome distributions, then a strong societal rationale exists to build systems of care designed to transfer intracerebral hemorrhage patients to specialized neuro-ICUs.

Transfer time to a high-volume center for patients with subarachnoid hemorrhage does not affect outcomes.

OBJECTIVES: The objective of our study was to examine patients with aneurysmal subarachnoid hemorrhage transferred and directly admitted to our institution in order to determine how transfer time affects outcomes. METHODS: A retrospective cohort study was performed of all patients undergoing treatment for aneurysmal subarachnoid hemorrhage between 2005 and 2012 at the University of Michigan. Variables, including transfer time, were tested for their independent association with the primary outcomes of symptomatic vasospasm and 12-month outcome as well as secondary outcomes of aneurysm rebleeding and 12-month mortality. RESULTS: During the study period, 263 (87.4%) patients were transferred to our institution and 38 (12.6%) were directly admitted for treatment of aneurysmal subarachnoid hemorrhage. Transfer time was not associated with the occurrence of symptomatic vasospasm, 12-month outcome, rebleeding, or 12-month mortality. Higher Hunt-Hess grade was associated with the occurrence of symptomatic vasospasm as well as with poorer 12-month outcome. CONCLUSIONS: Transfer time was not associated with the occurrence of symptomatic vasospasm, 12-month outcome, rebleeding, or 12-month mortality. We believe our data argue that protocols should emphasize early resuscitation and stabilization followed by safe transfer rather than a hyperacute transfer paradigm. However, transfer time should be minimized as much as possible so as not to delay time to definitive treatment.

Inter-observer agreement on the diagnosis of neurocardiogenic injury following aneurysmal subarachnoid hemorrhage.

BACKGROUND: Neurocardiogenic injury results from increased sympathetic nervous system activation following acute brain injury. No diagnostic criteria for neurocardiogenic injury exist, and agreement has not been tested. We investigated the agreement by neurointensivists for the presence of neurocardiogenic injury on routine cardiac studies. METHODS: Six neurointensivists rated 100 consecutive cases of aneurysmal subarachnoid hemorrhage (aSAH) for the presence of neurocardiogenic injury. A fixed-panel design was employed for the agreement among the whole cohort, as well as stratified by modified Fisher Scale (mFs), Hunt and Hess grade, gender, and the presence of elevated cardiac enzymes. Overall percent agreement, paired agreement, and agreement above change (Fleiss' Kappa) were calculated. Overall percent agreement between groups was compared using Chi square tests. RESULTS: Six raters completed the survey for a total 600 responses. Overall percent agreement was 79.3 %, and agreement among cases at least one rater thought had neurocardiogenic injury was 66.5 % (paired agreement). Fleiss' Kappa was 0.66 (95 % CI, 0.1-0.71; p < 0.0001), indicating substantial agreement above chance. Similarly, on subgroup analysis, significant agreement beyond chance was seen in all groups (p < 0.001). Overall percent agreement was significantly better among mFs 3-4 compared to mFs ≤ 2 (81.3 vs. 63.6 %; p = 0.018) and among cases with positive cTI (96.9 vs. 70.1 %; p ≤ 0.001). CONCLUSIONS: Overall, we demonstrated substantial agreement for the presence of neurocardiogenic injury on early cardiac studies following aSAH. However, inter-observer variability increased when evaluating patients without the objective finding of elevated cTI and among those with lower clinical and radiographic grades.

Is early clinical evidence of autonomic shift predictive of infection after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Autonomic shift (AS), characterized by increased sympathetic nervous system activation, has been implicated in neurologically mediated cardiopulmonary dysfunction and immunodepression after stroke. We investigated the prevalence of AS defined by readily available clinical parameters and determined the association of AS with subsequent infection in a cohort of patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS: Data were obtained from a single-center cohort study of aSAH patients admitted from January 1, 2007, through April 1, 2012. AS was defined as at least 1 early (<72 hours) routine clinical marker of neurologically mediated cardiopulmonary dysfunction based on electrocardiogram, echocardiogram, cardiac enzymes, or neurogenic pulmonary edema. Multivariable logistic regression models were developed to evaluate the association between AS and subsequent infection after adjusting for other covariates. RESULTS: A total of 167 patients were included in the analysis (mean age 56, 27% men). AS was seen in 66 of 167 patients (40%; 95% confidence interval [CI], 32%-47%), and infection was seen in 80 of 167 patients (48%; 95% CI, 40%-55%). AS was associated with subsequent infection on unadjusted analysis (odds ratio [OR] 2.11; 95% CI, 1.12-3.97); however, this association was no longer significant when adjusting for other predictors of infection (OR 1.36; 95% CI, .67-2.76). Age, clinical grade, and aneurysm location were all independent predictors of infection after aSAH. CONCLUSIONS: We identified AS based on readily available clinical markers in 40% of patients with aSAH, though AS defined by these clinical criteria was not an independent predictor of infection. Additional studies may be warranted to determine the optimal definition of AS and the clinical significance of this finding.

Effect of Ambient Voice Technology, Natural Language Processing, and Artificial Intelligence on the Patient-Physician Relationship.

BACKGROUND: The method of documentation during a clinical encounter may affect the patient-physician relationship. OBJECTIVES: Evaluate how the use of ambient voice recognition, coupled with natural language processing and artificial intelligence (DAX™) affects the patient-physician relationship is not known. METHODS: A prospective observational study within a community teaching health system. The primary aim was evaluating any difference on the PDQR-9 scale between primary care encounters in which DAX™ was utilized for documentation as compared to those that did not. A signal arm open-label phase was also performed to query direct feedback from patients. RESULTS: A total of 288 patients were include in the open-label arm and 304 patients were included in the masked phase of the study comparing encounters with and without DAX™ use. In the open label phase patients strongly agreed that the provider was more focused on them, spent less time typing and made the encounter feel more personable. In the masked phase of the study no difference was seen in the rank order of the total PDQR-9 score between patients whose encounters used DAX™ (median 45 [IQR 8]) and those which did not (median 45 [IQR 3.5]; p=0.31). The adjusted odds ratio for DAX™ use was 0.8 (95% CI 0.48-1.34) for the patient reporting complete satisfaction on how well their clinician listened to them during their encounter. CONCLUSION: Patients strongly agreed with the use of ambient voice recognition, coupled with natural language processing and artificial intelligence (DAX™) for documentation in primary care. However, no difference was detected in the patient-physician relationship on the PDQR-9 scale.

Hamilton's rule in multi-level selection models.

Hamilton's rule is regarded as a useful tool in the understanding of social evolution, but it relies on restrictive, overly simple assumptions. Here we model more realistic situations, in which the traditional Hamilton's rule generally fails to predict the direction of selection. We offer modifications that allow accurate predictions, but also show that these Hamilton's rule type inequalities do not predict long-term outcomes. To illustrate these issues we propose a two-level selection model for the evolution of cooperation. The model describes the dynamics of a population of groups of cooperators and defectors of various sizes and compositions and contains birth-death processes at both the individual level and the group level. We derive Hamilton-like inequalities that accurately predict short-term evolutionary change, but do not reliably predict long-term evolutionary dynamics. Over evolutionary time, cooperators and defectors can repeatedly change roles as the favored type, because the amount of assortment between cooperators changes in complicated ways due to both individual-level and group-level processes. The equation that governs the dynamics of cooperator/defector assortment is a certain partial differential equation, which can be solved numerically, but whose behaviour cannot be predicted by Hamilton's rules, because Hamilton's rules only contain first-derivative information. In addition, Hamilton's rules are sensitive to demographic fitness effects such as local crowding, and hence models that assume constant group sizes are not equivalent to models like ours that relax that assumption. In the long-run, the group distribution typically reaches an equilibrium, in which case Hamilton's rules necessarily become equalities.

Comparison of accuracy of optic nerve ultrasound for the detection of intracranial hypertension in the setting of acutely fluctuating vs stable intracranial pressure: post-hoc analysis of data from a prospective, blinded single center study.

INTRODUCTION: Optic nerve sheath diameter (ONSD) measurement with bedside ultrasound has been shown in many studies to accurately detect high intracranial pressure (ICP). The accuracy of point-in-time ONSD measurement in the presence of ongoing fluctuation of ICP between high and normal is not known. Recent laboratory investigation suggests that reversal of optic nerve sheath distension may be impaired following bouts of intracranial hypertension. Our objective was to compare the accuracy of ONSD measurement in the setting of fluctuating versus stable ICP. METHODS: This was a retrospective analysis of data from prospective study comparing ONSD to invasive ICP. Patients with invasive ICP monitors in the ICU underwent ONSD measurement with simultaneous blinded recording of ICP from the invasive monitor. Three measurements were made in each eye. Significant acute ICP fluctuation (SAIF) was defined in two different ways; as the presence of ICP both above and below 20 mmHg within a cluster of six measurements (Definition 1) and as a magnitude of fluctuation >10 mmHg within the cluster (Definition 2). The accuracy of point-in-time ONSD measurements for the detection of concurrent ICP >20 mmHg within clusters fulfilling a specific definition of SAIF was compared to the accuracy of ONSD measurements within clusters not fulfilling the particular definition by comparison of independent receiver operating characteristic (ROC) curves. RESULTS: A total of 613 concurrent ONSD-ICP measurements in 109 clusters were made in 73 patients. Twenty-three (21%) clusters fulfilled SAIF Definition 1 and 17 (16%) SAIF Definition 2. For Definition 1, the difference in the area under the curve (AUC) of ROC curves for groups with and without fluctuation was 0.10 (P = 0.0001). There was a fall in the specificity from 98% (95% CI 96 to 99%) to 74% (63 to 83%) and in the positive predictive value from 89% (80 to 95%) to 76% (66 to 84%) with fluctuation. For Definition 2, also, there was a significant difference between the AUC of ROC curves of groups with fluctuation-magnitude >10 mmHg and those with fluctuation-magnitude 5 to 10 mmHg (0.06, P = 0.04) as well as <5 mmHg (0.07, P = 0.01). CONCLUSIONS: Specificity and PPV of ONSD for ICP >20 mmHg are substantially decreased in patients demonstrating acute fluctuation of ICP between high and normal. This may be because of delayed reversal of nerve sheath distension.

A population-based analysis of ethnic differences in admission to the intensive care unit after stroke.

BACKGROUND: Mexican-Americans (MAs) have shown lower post-stroke mortality compared to non-hispanic whites (NHWs). Limited evidence suggests race/ethnic differences exist in intensive care unit (ICU) admissions following stroke. Our objective was to investigate the association of ethnicity with admission to the ICU following stroke. METHODS: Cases of intracerebral hemorrhage and acute ischemic stroke were prospectively ascertained as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project for the period of January 2000 through December 2009. Logistic regression models fitted within the generalized additive model framework were used to test associations between ethnicity and ICU admission and potential confounders. An interaction term between age and ethnicity was investigated in the final model. RESULTS: A total 1,464 cases were included in analysis. MAs were younger, more likely to have diabetes, and less likely to have atrial fibrillation, health insurance, or high school diploma than NHWs. On unadjusted analysis, there was a trend toward MAs being more likely to be admitted to ICU than NHWs (34.6 vs 30.3 %; OR = 1.22; 95 % CI 0.98-1.52; p = 0.08). However, on adjusted analysis, no overall association between MA ethnicity and ICU admission (OR = 1.13; 95 % CI 0.85-1.50) was found. When an interaction term for age and ethnicity was added to this model, there was only borderline evidence for effect modification by age of the ethnicity/ICU relationship (p = 0.16). CONCLUSIONS: No overall association between ethnicity and ICU admission was observed in this community. ICU utilization alone does not likely explain ethnic differences in survival following stroke between MAs and NHWs.

Ventilator avoidance among critically ill COVID-19 patients with acute respiratory distress syndrome.

OBJECTIVE: To determine the incidence and significance of ventilator avoidance in patients with critical coronavirus disease 2019 (COVID-19). METHODS: This prospective observational cohort study evaluated hospital mortality and 1-year functional outcome among critically ill patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated acute respiratory distress syndrome (ARDS). The explanatory variable was ventilator avoidance, modeled as 'initial refusal' of intubation (yes/no). Modified Rankin Scale (mRS) scores were obtained from surviving patients (or their surrogates) via phone or email questionnaire. RESULTS: Among patients for whom intubation was recommended (n = 102), 40 (39%) initially refused (95% confidence interval [CI] 30%, 49%). The risk of death was 79.3% (49/62) in those who did not initially refuse intubation compared with 77.5% (31/40) in those who initially refused, with an adjusted odds ratio for death of 1.27 (95% CI 0.47, 3.48). The distribution of 1-year mRS scores was not significantly different between groups. CONCLUSION: Among critically ill patients with COVID-19-associated ARDS, ventilator avoidance was common, but was not associated with increased in-hospital mortality or 1-year functional outcome.

Healthcare-acquired coronavirus disease 2019 (COVID-19) is less symptomatic than community-acquired disease among healthcare workers.

OBJECTIVE: We hypothesized that healthcare workers (HCWs) with high-risk exposures outside the healthcare system would have less asymptomatic coronavirus 2019 (COVID-19) disease and more symptoms than those without such exposures. DESIGN: A longitudinal point prevalence study was conducted during August 17-September 4, 2020 (period 1) and during December 2-23, 2020 (period 2). SETTING: Community based teaching health system. PARTICIPANTS: All HCWs were invited to participate. Among HCWs who acquired COVID-19, logistic regression models were used to evaluate the adjusted odds of asymptomatic disease using high-risk exposure outside the healthcare system as the explanatory variable. The number of symptoms between exposure groups was evaluated with the Wilcoxon rank-sum test. The risk of seropositivity among all HCS by work exposure was evaluated during both periods. INTERVENTIONS: Survey and serological testing. RESULT: Seroprevalence increased from 1.9% (95% confidence interval [CI], 1.2%-2.6%) to 13.7% (95% CI, 11.9%-15.5%) during the study. Only during period 2 did HCWs with the highest work exposure (versus low exposure) have an increased risk of seropositivity (risk difference [RD], 7%; 95% CI, 1%-13%). Participants who had a high-risk exposure outside of work (compared to those without) had a decreased probability of asymptomatic disease (odds ratio [OR], 0.38; 95% CI, 0.16-0.86) and demonstrated more symptoms (median 3 [IQR, 2-6] vs 1 [IQR, 0-4]; P = .001). CONCLUSIONS: Healthcare-acquired COVID-19 increases the probability of asymptomatic or mild COVID-19 disease compared to community-acquired disease. This finding suggests that infection prevention strategies (including masks and eye protection) may be mitigating inoculum and supports the variolation theory in COVID-19.

Stroke Prevention in Symptomatic Large Artery Intracranial Atherosclerosis Practice Advisory: Report of the AAN Guideline Subcommittee.

BACKGROUND AND OBJECTIVES: To review treatments for reducing the risk of recurrent stroke or death in patients with symptomatic intracranial atherosclerotic arterial stenosis (sICAS). METHODS: The development of this practice advisory followed the process outlined in the American Academy of Neurology Clinical Practice Guideline Process Manual, 2011 Edition, as amended. The systematic review included studies through November 2020. Recommendations were based on evidence, related evidence, principles of care, and inferences. MAJOR RECOMMENDATIONS: Clinicians should recommend aspirin 325 mg/d for long-term prevention of stroke and death and should recommend adding clopidogrel 75 mg/d to aspirin for up to 90 days to further reduce stroke risk in patients with severe (70%-99%) sICAS who have low risk of hemorrhagic transformation. Clinicians should recommend high-intensity statin therapy to achieve a goal low-density lipoprotein cholesterol level <70 mg/dL, a long-term blood pressure target of <140/90 mm Hg, at least moderate physical activity, and treatment of other modifiable vascular risk factors for patients with sICAS. Clinicians should not recommend percutaneous transluminal angioplasty and stenting for stroke prevention in patients with moderate (50%-69%) sICAS or as the initial treatment for stroke prevention in patients with severe sICAS. Clinicians should not routinely recommend angioplasty alone or indirect bypass for stroke prevention in patients with sICAS outside clinical trials. Clinicians should not recommend direct bypass for stroke prevention in patients with sICAS. Clinicians should counsel patients about the risks of percutaneous transluminal angioplasty and stenting and alternative treatments if one of these procedures is being contemplated.

Lack of association between decompressive craniectomy and conversion to donor status.

There has been a recent resurgence in the use of decompressive craniectomy (DC) following severe brain injury. The aim of this study was to evaluate any association between DC and solid organ donation. We performed a retrospective, single-center, cohort study involving referrals to the local organ procurement organization, excluding those with anoxic brain injury. Of subjects referred, 64 (53%) were deemed eligible for donation and 29 (24%) converted to donor status. DC was performed with similar frequency in donors and non-donors (41% vs. 29%; p = 0.23). Patients with DC had similar odds of donation as those without DC (odds ratio 1.70, 95% CI 0.72-4.03), including after adjustment for age and Glasgow Coma Scale score (odds ratio 1.31, 95% CI 0.53-3.24). The most common reason eligible patients failed to convert to donor status was failure to pursue organ procurement because of the belief that the patient would not progress to neurological death or be a candidate for donation following cardiac death. Decompressive craniectomy was not uncommon among referrals to organ procurement organizations who ultimately become solid organ donors. Continued communication between the organ donation coordinators and the treating team has potential to decrease missed opportunities for organ donation.

Real-time ultrasound-guided percutaneous dilatational tracheostomy: a feasibility study.

INTRODUCTION: Ultrasound (US) performed prior to percutaneous tracheostomy (PT) may be useful in avoiding injury to pretracheal vascular structures and in avoiding high placement of the tube. Bedside real-time US guidance with visualization of needle path is routinely utilized for other procedures such as central venous catheterization, and may enhance the safety and accuracy of PT without causing airway occlusion or hypercarbia. Our objective was to demonstrate that PT performed under real-time US guidance with visualization of needle path during tracheal puncture is feasible, including in patients with features that increase the technical difficulty of PT. METHODS: Mechanically ventilated patients with acute brain injury requiring tracheostomy underwent US guided PT. The orotracheal tube was withdrawn using direct laryngoscopy. The trachea was punctured under real-time US guidance (with visualization of the needle path) while using the acoustic shadows of the cricoid and the tracheal rings to identify the level of puncture. After guidewire passage the site and level of entry was verified using the bronchoscope, which was then withdrawn. Following dilatation and tube placement, placement in the airway was confirmed using auscultation and the "lung sliding" sign on US. Bronchoscopy and chest X-ray were then performed to identify any complications. RESULTS: Thirteen patients successfully underwent US guided PT. Three patients were morbidly obese, two were in cervical spine precautions and one had a previous tracheostomy. In all 13 patients bronchoscopy confirmed that guidewire entry was through the anterior wall and between the first and fifth tracheal rings. There was no case of tube misplacement, pneumothorax, posterior wall injury, significant bleeding or other complication during the procedure. CONCLUSIONS: Percutaneous tracheostomy performed under real-time ultrasound guidance is feasible and appears accurate and safe, including in patients with morbid obesity and cervical spine precautions. Larger studies are required to further define the safety and relative benefits of this technique. TRIAL REGISTRATION: UMIN Clinical Trials Registry, UMIN000005023.

Locally-administered intrathecal thrombolytics following aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis.

BACKGROUND: The volume and clearance rate of blood in the basal cisterns and ventricles are important predictors of complications following aneurysmal subarachnoid hemorrhage (SAH). Thus, there is a strong rationale for interventions aimed at accelerating the clearance of blood. METHODS: We systematically searched MEDLINE, EMBASE, Cochrane databases, references of review articles and gray literature sources to identify randomized controlled trials (RCTs) assessing the efficacy of locally-administered, intrathecal thrombolytics in patients with SAH. Primary outcomes included the occurrence of poor neurologic recovery and delayed neurologic deficits (DNDs). Secondary outcomes included angiographic vasospasm, chronic hydrocephalus and treatment-related complications. Data were extracted and appraised independently and in duplicate, using standardized forms. Fixed or random effects models, as appropriate based on the degree of study heterogeneity were applied to calculate summary measures. RESULTS: Five RCTs, enrolling 465 patients, met eligibility criteria. The methodology, results and risk of bias varied considerably across individual studies. Overall, use of intrathecal thrombolytics was associated with significant reductions in the development of poor outcomes (OR 0.52, 0.34-0.78, P < 0.01), DNDs (OR 0.54, 0.34-0.87, P = 0.01), angiographic vasospasm (OR 0.32, 0.15-0.70, P < 0.01) and chronic hydrocephalus (OR 0.33, 0.15-0.74, P < 0.01), without any increment in hemorrhagic or infectious complications. These findings were dampened by the exclusion of a study which concomitantly administered intrathecal vasodilators and thrombolytics. CONCLUSIONS: Current data suggests that intrathecal thrombolytics improve outcomes following SAH. However, there are important limitations to existing RCTs, with considerable risk of bias. Further standardization of techniques and evaluation in larger, more rigorous RCTs is required.

The clinical significance of peripherally inserted central venous catheter-related deep vein thrombosis.

BACKGROUND: Peripherally inserted central venous catheters (PICCs) are being increasingly utilized in hospitalized patients as alternatives to centrally inserted central venous catheters (CICVCs). However, concern exists over the risk of PICC-related large vein thrombosis (PRLVT). The incidence rate and significance of symptomatic PRLVT in critically ill patients admitted to the neurological intensive care unit (ICU) is not known. METHODS: Retrospective descriptive study of consecutive PICCs placed in critically ill patients admitted to a tertiary care neurological ICU between March 2008 and February 2010. Symptomatic PRVLT was defined as an event that prompted Duplex ultrasound of the ipsilateral extremity in which an acute, proximal large vein thrombosis was confirmed in association with the PICC or confirmed within 5 days of PICC removal. Incidence rate of PRLVT and catheter-related complications were calculated per "line" (catheter). Descriptive statistics were performed with two-sample, and t-tests for age and categorical variables were assessed by Chi-square test or Fishers exact test as appropriate RESULTS: Four hundred and seventy-nine lines were placed during the study period with 39 developing a symptomatic PRLVT (incidence rate = 8.1%). Male gender was associated with development of a thrombosis (P = 0.02), but size (P = 0.21) and location of catheter were not (P = 0.30). Median line dwell time was 12 days (IQR 16) with a dwell time of 8 days (IQR 9) until thrombosis diagnosis. Pulmonary embolus attributed to PRLVT occurred in 1.3% of line placements and 15% of symptomatic PRLVT. The majority of patients had their line removed. In addition, some patients also had anticoagulation initiated or a superior vena cava filter placed. CONCLUSIONS: Symptomatic PRLVT is not uncommon in critically ill patients admitted to the neurological ICU. Future research should focus on indentifying modifiable risk factors for PRLVT and on comparing major cumulative complication rates between PICCs and CICVCs.

Optic nerve ultrasound for the detection of raised intracranial pressure.

BACKGROUND: Optic nerve ultrasonography (ONUS) may help identify raised intracranial pressure (ICP). The optimal optic nerve sheath diameter (ONSD) cut-off for the identification of intracranial hypertension has not been established, with some clinical studies suggesting a higher cut-off than may be expected on the basis of prior laboratory investigation. OBJECTIVE: To validate ONUS performed by neurointensivists as a technique for the detection of intracranial hypertension and identify the optimal ONSD criterion for the detection of ICP > 20 mmHg. METHODS: Prospective blinded observational study. Patients in the ICU with either external ventricular drains or intraparenchymal ICP monitors at risk for intracranial hypertension were enrolled. The ONSD was measured by neurointensivists at the bedside with simultaneous invasive ICP measurement. An ROC curve was constructed to determine the optimal ONSD for the detection of ICP >  20 mmHg. MEASUREMENTS AND RESULTS: A total of 536 ONSD measurements were performed on 65 patients. Diagnoses included subarachnoid hemorrhage, traumatic brain injury, intracerebral hemorrhage, ischemic stroke and brain tumor. ROC curve analysis revealed area under the curve (AUC) = 0.98 (95% CI 0.96-0.99; P < 0.0001 for AUC = 0.5). Optimal ONSD for detection of ICP > 20 mmHg was ≥0.48 cm sensitivity 96% (95% CI 91-99%); specificity 94% (92-96%). Sensitivity of the higher cutoff of ≥0.52 cm proposed by some authors was only 67% (58-75%), with specificity 98% (97-99%). CONCLUSIONS: Bedside ONSD measurement, performed by neurointensivists, is an accurate, non-invasive method to identify ICP > 20 mmHg in a heterogeneous group of patients with acute brain injury. ONSD ≥0.48 cm has the greatest accuracy, however, internal validation of ONSD criteria may be required.