Entry remnants in flow-diverted aneurysms: Does branch geometry influence aneurysm closure?

Objective Numerous studies have suggested a relationship between delayed occlusion of intracranial aneurysms treated with the Pipeline Embolization Device (PED) and the presence of an incorporated branch. However, in some cases, flow diversion may still be the preferred treatment option. This study sought to determine whether geometric factors pertaining to relative size and angulation of branch vessel(s) can be measured in a reliable fashion and whether they are related to occlusion rates. Methods Eighty aneurysms treated at a single neurovascular center from November 2008 to June 2014 were identified. Two blinded raters prospectively reviewed the imaging performed at the time of the procedure and measured the following geometric variables: inflow jet/incorporated branch direction angle and branch artery/ parent artery ratio. Delayed occlusion was defined as the absence of complete aneurysmal occlusion at one year. Analysis was performed using logistic regression and intra-class correlation co-efficient (ICC). Results Twenty-four (30%) aneurysms with 28 incorporated branches were identified. A trend toward higher inflow jet/incorporated branch direction angle was found in the group of aneurysms demonstrating delayed occlusion when compared to the group with complete occlusion. ICC revealed high correlation. Overall lower one-year occlusion rates of 53% versus 73% for aneurysms with and without incorporated branches, respectively, were also noted. Conclusions The presence of an incorporated branch conferred a 20% absolute risk increase for delayed aneurysmal occlusion. Incorporated branches with a larger angle between the inflow jet and the incorporated branch direction exhibited a trend toward lower occlusion rates. This might be further investigated using a multicenter approach in conjunction with other potentially relevant clinical and angiographic variables.

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A Difference in Mortality Rate and Incidence of Kernicterus Among Premature Infants Allotted to Two Prophylactic Antibacterial Regimens, by William A. Silverman, et al, Pediatrics, 1956;18:614–624

PEDIATRICS ◽

10.1542/peds.102.s1.225 ◽

1998 ◽

Vol 102 (Supplement_1) ◽

pp. 225-227

Author(s):

John C. Sinclair

Keyword(s):

Birth Weight ◽

Death Rate ◽

Prophylactic Treatment ◽

Absolute Risk ◽

Risk Increase ◽

Serious Infections ◽

Significant Difference ◽

Postmortem Blood ◽

High Incidence ◽

To Receive

Background. Low birth-weight (LBW) infants have a high incidence of serious infections. These are difficult to diagnose early. Thus, prophylactic treatment with antibiotics appears to be rational, but the best choice of antibiotics is uncertain. Objective. In newborn LBW infants, to compare the effects on death rate and principal findings at necropsy of two prophylactic antibacterial regimens, oxytetracycline (OT) versus penicillin/sulfisoxazole (P/S). Methods. Consecutively admitted LBW infants (N = 193) were randomly assigned, within three birth-weight strata, to receive either subcutaneous 0T or a combination of P/S. The primary outcomes were death before 120 hours, death before 28 days, and principal diagnoses at necropsy. Results. Infants allocated to P/S had a large and statistically significant increase in death rate, determined up to 120 hours (OT, 20.6%; P/S, 48.4%; absolute risk increase, 27.8%) and up to 28 days (0T, 27.8%; P/S, 63.2%; absolute risk increase, 35.3%). This increase in deaths was not attributable to death from infection; the incidence of positive postmortem blood culture results was lower in the P/S group, and there was no significant difference between groups in the incidence of pneumonia or other infections at necropsy. However, in the P/S group, there was a large, unexpected, and statistically significant increase in the finding of kernicterus at necropsy among necropsied deaths occurring up to 120 hours (0T, 6.3%; P/S 36.4%; absolute risk increase 30.1%) and up to 28 days (0T, 4.5%; P/S, 43.2%; absolute risk increase, 38.7%). Conclusions. Infants who received P/S died at a significantly higher rate and had a higher rate of kernicterus at necropsy than those who received OT. The mechanism of the differences observed in rates of mortality and death with kernicterus is unknown.

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Abstract WMP51: Risk and Timing of of Ischemic Stroke Following Acute Myocardial Infarction

Stroke ◽

10.1161/str.48.suppl_1.wmp51 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Alexander E Merkler ◽

Gino Gialdini ◽

Santosh Murthy ◽

Shadi Yaghi ◽

Babak Navi ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Ischemic Stroke ◽

Stroke Risk ◽

Absolute Risk ◽

Absolute Increase ◽

Risk Increase ◽

Immortal Time Bias ◽

Acute Mi ◽

The Absolute

Background: Acute myocardial infarction (MI) has long been reported as a risk factor for ischemic stroke, but the magnitude and duration of risk remains uncertain. Methods: We performed a crossover-cohort study using inpatient and outpatient claims data from a nationally representative 5% sample of Medicare beneficiaries from 2008 through 2014. We identified all patients ≥66 years of age with a first-recorded hospitalization for acute MI. The primary outcome was ischemic stroke. All predictors and outcomes were defined using previously validated ICD-9-CM codes. To exclude stroke that may have been due to percutaneous coronary intervention, we included only cases of ischemic stroke that occurred after discharge from the MI hospitalization. We compared the risk of ischemic stroke in successive 4-week periods during the 12 weeks after MI versus the corresponding 4-week periods 1 year later. To avoid immortal time bias, we limited our cohort to patients who remained alive and insured throughout the 15 month study period. Odds ratios (OR) and absolute risk differences were calculated using the Mantel-Haenszel estimator for matched data. Results: We identified 22,798 patients with an acute MI in whom the mean age was 77.4 (±7.9) years and 50.3% were women. In the 12 weeks after discharge, 216 patients (0.95%) developed a stroke, as compared to 21 (0.09%) patients in the corresponding 12-week period 1 year later. The absolute increase in stroke risk was 0.45% (95% confidence interval [CI], 0.36-0.55%) in the first 4 weeks after acute MI compared to the 4-week time period 1 year later, corresponding to an OR of 18.2 (95% CI, 8.1-50.6). The absolute risk increase was 0.24% (95% CI, 0.16-0.31%) during weeks 5-8 (OR, 8.7; 95% CI, 4.0-22.6) and 0.17% (95% CI, 0.10-0.23%) during weeks 9-12 (OR, 5.8; 95% CI, 2.7-14.1). Conclusions: Acute MI is associated with a substantially elevated short-term risk of ischemic stroke. This risk was independent of periprocedural stroke risk in the setting of coronary reperfusion therapies.

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Gastrointestinal bleeding risk following concomitant treatment with oral glucocorticoids in patients on non-vitamin K oral anticoagulants

Heart ◽

10.1136/heartjnl-2021-319503 ◽

2021 ◽

pp. heartjnl-2021-319503

Author(s):

Anders Holt ◽

Paul Blanche ◽

Bochra Zareini ◽

Peter Vibe Rasmussen ◽

Jarl Emanuel Strange ◽

...

Keyword(s):

Gastrointestinal Bleeding ◽

Vitamin K ◽

Absolute Risk ◽

Oral Anticoagulants ◽

Concomitant Treatment ◽

Short Term ◽

Oral Glucocorticoid ◽

Risk Increase ◽

Daily Dose ◽

Oral Glucocorticoids

ObjectiveGastrointestinal bleeding (GIB) risk in relation to concomitant treatment with non-vitamin K oral anticoagulants (NOAC) and oral glucocorticoids is insufficiently explored. We aimed to investigate the short-term risk following coexposure.MethodsThis is a register-based, nationwide Danish study including patients with atrial fibrillation on NOACs during 2012–2018. Patients were defined as exposed to oral glucocorticoids if they claimed a prescription within 60 days prior to GIB. We investigated the associations between GIB and oral glucocorticoid exposure, reporting HRs via a nested case–control design and absolute risk via a cohort design. Matching terms were age, sex, calendar year, follow-up time and NOAC agent.Results98 376 patients on NOACs (median age: 75 years (IQR: 68–82), 44% female) were included, and 16% redeemed at least one oral glucocorticoid prescription within 3 years. HRs of GIB were increased comparing exposed with non-exposed patients (<20 mg daily dose, HR 1.54 (95% CI 1.29 to 1.84); ≥20 mg daily dose, HR 2.19 (95% CI 1.81 to 2.65)). 60-day standardised absolute risk of GIB following first claimed oral glucocorticoid prescription increased compared with non-exposed: 60-day absolute risk: 0.71% (95% CI 0.58% to 0.85%) vs 0.38% (95% CI 0.32% to 0.43%). The relative risk was elevated as well: risk ratio of 1.89 (95% CI 1.43 to 2.36).ConclusionsConcomitant treatment with NOACs and oral glucocorticoids was associated with a short-term rate and risk increase of GIB compared with patients only on NOACs. This could have implications for clinical management, necessitating closer monitoring or other risk mitigation strategies during episodes of cotreatment with oral glucocorticoids.

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A Combined Approach to Treatment of the Dissecting Middle Cerebral Artery Fusiform Aneurysm

Interventional Neuroradiology ◽

10.1177/159101990901500314 ◽

2009 ◽

Vol 15 (3) ◽

pp. 349-354 ◽

Cited By ~ 3

Author(s):

T. Hrbáč ◽

P. Drábek ◽

P. Klement ◽

V. Procházka

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Artery Occlusion ◽

Parent Artery ◽

Fusiform Aneurysm ◽

Neurological Sequelae ◽

Parent Artery Occlusion ◽

Aneurysm Embolization ◽

Mca Aneurysm ◽

One Year

A fusiform aneurysm in the terminal M1 middle cerebral artery (MCA) segment was treated by a construction of a high-flow arterial extracranial-intracranial (EC-IC) bypass. Due to severe bypass vasospasms, local vasodilating agents together with percutaneous angioplasty and stent implantation were applied, but failed due to subsequent bypass occlusion. To remedy this complication a new bypass was created from a segment of the saphenous vein, followed by MCA aneurysm embolization and parent artery occlusion. One year after the surgery, the venous bypass remains patent and the aneurysm occluded, with the patient fully active, without any neurological sequelae.

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The Roles of Sink Size and Location in the Partitioning of Assimilates in Wheat Ears

Functional Plant Biology ◽

10.1071/pp9830313 ◽

1983 ◽

Vol 10 (3) ◽

pp. 313 ◽

Cited By ~ 15

Author(s):

MG Cook ◽

LT Evans

Keyword(s):

Relative Size ◽

Experimental System ◽

Relative Distance ◽

Vascular Connection ◽

Factors Influencing ◽

Geometric Factors ◽

Sink Size ◽

Stem Reserves

Geometric factors influencing the partitioning of 14C-labelled photosynthate between two sinks were examined in wheat ears. An awn on one spikelet was the only source of current assimilate while grains in two other spikelets were the competing sinks. The number of grains in these and their distance and vascular connection to the source were varied, while access to stem reserves could be cut off by heat ringing. Even this apparently simple experimental system presented a number of complications, such as a bias in favour of 14C movement to the upper spikelets within an ear and to the upper grains within a spikelet. These are considered before results on the effect of relative size, distance and vascular connection are described. The larger sink obtained more than its pro-rata share of 14C, usually more than the square of its size relative to the smaller sink. Partitioning between sinks of differing distance was in proportion to 1/d�, where d is the relative distance of the two sinks from the source. A sink on the opposite side of the ear received only one-tenth to one-thirtieth as much as a comparable sink on the same side as the source and the competing sink.

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Association Between Minimum Inhibitory Concentration, Beta-lactamase Genes and Mortality for Patients Treated With Piperacillin/Tazobactam or Meropenem From the MERINO Study

Clinical Infectious Diseases ◽

10.1093/cid/ciaa1479 ◽

2020 ◽

Author(s):

A Henderson ◽

D L Paterson ◽

M D Chatfield ◽

P A Tambyah ◽

D C Lye ◽

...

Keyword(s):

Minimum Inhibitory Concentration ◽

Inhibitory Concentration ◽

Absolute Risk ◽

Definitive Treatment ◽

Beta Lactam ◽

Primary Analysis ◽

Treatment Groups ◽

Risk Increase ◽

Mortality Difference ◽

Post Hoc

Abstract Introduction This study aims to assess the association of piperacillin/tazobactam and meropenem minimum inhibitory concentration (MIC) and beta-lactam resistance genes with mortality in the MERINO trial. Methods Blood culture isolates from enrolled patients were tested by broth microdilution and whole genome sequencing at a central laboratory. Multivariate logistic regression was performed to account for confounders. Absolute risk increase for 30-day mortality between treatment groups was calculated for the primary analysis (PA) and the microbiologic assessable (MA) populations. Results In total, 320 isolates from 379 enrolled patients were available with susceptibility to piperacillin/tazobactam 94% and meropenem 100%. The piperacillin/tazobactam nonsusceptible breakpoint (MIC >16 mg/L) best predicted 30-day mortality after accounting for confounders (odds ratio 14.9, 95% confidence interval [CI] 2.8–87.2). The absolute risk increase for 30-day mortality for patients treated with piperacillin/tazobactam compared with meropenem was 9% (95% CI 3%–15%) and 8% (95% CI 2%–15%) for the original PA population and the post hoc MA populations, which reduced to 5% (95% CI −1% to 10%) after excluding strains with piperacillin/tazobactam MIC values >16 mg/L. Isolates coharboring extended spectrum β-lactamase (ESBL) and OXA-1 genes were associated with elevated piperacillin/tazobactam MICs and the highest risk increase in 30-day mortality of 14% (95% CI 2%–28%). Conclusions After excluding nonsusceptible strains, the 30-day mortality difference from the MERINO trial was less pronounced for piperacillin/tazobactam. Poor reliability in susceptibility testing performance for piperacillin/tazobactam and the high prevalence of OXA coharboring ESBLs suggests that meropenem remains the preferred choice for definitive treatment of ceftriaxone nonsusceptible Escherichia coli and Klebsiella.

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One-year outcomes in atrial fibrillation presenting during infections: a nationwide registry-based study

European Heart Journal ◽

10.1093/eurheartj/ehz873 ◽

2019 ◽

Vol 41 (10) ◽

pp. 1112-1119 ◽

Cited By ~ 4

Author(s):

Anna Gundlund ◽

Jonas Bjerring Olesen ◽

Jawad H Butt ◽

Mathias Aagaard Christensen ◽

Gunnar H Gislason ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cox Regression ◽

Absolute Risk ◽

First Year ◽

Thromboembolic Events ◽

Nationwide Registry ◽

Increased Risk ◽

Study Population ◽

Multivariable Analyses ◽

One Year

Abstract Aims Thromboprophylaxis guidelines for patients with concurrent atrial fibrillation (AF) during infections are unclear and not supported by data. We compared 1-year outcomes in patients with infection-related AF and infection without AF. Methods and results By crosslinking Danish nationwide registry data, AF naïve patients admitted with infection (1996–2016) were identified. Those with AF during the infection (infection-related AF) were matched 1:3 according to age, sex, type of infection, and year with patients with infection without AF. Outcomes (AF, thromboembolic events) were assessed by multivariable Cox regression. The study population comprised 30 307 patients with infection-related AF and 90 912 patients with infection without AF [median age 79 years (interquartile range 71–86), 47.6% males in both groups]. The 1-year absolute risk of AF and thromboembolic events were 36.4% and 7.6%, respectively (infection-related AF) and 1.9% and 4.4%, respectively (infection without AF). In the multivariable analyses, infection-related AF was associated with an increased long-term risk of AF and thromboembolic events compared with infection without AF: hazard ratio (HR) 25.98, 95% confidence interval (CI) 24.64–27.39 for AF and HR 2.10, 95% CI 1.98–2.22 for thromboembolic events. Further, differences in risks existed across different subtypes of infections. Conclusion During the first year after discharge, 36% of patients with infection-related AF had a new hospital contact with AF. Infection-related AF was associated with increased risk of thromboembolic events compared with infection without AF and our results suggest that AF related to infection may merit treatment and follow-up similar to that of AF not related to infection.

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Recommendations for Primary Prevention of Skin Melanoma

10.1101/2020.08.25.20181610 ◽

2020 ◽

Author(s):

Tonis Tasa ◽

Mikk Puustusmaa ◽

Neeme Tonisson ◽

Berit Kolk ◽

Peeter Padrik

Keyword(s):

Primary Prevention ◽

Health Behavior ◽

Association Studies ◽

Absolute Risk ◽

Personalized Recommendation ◽

Individual Risk ◽

Polygenic Risk Score ◽

Genome Wide Association Studies ◽

Risk Increase ◽

Incident Cases

Melanoma (MEL) is an aggressive form of skin cancer, causing over 60,000 deaths every year and it is considered one of the fastest-growing cancer forms. Genome-wide association studies have identified numerous genetic variants (SNPs) independently associated with MEL. The effects of such SNPs can be combined into a single polygenic risk score (PRS). Stratification of individuals according to PRS could be introduced to the primary prevention of melanoma. Our aim was to combine PRS with health behavior recommendations to develop a personalized recommendation for primary prevention of melanoma. Previously published PRS models for predicting the risk of melanoma were collected from the literature. Models were validated on the UK Biobank dataset consisting of a total of 487,410 quality-controlled genotypes with 3791 prevalent and 2345 incident cases. The best performing sex-specific models were selected based on the AUC in prevalent data and independently validated on an independent UKBB incident dataset for females and males separately. The best performing model included 28 SNPs. The C-index of the best performing model in the dataset was 0.59 (0.009) and hazard ratio (HR) per unit of PRS was 1.38 (standard error of log (HR) = 0.03) for both males and females. We performed absolute risk simulations on the Estonian population and developed individual risk-based clinical follow-up recommendations. Both models were able to identify individuals with more than a 2-fold risk increase. The observed 10-year risks of developing melanoma for individuals in the 99th percentile exceeded the risk of individuals in the 1st percentile more than 4.5-fold. We have developed a PRS-based recommendations pipeline for individual health behavior suggestions to support melanoma prevention.

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Aggression and Competition for Space and Food in Captive Juvenile Tuatara (Sphenodon Punctatus)

10.26686/wgtn.16968403.v1 ◽

2021 ◽

Author(s):

◽

Laura Luise Barbara Woerner

Keyword(s):

Intraspecific Competition ◽

Early Stage ◽

Relative Size ◽

Small Female ◽

Juvenile Mortality ◽

Competition For Space ◽

In Captivity ◽

Sphenodon Punctatus ◽

In The Wild ◽

One Year

<p>Intraspecific competition is of importance in the wild and captivity, as the interaction among individuals for resources can affect growth, survival, and ultimately fitness. Tuatara, Sphenodon punctatus, are endemic to New Zealand and the sole representatives of the reptile Order Rhynchocephalia, and their recovery plan outlines the importance of head-started individuals to supplement existing populations and provide stock to start new populations. Head-starting is a widespread conservation tool for raising juveniles in captivity prior to release in the wild, with the aim of reducing juvenile mortality and providing populations with more individuals. However, mortality differs between sexes and juvenile tuatara show enormous variation in size in captivity. I investigated aggression and competition for space and food in a tuatara head-starting facility to determine whether intraspecific competition may affect mortality and growth. Pairs of one-year-old tuatara, S. punctatus, were chosen according to sex and relative size, e.g. a big male and a small female or two similar sized females. Seven scenarios were replicated four times with different pairs. Behaviour (including two feeding trials) was recorded over a six day period via security cameras and direct observations. The number of aggressive conflicts differed among scenarios, and male-male dyads were significantly more aggressive than female-female dyads. Dominance hierarchies were established in 18 of 28 experimental pairs, with bigger animals being dominant. Conflicts include chasing, biting or colliding at full speed. One year old juveniles did not compete for space. They did not use space exclusively, but stopped clustering and had developed aggressive behaviour, suggesting that they are not territorial yet but in an early stage of transition towards territoriality as seen in older juveniles and adults. Space use and avoidance in space and time did not differ among social scenarios and the latter were negligible, but they marked a novel enclosure with urine and faeces. Juveniles competed directly and indirectly for food. Dominant individuals were likely to secure more food than submissive individuals. Females acquired less food when paired with males of bigger or similar size, and acquired about equal shares when paired with a smaller male. While bigger males acquired slightly more food when paired with smaller males, this was not the case in differently sized females. Interference behaviours such as chasing and food stealing were mostly directed from bigger towards smaller individuals. Captive group housing has consequences for competition and aggression, and may directly influence survival. As juvenile tuatara mortality is female-biased, and aggression against females in bigger male-biased groups common, I recommend keeping sexes separate, and assorting groups by size with more spacious enclosures for male groups. These modifications should improve health and numbers of juveniles for release, improve recruitment into the reproductive adult population, and ultimately create more successful head-starting facilities.</p>

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Thrombophilia in the young

Hämostaseologie ◽

10.1055/s-0037-1616915 ◽

2008 ◽

Vol 28 (01/02) ◽

pp. 16-20 ◽

Cited By ~ 10

Author(s):

K. Kurnik ◽

A. Krümpel ◽

M. Stoll ◽

U. Nowak-Göttl

Keyword(s):

Risk Factors ◽

Screening Program ◽

Absolute Risk ◽

Protein S ◽

Factor V ◽

Antithrombin Deficiency ◽

Risk Increase ◽

Factor Ii ◽

Venous Thromboembolic Events ◽

The Impact

SummaryVenous thromboembolism (VTE) is a rare disease that is being increasingly diagnosed and recognized in paediatrics in the past decade, usually as a secondary complication of primary severe underlying diseases. Apart from acquired thrombophilic risk factors, such as lupus anticoagulants, inherited thrombophilias (IT) have been established as risk factors for venous thromboembolic events in adults. In children with idiopathic VTE and in paediatric populations in which thromboses were associated with underlying medical diseases, IT have been described as additional prothrombotic risk factors. Follow-up data for VTE recurrence in children are available and suggest a recurrence rate of approximately 3% in neonates and 8% in other children. Here we present a review of the impact of IT on early onset of VTE and recurrence in children. Statistically significant associations between the IT traits investigated, e.g. factor V G1691A, factor II G20210A, protein C-, protein S-, antithrombin deficiency, elevated lipoprotein (a), combined IT and VTE onset were reported. In addition, statistically significant associations with recurrent VTE were calculated for protein S-, antithrombin-deficiency, and the factor II variant and combined IT. The absolute risk increase for VTE recurrence associated with IT ranged from 9.8 % for children carrying the factorII variant to 26% and 29% in children with combined IT and protein S-deficiency, respectively. Data obtained gave evidence that the detection of IT is clinically meaningful in children with VTE and underlines the importance of a paediatric thrombophilia screening program. Based on these data treatment algorithms have to be discussed.

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