Embolic Agent Choice in Middle Meningeal Artery Embolization as Primary or Adjunct Treatment for Chronic Subdural Hematoma: A Systematic Review and Meta-analysis.

BACKGROUND: Middle meningeal artery embolization is an emerging treatment option for chronic subdural hematomas. PURPOSE: Our aim was to assess outcomes following middle meningeal artery embolization by different techniques, including in comparison with traditional surgical methods. DATA SOURCES: We searched the literature databases from inception to March 2022. DATA SELECTION: We selected studies reporting outcomes after middle meningeal artery embolization as a primary or adjunctive treatment for chronic subdural hematoma. DATA ANALYSIS: We analyzed the risk of recurrence of chronic subdural hematoma, reoperation for recurrence or residual hematoma, complications, and radiologic and clinical outcomes using random effects modeling. Additional analyses were performed on the basis of whether middle meningeal artery embolization was used as the primary or adjunct treatment and by embolic agent type. DATA SYNTHESIS: Twenty-two studies were included with 382 patients with middle meningeal artery embolization and 1373 surgical patients. The rate of subdural hematoma recurrence was 4.1%. Fifty (4.2%) patients underwent a reoperation for a recurrent or residual subdural hematoma. Thirty-six (2.6%) experienced postoperative complications. The rates of good radiologic and clinical outcomes were 83.1% and 73.3%, respectively. Middle meningeal artery embolization was significantly associated with decreased odds of subdural hematoma reoperation (OR = 0.48; 95% CI, 23.4-99.1; P = .047) compared with surgery. The lowest rates of subdural hematoma radiologic recurrence, reoperation, and complications were observed among patients receiving embolization with Onyx, whereas good overall clinical outcome occurred most commonly with combined polyvinyl alcohol and coils. LIMITATIONS: A limitation was the retrospective design of studies included. CONCLUSIONS: Middle meningeal artery embolization is safe and effective, either as a primary or adjunctive treatment. Treatment using Onyx seems to yield lower rates of recurrence, rescue operation, and complications whereas particles and coils produce good overall clinical outcomes.

CTA Protocols in a Telestroke Network Improve Efficiency for Both Spoke and Hub Hospitals.

BACKGROUND AND PURPOSE: Telestroke networks support screening for patients with emergent large-vessel occlusions who are eligible for endovascular thrombectomy. Ideal triage processes within telestroke networks remain uncertain. We characterize the impact of implementing a routine spoke hospital CTA protocol in our integrated telestroke network on transfer and thrombectomy patterns. MATERIALS AND METHODS: A protocol-driven CTA process was introduced at 22 spoke hospitals in November 2017. We retrospectively identified prospectively collected patients who presented to a spoke hospital with National Institutes of Health Stroke Scale scores ≥6 between March 1, 2016 and March 1, 2017 (pre-CTA), and March 1, 2018 and March 1, 2019 (post-CTA). We describe the demographics, CTA utilization, spoke hospital retention rates, emergent large-vessel occlusion identification, and rates of endovascular thrombectomy. RESULTS: There were 167 patients pre-CTA and 207 post-CTA. The rate of CTA at spoke hospitals increased from 15% to 70% (P < .001). Despite increased endovascular thrombectomy screening in the extended window, the overall rates of transfer out of spoke hospitals remained similar (56% versus 54%; P = .83). There was a nonsignificant increase in transfers to our hub hospital for endovascular thrombectomy (26% versus 35%; P = .12), but patients transferred >4.5 hours from last known well increased nearly 5-fold (7% versus 34%; P < .001). The rate of endovascular thrombectomy performed on patients transferred for possible endovascular thrombectomy more than doubled (22% versus 47%; P = .011). CONCLUSIONS: Implementation of CTA at spoke hospitals in our telestroke network was feasible and improved the efficiency of stroke triage. Rates of patients retained at spoke hospitals remained stable despite higher numbers of patients screened. Emergent large-vessel occlusion confirmation at the spoke hospital lead to a more than 2-fold increase in thrombectomy rates among transferred patients at the hub.

A whole water catchment approach to investigating the origin and distribution of Cryptosporidium species.

AIMS: Investigating the distribution and origin of Cryptosporidium species in a water catchment affected by destocking and restocking of livestock as a result of a foot and mouth disease epidemic. METHODS AND RESULTS: Surface water, livestock and wildlife samples were screened for Cryptosporidium and oocysts characterised by sequencing SSU rRNA and COWP loci, and fragment analysis of ML1, ML2 and GP60 microsatellite loci. Oocyst concentrations in water samples (0-20.29 per 10 l) were related to rainfall events, amount of rainfall and topography. There was no detectable impact from catchment restocking. Cryptosporidium spp. found in water were indicative of livestock (Cryptosporidium andersoni and Cryptosporidium parvum) and wildlife (novel genotypes) sources. However, C. andersoni was not found in any animals sampled. Calf infections were age related; C. parvum was significantly more common in younger animals (<4 weeks old). Older calves shared Cryptosporidium bovis, Cryptosporidium ryanae and C. parvum. Wildlife shed C. parvum, Cryptosporidium ubiquitum, muskrat genotype II and deer genotype. CONCLUSIONS: Several factors affect the occurrence of Cryptosporidium within a catchment. In addition to farmed and wild animal hosts, topography and rainfall patterns are particularly important. SIGNIFICANCE AND IMPACT OF THE STUDY: These factors must be considered when undertaking risk-based water safety plans.

Microbial water pollution: a screening tool for initial catchment-scale assessment and source apportionment.

The European Union Water Framework Directive requires that Management Plans are developed for individual River Basin Districts. From the point of view of faecal indicator organisms (FIOs), there is a critical need for screening tools that can provide a rapid assessment of the likely FIO concentrations and fluxes within catchments under base- and high-flow conditions, and of the balance ('source apportionment') between agriculture- and sewage-derived sources. Accordingly, the present paper reports on: (1) the development of preliminary generic models, using water quality and land cover data from previous UK catchment studies for assessing FIO concentrations, fluxes and source apportionment within catchments during the summer bathing season; (2) the calibration of national land use data, against data previously used in the models; and (3) provisional FIO concentration and source-apportionment assessments for England and Wales. The models clearly highlighted the crucial importance of high-flow conditions for the flux of FIOs within catchments. At high flow, improved grassland (and associated livestock) was the key FIO source; FIO loadings derived from catchments with high proportions of improved grassland were shown to be as high as from urbanized catchments; and in many rural catchments, especially in NW and SW England and Wales, which are important areas of lowland livestock (especially dairy) farming, ≥ 40% of FIOs was assessed to be derived from agricultural sources. In contrast, under base-flow conditions, when there was little or no runoff from agricultural land, urban (i.e. sewerage-related) sources were assessed to dominate, and even in rural areas the majority of FIOs were attributed to urban sources. The results of the study demonstrate the potential of this type of approach, particularly in light of climate change and the likelihood of more high-flow events, in underpinning informed policy development and prioritization of investment.

Flow-mediated dilation and intima-media thickness of the brachial and axillary arteries in individuals with and without inducible axillary artery compression.

The presence of axillary artery aneurysm and/or thrombus in overhead throwing athletes has been linked, theoretically, with the finding of compression by the humeral head induced by a diagnostic arm maneuver. However, whether this intermittent compression is incidental or of pathological significance has yet to be determined. Flow-mediated vasodilation (FMD), intima-media thickness (IMT) and maximum vasodilatory capacity were measured locally (3rd portion of the axillary artery) and downstream (brachial artery) in individuals previously tested for inducible axillary artery compression (compressor group [COMP]: n=8, mean (SD) age: 23 (4) y; "noncompressor" control group [NONCOMP]: n=8, 26 (4) y). A high-resolution ultrasound machine recorded arterial diameter and blood flow velocity. A rapid inflation/deflation pneumatic cuff placed distal to the site of measurement induced reactive hyperemia. Custom-designed wall tracking software with synchronized Doppler waveform analysis detected changes in arterial diameter, blood flow velocity and shear rate from baseline to 3min after cuff deflation. Glyceryl trinitrate and/or ischemic hand grip exercises were administered to induce maximum vasodilation. No significant differences in FMD, IMT or maximum vasodilator capacity were observed between groups at the axillary artery. However, the downstream brachial FMD response was significantly diminished in the COMP group (6.38 [3.28]%) compared with the NONCOMP group (10.38 [2.74]%; p=0.006) despite a comparable shear rate between groups (COMP: 81.92 (44.55) s(-1); NONCOMP: 83.18 (40.02) s(-1); p=0.961). Pooled data revealed a significant negative relationship (r=-0.52, p=0.038) between the FMD response and degree of arterial compression. These results suggest a chronic change in downstream vascular function in individuals demonstrating clinically significant inducible axillary artery compression.

Faecal indicator organism concentrations and catchment export coefficients in the UK.

Characterisation of faecal indicator organism (FIO) concentrations and export coefficients for catchments with particular combinations of land use and under specific climatic regimes is critical in developing models to predict daily loads and apportion sources of the microbial parameters used to regulate water quality. Accordingly, this paper presents a synthesis of FIO concentration and export coefficient data for the summer bathing season, with some comparative winter data, for 205 river/stream sampling points widely distributed across mainland UK. In terms of both geometric mean (GM) FIO concentrations and export coefficients (expressed as cfu km(-2) h(-1)), the results reveal (1) statistically significant elevations at high flow compared with base flow, with concentrations typically increasing by more than an order of magnitude and export coefficients by about two orders; (2) significantly higher values in summer than in winter under high-flow conditions; and (3) extremely wide variability between the catchments (e.g. four orders of magnitude range for GM faecal coliform concentrations), which closely reflects land use-with urban areas and improved pastures identified as key FIO sources. Generally, these two most polluting land uses are concentrated in lowland areas where runoff (m3 km(-2) h(-1)) is low compared with upland areas, which in the UK are dominated by rough grazing and forestry. Consequently, contrasts in export coefficients between land use types are less than for FIO concentrations. The GMs reported for most land use categories are based on 13 sites and exhibit quite narrow confidence intervals. They may therefore be applied with some confidence to other catchments in the UK and similar geographical regions elsewhere. Examples are presented to illustrate how the results can be used to estimate daily summer base- and high-flow FIO loads for catchments with different land use types, and to assess the likely effectiveness of certain strategies for reducing FIO pollutant loadings in areas with extensive areas of lowland improved pasture.

Faecal indicator organism concentrations in sewage and treated effluents.

The importance of faecal indicator organism (FIO) fluxes within drainage basins is increasing as the European Union (EU) Water Framework Directive and the United States Clean Water Act place requirements on regulators to manage point and diffuse sources of microbial pollution causing non-compliance (EU) or impairment (US) of receiving waters. Central to this management task is knowledge of the likely FIO concentrations in raw sewage and treated effluents, but few empirical data have been published in the peer-reviewed literature. Accordingly, this paper presents results for 1933 samples from 162 different sewage discharge sites in the UK and Jersey, which encompass 12 types of sewage-related discharge, representative of untreated sewage and primary-, secondary- and tertiary-treated effluents. Geometric means (GMs) and 95% confidence intervals (CIs) have been used to characterise base- and high-flow FIO concentrations. The data sets and sub-sets are mostly quite large (n 40) and may therefore be applied with some confidence to comparable discharge sites in similar geographical regions. Very marked, statistically significant reductions in GM FIO concentrations result from secondary and tertiary treatment, and there are statistically significant differences between some secondary and some tertiary treatments. Flow conditions are also shown to be important: untreated sewage and effluent from primary treatment plant have lower concentrations at high flow, due to dilution within combined sewerage systems, whereas some treated effluents (e.g. from activated sludge plant) have higher concentrations at high flow because of the shorter residence time within the plant. Under base-flow conditions, secondary treatments result in estimated GM FIO reductions of 95.22-99.29% (cf. primary-treated effluent). Corresponding figures for tertiary treatment plants (cf. secondary-treated effluent) are 93.24-96.59% for reedbed/grass plots and 99.71-99.92% for UV disinfection. Results suggest that secondary and tertiary treatment plants are less effective under high-flow conditions, but further high-flow sampling is required to confirm this.

Quantitative catchment profiling to apportion faecal indicator organism budgets for the Ribble system, the UK's sentinel drainage basin for Water Framework Directive research.

Under the EU Water Framework Directive (WFD) 20/60/EC and the US Federal Water Pollution Control Act 2002 management of water quality within river drainage basins has shifted from traditional point-source control to a holistic approach whereby the overall contribution of point and diffuse sources of pollutants has to be considered. Consequently, there is a requirement to undertake source-apportionment studies of pollutant fluxes within catchments. The inclusion of the Bathing Water Directive (BWD), under the list of 'protected areas' in the WFD places a requirement to control sources of faecal indicator organisms within catchments in order to achieve the objectives of both the BWD (and its revision - 2006/7/EC) and the WFD. This study was therefore initiated to quantify catchment-derived fluxes of faecal indicator compliance parameters originating from both point and diffuse sources. The Ribble drainage basin is the single UK sentinel WFD research catchment and discharges to the south of the Fylde coast, which includes a number of high profile, historically non-compliant, bathing waters. Faecal indicator concentrations (faecal coliform concentrations are reported herein) were measured at 41 riverine locations, the 15 largest wastewater treatment works (WwTWs) and 15 combined sewer overflows (CSOs) across the Ribble basin over a 44-day period during the 2002 bathing season. The sampling programme included targeting rainfall-induced high flow events and sample results were categorised as either base flow or high flow. At the riverine sites, geometric mean faecal coliform concentrations showed statistically significant elevation at high flow compared to base flow. The resultant faecal coliform flux estimates revealed that over 90% of the total organism load to the Ribble Estuary was discharged by sewage related sources during high flow events. These sewage sources were largely related to the urban areas to the south and east of the Ribble basin, with over half the load associated with the relatively small subcatchment of the River Douglas. The majority of this load was attributed to two WwTWs that discharge through a common outfall close to the tidal limit of this catchment. Budgets adjusted to accommodate the impact of proposed UV disinfection of these effluents showed that the load from these sources would be reduced significantly during base flow conditions. However, during high flow events loads would still remain high due to the operation of storm sewage overflows from stormwater retention tanks. The study identified untreated storm sewage spills from urban infrastructure and WwTW stormwater retention tanks as the dominant component of the high flow flux of faecal indicators to receiving waters of the Fylde coast and the associated bathing waters.

The microbiological quality of seven large commercial private water supplies in the United Kingdom.

Some 1% of the UK population derives their potable water from 140,000 private water supplies (PWSs) regulated by Local Authorities. The overwhelming majority of these are very small domestic supplies serving a single property or a small number of properties. Treatment for such supplies is rudimentary or non-existent and their microbiological quality has been shown to be poor in every published study to date. Private water supplies serving commercial enterprises such as hotels, restaurants, food production premises and factories are more frequently treated and subject to closer regulation in the United Kingdom. As a result, it has been assumed that these larger commercial supplies are less likely to experience elevated faecal indicator and pathogen concentrations at the consumer tap which have been observed at small domestic supplies.This paper reports on intensive monitoring at seven commercial private water supplies (six of which were treated) spread throughout the UK serving hotels, holiday parks and food production enterprises. Daily sampling of 'potable' water, both at the consumer tap and using large volume filtration for Giardia and Cryptosporidium spp. was conducted over two six week periods in the spring and autumn of 2000. This allowed the effects of short term episodic peaks in faecal indicator and pathogen concentration to be quantified. All the supplies experienced intermittent pathogen presence and only one, a chlorinated deep borehole supply, fully complied with UK water quality regulations during both periods of sampling.Poor microbiological water quality typically followed periods of heavy rainfall. This suggests that the design and installation of such systems should be undertaken only after the likely range of raw water quality has been characterised, which requires a thorough understanding of the effects of flow and seasonality on raw water quality. There is no reason to suspect that the monitored sites are uncharacteristic of other commercial supplies and the results reinforce public health concerns related to domestic supplies. Furthermore, the pattern of contamination is highly episodic, commonly lasting only a few days. Thus, the relatively infrequent regulatory monitoring of such supplies would be unlikely to identify the poor water quality episodes and does not provide the data necessary for public health protection. Although some statistical relationship was found between faecal indicator organisms and the presence of pathogens, the use of FIOs in assessments of regulatory compliance may not always provide a reliable measure of public health risk, i.e. indicator absence does not preclude pathogen presence. The results of this study suggest that a risk assessment system similar to the WHO 'Water Safety Planning' approach might offer a more appropriate regulatory paradigm for private water supplies.

Reducing fluxes of faecal indicator compliance parameters to bathing waters from diffuse agricultural sources: the Brighouse Bay study, Scotland.

The European Water Framework Directive requires the integrated management of point and diffuse pollution to achieve 'good' water quality in 'protected areas'. These include bathing waters, which are regulated using faecal indicator organisms as compliance parameters. Thus, for the first time, European regulators are faced with the control of faecal indicator fluxes from agricultural sources where these impact on bathing water compliance locations. Concurrently, reforms to the European Union (EU) Common Agricultural Policy offer scope for supporting on-farm measures producing environmental benefits through the new 'single farm payments' and the concept of 'cross-compliance'. This paper reports the first UK study involving remedial measures, principally stream bank fencing, designed to reduce faecal indicator fluxes at the catchment scale. Considerable reduction in faecal indicator flux was observed, but this was insufficient to ensure bathing water compliance with either Directive 76/160/EEC standards or new health-evidence-based criteria proposed by WHO and the European Commission.

Human Experience Modeler: context-driven cognitive retraining to facilitate transfer of learning.

We describe a cognitive rehabilitation mixed-reality system that allows therapists to explore natural cuing, contextualization, and theoretical aspects of cognitive retraining, including transfer of training. The Human Experience Modeler (HEM) mixed-reality environment allows for a contextualized learning experience with the advantages of controlled stimuli, experience capture and feedback that would not be feasible in a traditional rehabilitation setting. A pilot study for testing the integrated components of the HEM is discussed where the participant presents with working memory impairments due to an aneurysm.

Estimation of diffuse and point source microbial pollution in the ribble catchment discharging to bathing waters in the north west of England.

Achieving compliance with the mandatory standards of the 1976 Bathing Water Directive (76/160/EEC) is required at all U.K. identified bathing waters. In recent years, the Fylde coast has been an area of significant investments in 'point source' control, which have not proven, in isolation, to satisfactorily achieve compliance with the mandatory, let alone the guide, levels of water quality in the Directive. The potential impact of riverine sources of pollution was first confirmed after a study in 1997. The completion of sewerage system enhancements offered the potential for the study of faecal indicator delivery from upstream sources comprising both point sources and diffuse agricultural sources. A research project to define these elements commenced in 2001. Initially, a desk study reported here, estimated the principal infrastructure contributions within the Ribble catchment. A second phase of this investigation has involved acquisition of empirical water quality and hydrological data from the catchment during the 2002 bathing season. These data have been used further to calibrate the 'budgets' and 'delivery' modelling and these data are still being analysed. This paper reports the initial desk study approach to faecal indicator budget estimation using available data from the sewerage infrastructure and catchment sources of faecal indicators.

Decay of intestinal enterococci concentrations in high-energy estuarine and coastal waters: towards real-time T90 values for modelling faecal indicators in recreational waters.

Intestinal enterococci are the principal 'health-evidence-based' parameter recommended by WHO for the assessment of marine recreational water compliance. Understanding the survival characteristics of these organisms in nearshore waters is central to public health protection using robust modelling to effect real-time prediction of water quality at recreation sites as recently suggested by WHO and the Commission of the European Communities Previous models have more often focused on the coliform parameters and assumed two static day-time and night-time T90 values to characterise the decay process. The principal driver for enterococci survival is the received dose of irradiance from sunlight. In the water column, transmission of irradiance is determined by turbidity produced by suspended material. This paper reports the results of irradiated microcosm experiments using simulated sunlight to investigate the decay of intestinal enterococci in relatively turbid estuarine and coastal waters collected from the Severn Estuary and Bristol Channel, UK. High-turbidity estuarine waters produced a T90 value of 39.5 h. Low-turbidity coastal waters produced a much shorter T90 value of 6.6 h. In experiments receiving no irradiation, high-turbidity estuarine waters also produced a longer T90 of 65.1 h compared with corresponding low-turbidity coastal waters, T90 24.8 h. Irradiated T90 values were correlated with salinity, turbidity and suspended solids (r>0.8, p<0.001). The results suggest that enterococci decay in irradiated experiments with turbidity >200 NTU is similar to decay observed under dark conditions. Most significantly, these results suggest that modelling turbidity and or suspended solids offers a potential means of predicting T90 values in 'real-time' for discrete cells of a hydrodynamic model.

Mid-latency auditory evoked response during propofol and alfentanil anaesthesia.

BACKGROUND: Propofol has been shown to affect the mid-latency auditory evoked response (MLAER) in a dose-dependant manner. Few studies have investigated the addition of alfentanil. Myogenic responses, such as the post-auricular responses (PAR), can confound the MLAER but there has been little investigation as to which electrode site reduces this interference. METHODS: We studied the MLAER in 27 women. They received an infusion of alfentanil 15 micro g kg(-1) h(-1), followed by either a high or low infusion regimen of propofol (final infusion rates 6 and 3 mg kg(-1) h(-1)). We compared the results with those of our study using propofol alone. We collected the data from two electrode sites: vertex-inion and vertex-mastoid. We evaluated the occurrence of the PAR and the shape of the MLAER at each electrode site. RESULTS: The infusion rate of propofol associated with loss of the eyelash response in 50% of subjects was 3.3 mg kg(-1) h(-1). This was significantly lower than using propofol alone (5.8 mg kg(-1) h(-1)). Nb latency was the best MLAER discriminator of unconsciousness (sensitivity 94%, specificity 88%), with a threshold of 46 ms (propofol alone was 53 ms). The addition of alfentanil did not alter the relationship between propofol infusion rate and MLAER. The vertex-inion electrode site gave the best protection against PAR in awake subjects (P=0.0003), and after 30 min of propofol infusion (P=0.06). The magnitude of the MLAER obtained from the vertex-mastoid electrodes was larger than from the other site, although the increase was not consistent throughout the waveform (brain stem 100%, Nb 14%). CONCLUSIONS: Addition of alfentanil lowers the propofol infusion rate required to produce unconsciousness and the Nb latency that predicts it. The better of the two sites to reduce the incidence of PAR is the vertex-inion electrode site.

The Ergonomics Society--the Society Lectures 1999: the Ergonomics Society: 50 years of growth.

Developments in the Society are outlined since the early history was described by Edholm and Murrell. Major changes in the Society's operation and the context in which these changes took place are given. The changes in research directions, growth in educational facilities for professional education and the ever widening areas for the application of ergonomics are discussed. The consequences of these developments for the expansion of a recognition of the contribution of ergonomics, and the position of professionals in the international scene are touched upon.

An investigation of learning during propofol sedation and anesthesia using the process dissociation procedure.

BACKGROUND: Many studies have shown that patients may remember words learned during apparently adequate anesthesia. Performance on memory tests may be influenced by explicit and implicit memory. We used the process dissociation procedure to estimate implicit and explicit memory for words presented during sedation or anesthesia. METHODS: We investigated intraoperative learning in 72 women undergoing pervaginal oocyte collection during propofol and alfentanil infusion. One word list was played once before infusion, another was played 10 times during surgery. Venous blood was taken for propofol assay at the end of the intraoperative list. Behavioral measures of anesthetic depth (eyelash reflex, hand squeeze response to command) were recorded and used to adjust the dose of anesthetic where clinically appropriate. On recovery, memory was assessed using an auditory word stem completion test with inclusion and exclusion instructions. RESULTS: The mean blood propofol concentration was 2.5 microg/ml (median, 2.3 microg/ml; range, 0.7-6.1 microg/ml). Mean alfentanil dose was 2.1 mg (median, 2.0 mg; range, 1.2-3.4 mg). Comparison of target and distractor hits in the inclusion condition showed memory for preoperative words only. However, the process dissociation procedure estimates showed explicit (mean, 0.18; P < 0.001) and implicit (mean, 0.05; P < 0.05) memory for the preoperative words, and a small amount of explicit memory for the intraoperative words (mean, 0.06; 95% confidence interval, 0.01-0.10). Memory performance did not differ between the 17 patients who consistently responded to command and eyelash reflex and the 32 patients who remained unresponsive. Blood propofol concentration and alfentanil dose did not correlate with memory for the intraoperative list. CONCLUSIONS: There was no unprompted recall of surgery, but the process dissociation procedure showed memory for words presented during surgery. This memory was apparently explicit but did not correlate with the measures of depth of anesthesia used.