Cardiopulmonary bypass (CPB) induces a systemic inflammatory reaction that may contribute to postoperative complications. Preventing this reaction with steroids may improve outcomes. We performed a ...systematic review to evaluate the impact of prophylactic steroids on clinical outcomes in patients undergoing on-pump cardiac surgery.
We searched MEDLINE, EMBASE, and Cochrane CENTRAL for randomised controlled trials (RCTs) comparing perioperative corticosteroid administration with a control group in adults undergoing CPB. Outcomes of interest included mortality, myocardial infarction, and new onset atrial fibrillation. We assessed the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach.
Fifty-six RCTs published between 1977 and 2015 were included in this meta-analysis. Mortality was not significantly different between groups 3.0% (215/7258 patients) in the steroid group and 3.5% (252/7202 patients) in the placebo group; relative risk (RR), 0.85; 95% confidence interval (CI), 0.71–1.01; P=0.07; I2 = 0%. Myocardial injury was more frequent in the steroid group 8.0% (560/6989 patients), compared with 6.9% (476/6929 patients); RR, 1.17, 95% CI, 1.04–1.31; P=0.008; I2=0%. New onset atrial fibrillation was lower in the steroid group 25.7% (1792/6984 patients) compared with 28.3% (1969/6964 patients), RR, 0.91, 95% CI, 0.86–0.96, P=0.0005, I2=43%; this beneficial effect was limited to small trials (P for interaction <0.00001).
After randomising 16 013 patients, steroid administration at the time of cardiac surgery had an unclear impact on mortality, increased the risk of myocardial injury, and the impact on atrial fibrillation should be viewed with caution given that large trials showed no effect.
INTRODUCTION The process of fellowship selection remains unclear and heterogeneous among subspecialties in neurosurgery. METHODS We distributed an online, nationwide survey to 153 U.S. neurosurgical ...residents (postgraduate years 5–7) identified via the American Association of Neurological Surgeons resident database. RESULTS Sixty-nine residents responded to the survey, representing a variety of subspecialties. Most residents applied for 2–5 programs (45%) and completed 2–5 interviews (45%). The primary methods of finding fellowships were via word of mouth (68%) and faculty mentors (67%), followed by Web sites and reaching out to fellowship directors (54%) and online database searching (46%). Although many residents applied for fellowships in postgraduate year 5 of training (39%), there was significant variability in times for interviews and offer letters. Most residents accepted their first offer (75%). Most respondents (93%) believed that national neurosurgical societies should help improve the fellowship application process, with reasons including a common application and due dates (29%), fellowship database with program details (29%), and improved coordination of interviews (23%). Regarding a nationalized match system, residents were roughly split among opposed (38.6%), neutral (26.3%), and supportive (35.1%). CONCLUSION These survey results suggested that the neurosurgical fellowship application process could be improved by a common application, public listing of programs, standardized dates for application, and improved coordination of interviews. Residents are generally supportive of having an improved organization of the match and/or a national fellowship match.
INTRODUCTION Over past the past few years mechanical thrombectomy has become the standard of care for large vessel occlusion stroke patients. Despite the extra cost of endovascular mechanical ...thrombectomy (MT) procedure costs more than traditional medical management and intravenous thrombolysis for stroke. However, considering the improvement in functional outcomes and lower rates of disability with MT, several studies have reported MT to be cost effective. The cost effectiveness estimates depend on the cost of procedure and rehabilitation which is varies across different regions. METHODS We searched PubMed, Cochrane and EMBASE to include studies on the cost effectiveness of mechanical thrombectomy published over a period of 10 years i.e., January 2010-March, 2020. We used “cost effectiveness”, “cost utility”, “mechanical thrombectomy” and “endovascular treatment of stroke” were used in different combinations. The country of cost effectiveness assessment, assumptions about cost of mechanical thrombectomy and rehabilitation, and efficacy input used for cost effectiveness analysis were recorded. RESULTS Fifteen studies from 8 countries in 4 continents were included in the study. Six of these studies were from the US. Two studies from France, 1 from Netherlands, 2 from United Kingdom, 1 from Canada, 1 from China, 1 from Sweden and 1 from Australia. Cost per quality of life year (cost/QALY) was the most commonly reported outcome. Cost per QALY ranged from 3110 US $ (USA) to 14,881 US $ (France). The most common source of efficacy data was meta-analysis of mechanical thrombectomy clinical trials (N = 5) followed by SWIFT PRIME (N = 3), MERCI (N = 3), MR CLEAN (N = 1), THRACE (N = 1) and expert panel opinion (N = 1). One study used efficacy input from 5 different clinical trials. Using a willingness to pay threshold of 50,000 USD, all studies concluded that MT was cost effective irrespective of the efficacy model used. CONCLUSION Mechanical thrombectomy is more cost effective than medical management and intravenous thrombolysis across various health systems in different countries. The cost benefit persists regardless of the efficacy model used.
INTRODUCTION Transradial access for neurointervention is fast becoming popular among neurointerventionists. Failure to obtain radial artery access is considered an indication for conversion to a ...transfemoral approach. However, the potential complications of a transfemoral approach can be avoided by using ulnar artery access. METHODS Consecutive patients who underwent diagnostic angiography or neurointerventional procedures via ulnar access between July 1, 2019 and April 15, 2020 were included. Data on demographics, procedure indication, devices, technique, and complications were recorded. A descriptive analysis was performed. RESULTS Ulnar artery access was obtained for 21 procedures in 18 patients. Mean patient age was 70.3 + 7.8 years; 9 (50.0%) were men. Thirteen diagnostic angiograms and 8 neurointerventions (3-left middle meningeal artery, 2-carotid artery stenting, 2-angioplasty, and 1-mechanical thrombectomy for in-stent thrombosis) were performed. All procedures except 1 were performed using a right-sided ulnar artery approach with ultrasound guidance. Indications for ulnar artery access included small caliber radial artery pulse (n = 9), radial artery occlusion (n = 10), and radial artery preservation for potential bypass (n = 2). A 5-French sheath was used for diagnostic procedures; a 6-French sheath was used for neurointerventions. A TR band (Terumo Interventional) was used for closure. No case required conversion to femoral access. No access-related complication was noticed. CONCLUSION Ulnar artery access is safe and feasible for diagnostic and interventional neuroangiographic procedures. It provides a useful alternative to transradial access, potentially avoiding complications associated with transfemoral access.
INTRODUCTION The aftermath of the Affordable Care Act witnessed the rise of narrow network, which feature fewer providers in exchange for lower premiums. Debate still continues on whether narrow ...networks provide adequate access to healthcare, especially in specialty care services like neurosurgery. METHODS The 2019 Marketplace Public Use Files were queried for “silver” plans, identifying a total of 11 plans across 3 insurance companies. Online search engines were used to identify the number of in-network neurosurgeons within 20–25 miles of zip codes at the center of each county. The primary outcome was the number of “neurosurgeon-deficient plans”, defined as those having no in-network neurosurgeons within the assigned mile radius. RESULTS Of all individuals who purchased an insurance plan, 73% (n = 185,797/255,246) opted for a silver plan. Out of 111 active neurosurgeons in NJ, 25% (n = 28/111) did not participate in any of the silver plans. Analysis showed 8 plans as neurosurgeon-deficient in Sussex and Warren. Meanwhile, majority of the silver plans provided access to >5 neurosurgeons within 20–25 miles of most (n = 17/21) county centers. CONCLUSION In more densely populated states like New Jersey, the impact of narrow networks on neurosurgical coverage is less apparent. However, frustrations regarding access to care still exist as nearly 25% of neurosurgeons do not participate in the standard ACA insurance product. Furthermore, guidelines that define network adequacy in neurosurgery remain elusive, which calls for more robust parameters to monitor and ensure adequate access to healthcare.
This work was performed to objectively measure and assess the robustness and tracking performance of fractional order of proportional, integral and derivative (FOPID) controller as compared to the ...conventional PID control. In satellite research and development, the satellite undergoes numerous tests such as thermal, acoustic and vibration tests in the cleanroom environment. However, due to space limitation in the cleanroom and the sensitive components of the satellite, it requires vibration-free, smooth and precise motion when handling the satellite. In addition, measurement interference might occur due to cable routing during procedures or tasks performed by an operator. Unlike the previous work, the robustness analysis of FOPID controller was not systematically conducted. In this paper, the analysis took into account the actuator dynamics, and various tests were considered to measure the robustness of FOPID controller. The designed FOPID controller was implemented on the scissor-type lifting mechanism of motorized adjustable vertical platform (MAVeP) model, and its performance was compared with the traditional PID controller. A comprehensive verification using MATLAB and Solidworks was carried out to generate the model and conduct the analysis. Both controllers were initially tuned using Nichol-Ziegler technique, and the additional FOPID controller parameters was tuned using the Astrom-Hagglund method. From the simulation work, it was found that the FOPID controller’s tracking error was reduced between 10 % - 50 % for the disturbance rejection tests and reference to disturbance ratio (RDR) spectrum was higher as compared to PID. The analysis in this paper was predicted to be the main driver to implement FOPID controller in the complex system in the industry, especially for sensitive material handling and transportation such as satellite.
INTRODUCTION Neurointerventional procedures have traditionally been performed via transfemoral access. However, according to interventional cardiology literature, transradial access can have ...decreased access site complications and possibly decreased mortality compared to transfemoral access. Reported limitations for wide adoption of transradial access in neurointerventional procedures include the learning curve. METHODS All neurointerventional procedures performed at a single institution with a transradial first approach were identified from Aug 2017 to January 2020. Demographic and clinical information were identified. Access site complications were recorded. Univariate analysis was performed to identify predictors of transradial failure. Covariates with P < .15 were inputted into a multivariate model with statistical significance set at P < .05. RESULTS A total of 350 transradial neurointerventional procedures were performed in 313 patients. The mean age was 68.2 years and 51% female. Most procedures (95%) used 6F radial sheaths for access. Biaxial system (e.g. microcatheter and microwire) was used in most procedures (61%). There were 81 aneurysm interventions, 73 embolization procedures, 69 angioplasty/stenting procedures, 116 mechanical thrombectomies including 93 involving the anterior circulation, and 11 vasospasm treatments. There was a remarkably high procedure completion rate with a transradial approach (96%, 335/350). Thirteen procedures were converted to transfemoral access (3.7%), 1 procedure converted to transbrachial access, and 1 procedure aborted completely. On multivariate analysis, decreasing age, female gender, and left-sided target artery were predictive of transradial failure. Radial access site complications were extremely rare (0.6%, 2/350 - 1 forearm hematoma, 1 radial artery occlusion). CONCLUSION In a high-volume endovascular center, transradial approach to a wide variety of neurointerventional procedures is both safe and feasible. Predictors of transradial failure include decreasing age, female gender, and left-sided target artery.
Assessment of face specificity in prosopagnosia is hampered by difficulty in gauging pre-morbid expertise for non-face object categories, for which humans vary widely in interest and experience. In ...this study, we examined the correlation between visual and verbal semantic knowledge for cars to determine if visual recognition accuracy could be predicted from verbal semantic scores. We had 33 healthy subjects and six prosopagnosic patients first rated their own knowledge of cars. They were then given a test of verbal semantic knowledge that presented them with the names of car models, to which they were to match the manufacturer. Lastly, they were given a test of visual recognition, presenting them with images of cars to which they were to provide information at three levels of specificity: model, manufacturer and decade of make. In controls, while self-ratings were only moderately correlated with either visual recognition or verbal semantic knowledge, verbal semantic knowledge was highly correlated with visual recognition, particularly for more specific levels of information. Item concordance showed that less-expert subjects were more likely to provide the most specific information (model name) for the image when they could also match the manufacturer to its name. Prosopagnosic subjects showed reduced visual recognition of cars after adjusting for verbal semantic scores. We conclude that visual recognition is highly correlated with verbal semantic knowledge, that formal measures of verbal semantic knowledge are a more accurate gauge of expertise than self-ratings, and that verbal semantic knowledge can be used to adjust tests of visual recognition for pre-morbid expertise in prosopagnosia.
Introduction
Incorporating end-user input into the design of new vaginal microbicides for women is key to optimizing their uptake, consistent use, and, ultimately, success in combatting the ...heterosexual HIV epidemic.
Methods
The Quatro Study assessed four placebo forms of vaginally inserted HIV-microbicides among young microbicide-naïve African women: on-demand film, insert and gel, and monthly ring. Participants randomly used each product for 1 month and provided product satisfaction ratings (1–5 scale), and opinions on product attributes and potential alternative designs. Qualitative data were collected through focus group discussions at study exit. Multivariable associations between attribute opinions and overall product rating were examined using Poisson regression models with robust standard errors to assess the attributes most influential to satisfaction.
Results
Overall opinions of products and their individual attributes were generally positive; all products were rated either 4 or a 5 by ≥ 50% of participants. Attributes related to ease of use and interference with normal activities were the most salient predictors of satisfaction. Preferences for duration of use tended toward relatively shorter use periods for the ring (i.e., 1–3 months vs. 12 months) and for coitally independent dosing for the on-demand products.
Conclusions
How well a product fit in with participants’ lifestyles was important to their overall satisfaction. For on-demand products, greater flexibility around timing of use was desired, to avoid coital dependency of the dosing.
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