Incorporating platelet-to-white blood cell ratio into survival prediction models for intracerebral hemorrhage: a nomogram approach

 What the fuck are the interventions needed when this long-term survival is not assured?  THAT IS THE RESEARCH NEEDED, NOT THIS!

Incorporating platelet-to-white blood cell ratio into survival prediction models for intracerebral hemorrhage: a nomogram approach

Jiake Xu^1,2†Xing Wang^1,2†Wei Chen^1,2Meng Tian^1,2Chao You^1,2*

• ¹Department of Neurosurgery, Neurosurgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan, China
• ²West China Brain Research Centre, West China Hospital, Sichuan University, Chengdu, Sichuan, China

Background: Predicting long-term survival in intensive care unit patients with intracerebral hemorrhage (ICH) is crucial. This study aimed to develop a platelet-to-white blood cell ratio (PWR) incorporated nomogram for long-term survival prediction.

Methods: A retrospective analysis was conducted on 1,728 ICH patients in the MIMIC-IV 2.2 database. The independent prognostic value of PWR for 1-year mortality was assessed. A nomogram was developed using LASSO and Cox regression to predict 1-year survival, incorporating PWR and other factors. The performance of the nomogram was evaluated through calibration curves, area under the curve, Delong test, net reclassification index, integrated discrimination improvement, and decision curve analysis.

Results: The nomogram, which included age, weight, Glasgow Coma Scale (GCS) score, mechanical ventilation, glucose, red blood cell (RBC) count, blood urea nitrogen (BUN), and PWR, showed good predictive performance for 1-year survival. The C-index was 0.736 (95% CI = 0.716–0.756) for the training set and 0.766 (95% CI = 0.735–0.797) for the testing set. Higher age and ventilation increased mortality risk, while higher weight, GCS score, RBC count, and PWR decreased risk. The nomogram outperformed conventional scores.

Conclusions: A nomogram incorporating PWR as a prognostic factor accurately predicts long-term survival in ICH patients. However, validation in large-scale multicenter studies and further exploration of biomarkers are needed.

Introduction

Intracerebral hemorrhage (ICH) accounts for about 15% of all strokes and imposes a significant global burden in terms of disability-adjusted life years, often leading to various levels of functional impairment (1). Unlike ischemic strokes, there are currently no effective clinical treatments to prevent neuronal damage or promote neural repair for ICH (2, 3). Therefore, it is essential to fully understand the severity of ICH prognosis early on and identify risk factors that lead to poor outcomes in ICH patients to prepare for prevention and treatment.

Evaluating disease severity through scoring systems is beneficial for assessing patient prognosis and adjusting treatment plans. Many ICH scoring systems have been developed to date, primarily combining basic patient information with parameters obtained from computed tomography (CT) and neurological examinations (4, 5). It is widely accepted that the pathophysiological process of ICH consists of two stages: primary injury and more complex secondary injury. Inflammation is closely related to the progression of secondary injury and directly affects treatment outcomes (6). Current research suggests that inflammation induced by ICH manifests as changes in peripheral blood immune cells (7), with many inflammation markers related to disease progression, such as platelets, white blood cell (WBC) count, and neutrophils, easily obtainable through routine laboratory tests. Moreover, ratios of certain variables, such as the neutrophil-to-lymphocyte ratio (NLR), provide more stable predictive performance compared to single variables and have found widespread application in clinical settings (8).

The platelet-to-white blood cell ratio (PWR), a newly discovered inflammatory biomarker similar to NLR, has shown excellent predictive performance in ischemic stroke patients, although its role as an independent prognostic factor in ICH patients remains to be confirmed (9–11). Given its unique characteristics, PWR reflects both inflammation and coagulation processes, which are key factors in the pathophysiology of ICH. Unlike other indicators such as NLR, PWR provides a more comprehensive view by combining information on platelet function and immune response, making it a robust indicator of patient status. Additionally, PWR is easily obtainable through routine laboratory tests, making it a practical and accessible marker for clinical use. Incorporating these readily available laboratory markers into scoring systems may help create more convenient and accurate prediction models (12). Additionally, while many scoring systems have been developed, most only predict in-hospital or one-month mortality rates, with few studies focusing on longer-term outcomes such as 1-year prognoses (5).

In this study, we first examined the role of the PWR in predicting ICH mortality. To more accurately assess the prognosis of ICH patients, we developed a prediction model incorporating PWR using the lasso method and multivariate regression analyses and constructed corresponding nomograms for predicting 3-month, 6-month, and 1-year survival. By validating the nomograms, we evaluated the accuracy and reliability of this model in predicting ICH survival. This study aims to provide clinicians with a more effective tool for assessing the prognosis of hemorrhagic stroke patients, thereby enabling the development of more appropriate treatment plans.

More at link.

Maimonides Stroke Center Ranked #1 in the Nation for Patient Survival - Brooklyn, NY

Big fucking whoopee.

'Survival' NOT 100% RECOVERY. And they tout useless stuff like Get With The Guidelines and other processes rather than RESULTS. So they got you surviving the stroke but say nothing about your full recovery chances. Good but misleading PR. This is not something to crow about. But they do 'care' about you 5 times.

 

MaimonidesStroke Center Ranked #1 in the Nation for Patient Survival

By Kings County Politics

Posted on July 16, 2019

The Comprehensive Stroke Center at Maimonides Medical Center has the highest survival rate of any hospital stroke program in the US, according to the most recent mortality report published by the federal government.

“Our nationally acclaimed Stroke Center remains committed to achieving superior stroke patient outcomes,” says Kenneth D. Gibbs, President and CEO of Maimonides Medical Center. “The outstanding care that is delivered demonstrates one of the many reasons why our hospital is among the Top 10 in the nation for overall clinical excellence.”

Led by Program Director Dr. Tony Qingliang Wang, the fully accredited Comprehensive Stroke Center at Maimonides is comprised of a distinguished team of specialists working together to provide exceptional care. Physicians and nurses in emergency medicine, interventional neuroradiology, vascular and neurosurgery, neurocritical care and rehabilitation medicine collaborate to deliver a full range of technologically advanced diagnostic and treatment services to all patients.

“As the fifth leading cause of death in the United States, stroke impacts a significant part of our population,” explains Dr. Wang. “A person suffers a stroke approximately every 40 seconds in the US, someone dies from stroke ever four minutes, and 80 percent of strokes can be prevented. So when it comes to diagnosis and treatment, every moment counts.”

In addition to the superb results reported by the federal government, the Comprehensive Stroke Center at Maimonides has earned American Stroke Association top honors for the eighth consecutive year, receiving the Get With The Guidelines^®– Stroke Gold Plus Achievement Award and the Target: Stroke^SM Honor Roll Elite Plus – the ASA’s highest level of recognition for stroke care excellence.

Dr. Wang joined Mr. Gibbs, State Assembly Member Steven Cymbrowitz (D-Sheepshead Bay, Manhattan Beach, Brighton Beach) and City Council Member Dr. Mathieu Eugene (D-Flatbush, East Flatbush, Prospect Lefferts Gardens) at the hospital’s recent Stroke Awareness Flag-Raising. He stressed the importance of acting quickly when witnessing possible signs of a stroke: “If you suspect you or a loved one may be experiencing a stroke, phoning 911 immediately can make a big difference.”

Since blood flow to part of the brain is cut off during a stroke, acting fast can help minimize the risk of brain damage and ensure care is received promptly.

The National Stroke Association provides a useful acronym to help identify stroke symptoms and respond quickly, “BE FAST.” In the event someone might be experiencing a stroke, be sure to observe these crucial signs:

Thrombectomy offers survival benefit for acute stroke

Are we supposed to praise you for taking the tyranny of low expectations to new heights?  Just survival is not the goal, 100% RECOVERY IS THE ONLY GOAL.  

 

WHEN THE HELL IS THAT GOING TO BE THE GOAL OF ALL STROKE LEADERS?

Thrombectomy offers survival benefit for acute stroke

April 10, 2019 | Daniel Allar | Vascular & Endovascular

Endovascular thrombectomy (EVT) significantly reduced the risk of 90-day mortality in patients with acute ischemic stroke compared to medical therapy alone, according to a meta-analysis of 10 randomized trials cited in the 2018 update to American stroke guidelines.
The authors drew a parallel from acute ischemic stroke (AIS) care to interventions for acute myocardial infarction. They pointed out that intravenous thrombolysis (IT) was originally offered as a way to improve outcomes in both instances but was later deemed inferior to interventional strategies—primary PCI in the case of acute MI and EVT in the case of AIS.
“However, unlike with the use of IT for myocardial infarction, mortality benefits of IT for AIS were not seen in short-term or long-term follow-up (of randomized trials),” lead author Yingfeng Lin, MD, with Heinrich-Heine-University in Dusseldorf, Germany, and colleagues wrote in JAMA Neurology. “In logic succession, all EVT trials focused on measures of functional recovery from AIS and were underpowered to detect differences in mortality, just like subsequent meta-analyses.”

To better analyze whether thrombectomy also comes with a survival benefit, Lin et al. pooled results from 10 randomized clinical trials of EVT versus medical therapy which were cited in the American Stroke Association/American Heart Association’s 2018 guidelines for AIS.
For the 2,313 patients included in those studies, EVT reduced by 3.7% the odds of 90-day mortality compared to medical therapy (15% vs 18.7%). The researchers calculated that 27 patients would need to be treated with EVT instead of medical therapy to prevent one all-cause death at 90 days.
This difference was deemed statistically significant and was similar to trials evaluating early-window or late-window interventions. Late-window randomized clinical trials (RCTs) included those in which EVT was offered at least six hours after symptom onset.
However, there was no significant difference in the risk for intracranial hemorrhage over 90 days for patients treated with EVT (4.2%) or medical therapy (4%).

“Thus, the observed risk reduction for mortality probably does not originate from differences in adverse effects but from the functional benefits of EVT also translating to improved 90-day survival,” the authors wrote.
“Taken together, there is considerable evidence in guideline-referenced RCTs that EVT significantly benefits survival during the first 90 days after AIS compared with medical therapy alone. We cannot help but see the parallels: endovascular strategies may well turn out to be as successful in AIS as in myocardial infarction.”
According to the researchers, the inclusion of trials with different designs—such as an early versus late intervention window—along with different generations of devices warrants “considerable caution” when interpreting the results.
“However, new EVT trials designed to show mortality differences in AIS might never be performed; thus, a meta-analysis of available data may be the only way to analyze short-term survival,” they wrote.

Stroke-Certified Centers Have Better Early Survival Rates

All these damned statistics and they still tell you nothing useful. No way to use this to compare which hospital to go to. What would be even more useful would be the disability rate and severity of stroke for each hospital.
http://www.medpagetoday.com/Cardiology/Strokes/59332?xid=nl_mpt_cardiodaily_2016-07-27&eun=g424561d0r

• by Kristin Jenkins
  Contributing Writer, MedPage Today

• This article is a collaboration between MedPage Today® and:
  

Action Points

• Note that this study of Medicare administrative data found improved survival when patients with ischemic stroke were treated at a Primary Stroke Center.
• Be aware that assumptions in the data (such as the use of zip code centroids as home location) could have subtly biased these results.

Sending stroke patients to a primary stroke center (PSC) for specialized treatment was associated with better early survival than at noncertified hospitals, a retrospective cohort study showed.
The study revealed that admission to PSCs -- centers certified by The Joint Commission to ensure adherence to guidelines and efficient delivery of disease-specific care -- was associated with 1.8% (95% CI −2.1% to −1.4%) lower 7-day and 1.8% (95% CI −2.3% to −1.4%) lower 30-day case fatality.
However, travelling 60 minutes to a PSC offset the 7-day survival advantage, Kimon Bekelis, MD, of Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and colleagues reported online in JAMA Internal Medicine.
Similarly, if the 'drip and ship' trip took longer than 90 minutes, the travel time offset the 30-day survival advantage, according to researchers.
"These results are statistically significant and are clinically significant, implying one life saved for every 56 treated in a PSC," the researchers wrote.
"With the current distribution of PSCs, 16.4% of patients are located at least 90 minutes by ground transportation from the nearest PSC," they noted. "Further investigations are necessary to identify the best combination of approaches to improve access to centers of excellence and stroke outcomes."
Sending patients via air could get almost all patients to a PSC on time, the researchers suggested. Expanding telemedicine applications, upgrading smaller hospitals into Acute Stroke-Ready Hospitals, and creating a broader hospital network could also improve access to specialized stroke care, they said.
But improving stroke survival by getting patients to a specialized treatment center in the first 90 minutes only works for patients eligible for reperfusion therapy and those with hemorrhagic stroke requiring immediate clot evacuation or ventriculostomy, Lee H. Schwamm, MD, of the Stroke Service at Massachusetts General Hospital, Harvard Medical School, Boston, said in an accompanying editorial.
Hemorrhagic stroke carries with it less diagnostic uncertainty, a greater likelihood of transfer, but also greater mortality than ischemic stroke. Relatively few patients with hemorrhagic stroke have a dramatically altered outcome despite treatment in the "golden hour," he pointed out.
"Until we have data from randomized trials of pre-hospital triage, it is unlikely given the prevalence of stroke that we will find a more refined and pragmatic recommendation than the following: if it is a disabling stroke that started in the last 6 hours, then go to the highest-level stroke center that is within 30 to 45 extra minutes of drive time," Schwamm wrote. "However, because many hospitals with the highest levels of stroke resources are urban medical centers struggling to manage their annual increases in ED volume, this approach to sorting may increase competing risks to patient outcome."
When large-vessel occlusion is suspected and the patient re-routing mechanism kicks into high gear, "let us make sure that the destination of interest can deliver the goods," Schwamm added. "In the words of Albus Dumbledore, 'We must all face the choice between what is right, and what is easy. ...'"
For "smart triage," what's needed is a unified stroke care system that brings together centers that report performance data, Schwamm suggested. "Stroke incidence and 90-day functional outcomes should become a reportable disease so that meaningful data can be collected on all patients with stroke," he said.
Smartphone apps could determine the best possible destination for each patient, factoring in crucial data such as the stroke onset time, severity, travel times, hospital door-to-needle and door-to-puncture times, re-canalization success rates, and in-hospital mortality.
"Such a prehospital system should adhere to national standards but be customized to reflect the local resources, prevalence of stroke, best available screening tools, acceptable levels of erroneous triage, and competing costs of the additional transport and reduced EMS availability," Schwann said. "It will not be easy, but it is well worth doing."
The study looked at 865,184 Medicare beneficiaries seen with a stroke from Jan. 1, 2010, to Dec. 31, 2013. Mean age was 78.9 years and 55.5% were female.
More than half of the cohort (53.9%) was treated at one of 976 PSCs in the nation. Drive times were calculated based on zip code centroids and StreetMap North America was used to calculate the optimal travel time routes.
Although researchers had no information on where the patient was at the time of the stroke, the Framingham Study has demonstrated that most strokes happen at home, so they used population-weighted zip code points to represent patient origins.
Almost one-quarter of patients lived closer to a PSC than to a non-PSC institution. The review showed that patients admitted to a PSC were more likely to receive IV tissue plasminogen activator (6.0% versus 2.8%) or undergo mechanical thrombectomy (1.0% versus 0.2%) for ischemic stroke compared with their counterparts taken to non-PSC institutions.
The review also showed that differential travel time was a strong factor in PSC admission. A total of 87.5% of patients were admitted to a PSC when it was at least 1 hour closer than the nearest non-PSC institution. On the other hand, only 38.8% of patients were admitted to a PSC when it was 1 hour farther from the non-PSC institution.
"We did not find evidence that those who lived nearest to a PSC were sicker than those living far from a PSC: predicted mortality in the former was 15.8%, while that in the latter was 15.7%" (P=0.57), Bekelis and colleagues said.
Receiving treatment in a PSC was associated with a 30-day survival benefit for patients who travelled for:

• 20 minutes (adjusted difference 2.7%, 95% CI 1.5%-3.9%)
• 20 to 39 minutes (AD 1.8%, 95% CI 1.3%-2.2%)
• 40 to 59 minutes (AD 2.6%, 95% CI 0.7%-2.8%)
• 60 to 89 minutes (AD 1.7%, 95% CI 0.2%-2.4%)

The study had a number of limitations, the researchers acknowledged, including residual confounding caused by differences in time from stroke onset as well as the fact that stroke severity was unmeasured in the Medicare claims data. In addition, assigning populations to zip code centroids may have given falsely low travel times for some patients while overestimating travel times for others, they said.

When People Ask How My Life Changed After Surviving a Hemorrhagic Stroke

My version is this:

Why my stroke was the best thing to ever happen to me'.

How My Life Changed After Surviving a Hemorrhagic Stroke