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Extended Time Window for Stroke Treatment. The Public Gets the Wrong Message

February 5, 2018 Leave a comment

The recent presentation and publication of two clinical trials supporting the effective treatment of ischemic stroke as long as 24 hours after onset have been widely disseminated by the press. Articles have correctly hailed this as a major advance in stroke diagnosis and treatment. Both the DEFUSE 3 and DAWN trials have robust treatment effects, in some cases stronger than for patients treated within 6 hours. The studies are presented as a dramatic advance which could be misunderstood as benefiting all stroke patients.

The Washington Post reported “New research will radically change response to strokes”. The article makes the following statement: “The new findings suggest they (doctors) may have as long as 16 hours in many cases”. It is the word many that can be misleading to anyone reading this message. The tone of most articles emphasizes that it will now be possible to treat stroke patients as long as 24 hours after symptoms. What is not generally stated, however, is that this approach will only benefit a minority of stroke patients, and that for most strokes “Time is Brain” still applies, and that a person experiencing stroke symptoms should get to a stroke center as soon as possible to have an opportunity to preserve brain tissue which is at risk.

A patient told me this past week that “I am up to date with the news. I know that I can take 24 hours to get to the hospital if I am having a stroke”. I am certain that this was not the intended message, but this is the way it has been perceived. If I had any doubt, last night a member of our local volunteer EMS called ahead to our ED with a patient whose stroke started 12 hours earlier, commenting that he knew there was still ‘plenty of time’.

The most important information to be derived from these studies is that not all strokes progress at the same rate, and there are now diagnostic studies to find the patients who have blockage of major arteries, but have not yet sustained major damage. These are the patients that were shown to benefit in these treatment trials. And the fact that they can greatly benefit from treatment so late is indeed revolutionary.

These late treatment trials will indeed lead to widespread changes in stroke care, especially in the treatment of patients who wake up with stroke symptoms, and have previously been automatically excluded from treatment. Hospitals in these studies utilized specialized CT scans, with software for automatic analysis that is not yet widely available. As stroke care advances, the ability to get the right patients to centers that can perform the advanced interventional therapies will become widespread. But for now, the extended time windows for treatment will only be available to a small minority of stroke patients.

 

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Categories: Healthcare

Using Twitter to Treat Stroke

June 11, 2015 2 comments

Yesterday, a 97 year old woman arrived in our emergency department after suddenly becoming unable to speak, and having weakness over the right side of her body. She was brought in by her husband, also in his 90s. We needed to make some immediate decisions about our options for treatment of this devastating condition, but it was necessary to find out when the symptoms started. Treatment for stroke requires having this knowledge, because treatments can only be administered within a narrow time window. The clot dissolving medication, tPA, could not be administered in this patient later than three hours following her first symptoms.

When we asked her husband when this all started, he told us he was uncertain about the time, but he did know one thing – ‘it happened during the seventh inning of the Yankee game’. We needed to find out immediately when the game was in the seventh inning. On to the Internet. A box score was not helpful. I decided to search Twitter for ‘Yankees’, and the line of tweets was immediately traced back to what we wanted. We discovered that the time was two hours earlier. The patient was treated with tPA and, and has demonstrated some improvement.

One more tool in stroke treatment. Twitter.

Categories: Healthcare

OneNote on Windows RT. What it tells us about Microsoft Now

November 21, 2013 Leave a comment

One of the unrecognized jewels of Microsoft software is OneNote. It is a great application for note taking, organization, and project planning. For years, Microsoft has not recognized how OneNote could represent their company to the users they were losing. The people at Evernote recognized this opportunity, and their success represents an understanding of people store and utilize this type of data across multiple devices. OneNote is now available for IOS devices, including the iPad and iPhone, in addition to Windows Phone and Windows itself.

The new Microsoft Surface 2 is a great piece of tablet hardware for students and others working on productivity applications. You can read about it elsewhere. It runs on the version of Windows for tablets called Windows RT. One of the selling points of the Surface 2 is that it runs a version of Microsoft Office, which includes OneNote.

Note taking applications on tablets are expected to have one function, audio recording. While it is possible to record audio in OneNote on a desktop running Windows, the version of OneNote for Windows RT cannot record audio. Does this mean that Microsoft cannot engineer this feature? Of course not. It tells us about the organization of the company and how they still somehow miss what their competition is doing. This is a problem of integrating across product groups, and understanding how customers use their products.

Challenge and opportunity for the new CEO of Microsoft.

Categories: Uncategorized

Thoughts on the Blackberry Revival

January 21, 2013 1 comment

Blackberry is back in the news again. Having missed the smartphone revolution, and being eclipsed by the iPhone and Android phones in particular, many have written obituaries for the company. When they reported their earning last month, there was a decrease in subscribers for the first time, although at 79 million, it was still more than one year ago. There is great interest in their new products, known as Blackberry 10, to be introduced January 30, and the stock price has been steadily rising over the past few months. Does RIM have another chance? I will let you draw your own conclusion. Let’s look at some facts.

Blackberry is a secure platform. It is generally appreciated that messaging on Blackberry is the most secure among phone systems. It has an established niche in government, law, and other fields requiring high level security.

Blackberry continues to be used by a group that values email and messaging above all else. At the recent Consumer Electronics Show (CES), the Wired Blog noted ‘I have seen an incredible amount of Blackberries and Galaxy Notes’. These users know what they are missing, and that is a decent browser and a map application. They may not be interested in loading their phones with Apps. We all know who these people are. They trust Blackberry.

Microsoft has given RIM an opportunity. They have committed several errors with Windows Phone. New Nokia phones running WP 7.5 cannot be upgraded to WP 8, and developers have not exactly flocked to the platform. Many basic Apps are not yet available, or equivalent to those on IOS or Android. RIM released developer tools well in advance (as opposed to Microsoft), and there is good reason to believe that many desired applications may be available for Blackberry 10.

Carriers are interested in Blackberry 10. The four major carriers (Verizon, AT&T, Sprint, and t-Mobile) have all announced that they will be carrying the new phones, and RIM mentioned on their earnings call that 150 carriers around the world are interested in the new platform.

The iPhone and Android are no longer new. The Samsung commercial where a young man is saving a spot in line for what is obviously an iPhone launch rings true. An innovative operating system that carries forward the features that have made Blackberry successful may be surprisingly attractive.

Blackberry can compete with Apple. Unlike Android and Windows Phone, where multiple manufacturers compete on price and features, RIM, like Apple, controls the hardware and software. And Blackberry, because of its user base, may still command the image of a premium product.

In the end, it may come down to how well RIM has executed the transition to the new Blackberry 10 operating system. After all, Palm is gone because they failed to execute, and RIM may suffer the same fate. But in the world of professionals there may be room for another platform, especially one that corporations and professionals have trusted in the past. We have watched the evolution of the Blackberry Playbook, which runs the same basic software. It has excellent multitasking, and a more than acceptable browser.

We have heard promises before. Until we have the phone in our hands we will not be any better at predicting the future of Blackberry.

Categories: Mobile

Afghanistan and the Future of Stroke Treatment

March 29, 2012 Leave a comment

The treatment of stroke was revolutionized in 1996 when the FDA approved a clot-dissolving drug, alteplase (tPA). It remains our only available medical treatment for the most common type of stroke, although several types of drugs have been studied over the years. Alteplase (tPA) is not ideal, however, and in some cases produces only limited benefit. The search for more effective drugs continues.

In last week’s edition of The New England Journal of Medicine, one of the world’s most prestigious medical journals, a group of investigators from Australia published a study investigating another clot dissolving drug for stroke, tenecteplase (TNK). This study can be viewed as preliminary (phase IIB), and applies to only those patients studied, who were selected by very strict criteria following special CT scan exams, known as CT angiography and CT perfusion. Over 2700 patients were screened to find 75 eligible for the study. The bottom line is that tenecteplase was better than alteplace at opening clogged arteries, and the patients treated with tenecteplase had better clinical results. Tenecteplase, like alteplace before it, is currently FDA approved for the treatment of myocardial infarction.

The path for tenecteplase to reach stroke patients in the United States would need to first include a phase III clinical trial to determine efficacy in the much larger group of patients that are currently eligible for alteplase, rather than the selected group in this study.

It will not be easy. A trial studying tenecteplase in the United States, sponsored by the National Institutes of Health, was performed between 2006 and 2008. It was stopped early because the number of patients being recruited was considered too low to continue. While our country is spending $2 billion per week on the war in Afghanistan, funding for studies on stroke treatment is difficult to come by.

Stroke is a common, devastating condition. We have a potentially more effective treatment with a drug that has been developed for another use. A new clinical trial needs to be conducted in the United States. Whether the money comes from the government, industry, private philanthropy or a combination, this type of work must be supported by all of us.

Categories: Uncategorized

Saving Medicare: Boomers, Doctors and Legislators Need to Understand

July 22, 2011 3 comments

A few weeks ago a patient came into my office referred for evaluation regarding surgery on her carotid artery. Although she had no symptoms, her primary physician had performed carotid ultrasound and found a severe narrowing on one side. She presented the results of this examination, and several additional diagnostic studies that had been performed recently. As it turned out, the doppler was inaccurate and she did not have any narrowing. As I explained this to the patient, I asked her if she understood that this test might not have been necessary. She replied, “He is a nice man, he deserves to make a living”.

Think about what is wrong with this picture and how things can be improved to save Medicare funds.

Unnecessary tests are being performed. This is widely known and understood. It is a way for physicians to generate income that is much easier than seeing additional patients. Patients don’t mind as long as they don’t feel the cost. Physicians do this testing at least partially because they are not paid enough to see patients. Some testing is a result of self-referral, such as the radiology report that says “consider performing the following examination for clarification”.

Physician’s time is not valued. In the case of this patient, I was able to help her avoid a possible surgical procedure and additional testing, saving the system thousands of dollars. In relationship to this visit, I fielded telephone calls from the patient, her children, and the referring physician. Payment for the visit does not compensate for this time. Doctors are unique among professionals in this respect; their time has no value and is regarded as free. Try this with your lawyer, accountant, or plumber.

Medicare beneficiaries don’t want any cuts. A recent study published in the New England Journal of Medicine indicated that most seniors are not willing to discuss any cuts in Medicare.

Everyone knows we are at a critical time. As we accept that resources are no longer infinite, all stakeholders need to accept that they will play a role in the survival of Medicare. Changes in behavior can be promoted by system modification. Some ideas:

Time for Medicine to leave the sidelines and reduce waste. Every medical specialty knows where the waste is in their field. Legislators should challenge medical associations to reduce costs without denying useful services.

Patients need to feel the cost of medical care. Before every test and procedure, patients should be informed of what the system will pay. The idea of annual coverage limits on ambulatory diagnostic services is not unthinkable.

Doctors should be paid for their time. The technology is available to allow physicians to be paid for actually talking to patients, in person or by telephone. Appropriate systems can control abuse; there are only a limited number of hours in the day.

Payment systems need to be implemented that prevent abuse and fraud. The credit card companies know how to do this, and it is long past due in healthcare. We have written about this previously.

It is time for the providers and consumers of healthcare to face the fact that they have allowed insurers and legislators to dictate changes in the healthcare system that do not improve healthcare or control costs. Soon it will be too late. Medical societies should step forward, doctors should present the facts to their patients, and legislators should encourage the achievement of these goals.

Categories: Healthcare

How Microsoft Can Replace RIM in the Enterprise

July 20, 2011 3 comments

It has been an interesting year in the smartphone space. The iPhone and Android continue to gain market share at the expense of other platforms such as Blackberry and Windows. RIM, the maker of Blackberry, has not introduced a new phone in months, and is struggling to introduce their next generation operating system. The battle will be drawn for third place after the two leaders. Microsoft is presented with an opportunity they have not had in years. Their new mobile OS, Windows Phone 7, has been well received. And the coming update to Windows Phone, known as Mango, brings it up to a truly competitive level. But one set of features can make it a true competitor to Blackberry, secure enterprise messaging.

RIM made the Blackberry a fixture in the enterprise by creating a secure software platform, Blackberry Enterprise Server, that works with Microsoft Exchange and brings the messaging synchronization to mobile devices. That was years ago. Now Microsoft, after too many missteps, has a phone OS that is modern, that is attracting development, and that has first class phone manufacturers such as Nokia and Samsung preparing to introduce new devices.

Blackberry has two features that continue to hold customers, secure email and Blackberry Messenger. Providing these features in Windows Phone, combined with Exchange Server, Sharepoint, and Office, Microsoft can give the enterprise a reason to migrate from Blackberry to their new platform. They can become the third mobile ecosystem.

Categories: Uncategorized