Low profile sheaths in pediatric neurointervention: a multicenter experience

BackgroundPediatric neurointervention is challenged by the appropriateness of adult catheters and devices. This multicenter report on the smallest groin access sheaths offers technical notes and clinical outcomes in the pediatric neurointerventional population.MethodsAll pediatric neurointerventional cases from 2019 to 2021 were reviewed for use of a 3.3F Pediavascular or a 4F Merit Prelude Ideal low profile sheath. Hospital records were reviewed for complications and technical notes and compared with arterial groin access with the 4F Terumo Pinnacle in infants less than 1 year old, before the low profile sheaths at one author’s institution were introduced.ResultsFrom January 1, 2019 to March 31, 2021 there were 347 procedures performed at Boston Children’s Hospital and University of Wisconsin. Forty-four procedures in 26 patients were identified in which a 3.3F (38 cases, 20 patients) or 4F (6 cases, 6 patients) sheath was used. The average age was 2.2 years (1.5 days to 18 years). Retinoblastoma intra-arterial chemotherapy infusion (18 of 44) was the most common indication. The remaining procedures comprised vein of Galen embolization (12), diagnostic cerebral angiography (13), and one preoperative tumor embolization. Morbidity included a groin hematoma and decreased pulses (4.5%). No major groin complications occurred. There was no statistically significant difference compared with the historical cohort (132 procedures), which had seven instances of decreased pulses (5.3%, p>0.05).ConclusionThe 3.3F Pediavascular and 4F Merit Prelude Ideal sheaths are easily incorporated into the pediatric neurointerventionalist’s armamentarium for infants and readily accommodate various microcatheters for distal embolization and catheterization.

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Operational experience of the Dutch helicopter emergency medical services (HEMS) during the initial phase of the COVID-19 pandemic: jeopardy on the prehospital care system?

European Journal of Trauma and Emergency Surgery ◽

10.1007/s00068-020-01569-w ◽

2021 ◽

Author(s):

Quinten G. H. Rikken ◽

Sarah Mikdad ◽

Mathijs T. Carvalho Mota ◽

Marcel A. De Leeuw ◽

Patrick Schober ◽

...

Keyword(s):

The Netherlands ◽

Initial Phase ◽

Prehospital Care ◽

Operational Experience ◽

Level Of Evidence ◽

Historical Cohort ◽

Significant Difference ◽

One Year ◽

Retrospective Comparative Study ◽

Global And Local

Abstract Purpose The SARS-CoV-2 virus has disrupted global and local medical supply chains. To combat the spread of the virus and prevent an uncontrolled outbreak with limited resources, national lockdown protocols have taken effect in the Netherlands since March 13th, 2020. The aim of this study was to describe the incidence, type and characteristics of HEMS and HEMS-ambulance ‘Lifeliner 1’ dispatches during the initial phase of the COVID-19 pandemic compared to the same period one year prior. Methods A retrospective review of all HEMS and HEMS-ambulance ‘Lifeliner 1’ dispatches was performed from the start of Dutch nationwide lockdown orders from March 13th until May 13th, 2020 and the corresponding period one year prior. Dispatch-, operational-, patient-, injury-, and on-site treatment characteristics were extracted for analysis. In addition, the rate of COVID-19 positively tested HEMS personnel and the time physicians were unable to take call was described. Results During the initial phase of the COVID-19 pandemic, the HEMS and HEMS-ambulance was requested in 528 cases. One year prior, a total of 620 requests were received. The HEMS (helicopter and ambulance) was cancelled after deployment in 56.4% of the COVID-19 cohort and 50.7% of the historical cohort (P = 0.05). Incident location type did not differ between the two cohorts, specifically, there was no significant difference in the number of injuries that occurred at home in pandemic versus non-pandemic circumstances. Besides a decrease in the number of falls, the distribution of mechanisms of injury remained similar during the COVID-19 study period. There was no difference in self-inflicted injuries observed. Prehospital interventions remained similar during the COVID-19 pandemic compared to one year prior. Specifically, prehospital intubation did not differ between the two cohorts. The rate of COVID-19 positively tested HEMS personnel was 23.1%. Physicians who tested positive were unable to take call for a mean of 25 days (range 8–53). Conclusion A decrease in the number of deployments and increase in the number of cancelled missions was observed during the COVID-19 study period. No major differences in operational- and injury characteristics were found for HEMS and HEMS-ambulance dispatches between the initial phase of the COVID-19 pandemic in the Netherlands and the same period one year prior. These findings highlight the importance of continued operability of the HEMS, even during pandemic circumstances. Level of evidence III, retrospective comparative study.

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Impact of pretreatment anemia on upfront abiraterone acetate therapy for metastatic hormone-sensitive prostate cancer: a multicenter retrospective study

BMC Cancer ◽

10.1186/s12885-021-08206-8 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Teppei Okamoto ◽

Daisuke Noro ◽

Shingo Hatakeyama ◽

Shintaro Narita ◽

Koji Mitsuzuka ◽

...

Keyword(s):

Prostate Cancer ◽

Prognostic Factor ◽

Abiraterone Acetate ◽

Tumor Burden ◽

Hazard Ratio ◽

Historical Cohort ◽

High Tumor Burden ◽

Significant Difference ◽

Hormone Sensitive ◽

The Impact

Abstract Background Anemia has been a known prognostic factor in metastatic hormone-sensitive prostate cancer (mHSPC). We therefore examined the effect of anemia on the efficacy of upfront abiraterone acetate (ABI) in patients with mHSPC. Methods We retrospectively evaluated 66 mHSPC patients with high tumor burden who received upfront ABI between 2018 and 2020 (upfront ABI group). We divided these patients into two groups: the anemia-ABI group (hemoglobin < 13.0 g/dL, n = 20) and the non-anemia-ABI group (n = 46). The primary objective was to examine the impact of anemia on the progression-free survival (PFS; clinical progression or PC death before development of castration resistant PC) of patients in the upfront ABI group. Secondary objectives included an evaluation of the prognostic significance of upfront ABI and a comparison with a historical cohort (131 mHSPC patients with high tumor burden who received androgen deprivation therapy (ADT/complete androgen blockade [CAB] group) between 2014 and 2019). Results We found that the anemia-ABI group had a significantly shorter PFS than the non-anemia-ABI group. A multivariate Cox regression analysis showed that anemia was an independent prognostic factor of PFS in the upfront ABI group (hazard ratio, 4.66; P = 0.014). Patients in the non-anemia-ABI group were determined to have a significantly longer PFS than those in the non-anemia-ADT/CAB group (n = 68) (P < 0.001). However, no significant difference was observed in the PFS between patients in the anemia-ABI and the anemia-ADT/CAB groups (n = 63). Multivariate analyses showed that upfront ABI could significantly prolong the PFS of patients without anemia (hazard ratio, 0.17; P < 0.001), whereas ABI did not prolong the PFS of patients with anemia. Conclusion Pretreatment anemia was a prognostic factor among mHSPC patients who received upfront ABI. Although the upfront ABI significantly improved the PFS of mHSPC patients without anemia, its efficacy in patients with anemia might be limited.

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Comparison of endoscopic activity before and during the covid pandemic at a tertiary care hospital in South Punjab

10.1101/2021.10.11.21264820 ◽

2021 ◽

Author(s):

Farooq Mohyud Din ◽

Muhammad Asif Gul ◽

Nouman Hameed ◽

Rizwan Hameed ◽

Yasir Zaidi ◽

...

Keyword(s):

Gastrointestinal Bleeding ◽

Tertiary Care ◽

Healthcare Delivery ◽

Absolute Number ◽

Care Hospital ◽

Common Indication ◽

Endoscopic Procedures ◽

Significant Difference ◽

Internal Hemorrhoids ◽

One Year

Introduction: Coronavirus disease 2019 (COVID-19) has resulted in dramatic changes to healthcare delivery. Endoscopic activity has had frequent disruptions during this pandemic. The objective of the study was to see the influence of pandemic over the endoscopic activity. Methods: This retrospective analysis of endoscopic activity was undertaken at Nishtar Hospital Multan. Procedural analysis was done in the three months immediately after covid lockdown (1st April till 30th June 2020) and was compared to a similar period one year back. Results: Five hundred and fifty-four (68.5%) patients underwent endoscopic procedures during the three months of pre-COVID era, while this number reduced to half (n=255, 31.5%) patients during the covid pandemic. Even though the absolute number of Esophagogastroduodenoscopies (EGDs) reduced during the pandemic, patients were more likely to undergo EGDs during the COVID pandemic in contrast to the era before the pandemic (79% versus 66%, p = 0.002). The most common indication for EGD was upper gastrointestinal bleeding (UGIB). The percentage of EGDs done for UGIB rose from almost 60% to 80% during the covid pandemic (p < 0.001). The most common findings were esophageal varices and portal gastropathy (non-significant difference during and before the pandemic). Percentage of ERCPs done for obstructive jaundice doubled during the COVID pandemic (33% versus 65%, p = 0.002).The most common indication for sigmoidoscopy or colonoscopy was lower gastrointestinal bleeding. However, no significant difference was found before and during the covid pandemic (41.7% and 45.8% respectively, p=0.72). Internal hemorrhoids were the most common endoscopic finding. Colon cancer diagnosis reduced from 10% to undetected during the pandemic period. Conclusion: COVID pandemic resulted in a considerable reduction in all types of endoscopic procedures. The majority of procedures were done for emergency indications like gastrointestinal bleeding. Rates of cancer detection were significantly reduced. MeSH: Endoscopy, COVID-19, Gastroenterology

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Importance of Treatment Institution in Head and Neck Cancer Radiotherapy

Otolaryngology ◽

10.1016/j.otohns.2009.03.019 ◽

2009 ◽

Vol 141 (2) ◽

pp. 172-176 ◽

Cited By ~ 12

Author(s):

Gregory J. Kubicek ◽

Fen Wang ◽

Eashwar Reddy ◽

Yelizaveta Shnayder ◽

Cristina E. Cabrera ◽

...

Keyword(s):

Head And Neck Cancer ◽

Treatment Outcome ◽

Head And Neck ◽

Neck Cancer ◽

Time Course ◽

Medical Center ◽

Recurrence Rates ◽

Historical Cohort ◽

Initial Surgery ◽

Significant Difference

OBJECTIVE: The treatment for head and neck cancer (HNC) often involves radiotherapy. Many HNC patients are treated at the academic center (AC) where the initial surgery or diagnosis was made. Because of the lengthy time course for radiotherapy, some patients are treated at community radiation facilities (non-AC) rather than the AC despite potential AC advantages in terms of experience and technology. Our goal is to determine if these potential AC advantages correspond to a difference in treatment outcome. STUDY DESIGN: Historical cohort study. SETTING: University of Kansas Medical Center, Kansas City, Kansas. SUBJECTS AND METHODS: Review of records of patients with HNC cancers evaluated at the otolaryngology (ENT) department of an AC. Each patient's information and treatment characteristics were recorded, including radiotherapy treatment venue and treatment outcome. RESULTS: Three hundred seventy-four patients were analyzed, 263 were treated at an AC and 101 at a non-AC. Patients treated at a non-AC were more likely to present with earlier stage tumors, be treated with radiation alone rather than chemoradiotherapy, and be treated with adjuvant rather than primary radiotherapy. There was no difference in overall survival or recurrence rates between AC and non-AC. CONCLUSION: Patients treated at an AC are more likely to have advanced stage tumors and receive chemoradiotherapy as their primary treatment. In analyses of matching patient subsets, there was no significant difference in patient outcomes. Patients can be treated at a non-AC without affecting outcome compared with treatment at an AC.

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Bronchiolitis as a Possible Cause of Wheezing in Childhood: New Evidence

PEDIATRICS ◽

10.1542/peds.74.1.1 ◽

1984 ◽

Vol 74 (1) ◽

pp. 1-10

Author(s):

Kenneth M. McConnochie ◽

Klaus J. Roghmann ◽

Suzanne J. Klein ◽

Thomas K. Mclnery ◽

James B. MacWhinney ◽

...

Keyword(s):

Control Group ◽

Historical Cohort ◽

Practice Population ◽

Confounding Variables ◽

Significant Difference ◽

History Of ◽

Age Range ◽

New Evidence ◽

Possible Cause ◽

Allergic Manifestations

A historical cohort study was performed in order to assess the hypothesis that even mild bronchiolitis in infancy is a predictor of wheezing later in childhood. Subjects who had experienced bronchiolitis and a matched control group were compared in terms of reported wheezing 8 years later. A highly significant difference was found between the bronchiolitis group and the control group in terms of current wheezing (P < .0001, relative risk 3.24). This difference was maintained after adjusting for many potentially confounding variables including family history of allergy and other allergic manifestations in the child. Results suggested that 13.6% of a normal practice population in the age range 6 to 9 years currently wheeze, but that 44.1% of children who experienced bronchiolitis currently wheeze. Based on the incidence of bronchiolitis (4.27/100 children in their first 2 years of life) and the relative odds for wheezing derived from a logistic regression model including variables that measured passive smoking, genetic tendency to wheeze, and bronchiolitis, calculations of attributable risk suggested that wheezing in 9.4% of the population of children who currently wheeze was attributable to bronchiolitis.

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OS10.1 Survival analysis of IDH wildtype astrocytomas with molecular features of glioblastoma, WHO grade IV

Neuro-Oncology ◽

10.1093/neuonc/noz126.067 ◽

2019 ◽

Vol 21 (Supplement_3) ◽

pp. iii20-iii20 ◽

Cited By ~ 2

Author(s):

C M S Tesileanu ◽

J A F Koekkoek ◽

L Dirven ◽

H J Dubbink ◽

J M Kros ◽

...

Keyword(s):

Molecular Data ◽

Lower Grade ◽

Who Grade ◽

Historical Cohort ◽

Molecular Features ◽

Tert Promoter ◽

Significant Difference ◽

Tert Promoter Mutations ◽

Grade Ii ◽

Promoter Mutations

Abstract BACKGROUND Recently, isocitrate dehydrogenase wildtype (IDHwt) lower grade gliomas (LGGs) that have a telomerase reverse transcriptase (TERT) promoter mutation and/or gain of chromosome 7 combined with loss of chromosome 10 and/or epidermal growth factor receptor amplification have been reclassified as IDHwt astrocytomas with molecular features of glioblastoma, WHO grade IV (‘astrocytomas IDHwt, WHO IV’). Survival of these tumors meeting the criteria of these tumors is less well studied. The objective of this study is to compare the overall survival (OS) between the IDHwt astrocytomas, WHO IV and histological glioblastomas (GBMs). MATERIAL AND METHODS In this retrospective multicenter cohort study, all adult patients with a newly diagnosed IDHwt LGG (histologically WHO grade II or III) and with molecular data available were selected from the Erasmus MC and the LUMC from October 2002 to April 2019. LGG patients showing contrast enhancement with necrosis on the MRI at the time of histological diagnosis were excluded. Molecular data were determined using a diagnostic NGS panel. A historical cohort of 195 patients with IDHwt GBMs with molecular data available was used to compare OS. OS was measured from the date of the first diagnostic MR scan. RESULTS 79 IDHwt LGG patients were identified of which 62 patients had molecular features of glioblastoma (‘astrocytomas IDHwt, WHO IV’), 11 patients did not have these molecular features (‘astrocytomas IDHwt, WHO II & III’). In the remaining 6 patients the molecular data were not conclusive (astrocytomas IDHwt, WHO NOS). Patients with astrocytomas IDHwt, WHO IV were slightly older at diagnosis (median age = 57 years) than patients with GBMs IDHwt in the reference cohort or astrocytomas IDHwt, WHO II & III (respectively: median age 55 years, p=0.032 and 47 years, p=0.035). The relatively young age of our GBM IDHwt cohort reflects more extensive molecular testing in younger patients and histologically lower grade tumors. The median OS of astrocytomas IDHwt, WHO IV (23.8 months) was similar to the median OS of GBMs (19.2 months, log-rank test p=0.37). The median OS in 19 patients with only TERT promoter mutations was 16.8 months, similar to GBMs (p=0.94). CONCLUSION There is no statistically significant difference between the OS of IDHwt astrocytomas with molecular features of glioblastoma and the OS of true glioblastomas. Grade II and III IDHwt astrocytoma with molecular features of glioblastoma should be designated WHO grade IV. The presence of TERT promoter mutations alone in this histological context also qualifies for this designation.

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Low-Profile Dual Small Plate Fixation Is Biomechanically Similar to Larger Superior or Anteroinferior Single Plate Fixation of Midshaft Clavicle Fractures

The American Journal of Sports Medicine ◽

10.1177/0363546519865251 ◽

2019 ◽

Vol 47 (11) ◽

pp. 2678-2685 ◽

Cited By ~ 3

Author(s):

Connor G. Ziegler ◽

Zachary S. Aman ◽

Hunter W. Storaci ◽

Hannah Finch ◽

Grant J. Dornan ◽

...

Keyword(s):

Plate Fixation ◽

Bending Stiffness ◽

Torsional Stiffness ◽

Single Plate ◽

Low Profile ◽

Significant Difference ◽

Dual Plating ◽

Load To Failure ◽

Clavicle Fractures ◽

Cadaveric Model

Background: Limited biomechanical data exist for dual small plate fixation of midshaft clavicle fractures, and no prior study has concurrently compared dual small plating to larger superior or anteroinferior single plate and screw constructs. Purpose: To biomechanically compare dual small orthogonal plating, superior plating, and anteroinferior plating of midshaft clavicle fractures by use of a cadaveric model. Study Design: Descriptive laboratory study. Methods: The study used 18 cadaveric clavicle specimens (9 pairs total), and 3 plating techniques were studied: anteroinferior, superior, and dual. The dual plating technique used smaller diameter plates and screws (1.6-mm thickness) than the other, single plate techniques (3.3-mm thickness). Each of the 9 clavicle pairs was randomly assigned a combination of 2 plating techniques, and randomization was used to determine which techniques were used for the right and left specimens. Clavicles were plated and then osteotomized to create an inferior butterfly fracture model, which was then fixed with a single interfragmentary screw. Clavicle specimens were then potted for mechanical testing. Initial bending, axial, and torsional stiffness of each construct was determined through use of a randomized nondestructive cyclic testing protocol followed by load to failure. Results: No significant differences were found in cyclical axial ( P = .667) or torsional ( P = .526) stiffness between plating groups. Anteroinferior plating demonstrated significantly higher cyclical bending stiffness than superior plating ( P = .005). No significant difference was found in bending stiffness between dual plating and either anteroinferior ( P = .129) or superior plating ( P = .067). No significant difference was noted in load to failure among plating methods ( P = .353). Conclusion: Dual plating with a smaller plate-screw construct is biomechanically similar to superior and anteroinferior single plate fixation that uses larger plate-screw constructs. No significant differences were found between dual plating and either superior or anteroinferior single plating in axial, bending, or torsional stiffness or in bending load to failure. Dual small plating is a viable option for fixing midshaft clavicle fractures and may be a useful low-profile technique that avoids a larger and more prominent plate-screw construct. Clinical Relevance: Plate prominence and hardware irritation are commonly reported complaints and reasons for revision surgery after plate fixation of midshaft clavicle fractures. Dual small plate fixation has been used to improve cosmetic acceptability, minimize hardware irritation, and decrease reoperation rate. Biomechanically, dual small plate fixation performed similarly to larger single plate fixation in this cadaveric model of butterfly fracture.

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Preoperative Renal Tumor Embolization

Acta Radiologica ◽

10.1177/028418518702800315 ◽

1987 ◽

Vol 28 (3) ◽

pp. 303-306 ◽

Cited By ~ 6

Author(s):

A.-R. Fischedick ◽

P. E. Peters ◽

G. Kleinhans ◽

E. Pfeifer

Keyword(s):

Statistical Evaluation ◽

Renal Tumor ◽

Operation Time ◽

Renal Tumors ◽

Preoperative Embolization ◽

Tumor Embolization ◽

Duration Of Hospital Stay ◽

Significant Difference ◽

Medical Reports ◽

Staging Classification

The medical reports of 113 patients operated upon for renal tumors were retrospectively reviewed to assess the value of preoperative embolization. Coils or ethanol were used preoperatively in 55 patients while 58 patients underwent nephrectomy without embolization. The tumors were staged according to the TNM and the Robson staging classification. T1 and T2 tumors as well as T3 and T4 tumors were grouped together for statistical evaluation. There was no significant difference in intraoperative blood loss, operation time and survival rate between patients undergoing preoperative embolization and those who had only nephrectomy. Duration of hospital stay was always longer in the preoperatively embolized group. Preoperative embolization of renal tumors neither improved the patients' outcome nor reduced the surgical risk. Robson's classification, stage III/IV, did not show any significant differences for embolized patients or for those nephrectomized without embolization.

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Conservative Management of Asymptomatic Spinal Lipomas of the Conus

Neurosurgery ◽

10.1227/01.neu.0000114923.76542.81 ◽

2004 ◽

Vol 54 (4) ◽

pp. 868-875 ◽

Cited By ~ 106

Author(s):

Abhaya V. Kulkarni ◽

Alain Pierre-Kahn ◽

Michel Zerah

Keyword(s):

Conservative Management ◽

Proportional Hazards Model ◽

Cox Proportional Hazards Model ◽

Neurological Deterioration ◽

Long Term Results ◽

Early Surgery ◽

Historical Cohort ◽

Asymptomatic Children ◽

Asymptomatic Patients ◽

Significant Difference

Abstract OBJECTIVE The natural history of spinal lipomas of the conus (SLCs) has not been well studied. Because of disappointing long-term results with early surgical treatment of asymptomatic children with SLCs, we have followed a protocol of conservative management for these patients. The results are presented in this report. METHODS Since 1994, all asymptomatic children with SLCs who were examined at Necker-Enfants Malades Hospital were subject to a protocol of conservative management. The records for those patients were reviewed, to determine the incidence and timing of neurological deterioration. The findings were compared with those for a previously reported historical cohort of asymptomatic patients who underwent early surgery at our institution. RESULTS Fifty-three asymptomatic children (35 girls and 18 boys) with SLCs were monitored, with conservative management. During a mean follow-up period of 4.4 years (range, 12 mo to 9 yr), 13 patients (25%) exhibited neurological deterioration. At 9 years, the actuarial risks of deterioration, as determined with the Kaplan-Meier method, were 33% for the conservatively treated patients and 46% for the surgically treated patients. With a Cox proportional-hazards model, there was no significant difference in the risks of neurological deterioration for patients who were treated conservatively and those who underwent early surgery. CONCLUSION The incidences and patterns of neurological deterioration seemed to be very similar, regardless of whether early surgery was performed. These results suggest that conservative treatment of asymptomatic patients is a reasonable option. A more definitive randomized study will be required to clarify the relative efficacy of early surgery for SLCs among asymptomatic patients.

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A Study of Surgical Complications of Ventilation Tube Insertion in Children in Central Iran

Journal of Comprehensive Pediatrics ◽

10.5812/compreped.102108 ◽

2020 ◽

Vol 11 (3) ◽

Author(s):

Mostafa Vahedian ◽

Amrollah Salimi ◽

Omid Garkaz ◽

Seyedeh Tasnim Abdi ◽

Somayeh Donyadideh ◽

...

Keyword(s):

Medical History ◽

Surgical Complications ◽

Ventilation Tube ◽

Tube Insertion ◽

Childhood Diseases ◽

Chi Square ◽

Historical Cohort ◽

Family Medical History ◽

Significant Difference ◽

Chi Square Test

Background: Middle ear inflammation and fluid accumulation are one of the most common childhood diseases. Untreated or chronic ear inflammation can lead to more serious complications, including hearing loss, eardrum rupture, adhesive otitis media, tympanosclerosis, temporal bone necrosis, and cholesteatoma. Ventilation tube insertion is one of the best treatments to cure these diseases. Objectives: This aimed to observe children suffering from ear inflammation who were candidates for VT insertion surgery and study surgical complications. Methods: A historical cohort study was performed, and 205 VT surgeries were studied. Demographic information of children (like age, sex, and family medical history) was gathered through their medical records and probable complications, including otorrhea, tympanosclerosis, atrophy, and eardrum rupture were noticed through medical examinations and interviews. Data were analyzed using descriptive statistics, chi-square test, independent t-test, Fisher’s exact, and Mann-Whitney U-test. Results: The results showed that 57% of surgery cases were boys, and 43% were girls, both having no family medical history. Serous otitis with tonsillar hypertrophy was reported in 200 cases (97.6%), which had concurrent adenoidectomy or adenotonsillectomy. The frequency of otorrhea, tympanosclerosis, atrophy, perforation, and serous otitis recurrence was 2%, 12.2%, 6.8%, 1.5%, and 14.1%, respectively. Serous otitis recurrence was reported in 3.9% of cases with T-tube insertion. Conclusions: The findings of this study show no significant difference in surgical complications between the two groups of girls and boys. But studying the relationship between the age of patients and the timing of surgery shows that the mean age of girls is significantly higher.

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