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Biousse V, Najjar RP, Tang Z, Lin MY, Wright DW, Keadey MT, Wong TY, Bruce BB, Milea D, Newman NJ. Application of a Deep Learning System to Detect Papilledema on Nonmydriatic Ocular Fundus Photographs in an Emergency Department. Am J Ophthalmol 2024; 261:199-207. [PMID: 37926337 DOI: 10.1016/j.ajo.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/26/2023] [Accepted: 10/26/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE The Fundus photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department (FOTO-ED) studies showed that ED providers poorly recognized funduscopic findings in patients in the ED. We tested a modified version of the Brain and Optic Nerve Study Artificial Intelligence (BONSAI) deep learning system on nonmydriatic fundus photographs from the FOTO-ED studies to determine if the deep learning system could have improved the detection of papilledema had it been available to ED providers as a real-time diagnostic aid. DESIGN Retrospective secondary analysis of a cohort of patients included in the FOTO-ED studies. METHODS The testing data set included 1608 photographs obtained from 828 patients in the FOTO-ED studies. Photographs were reclassified according to the optic disc classification system used by the deep learning system ("normal optic discs," "papilledema," and "other optic disc abnormalities"). The system's performance was evaluated by calculating the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity using a 1-vs-rest strategy, with reference to expert neuro-ophthalmologists. RESULTS The BONSAI deep learning system successfully distinguished normal from abnormal optic discs (AUC 0.92 [95% confidence interval {CI} 0.90-0.93]; sensitivity 75.6% [73.7%-77.5%] and specificity 89.6% [86.3%-92.8%]), and papilledema from normal and others (AUC 0.97 [0.95-0.99]; sensitivity 84.0% [75.0%-92.6%] and specificity 98.9% [98.5%-99.4%]). Six patients with missed papilledema in 1 eye were correctly identified by the deep learning system as having papilledema in the other eye. CONCLUSIONS The BONSAI deep learning system was able to reliably identify papilledema and normal optic discs on nonmydriatic photographs obtained in the FOTO-ED studies. Our deep learning system has excellent potential as a diagnostic aid in EDs and non-ophthalmology clinics equipped with nonmydriatic fundus cameras. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.
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Affiliation(s)
- Valérie Biousse
- From the Department of Ophthalmology (V.B., M.Y.L., B.B.B., N.J.N.), Emory University School of Medicine, Atlanta, Georgia, USA; Department of Neurology (V.B., B.B.B., N.J.N.), Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Raymond P Najjar
- Singapore Eye Research Institute and Singapore National Eye Centre (R.P.N., Z.T., T.Y.W., D.M.), Singapore; Duke-NUS Medical School (R.P.N., T.Y.W., D.M.), National University of Singapore, Singapore; Eye N' Brain Research Group (R.P.N.), Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Center for Innovation and Precision Eye Health (R.P.N.), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Zhiqun Tang
- Singapore Eye Research Institute and Singapore National Eye Centre (R.P.N., Z.T., T.Y.W., D.M.), Singapore
| | - Mung Yan Lin
- From the Department of Ophthalmology (V.B., M.Y.L., B.B.B., N.J.N.), Emory University School of Medicine, Atlanta, Georgia, USA
| | - David W Wright
- Department of Emergency Medicine (D.W.W., M.T.K.), Emory University School of Medicine, Atlanta, Georgia, USA
| | - Matthew T Keadey
- Department of Emergency Medicine (D.W.W., M.T.K.), Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tien Y Wong
- Singapore Eye Research Institute and Singapore National Eye Centre (R.P.N., Z.T., T.Y.W., D.M.), Singapore; Duke-NUS Medical School (R.P.N., T.Y.W., D.M.), National University of Singapore, Singapore; Tsinghua Medicine (T.Y.W.), Tsinghua University, China
| | - Beau B Bruce
- From the Department of Ophthalmology (V.B., M.Y.L., B.B.B., N.J.N.), Emory University School of Medicine, Atlanta, Georgia, USA; Department of Neurology (V.B., B.B.B., N.J.N.), Emory University School of Medicine, Atlanta, Georgia, USA; Rollins School of Public Health (B.B.B.), Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dan Milea
- Singapore Eye Research Institute and Singapore National Eye Centre (R.P.N., Z.T., T.Y.W., D.M.), Singapore; Duke-NUS Medical School (R.P.N., T.Y.W., D.M.), National University of Singapore, Singapore
| | - Nancy J Newman
- From the Department of Ophthalmology (V.B., M.Y.L., B.B.B., N.J.N.), Emory University School of Medicine, Atlanta, Georgia, USA; Department of Neurology (V.B., B.B.B., N.J.N.), Emory University School of Medicine, Atlanta, Georgia, USA; Department of Neurological Surgery (N.J.N.), Emory University School of Medicine, Atlanta, Georgia, USA
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Pradilla G, Ratcliff JJ, Hall AJ, Saville BR, Allen JW, Paulon G, McGlothlin A, Lewis RJ, Fitzgerald M, Caveney AF, Li XT, Bain M, Gomes J, Jankowitz B, Zenonos G, Molyneaux BJ, Davies J, Siddiqui A, Chicoine MR, Keyrouz SG, Grossberg JA, Shah MV, Singh R, Bohnstedt BN, Frankel M, Wright DW, Barrow DL. Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage. N Engl J Med 2024; 390:1277-1289. [PMID: 38598795 DOI: 10.1056/nejmoa2308440] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
BACKGROUND Trials of surgical evacuation of supratentorial intracerebral hemorrhages have generally shown no functional benefit. Whether early minimally invasive surgical removal would result in better outcomes than medical management is not known. METHODS In this multicenter, randomized trial involving patients with an acute intracerebral hemorrhage, we assessed surgical removal of the hematoma as compared with medical management. Patients who had a lobar or anterior basal ganglia hemorrhage with a hematoma volume of 30 to 80 ml were assigned, in a 1:1 ratio, within 24 hours after the time that they were last known to be well, to minimally invasive surgical removal of the hematoma plus guideline-based medical management (surgery group) or to guideline-based medical management alone (control group). The primary efficacy end point was the mean score on the utility-weighted modified Rankin scale (range, 0 to 1, with higher scores indicating better outcomes, according to patients' assessment) at 180 days, with a prespecified threshold for posterior probability of superiority of 0.975 or higher. The trial included rules for adaptation of enrollment criteria on the basis of hemorrhage location. A primary safety end point was death within 30 days after enrollment. RESULTS A total of 300 patients were enrolled, of whom 30.7% had anterior basal ganglia hemorrhages and 69.3% had lobar hemorrhages. After 175 patients had been enrolled, an adaptation rule was triggered, and only persons with lobar hemorrhages were enrolled. The mean score on the utility-weighted modified Rankin scale at 180 days was 0.458 in the surgery group and 0.374 in the control group (difference, 0.084; 95% Bayesian credible interval, 0.005 to 0.163; posterior probability of superiority of surgery, 0.981). The mean between-group difference was 0.127 (95% Bayesian credible interval, 0.035 to 0.219) among patients with lobar hemorrhages and -0.013 (95% Bayesian credible interval, -0.147 to 0.116) among those with anterior basal ganglia hemorrhages. The percentage of patients who had died by 30 days was 9.3% in the surgery group and 18.0% in the control group. Five patients (3.3%) in the surgery group had postoperative rebleeding and neurologic deterioration. CONCLUSIONS Among patients in whom surgery could be performed within 24 hours after an acute intracerebral hemorrhage, minimally invasive hematoma evacuation resulted in better functional outcomes at 180 days than those with guideline-based medical management. The effect of surgery appeared to be attributable to intervention for lobar hemorrhages. (Funded by Nico; ENRICH ClinicalTrials.gov number, NCT02880878.).
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Affiliation(s)
- Gustavo Pradilla
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Jonathan J Ratcliff
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Alex J Hall
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Benjamin R Saville
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Jason W Allen
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Giorgio Paulon
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Anna McGlothlin
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Roger J Lewis
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Mark Fitzgerald
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Angela F Caveney
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Xiao T Li
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Mark Bain
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Joao Gomes
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Brain Jankowitz
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Georgios Zenonos
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Bradley J Molyneaux
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Jason Davies
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Adnan Siddiqui
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Michael R Chicoine
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Salah G Keyrouz
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Jonathan A Grossberg
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Mitesh V Shah
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Ranjeet Singh
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Bradley N Bohnstedt
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Michael Frankel
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - David W Wright
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Daniel L Barrow
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
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Bark D, Boman M, Depreitere B, Wright DW, Lewén A, Enblad P, Hånell A, Rostami E. Refining outcome prediction after traumatic brain injury with machine learning algorithms. Sci Rep 2024; 14:8036. [PMID: 38580767 PMCID: PMC10997790 DOI: 10.1038/s41598-024-58527-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 04/01/2024] [Indexed: 04/07/2024] Open
Abstract
Outcome after traumatic brain injury (TBI) is typically assessed using the Glasgow outcome scale extended (GOSE) with levels from 1 (death) to 8 (upper good recovery). Outcome prediction has classically been dichotomized into either dead/alive or favorable/unfavorable outcome. Binary outcome prediction models limit the possibility of detecting subtle yet significant improvements. We set out to explore different machine learning methods with the purpose of mapping their predictions to the full 8 grade scale GOSE following TBI. The models were set up using the variables: age, GCS-motor score, pupillary reaction, and Marshall CT score. For model setup and internal validation, a total of 866 patients could be included. For external validation, a cohort of 369 patients were included from Leuven, Belgium, and a cohort of 573 patients from the US multi-center ProTECT III study. Our findings indicate that proportional odds logistic regression (POLR), random forest regression, and a neural network model achieved accuracy values of 0.3-0.35 when applied to internal data, compared to the random baseline which is 0.125 for eight categories. The models demonstrated satisfactory performance during external validation in the data from Leuven, however, their performance were not satisfactory when applied to the ProTECT III dataset.
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Affiliation(s)
- D Bark
- Department of Medical Sciences Neurosurgery, Uppsala University, Uppsala, Sweden
| | - M Boman
- Division of Clinical Epidemiology, Department of Medicine Solna, Stockholm, Sweden
- Department of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - B Depreitere
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - D W Wright
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - A Lewén
- Department of Medical Sciences Neurosurgery, Uppsala University, Uppsala, Sweden
| | - P Enblad
- Department of Medical Sciences Neurosurgery, Uppsala University, Uppsala, Sweden
| | - A Hånell
- Department of Medical Sciences Neurosurgery, Uppsala University, Uppsala, Sweden
| | - E Rostami
- Department of Medical Sciences Neurosurgery, Uppsala University, Uppsala, Sweden.
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden.
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Ray HJ, Okrent Smolar AL, Dattilo M, Bouthour W, Berman G, Peragallo JH, Kedar S, Pendley AM, Greene JG, Keadey MT, Wright DW, Bruce BB, Newman NJ, Biousse V. The Increasing Burden of Emergency Department and Inpatient Consultations for "Papilledema". J Neuroophthalmol 2024:00041327-990000000-00596. [PMID: 38502219 DOI: 10.1097/wno.0000000000002120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Increasing incidence of idiopathic intracranial hypertension (IIH), overreported radiologic signs of intracranial hypertension, difficult access to outpatient neuro-ophthalmology services, poor insurance coverage, and medicolegal concerns have lowered the threshold for emergency department (ED) visits for "papilledema." Our objective was to examine referral patterns and outcomes of neuro-ophthalmology ED and inpatient consultations for concern for papilledema. METHODS At one university-based quaternary care center, all adults referred for "papilledema" over one year underwent a standardized ED "papilledema protocol." We collected patient demographics, final diagnoses, and referral patterns. RESULTS Over 1 year, 153 consecutive patients were referred for concern for papilledema. After papilledema protocol, 89 of 153 patients (58%) had bilateral optic disc edema, among whom 89% (79/89) had papilledema (intracranial hypertension). Of the 38 of 153 (25%) consultations for suspected disorder of intracranial pressure without previous fundus examination (Group 1), 74% (28/38) did not have optic disc edema, 21% (8/38) had papilledema, and 5% (2/38) had other causes of bilateral disc edema. Of the 89 of 153 (58%) consultations for presumed papilledema seen on fundus examination (Group 2), 58% (66/89) had confirmed papilledema, 17% (15/89) had pseudopapilledema, and 9% (8/89) had other causes of bilateral optic disc edema. Of the 26 of 153 (17%) patients with known IIH (Group 3), 5 had papilledema and 4 required urgent intervention. The most common diagnosis was IIH (58/79). Compared with IIH, patients with secondary causes of intracranial hypertension were older (P = 0.002), men (P < 0.001), not obese (P < 0.001), and more likely to have neurologic symptoms (P = 0.002). CONCLUSION Inpatient and ED consultations for "papilledema" are increasing. Of the 153 ED and inpatient neuro-ophthalmology consultations seen for "papilledema" over 1 year, one-third of patients with optic disc edema of unknown cause before presentation to our ED had new vision- or life-threatening disease, supporting the need for prompt identification and evaluation of optic disc edema in the ED. In the face of limited access to neuro-ophthalmologists, this study supports the need for emergency department access to expert eye-care evaluation or ocular fundus camera for prompt identification of optic disc edema and standardized evaluation for neurologic emergencies.
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Affiliation(s)
- Hetal J Ray
- Department of Ophthalmology (HJR, ALOS, MD, WB, GB, JHP, SK, BBB, NJN, VB), Neurology (SK, JGG, NJN, VB), and Emergency Medicine (AMP, MTK, DWW), Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology (BBB), Rollins School of Public Health, Emory University, Atlanta, Georgia; and Department of Neurological Surgery (NJN), Emory University School of Medicine, Atlanta, Georgia
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Busse LW, Schaich CL, Chappell MC, McCurdy MT, Staples EM, Ten Lohuis CC, Hinson JS, Sevransky JE, Rothman RE, Wright DW, Martin GS, Khanna AK. Association of Active Renin Content With Mortality in Critically Ill Patients: A Post hoc Analysis of the Vitamin C, Thiamine, and Steroids in Sepsis (VICTAS) Trial. Crit Care Med 2024; 52:441-451. [PMID: 37947484 PMCID: PMC10876175 DOI: 10.1097/ccm.0000000000006095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Sepsis is a leading cause of mortality. Predicting outcomes is challenging and few biomarkers perform well. Defects in the renin-angiotensin system (RAS) can predict clinical outcomes in sepsis and may outperform traditional biomarkers. We postulated that RAS dysfunction (elevated active renin, angiotensin 1-7 [Ang-(1-7)], and angiotensin-converting enzyme 2 (ACE2) activity with depressed Ang-II and ACE activity) would be associated with mortality in a cohort of septic patients. DESIGN Post hoc analysis of patients enrolled in the Vitamin C, Thiamine, and Steroids in Sepsis (VICTAS) randomized controlled trial. SETTING Forty-three hospitals across the United States. PATIENTS Biorepository samples of 103 patients. INTERVENTIONS We analyzed day 0 (within 24 hr of respiratory failure, septic shock, or both) and day 3 samples ( n = 103 and 95, respectively) for assessment of the RAS. The association of RAS values with 30-day mortality was determined using Cox proportional hazards regression with multivariable adjustments for age, sex, VICTAS treatment arm, systolic blood pressure, Sequential Organ Failure Assessment Score, and vasopressor use. MEASUREMENTS AND MAIN RESULTS High baseline active renin values were associated with higher 30-day mortality when dichotomized to the median of 188.7 pg/mL (hazard ratio [HR] = 2.84 [95% CI, 1.10-7.33], p = 0.031) or stratified into quartiles (Q1 = ref, HR Q2 = 2.01 [0.37-11.04], HR Q3 = 3.22 [0.64-16.28], HR Q4 = 5.58 [1.18-26.32], p for linear trend = 0.023). A 1- sd (593.6 pg/mL) increase in renin from day 0 to day 3 was associated with increased mortality (HR = 3.75 [95% CI, 1.94-7.22], p < 0.001), and patients whose renin decreased had improved survival compared with those whose renin increased (HR 0.22 [95% CI, 0.08-0.60], p = 0.003). Ang-(1-7), ACE2 activity, Ang-II and ACE activity did not show this association. Mortality was attenuated in patients with renin over the median on day 0 who received the VICTAS intervention, but not on day 3 ( p interaction 0.020 and 0.137, respectively). There were no additional consistent patterns of mortality on the RAS from the VICTAS intervention. CONCLUSIONS Baseline serum active renin levels were strongly associated with mortality in critically ill patients with sepsis. Furthermore, a greater relative activation in circulating renin from day 0 to day 3 was associated with a higher risk of death.
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Affiliation(s)
- Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Christopher L Schaich
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Mark C Chappell
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Erin M Staples
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University, The Johns Hopkins Hospital, Baltimore, MD
| | - David W Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
- Grady Marcus Trauma and Emergency Care Center, Atlanta, GA
| | - Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Ashish K Khanna
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Emergency Medicine, Johns Hopkins University, The Johns Hopkins Hospital, Baltimore, MD
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
- Grady Marcus Trauma and Emergency Care Center, Atlanta, GA
- Department of Anesthesiology, Section of Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
- Outcomes Research Consortium, Cleveland, OH
- Perioperative Outcomes and Informatics Collaborative, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC
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Okrent Smolar AL, Ray HJ, Dattilo M, Bouthour W, Berman G, Peragallo JH, Kedar S, Pendley AM, Greene JG, Keadey MT, Wright DW, Bruce BB, Newman NJ, Biousse V. Neuro-ophthalmology Emergency Department and Inpatient Consultations at a Large Academic Referral Center. Ophthalmology 2023; 130:1304-1312. [PMID: 37544433 DOI: 10.1016/j.ophtha.2023.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 07/17/2023] [Accepted: 07/31/2023] [Indexed: 08/08/2023] Open
Abstract
PURPOSE Prompt neuro-ophthalmology consultation prevents diagnostic errors and improves patient outcomes. The scarcity of neuro-ophthalmologists means that the increasing outpatient demand cannot be met, prompting many emergency department (ED) referrals by non-neuro-ophthalmologists. We describe our quaternary care institution's ED and inpatient neuro-ophthalmology consultation patterns and patient outcomes. DESIGN Prospective observational study. PARTICIPANTS Consecutive neuro-ophthalmology ED and inpatient consultation requests over 1 year. METHODS We collected patient demographics, distance traveled, insurance status, referring provider details, consultation question, final diagnosis, complexity of consultation, time of consultation, and need for outpatient follow-up. MAIN OUTCOME MEASURES Consultation patterns and diagnoses, complexity, and follow-up. RESULTS Of 494 consecutive adult ED and inpatient neuro-ophthalmology consultations requested over 1 year, 241 of 494 consultations (49%) occurred at night or during weekends. Of ED consultations (322 of 494 [65%]), 127 of 322 consultations (39%) occurred during weekdays, 126 of 322 consultations (39%) occurred on weeknights, and 69 of 322 consultations (22%) occurred on weekends or holidays. Of 322 ED consultations, 225 of 322 consultations (70%) were patients who initially sought treatment in the ED with a neuro-ophthalmic chief symptom. Of the 196 patients sent to the ED by a health care professional, 148 patients (148/196 [76%]) were referred by eye care specialists (74 optometrists and 74 ophthalmologists). The most common ED referral questions were for papilledema (75 of 322 [23%]) and vision loss (72 of 322 [22%]). A total of 219 of 322 patients (68%) received a final active neuro-ophthalmic diagnosis, 222 of 322 patients (69%) were cases of high or very high complexity, and 143 of 322 patients (44%) required admission. Inpatient consultations (n = 172) were requested most frequently by hospitalists, including neurologists (71 of 172 [41%]) and oncologists (20 of 172 [12%]) for vision loss (43 of 172 [25%]) and eye movement disorders (36 of 172 [21%]) and by neurosurgeons (58 of 172 [33%]) for examination for mass or a preoperative evaluation (19 of 172 [11%]). An active neuro-ophthalmic diagnosis was confirmed in 67% of patients (116 of 172). Outpatient neuro-ophthalmology follow-up was required for 291 of 494 patients (59%). CONCLUSIONS Neuro-ophthalmology consultations are critical to the diagnosis and management in the hospital setting. In the face of a critical shortage of neuro-ophthalmologists, this study highlights the need for technological and diagnostic aids for greater outpatient access. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
| | - Hetal J Ray
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Michael Dattilo
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Walid Bouthour
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Gabriele Berman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Jason H Peragallo
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Sachin Kedar
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Andrew M Pendley
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - James G Greene
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Matthew T Keadey
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - David W Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Beau B Bruce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Nancy J Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurology, Emory University School of Medicine, Atlanta, Georgia.
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7
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Moore RC, Kuehn KS, Heaton A, Sundermann EE, Campbell LM, Torre P, Umlauf A, Moore DJ, Kosoris N, Wright DW, LaPlaca MC, Waldrop D, Anderson AM. An Automated Virtual Reality Program Accurately Diagnoses HIV-Associated Neurocognitive Disorders in Older People With HIV. Open Forum Infect Dis 2023; 10:ofad592. [PMID: 38149107 PMCID: PMC10750141 DOI: 10.1093/ofid/ofad592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/27/2023] [Indexed: 12/28/2023] Open
Abstract
Background HIV-associated neurocognitive disorders (HANDs) remain prevalent despite antiretroviral therapy, particularly among older people with HIV (PWH). However, the diagnosis of HAND is labor intensive and requires expertise to administer neuropsychological tests. Our prior pilot work established the feasibility and accuracy of a computerized self-administered virtual reality program (DETECT; Display Enhanced Testing for Cognitive Impairment and Traumatic Brain Injury) to measure cognition in younger PWH. The present study expands this to a larger sample of older PWH. Methods We enrolled PWH who were ≥60 years old, were undergoing antiretroviral therapy, had undetectable plasma viral loads, and were without significant neuropsychological confounds. HAND status was determined via Frascati criteria. Regression models that controlled for demographic differences (age, sex, education, race/ethnicity) examined the association between DETECT's cognition module and both HAND status and Global Deficit Score (GDS) derived via traditional neuropsychological tests. Results Seventy-nine PWH (mean age, 66 years; 28% women) completed a comprehensive neuropsychological battery and DETECT's cognition module. Twenty-five (32%) had HAND based on the comprehensive battery. A significant correlation was found between the DETECT cognition module and the neuropsychological battery (r = 0.45, P < .001). Furthermore, in two separate regression models, HAND status (b = -0.79, P < .001) and GDS impairment status (b = -0.83, P < .001) significantly predicted DETECT performance. Areas under the curve for DETECT were 0.78 for differentiating participants by HAND status (HAND vs no HAND) and 0.85 for detecting GDS impairment. Conclusions The DETECT cognition module provides a novel means to identify cognitive impairment in older PWH. As DETECT is fully immersive and self-administered, this virtual reality tool holds promise as a scalable cognitive screening battery.
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Affiliation(s)
- Raeanne C Moore
- Department of Psychiatry, School of Medicine, University of California at San Diego, La Jolla, California, USA
| | - Kevin S Kuehn
- Department of Psychiatry, School of Medicine, University of California at San Diego, La Jolla, California, USA
| | - Anne Heaton
- Department of Psychiatry, School of Medicine, University of California at San Diego, La Jolla, California, USA
| | - Erin E Sundermann
- Department of Psychiatry, School of Medicine, University of California at San Diego, La Jolla, California, USA
| | - Laura M Campbell
- Department of Psychiatry, School of Medicine, University of California at San Diego, La Jolla, California, USA
- University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego State University, San Diego, California, USA
| | - Peter Torre
- San Diego State University, San Diego, California, USA
| | - Anya Umlauf
- Department of Psychiatry, School of Medicine, University of California at San Diego, La Jolla, California, USA
| | - David J Moore
- Department of Psychiatry, School of Medicine, University of California at San Diego, La Jolla, California, USA
| | | | - David W Wright
- Department of Emergency Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Michelle C LaPlaca
- Department of Biomedical Engineering, Georgia Tech and Emory University, Atlanta, Georgia, USA
| | - Drenna Waldrop
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Albert M Anderson
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
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8
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Yaseen A, Robertson C, Cruz Navarro J, Chen J, Heckler B, DeSantis SM, Temkin N, Barber J, Foreman B, Diaz-Arrastia R, Chesnut R, Manley GT, Wright DW, Vassar M, Ferguson AR, Markowitz AJ, Yamal JM. Integrating, Harmonizing, and Curating Studies With High-Frequency and Hourly Physiological Data: Proof of Concept from Seven Traumatic Brain Injury Data Sets. J Neurotrauma 2023; 40:2362-2375. [PMID: 37341031 DOI: 10.1089/neu.2023.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
Abstract
Research in severe traumatic brain injury (TBI) has historically been limited by studies with relatively small sample sizes that result in low power to detect small, yet clinically meaningful outcomes. Data sharing and integration from existing sources hold promise to yield larger more robust sample sizes that improve the potential signal and generalizability of important research questions. However, curation and harmonization of data of different types and of disparate provenance is challenging. We report our approach and experience integrating multiple TBI data sets containing collected physiological data, including both expected and unexpected challenges encountered in the integration process. Our harmonized data set included data on 1536 patients from the Citicoline Brain Injury Treatment Trial (COBRIT), Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial (EPO Severe TBI), BEST-TRIP, Progesterone for the Treatment of Traumatic Brain Injury III Clinical Trial (ProTECT III), Transforming Research and Clinical Knowledge in Traumatic brain Injury (TRACK-TBI), Brain Oxygen Optimization in Severe Traumatic Brain Injury Phase-II (BOOST-2), and Ben Taub General Hospital (BTGH) Research Database studies. We conclude with process recommendations for data acquisition for future prospective studies to aid integration of these data with existing studies. These recommendations include using common data elements whenever possible, a standardized recording system for labeling and timing of high-frequency physiological data, and secondary use of studies in systems such as Federal Interagency Traumatic Brain Injury Research Informatics System (FITBIR), to engage investigators who collected the original data.
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Affiliation(s)
- Ashraf Yaseen
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, USA
| | - Claudia Robertson
- Department of Neurosurgery, and University of Washington, Seattle, Washington, USA
| | - Jovany Cruz Navarro
- Department of Anesthesiology Baylor College of Medicine, University of Washington, Seattle, Washington, USA
| | - Jingxiao Chen
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, USA
| | - Brian Heckler
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, USA
| | - Stacia M DeSantis
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, USA
| | - Nancy Temkin
- Department of Department of Neurological Surgery and Biostatistics, University of Washington, Seattle, Washington, USA
| | - Jason Barber
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Randall Chesnut
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Geoffrey T Manley
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David W Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mary Vassar
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Adam R Ferguson
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Amy J Markowitz
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jose-Miguel Yamal
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, USA
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9
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Sarigul B, Bell RS, Chesnut R, Aguilera S, Buki A, Citerio G, Cooper DJ, Diaz-Arrastia R, Diringer M, Figaji A, Gao G, Geocadin RG, Ghajar J, Harris O, Hoffer A, Hutchinson P, Joseph M, Kitagawa R, Manley G, Mayer SA, Menon DK, Meyfroidt G, Michael DB, Oddo M, Okonkwo DO, Patel MB, Robertson C, Rosenfeld JV, Rubiano AM, Sahuquillo J, Servadei F, Shutter L, Stein DD, Stocchetti N, Taccone FS, Timmons SD, Tsai E, Ullman JS, Vespa P, Videtta W, Wright DW, Zammit C, Hawryluk GWJ. Prognostication and Goals of Care Decisions in Severe Traumatic Brain Injury: A Survey of The Seattle International Severe Traumatic Brain Injury Consensus Conference Working Group. J Neurotrauma 2023; 40:1707-1717. [PMID: 36932737 DOI: 10.1089/neu.2022.0414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
Abstract Best practice guidelines have advanced severe traumatic brain injury (TBI) care; however, there is little that currently informs goals of care decisions and processes despite their importance and frequency. Panelists from the Seattle International severe traumatic Brain Injury Consensus Conference (SIBICC) participated in a survey consisting of 24 questions. Questions queried use of prognostic calculators, variability in and responsibility for goals of care decisions, and acceptability of neurological outcomes, as well as putative means of improving decisions that might limit care. A total of 97.6% of the 42 SIBICC panelists completed the survey. Responses to most questions were highly variable. Overall, panelists reported infrequent use of prognostic calculators, and observed variability in patient prognostication and goals of care decisions. They felt that it would be beneficial for physicians to improve consensus on what constitutes an acceptable neurological outcome as well as what chance of achieving that outcome is acceptable. Panelists felt that the public should help to define what constitutes a good outcome and expressed some support for a "nihilism guard." More than 50% of panelists felt that if it was certain to be permanent, a vegetative state or lower severe disability would justify a withdrawal of care decision, whereas 15% felt that upper severe disability justified such a decision. Whether conceptualizing an ideal or existing prognostic calculator to predict death or an unacceptable outcome, on average a 64-69% chance of a poor outcome was felt to justify treatment withdrawal. These results demonstrate important variability in goals of care decision making and a desire to reduce this variability. Our panel of recognized TBI experts opined on the neurological outcomes and chances of those outcomes that might prompt consideration of care withdrawal; however, imprecision of prognostication and existing prognostication tools is a significant impediment to standardizing the approach to care-limiting decisions.
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Affiliation(s)
| | - Randy S Bell
- Uniformed Services University of Health Sciences, Avera Brain and Spine Institute, Sioux Falls, South Dakota, USA
| | - Randall Chesnut
- Departments of Neurological Surgery and Orthopaedic Surgery, School of Global Health, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | | | - Andras Buki
- Department of Neurosurgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- NeuroIntensive Care, Department of Neuroscience, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - D Jamie Cooper
- Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, Alfred Hospital, Melbourne, Victoria, Australia
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - Michael Diringer
- Department of Neurology, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Anthony Figaji
- Department of Neurosurgery, Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Guoyi Gao
- Division of Neurotrauma, Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Romergryko G Geocadin
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jamshid Ghajar
- Department of Neurosurgery, Stanford Neuroscience Health Center, Palo Alto, California, USA
| | | | - Alan Hoffer
- University Hospitals of Cleveland, Cleveland, Ohio, USA
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Mathew Joseph
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ryan Kitagawa
- Vivian L Smith Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - Geoffrey Manley
- Department of Neurosurgery, University of California San Francisco, San Francisco General Hospital & Trauma Center, San Francisco, California, USA
| | - Stephan A Mayer
- Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Daniel B Michael
- Department of Neurosurgery, Oakland University William Beaumont School of Medicine, Beaumont Health, Michigan Head & Spine Institute, Southfield, Michigan, USA
| | - Mauro Oddo
- Directorate of Innovation and Clinical Research, CHUV-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - David O Okonkwo
- Departments of Neurological Surgery, Neurology and Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center; Center for Health Services Research; Tennessee Valley Healthcare System, Veterans Affairs Medical Center; Section of Surgical Sciences, Department of Surgery, Division of Acute Care Surgery Vanderbilt University Medical Center, Nashville, Tennessee
| | - Claudia Robertson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Andres M Rubiano
- INUB/MEDITECH Research Group, Neurosciences Institute, El Bosque University, Bogotá, Colombia
- MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Juan Sahuquillo
- Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Spain
| | - Franco Servadei
- Department of Neurosurgery, IRCCS Humanitas Research Hospital and Humanitas University, Milano, Italy
| | - Lori Shutter
- Critical Care Medicine, Neurology and Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Deborah D Stein
- Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Dipartimento Fisiopatologia e Trapianti Universita di Milano, Scuola di Specializzazione Anestesia, Rianimazione, Terapia Intensiva e del Dolore, Neurorianimazione, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Milano, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles (ULB) Brussels, Belgium
| | - Shelly D Timmons
- Department of Neurological Surgery, Indiana University School of Medicine, Indiana, USA
| | - Eve Tsai
- Division of Neurosurgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jamie S Ullman
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Paul Vespa
- Department of Neurosurgery and Neurology, UCLA School of Medicine, Neurocritical Care, Ronald Reagan UCLA Medical Center, UCLA Medical Center, Santa Monica, California, USA
| | - Walter Videtta
- Intensive Care Medicine, Posadas Hospital, Buenos Aires, Argentina
| | - David W Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christopher Zammit
- Department of Emergency Medicine, University of Rochester Medical Center, School of Medicine and Dentistry, Rochester, New York, USA
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10
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Chesnut RM, Aguilera S, Buki A, Bulger EM, Citerio G, Cooper DJ, Arrastia RD, Diringer M, Figaji A, Gao G, Geocadin RG, Ghajar J, Harris O, Hawryluk GWJ, Hoffer A, Hutchinson P, Joseph M, Kitagawa R, Manley G, Mayer S, Menon DK, Meyfroidt G, Michael DB, Oddo M, Okonkwo DO, Patel MB, Robertson C, Rosenfeld JV, Rubiano AM, Sahuquillo J, Servadei F, Shutter L, Stein DM, Stocchetti N, Taccone FS, Timmons SD, Tsai EC, Ullman JS, Videtta W, Wright DW, Zammit C. Perceived Utility of Intracranial Pressure Monitoring in Traumatic Brain Injury: A Seattle International Brain Injury Consensus Conference Consensus-Based Analysis and Recommendations. Neurosurgery 2023; 93:399-408. [PMID: 37171175 PMCID: PMC10319366 DOI: 10.1227/neu.0000000000002516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/02/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Intracranial pressure (ICP) monitoring is widely practiced, but the indications are incompletely developed, and guidelines are poorly followed. OBJECTIVE To study the monitoring practices of an established expert panel (the clinical working group from the Seattle International Brain Injury Consensus Conference effort) to examine the match between monitoring guidelines and their clinical decision-making and offer guidance for clinicians considering monitor insertion. METHODS We polled the 42 Seattle International Brain Injury Consensus Conference panel members' ICP monitoring decisions for virtual patients, using matrices of presenting signs (Glasgow Coma Scale [GCS] total or GCS motor, pupillary examination, and computed tomography diagnosis). Monitor insertion decisions were yes, no, or unsure (traffic light approach). We analyzed their responses for weighting of the presenting signs in decision-making using univariate regression. RESULTS Heatmaps constructed from the choices of 41 panel members revealed wider ICP monitor use than predicted by guidelines. Clinical examination (GCS) was by far the most important characteristic and differed from guidelines in being nonlinear. The modified Marshall computed tomography classification was second and pupils third. We constructed a heatmap and listed the main clinical determinants representing 80% ICP monitor insertion consensus for our recommendations. CONCLUSION Candidacy for ICP monitoring exceeds published indicators for monitor insertion, suggesting the clinical perception that the value of ICP data is greater than simply detecting and monitoring severe intracranial hypertension. Monitor insertion heatmaps are offered as potential guidance for ICP monitor insertion and to stimulate research into what actually drives monitor insertion in unconstrained, real-world conditions.
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Affiliation(s)
- Randall M. Chesnut
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Orthopaedic Surgery, University of Washington, Seattle, Washington, USA
- School of Global Health, University of Washington, Seattle, Washington, USA
- Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Sergio Aguilera
- Almirante Nef Naval Hospital, Valparaiso University, Viña Del Mar, Chile
- Valparaiso University, Valparaiso, Chile
| | - Andras Buki
- Department of Neurosurgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Eileen M. Bulger
- Department of Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Neuroscience Department, NeuroIntensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Monza, Italy
| | - D. Jamie Cooper
- Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Ramon Diaz Arrastia
- Department of Neurology, Penn Presbyterian Medical Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael Diringer
- Department of Neurology, Washington University School of Medicine, St Louis, USA
- Department of Neurology, Barnes-Jewish Hospital, St Louis, Missouri, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, Groote Schuur Hospital, University of Cape Town, Observatory 7925, South Africa
| | - Guoyi Gao
- Department of Neurosurgery, Renji Hospital, Shanghai Institute of Head Trauma, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Romergryko G. Geocadin
- Departments of Neurology, Neurological Surgery, Anesthesiology-Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jamshid Ghajar
- Department of Neurosurgery, Stanford Neuroscience Health Center, Palo Alto, California, USA
| | - Odette Harris
- Department of Neurosurgery, Stanford University School of Medicine, Center for Academic Medicine, Stanford, California, USA
| | - Gregory W. J. Hawryluk
- Cleveland Clinic Akron General Neurosciences Center, Fairlawn, Ohio, USA
- Uniformed Services University, Bethesda, Maryland, USA
- Brain Trauma Foundation, New York City, New York, USA
| | - Alan Hoffer
- UH Cleveland Medical Center, Cleveland, Ohio, USA
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge and Cambridge Biomedical Campus, Cambridge, UK
| | - Mathew Joseph
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ryan Kitagawa
- Vivian L Smith Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - Geoffrey Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Department of Neurosurgery, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Stephan Mayer
- Westchester Health Network, New York Medical College, Valhalla, New York, USA
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Daniel B. Michael
- Department of Neurosurgery, Beaumont Health, Michigan Head and Spine Institute, Oakland University William Beaumont School of Medicine, Southfield, Michigan, USA
| | - Mauro Oddo
- CHUV Medical Directorate and Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - David O. Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center Presbyterian, Pittsburgh, Pennsylvania, USA
| | - Mayur B. Patel
- Department of Surgery, Division of Acute Care Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Claudia Robertson
- Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, Texas, USA
| | - Jeffrey V. Rosenfeld
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
| | - Andres M. Rubiano
- INUB/MEDITECH Research Group, Neurosciences Institute, El Bosque University, Bogotá, Colombia
- MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Juain Sahuquillo
- Department of Neurosurgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona: Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Franco Servadei
- Department of Biomedical Sciences, Humanitas University and IRCCS Humanitas Research Hospital, Milano, Italy
| | - Lori Shutter
- Department of Critical Care Medicine, Neurology and Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Deborah M. Stein
- University of Maryland School of Medicine, Adult Critical Care Services, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
- Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Shelly D. Timmons
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eve C. Tsai
- Suruchi Bhargava Chair in Spinal Cord and Brain Regeneration Research, The Ottawa Hospital, Department of Surgery, Division of Neurosurgery, University of Ottawa, Civic Campus, Ottawa, Ontario, Canada
| | - Jamie S. Ullman
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York, USA
| | - Walter Videtta
- Intensive Care, Posadas Hospital, Buenos Aires, Argentina
| | - David W. Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christopher Zammit
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
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11
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Harder TJ, Leary OP, Yang Z, Lucke-Wold B, Liu DD, Still ME, Zhang M, Yeatts SD, Allen JW, Wright DW, Merck D, Merck LH. Early Signs of Elevated Intracranial Pressure on Computed Tomography Correlate With Measured Intracranial Pressure in the Intensive Care Unit and Six-Month Outcome After Moderate to Severe Traumatic Brain Injury. J Neurotrauma 2023; 40:1603-1613. [PMID: 37082956 PMCID: PMC10458381 DOI: 10.1089/neu.2022.0433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. Early triage and treatment after TBI have been shown to improve outcome. Identifying patients at risk for increased intracranial pressure (ICP) via baseline computed tomography (CT) , however, has not been validated previously in a prospective dataset. We hypothesized that acute CT findings of elevated ICP, combined with direct ICP measurement, hold prognostic value in terms of six-month patient outcome after TBI. Data were obtained from the Progesterone for Traumatic Brain Injury, Experimental Clinical Treatment (ProTECTIII) multi-center clinical trial. Baseline CT scans for 881 participants were individually reviewed by a blinded central neuroradiologist. Five signs of elevated ICP were measured (sulcal obliteration, lateral ventricle compression, third ventricle compression, midline shift, and herniation). Associations between signs of increased ICP and outcomes (six-month functional outcome and death) were assessed. Secondary analyses of 354 patients with recorded ICP monitoring data available explored the relationships between hemorrhage phenotype/anatomic location, sustained ICP ≥20 mm Hg, and surgical intervention(s). Univariate and multi-variate logistic/linear regressions were performed; p < 0.05 is defined as statistically significant. Imaging characteristics associated with ICP in this cohort include sulcal obliteration (p = 0.029) and third ventricular compression (p = 0.039). Univariate regression analyses indicated that increasing combinations of the five defined signs of elevated ICP were associated with death, poor functional outcome, and time to death. There was also an increased likelihood of death if patients required craniotomy (odds ratio [OR] = 4.318, 95% confidence interval [1.330-16.030]) or hemicraniectomy (OR = 2.993 [1.109-8.482]). On multi-variate regression analyses, hemorrhage location was associated with death (posterior fossa, OR = 3.208 [1.120-9.188] and basal ganglia, OR = 3.079 [1.178-8.077]). Volume of hemorrhage >30 cc was also associated with increased death, OR = 3.702 [1.575-8.956]). The proportion of patient hours with sustained ICP ≥20 mm Hg, and maximum ICP ≥20 mm Hg were also directly correlated with increased death (OR = 6 4.99 [7.731-635.51]; and OR = 1.025 [1.004-1.047]), but not with functional outcome. Poor functional outcome was predicted by concurrent presence of all five radiographic signs of elevated ICP (OR = 4.44 [1.514-14.183]) and presence of frontal lobe (OR = 2.951 [1.265-7.067]), subarachnoid (OR = 2.231 [1.067-4.717]), or intraventricular (OR = 2.249 [1.159-4.508]) hemorrhage. Time to death was modulated by total patient days of elevated ICP ≥20 mm Hg (effect size = 3.424 [1.500, 5.439]) in the first two weeks of hospitalization. Sulcal obliteration and third ventricular compression, radiographic signs of elevated ICP, were significantly associated with measurements of ICP ≥20 mm Hg. These radiographic biomarkers were significantly associated with patient outcome. There is potential utility of ICP-related imaging variables in triage and prognostication for patients after moderate-severe TBI.
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Affiliation(s)
- Tyler J. Harder
- Department of Emergency Medicine, Brown University, Providence, Rhode Island, USA
| | - Owen P. Leary
- Department of Neurosurgery, Brown University, Providence, Rhode Island, USA
| | - Zhihui Yang
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - David D. Liu
- Department of Neurosurgery, Brown University, Providence, Rhode Island, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Megan E.H. Still
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Miao Zhang
- Department of Information Systems and Operation Management, University of Florida, Gainesville, Florida, USA
| | - Sharon D. Yeatts
- Department of Biostatistics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jason W. Allen
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia, USA
| | - David W. Wright
- Department of Emergency Medicine, Emory University, Atlanta, Georgia, USA
| | - Derek Merck
- Department of Radiology, University of Florida, Gainesville, Florida, USA
| | - Lisa H. Merck
- Department of Neurosurgery, Brown University, Providence, Rhode Island, USA
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
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12
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Lulla A, Lumba-Brown A, Totten AM, Maher PJ, Badjatia N, Bell R, Donayri CTJ, Fallat ME, Hawryluk GWJ, Goldberg SA, Hennes HMA, Ignell SP, Ghajar J, Krzyzaniak BP, Lerner EB, Nishijima D, Schleien C, Shackelford S, Swartz E, Wright DW, Zhang R, Jagoda A, Bobrow BJ. Prehospital Guidelines for the Management of Traumatic Brain Injury - 3rd Edition. PREHOSP EMERG CARE 2023:1-32. [PMID: 37079803 DOI: 10.1080/10903127.2023.2187905] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Affiliation(s)
- Al Lulla
- Department of Emergency Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Angela Lumba-Brown
- Department of Emergency Medicine, Stanford University, Stanford, California
| | - Annette M Totten
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Patrick J Maher
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Neeraj Badjatia
- Department of Neurocritical Care, Neurology, Anesthesiology, Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Randy Bell
- Uniformed Services University, Bethesda, Maryland
| | | | - Mary E Fallat
- Hiram C. Polk Jr Department of Pediatric Surgery, University of Louisville, Norton Children's Hospital, Louisville, Kentucky
| | - Gregory W J Hawryluk
- Department of Neurosurgery, Cleveland Clinic and Akron General Hospital, Fairlawn, Ohio
| | - Scott A Goldberg
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Halim M A Hennes
- Department of Pediatric Emergency Medicine, UT Southwestern Medical Center, Dallas Children's Medical Center, Dallas, Texas
| | - Steven P Ignell
- Department of Emergency Medicine, Stanford University, Stanford, California
| | - Jamshid Ghajar
- Department of Neurosurgery, Stanford University, Stanford, California
| | | | - E Brooke Lerner
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Daniel Nishijima
- Department of Emergency Medicine, UC Davis, Sacramento, California
| | - Charles Schleien
- Pediatric Critical Care, Cohen Children's Medical Center, Hofstra Northwell School of Medicine, Uniondale, New York
| | - Stacy Shackelford
- Trauma and Critical Care, USAF Center for Sustainment of Trauma Readiness Skills, Seattle, Washington
| | - Erik Swartz
- Department of Physical Therapy and Kinesiology, University of Massachusetts, Lowell, Massachusetts
| | - David W Wright
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - Rachel Zhang
- University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Andy Jagoda
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bentley J Bobrow
- Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
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13
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Xiao R, Ding C, Hu X, Clifford GD, Wright DW, Shah AJ, Al-Zaiti S, Zègre-Hemsey JK. Integrating multimodal information in machine learning for classifying acute myocardial infarction. Physiol Meas 2023; 44. [PMID: 36963114 PMCID: PMC10111877 DOI: 10.1088/1361-6579/acc77f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 03/24/2023] [Indexed: 03/26/2023]
Abstract
OBJECTIVE Prompt identification and recognization of myocardial ischemia/infarction (MI) is the most important goal in the management of acute coronary syndrome (ACS). The 12-lead electrocardiogram (ECG) is widely used as the initial screening tool for patients with chest pain but its diagnostic accuracy remains limited. There is early evidence that machine learning (ML) algorithms applied to ECG waveforms can improve performance. Most studies are designed to classify MI from healthy controls and thus are limited due to the lack of consideration of ECG abnormalities from other cardiac conditions, leading to false positives. Moreover, clinical information beyond ECG has not yet been well leveraged in existing ML models. APPROACH The present study considered downstream clinical implementation scenarios in the initial model design by dichotomizing study recordings from a public large-scale ECG dataset into a MI class and a non-MI class with the inclusion of MI-confounding conditions. Two experiments were conducted to systematically investigate the impact of two important factors entrained in the modeling process, including the duration of ECG, and the value of multimodal information for model training. A novel multimodal deep learning architecture was proposed to learn joint features from both ECG and patient demographics. MAIN RESULTS The multimodal model achieved better performance than the ECG-only model, with a mean area under the receiver operating characteristic curve (AUROC) of 92.1% and a mean accuracy of 87.4%, which is on par with existing studies despite the increased task difficulty due to the new class definition. By investigation of model explainability, it revealed the contribution of patient information in model performance and clinical concordance of the model's attention with existing clinical insights. SIGNIFICANCE The findings in this study help guide the development of ML solutions for prompt MI detection and move the models one step closer to real-world clinical applications.
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Affiliation(s)
- Ran Xiao
- Emory University, 1520 Clifton Rd, Atlanta, Georgia, 30322-1007, UNITED STATES
| | - Cheng Ding
- Department of Biomedical Engineering, Georgia Institute of Technology, ., Atlanta, Georgia, 30332-0002, UNITED STATES
| | - Xiao Hu
- Emory University, 1520 Clifton Rd, Atlanta, Georgia, 30322-1007, UNITED STATES
| | - Gari D Clifford
- Department of Biomedical Informatics, Emory University, 101 Woodruff Circle, Atlanta, Georgia, 30322-1007, UNITED STATES
| | - David W Wright
- Department of Emergency Medicine, Emory University, 100 Woodruff Circle, Atlanta, Georgia, 30322-1007, UNITED STATES
| | - Amit J Shah
- Department of Epidemiology, Emory University, 1518 Clifton Rd NE, Atlanta, Georgia, 30322-1007, UNITED STATES
| | - Salah Al-Zaiti
- University of Pittsburgh, 4200 Fifth Ave, Pittsburgh, Pennsylvania, 15261, UNITED STATES
| | - Jessica K Zègre-Hemsey
- The University of North Carolina at Chapel Hill, Carrington Hall, S Columbia St,, Chapel Hill, North Carolina, 27599, UNITED STATES
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14
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Ratcliff JJ, Hall AJ, Porto E, Saville BR, Lewis RJ, Allen JW, Frankel M, Wright DW, Barrow DL, Pradilla G. Early Minimally Invasive Removal of Intracerebral Hemorrhage (ENRICH): Study protocol for a multi-centered two-arm randomized adaptive trial. Front Neurol 2023; 14:1126958. [PMID: 37006503 PMCID: PMC10061000 DOI: 10.3389/fneur.2023.1126958] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 02/27/2023] [Indexed: 03/18/2023] Open
Abstract
BackgroundIntracerebral hemorrhage (ICH) is a potentially devastating condition with elevated early mortality rates, poor functional outcomes, and high costs of care. Standard of care involves intensive supportive therapy to prevent secondary injury. To date, there is no randomized control study demonstrating benefit of early evacuation of supratentorial ICH.MethodsThe Early Minimally Invasive Removal of Intracerebral Hemorrhage (ENRICH) Trial was designed to evaluate the minimally invasive trans-sulcal parafascicular surgery (MIPS) approach, a technique for safe access to deep brain structures and ICH removal using the BrainPath® and Myriad® devices (NICO Corporation, Indianapolis, IN). ENRICH is a multi-centered, two-arm, randomized, adaptive comparative-effectiveness study, where patients are block randomized by ICH location and Glasgow Coma Score (GCS) to early ICH evacuation using MIPS plus standard guideline-based management vs. standard management alone to determine if MIPS results in improved outcomes defined by the utility-weighted modified Rankin score (UWmRS) at 180 days as the primary endpoint. Secondary endpoints include clinical and economic outcomes of MIPS using cost per quality-adjusted life years (QALYs). The inclusion and exclusion criteria aim to capture a broad group of patients with high risk of significant morbidity and mortality to determine optimal treatment strategy.DiscussionENRICH will result in improved understanding of the benefit of MIPS for both lobar and deep ICH affecting the basal ganglia. The ongoing study will lead to Level-I evidence to guide clinicians treatment options in the management of acute treatment of ICH.Trial registrationThis study is registered with clinicaltrials.gov (Identifier: NCT02880878).
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Affiliation(s)
- Jonathan J. Ratcliff
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States
- Department of Neurology, Emory University School of Medicine, Grady Hospital, Atlanta, GA, United States
| | - Alex J. Hall
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Edoardo Porto
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Benjamin R. Saville
- Berry Consultants LLC, Austin, TX, United States
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Roger J. Lewis
- Berry Consultants LLC, Austin, TX, United States
- Department of Emergency Medicine, Harbor-UCLA Medical Center, UCLA, Torrance, CA, United States
| | - Jason W. Allen
- Department of Neurology, Emory University School of Medicine, Grady Hospital, Atlanta, GA, United States
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States
| | - Michael Frankel
- Department of Neurology, Emory University School of Medicine, Grady Hospital, Atlanta, GA, United States
| | - David W. Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Daniel L. Barrow
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
- *Correspondence: Gustavo Pradilla
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15
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Wu H, Wright DW, Allen JW, Ding V, Boothroyd D, Glushakova OY, Hayes R, Jiang B, Wintermark M. Accuracy of head computed tomography scoring systems in predicting outcomes for patients with moderate to severe traumatic brain injury: A ProTECT III ancillary study. Neuroradiol J 2023; 36:38-48. [PMID: 35533263 PMCID: PMC9893165 DOI: 10.1177/19714009221101313] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Several types of head CT classification systems have been developed to prognosticate and stratify TBI patients. OBJECTIVE The purpose of our study was to compare the predictive value and accuracy of the different CT scoring systems, including the Marshall, Rotterdam, Stockholm, Helsinki, and NIRIS systems, to inform specific patient management actions, using the ProTECT III population of patients with moderate to severe acute traumatic brain injury (TBI). METHODS We used the data collected in the patients with moderate to severe (GCS score of 4-12) TBI enrolled in the ProTECT III clinical trial. ProTECT III was a NIH-funded, prospective, multicenter, randomized, double-blind, placebo-controlled clinical trial designed to determine the efficacy of early administration of IV progesterone. The CT scoring systems listed above were applied to the baseline CT scans obtained in the trial. We assessed the predictive accuracy of these scoring systems with respect to Glasgow Outcome Scale-Extended at 6 months, disability rating scale score, and mortality. RESULTS A total of 882 subjects were enrolled in ProTECT III. Worse scores for each head CT scoring systems were highly correlated with unfavorable outcome, disability outcome, and mortality. The NIRIS classification was more strongly correlated than the Stockholm and Rotterdam CT scores, followed by the Helsinki and Marshall CT classification. The highest correlation was observed between NIRIS and mortality (estimated odds ratios of 4.83). CONCLUSION All scores were highly associated with 6-month unfavorable, disability and mortality outcomes. NIRIS was also accurate in predicting TBI patients' management and disposition.
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Affiliation(s)
- Haijun Wu
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
- Department of Radiology, Guangdong Provincial People's
Hospital, Guangdong Academy of Medical Sciences, Guangdong,
China
- Department of Emergency Medicine, Emory University School of Medicine
and Grady Memorial Hospital, Atlanta, GA, USA
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
- Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
- University of Virginia Cancer
Center, Charlottesville, VA, USA
- Department of Neurosurgery, Virginia Commonwealth
University, Richmond, VA, USA
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
| | - David W Wright
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
- Department of Radiology, Guangdong Provincial People's
Hospital, Guangdong Academy of Medical Sciences, Guangdong,
China
- Department of Emergency Medicine, Emory University School of Medicine
and Grady Memorial Hospital, Atlanta, GA, USA
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
- Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
- University of Virginia Cancer
Center, Charlottesville, VA, USA
- Department of Neurosurgery, Virginia Commonwealth
University, Richmond, VA, USA
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
| | - Jason W Allen
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
- Department of Radiology, Guangdong Provincial People's
Hospital, Guangdong Academy of Medical Sciences, Guangdong,
China
- Department of Emergency Medicine, Emory University School of Medicine
and Grady Memorial Hospital, Atlanta, GA, USA
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
- Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
- University of Virginia Cancer
Center, Charlottesville, VA, USA
- Department of Neurosurgery, Virginia Commonwealth
University, Richmond, VA, USA
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
| | - Victoria Ding
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
- Department of Radiology, Guangdong Provincial People's
Hospital, Guangdong Academy of Medical Sciences, Guangdong,
China
- Department of Emergency Medicine, Emory University School of Medicine
and Grady Memorial Hospital, Atlanta, GA, USA
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
- Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
- University of Virginia Cancer
Center, Charlottesville, VA, USA
- Department of Neurosurgery, Virginia Commonwealth
University, Richmond, VA, USA
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
| | - Derek Boothroyd
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
- Department of Radiology, Guangdong Provincial People's
Hospital, Guangdong Academy of Medical Sciences, Guangdong,
China
- Department of Emergency Medicine, Emory University School of Medicine
and Grady Memorial Hospital, Atlanta, GA, USA
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
- Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
- University of Virginia Cancer
Center, Charlottesville, VA, USA
- Department of Neurosurgery, Virginia Commonwealth
University, Richmond, VA, USA
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
| | - Olena Y Glushakova
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
- Department of Radiology, Guangdong Provincial People's
Hospital, Guangdong Academy of Medical Sciences, Guangdong,
China
- Department of Emergency Medicine, Emory University School of Medicine
and Grady Memorial Hospital, Atlanta, GA, USA
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
- Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
- University of Virginia Cancer
Center, Charlottesville, VA, USA
- Department of Neurosurgery, Virginia Commonwealth
University, Richmond, VA, USA
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
| | - Ron Hayes
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
- Department of Radiology, Guangdong Provincial People's
Hospital, Guangdong Academy of Medical Sciences, Guangdong,
China
- Department of Emergency Medicine, Emory University School of Medicine
and Grady Memorial Hospital, Atlanta, GA, USA
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
- Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
- University of Virginia Cancer
Center, Charlottesville, VA, USA
- Department of Neurosurgery, Virginia Commonwealth
University, Richmond, VA, USA
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
| | | | - Max Wintermark
- Max Wintermark, Department of Radiology,
Neuroradiology Division, Stanford University, 300 Pasteur Drive, Room S047,
Stanford, CA 94305-5105, USA.
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16
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Hawryluk GW, Selph S, Lumba-Brown A, Totten AM, Ghajar J, Aarabi B, Ecklund J, Shackelford S, Adams B, Adelson D, Armonda RA, Benjamin J, Boone D, Brody D, Dengler B, Figaji A, Grant G, Harris O, Hoffer A, Kitigawa R, Latham K, Neal C, Okonkwo DO, Pannell D, Rosenfeld JV, Rosenthal G, Rubiano A, Stein DM, Stippler M, Talbot M, Valadka A, Wright DW, Davis S, Bell R. Rationale and Methods for Updated Guidelines for the Management of Penetrating Traumatic Brain Injury. Neurotrauma Rep 2022; 3:240-247. [PMID: 35919507 PMCID: PMC9279118 DOI: 10.1089/neur.2022.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Penetrating traumatic brain injury (pTBI) affects civilian and military populations resulting in significant morbidity, mortality, and healthcare costs. No up-to-date and evidence-based guidelines exist to assist modern medical and surgical management of these complex injuries. A preliminary literature search revealed a need for updated guidelines, supported by the Brain Trauma Foundation. Methodologists experienced in TBI guidelines were recruited to support project development alongside two cochairs and a diverse steering committee. An expert multi-disciplinary workgroup was established and vetted to inform key clinical questions, to perform an evidence review and the development of recommendations relevant to pTBI. The methodological approach for the project was finalized. The development of up-to-date evidence- and consensus-based clinical care guidelines and algorithms for pTBI will provide critical guidance to care providers in the pre-hospital and emergent, medical, and surgical settings.
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Affiliation(s)
| | - Shelley Selph
- Department of Medical Informatics and Clinical Epidemiology, Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Angela Lumba-Brown
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford University, Palo Alto, California, USA
| | - Annette M. Totten
- Department of Medical Informatics and Clinical Epidemiology, Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Jamshid Ghajar
- Stanford Neuroscience Health Center, Stanford University School of Medicine, Stanford University, Palo Alto, California, USA
| | - Bizhan Aarabi
- University of Maryland Neurosurgery Associates, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - James Ecklund
- Inova Neuroscience and Spine Institute, Fairfax, Virginia, USA
| | - Stacy Shackelford
- Joint Trauma System, Department of Defense, Center of Excellence for Trauma, Baltimore, Maryland, USA
| | - Britton Adams
- Independent Duty Medical Technician (IDMT), Hurlburt Field, Florida, USA
| | - David Adelson
- Barrow Neurological Institute at Phoenix Children's Hospital, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Rocco A. Armonda
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - John Benjamin
- Anaethesia and Critical Care, Uniformed Services University, Bethesda, Maryland, USA
| | - Darrell Boone
- Department of Surgery, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | - David Brody
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University, Bethesda, Maryland, USA
| | - Bradley Dengler
- Department of Neurosurgery, Uniformed Services University, Bethesda, Maryland, USA
| | - Anthony Figaji
- Department of Neurosurgery, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Gerald Grant
- Department of Neurosurgery, Duke University, Raleigh, North Carolina, USA
| | - Odette Harris
- Department of Neurosurgery, Stanford University School of Medicine, Stanford University, Palo Alto, California, USA
| | - Alan Hoffer
- Department of Neurosurgery, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ryan Kitigawa
- McGovern Medical School, University of Texas, Houston, Texas, USA
| | - Kerry Latham
- Adult Outpatient Behavioral Health, Bethesda, Maryland, USA
| | - Christopher Neal
- Department of Neurosurgery Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dylan Pannell
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Guy Rosenthal
- Hadassah University Medical Center, Jerusalem, Israel
| | - Andres Rubiano
- INUB-Meditech Research Group, Neuroscience Institute, Universidad El Bosque, Bogota, Colombia
| | - Deborah M. Stein
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Martina Stippler
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Max Talbot
- Royal Canadian Medical Service, Canadian Armed Forces, Canadian Forces Base Borden, Ontario, Canada
| | - Alex Valadka
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - David W. Wright
- Department of Emergency Medicine, Emory University, Atlanta, Georgia, USA
| | - Shelton Davis
- Department of Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Randy Bell
- Department of Neurosurgery, Uniformed Services University, Bethesda, Maryland, USA
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17
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Wan S, Bhati AP, Wright DW, Wall ID, Graves AP, Green D, Coveney PV. Ensemble Simulations and Experimental Free Energy Distributions: Evaluation and Characterization of Isoxazole Amides as SMYD3 Inhibitors. J Chem Inf Model 2022; 62:2561-2570. [PMID: 35508076 PMCID: PMC9131449 DOI: 10.1021/acs.jcim.2c00255] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Optimization of binding affinities for ligands to their target protein is a primary objective in rational drug discovery. Herein, we report on a collaborative study that evaluates various compounds designed to bind to the SET and MYND domain-containing protein 3 (SMYD3). SMYD3 is a histone methyltransferase and plays an important role in transcriptional regulation in cell proliferation, cell cycle, and human carcinogenesis. Experimental measurements using the scintillation proximity assay show that the distributions of binding free energies from a large number of independent measurements exhibit non-normal properties. We use ESMACS (enhanced sampling of molecular dynamics with approximation of continuum solvent) and TIES (thermodynamic integration with enhanced sampling) protocols to predict the binding free energies and to provide a detailed chemical insight into the nature of ligand-protein binding. Our results show that the 1-trajectory ESMACS protocol works well for the set of ligands studied here. Although one unexplained outlier exists, we obtain excellent statistical ranking across the set of compounds from the ESMACS protocol and good agreement between calculations and experiments for the relative binding free energies from the TIES protocol. ESMACS and TIES are again found to be powerful protocols for the accurate comparison of the binding free energies.
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Affiliation(s)
- Shunzhou Wan
- Centre for Computational Science, Department of Chemistry, University College London, London WC1H 0AJ, U.K
| | - Agastya P Bhati
- Centre for Computational Science, Department of Chemistry, University College London, London WC1H 0AJ, U.K
| | - David W Wright
- Centre for Computational Science, Department of Chemistry, University College London, London WC1H 0AJ, U.K
| | - Ian D Wall
- GlaxoSmithKline, Gunnels Wood Road, Stevenage, Hertfordshire SG1 2NY, U.K
| | - Alan P Graves
- GlaxoSmithKline, 1250 South Collegeville Road, Collegeville, Pennsylvania 19426, United States
| | - Darren Green
- GlaxoSmithKline, Gunnels Wood Road, Stevenage, Hertfordshire SG1 2NY, U.K
| | - Peter V Coveney
- Centre for Computational Science, Department of Chemistry, University College London, London WC1H 0AJ, U.K.,Advanced Research Computing Centre, University College London, London WC1H 0AJ U.K.,Institute for Informatics, Faculty of Science, University of Amsterdam, 1098XH Amsterdam, The Netherlands
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18
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Tucker PW, Bull R, Hall A, Moran TP, Jain S, Sathian U, Simon HK, Gioia GA, Ratcliff JJ, Wright DW. Application of the RE-AIM Framework for the Pediatric Mild Traumatic Brain Injury Evaluation and Management Intervention: A Study Protocol for Program Evaluation. Front Public Health 2022; 9:740238. [PMID: 35252108 PMCID: PMC8891162 DOI: 10.3389/fpubh.2021.740238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 12/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background Children who experience a mild Traumatic Brain Injury (mTBI) may encounter cognitive and behavioral changes that often negatively impact school performance. Communication linkages between the various healthcare systems and school systems are rarely well-coordinated, placing children with an mTBI at risk for prolonged recovery, adverse impact on learning, and mTBI re-exposure. The objective of this study is to rigorously appraise the pediatric Mild Traumatic Brain Injury Evaluation and Management (TEaM) Intervention that was designed to enhance diagnosis and management of pediatric mTBI through enhanced patient discharge instructions and communication linkages between school and primary care providers. Methods This is a combined randomized and 2 × 2 quasi-experimental study design with educational and technology interventions occurring at the clinician level with patient and school outcomes as key endpoints. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework will be utilized as a mix methods approach to appraise a multi-disciplinary, multi-setting intervention with the intent of improving outcomes for children who have experienced mTBI. Discussion Utilization of the RE-AIM framework complemented with qualitative inquiry is suitable for evaluating effectiveness of the TEaM Intervention with the aim of emphasizing priorities regarding pediatric mTBI. This program evaluation has the potential to support the knowledge needed to critically appraise the impact of mTBI recovery interventions across multiple settings, enabling uptake of the best-available evidence within clinical practice.
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Affiliation(s)
- Paula W. Tucker
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States
- *Correspondence: Paula W. Tucker
| | - Rachel Bull
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Alex Hall
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Tim P. Moran
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Shabnam Jain
- Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Usha Sathian
- Urgent Care and Community Care Services, Children's Healthcare of Atlanta: Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Harold K. Simon
- Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Gerard A. Gioia
- Division of Pediatric Neuropsychology, Children's National Hospital, Rockville, MD, United States
| | - Jonathan J. Ratcliff
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - David W. Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States
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19
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Sanchez-Perez JA, Berkebile JA, Nevius BN, Ozmen GC, Nichols CJ, Ganti VG, Mabrouk SA, Clifford GD, Kamaleswaran R, Wright DW, Inan OT. A Wearable Multimodal Sensing System for Tracking Changes in Pulmonary Fluid Status, Lung Sounds, and Respiratory Markers. Sensors (Basel) 2022; 22:s22031130. [PMID: 35161876 PMCID: PMC8838360 DOI: 10.3390/s22031130] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/23/2022] [Accepted: 01/29/2022] [Indexed: 12/17/2022]
Abstract
Heart failure (HF) exacerbations, characterized by pulmonary congestion and breathlessness, require frequent hospitalizations, often resulting in poor outcomes. Current methods for tracking lung fluid and respiratory distress are unable to produce continuous, holistic measures of cardiopulmonary health. We present a multimodal sensing system that captures bioimpedance spectroscopy (BIS), multi-channel lung sounds from four contact microphones, multi-frequency impedance pneumography (IP), temperature, and kinematics to track changes in cardiopulmonary status. We first validated the system on healthy subjects (n = 10) and then conducted a feasibility study on patients (n = 14) with HF in clinical settings. Three measurements were taken throughout the course of hospitalization, and parameters relevant to lung fluid status—the ratio of the resistances at 5 kHz to those at 150 kHz (K)—and respiratory timings (e.g., respiratory rate) were extracted. We found a statistically significant increase in K (p < 0.05) from admission to discharge and observed respiratory timings in physiologically plausible ranges. The IP-derived respiratory signals and lung sounds were sensitive enough to detect abnormal respiratory patterns (Cheyne–Stokes) and inspiratory crackles from patient recordings, respectively. We demonstrated that the proposed system is suitable for detecting changes in pulmonary fluid status and capturing high-quality respiratory signals and lung sounds in a clinical setting.
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Affiliation(s)
- Jesus Antonio Sanchez-Perez
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30313, USA; (J.A.B.); (G.C.O.); (S.A.M.); (O.T.I.)
- Correspondence:
| | - John A. Berkebile
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30313, USA; (J.A.B.); (G.C.O.); (S.A.M.); (O.T.I.)
| | - Brandi N. Nevius
- Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA;
| | - Goktug C. Ozmen
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30313, USA; (J.A.B.); (G.C.O.); (S.A.M.); (O.T.I.)
| | - Christopher J. Nichols
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA 30332, USA; (C.J.N.); (G.D.C.); (R.K.)
| | - Venu G. Ganti
- Bioengineering Graduate Program, Georgia Institute of Technology, Atlanta, GA 30332, USA;
| | - Samer A. Mabrouk
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30313, USA; (J.A.B.); (G.C.O.); (S.A.M.); (O.T.I.)
| | - Gari D. Clifford
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA 30332, USA; (C.J.N.); (G.D.C.); (R.K.)
- Department of Biomedical Informatics, Emory University, Atlanta, GA 30332, USA
| | - Rishikesan Kamaleswaran
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA 30332, USA; (C.J.N.); (G.D.C.); (R.K.)
- Department of Biomedical Informatics, Emory University, Atlanta, GA 30332, USA
- Department of Emergency Medicine, Emory University, Atlanta, GA 30332, USA;
| | - David W. Wright
- Department of Emergency Medicine, Emory University, Atlanta, GA 30332, USA;
| | - Omer T. Inan
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30313, USA; (J.A.B.); (G.C.O.); (S.A.M.); (O.T.I.)
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA 30332, USA; (C.J.N.); (G.D.C.); (R.K.)
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20
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Neumar RW, Blomkalns AL, Cairns CB, D’Onofrio G, Kuppermann N, Lewis RJ, Newgard CD, O’Neil BJ, Rathlev NK, Rothman RE, Wright DW. Emergency medicine research: 2030 strategic goals. Acad Emerg Med 2022; 29:241-251. [PMID: 34363718 DOI: 10.1111/acem.14367] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 07/17/2021] [Accepted: 08/01/2021] [Indexed: 11/29/2022]
Abstract
All academic medical specialties have the obligation to continuously create new knowledge that will improve patient care and outcomes. Emergency medicine (EM) is no exception. Since its origins over 50 years ago, EM has struggled to fulfill its research mission. EM ranks last among clinical specialties in the percentage of medical school faculty who are National Institutes of Health (NIH)-funded principal investigators (PIs; 1.7%) and the percentage of medical school departments with NIH-funded PIs (33%). Although there has been a steady increase in the number of NIH-funded projects and total NIH dollars, the slowing growth in the number of NIH-funded PIs and lack of growth in the number of EM departments with NIH-funded PIs is cause for concern. In response, the Association of Academic Chairs of Emergency Medicine (AACEM) Research Task Force proposes a set of 2030 strategic goals for the EM research enterprise that are based on sustaining historic growth rates in NIH funding. These goals have been endorsed by the AACEM Executive Committee and the boards of Society for Academic Emergency Medicine (SAEM), American College of Emergency Physicians (ACEP), and American Academy of Emergency Medicine (AAEM). The 2030 strategic goals include 200 NIH-funded projects led by 150 EM PIs in at least 50 EM departments with over $100M in annual funding resulting in over 3% of EM faculty being NIH-funded PIs. Achieving these goals will require a targeted series of focused strategies to increase the number of EM faculty who are competitive for NIH funding. This requires a coordinated, intentional effort with investments at the national, departmental, and individual levels. These efforts are ideally led by medical school department chairs, who can create the culture and provide the resources needed to be successful. The specialty of EM has the obligation to improve the health of the public and to fulfill its research mission.
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Affiliation(s)
- Robert W. Neumar
- Department of Emergency Medicine University of Michigan Medical School Ann Arbor Michigan USA
| | - Andra L. Blomkalns
- Department of Emergency Medicine Stanford University School of Medicine Stanford California USA
| | | | - Gail D’Onofrio
- Department of Emergency Medicine Yale University School of Medicine New Haven Connecticut USA
| | - Nathan Kuppermann
- Department of Emergency Medicine University of California, Davis, School of Medicine Sacramento California USA
| | - Roger J. Lewis
- Department of Emergency Medicine Harbor–UCLA Medical Center Los Angeles California USA
| | - Craig D. Newgard
- Department of Emergency Medicine Oregon Health & Science University Portland Oregon USA
| | - Brian J. O’Neil
- Department of Emergency Medicine Wayne State University/Detroit Medical Center Detroit Michigan USA
| | - Niels K. Rathlev
- Department of Emergency Medicine University of Massachusetts Medical School Baystate Health Springfield Massachusetts USA
| | - Richard E. Rothman
- Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - David W. Wright
- Department of Emergency Medicine Emory University School of Medicine Atlanta Georgia USA
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21
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Moore CP, Pieterson K, DeSousa JM, Toote LE, Wright DW. Characterization and utility of immobilized metal affinity-functionalized cellulose membranes for point-of-care malaria diagnostics. J Chromatogr B Analyt Technol Biomed Life Sci 2021; 1186:123023. [PMID: 34788723 PMCID: PMC8633758 DOI: 10.1016/j.jchromb.2021.123023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/29/2021] [Accepted: 10/30/2021] [Indexed: 11/18/2022]
Abstract
Immobilized metal affinity chromatography (IMAC) is a well-established technique for protein separation and purification. IMAC has been previously utilized to capture the malaria biomarker histidine-rich protein 2 (HRP2) from blood, enhancing the sensitivity of field-appropriate diagnostic tools such as lateral flow assays. However, little work has been done to translate this technique to a truly field-usable design. In this study, IMAC-functionalized cellulose membranes are created and characterized fully for future use in applied malaria diagnostics. IMAC-functionalized cellulose membranes were investigated across a range of cellulose substrates, IMAC ligands, and divalent transition metals before use in a capture and elution flowthrough workflow. Following characterization and optimization, it was found that iminodiacetic acid bound to Zn(II) was the most promising ligand-metal pair, with three available coordination sites and a molar loading capacity of 57.7 μmol of metal/cm3 of cellulose. Using these parameters, more than 99% of HRP2 was captured from a large-volume lysed blood sample in a simple flow-through assay and 89% of the captured protein was eluted from the membrane using the chelating compound ethylenediaminetetraacetic acid. Use of this enhancement protocol on an in-house HRP2 lateral flow assay (LFA) yielded a limit of detection of 7 parasites/μL, a 15.8x enhancement factor compared to traditional LFA methods.
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Affiliation(s)
- Carson P Moore
- Vanderbilt University, Department of Chemistry, 1234 Stevenson Center Lane, Nashville, TN 37212, USA
| | - Kristina Pieterson
- Vanderbilt University, Department of Chemistry, 1234 Stevenson Center Lane, Nashville, TN 37212, USA
| | - Jenna M DeSousa
- Vanderbilt University, Department of Chemistry, 1234 Stevenson Center Lane, Nashville, TN 37212, USA
| | - Lauren E Toote
- Elizabethtown College, Department of Chemistry and Biochemistry, 1 Alpha Drive, Elizabethtown, PA 17022, USA
| | - David W Wright
- Vanderbilt University, Department of Chemistry, 1234 Stevenson Center Lane, Nashville, TN 37212, USA.
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22
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Bhatt NR, Backster A, Ido MS, Nogueira RG, Bayakly R, Wright DW, Frankel MR. Impact of Intravenous Alteplase Door-to-Needle Times on 2-Year Mortality in Patients With Acute Ischemic Stroke. Front Neurol 2021; 12:747185. [PMID: 34721274 PMCID: PMC8548610 DOI: 10.3389/fneur.2021.747185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 09/17/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: We sought to determine whether administration of Intravenous Thrombolysis (IVT) to patients with Acute Ischemic Stroke (AIS) within 60 min from hospital arrival is associated with lower 2-year mortality. Methods: This retrospective study was conducted among patients receiving IVT in hospitals participating in the Georgia Coverdell Acute Stroke Registry (GCASR) from January 1, 2008 through June 30, 2018. Two-year mortality data was obtained by linking the 2008–2018 Georgia Discharge Data System data and the 2008–2020 Georgia death records. We analyzed the study population in two groups based on the time from hospital arrival to initiation of IVT expressed as Door to Needle time (DTN) in a dichotomized (DTN ≤ 60 vs. > 60 min) fashion. Results: The median age of patients was 68 years, 49.4% were females, and the median NIHSS was 9. DTN ≤60 min was associated with lower 30-day [odds ratio (OR), 0.62; 95% CI, 0.52–0.73; P < 0.0001], 1-year (OR, 0.71; 95% CI, 0.61–0.83; P < 0.0001) and 2-year (OR, 0.76; 95% CI, 0.65–0.88; P = 0.001) mortality as well as lower rates of sICH at 36 h (OR, 0.57; 95% CI, 0.43–0.75; P = 0.0001), higher rates of ambulation at discharge (OR, 1.38; 95% CI, 1.25–1.53; P < 0.0001) and discharge to home (OR, 1.36; 95% CI, 1.23–1.52; P < 0.0001). Conclusion: Faster DTN in patients with AIS was associated with lower 2-year mortality across all age, gender and race subgroups. These findings reinforce the need for intensifying quality improvement measures to reduce DTN in AIS patients.
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Affiliation(s)
- Nirav R Bhatt
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
| | - Anika Backster
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Moges S Ido
- Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, Atlanta, GA, United States.,Georgia Department of Public Health, Division of Health Protection, Epidemiology Program, Atlanta, GA, United States
| | - Raul G Nogueira
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
| | - Rana Bayakly
- Georgia Department of Public Health, Division of Health Protection, Epidemiology Program, Atlanta, GA, United States
| | - David W Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Michael R Frankel
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
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23
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Korley F, Pauls Q, Yeatts SD, Jones CMC, Corbett-Valade E, Silbergleit R, Frankel M, Barsan W, Cahill ND, Bazarian JJ, Wright DW. Progesterone Treatment Does Not Decrease Serum Levels of Biomarkers of Glial and Neuronal Cell Injury in Moderate and Severe Traumatic Brain Injury Subjects: A Secondary Analysis of the Progesterone for Traumatic Brain Injury, Experimental Clinical Treatment (ProTECT) III Trial. J Neurotrauma 2021; 38:1953-1960. [PMID: 33319651 PMCID: PMC8260894 DOI: 10.1089/neu.2020.7072] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Early treatment of moderate/severe traumatic brain injury (TBI) with progesterone does not improve clinical outcomes. This is in contrast with findings from pre-clinical studies of progesterone in TBI. To understand the reasons for the negative clinical trial, we investigated whether progesterone treatment has the desired biological effect of decreasing brain cell death. We quantified brain cell death using serum levels of biomarkers of glial and neuronal cell death (glial fibrillary acidic protein [GFAP], ubiquitin carboxy-terminal hydrolase-L1 [UCH-L1], S100 calcium-binding protein B [S100B], and Alpha II Spectrin Breakdown Product 150 [SBDP]) in the Biomarkers of Injury and Outcome-Progesterone for Traumatic Brain Injury, Experimental Clinical Treatment (BIO-ProTECT) study. Serum levels of GFAP, UCHL1, S100B, and SBDP were measured at baseline (≤4 h post-injury and before administration of study drug) and at 24 and 48 h post-injury. Serum progesterone levels were measured at 24 and 48 h post-injury. The primary outcome of ProTECT was based on the Glasgow Outcome Scale-Extended assessed at 6 months post-randomization. We found that at baseline, there were no differences in biomarker levels between subjects randomized to progesterone treatment and those randomized to placebo (p > 0.10). Similarly, at 24 and 48 h post-injury, there were no differences in biomarker levels in the progesterone versus placebo groups (p > 0.15). There was no statistically significant correlation between serum progesterone concentrations and biomarker values obtained at 24 and 48 h. When examined as a continuous variable, baseline biomarker levels did not modify the association between progesterone treatment and neurological outcome (p of interaction term >0.39 for all biomarkers). We conclude that progesterone treatment does not decrease levels of biomarkers of glial and neuronal cell death during the first 48 h post-injury.
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Affiliation(s)
- Frederick Korley
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Qi Pauls
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sharon D. Yeatts
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Courtney Marie Cora Jones
- Departments of Emergency Medicine, Neurosurgery, and Physical Medicine and Rehabilitation, School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
- Public Health Sciences, Neurosurgery, and Physical Medicine and Rehabilitation, School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
| | - Emily Corbett-Valade
- Departments of Emergency Medicine, Neurosurgery, and Physical Medicine and Rehabilitation, School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
| | - Robert Silbergleit
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Michael Frankel
- Department of Neurology, Grady Memorial Hospital, Marcus Stroke and Neuroscience Center, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - William Barsan
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nathan D. Cahill
- School of Mathematical Sciences, Rochester Institute of Technology, Rochester, New York, USA
| | - Jeffrey J. Bazarian
- Departments of Emergency Medicine, Neurosurgery, and Physical Medicine and Rehabilitation, School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
- Public Health Sciences, Neurosurgery, and Physical Medicine and Rehabilitation, School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
- Departments of Neurology, Neurosurgery, and Physical Medicine and Rehabilitation, School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
| | - David W. Wright
- Department of Emergency Medicine, Grady Memorial Hospital, Marcus Stroke and Neuroscience Center, School of Medicine, Emory University, Atlanta, Georgia, USA
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24
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Tzepos RG, Raman E, Toote LE, Wright DW, Gerdon AE. Signal Amplification with Co(III) Protoporphyrin IX Nanoparticles and Anodic Stripping Voltammetry. ELECTROANAL 2021. [DOI: 10.1002/elan.202100108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Robert G. Tzepos
- Emmanuel College Department of Chemistry and Physics 400 Fenway Boston MA 02115
| | - Easwer Raman
- Emmanuel College Department of Chemistry and Physics 400 Fenway Boston MA 02115
| | - Lauren E. Toote
- Elizabethtown College Department of Chemistry and Biochemistry 1 Alpha Drive Elizabethtown PA 17022
| | - David W. Wright
- Vanderbilt University Department of Chemistry 7330 Stevenson Center Nashville TN 37235
| | - Aren E. Gerdon
- Emmanuel College Department of Chemistry and Physics 400 Fenway Boston MA 02115
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25
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Espinoza TR, Hendershot KA, Liu B, Knezevic A, Jacobs BB, Gore RK, Guskiewicz KM, Bazarian JJ, Phelps SE, Wright DW, LaPlaca MC. A Novel Neuropsychological Tool for Immersive Assessment of Concussion and Correlation with Subclinical Head Impacts. Neurotrauma Rep 2021; 2:232-244. [PMID: 34223554 PMCID: PMC8240822 DOI: 10.1089/neur.2020.0022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Mild traumatic brain injury (mTBI) remains a diagnostic challenge and therefore strategies for objective assessment of neurological function are key to limiting long-term sequelae. Current assessment methods are not optimal in austere environments such as athletic fields; therefore, we developed an immersive tool, the Display Enhanced Testing for Cognitive Impairment and mTBI (DETECT) platform, for rapid objective neuropsychological (NP) testing. The objectives of this study were to assess the ability of DETECT to accurately identify neurocognitive deficits associated with concussion and evaluate the relationship between neurocognitive measures and subconcussive head impacts. DETECT was used over a single season of two high school and two college football teams. Study participants were instrumented with Riddell Head Impact Telemetry (HIT) sensors and a subset tested with DETECT immediately after confirmed impacts for different combinations of linear and rotational acceleration. A total of 123 athletes were enrolled and completed baseline testing. Twenty-one players were pulled from play for suspected concussion and tested with DETECT. DETECT was 86.7% sensitive (95% confidence interval [CI]: 59.5%, 98.3%) and 66.7% specific (95% CI: 22.3%, 95.7%) in correctly identifying athletes with concussions (15 of 21). Weak but significant correlations were found between complex choice response time (processing speed and divided attention) and both linear (Spearman rank correlation coefficient 0.262, p = 0.02) and rotational (Spearman coefficient 0.254, p = 0.03) acceleration on a subset of 76 players (113 DETECT tests) with no concussion symptoms. This study demonstrates that DETECT confers moderate to high sensitivity in identifying acute cognitive impairment and suggests that football impacts that do not result in concussion may negatively affect cognitive performance immediately following an impact. Specificity, however, was not optimal and points to the need for additional studies across multiple neurological domains. Given the need for more objective concussion screening in triage situations, DETECT may provide a solution for mTBI assessment.
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Affiliation(s)
- Tamara R Espinoza
- Department of Emergency Medicine, Division of Emergency Neurosciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kristopher A Hendershot
- Department of Emergency Medicine, Division of Emergency Neurosciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Brian Liu
- Georgia Tech Research Institute (GTRI), Advanced Human Integration Branch, Atlanta, Georgia, USA
| | - Andrea Knezevic
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Breanne B Jacobs
- Department of Emergency Medicine, Division of Emergency Neurosciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Russell K Gore
- Complex Concussion Clinic, Shepherd Center, Atlanta, Georgia, USA
| | - Kevin M Guskiewicz
- Department of Exercise and Sport Science, University of North Carolina, North Carolina, USA
| | - Jeffery J Bazarian
- Department of Emergency Medicine, University of Rochester, Rochester, New York, USA
| | - Shean E Phelps
- Georgia Tech Research Institute (GTRI), Advanced Human Integration Branch, Atlanta, Georgia, USA
| | - David W Wright
- Department of Emergency Medicine, Division of Emergency Neurosciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michelle C LaPlaca
- Department of Biomedical Engineering, Georgia Institute of Technology/Emory University, Atlanta, Georgia, USA
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26
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DeSousa JM, Jorge MZ, Lindsay HB, Haselton FR, Wright DW, Scherr TF. Inductively coupled plasma optical emission spectroscopy as a tool for evaluating lateral flow assays. Anal Methods 2021; 13:2137-2146. [PMID: 33876162 DOI: 10.1039/d1ay00236h] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Lateral flow assays (LFAs) are immunochromatographic point-of-care devices that have greatly impacted disease diagnosis through their rapid, inexpensive, and easy-to-use form factor. While LFAs have been successful as field-deployable tools, they have a relatively poor limit of detection when compared to more complex methods. Moreover, most design and manufacturing optimization is achieved through time- and resource-intensive brute-force optimization. Despite increased interests in LFA manufacturing, more quantitative tools are needed to study current manufacturing protocols and therefore, optimize and streamline development of these devices further. In this work, we focus on a critical LFA component, colloidal gold conjugated to a detection antibody, one of the most commonly used reporter elements. This study utilizes inductively coupled plasma optical emission spectroscopy (ICP-OES) in conjunction with a lateral flow reader to quantitatively analyze colloidal gold distributions at the read-out test and control lines, as well as residual gold on the conjugate pad and other flow through regions. Our goals are to develop a more rigorous understanding of current LFA designs as well as a quantitative understanding of shortcomings of operational characteristics for future improvement. To our knowledge, this is the first time that ICP-OES has been used to study the initial distribution of colloidal gold on an unused LFA and its redistribution after a test is performed. Using three different brands of commercially available malaria LFAs, gold content was measured within each section of an LFA at varying parasite test concentrations. As expected, the total mass of gold remained unchanged after LFA use; however, the total mass of initial gold and its redistribution varied among manufacturers. Importantly, there are also some inherent inefficiencies that exist in these commercial LFA designs; for example, only 30% of the total gold deposited onto Brand A LFAs binds to the test and control lines, sections of the test that contain interpretable signal. Using information gathered with this method, future devices could be more purposefully engineered to focus on improved binding efficiency, resulting in reduced costs, improved limit of detection, and diminished test-to-test and manufacturer-to-manufacturer variability.
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Affiliation(s)
- Jenna M DeSousa
- Department of Chemistry, Vanderbilt University, Nashville, TN, USA.
| | - Micaella Z Jorge
- Department of Chemistry, Vanderbilt University, Nashville, TN, USA.
| | - Hayley B Lindsay
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA
| | - Frederick R Haselton
- Department of Chemistry, Vanderbilt University, Nashville, TN, USA. and Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA
| | - David W Wright
- Department of Chemistry, Vanderbilt University, Nashville, TN, USA.
| | - Thomas F Scherr
- Department of Chemistry, Vanderbilt University, Nashville, TN, USA.
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27
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Leary OP, Merck LH, Yeatts SD, Pan I, Liu DD, Harder TJ, Jung S, Collins S, Braileanu M, Gokaslan ZL, Allen JW, Wright DW, Merck D. Computer-Assisted Measurement of Traumatic Brain Hemorrhage Volume Is More Predictive of Functional Outcome and Mortality than Standard ABC/2 Method: An Analysis of Computed Tomography Imaging Data from the Progesterone for Traumatic Brain Injury Experimental Clinical Treatment Phase-III Trial. J Neurotrauma 2021; 38:604-615. [PMID: 33191851 PMCID: PMC7898408 DOI: 10.1089/neu.2020.7209] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Hemorrhage volume is an important variable in emergently assessing traumatic brain injury (TBI). The most widely used method for rapid volume estimation is ABC/2, a simple algorithm that approximates lesion geometry as perfectly ellipsoid. The relative prognostic value of volume measurement based on more precise hematoma topology remains unknown. In this study, we compare volume measurements obtained using ABC/2 versus computer-assisted volumetry (CAV) for both intra- and extra-axial traumatic hemorrhages, and then quantify the association of measurements using both methods with patient outcome following moderate to severe TBI. A total of 517 computer tomography (CT) scans acquired during the Progesterone for Traumatic Brain Injury Experimental Clinical Treatment Phase-III (ProTECTIII) multi-center trial were retrospectively reviewed. Lesion volumes were measured using ABC/2 and CAV. Agreement between methods was tested using Bland-Altman analysis. Relationship of volume measurements with 6-month mortality, Extended Glasgow Outcome Scale (GOS-E), and Disability Rating Scale (DRS) were assessed using linear regression and area under the curve (AUC) analysis. In subdural hematoma (SDH) >50cm3, ABC/2 and CAV produce significantly different volume measurements (p < 0.0001), although the difference was not significant for smaller SDH or intra-axial lesions. The disparity between ABC/2 and CAV measurements varied significantly with hematoma size for both intra- and extra-axial lesions (p < 0.0001). Across all lesions, volume was significantly associated with outcome using either method (p < 0.001), but CAV measurement was a significantly better predictor of outcome than ABC/2 estimation for SDH. Among large traumatic SDH, ABC/2 significantly overestimates lesion volume compared with measurement based on precise bleed topology. CAV also offers significantly better prediction of patient functional outcofme and mortality.
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Affiliation(s)
- Owen P. Leary
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
- Department of Diagnostic Imaging, and Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
| | - Lisa H. Merck
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
- Department of Diagnostic Imaging, and Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville Florida, USA
| | - Sharon D. Yeatts
- Department of Health Sciences, Medical University of South Carolina, Charleston South Carolina, USA
| | - Ian Pan
- Department of Diagnostic Imaging, and Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
| | - David D. Liu
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
| | - Tyler J. Harder
- Department of Diagnostic Imaging, and Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
| | - Stefan Jung
- Department of Diagnostic Imaging, and Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
| | - Scott Collins
- Department of Diagnostic Imaging, and Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
| | - Maria Braileanu
- Department of Radiology and Emory University School of Medicine, Atlanta Georgia, USA
| | - Ziya L. Gokaslan
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
| | - Jason W. Allen
- Department of Radiology and Emory University School of Medicine, Atlanta Georgia, USA
| | - David W. Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta Georgia, USA
| | - Derek Merck
- Department of Diagnostic Imaging, and Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville Florida, USA
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28
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Sevransky JE, Rothman RE, Hager DN, Bernard GR, Brown SM, Buchman TG, Busse LW, Coopersmith CM, DeWilde C, Ely EW, Eyzaguirre LM, Fowler AA, Gaieski DF, Gong MN, Hall A, Hinson JS, Hooper MH, Kelen GD, Khan A, Levine MA, Lewis RJ, Lindsell CJ, Marlin JS, McGlothlin A, Moore BL, Nugent KL, Nwosu S, Polito CC, Rice TW, Ricketts EP, Rudolph CC, Sanfilippo F, Viele K, Martin GS, Wright DW. Effect of Vitamin C, Thiamine, and Hydrocortisone on Ventilator- and Vasopressor-Free Days in Patients With Sepsis: The VICTAS Randomized Clinical Trial. JAMA 2021; 325:742-750. [PMID: 33620405 PMCID: PMC7903252 DOI: 10.1001/jama.2020.24505] [Citation(s) in RCA: 144] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Sepsis is a common syndrome with substantial morbidity and mortality. A combination of vitamin C, thiamine, and corticosteroids has been proposed as a potential treatment for patients with sepsis. OBJECTIVE To determine whether a combination of vitamin C, thiamine, and hydrocortisone every 6 hours increases ventilator- and vasopressor-free days compared with placebo in patients with sepsis. DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized, double-blind, adaptive-sample-size, placebo-controlled trial conducted in adult patients with sepsis-induced respiratory and/or cardiovascular dysfunction. Participants were enrolled in the emergency departments or intensive care units at 43 hospitals in the United States between August 2018 and July 2019. After enrollment of 501 participants, funding was withheld, leading to an administrative termination of the trial. All study-related follow-up was completed by January 2020. INTERVENTIONS Participants were randomized to receive intravenous vitamin C (1.5 g), thiamine (100 mg), and hydrocortisone (50 mg) every 6 hours (n = 252) or matching placebo (n = 249) for 96 hours or until discharge from the intensive care unit or death. Participants could be treated with open-label corticosteroids by the clinical team, with study hydrocortisone or matching placebo withheld if the total daily dose was greater or equal to the equivalent of 200 mg of hydrocortisone. MAIN OUTCOMES AND MEASURES The primary outcome was the number of consecutive ventilator- and vasopressor-free days in the first 30 days following the day of randomization. The key secondary outcome was 30-day mortality. RESULTS Among 501 participants randomized (median age, 62 [interquartile range {IQR}, 50-70] years; 46% female; 30% Black; median Acute Physiology and Chronic Health Evaluation II score, 27 [IQR, 20.8-33.0]; median Sequential Organ Failure Assessment score, 9 [IQR, 7-12]), all completed the trial. Open-label corticosteroids were prescribed to 33% and 32% of the intervention and control groups, respectively. Ventilator- and vasopressor-free days were a median of 25 days (IQR, 0-29 days) in the intervention group and 26 days (IQR, 0-28 days) in the placebo group, with a median difference of -1 day (95% CI, -4 to 2 days; P = .85). Thirty-day mortality was 22% in the intervention group and 24% in the placebo group. CONCLUSIONS AND RELEVANCE Among critically ill patients with sepsis, treatment with vitamin C, thiamine, and hydrocortisone, compared with placebo, did not significantly increase ventilator- and vasopressor-free days within 30 days. However, the trial was terminated early for administrative reasons and may have been underpowered to detect a clinically important difference. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03509350.
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Affiliation(s)
- Jonathan E. Sevransky
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Emory University School of Medicine, Atlanta, Georgia
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
| | - Richard E. Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David N. Hager
- Division of Pulmonary Critical Care, Johns Hopkins University, Baltimore, Maryland
| | - Gordon R. Bernard
- Division of Pulmonary Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Samuel M. Brown
- Division of Pulmonary Critical Care, Intermountain Medical Center and University of Utah, Salt Lake City
| | - Timothy G. Buchman
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Laurence W. Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Emory University School of Medicine, Atlanta, Georgia
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
| | - Craig M. Coopersmith
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Christine DeWilde
- Division of Pulmonary Critical Care, Virginia Commonwealth University, Richmond
| | - E. Wesley Ely
- Division of Pulmonary Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
- Johns Hopkins Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Baltimore, Maryland
- Veteran’s Affairs Tennessee Valley Geriatric Research Education Clinical Center (GRECC), Nashville
| | | | - Alpha A. Fowler
- Division of Pulmonary Critical Care, Virginia Commonwealth University, Richmond
| | - David F. Gaieski
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Michelle N. Gong
- Department of Critical Care, Montefiore Medical Center, Bronx, New York
| | - Alex Hall
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - Jeremiah S. Hinson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Michael H. Hooper
- Division of Pulmonary Critical Care, Sentara Healthcare, Norfolk, Virginia
| | - Gabor D. Kelen
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Akram Khan
- Division of Pulmonary Critical Care, Oregon Health & Science University, Portland
| | - Mark A. Levine
- Molecular and Clinical Nutrition Section, National Institutes of Health, Bethesda, Maryland
| | - Roger J. Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
- Lundquist Institute for Biomedical Innovation, Torrance, California
| | - Chris J. Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jessica S. Marlin
- Vanderbilt Coordinating Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Brooks L. Moore
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | | | - Samuel Nwosu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carmen C. Polito
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Emory University School of Medicine, Atlanta, Georgia
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
| | - Todd W. Rice
- Division of Pulmonary Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Erin P. Ricketts
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Fred Sanfilippo
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kert Viele
- Berry Consultants LLC, Austin, Texas
- Department of Biostatistics, University of Kentucky, Lexington
| | - Greg S. Martin
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Emory University School of Medicine, Atlanta, Georgia
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
| | - David W. Wright
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
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29
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van der Horst M, Karamchand L, Bauer WS, Nel AJM, Blackburn JM, Wright DW. The cyanobacterial lectin, microvirin-N, enhances the specificity and sensitivity of lipoarabinomannan-based TB diagnostic tests. Analyst 2021; 146:1207-1215. [PMID: 33367346 PMCID: PMC8374243 DOI: 10.1039/d0an01725f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 12/09/2020] [Indexed: 01/04/2023]
Abstract
Tuberculosis (TB) is one of the top ten causes of death globally, despite being treatable. The eradication of TB disease requires, amongst others, diagnostic tests with high specificity and sensitivity that will work at the point of care (POC) in low-resource settings. The TB surface glycolipid antigen, mannose-capped lipoarabinomannan (ManLAM) currently serves as the only POC molecular diagnostic biomarker suitable for use in low cost immunoassays. Here, we demonstrate the high affinity and exceptional specificity of microvirin-N (MVN), a 14.3 kDa cyanobacterial lectin, toward H37Rv TB ManLAM and utilize it to develop a novel on-bead ELISA. MVN binds to ManLAM with sub-picomolar binding affinity, but does not bind to other variants of LAM expressed by non-pathogenic mycobacteria - a level of binding specificity and affinity that current commercially available anti-LAM antibodies cannot achieve. An on-bead ELISA was subsequently developed using MVN-functionalized magnetic beads which allows for the specific capture of ManLAM from human urine with a limit of detection (LOD) of 1.14 ng mL-1 and no cross-reactivity when tested with PILAM, a variant of LAM found on non-pathogenic mycobacteria.
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Affiliation(s)
- Megan van der Horst
- Department of Chemistry, Vanderbilt UniversityStation B 351822NashvilleTN37235USA
| | - Leshern Karamchand
- University of Cape Town, Faculty of Health Sciences, Institute of Infectious Disease and Molecular Medicine; Department of Integrative Biomedical SciencesAnzio RoadObservatory7925South Africa
| | - Westley S. Bauer
- Department of Chemistry, Vanderbilt UniversityStation B 351822NashvilleTN37235USA
| | - Andrew J. M. Nel
- University of Cape Town, Faculty of Health Sciences, Institute of Infectious Disease and Molecular Medicine; Department of Integrative Biomedical SciencesAnzio RoadObservatory7925South Africa
| | - Jonathan M. Blackburn
- University of Cape Town, Faculty of Health Sciences, Institute of Infectious Disease and Molecular Medicine; Department of Integrative Biomedical SciencesAnzio RoadObservatory7925South Africa
| | - David W. Wright
- Department of Chemistry, Vanderbilt UniversityStation B 351822NashvilleTN37235USA
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30
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da Silva JF, Hernandez-Romieu AC, Browning SD, Bruce BB, Natarajan P, Morris SB, Gold JAW, Neblett Fanfair R, Rogers-Brown J, Rossow J, Szablewski CM, Oosmanally N, D’Angelo MT, Drenzek C, Murphy DJ, Hollberg J, Blum JM, Jansen R, Wright DW, Sewell W, Owens J, Lefkove B, Brown FW, Burton DC, Uyeki TM, Patel PR, Jackson BR, Wong KK. COVID-19 Clinical Phenotypes: Presentation and Temporal Progression of Disease in a Cohort of Hospitalized Adults in Georgia, United States. Open Forum Infect Dis 2021; 8:ofaa596. [PMID: 33537363 PMCID: PMC7798484 DOI: 10.1093/ofid/ofaa596] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/03/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The epidemiological features and outcomes of hospitalized adults with coronavirus disease 2019 (COVID-19) have been described; however, the temporal progression and medical complications of disease among hospitalized patients require further study. Detailed descriptions of the natural history of COVID-19 among hospitalized patients are paramount to optimize health care resource utilization, and the detection of different clinical phenotypes may allow tailored clinical management strategies. METHODS This was a retrospective cohort study of 305 adult patients hospitalized with COVID-19 in 8 academic and community hospitals. Patient characteristics included demographics, comorbidities, medication use, medical complications, intensive care utilization, and longitudinal vital sign and laboratory test values. We examined laboratory and vital sign trends by mortality status and length of stay. To identify clinical phenotypes, we calculated Gower's dissimilarity matrix between each patient's clinical characteristics and clustered similar patients using the partitioning around medoids algorithm. RESULTS One phenotype of 6 identified was characterized by high mortality (49%), older age, male sex, elevated inflammatory markers, high prevalence of cardiovascular disease, and shock. Patients with this severe phenotype had significantly elevated peak C-reactive protein creatinine, D-dimer, and white blood cell count and lower minimum lymphocyte count compared with other phenotypes (P < .01, all comparisons). CONCLUSIONS Among a cohort of hospitalized adults, we identified a severe phenotype of COVID-19 based on the characteristics of its clinical course and poor prognosis. These findings need to be validated in other cohorts, as improved understanding of clinical phenotypes and risk factors for their development could help inform prognosis and tailored clinical management for COVID-19.
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Affiliation(s)
- Juliana F da Silva
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alfonso C Hernandez-Romieu
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service
| | - Sean D Browning
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Beau B Bruce
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Pavithra Natarajan
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sapna B Morris
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service
| | - Jeremy A W Gold
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Robyn Neblett Fanfair
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service
| | - Jessica Rogers-Brown
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - John Rossow
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service
| | - Christine M Szablewski
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Georgia Department of Public Health, Atlanta, Georgia, USA
| | | | | | - Cherie Drenzek
- Georgia Department of Public Health, Atlanta, Georgia, USA
| | - David J Murphy
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Julie Hollberg
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - James M Blum
- Emory University School of Medicine, Atlanta, Georgia, USA
- Georgia Clinical & Translational Science Alliance, Atlanta, Georgia, USA
| | | | - David W Wright
- Georgia Clinical & Translational Science Alliance, Atlanta, Georgia, USA
- Grady Health System, Atlanta, Georgia, USA
| | | | - Jack Owens
- Phoebe Putney Memorial Hospital, Albany, Georgia, USA
| | | | - Frank W Brown
- Georgia Clinical & Translational Science Alliance, Atlanta, Georgia, USA
- Emory Decatur Hospital, Decatur, Georgia, USA
| | - Deron C Burton
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service
| | - Timothy M Uyeki
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service
| | - Priti R Patel
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service
| | - Brendan R Jackson
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service
| | - Karen K Wong
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service
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31
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Hawryluk GWJ, Rubiano AM, Totten AM, O'Reilly C, Ullman JS, Bratton SL, Chesnut R, Harris OA, Kissoon N, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Lumba-Brown A, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations. Neurosurgery 2020; 87:427-434. [PMID: 32761068 PMCID: PMC7426189 DOI: 10.1093/neuros/nyaa278] [Citation(s) in RCA: 143] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 05/28/2020] [Indexed: 11/25/2022] Open
Abstract
When the fourth edition of the Brain Trauma Foundation's Guidelines for the Management of Severe Traumatic Brain Injury were finalized in late 2016, it was known that the results of the RESCUEicp (Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension) randomized controlled trial of decompressive craniectomy would be public after the guidelines were released. The guideline authors decided to proceed with publication but to update the decompressive craniectomy recommendations later in the spirit of “living guidelines,” whereby topics are updated more frequently, and between new editions, when important new evidence is published. The update to the decompressive craniectomy chapter presented here integrates the findings of the RESCUEicp study as well as the recently published 12-mo outcome data from the DECRA (Decompressive Craniectomy in Patients With Severe Traumatic Brain Injury) trial. Incorporation of these publications into the body of evidence led to the generation of 3 new level-IIA recommendations; a fourth previously presented level-IIA recommendation remains valid and has been restated. To increase the utility of the recommendations, we added a new section entitled Incorporating the Evidence into Practice. This summary of expert opinion provides important context and addresses key issues for practitioners, which are intended to help the clinician utilize the available evidence and these recommendations. The full guideline can be found at: https://braintrauma.org/guidelines/guidelines-for-the-management-of-severe-tbi-4th-ed#/.
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Affiliation(s)
- Gregory W J Hawryluk
- Section of Neurosurgery, GB1-Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Andres M Rubiano
- INUB-MEDITECH Research Group, Universidad El Bosque, Bogota, Colombia.,Valle Salud Clinic, Cali, Colombia
| | | | | | - Jamie S Ullman
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | | | | | | | | | - Lori Shutter
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert C Tasker
- Harvard Medical School & Boston Children's Hospital, Boston, Massachusetts
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Wan S, Potterton A, Husseini FS, Wright DW, Heifetz A, Malawski M, Townsend-Nicholson A, Coveney PV. Hit-to-lead and lead optimization binding free energy calculations for G protein-coupled receptors. Interface Focus 2020; 10:20190128. [PMID: 33178414 PMCID: PMC7653344 DOI: 10.1098/rsfs.2019.0128] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2020] [Indexed: 12/13/2022] Open
Abstract
We apply the hit-to-lead ESMACS (enhanced sampling of molecular dynamics with approximation of continuum solvent) and lead-optimization TIES (thermodynamic integration with enhanced sampling) methods to compute the binding free energies of a series of ligands at the A1 and A2A adenosine receptors, members of a subclass of the GPCR (G protein-coupled receptor) superfamily. Our predicted binding free energies, calculated using ESMACS, show a good correlation with previously reported experimental values of the ligands studied. Relative binding free energies, calculated using TIES, accurately predict experimentally determined values within a mean absolute error of approximately 1 kcal mol-1. Our methodology may be applied widely within the GPCR superfamily and to other small molecule-receptor protein systems.
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Affiliation(s)
- Shunzhou Wan
- Centre for Computational Science, Department of Chemistry, University College London, London WC1H 0AJ, UK
| | - Andrew Potterton
- Institute of Structural and Molecular Biology, Research Department of Structural and Molecular Biology, Division of Biosciences, University College London, London WC1E 6BT, UK
| | - Fouad S. Husseini
- Centre for Computational Science, Department of Chemistry, University College London, London WC1H 0AJ, UK
| | - David W. Wright
- Centre for Computational Science, Department of Chemistry, University College London, London WC1H 0AJ, UK
| | - Alexander Heifetz
- Institute of Structural and Molecular Biology, Research Department of Structural and Molecular Biology, Division of Biosciences, University College London, London WC1E 6BT, UK
- Evotec (UK) Ltd, 114 Innovation Drive, Milton Park, Abingdon OX14 4RZ, UK
| | - Maciej Malawski
- ACK Cyfronet, AGH University of Science and Technology, Nawojki 11, 30-950, Kraków, Poland
| | - Andrea Townsend-Nicholson
- Institute of Structural and Molecular Biology, Research Department of Structural and Molecular Biology, Division of Biosciences, University College London, London WC1E 6BT, UK
| | - Peter V. Coveney
- Centre for Computational Science, Department of Chemistry, University College London, London WC1H 0AJ, UK
- Computational Science Laboratory, Institute for Informatics, Faculty of Science, University of Amsterdam, 1098XH Amsterdam, The Netherlands
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Kantor AG, Markwalter CF, Nourani A, Wright DW. An antibody-free dual-biomarker rapid enrichment workflow (AnDREW) improves the sensitivity of malaria rapid diagnostic tests. Anal Biochem 2020; 612:114020. [PMID: 33207186 DOI: 10.1016/j.ab.2020.114020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/13/2020] [Accepted: 11/09/2020] [Indexed: 11/15/2022]
Abstract
Rapid diagnostic tests (RDTs) are critical to the success of malaria elimination campaigns. These tests are rapid, user-friendly, and field-deployable to resource-limited regions. However, RDTs demonstrate poor sensitivity because they can only tolerate a small (5 μL) volume of blood, which limits the amount of protein biomarker delivered to the test. We have developed the Antibody-free Dual-biomarker Rapid Enrichment Workflow (AnDREW) for purifying histidine-rich protein 2 (HRP2) and Plasmodium lactate dehydrogenase (PLDH) from large volume (150 μL) blood samples. We used Zn(II)NTA and aptamer-conjugated magnetic beads to capture HRP2 and PLDH, respectively. Both biomarkers were then eluted into RDT-compatible volumes using ethylene diamine tetraacetic acid (EDTA). We optimized both bead conjugates individually by enzyme-linked immunosorbent assays (ELISAs) and then combined the optimized capture and elution assays for both biomarkers to produce the AnDREW. The AnDREW-enhanced RDTs exhibited a 11-fold and 9-fold improvement in analytical sensitivity for detection of HRP2 and PLDH, respectively, when compared to unenhanced RDTs. Moreover, the limit of detection for PLDH was improved 11-fold for the AnDREW-enhanced RDTs (3.80 parasites/μL) compared to unenhanced RDTs (42.31 parasites/μL). Importantly, the AnDREW utilizes a pan-specific PLDH aptamer and improves upon existing methods by eluting both biomarkers without complexed antibodies.
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Affiliation(s)
- Andrew G Kantor
- Department of Chemistry, Vanderbilt University, Nashville, TN, 37235, USA
| | | | - Armin Nourani
- Department of Chemistry, Vanderbilt University, Nashville, TN, 37235, USA
| | - David W Wright
- Department of Chemistry, Vanderbilt University, Nashville, TN, 37235, USA.
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Yaffee AQ, Peacock E, Seitz R, Hughes G, Haun P, Ross M, Moran TP, Pendley A, Terry N, Wright DW. Preparedness, Adaptation, and Innovation: Approach to the COVID-19 Pandemic at a Decentralized, Quaternary Care Department of Emergency Medicine. West J Emerg Med 2020; 21:63-70. [PMID: 33052812 PMCID: PMC7673894 DOI: 10.5811/westjem.2020.8.48624] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/19/2020] [Indexed: 01/17/2023] Open
Abstract
The COVID-19 pandemic has required healthcare systems to be creative and adaptable in response to an unprecedented crisis. Below we describe how we prepared for and adapted to this pandemic at our decentralized, quaternary-care department of emergency medicine, with specific recommendations from our experience. We discuss our longstanding history of institutional preparedness, as well as adaptations in triage, staffing, workflow, and communications. We also discuss innovation through working with industry on solutions in personal protective equipment, as well as telemedicine and methods for improving morale. These preparedness and response solutions and recommendations may be useful moving forward as we transition between response and recovery in this pandemic as well as future pandemics.
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Affiliation(s)
- Anna Q Yaffee
- Emory University, Department of Emergency Medicine, Atlanta, Georgia
| | - Elizabeth Peacock
- Emory University, Department of Emergency Medicine, Atlanta, Georgia
| | - Roslyn Seitz
- Emory University, Department of Emergency Medicine, Atlanta, Georgia
| | - George Hughes
- Emory University, Department of Emergency Medicine, Atlanta, Georgia
| | - Philip Haun
- Emory University, Department of Emergency Medicine, Atlanta, Georgia
| | - Michael Ross
- Emory University, Department of Emergency Medicine, Atlanta, Georgia
| | - Tim P Moran
- Emory University, Department of Emergency Medicine, Atlanta, Georgia
| | - Andrew Pendley
- Emory University, Department of Emergency Medicine, Atlanta, Georgia
| | - Nataisia Terry
- Emory University, Department of Emergency Medicine, Atlanta, Georgia
| | - David W Wright
- Emory University, Department of Emergency Medicine, Atlanta, Georgia
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Jackson BR, Gold JAW, Natarajan P, Rossow J, Neblett Fanfair R, da Silva J, Wong KK, Browning SD, Bamrah Morris S, Rogers-Brown J, Hernandez-Romieu AC, Szablewski CM, Oosmanally N, Tobin-D'Angelo M, Drenzek C, Murphy DJ, Hollberg J, Blum JM, Jansen R, Wright DW, SeweSll WM, Owens JD, Lefkove B, Brown FW, Burton DC, Uyeki TM, Bialek SR, Patel PR, Bruce BB. Predictors at admission of mechanical ventilation and death in an observational cohort of adults hospitalized with COVID-19. Clin Infect Dis 2020; 73:e4141-e4151. [PMID: 32971532 PMCID: PMC7543323 DOI: 10.1093/cid/ciaa1459] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Indexed: 01/08/2023] Open
Abstract
Background Coronavirus disease (COVID-19) can cause severe illness and death. Predictors of poor outcome collected on hospital admission may inform clinical and public health decisions. Methods We conducted a retrospective observational cohort investigation of 297 adults admitted to eight academic and community hospitals in Georgia, United States, during March 2020. Using standardized medical record abstraction, we collected data on predictors including admission demographics, underlying medical conditions, outpatient antihypertensive medications, recorded symptoms, vital signs, radiographic findings, and laboratory values. We used random forest models to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CI) for predictors of invasive mechanical ventilation (IMV) and death. Results Compared with age <45 years, ages 65–74 years and ≥75 years were predictors of IMV (aOR 3.12, CI 1.47–6.60; aOR 2.79, CI 1.23–6.33) and the strongest predictors for death (aOR 12.92, CI 3.26–51.25; aOR 18.06, CI 4.43–73.63). Comorbidities associated with death (aORs from 2.4 to 3.8, p <0.05) included end-stage renal disease, coronary artery disease, and neurologic disorders, but not pulmonary disease, immunocompromise, or hypertension. Pre-hospital use vs. non-use of angiotensin receptor blockers (aOR 2.02, CI 1.03–3.96) and dihydropyridine calcium channel blockers (aOR 1.91, CI 1.03–3.55) were associated with death. Conclusions After adjustment for patient and clinical characteristics, older age was the strongest predictor of death, exceeding comorbidities, abnormal vital signs, and laboratory test abnormalities. That coronary artery disease, but not chronic lung disease, was associated with death among hospitalized patients warrants further investigation, as do associations between certain antihypertensive medications and death.
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Affiliation(s)
| | - Jeremy A W Gold
- CDC COVID-19 Emergency Response.,Epidemic Intelligence Service, CDC
| | | | - John Rossow
- CDC COVID-19 Emergency Response.,U.S. Public Health Service.,Epidemic Intelligence Service, CDC
| | | | | | - Karen K Wong
- CDC COVID-19 Emergency Response.,U.S. Public Health Service
| | - Sean D Browning
- CDC COVID-19 Emergency Response.,Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | | | - Jessica Rogers-Brown
- CDC COVID-19 Emergency Response.,Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Alfonso C Hernandez-Romieu
- CDC COVID-19 Emergency Response.,U.S. Public Health Service.,Epidemic Intelligence Service, CDC.,Emory University School of Medicine
| | - Christine M Szablewski
- CDC COVID-19 Emergency Response.,U.S. Public Health Service.,Epidemic Intelligence Service, CDC.,Georgia Department of Public Health, Atlanta, Georgia
| | | | | | | | | | | | - James M Blum
- Emory University School of Medicine.,Georgia Clinical & Translational Science Alliance, Atlanta, Georgia
| | | | - David W Wright
- Emory University School of Medicine.,Grady Health System, Atlanta, Georgia
| | | | - Jack D Owens
- Phoebe Putney Memorial Hospital, Albany, Georgia
| | | | - Frank W Brown
- Emory University School of Medicine.,Emory Decatur Hospital, Decatur, Georgia
| | - Deron C Burton
- CDC COVID-19 Emergency Response.,U.S. Public Health Service
| | | | | | - Priti R Patel
- CDC COVID-19 Emergency Response.,U.S. Public Health Service
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Oyesanya TO, Moran TP, Espinoza TR, Wright DW. Regional Variations in Rehabilitation Outcomes of Adult Patients With Traumatic Brain Injury: A Uniform Data System for Medical Rehabilitation Investigation. Arch Phys Med Rehabil 2020; 102:68-75. [PMID: 32861669 DOI: 10.1016/j.apmr.2020.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To examine regional differences in rehabilitation outcomes among adult patients with moderate-to-severe traumatic brain injury (TBI) who received care at an inpatient rehabilitation facility (IRF). DESIGN We conducted a secondary analysis of a large, multi-center dataset from the Uniform Data System for Medical Rehabilitation. SETTING More than 70% of all IRFs in the United States. PARTICIPANTS Adult TBI patients (N=175,358) aged 18 years or older who were admitted and discharged from an IRF in the United States between 2004 and 2014. Qualifying etiology included traumatic brain dysfunction Impairment Group codes 02.21 (traumatic, open injury) and 02.22 (traumatic, closed injury). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Discharge functional status (total, cognitive, motor), length of stay, and discharge to home. RESULTS Patient and clinical characteristics varied significantly by geographic location, as did median functional status, length of stay, and percentage of patients discharged home. The region where IRF care was received, race and ethnicity, age, occurrence of 1 or more falls during the IRF stay, case mix group, and insurance status were associated with discharge functional status, length of stay, and discharge to home. CONCLUSIONS Our findings provide evidence of geographic differences in outcomes and potential disparities in care of TBI patients who received IRF care. More research is needed to identify TBI patients at risk for poor discharge outcomes to inform development and testing of interventions to reduce disparities in outcomes for these patients.
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Affiliation(s)
| | - Tim P Moran
- Department of Emergency Medicine, School of Medicine, Emory University, Atlanta, GA
| | - Tamara R Espinoza
- Department of Emergency Medicine, School of Medicine, Emory University, Atlanta, GA
| | - David W Wright
- Department of Emergency Medicine, School of Medicine, Emory University, Atlanta, GA
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37
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Yeatts SD, Martin RH, Meurer W, Silbergleit R, Rockswold GL, Barsan WG, Korley FK, Wright DW, Gajewski BJ. Sliding Scoring of the Glasgow Outcome Scale-Extended as Primary Outcome in Traumatic Brain Injury Trials. J Neurotrauma 2020; 37:2674-2679. [PMID: 32664792 DOI: 10.1089/neu.2019.6969] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The Glasgow Outcome Scale-Extended (GOS-E), an ordinal scale measuring global outcome, is used commonly as the primary outcome measure in clinical trials of traumatic brain injury. Analysis is often based on a dichotomization and thus has inherent statistical limitations, including loss of information related to the collapse of adjacent categories. A fixed dichotomization defines favorable outcome consistently for all subjects, whereas a sliding dichotomy tailors the definition of favorable outcome according to baseline prognosis/severity. Literature indicates that the sliding dichotomy is more statistically efficient than the fixed dichotomy; however, the sliding dichotomy still collapses categories and therefore discards information. We propose an alternative, a sliding scoring system for the GOS-E, intended to address the limitations of the sliding dichotomy. The score is assigned based on the number of levels between the achieved score and the favorable cut-point. The proposed scoring system reflects the magnitude of change, where change is defined according to each subject's baseline prognosis. Because the score is approximately continuous, statistical methods can rely on the normal distribution, both for analysis and study design. Two examples show the corresponding potential for improved power. A sliding score approach allows for quantification of the magnitude of change while still accounting for prognosis. Scientific advantages include increased power and an intuitive interpretation.
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Affiliation(s)
- Sharon D Yeatts
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Reneé H Martin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - William Meurer
- Department of Emergency Medicine, University of Michigan. Ann Arbor, Michigan, USA.,Visiting medical and statistical scientist, Berry Consultants, Austin, Texas, USA
| | - Robert Silbergleit
- Department of Emergency Medicine, University of Michigan. Ann Arbor, Michigan, USA
| | - Gaylan L Rockswold
- Department of Neurosurgery, University of Minnesota, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - William G Barsan
- Department of Emergency Medicine, University of Michigan. Ann Arbor, Michigan, USA
| | - Frederick K Korley
- Department of Emergency Medicine, University of Michigan. Ann Arbor, Michigan, USA
| | - David W Wright
- Department of Emergency Medicine, Emory University, Atlanta, Georgia, USA
| | - Byron J Gajewski
- Department of Biostatistics & Data Science, University of Kansas Medical Center. Kansas City, Kansas, USA
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38
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Schrager JD, Schuler K, Isakov AP, Wright DW, Yaffee AQ, Jacobson KL, Parker RM, Goolsby C. Development and Usability Testing of a Web-based COVID-19 Self-triage Platform. West J Emerg Med 2020; 21:1054-1058. [PMID: 32970554 PMCID: PMC7514387 DOI: 10.5811/westjem.2020.7.48217] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/24/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction The development and deployment of a web-based, self-triage tool for severe respiratory syndrome coronavirus 2 (COVID-19 disease) aimed at preventing surges in healthcare utilization could provide easily understandable health guidance with the goal of mitigating unnecessary emergency department (ED) and healthcare visits. We describe the iterative development and usability testing of such a tool. We hypothesized that adult users could understand and recall the recommendations provided by a COVID-19 web-based, self-triage tool. Methods We convened a multidisciplinary panel of medical experts at two academic medical schools in an iterative redesign process of a previously validated web-based, epidemic screening tool for the current COVID-19 pandemic. We then conducted a cross-sectional usability study over a 24-hour period among faculty, staff, and students at the two participating universities. Participants were randomly assigned a pre-written health script to enter into the self-triage website for testing. The primary outcome was immediate recall of website recommendations. Secondary outcomes included usability measures. We stratified outcomes by demographic characteristics. Results A final sample of 877 participants (mean age, 32 years [range, 19–84 years]; 65.3% female) was used in the analysis. We found that 79.4% of the participants accurately recalled the recommendations provided by the website. Almost all participants (96.9%) found the website easy to use and navigate. Conclusion Adult users of a COVID-19 self-triage website, recruited from an academic setting, were able to successfully recall self-care instructions from the website and found it user-friendly. This website appears to be a feasible way to provide evidence-based health guidance to adult patients during a pandemic. Website guidance could be used to reduce unnecessary ED and healthcare visits.
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Affiliation(s)
- Justin D Schrager
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
| | - Keke Schuler
- National Center for Disaster Medicine and Public Health, Department, Bethesda, Maryland
| | - Alexander P Isakov
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
| | - David W Wright
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
| | - Anna Q Yaffee
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
| | - Kara L Jacobson
- Rollins School of Public Health, Department of Health Policy and Management, Atlanta, Georgia
| | - Ruth M Parker
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
| | - Craig Goolsby
- Uniformed Services University of the Health Sciences, Department of Military and Emergency Medicine, Bethesda, Maryland
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Asselin PD, Gu Y, Merchant-Borna K, Abar B, Wright DW, Qiu X, Bazarian JJ. Spatial regression analysis of MR diffusion reveals subject-specific white matter changes associated with repetitive head impacts in contact sports. Sci Rep 2020; 10:13606. [PMID: 32788605 PMCID: PMC7423936 DOI: 10.1038/s41598-020-70604-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/26/2020] [Indexed: 02/06/2023] Open
Abstract
Repetitive head impacts (RHI) are a growing concern due to their possible neurocognitive effects, with research showing a season of RHI produce white matter (WM) changes seen on neuroimaging. We conducted a secondary analysis of diffusion tensor imaging (DTI) data for 28 contact athletes to compare WM changes. We collected pre-season and post-season DTI scans for each subject, approximately 3 months apart. We collected helmet data for the athletes, which we correlated with DTI data. We adapted the SPatial REgression Analysis of DTI (SPREAD) algorithm to conduct subject-specific longitudinal DTI analysis, and developed global inferential tools using functional norms and a novel robust p value combination test. At the individual level, most detected injured regions (93.3%) were associated with decreased FA values. Using meta-analysis techniques to combine injured regions across subjects, we found the combined injured region at the group level occupied the entire WM skeleton, suggesting the WM damage location is subject-specific. Several subject-specific functional summaries of SPREAD-detected WM change, e.g., the [Formula: see text] norm, significantly correlated with helmet impact measures, e.g. cumulative unweighted rotational acceleration (adjusted p = 0.0049), time between hits rotational acceleration (adjusted p value 0.0101), and time until DTI rotational acceleration (adjusted p = 0.0084), suggesting RHIs lead to WM changes.
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Affiliation(s)
- Patrick D Asselin
- Department of Pediatrics, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Yu Gu
- Department of Biostatistics and Computational Biology, University of Rochester, 265 Crittenden Blvd, CU 420630, Rochester, NY, 14642-0630, USA
| | - Kian Merchant-Borna
- Department of Emergency Medicine, School of Medicine and Dentistry, University of Rochester, 265 Crittenden Blvd, Box 655C, Rochester, NY, 14642, USA
| | - Beau Abar
- Department of Emergency Medicine, School of Medicine and Dentistry, University of Rochester, 265 Crittenden Blvd, Box 655C, Rochester, NY, 14642, USA
| | - David W Wright
- Department of Emergency Medicine, Emory University, 49 Jesse Hill Jr. Drive, Atlanta, GA, 30303, USA
| | - Xing Qiu
- Department of Biostatistics and Computational Biology, University of Rochester, 265 Crittenden Blvd, CU 420630, Rochester, NY, 14642-0630, USA.
| | - Jeff J Bazarian
- Department of Emergency Medicine, School of Medicine and Dentistry, University of Rochester, 265 Crittenden Blvd, Box 655C, Rochester, NY, 14642, USA
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Kumar RG, DiSanto D, Awan N, Vaughan LE, Levochkina MS, Weppner JL, Wright DW, Berga SL, Conley YP, Brooks MM, Wagner AK. Temporal Acute Serum Estradiol and Tumor Necrosis Factor-α Associations and Risk of Death after Severe Traumatic Brain Injury. J Neurotrauma 2020; 37:2198-2210. [PMID: 32375598 DOI: 10.1089/neu.2019.6577] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Severe traumatic brain injury (TBI) activates a robust systemic response that involves inflammatory and other factors, including estradiol (E2), associated with increased deaths. Tumor necrosis factor-alpha (TNFα) is a significant mediator of systemic shock, and it is an extra-gonadal transcription factor for E2 production. The study objectives were to test the hypotheses: (1) a positive feedback relationship exists between acute serum TNFα and E2; and (2) acute concentrations of E2 and TNFα are prognostic indicators of death after severe TBI. This prospective cohort study included N = 157 adults with severe TBI. Serum samples were collected for the first five days post-injury. The TNFα and E2 levels were averaged into two time epochs: first 72 h (T1) and second 72 h post-injury (T2). A cross-lag panel analysis conducted between T1 and T2 TNFα and E2 levels showed significant cross-lag effects: T1 TNFα and T1 E2 were related to T2 E2 and T2 TNFα, respectively. Cox proportional hazards multi variable regression models determined that increases in T1 E2 (hazard ratio [HR] = 1.79, 95% confidence interval [CI]: 1.15, 2.81), but not T2 E2 (HR = 0.91, 95% CI: 0.56, 1.47), were associated with increased risk of death. Increased T2 TNFα (HR = 2.47, 95% CI: 1.35, 4.53), and T1 TNFα (HR = 1.47, 95% CI: 0.99, 2.19), to a lesser degree, were associated with increased risk of death. Relationships of death with T2 TNFα and T1 E2 were mediated partially by cardiovascular, hepatic, and renal dysfunction. Both E2 and TNFα are systemic, reciprocally related biomarkers that may be indicative of systemic compromise and increased risk of death after severe TBI.
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Affiliation(s)
- Raj G Kumar
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dominic DiSanto
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nabil Awan
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Leah E Vaughan
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Marina S Levochkina
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Justin L Weppner
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David W Wright
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - Sarah L Berga
- Department of Reproductive Endocrinology, University of Utah, Salt Lake City, Utah
| | - Yvette P Conley
- School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Maria M Brooks
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amy K Wagner
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania.,Center for Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania
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Wright DW, Richardson RA, Edeling W, Lakhlili J, Sinclair RC, Jancauskas V, Suleimenova D, Bosak B, Kulczewski M, Piontek T, Kopta P, Chirca I, Arabnejad H, Luk OO, Hoenen O, Węglarz J, Crommelin D, Groen D, Coveney PV. Building Confidence in Simulation: Applications of EasyVVUQ. Adv Theory Simul 2020. [DOI: 10.1002/adts.201900246] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- David W. Wright
- Centre for Computational ScienceDepartment of ChemistryUniversity College London London WC1H 0AJ UK
| | - Robin A. Richardson
- Centre for Computational ScienceDepartment of ChemistryUniversity College London London WC1H 0AJ UK
| | - Wouter Edeling
- Centrum Wiskunde & Informatica Science Park 123 Amsterdam 1098 XG The Netherlands
| | - Jalal Lakhlili
- Max‐Planck Institute for Plasma Physics, Garching Boltzmannstraße 2 Garching bei München 85748 Germany
| | - Robert C. Sinclair
- Centre for Computational ScienceDepartment of ChemistryUniversity College London London WC1H 0AJ UK
| | - Vytautas Jancauskas
- Leibniz Supercomputing Centre Boltzmannstraße 1 Garching bei München 85748 Germany
| | | | - Bartosz Bosak
- Poznań Supercomputing and Networking Center ul. Jana Pawła II 10 Poznań 61‐139 Poland
| | - Michal Kulczewski
- Poznań Supercomputing and Networking Center ul. Jana Pawła II 10 Poznań 61‐139 Poland
| | - Tomasz Piontek
- Poznań Supercomputing and Networking Center ul. Jana Pawła II 10 Poznań 61‐139 Poland
| | - Piotr Kopta
- Poznań Supercomputing and Networking Center ul. Jana Pawła II 10 Poznań 61‐139 Poland
| | - Irina Chirca
- Centre for Computational ScienceDepartment of ChemistryUniversity College London London WC1H 0AJ UK
| | | | - Onnie O. Luk
- Max‐Planck Institute for Plasma Physics, Garching Boltzmannstraße 2 Garching bei München 85748 Germany
| | - Olivier Hoenen
- Max‐Planck Institute for Plasma Physics, Garching Boltzmannstraße 2 Garching bei München 85748 Germany
| | - Jan Węglarz
- Institute of Computing SciencePoznan University of Technology Piotrowo 2 Poznań 60‐965 Poland
| | - Daan Crommelin
- Centrum Wiskunde & Informatica Science Park 123 Amsterdam 1098 XG The Netherlands
- Korteweg‐de Vries InstituteUniversity of Amsterdam Science Park 105‐107 Amsterdam 1098 XG The Netherlands
| | | | - Peter V. Coveney
- Centre for Computational ScienceDepartment of ChemistryUniversity College London London WC1H 0AJ UK
- Informatics InstituteUniversity of Amsterdam Amsterdam 1090 GH Netherlands
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42
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Gore RK, Saldana C, Wright DW, Klein AM. Intubation Containment System for Improved Protection From Aerosolized Particles During Airway Management. IEEE J Transl Eng Health Med 2020; 8:1600103. [PMID: 32518738 PMCID: PMC7250066 DOI: 10.1109/jtehm.2020.2993531] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/01/2020] [Accepted: 05/05/2020] [Indexed: 01/25/2023]
Abstract
Objectives: Worldwide efforts to protect front line providers performing
endotracheal intubation during the COVID-19 pandemic have led to innovative
devices. Authors evaluated the aerosol containment effectiveness of a novel
intubation aerosol containment system (IACS) compared with a recently promoted
intubation box and no protective barrier. Methods: In a simulation center at the
authors’ university, the IACS was compared to no protective barrier and
an intubation box. Aerosolization was simulated using a commercial fog machine
and leakage of aerosolize mist was visually assessed. Results: The IACS appeared
to contain the aerosolized mist, while the intubation box allowed for mist to
contact the laryngoscopist and contaminate the clinical space through arm port
holes and the open caudal end. Both devices protected the laryngoscopist better
than no protective barrier. Discussion: The IACS with integrated sleeves and
plastic drape appears to offer superior protection for the laryngoscopist and
assistant providers from aerosolized particles.
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Affiliation(s)
- Russell K Gore
- Department of Biomedical EngineeringGeorgia Institute of TechnologyAtlantaGA30332USA.,Shepherd CenterAtlantaGA30309USA
| | - Christopher Saldana
- Department of Mechanical EngineeringGeorgia Institute of TechnologyAtlantaGA30332USA
| | - David W Wright
- Department of Emergency MedicineEmory UniversityAtlantaGA30322USA
| | - Adam M Klein
- Department of OtolaryngologyEmory UniversityAtlantaGA30322USA
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43
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Gold JAW, Wong KK, Szablewski CM, Patel PR, Rossow J, da Silva J, Natarajan P, Morris SB, Fanfair RN, Rogers-Brown J, Bruce BB, Browning SD, Hernandez-Romieu AC, Furukawa NW, Kang M, Evans ME, Oosmanally N, Tobin-D'Angelo M, Drenzek C, Murphy DJ, Hollberg J, Blum JM, Jansen R, Wright DW, Sewell WM, Owens JD, Lefkove B, Brown FW, Burton DC, Uyeki TM, Bialek SR, Jackson BR. Characteristics and Clinical Outcomes of Adult Patients Hospitalized with COVID-19 - Georgia, March 2020. MMWR Morb Mortal Wkly Rep 2020; 69:545-550. [PMID: 32379729 PMCID: PMC7737948 DOI: 10.15585/mmwr.mm6918e1] [Citation(s) in RCA: 325] [Impact Index Per Article: 81.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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44
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Lindsell CJ, McGlothlin A, Nwosu S, Rice TW, Hall A, Bernard GR, Busse LW, Ely EW, Fowler AA, Gaieski DF, Hinson JS, Hooper MH, Jackson JC, Kelen GD, Levine M, Martin GS, Rothman RE, Sevransky JE, Viele K, Wright DW, Hager DN. In response: Letter on update to the Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) protocol. Trials 2020; 21:351. [PMID: 32317004 PMCID: PMC7175511 DOI: 10.1186/s13063-020-04290-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 03/28/2020] [Indexed: 11/10/2022] Open
Abstract
TRIAL REGISTRATION ClinicalTrials.gov: NCT03509350. Registered on 26 April 2018.
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Affiliation(s)
| | | | - Samuel Nwosu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W Rice
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Alex Hall
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA.,Grady Memorial Hospital, Atlanta, GA, USA
| | - Gordon R Bernard
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - E Wesley Ely
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
| | - Alpha A Fowler
- Division of Pulmonary Disease & Critical Care Medicine, Department of Internal Medicine, The VCU Johnson Center for Critical Care and Pulmonary Research, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - David F Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Michael H Hooper
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Eastern Virginia Medical School and Sentara Healthcare, Norfolk, VA, USA
| | - James C Jackson
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA.,Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Gabor D Kelen
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Mark Levine
- Molecular & Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 10 Center Drive, Bethesda, MD, USA
| | - Greg S Martin
- Grady Memorial Hospital, Atlanta, GA, USA.,Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA
| | | | - David W Wright
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA.,Grady Memorial Hospital, Atlanta, GA, USA
| | - David N Hager
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins University, 1800 Orleans Street, Suite 9121, Baltimore, MD, 21287, USA
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45
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Zalesky CC, Moran TP, Koval RR, Usher J, Ratcliff JJ, Wu D, Wright DW. A prospective cross-sectional study examining the documented evaluation of patients at high risk for mild traumatic brain injury. Am J Emerg Med 2020; 42:150-160. [PMID: 32165070 DOI: 10.1016/j.ajem.2020.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 02/04/2020] [Accepted: 02/12/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVES Annually, the CDC reports that 2.5 million Emergency Department (ED) visits occur due to Traumatic Brain Injuries (TBI) with nearly 75% classified as mild TBI (mTBI). Generally, these injuries are thought to be under recognized. This study was done to determine the proportion of patients, who were considered high risk for an mTBI, that had documentation of an mTBI evaluation. METHODS A prospective cross-section of patients was identified using a 3-question screen at the time of triage: did an injury occur; was the mechanism consistent with mTBI; and was there a period of altered mental status. Chart review was completed for these patients who were thought to meet a minimum threshold warranting an evaluation for mTBI. RESULTS 38,621 patients were screened over 16 weeks, of whom 441 (1.14%) were identified as being high risk for having an mTBI and met inclusion criteria. Recommended portions of an mTBI evaluation occurred in fewer than 50% of patients. In total, 98 subjects were diagnosed with an mTBI, and 49 received mTBI discharge instructions. The odds ratio for the subgroup of patients who had documented criteria sufficient for diagnosis revealed that an isolated head injury increased a patient's odds of a documented diagnosis by 2.1 times (95%, 1.3-3.4). CONCLUSIONS Many patients with a possible mTBI did not have significant portions of an mTBI evaluation documented, and roughly half of the patients with a documented mTBI diagnosis did not receive discharge education. Changes in clinicians' approach to mTBI must occur to ensure patients receive appropriate evaluations, management, and education.
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Affiliation(s)
- C Christopher Zalesky
- University of Cincinnati College of Medicine, Department of Emergency Medicine, Cincinnati, OH, United States of America.
| | - Tim P Moran
- Emory University School of Medicine, Department of Emergency Medicine Atlanta, GA, United States of America
| | - Rachel R Koval
- Emory University School of Medicine, Department of Emergency Medicine Atlanta, GA, United States of America
| | - Jasmine Usher
- Grady Memorial Hospital, Atlanta, GA, United States of America
| | - Jonathan J Ratcliff
- Emory University School of Medicine, Department of Emergency Medicine Atlanta, GA, United States of America
| | - Daniel Wu
- Emory University School of Medicine, Department of Emergency Medicine Atlanta, GA, United States of America; Grady Memorial Hospital, Atlanta, GA, United States of America
| | - David W Wright
- Emory University School of Medicine, Department of Emergency Medicine Atlanta, GA, United States of America
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46
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Chesnut R, Aguilera S, Buki A, Bulger E, Citerio G, Cooper DJ, Arrastia RD, Diringer M, Figaji A, Gao G, Geocadin R, Ghajar J, Harris O, Hoffer A, Hutchinson P, Joseph M, Kitagawa R, Manley G, Mayer S, Menon DK, Meyfroidt G, Michael DB, Oddo M, Okonkwo D, Patel M, Robertson C, Rosenfeld JV, Rubiano AM, Sahuquillo J, Servadei F, Shutter L, Stein D, Stocchetti N, Taccone FS, Timmons S, Tsai E, Ullman JS, Vespa P, Videtta W, Wright DW, Zammit C, Hawryluk GWJ. A management algorithm for adult patients with both brain oxygen and intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive Care Med 2020; 46:919-929. [PMID: 31965267 PMCID: PMC7210240 DOI: 10.1007/s00134-019-05900-x] [Citation(s) in RCA: 172] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 12/14/2019] [Indexed: 12/20/2022]
Abstract
Background Current guidelines for the treatment of adult severe traumatic brain injury (sTBI) consist of high-quality evidence reports, but they are no longer accompanied by management protocols, as these require expert opinion to bridge the gap between published evidence and patient care. We aimed to establish a modern sTBI protocol for adult patients with both intracranial pressure (ICP) and brain oxygen monitors in place. Methods Our consensus working group consisted of 42 experienced and actively practicing sTBI opinion leaders from six continents. Having previously established a protocol for the treatment of patients with ICP monitoring alone, we addressed patients who have a brain oxygen monitor in addition to an ICP monitor. The management protocols were developed through a Delphi-method-based consensus approach and were finalized at an in-person meeting. Results We established three distinct treatment protocols, each with three tiers whereby higher tiers involve therapies with higher risk. One protocol addresses the management of ICP elevation when brain oxygenation is normal. A second addresses management of brain hypoxia with normal ICP. The third protocol addresses the situation when both intracranial hypertension and brain hypoxia are present. The panel considered issues pertaining to blood transfusion and ventilator management when designing the different algorithms. Conclusions These protocols are intended to assist clinicians in the management of patients with both ICP and brain oxygen monitors but they do not reflect either a standard-of-care or a substitute for thoughtful individualized management. These protocols should be used in conjunction with recommendations for basic care, management of critical neuroworsening and weaning treatment recently published in conjunction with the Seattle International Brain Injury Consensus Conference. Electronic supplementary material The online version of this article (10.1007/s00134-019-05900-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Randall Chesnut
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, 325 Ninth Ave, Mailstop 359766, Seattle, Washington, 98104-2499, USA.,Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, 325 Ninth Ave, Mailstop 359766, Seattle, Washington, 98104-2499, USA
| | - Sergio Aguilera
- Almirante Nef Naval Hospital, Viña del Mar, Chile.,Valparaiso University, Valparaiso, Chile
| | - Andras Buki
- Department of Neurosurgery, Medical School and Szentágothai Research Centre, Ifjúság útja 20, 7624, Pécs, Hungary.,University of Pécs, Pécs, Hungary
| | - Eileen Bulger
- Department of Surgery, Harborview Medical Center, University of Washington, 325 Ninth Ave, Seattle, WA, 98104-2499, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Neuro-Intensive Care, Department of Emergency and Intensive Care, ASST, San Gerardo Hospital, Monza, Italy
| | - D Jamie Cooper
- Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Monash, Australia.,Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
| | - Ramon Diaz Arrastia
- University of Pennsylvania Perelman School of Medicine, Penn Presbyterian Medical Center, 51 North 39th Street, Philadelphia, PA, 19104, USA
| | - Michael Diringer
- Department of Neurology, Barnes-Jewish Hospital, Washington University School of Medicine, 1 Barnes-Jewish Hospital Plaza, St. Louis, MO, 63110, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, H53 Old Main Building, Groote Schuur Hospital, Main Road, Observatory, 7925, South Africa
| | - Guoyi Gao
- Department of Neurosurgery, Renji Hospital, Shanghai Institute of Head Trauma, Shanghai Jiaotong University School of Medicine, 1630 Dongfang Road, Shanghai, 200127, China
| | - Romer Geocadin
- Johns Hopkins University School of Medicine, 1800 Orleans St. Sheikh Zayed Tower, Baltimore, MD, 21287, USA
| | - Jamshid Ghajar
- Stanford Neuroscience Health Center, 213 Quarry Rd 4th Fl MC 5958, Palo Alto, CA, 94304, USA
| | - Odette Harris
- Department of Neurosurgery, Pasteur Drive, Room R205, Edward's Building, MC 5327, Stanford, CA, 94305, USA
| | - Alan Hoffer
- Department of Neurological Surgery, School of Medicine, Case Western Reserve University, 11100 Euclid Avenue, HAN 5042, Cleveland, OH, 44106, USA
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Mathew Joseph
- Department of Neurological Sciences, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
| | - Ryan Kitagawa
- Vivian L Smith Department of Neurosurgery, McGovern Medical School at UTHealth, 6400 Fannin St, Suite 2800, Houston, TX, 77030, USA
| | - Geoffrey Manley
- University of California San Francisco, San Francisco General Hospital and Trauma Center, 1001 Potrero Ave., Bldg 1, Room 101, San Francisco, CA, 94110, USA
| | - Stephan Mayer
- Neurology, K-11, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - David K Menon
- Division of Anaesthesia, University of Cambridge and Addenbrooke's Hospital, Addenbrooke's Hospital, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Herestraat 49, Box 7003 63, 3000, Leuven, Belgium
| | - Daniel B Michael
- Oakland University William Beaumont School of Medicine, Beaumont Health, Michigan Head and Spine Institute, Southfield, MI, USA
| | - Mauro Oddo
- Department of Intensive Care Medicine, CHUV-Lausanne University Hospital, University of Lausanne, Faculty of Biology and Medicine, Lausanne, Switzerland
| | - David Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mayur Patel
- Vanderbilt University Medical Center, Nashville, USA
| | - Claudia Robertson
- Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia.,Department of Surgery, Monash University, Melbourne, Australia
| | - Andres M Rubiano
- INUB/MEDITECH Research Group, Neurosciences Institute, El Bosque University, Bogotá, Colombia.,MEDITECH Foundation, Clinical Research, Calle 7-A # 44-95, 760036, Cali, Colombia
| | | | - Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy.,World Federation of Neurosurgical Societies, Nyon, Switzerland
| | - Lori Shutter
- University of Pittsburgh Medical Center, 3550 Terrace St, Room 646, Pittsburgh, PA, 15261, USA
| | - Deborah Stein
- Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, 1001 Potrero Ave., Ward 3A, San Francisco, CA, 94110, USA
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy.,Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Shelly Timmons
- Department of Neurological Surgery, Penn State University Milton S. Hershey Medical Center, 30 Hope Dr., Suite 1200
- Building B, Hershey, PA, 17033, USA
| | - Eve Tsai
- Suruchi Bhargava Chair in Spinal Cord and Brain Regeneration Research, University of Ottawa, The Ottawa Hospital, C2 Neurosciences Unit, The Ottawa Hosptial, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - Jamie S Ullman
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine At Hofstra/Northwell North, Shore University Hospital, 300 Community Drive, 9 Tower, Manhasset, NY, USA
| | - Paul Vespa
- Ronald Reagan UCLA Medical Center, UCLA Medical Center, Santa Monica, Santa Monica, USA
| | | | - David W Wright
- Emory University School of Medicine, 49 Jesse Hill Jr Dr, Atlanta, GA, 30303, USA
| | - Christopher Zammit
- School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 655C, Rochester, NY, 14642, USA
| | - Gregory W J Hawryluk
- Section of Neurosurgery, University of Manitoba, GB1, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada.
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47
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Wright DW, Husseini F, Wan S, Meyer C, van Vlijmen H, Tresadern G, Coveney PV. Application of the ESMACS Binding Free Energy Protocol to a Multi-Binding Site Lactate Dehydogenase A Ligand Dataset. Adv Theory Simul 2020; 3:1900194. [PMID: 34553124 PMCID: PMC8438761 DOI: 10.1002/adts.201900194] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/29/2019] [Indexed: 12/17/2022]
Abstract
Over the past two decades, the use of fragment-based lead generation has become a common, mature approach to identify tractable starting points in chemical space for the drug discovery process. This approach naturally involves the study of the binding properties of highly heterogeneous ligands. Such datasets challenge computational techniques to provide comparable binding free energy estimates from different binding modes. The performance of a range of statistically robust ensemble-based binding free energy calculation protocols, called ESMACS (enhanced sampling of molecular dynamics with approximation of continuum solvent), is evaluated. Ligands designed to target two binding pockets in the lactate dehydogenase, a target protein, which vary in size, charge, and binding mode, are studied. When compared to experimental results, excellent statistical rankings are obtained across this highly diverse set of ligands. In addition, three approaches to account for entropic contributions are investigated: 1) normal mode analysis, 2) weighted solvent accessible surface area (WSAS), and 3) variational entropy. Normal mode analysis and WSAS correlate strongly with each other-although the latter is computationally far cheaper-but do not improve rankings. Variational entropy corrects exaggerated discrimination of ligands bound in different pockets but creates three outliers which reduce the quality of the overall ranking.
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Affiliation(s)
- David W. Wright
- Centre for Computational ScienceDepartment of ChemistryUniversity College LondonLondonWC1H 0AJUK
| | - Fouad Husseini
- Centre for Computational ScienceDepartment of ChemistryUniversity College LondonLondonWC1H 0AJUK
| | - Shunzhou Wan
- Centre for Computational ScienceDepartment of ChemistryUniversity College LondonLondonWC1H 0AJUK
| | - Christophe Meyer
- Janssen Research & DevelopmentTurnhoutseweg 30B‐2340BeerseBelgium
| | | | - Gary Tresadern
- Janssen Research & DevelopmentTurnhoutseweg 30B‐2340BeerseBelgium
| | - Peter V. Coveney
- Centre for Computational ScienceDepartment of ChemistryUniversity College LondonLondonWC1H 0AJUK
- Computational Science LaboratoryInstitute for InformaticsFaculty of ScienceUniversity of AmsterdamAmsterdam1098XHThe Netherlands
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48
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Lindsell CJ, McGlothlin A, Nwosu S, Rice TW, Hall A, Bernard GR, Busse LW, Ely EW, Fowler AA, Gaieski DF, Hinson JS, Hooper MH, Jackson JC, Kelen GD, Levine M, Martin GS, Rothman RE, Sevransky JE, Viele K, Wright DW, Hager DN. Update to the Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) protocol: statistical analysis plan for a prospective, multicenter, double-blind, adaptive sample size, randomized, placebo-controlled, clinical trial. Trials 2019; 20:670. [PMID: 31801567 PMCID: PMC6894243 DOI: 10.1186/s13063-019-3775-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/09/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Observational research suggests that combined therapy with Vitamin C, thiamine and hydrocortisone may reduce mortality in patients with septic shock. METHODS AND DESIGN The Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) trial is a multicenter, double-blind, adaptive sample size, randomized, placebo-controlled trial designed to test the efficacy of combination therapy with vitamin C (1.5 g), thiamine (100 mg), and hydrocortisone (50 mg) given every 6 h for up to 16 doses in patients with respiratory or circulatory dysfunction (or both) resulting from sepsis. The primary outcome is ventilator- and vasopressor-free days with mortality as the key secondary outcome. Recruitment began in August 2018 and is ongoing; 501 participants have been enrolled to date, with a planned maximum sample size of 2000. The Data and Safety Monitoring Board reviewed interim results at N = 200, 300, 400 and 500, and has recommended continuing recruitment. The next interim analysis will occur when N = 1000. This update presents the statistical analysis plan. Specifically, we provide definitions for key treatment and outcome variables, and for intent-to-treat, per-protocol, and safety analysis datasets. We describe the planned descriptive analyses, the main analysis of the primary end point, our approach to secondary and exploratory analyses, and handling of missing data. Our goal is to provide enough detail that our approach could be replicated by an independent study group, thereby enhancing the transparency of the study. TRIAL REGISTRATION ClinicalTrials.gov, NCT03509350. Registered on 26 April 2018.
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Affiliation(s)
| | | | - Samuel Nwosu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W Rice
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alex Hall
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA.,Grady Memorial Hospital, Atlanta, GA, USA
| | - Gordon R Bernard
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - E Wesley Ely
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
| | - Alpha A Fowler
- Division of Pulmonary Disease & Critical Care Medicine, Department of Internal Medicine, The VCU Johnson Center for Critical Care and Pulmonary Research, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - David F Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Michael H Hooper
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Eastern Virginia Medical School and Sentara Healthcare, Norfolk, VA, USA
| | - James C Jackson
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA.,Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gabor D Kelen
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Mark Levine
- Molecular & Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 10 Center Drive, Bethesda, MD, USA
| | - Greg S Martin
- Grady Memorial Hospital, Atlanta, GA, USA.,Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA
| | | | - David W Wright
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA.,Grady Memorial Hospital, Atlanta, GA, USA
| | - David N Hager
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins University, 1800 Orleans Street, Suite 9121, Baltimore, MD, 21287, USA
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Fjelldal PG, Hansen TJ, Karlsen Ø, Wright DW. Effects of laboratory salmon louse infection on Arctic char osmoregulation, growth and survival. Conserv Physiol 2019; 7:coz072. [PMID: 31723431 PMCID: PMC6839430 DOI: 10.1093/conphys/coz072] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 06/13/2019] [Accepted: 08/19/2019] [Indexed: 06/02/2023]
Abstract
High salmon lice (Lepeophtheirus salmonis) infestation levels resulting from intensive salmonid sea-cage aquaculture can threaten populations of wild salmonid hosts. This includes anadromous Arctic char (Salvelinus alpinus), which rely on short migrations into more productive seawater environments to build energy stores for maturation, spawning and over-wintering in freshwater. Elevated salmon lice burdens may limit the benefits of migration by constraining osmoregulation, growth, survival and reproduction. To test for these effects, we simulated anadromous migration in tanks by transferring individually tagged Arctic char smolts (n = 352, averaging 133 g) to seawater where they were infected with salmon lice or left as uninfected controls for 1 month, and then transferring them back to freshwater for 2 months. After the seawater phase, infected post-smolts had a mean of 0.33 (range of 0.09-0.91) mobile lice g-1 fish weight. At this point, specific growth rates (SGRs) dropped in infected compared to control fish (0.1% vs. 1.6% day-1). Higher plasma Na+ and osmolality in infected fish also indicate osmoregulatory impairment. Throughout the study, mortality was 18.2% and 1.7% in infected and control groups, but sexual maturation was low and comparable between groups. Infection intensity correlated positively with mortality rate and plasma Cl-, and correlated negatively with SGR and condition factor (CF). CF dropped (ΔCF < 0) at intensities of >0.09 lice g-1 fish weight, and intensities of >0.3 causing zero or negative SGRs and increased mortality were particularly concerning. If infection intensities reach these levels in the wild, char could be impacted by growth restrictions and increased mortality rates, which potentially cause shorter migration durations, lowered reproductive success and possibly also selection against anadromy. This study provides vital information for conservation practitioners wanting to understand the physiologically derived burden salmon lice can have on Arctic char populations, and can be used to define thresholds in the monitoring and conservation of Arctic char populations affected by aquaculture-driven salmon lice infestations.
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Affiliation(s)
- P G Fjelldal
- Institute of Marine Research (IMR), Matre Aquaculture Research Station, 5984 Matredal, Norway
| | - T J Hansen
- Institute of Marine Research (IMR), Matre Aquaculture Research Station, 5984 Matredal, Norway
| | - Ø Karlsen
- Institute of Marine Research (IMR), PO Box 1870, Nordnes, 5817 Bergen, Norway
| | - D W Wright
- Department of Primary Industries, Narrandera Fisheries Centre, PO Box 182, Narrandera, New South Wales, Australia
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50
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Koval RR, Zalesky CC, Moran TP, Moore JC, Ratcliff JJ, Wu DT, Wright DW. Concussion Care in the Emergency Department: A Prospective Observational Brief Report. Ann Emerg Med 2019; 75:483-490. [PMID: 31685254 DOI: 10.1016/j.annemergmed.2019.08.419] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 07/27/2019] [Accepted: 08/09/2019] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE Emergency physicians are often the initial-and only-clinical providers for patients who have sustained a mild traumatic brain injury. This prospective observational study seeks to examine the practice patterns of clinicians in an academic Level I trauma center as they relate to the evaluation of patients who were presumed to be at high risk for mild traumatic brain injury. Specifically, we describe the frequency of a documented mild traumatic brain injury evaluation, diagnosis, and discharge education. METHODS This pilot study took place in a single academic Level I trauma and emergency care center during a 4-week period. Patients were identified by triage nurses, who determined whether they responded affirmatively to 2 questions that indicated a potential risk for mild traumatic brain injury. Data were abstracted from emergency department clinician documentation on identified patients to describe the frequency of a documented mild traumatic brain injury evaluation (history and physical examination), diagnosis, and discharge education among those who were identified to be at risk for a mild traumatic brain injury. RESULTS Ninety-eight subjects were included in the present study. Documentation of a mild traumatic brain injury evaluation was present for less than 50% of patients, a final diagnosis of mild traumatic brain injury was included for 36 (37%; 95% confidence interval 27.8% to 46.7%), and discharge education was provided to 15 (15%; 95% confidence interval 9.2% to 21.4%). Of the 36 patients who received a documented mild traumatic brain injury diagnosis, 15 (41.5%; 95% confidence interval 26.7% to 57.9%) received mild traumatic brain injury-specific discharge education. CONCLUSION This study suggests that the majority of patients at high risk for mild traumatic brain injury have no documentation of an evaluation for one. Also, patients with a mild traumatic brain injury diagnosis were unlikely to receive appropriate discharge education about it. Education and standardization are needed to ensure that patients at risk for mild traumatic brain injury receive appropriate evaluation and care.
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Affiliation(s)
- Rachel R Koval
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA.
| | | | - Tim P Moran
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
| | | | - Jonathan J Ratcliff
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
| | - Daniel T Wu
- Grady Health System, Atlanta, GA; Emory University School of Medicine, Atlanta, GA
| | - David W Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
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