scholarly journals Effects of a Feedback-Demanding Stroke Clock on Acute Stroke Management

Stroke ◽  
2020 ◽  
Vol 51 (10) ◽  
pp. 2895-2900
Author(s):  
Mathias Fousse ◽  
Daniel Grün ◽  
Stefan A. Helwig ◽  
Silke Walter ◽  
Adam Bekhit ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Acute Stroke ◽  
Neurological Examination ◽  
Point Of Care ◽  
Intravenous Thrombolysis ◽  
Stroke Management ◽  
Active Feedback ◽  
Diagnostic Work ◽  
Work Up ◽  
Diagnostic Work Up

Background and Purpose: This randomized study aimed to evaluate whether the use of a stroke clock demanding active feedback from the stroke physician accelerates acute stroke management. Methods: For this randomized controlled study, a large-display alarm clock was installed in the computed tomography room, where admission, diagnostic work-up, and intravenous thrombolysis occurred. Alarms were set at the following target times after admission: (1) 15 minutes (neurological examination completed); (2) 25 minutes (computed tomography scanning and international normalized ratio determination by point-of-care laboratory completed); and (3) 30 minutes (intravenous thrombolysis started). The responsible stroke physician had to actively provide feedback by pressing a buzzer button. The alarm could be avoided by pressing the button before time out. Times to therapy decision (primary end point, defined as the end of all diagnostic work-up required for decision for or against recanalizing treatment), neurological examination, imaging, point-of-care laboratory, needle, and groin puncture were assessed by a neutral observer. Functional outcome (modified Rankin Scale) was assessed at day 90. Results: Of 107 participants, 51 stroke clock patients exhibited better stroke-management metrics than 56 control patients. Times from door to (1) end of all indicated diagnostic work-up (treatment decision time; 16.73 versus 26.00 minutes, P <0.001), (2) end of neurological examination (7.28 versus 10.00 minutes, P <0.001), (3) end of computed tomography (11.17 versus 14.00 minutes, P =0.002), (4) end of computed tomography angiography (14.00 versus 17.17 minutes, P =0.001), (5) end of point-of-care laboratory testing (12.14 versus 20.00 minutes, P <0.001), and (6) needle times (18.83 versus 47.00 minutes, P =0.016) were improved. In contrast, door-to-groin puncture times and functional outcomes at day 90 were not significantly different. Conclusions: This study showed that the use of a stroke clock demanding active feedback significantly improves acute stroke-management metrics and, thus, represents a potential low-cost strategy for streamlining time-sensitive stroke treatment.

The Role of Cranial Computed Tomography in the Diagnostic Work-up of Headache

1996 ◽  
Vol 36 (6) ◽  
pp. 347-348 ◽  
Author(s):  
Philippe Demaerel ◽  
Ignace Boelaert ◽  
Guy Wilms ◽  
Albert L. Baert
Keyword(s):  
Computed Tomography ◽  
Cranial Computed Tomography ◽  
Diagnostic Work ◽  
Work Up ◽  
Diagnostic Work Up

scholarly journals PET-PANC: multicentre prospective diagnostic accuracy and health economic analysis study of the impact of combined modality 18fluorine-2-fluoro-2-deoxy-d-glucose positron emission tomography with computed tomography scanning in the diagnosis and management of pancreatic cancer

2018 ◽  
Vol 22 (7) ◽  
pp. 1-114 ◽  
Author(s):  
Paula Ghaneh ◽  
Robert Hanson ◽  
Andrew Titman ◽  
Gill Lancaster ◽  
Catrin Plumpton ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Pancreatic Cancer ◽  
Chronic Pancreatitis ◽  
Diagnostic Accuracy ◽  
Cost Effective ◽  
Diagnostic Value ◽  
Pet Ct ◽  
Diagnostic Work ◽  
Work Up ◽  
Diagnostic Work Up

Background Pancreatic cancer diagnosis and staging can be difficult in 10–20% of patients. Positron emission tomography (PET)/computed tomography (CT) adds precise anatomical localisation to functional data. The use of PET/CT may add further value to the diagnosis and staging of pancreatic cancer. Objective To determine the incremental diagnostic accuracy and impact of PET/CT in addition to standard diagnostic work-up in patients with suspected pancreatic cancer. Design A multicentre prospective diagnostic accuracy and clinical value study of PET/CT in suspected pancreatic malignancy. Participants Patients with suspected pancreatic malignancy. Interventions All patients to undergo PET/CT following standard diagnostic work-up. Main outcome measures The primary outcome was the incremental diagnostic value of PET/CT in addition to standard diagnostic work-up with multidetector computed tomography (MDCT). Secondary outcomes were (1) changes in patients’ diagnosis, staging and management as a result of PET/CT; (2) changes in the costs and effectiveness of patient management as a result of PET/CT; (3) the incremental diagnostic value of PET/CT in chronic pancreatitis; (4) the identification of groups of patients who would benefit most from PET/CT; and (5) the incremental diagnostic value of PET/CT in other pancreatic tumours. Results Between 2011 and 2013, 589 patients with suspected pancreatic cancer underwent MDCT and PET/CT, with 550 patients having complete data and in-range PET/CT. Sensitivity and specificity for the diagnosis of pancreatic cancer were 88.5% and 70.6%, respectively, for MDCT and 92.7% and 75.8%, respectively, for PET/CT. The maximum standardised uptake value (SUVmax.) for a pancreatic cancer diagnosis was 7.5. PET/CT demonstrated a significant improvement in relative sensitivity (p = 0.01) and specificity (p = 0.023) compared with MDCT. Incremental likelihood ratios demonstrated that PET/CT significantly improved diagnostic accuracy in all scenarios (p < 0.0002). PET/CT correctly changed the staging of pancreatic cancer in 56 patients (p = 0.001). PET/CT influenced management in 250 (45%) patients. PET/CT stopped resection in 58 (20%) patients who were due to have surgery. The benefit of PET/CT was limited in patients with chronic pancreatitis or other pancreatic tumours. PET/CT was associated with a gain in quality-adjusted life-years of 0.0157 (95% confidence interval –0.0101 to 0.0430). In the base-case model PET/CT was seen to dominate MDCT alone and is thus highly likely to be cost-effective for the UK NHS. PET/CT was seen to be most cost-effective for the subgroup of patients with suspected pancreatic cancer who were thought to be resectable. Conclusion PET/CT provided a significant incremental diagnostic benefit in the diagnosis of pancreatic cancer and significantly influenced the staging and management of patients. PET/CT had limited utility in chronic pancreatitis and other pancreatic tumours. PET/CT is likely to be cost-effective at current reimbursement rates for PET/CT to the UK NHS. This was not a randomised controlled trial and therefore we do not have any information from patients who would have undergone MDCT only for comparison. In addition, there were issues in estimating costs for PET/CT. Future work should evaluate the role of PET/CT in intraductal papillary mucinous neoplasm and prognosis and response to therapy in patients with pancreatic cancer. Study registration Current Controlled Trials ISRCTN73852054 and UKCRN 8166. Funding The National Institute for Health Research Health Technology Assessment programme.

Pulmonary Artery Sling: A New Diagnostic Tool and Clinical Review

PEDIATRICS ◽  
1982 ◽  
Vol 69 (4) ◽  
pp. 472-475
Author(s):  
Karen S. Rheuban ◽  
Nancy Ayres ◽  
J. Gordon Still ◽  
Bennett Alford
Keyword(s):  
Computed Tomography ◽  
Pulmonary Artery ◽  
Diagnostic Tool ◽  
Vascular Ring ◽  
Vascular Anomaly ◽  
Pulmonary Artery Sling ◽  
Cardiovascular Malformation ◽  
Diagnostic Work ◽  
Work Up ◽  
Diagnostic Work Up

The pulmonary artery sling is a vascular anomaly that produces severe respiratory disease in infancy. The differential diagnosis is lengthy, and the diagnostic work-up frequently includes such invasive maneuvers as bronchography, bronchoscopy, and cardiac catheterization. In this paper the use of a new noninvasive diagnostic tool, computed tomography, to aid in the diagnosis of this form of vascular ring, is discussed and a review of salient features of this cardiovascular malformation is presented.

Sensitive Detection of Atrial Fibrillation in Acute Stroke Patients by Short-Term Bedside Electrocardiography Monitoring Software Analysis

2018 ◽  
Vol 45 (1-2) ◽  
pp. 54-60
Author(s):  
Linda Sarah Ross ◽  
Markus Bettin ◽  
Simon Kochhäuser ◽  
Martin Ritter ◽  
Jens Minnerup ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Acute Stroke ◽  
Predictive Value ◽  
Cryptogenic Stroke ◽  
Ecg Monitoring ◽  
Stroke Patients ◽  
Software Analysis ◽  
Diagnostic Work ◽  
Work Up ◽  
Diagnostic Work Up

Background: Atrial fibrillation (AF) is an important cause of stroke. Continuous electrocardiography (ECG) monitoring with software-based analysis algorithms has been suggested to enhance the AF detection rate. We investigated the ability of stroke risk analysis (SRA) in the detection of AF in acute stroke patients. Methods: Consecutive stroke patients numbering 1,153 were screened. Patients with cardioembolic stroke related to AF (n = 296, paroxysmal n = 63, persistent n = 233) and patients with cryptogenic stroke (n = 309) after standard diagnostic work-up (bedside ECG monitoring, ultrasound, transesophageal echocardiography, 24 h Holter ECG) received SRA during their stay at the Stroke Unit. Determination of AF risk by SRA in the patients with AF and in the patient group with cryptogenic stroke was assessed and compared. Results: Median SRA monitoring analysis time was 16 h (range 2–206 h, interquartile range 10–36). In AF patients, SRA also detected a possible or definitive AF in 98%. The overall sensitivity of SRA to detect possible or definitive AF in patients with proven AF by standard diagnostic work up and cryptogenic stroke was 98%, specificity 27%, positive predictive value 56%, and the negative predictive value (NPV) was 92%. Area under ROC curve was 0.622. Conclusion: SRA was found to be highly sensitive to detect possible or definitive AF in clinical routine within a short monitoring time. However, low specificity and poor accuracy do not allow diagnosing AF by SRA alone, but with the high NPV compared to current diagnostic standard, it is a valid diagnostic tool to rule out AF. Thereby, SRA is a contribution to clarify stroke etiology.

scholarly journals Prehospital triage of patients suffering severe dyspnoea using N-terminal pro-brain natriuretic peptide, the PreBNP trial: a randomised controlled clinical trial

2017 ◽  
Vol 7 (4) ◽  
pp. 302-310 ◽  
Author(s):  
Morten T Bøtker ◽  
Maren T Jørgensen ◽  
Carsten Stengaard ◽  
Sophie-Charlott Seidenfaden ◽  
Mona Tarpgaard ◽  
...  
Keyword(s):  
Critical Care ◽  
Brain Natriuretic Peptide ◽  
Natriuretic Peptide ◽  
Point Of Care ◽  
Routine Work ◽  
Diagnostic Work ◽  
Work Up ◽  
Critical Care Team ◽  
Diagnostic Work Up ◽  
Severe Dyspnoea

Purpose: The purpose of this study was to examine whether the addition of brain natriuretic peptide measurement to the routine diagnostic work-up by prehospital critical care team physicians improves triage in patients with severe dyspnoea. Methods: Prehospital critical care team physicians randomly assigned patients older than 18 years with severe dyspnoea to routine diagnostic work-up or diagnostic work-up with incorporated point-of-care N-terminal pro-brain natriuretic peptide (NT-proBNP) measurement. The primary endpoint was the proportion of patients with dyspnoea of primary cardiac origin triaged directly to a department of cardiology. Results: A total of 747 patients were randomly assigned and 711 patients consented to participate, 350 were randomly assigned to the NT-proBNP group and 361 to the routine work-up group. NT-proBNP was measured in 90% (315/350) of patients in the NT-proBNP group and in 19% (70/361) of patients in the routine work-up group. There was no difference in the proportion of patients with dyspnoea of primary cardiac origin triaged directly to a department of cardiology between the NT-proBNP group and the routine work-up group (75% vs. 69%, P=0.22) in the intention-to-treat analysis. Sensitivity analysis according to the de facto diagnostics performed showed results consistent with this. No differences in hospital length of stay, intensive care unit admission rates or mortality between the NT-proBNP group and the routine work-up group were observed. Conclusion: Routine supplementary point-of-care measurement of NT-proBNP in patients with severe dyspnoea did not improve triage of patients with dyspnoea primarily caused by heart disease. ClinicalTrials.gov identifier NCT02050282.

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