Total 1-year hospital cost of middle meningeal artery embolization compared to surgery for chronic subdural hematomas: a propensity-adjusted analysis

BackgroundMiddle meningeal artery (MMA) embolization results in fewer treatment failures than surgical evacuation for chronic subdural hematomas (cSDHs). We compared the total 1-year hospital cost for MMA embolization versus surgical evacuation for patients with cSDH.MethodsData for patients who presented with cSDHs from January 1, 2018, through May 31, 2020, were retrospectively reviewed. Patients were grouped by initial treatment (surgery vs MMA embolization), and total hospital cost was obtained. A propensity-adjusted analysis was performed. The primary outcome was difference in mean hospital cost between treatments.ResultsOf 170 patients, 48 (28%) underwent embolization and 122 (72%) underwent surgery. cSDHs were larger in the surgical (20.5 (6.7) mm) than in the embolization group (16.9 (4.6) mm; P<0.001); and index hospital length of stay was longer in the surgical group (9.8 (7.0) days) than in the embolization group (5.7 (2.4) days; P<0.001). More patients required additional hematoma treatment in the surgical cohort (16%) than in the embolization cohort (4%; P=0.03), and more required readmission in the surgical cohort (28%) than in the embolization cohort (13%; P=0.04). After propensity adjustment, MMA embolization was associated with a lower total hospital cost compared to surgery (mean difference −$32 776; 95% CI −$52 766 to −$12 787; P<0.001). A propensity-adjusted linear regression analysis found that unexpected additional treatment was the only significant contributor to total hospital cost (mean difference $96 357; 95% CI $73 886 to $118 827; P<0.001).ConclusionsMMA embolization is associated with decreased total hospital cost compared with surgery for cSDHs. This lower cost is directly related to the decreased need for additional treatment interventions.

A propensity-adjusted comparison of endoscopic endonasal surgery versus transcranial microsurgery for pediatric craniopharyngioma: a single-center study

OBJECTIVE When comparing endoscopic endonasal surgery (EES) and transcranial microsurgery (TCM) for adult and mixed-age population craniopharyngiomas, EES has become an alternative to TCM. To date, studies comparing EES and TCM for pediatric craniopharyngiomas are sparse. In this study, the authors aimed to compare postoperative complications and surgical outcomes between EES and TCM for pediatric craniopharyngiomas. METHODS The data of pediatric patients with craniopharyngiomas who underwent surgery between February 2009 and June 2021 at a single center were retrospectively reviewed. All included cases were divided into EES and TCM groups according to the treatment modality received. The baseline characteristics of patients were compared between the groups, as well as surgical results, perioperative complications, and long-term outcomes. To control for confounding factors, propensity-adjusted analysis was performed. RESULTS Overall, 51 pediatric craniopharyngioma surgeries were identified in 49 patients, among which 35 were treated with EES and 16 were treated with TCM. The proportion of gross-total resection (GTR) was similar between the groups (94.3% for EES vs 75% for TCM, p = 0.130). TCM was associated with a lower rate of hypogonadism (33.3% vs 64.7%, p = 0.042) and a higher rate of growth hormone deficiency (73.3% vs 26.5%, p = 0.002), permanent diabetes insipidus (DI) (60.0% vs 29.4%, p = 0.043), and panhypopituitarism (80.0% vs 47.1%, p = 0.032) at the last follow-up. CSF leakage only occurred in the EES group, with no significant difference observed between the groups (p > 0.99). TCM significantly increased the risk of worsened visual outcomes (25.0% vs 0.0%, p = 0.012). However, TCM was associated with a significantly longer median duration of follow-up (66.0 vs 40.5 months, p = 0.007) and a significantly lower rate of preoperative hypogonadism (18.8% vs 60.0%, p = 0.006). The propensity-adjusted analysis revealed no difference in the rate of recurrence, hypogonadism, or permanent DI. Additionally, EES was associated with a lower median gain in BMI (1.5 kg/m2 vs 7.5 kg/m2, p = 0.046) and better hypothalamic function (58.3% vs 8.3%, p = 0.027) at the last follow-up. CONCLUSIONS Compared with TCM, EES was associated with a superior visual outcome, better endocrinological and hypothalamic function, and less BMI gain, but comparable rates of GTR, recurrence, and perioperative complications. These findings have indicated that EES is a safe and effective surgical modality and can be a viable alternative to TCM for pediatric midline craniopharyngiomas.

Evolving Strategies for the Structuring of Working Capital Loans during Covid Times: An Analysis of Select Indian Private Sector Banks

Predicting human behavior is a difficult task, yet bankers perform this regularly while sanctioning working capital loans, so that money advanced is recoverable. For this, they try to assess credit worthiness of clients based on past performance through financials and banking habits amongst other parameters. Clients also look at fees and instalment burden, duration of loan, etc. However, with the adverse impact of Covid pandemic on earning capacities, banks need to relook at the way they structure loans. This study suggests that customer-focused, risk-adjusted analysis should be undertaken to reduce non-performing assets and improve asset portfolio quality of banks.

Ethnicity and outcomes in COVID-19 in the United Kingdom: a systematic review and meta-analysis

This systematic review and meta-analysis evaluated the clinical outcomes of COVID-19 disease in the ethnic minorities of the UK in comparison to the White ethnic group. Medline, Embase, Cochrane, MedRxiv, and Prospero were searched for articles published between May 2020 to April 2021. PROSPERO ID: CRD42021248117. Fourteen studies (767177 participants) were included in the review. In the adjusted analysis, the pooled Odds Ratio (OR) for the mortality outcome was higher for the Black (1.83, 95% CI: 1.21-2.76), Asian (1.16, 95% CI: 0.85-1.57), and Mixed and Other (MO) groups (1.12, 95% CI: 1.04-1.20) compared to the White group. The adjusted and unadjusted ORs of intensive care admission were more than double for all ethnicities (OR Black 2.32, 95% CI: 1.73-3.11, Asian 2.34, 95% CI: 1.89-2.90, MO group 2.26, 95% CI: 1.64-3.11). In the adjusted analysis of mechanical ventilation need the ORs were similarly significantly raised (Black group 2.03, 95% CI: 1.80-2.29, Asian group 1.84, 95% CI: 1.20-2.80, MO 2.09, 95% CI: 1.35-3.22). This review confirmed that all ethnic groups in the UK suffered from increased disease severity and mortality with regards to COVID-19. This has urgent public health and policy implications to reduce the health disparities.

Propensity score-adjusted analysis on stent-assisted coiling versus coiling alone for ruptured intracranial aneurysms

Stent-assisted coiling (SAC) for ruptured intracranial aneurysms (RIAs) remains controversial due to an inherent risk of potential thromboembolic and hemorrhagic complications. We compared SAC and coiling alone for the management of RIAs using propensity score-adjustment. Sixty-four patients treated by SAC and 220 by stand-alone coiling were retrospectively reviewed and compared using inverse probability of treatment weighting (IPTW) with propensity scores. Functional outcome, procedure-related and overall complications and angiographic results were analyzed. Aneurysms treated by SAC had a larger diameter, a wider neck and were more frequently located at the posterior circulation. SAC had a higher risk for thromboembolic complications (17.2% vs. 7.7%, p = 0.025), however, this difference did not persist in the IPTW analysis (OR 1.2, 95% CI 0.7–2.3, adjusted p = 0.458). In the adjusted analysis, rates of procedural cerebral infarction (p = 0.188), ventriculostomy-related hemorrhage (p = 0.584), in-hospital mortality (p = 0.786) and 6-month favorable functional outcome (p = 0.471) were not significantly different between the two groups. SAC yielded a higher complete occlusion (80.0% vs. 67.2%, OR 3.2, 95% CI 1.9–5.4, p < 0.001) and a lower recanalization rate (17.5% vs. 26.1%, OR 0.3, 95% CI 0.2–0.6, p < 0.001) than stand-alone coiling at 6-month follow-up. In conclusion, SAC of large and wide-necked RIAs provided higher aneurysm occlusion and similar clinical outcome, when compared to stand-alone coiling.

Effect of Maternal Obstructive Sleep Apnea-Hypopnea on 24-Hour Blood Pressure, Nocturnal Blood Pressure Dipping and Arterial Stiffness in Hypertensive Disorders of Pregnancy

Rationale: Maternal obstructive sleep apnea-hypopnea (OSAH) is associated with hypertensive disorders of pregnancy (HDP). Attenuation of the normal nocturnal blood pressure (BP) decline (non-dipping) is associated with adverse pregnancy outcomes. OSAH is associated with nocturnal non-dipping in the general population, but this has not been studied in pregnancy. We therefore analyzed baseline data from an ongoing RCT (NCT03309826) assessing the impact of OSAH treatment on HDP outcomes, to evaluate the relationship of OSAH to 24-h BP profile, in particular nocturnal BP dipping, and measures of arterial stiffness.Methods: Women with a singleton pregnancy and HDP underwent level II polysomnography. Patients with OSAH (apnea-hypopnea index (AHI) ≥ 5 events/h) then underwent 24-h ambulatory BP monitoring and arterial stiffness measurements (applanation tonometry, SphygmoCor). Positive dipping was defined as nocturnal systolic blood pressure (SBP) dip ≥ 10%. The relationships between measures of OSAH severity, measures of BP and arterial stiffness were evaluated using linear regression analyses.Results: We studied 51 HDP participants (36.5 ± 4.9 years, BMI 36.9 ± 8.6 kg/m2) with OSAH with mean AHI 27.7 ± 26.4 events/h at 25.0 ± 4.9 weeks’ gestation. We found no significant relationships between AHI or other OSA severity measures and mean 24-h BP values, although BP was generally well-controlled. Most women were SBP non-dippers (78.4%). AHI showed a significant inverse correlation with % SBP dipping following adjustment for age, BMI, parity, gestational age, and BP medications (β = −0.11, p = 0.02). Significant inverse correlations were also observed between AHI and DBP (β = −0.16, p = 0.01) and MAP (β = −0.13, p = 0.02) % dipping. Oxygen desaturation index and sleep time below SaO2 90% were also inversely correlated with % dipping. Moreover, a significant positive correlation was observed between carotid-femoral pulse wave velocity (cfPWV) and REM AHI (β = 0.02, p = 0.04) in unadjusted but not adjusted analysis.Conclusion: Blood pressure non-dipping was observed in a majority of women with HDP and OSAH. There were significant inverse relationships between OSAH severity measures and nocturnal % dipping. Increased arterial stiffness was associated with increasing severity of OSAH during REM sleep in unadjusted although not adjusted analysis. These findings suggest that OSAH may represent a therapeutic target to improve BP profile and vascular risk in HDP.

Determinants and prognostic relevance of aortic stiffness in patients with recent ST-elevation myocardial infarction

Background The association between aortic stiffness, cardiovascular risk factors and prognosis in patients with recent ST-elevation myocardial infarction (STEMI) is poorly understood. We analyzed the relationship between cardiovascular risk factors and arterial stiffening and assessed its prognostic significance in patients with recent STEMI. Methods We prospectively enrolled 408 consecutive patients who sustained a first STEMI and underwent primary percutaneous coronary intervention (PPCI). Aortic pulse wave velocity (PWV), a direct measure of aortic stiffness, was determined by the transit-time method using velocity-encoded, phase-contrast cardiac magnetic resonance imaging. Patient characteristics were acquired at baseline and major adverse cardiac and cerebrovascular events (MACCE) were assessed at 13 (interquartile range [IQR] 12–31) months. Cox regressionand logistic regression analysis were performed to explore predictors of PWV and MACCE. Results Median aortic PWV was 6.6 m/s (IQR 5.6–8.3m/s). In multivariable analysis, age (odds ratio [OR] 1.10, 95% confidence interval [CI], 1.08–1.14, p&lt;0.001) and hypertension (OR 2.45, 95% CI, 1.53–3.91, p&lt;0.001) were independently associated with increased PWV. Sex, diabetes, smoking status, dyslipidemia, and obesity were not significantly associated with PWV in adjusted analysis (all p&gt;0.05). High PWV significantly and independently predicted occurrence of MACCE in adjusted analysis (hazard ratio [HR] 2.45, 95% CI 1.19–5.04, p=0.014). Conclusion In patients with recent STEMI, the impact of classical cardiovascular risk factors on aortic stiffness is mainly dependent on age and increased blood pressure. Increased aortic stiffness is associated with adverse clinical outcome post-STEMI, suggesting it as a relevant therapeutic target in this population. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Austrian Science Fund (FWF)Austrian Society of Cardiology Figure 1. Biorender.com

Disaggregating Pacific Islanders and major Asian subpopulations to reveal hidden breast cancer disparities.

80 Background: The Asian American, Native Hawaiian, and Other Pacific Islander (AA/NHPI) population is the fastest growing and most socioeconomically heterogeneous racial/ethnic group in the US. AA/NHPI breast cancer outcomes are often reported as superior to Non-Hispanic Whites (NHW) however evidence suggests aggregating AA/NHPI masks disparities among subpopulations. As NHPI is often ignored as one of five official US races, this study aims to disaggregate AA and NHPI to unmask breast cancer disparities. Methods: An IRB exempt, retrospective cohort study using the National Cancer Database was conducted for women diagnosed with breast cancer in 2004-2016. AA and NHPI patients were compared with the majority NHW group. AA was separated into pertinent geographical origins: East Asian (EA; Chinese, Japanese, Korean), South Asian (SA; Indian, Pakistani), and Southeast Asian (SEA; Filipino, Vietnamese, Laotian, Hmong, Cambodian). Descriptive statistics were used. Logistic and Cox proportional hazard regressions assessed adjusted Odds Ratios (aORs) and adjusted Hazards Ratios (aHR), respectively, with 95% confidence intervals (95%CI). Analyses were adjusted for patient factors (age, insurance, income, rural/urban, education, hospital region, hospital distance, Deyo comorbidity score) and cancer characteristics (grade, stage, metastases, diagnosis year, hormone status). Results: Of 2,073,822 women there were 28,311 EA, 13,259 SA, 21,645 SEA, 5,375 NHPI, and 2,005,232 NHW. The median age was 62 years with median 66 month follow-up. Compared to NHW (9.6%), presentation with late-stage disease (Stage III/IV) was higher in NHPI (12%), SA (12%), and SEA (11%), but not EA (7.5%). On adjusted analysis (Table), EA was the only group with a statistical difference from NHW with aOR=0.85 (95%CI=0.76-0.94). Kaplan-Meier test for overall survival (OS) showed differences between ethnic/racial groups with NHPI having worse OS than AA subpopulations (p<0.0001). On adjusted analysis (Table), all AA subpopulations had lower risk of death compared to NHW: EA (aHR=0.69; 95%CI=0.64-0.74), SA (aHR=0.65; 95CI=0.59-0.71), and SEA (aHR=0.78; 95%CI=0.73-0.84) however the NHPI group had a greater risk of death (aHR=1.14; 95%CI=1.02-1.28). Conclusions: NHPI women with breast cancer have worse outcomes compared to NHW. This is masked by superior AA outcomes when aggregated. The continual improper aggregation of AA with NHPI downplays NHPI cancer disparities. Proper disaggregation of NHPI from AA warrants greater attention.[Table: see text]

Covariate Adjustment in Randomized Controlled Trials

Introduction & Objective: Unadjusted analyses, fully adjusted analyses, or adjusted analyses based on tests of significance on covariate imbalance are recommended for covariate adjustment in randomized controlled trials. It has been indicated that the tests of significance on baseline comparability is inappropriate, rather it is important to indicate the strength of relationship with outcomes. Our goal is to understand when the adjustment should be used in randomized controlled trials. Methods: Unadjusted analysis, fully adjusted analysis, and adjusted analysis based on baseline comparability were examined under null and alternative hypothesis by simulation studies. Each data set was simulated 3000 times for a total of 9 scenarios for sample sizes of 20, 40, and 100 each with baseline thresholds of 0.05, 0.1, and 0.2. Each scenario was examined by the change in magnitude of correlation from 0.1 to 0.9. Results: Power of fully adjusted analysis under alternative hypothesis was increased as the correlation increased while adjusted analysis based on the covariate imbalance did not compare favorably to the unadjusted analysis. Type 1 error was decreased in adjusted analysis based on the covariate imbalance under null hypothesis. It was then observed that p-value does not follow a uniform distribution under the null hypothesis. Conclusion: Unadjusted and fully adjusted analyses were valid analyses. Full adjustment could potentially increase the power if adjustment is known. However, adjusted analysis based on the test of significance on covariate imbalance may not be a valid analysis. Tests of significance should not be used for comparing baseline comparability.