A trial of imaging selection and endovascular treatment for ischemic stroke.

BACKGROUND: Whether brain imaging can identify patients who are most likely to benefit from therapies for acute ischemic stroke and whether endovascular thrombectomy improves clinical outcomes in such patients remains unclear. METHODS: In this study, we randomly assigned patients within 8 hours after the onset of large-vessel, anterior-circulation strokes to undergo mechanical embolectomy (Merci Retriever or Penumbra System) or receive standard care. All patients underwent pretreatment computed tomography or magnetic resonance imaging of the brain. Randomization was stratified according to whether the patient had a favorable penumbral pattern (substantial salvageable tissue and small infarct core) or a nonpenumbral pattern (large core or small or absent penumbra). We assessed outcomes using the 90-day modified Rankin scale, ranging from 0 (no symptoms) to 6 (dead). RESULTS: Among 118 eligible patients, the mean age was 65.5 years, the mean time to enrollment was 5.5 hours, and 58% had a favorable penumbral pattern. Revascularization in the embolectomy group was achieved in 67% of the patients. Ninety-day mortality was 21%, and the rate of symptomatic intracranial hemorrhage was 4%; neither rate differed across groups. Among all patients, mean scores on the modified Rankin scale did not differ between embolectomy and standard care (3.9 vs. 3.9, P=0.99). Embolectomy was not superior to standard care in patients with either a favorable penumbral pattern (mean score, 3.9 vs. 3.4; P=0.23) or a nonpenumbral pattern (mean score, 4.0 vs. 4.4; P=0.32). In the primary analysis of scores on the 90-day modified Rankin scale, there was no interaction between the pretreatment imaging pattern and treatment assignment (P=0.14). CONCLUSIONS: A favorable penumbral pattern on neuroimaging did not identify patients who would differentially benefit from endovascular therapy for acute ischemic stroke, nor was embolectomy shown to be superior to standard care. (Funded by the National Institute of Neurological Disorders and Stroke; MR RESCUE ClinicalTrials.gov number, NCT00389467.).

Predictive combinations of monitor alarms preceding in-hospital code blue events.

Bedside monitors are ubiquitous in acute care units of modern healthcare enterprises. However, they have been criticized for generating an excessive number of false positive alarms causing alarm fatigue among care givers and potentially compromising patient safety. We hypothesize that combinations of regular monitor alarms denoted as SuperAlarm set may be more indicative of ongoing patient deteriorations and hence predictive of in-hospital code blue events. The present work develops and assesses an alarm mining approach based on finding frequent combinations of single alarms that are also specific to code blue events to compose a SuperAlarm set. We use 4-way analysis of variance (ANOVA) to investigate the influence of four algorithm parameters on the performance of the data mining approach. The results are obtained from millions of monitor alarms from a cohort of 223 adult code blue and 1768 control patients using a multiple 10-fold cross-validation experiment setup. Using the optimal setting of parameters determined in the cross-validation experiment, final SuperAlarm sets are mined from the training data and used on an independent test data set to simulate running a SuperAlarm set against live regular monitor alarms. The ANOVA shows that the content of a SuperAlarm set is influenced by a subset of key algorithm parameters. Simulation of the extracted SuperAlarm set shows that it can predict code blue events one hour ahead with sensitivity between 66.7% and 90.9% while producing false SuperAlarms for control patients that account for between 2.2% and 11.2% of regular monitor alarms depending on user-supplied acceptable false positive rate. We conclude that even though the present work is still preliminary due to the usage of a moderately-sized database to test our hypothesis it represents an effort to develop algorithms to alleviate the alarm fatigue issue in a unique way.

Intensive care unit robotic telepresence facilitates rapid physician response to unstable patients and decreased cost in neurointensive care.

BACKGROUND: The timely assessment and treatment of ICU patients is important for neurosurgeons and neurointensivists. We hypothesized that the use of RTP can improve physician rapid response to unstable ICU patients. METHODS: This is a prospective study using a before-after, cohort-control design to test the effectiveness of RTP. Physicians used RTP to make rounds in the ICU in response to nursing pages. Data concerning several aspects of the RTP interaction including the latency of the response, the problem being treated, the intervention that was ordered, and the type of information gathered using the RTP were documented. The effect of RTP on ICU length of stay and cost was assessed. RESULTS: The use of RTP was associated with a reduction in latency of attending physician face-to-face response for routine and urgent pages compared to conventional care (RTP: 9.2 +/- 9.3 minutes vs conventional: 218 +/- 186 minutes). The response latencies to brain ischemia (7.8 +/- 2.8 vs 152 +/- 85 minutes) and elevated ICP (11 +/- 14 vs 108 +/- 55 minutes) were reduced (P < .001), as was the LOS for patients with SAH (2 days) and brain trauma (1 day). There was an increase in ICU occupancy by 11% compared with the prerobot era, and there was an ICU cost savings of $1.1 million attributable to the use of RTP. CONCLUSION: The use of RTP enabled rapid face-to-face attending physician response to ICU patients and resulted in decreased ICU cost and LOS.

Anesthesiology Point of Care project.

We are developing a dynamic prototype visual communication system for the operating room environs. This has classically been viewed as an isolated and impenetrable workplace. All medical experiences and all teaching remain in a one to one closed loop with no recall or subsequent sharing for the training and education of other colleagues. The "Anesthesia Point of Care" (APOC) concept embraces the sharing of, recording of, and presentation of various physiological and pharmacological events so that real time memory can be shared at a later time for the edification of other colleagues who were not present at the time of the primary learning event. In addition it also provides a remarkably rapid tool for fellow faculty to respond to obvious stress and crisis events that can be broadcast instantly at the time of happening. Finally, it also serves as an efficient and effective means of paging and general communication throughout the daily routines among various healthcare providers in anesthesiology who work as a team unit; these include the staff, residents, CRNAs, physician assistants, and technicians. This system offers a unique opportunity to eventually develop future advanced ideas that can include training exercises, presurgical evaluations, surgical scheduling and improvements in efficiency based upon earlier than expected case completion or conversely later than expected case completion and even as a unique window to development of improved billing itemization and coordination.

Design and rationale of the Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE) Trial.

RATIONALE: Multimodal imaging has the potential to identify acute ischaemic stroke patients most likely to benefit from late recanalization therapies. AIMS: The general aim of the Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy Trial is to investigate whether multimodal imaging can identify patients who will benefit substantially from mechanical embolectomy for the treatment of acute ischaemic stroke up to eight-hours from symptom onset. DESIGN: Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy is a randomized, controlled, blinded-outcome clinical trial. POPULATION STUDIED: Acute ischaemic stroke patients with large vessel intracranial internal carotid artery or middle cerebral artery M1 or M2 occlusion enrolled within eight-hours of symptom onset are eligible. The study sample size is 120 patients. STUDY INTERVENTION: Patients are randomized to endovascular embolectomy employing the Merci Retriever (Concentric Medical, Mountain View, CA) or the Penumbra System (Penumbra, Alameda, CA) vs. standard medical care, with randomization stratified by penumbral pattern. OUTCOMES: The primary aim of the trial is to test the hypothesis that the presence of substantial ischaemic penumbral tissue visualized on multimodal imaging (magnetic resonance imaging or computed tomography) predicts patients most likely to respond to mechanical embolectomy for treatment of acute ischaemic stroke due to a large vessel, intracranial occlusion up to eight-hours from symptom onset. This hypothesis will be tested by analysing whether pretreatment imaging pattern has a significant interaction with treatment as a determinant of functional outcome based on the distribution of scores on the modified Rankin Scale measure of global disability assessed 90 days post-stroke. Nested hypotheses test for (1) treatment efficacy in patients with a penumbral pattern pretreatment, and (2) absence of treatment benefit (equivalency) in patients without a penumbral pattern pretreatment. An additional aim will only be tested if the primary hypothesis of an interaction is negative: that patients treated with mechanical embolectomy have improved functional outcome vs. standard medical management.