Nationwide trends in intensive care unit utilization in the elective endovascular treatment of unruptured intracranial aneurysms.

OBJECTIVE: Multiple studies suggest routine post-operative intensive care unit (ICU) stays after endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs) is unnecessary, though rates of ICU utilization nationwide are unknown. We aim to evaluate rates and characteristics of ICU utilization in patients undergoing elective endovascular repair of UIAs. METHODS: This is a retrospective cohort study utilizing a nationwide private-payer database in the United States to evaluate the ICU utilization in patients undergoing elective endovascular repair of UIAs between 2005 and 2019. Demographics and pre-operative comorbidities as well as post-procedural complications and discharge status were compared. An analysis of charges and costs was also performed. RESULTS: Among 6218 patients who underwent elective EVT of a UIA, 4890 (78.6%) were admitted to the ICU post-operatively. There were no differences in age, sex, or Charlson comorbidity scores in patients admitted to the ICU post-operatively compared to those admitted elsewhere. ICU utilization was more common in urban locations compared to rural. 12.7% of patients had ICU-specific needs sufficient to be billed by a critical care provider. Total provider costs were significantly higher in patients utilizing the ICU post-operatively, even among uncomplicated patients with routine discharges. CONCLUSION: Most patients undergoing elective endovascular UIA repair in the United States are admitted to the ICU postoperatively. Only 12.7% have ICU needs, and these patients are predictable from pre-operative characteristics or peri-operative complications. Reducing ICU use in this subgroup of patients may be an important target to improve healthcare value in this patient population.

Early Celecoxib use in Patients with Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury (TBI) can cause rapid brain inflammation. There is debate over the safety and efficacy of anti-inflammatory agents in its treatment. With a particular focus on cyclooxygenase 2 (COX2) selective inhibition, we sought to determine the impact of celecoxib versus no celecoxib treatment on outcomes in patients with TBI and compare these with outcomes associated with nonselective COX inhibition (ibuprofen) and corticosteroid (dexamethasone) treatment. METHODS: This retrospective cohort study used TriNetX, a large publicly available global health research network, to gather clinical data extracted from the electronic medical records. Using International Classification of Diseases, Tenth Revision and pharmacy codes, we identified patients with TBI who were and were not treated with celecoxib, ibuprofen, and dexamethasone. Analysis was performed on propensity-matched and unmatched cohorts, which were matched on demographics, comorbidities, and neurological injuries. Our primary end point was 1-year survival. Secondary end points were ventilator and tracheostomy dependence, gastrostomy tube placement, seizures, and craniotomy. RESULTS: After propensity score matching, a total of 1443 patients were identified in both the celecoxib and no celecoxib cohorts. Ninety-two (6.4%) patients in the celecoxib cohort died within 1 year following TBI versus 145 (10.0%) in the no celecoxib cohort (odds ratio 0.61; 95% confidence interval 0.46-0.80; p = 0.0003). The 1-year survival rate was 96.1% in the celecoxib cohort versus 93.1% in the no celecoxib cohort (p < 0.0001). At the end of the 1-year period, celecoxib was associated with significantly lower gastrostomy tube dependence (p = 0.017), seizure activity (p = 0.027), and myocardial infarction (p = 0.021) compared with the control cohort. Ibuprofen was also associated with higher 1-year survival probability and lower rates of post-TBI complications. Dexamethasone was broadly associated with higher morbidity but was associated with higher 1-year survival probability compared with the no dexamethasone cohort. CONCLUSIONS: Early celecoxib and ibuprofen use within 5 days post TBI was associated with higher 1-year survival probabilities and fewer complications. With emerging yet controversial preclinical evidence to suggest that COX inhibition improves TBI outcomes, this population-level study offers suggestive support for these drugs' clinical benefit, which should be pursued in prospective clinical studies.

Enrollment of research subjects through telemedicine networks in a multicenter acute intracerebral hemorrhage clinical trial: design and methods.

BACKGROUND: Enrollment of subjects in acute stroke trials is often hindered by narrow timeframes, because a large proportion of patients arrive via transfers from outside facilities rather than primary arrival at the enrolling hospital. RATIONALE: Telemedicine networks have been increasingly used for provision of care for acute stroke patients at facilities outside of major academic centers. Treatment decisions made through telemedicine networks in patients with acute ischemic stroke have been shown to be safe, reliable, and effective. With the expanding use of this technology and the impediments to enrolling subjects into clinical trials, this approach can be applied successfully to the field of clinical research. METHODS AND CONCLUSIONS: The Antihypertensive Treatment of Acute Cerebral Hemorrhage II trial is a phase III randomized multicenter trial that has developed a protocol in collaboration with participating sites to implement the use of telemedicine networks for the enrollment of research subjects. The protocol describes the operating procedures and legal and Institutional Review Board perspectives for its implementation.

Enrollment of Research Subjects through Telemedicine Networks in a Multicenter Acute Intracerebral Hemorrhage Clinical Trial: Design and Methods.

BACKGROUND: Enrollment of subjects in acute stroke trials is often hindered by narrow timeframes, because a large proportion of patients arrive via transfers from outside facilities rather than primary arrival at the enrolling hospital. RATIONALE: Telemedicine networks have been increasingly utilized for provision of care for acute stroke patients at facilities outside of major academic centers. Treatment decisions made through Telemedicine networks in patients with acute ischemic stroke have been shown to be safe, reliable, and effective. With the expanding use of this technology and the impediments to enrolling subjects into clinical trials, this approach can be applied successfully to the field of clinical research. METHODS AND CONCLUSIONS: The antihypertensive treatment of acute cerebral hemorrhage II trial is a phase III randomized multicenter trial that has developed a protocol in collaboration with participating sites to implement the use of Telemedicine networks for the enrollment of research subjects. The protocol describes the operating procedures and legal and Institutional Review Board perspectives for its implementation.