Traumatic Brain Injury (TBI) is a complex, heterogeneous disease affecting millions of people in ... more Traumatic Brain Injury (TBI) is a complex, heterogeneous disease affecting millions of people in the U.S. each year [1]. Multimodal monitoring (MMM) is a relatively new attempt to access and monitor the brain post injury by incorporating multiple sources of information recorded in the intensive care unit (ICU) [2]. As a result, MMM has led to the creation of exhaustive datasets, allowing for the integration of many different signals and modalities pertaining to the management of severe TBI [2]–[4]. One of the most pressing questions about a TBI patient is whether an incident, or an event, will occur in the near future [5]. Additionally, clinicians require sufficient time before the onset of an event to administer a drug to the patient to avoid the oncoming event. Therefore, the aim of this work is to detect whether physiological events will occur in the future using the multimodal physiological data as features. In this study, we leverage both the breath and resolution of physiological data to predict the onset of physiological incidents 30 minutes before their onset. Specifically, we focus on three physiological events, namely high intercranial pressure (ICP), out of range diastolic arterial blood pressure (ABP), and out of range systolic ABP, using seven relevant modalities.
Executive Editor James W. Lockard Jr. Issues Editor Neeraj K. Kanwal Business Manager Neeraj K. K... more Executive Editor James W. Lockard Jr. Issues Editor Neeraj K. Kanwal Business Manager Neeraj K. Kanwal University News Martin Trichtinger World News Doug Hiller Opinions Elizabeth A. McGuire Features Patrick P. Sokas Sports Desk Shahab S. Minassian Managing Editor Edward H. Jasper Managing Associate Brenda Peterson Photography Editor Robert D. Lehman, Jr. Graphics Christine M. Kuhnl
Executive Editor James W. Lockard , Jr. Issue Editor Doug Hiller Business Manager Neeraj K. Kanwa... more Executive Editor James W. Lockard , Jr. Issue Editor Doug Hiller Business Manager Neeraj K. Kanwal University News Richard J. Perry World News Doug Hiller Opinions Elizabeth A. McGuire Features Patrick P. Sokas Sports Desk Shahab S. Minassian Managing Editor Edward H. Jasper Managing Associate Brenda Peterson Photography Editor Robert D. Lehman, Jr. Graphics Christine M. Kuhnl
Executive Editor James W. Lockard, Jr. Business Manager Neeraj K. Kanwal University News Richard ... more Executive Editor James W. Lockard, Jr. Business Manager Neeraj K. Kanwal University News Richard J . Perry World News Doug Hiller Opinions Elizabeth A. McGuire Features Patrick P. Sokas Sports Desk Shahab S. Minassian Managing Editor Edward H. Jasper Managing Associate Brenda Peterson Photography Editor Robert D. Lehman. Jr. Graphics Christine M. Kuhnl
Executive Editor Seth B. Paul Associate Editor Warren J. Ventriglia Business Manager Fredric Jay ... more Executive Editor Seth B. Paul Associate Editor Warren J. Ventriglia Business Manager Fredric Jay Matlin University News John Patrick Welch World News George Robert Coar Editorials Editor Steve Levine Features Mark Rubin Sports Editor Eli Saleeby Photo Editor Ken Buckwalter Circulation Victor Onufreiczuk Lee Wugofski Graphics and Art Steve Hulkower Commons Editor Brenda Peterso
For the past four years, we have been part of the US Army’s Hospital of the Future program and ha... more For the past four years, we have been part of the US Army’s Hospital of the Future program and have been investigating ways to address some of the remaining problems with a focus on “systems of monitors”. We are working with a wide group of collaborators to help develop the Integrated Clinical Environment (ICE) standard that is being promoted by Dr. Julian Goldman and the Medical Device Plug-and-Play organization (www.MDPnP.org). This article describes some of the problems we are addressing in both the acquisition of data and the use of data and our approach to solving them. We are focusing our particular developments in neuromonitoring as we believe the unique requirements of this area provide the most challenging environment to carry out such a development. Much of what we are doing requires a collaborative effort and we welcome participants.
Background: Multimodal monitoring is the standard of care in neuroscience intensive care units (n... more Background: Multimodal monitoring is the standard of care in neuroscience intensive care units (neuro-ICUs) and it has led to the creation of a data-rich environment. However, a "plug-and-play" interoperable approach is not yet available for medical devices in neuro-ICUs and this has hindered the creation and adoption of valuable informatics tools such as clinical decision support. Objective: This paper presents a review of the characteristics of the device interfaces that have been examined by Moberg Research, Inc. for the development of their platform for neurocritical care data integration. Methods: Neurocritical care device interfaces were reviewed by answering a series of questions designed to describe the adherence to specifications, the acceptance of standards, the overall quality of the protocols and to uncover potential pitfalls. Results: A total of 26 devices interfaces were examined in this process; 2 were discarded because of their analog nature. Device manufacturers did not provide protocol specification documents for 2 of the 24 device interfaces. In the case of device interfaces for which protocol specifications were provided, an unexpected degree of deviation was encountered. 18% of the protocol implementations exhibited a behavior substantially different from what expected based on the specifications. A large number (32%) exhibited undocumented behaviors. Out of the 24 examined protocol implementations, 3 did not provide a protocol version field in the output and only one was based on an existing communication and nomenclature standard. No form of identification for the device source and/or data types was included in the protocol for 29% of the investigated devices. One device did not specify the units either in the protocol specification or in the transmitted data. While some device protocols provided checksums or at least parity bits, 54% of the devices did not provide either. Conclusions: The results of this review revealed a lack of adherence to published/provided specifications, creating significant barriers to the development of connected, interoperable systems. Almost no data standardization was implemented in the analyzed protocols and many lacked transmission error detection schemes or source identification. These barriers impose a high degree of technological overhead for those who want to implement a connected neuro-ICU, making the development of custom interfaces costly and, ultimately, stifling innovation. Additionally, well-designed, standardized and documented device interfaces would reduce the risk of data misinterpretation and systematic medical errors. In order to reduce the currently identified barriers to connectivity, it is our recommendation that medical device manufacturers provide a well-designed and documented communication protocol for their devices. We also anticipate that our research will lead to the development of "best practices" that manufacturers could follow in the absence of widely adopted standards applicable to neurocritical care.
Purpose of Review Increasingly sophisticated systems for monitoring the brain have led to an incr... more Purpose of Review Increasingly sophisticated systems for monitoring the brain have led to an increase in the use of multimodality monitoring (MMM) to detect secondary brain injuries before irreversible damage occurs after brain trauma. This review examines the challenges and opportunities associated with MMM in this population. Recent Findings Locally and internationally, the use of MMM varies. Practical challenges include difficulties with data acquisition, curation, and harmonization with other data sources limiting collaboration. However, efforts toward integration of MMM data, advancements in data science, and the availability of cloud-based infrastructures are now affording the opportunity for MMM to advance the care of patients with brain trauma. Summary MMM provides data to guide the precision management of patients with traumatic brain injury in real time. While challenges exist, there are exciting opportunities for MMM to live up to this promise and to drive new insights into the physiology of the brain and beyond.
Brain injuries are complicated medical problems and their management requires data from disparate... more Brain injuries are complicated medical problems and their management requires data from disparate sources to extract actionable information. In neurocritical care, interoperability is lacking despite the perceived benefits. Several efforts have been underway, but none have been widely adopted, underscoring the difficulty of achieving this goal. We have identified the current pain points of data collection and integration based on the experience with two large multi-site clinical studies: Transforming Research And Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) in the United States and Collaborative European Neuro Trauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) in Europe. The variability of measurements across sites remains a barrier to uniform data collection. We found a need for annotation standards and for a standardized archive format for high-resolution data. Overall, the hidden cost for successful data collection was initially underestimated.Althou...
A relationship between reduced brain tissue oxygenation and poor outcome following severe traumat... more A relationship between reduced brain tissue oxygenation and poor outcome following severe traumatic brain injury has been reported in observational studies. We designed a Phase II trial to assess whether a neurocritical care management protocol could improve brain tissue oxygenation levels in patients with severe traumatic brain injury and the feasibility of a Phase III efficacy study. Randomized prospective clinical trial. Ten ICUs in the United States. One hundred nineteen severe traumatic brain injury patients. Patients were randomized to treatment protocol based on intracranial pressure plus brain tissue oxygenation monitoring versus intracranial pressure monitoring alone. Brain tissue oxygenation data were recorded in the intracranial pressure -only group in blinded fashion. Tiered interventions in each arm were specified and impact on intracranial pressure and brain tissue oxygenation measured. Monitors were removed if values were normal for 48 hours consecutively, or after 5 ...
Traumatic Brain Injury (TBI) is a complex, heterogeneous disease affecting millions of people in ... more Traumatic Brain Injury (TBI) is a complex, heterogeneous disease affecting millions of people in the U.S. each year [1]. Multimodal monitoring (MMM) is a relatively new attempt to access and monitor the brain post injury by incorporating multiple sources of information recorded in the intensive care unit (ICU) [2]. As a result, MMM has led to the creation of exhaustive datasets, allowing for the integration of many different signals and modalities pertaining to the management of severe TBI [2]–[4]. One of the most pressing questions about a TBI patient is whether an incident, or an event, will occur in the near future [5]. Additionally, clinicians require sufficient time before the onset of an event to administer a drug to the patient to avoid the oncoming event. Therefore, the aim of this work is to detect whether physiological events will occur in the future using the multimodal physiological data as features. In this study, we leverage both the breath and resolution of physiological data to predict the onset of physiological incidents 30 minutes before their onset. Specifically, we focus on three physiological events, namely high intercranial pressure (ICP), out of range diastolic arterial blood pressure (ABP), and out of range systolic ABP, using seven relevant modalities.
Executive Editor James W. Lockard Jr. Issues Editor Neeraj K. Kanwal Business Manager Neeraj K. K... more Executive Editor James W. Lockard Jr. Issues Editor Neeraj K. Kanwal Business Manager Neeraj K. Kanwal University News Martin Trichtinger World News Doug Hiller Opinions Elizabeth A. McGuire Features Patrick P. Sokas Sports Desk Shahab S. Minassian Managing Editor Edward H. Jasper Managing Associate Brenda Peterson Photography Editor Robert D. Lehman, Jr. Graphics Christine M. Kuhnl
Executive Editor James W. Lockard , Jr. Issue Editor Doug Hiller Business Manager Neeraj K. Kanwa... more Executive Editor James W. Lockard , Jr. Issue Editor Doug Hiller Business Manager Neeraj K. Kanwal University News Richard J. Perry World News Doug Hiller Opinions Elizabeth A. McGuire Features Patrick P. Sokas Sports Desk Shahab S. Minassian Managing Editor Edward H. Jasper Managing Associate Brenda Peterson Photography Editor Robert D. Lehman, Jr. Graphics Christine M. Kuhnl
Executive Editor James W. Lockard, Jr. Business Manager Neeraj K. Kanwal University News Richard ... more Executive Editor James W. Lockard, Jr. Business Manager Neeraj K. Kanwal University News Richard J . Perry World News Doug Hiller Opinions Elizabeth A. McGuire Features Patrick P. Sokas Sports Desk Shahab S. Minassian Managing Editor Edward H. Jasper Managing Associate Brenda Peterson Photography Editor Robert D. Lehman. Jr. Graphics Christine M. Kuhnl
Executive Editor Seth B. Paul Associate Editor Warren J. Ventriglia Business Manager Fredric Jay ... more Executive Editor Seth B. Paul Associate Editor Warren J. Ventriglia Business Manager Fredric Jay Matlin University News John Patrick Welch World News George Robert Coar Editorials Editor Steve Levine Features Mark Rubin Sports Editor Eli Saleeby Photo Editor Ken Buckwalter Circulation Victor Onufreiczuk Lee Wugofski Graphics and Art Steve Hulkower Commons Editor Brenda Peterso
For the past four years, we have been part of the US Army’s Hospital of the Future program and ha... more For the past four years, we have been part of the US Army’s Hospital of the Future program and have been investigating ways to address some of the remaining problems with a focus on “systems of monitors”. We are working with a wide group of collaborators to help develop the Integrated Clinical Environment (ICE) standard that is being promoted by Dr. Julian Goldman and the Medical Device Plug-and-Play organization (www.MDPnP.org). This article describes some of the problems we are addressing in both the acquisition of data and the use of data and our approach to solving them. We are focusing our particular developments in neuromonitoring as we believe the unique requirements of this area provide the most challenging environment to carry out such a development. Much of what we are doing requires a collaborative effort and we welcome participants.
Background: Multimodal monitoring is the standard of care in neuroscience intensive care units (n... more Background: Multimodal monitoring is the standard of care in neuroscience intensive care units (neuro-ICUs) and it has led to the creation of a data-rich environment. However, a "plug-and-play" interoperable approach is not yet available for medical devices in neuro-ICUs and this has hindered the creation and adoption of valuable informatics tools such as clinical decision support. Objective: This paper presents a review of the characteristics of the device interfaces that have been examined by Moberg Research, Inc. for the development of their platform for neurocritical care data integration. Methods: Neurocritical care device interfaces were reviewed by answering a series of questions designed to describe the adherence to specifications, the acceptance of standards, the overall quality of the protocols and to uncover potential pitfalls. Results: A total of 26 devices interfaces were examined in this process; 2 were discarded because of their analog nature. Device manufacturers did not provide protocol specification documents for 2 of the 24 device interfaces. In the case of device interfaces for which protocol specifications were provided, an unexpected degree of deviation was encountered. 18% of the protocol implementations exhibited a behavior substantially different from what expected based on the specifications. A large number (32%) exhibited undocumented behaviors. Out of the 24 examined protocol implementations, 3 did not provide a protocol version field in the output and only one was based on an existing communication and nomenclature standard. No form of identification for the device source and/or data types was included in the protocol for 29% of the investigated devices. One device did not specify the units either in the protocol specification or in the transmitted data. While some device protocols provided checksums or at least parity bits, 54% of the devices did not provide either. Conclusions: The results of this review revealed a lack of adherence to published/provided specifications, creating significant barriers to the development of connected, interoperable systems. Almost no data standardization was implemented in the analyzed protocols and many lacked transmission error detection schemes or source identification. These barriers impose a high degree of technological overhead for those who want to implement a connected neuro-ICU, making the development of custom interfaces costly and, ultimately, stifling innovation. Additionally, well-designed, standardized and documented device interfaces would reduce the risk of data misinterpretation and systematic medical errors. In order to reduce the currently identified barriers to connectivity, it is our recommendation that medical device manufacturers provide a well-designed and documented communication protocol for their devices. We also anticipate that our research will lead to the development of "best practices" that manufacturers could follow in the absence of widely adopted standards applicable to neurocritical care.
Purpose of Review Increasingly sophisticated systems for monitoring the brain have led to an incr... more Purpose of Review Increasingly sophisticated systems for monitoring the brain have led to an increase in the use of multimodality monitoring (MMM) to detect secondary brain injuries before irreversible damage occurs after brain trauma. This review examines the challenges and opportunities associated with MMM in this population. Recent Findings Locally and internationally, the use of MMM varies. Practical challenges include difficulties with data acquisition, curation, and harmonization with other data sources limiting collaboration. However, efforts toward integration of MMM data, advancements in data science, and the availability of cloud-based infrastructures are now affording the opportunity for MMM to advance the care of patients with brain trauma. Summary MMM provides data to guide the precision management of patients with traumatic brain injury in real time. While challenges exist, there are exciting opportunities for MMM to live up to this promise and to drive new insights into the physiology of the brain and beyond.
Brain injuries are complicated medical problems and their management requires data from disparate... more Brain injuries are complicated medical problems and their management requires data from disparate sources to extract actionable information. In neurocritical care, interoperability is lacking despite the perceived benefits. Several efforts have been underway, but none have been widely adopted, underscoring the difficulty of achieving this goal. We have identified the current pain points of data collection and integration based on the experience with two large multi-site clinical studies: Transforming Research And Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) in the United States and Collaborative European Neuro Trauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) in Europe. The variability of measurements across sites remains a barrier to uniform data collection. We found a need for annotation standards and for a standardized archive format for high-resolution data. Overall, the hidden cost for successful data collection was initially underestimated.Althou...
A relationship between reduced brain tissue oxygenation and poor outcome following severe traumat... more A relationship between reduced brain tissue oxygenation and poor outcome following severe traumatic brain injury has been reported in observational studies. We designed a Phase II trial to assess whether a neurocritical care management protocol could improve brain tissue oxygenation levels in patients with severe traumatic brain injury and the feasibility of a Phase III efficacy study. Randomized prospective clinical trial. Ten ICUs in the United States. One hundred nineteen severe traumatic brain injury patients. Patients were randomized to treatment protocol based on intracranial pressure plus brain tissue oxygenation monitoring versus intracranial pressure monitoring alone. Brain tissue oxygenation data were recorded in the intracranial pressure -only group in blinded fashion. Tiered interventions in each arm were specified and impact on intracranial pressure and brain tissue oxygenation measured. Monitors were removed if values were normal for 48 hours consecutively, or after 5 ...
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Papers by Richard Moberg