Clinical benefit of improved Prehospital stroke scales to detect stroke patients with large vessel occlusions: results from a conditional probabilistic model

Background Clinical scales to detect large vessel occlusion (LVO) may help to determine the optimal transport destination for patients with suspected acute ischemic stroke (AIS). The clinical benefit associated with improved diagnostic accuracy of these scales has not been quantified. Methods We used a previously reported conditional model to estimate the probability of good outcome (modified Rankin scale sore ≤2) for patients with AIS and unknown vessel status occurring in regions with greater proximity to a primary than to a comprehensive stroke center. Optimal rapid arterial occlusion evaluation (RACE) scale cutoff scores were calculated based on time-dependent effect-size estimates from recent randomized controlled trials. Probabilities of good outcome were compared between a triage strategy based on these cutoffs and a strategy based on a hypothetical perfect LVO detection tool with 100% diagnostic accuracy. Results In our model, the additional benefit of a perfect LVO detection tool as compared to optimal transport-time dependent RACE cutoff scores ranges from 0 to 5%. It is largest for patients with medium stroke symptom severity (RACE score 5) and in geographic environments with longer transfer time between the primary and comprehensive stroke center. Conclusion Based on a probabilistic conditional model, the results of our simulation indicate that more accurate prehospital clinical LVO detections scales may be associated with only modest improvements in the expected probability of good outcome for patients with suspected acute ischemic stroke and unknown vessel status

Multivariate CARMA processes, continuous-time state space models and complete regularity of the innovations of the sampled processes

The class of multivariate L\'{e}vy-driven autoregressive moving average (MCARMA) processes, the continuous-time analogs of the classical vector ARMA processes, is shown to be equivalent to the class of continuous-time state space models. The linear innovations of the weak ARMA process arising from sampling an MCARMA process at an equidistant grid are proved to be exponentially completely regular ($\beta$-mixing) under a mild continuity assumption on the driving L\'{e}vy process. It is verified that this continuity assumption is satisfied in most practically relevant situations, including the case where the driving L\'{e}vy process has a non-singular Gaussian component, is compound Poisson with an absolutely continuous jump size distribution or has an infinite L\'{e}vy measure admitting a density around zero.Comment: Published in at http://dx.doi.org/10.3150/10-BEJ329 the Bernoulli (http://isi.cbs.nl/bernoulli/) by the International Statistical Institute/Bernoulli Society (http://isi.cbs.nl/BS/bshome.htm

Quasi maximum likelihood estimation for strongly mixing state space models and multivariate L\'evy-driven CARMA processes

We consider quasi maximum likelihood (QML) estimation for general non-Gaussian discrete-ime linear state space models and equidistantly observed multivariate L\'evy-driven continuoustime autoregressive moving average (MCARMA) processes. In the discrete-time setting, we prove strong consistency and asymptotic normality of the QML estimator under standard moment assumptions and a strong-mixing condition on the output process of the state space model. In the second part of the paper, we investigate probabilistic and analytical properties of equidistantly sampled continuous-time state space models and apply our results from the discrete-time setting to derive the asymptotic properties of the QML estimator of discretely recorded MCARMA processes. Under natural identifiability conditions, the estimators are again consistent and asymptotically normally distributed for any sampling frequency. We also demonstrate the practical applicability of our method through a simulation study and a data example from econometrics

Disability Adjusted Life Years due to Ischaemic Stroke Preventable by Real-Time Stroke Detection—A Cost-Utility Analysis of Hypothetical Stroke Detection Devices

Background: Ischaemic stroke remains a significant contributor to permanent disability world-wide. Therapeutic interventions for acute ischaemic stroke (AIS) are available, but need to be administered early after symptom onset in order to be effective. Currently, one of the main factors responsible for poor clinical outcome is an unnecessary long time between symptom onset and arrival at a hospital (pre-hospital delay). In the future, technological devices with the capability of real-time detection of AIS may become available. The health economic implications of such devices have not been explored.Methods: We developed a novel probabilistic model to estimate the maximally allowable annual costs of different hypothetical real-time AIS detection devices in different populations given currently accepted willingness-to-pay thresholds. Distributions of model parameters were extracted from the literature. Effectiveness of the intervention was quantified as reduction in disability-adjusted life-years associated with faster access to thrombolysis and mechanical thrombectomy. Incremental costs were calculated from a societal perspective including acute treatment costs and long-term costs for nursing care, home help, and loss of production. The impact of individual model parameters was explored in one-way and multi-way sensitivity analyses.Results: The model yields significantly shorter prehospital delays and a higher proportion of acute ischaemic patients that fulfill the time-based eligibility criteria for thrombolysis or mechanical thrombectomy in the scenario with a real-time stroke detection device as compared to the control scenario. Depending on the sociodemographic and geographic characteristics of the study population and operating characteristics of the device, the maximally allowable annual cost for the device to operate in a cost-effective manner assuming a willingness-to-pay threshold of GBP 30.000 ranges from GBP 22.00 to GBP 9,952.00. Considering the results of multiway sensitivity analyses, the upper bound increases to GBP 29,449.10 in the subgroup of young patients with a very high annual risk of ischaemic stroke (50 years/20% annual risk).Conclusion: Data from probabilistic modeling suggest that real-time AIS detection devices can be expected to be cost-effective only for a small group of highly selected individuals

First-passage percolation on width-two stretches with exponential link weights

We consider the first-passage percolation problem on effectively one-dimensional graphs with vertex set {1,...,n}\times{0,1} and translation-invariant edge-structure. For three of six non-trivial cases we obtain exact expressions for the asymptotic percolation rate \chi\ by solving certain recursive distributional equations and invoking results from ergodic theory to identify \chi\ as the expected asymptotic one-step growth of the first-passage time from (0,0) to (n,0).Comment: 10 pages, one tabl