Inpatient-level care at home delivered by virtual wards and hospital at home: a systematic review and meta-analysis of complex interventions and their components.

BACKGROUND: Technology-enabled inpatient-level care at home services, such as virtual wards and hospital at home, are being rapidly implemented. This is the first systematic review to link the components of these service delivery innovations to evidence of effectiveness to explore implications for practice and research. METHODS: For this review (registered here https://osf.io/je39y ), we searched Cochrane-recommended multiple databases up to 30 November 2022 and additional resources for randomised and non-randomised studies that compared technology-enabled inpatient-level care at home with hospital-based inpatient care. We classified interventions into care model groups using three key components: clinical activities, workforce, and technology. We synthesised evidence by these groups quantitatively or narratively for mortality, hospital readmissions, cost-effectiveness and length of stay. RESULTS: We include 69 studies: 38 randomised studies (6413 participants; largely judged as low or unclear risk of bias) and 31 non-randomised studies (31,950 participants; largely judged at serious or critical risk of bias). The 69 studies described 63 interventions which formed eight model groups. Most models, regardless of using low- or high-intensity technology, may have similar or reduced hospital readmission risk compared with hospital-based inpatient care (low-certainty evidence from randomised trials). For mortality, most models had uncertain or unavailable evidence. Two exceptions were low technology-enabled models that involve hospital- and community-based professionals, they may have similar mortality risk compared with hospital-based inpatient care (low- or moderate-certainty evidence from randomised trials). Cost-effectiveness evidence is unavailable for high technology-enabled models, but sparse evidence suggests the low technology-enabled multidisciplinary care delivered by hospital-based teams appears more cost-effective than hospital-based care for those with chronic obstructive pulmonary disease (COPD) exacerbations. CONCLUSIONS: Low-certainty evidence suggests that none of technology-enabled care at home models we explored put people at higher risk of readmission compared with hospital-based care. Where limited evidence on mortality is available, there appears to be no additional risk of mortality due to use of technology-enabled at home models. It is unclear whether inpatient-level care at home using higher levels of technology confers additional benefits. Further research should focus on clearly defined interventions in high-priority populations and include comparative cost-effectiveness evaluation. TRIAL REGISTRATION: https://osf.io/je39y .

Comparison of intravenous ibuprofen and paracetamol for peri-operative analgesia in paediatric day care tonsillectomy.

OBJECTIVE: To determine the effectiveness of intravenous ibuprofen and acetaminophen as perioperative analgesics in paediatric patients undergoing day- care tonsillectomy with general anaesthesia. METHODS: The quasi-experimental stud y was conduc ted at the Ana esthe sia D epartment of Pa k Emirates M ilitary Hospital, Rawalpindi , Pak ist an, from July 20 21 to June 2022, and comp rised paediatric pa t ients aged 5-12 yea r s undergoing day- care tonsil lec tomy with gen era l anaesthesia. The sub jec ts were divid ed into two equa l groups. Patients in Group I received intravenous ibuprofen 7mg/kg and patients in Group P received intravenous paracetamol 10mg/kg im media t ely after induction of anaesthesi a. All patients recei ved standard general anaesthesia with endotracheal intubation. The primary outcome measured was revised faces pain score immediately after recovery and at the time of discharge 6 hours later. Adverse events were also noted. Data was analysed using SPSS 26. RESULTS: Of the 100 patients, there were 50(50%) in Group I; 21(42%) boys and 29(58%) girls with mean age 7.82±1.903 years. The remaining 50(50%) subjects were in Group P; 25(50%) boys and 25(50%) girls with mean age 7.68±1.812 years. At baseline, 44(88%) patients in Group I and 42(84%) in Group P reported no pain, while 6(12%) and 8(16%) patients in the two groups, respectively, reported pain (p=0.56). At discharge, 35(70%) patients in Group I and 18(36%) in Group P reported no pain (p<0.001). Adverse events were not significantly different between the groups (p>0.05). CONCLUSIONS: I ntravenous ibuprofen was found to b e a superior pain-killer than intravenous paracetamol for perioperative care of paediatric patients in day- care tonsillectomy.

Informal employment and catastrophic health expenditures: Evidence from Pakistan.

Workers in informal employment suffered significant out-of-pocket healthcare expenditures (OOPHEs) due to their low earnings and a lack of a social safety net or health insurance. There is little or no evidence of impoverishment caused by OOPHEs in the context of labor market categorization. Therefore, this study examines the economic burden of OOPHEs and its associated consequences on households, whose members are in informal employment. This study estimates the incidence of catastrophic health expenditures (CHEs) and impoverishment across the households in formal and informal employment and their key determinants in Pakistan by employing the data from the two rounds of the Household Integrated Economic Survey (2015-16, 2018-19). For measuring CHEs and impoverishment, the budget share and capacity-to-pay approaches are applied. Various thresholds are used to demonstrate the sensitivity of catastrophic measures. We found a higher incidence of catastrophic healthcare payments among the informal workers, that is, 4.03% and 7.11% for 2015-16 and 2018-19, respectively, at a 10% threshold, while at a 40% threshold, the incidence of CHEs is found to be 0.40% and 2.34% for 2015-16 and 2018-19, respectively. These OOPHEs caused 1.53% and 3.66% of households who are in informal employment to become impoverished, compared with their formal counterparts. The study demonstrates that the probability of incurring CHEs and becoming impoverished is high among informal workers, compared with their formal counterparts. This result has clear policy implications, in which to protect the informal workers, it is necessary to expand the insurance coverage, particularly during the COVID-19 response and recovery efforts.

Accuracy of a Smartwatch to Assess Heart Rate Monitoring and Atrial Fibrillation in Stroke Patients.

(1) Background: Consumer smartwatches may be a helpful tool to screen for atrial fibrillation (AF). However, validation studies on older stroke patients remain scarce. The aim of this pilot study from RCT NCT05565781 was to validate the resting heart rate (HR) measurement and the irregular rhythm notification (IRN) feature in stroke patients in sinus rhythm (SR) and AF. (2) Methods: Resting clinical HR measurements (every 5 min) were assessed using continuous bedside ECG monitoring (CEM) and the Fitbit Charge 5 (FC5). IRNs were gathered after at least 4 h of CEM. Lin's concordance correlation coefficient (CCC), Bland-Altman analysis, and mean absolute percentage error (MAPE) were used for agreement and accuracy assessment. (3) Results: In all, 526 individual pairs of measurements were obtained from 70 stroke patients-age 79.4 years (SD ± 10.2), 63% females, BMI 26.3 (IQ 22.2-30.5), and NIHSS score 8 (IQR 1.5-20). The agreement between the FC5 and CEM was good (CCC 0.791) when evaluating paired HR measurements in SR. Meanwhile, the FC5 provided weak agreement (CCC 0.211) and low accuracy (MAPE 16.48%) when compared to CEM recordings in AF. Regarding the accuracy of the IRN feature, analysis found a low sensitivity (34%) and high specificity (100%) for detecting AF. (4) Conclusion: The FC5 was accurate at assessing the HR during SR, but the accuracy during AF was poor. In contrast, the IRN feature was acceptable for guiding decisions regarding AF screening in stroke patients.

Association between efficiency and quality of care of public healthcare facilities: Evidence from Pakistan.

BACKGROUND: Maternal and child health is an important component of the Sustainable Development Goals. Pakistan has one of the worst maternal and neonatal health outcomes in the world. This is despite significant health system investments across the country. AIMS: The objectives of this study are twofold. First, the study estimates the technical efficiency of the public healthcare facilities in Pakistan, defined as the number of obstetric deliveries compared to the number of medical specialists, nurses, and other health and non-health staff members. Second, the study evaluates the relationship between efficiency and quality of care; the latter is measured in terms of maternal and neonatal mortality. MATERIALS & METHODS: The data were taken from the Pakistan Health Facility Assessment Survey. Efficiency score was calculated for 843 public healthcare facilities, using Stochastic Frontier Analysis. We then used two-stage residual inclusion approach with bootstrapping to evaluate the relationship between efficiency and quality. RESULTS AND DISCUSSION: The average efficiency score was 0.48 (range: 0-1) and none of the public healthcare facilities were on the frontier, implying that efficiency gains can be made across the board. The relationship between efficiency and quality is found to be positive and statistically significant, that is, more efficient healthcare facilities also had lower rates of maternal and neonatal mortality. CONCLUSION: We conclude that more efficient public healthcare facilities also had lower mortality rates, probably due to better infrastructure and health system financing.

Clinical Parameters and Epigenetic Biomarkers of Plaque Vulnerability in Patients with Carotid Stenosis.

Atheromatous disease is the first cause of death and dependency in developed countries and carotid artery atherosclerosis is one of the main causes of severe ischaemic strokes. Current management strategies are mainly based on the degree of stenosis and patient selection has limited accuracy. This information could be complemented by the identification of biomarkers of plaque vulnerability, which would permit patients at greater and lesser risk of stroke to be distinguished, thus enabling a better selection of patients for surgical or intensive medical treatment. Although several circulating protein-based biomarkers with significance for both the diagnosis of carotid artery disease and its prognosis have been identified, at present, none have been clinically implemented. This review focuses especially on the most relevant clinical parameters to take into account in routine clinical practice and summarises the most up-to-date data on epigenetic biomarkers of carotid atherosclerosis and plaque vulnerability.

Progressive Lacunar Strokes: A Predictive Score.

BACKGROUND AND PURPOSE: Progressive lacunar syndromes (PLS) occur in up to 20-30% of patients with lacunar strokes, increasing the risk of long term dependency. Our aim is to develop a predictive score to identify patients at high risk of presenting PLS. METHODS: We derived a risk score for PLS in a cohort of consecutive patients (n=187) presenting with one of the five classic lacunar syndromes (LS) and absence of vascular occlusion, perfusion deficit or symptomatic stenosis. A risk score was developed using the coefficients from the logistic regression model, and receiver operating characteristic (ROC) analysis was conducted to assess the prognostic value of the risk score. Sensitivity, specificity and accuracy were estimated for each total point score. RESULTS: Out of 187 patients included in our sample, 52 (27.8%) presented PLS. Previous history of diabetes mellitus (1 point), diastolic blood pressure at admission (2 points), clinical deficits consistent with a pure motor syndrome (1 point) and asymptomatic intracranial atheromatosis or stenosis in non-symptomatic territory (1 point) were independent predictors for PLS. The estimated area under the ROC curve for this model was 0.77 (95% CI,0.68 - 0.84). CONCLUSION: This score could be a useful tool in routine clinical practice to predict the occurrence of PLS, allowing the identification of those patients with LS who are at high risk of long term dependency due to early neurological worsening, and who would benefit the most from an intensive treatment.

Can blood glucose levels predict biochemical and haematological abnormalities in COVID -19 patients - Experience from a tertiary care hospital in Balochistan.

OBJECTIVE: To find out the association between poor glycaemic levels and biochemical and haematological abnormalities in patients of corona virus disease-2019. METHODS: The prospective, observational, cohort study was conducted at the Combined Military Hospital, Quetta, Pakistan, from September 2020 to February 2021, and comprised all patients who tested positive for coronavirus disease-2019 on polymerase chain reaction test and were subsequently admitted. The patients were divided into two groups on the basis of random blood glucose level at the time of admission; ≥11.1mmol/l (206mg/dl) in group A and 4-11.1mmol (74-206mg/dl) in group B. Association between categorical variables was evaluated and hazard ratio was measured. Data was analysed using SPSS 21. RESULTS: Of the 349 patients, there were 56(16%) in group A; 40(71.4%) males and 16(28.6%) females with age range 39-61 years. There were 293(84%) subjects in group B; 239(81.5%) males and 54(18.5%) females with age range 27-53 years. Overall, 75(21.4%) patients were known type 2 diabetics. A significant association was found between poor glycaemic control and raised levels of C-reactive protein, lactate dehydrogenase, ferritin, erythrocyte sedimentation rate, troponin, creatine kinase, creatine kinase-MB, alanine aminotransferase, creatinine and D-dimers (p<0.05). Inter-group differences were significant for acute kidney injury, acute liver injury, Intensive care unit admission for coagulation abnormalities and for overall mortality (p<0.05). CONCLUSIONS: Poor glycaemic control was found to be a risk factor for developing multisystem complications in patients of coronavirus disease-2019.

Women's Education, Spousal Agreement on Future Fertility Intentions, and Contraceptive Use in Pakistan.

In less egalitarian countries such as Pakistan, reproductive behaviors are gendered, with couples often disagreeing about their fertility goals. However, the dramatic changes in women's empowerment and messaging around reproductive behaviors in Pakistan in recent years may have affected how women's own characteristics and their concordance with their spouse on fertility goals are linked to contraception. Using matched couple data from two cycles of the Pakistan Demographic Health Survey (1990-1991 and 2017-2018), this paper examines the relative influence of husbands' and wives' fertility preferences, as well as women's education, on contraceptive use using linear probability models. Disagreement between couples declined modestly, by about four percentage points, over time. When disagreement about future fertility intentions occurs, wife's fertility preferences are more strongly related to contraceptive behavior, and this association has not changed over time. Although contraceptive use is positively associated with education, the link between women's education and contraceptive use has weakened over time due to increased use among uneducated women. Pakistani women's own fertility preferences are reflected in their contraceptive behavior, and contraceptive use is increasing among all women, even less educated women. Diffusion processes are likely at play, though more work is needed to identify these processes and potential barriers to contraceptive use.

Tradeoff between efficiency and perceived quality: evidence from patient-level data.

OBJECTIVES: To estimate technical efficiency scores of District Headquarter Hospitals (DHQHs) for obstetric services and to explore the relationship between the efficiency of DHQHs and the patients' satisfaction about the quality of services provided. DESIGN, SETTING AND PARTICIPANTS: Data from Health Facility Assessment (HFA) survey is used for efficiency measurement. The data on patient's perceptions and other control variables are taken from Client Exit Interviews part of the HFA survey. Two-stage residual inclusion, Ordered Logistic Regression and Least square dummy variable techniques are used to investigate the relationship between technical efficiency and patients' satisfaction level. MAIN OUTCOME MEASURE(S) AND RESULTS: The average efficiency score for Pakistan's DHQHs is 0.52, and not a single hospital is fully efficient. Moreover, the relationship between technical efficiency and patients' satisfaction is found to be negative and statistically significant indicating that an increase in hospital efficiency tends to decrease patients' satisfaction. The disaggregated analysis reveals that patients' satisfaction associated with the healthcare provider attitude and communication is more affected by technical efficiency. CONCLUSION: Patients' satisfaction level is more sensitive to physician's attitude and communication. This makes sense because the longer the consultation time, the more accurate the diagnosis would be. This, together with a comforting and confident physician, is likely to achieve better patients' satisfaction.

Troponin T Predicts Cardioembolic Aetiology and Clinical Outcome in Undetermined Ischaemic Stroke in Hyperacute Phase.

BACKGROUND: Elevated high-sensitivity cardiac troponin T (hs-cTnT) levels have been related to clinical outcome in stroke patients. However, the role of hs-cTnT and its potential as a biomarker in ischaemic stroke (IS) has not been well established. This study aims to determine whether basal hs-cTnT determination in the hyperacute phase of undetermined IS and transient ischaemic attack (TIA) can predict the cardioembolic aetiology and clinical outcome. METHODS: We prospectively studied 110 consecutive patients with undetermined acute IS and TIA. hs-cTnT levels were determined at hospital arrival. Large vessel stenosis/occlusion and previously known aetiologies at admission were exclusion criteria for this study. All patients were subjected to a complete aetiological evaluation. A 12-month follow-up was performed in all patients. The subtype of IS was evaluated following the SSS-TOAST criteria. We established two groups at admission: cardioembolic aetiology (group A) and noncardioembolic aetiologies (group B). RESULTS: The number of patients in each group was similar (group A: 52, 47.27%; group B, 58, 52.73%). Patients in group A had elevated hs-cTnT more frequently (61.54% versus 17.24%; P < .001). Group A patients had significantly higher mortality at 3 months (14.29% versus 1.82%, P = .025). In the multivariate analysis, elevated hs-cTnT was the only independent predictor of cardioembolic aetiology (odds ratio: 14.821; 95% confidence interval: 3.717-59.102, P < .001). CONCLUSION: Baseline hs-cTnT assessment in undetermined strokes and TIA during the hyperacute phase is independently associated with cardioembolic aetiology.

Assessment of Collateral Circulation Using Perfusion CT in Middle Cerebral Artery Thrombectomy-Treated Patients.

INTRODUCTION: The prognostic value of leptomeningeal collateral circulation in thrombectomy-treated patients remains unclear. We evaluated the construct validity of assessing leptomeningeal collateral circulation using a new regional perfusion CT source image-based approach, the Perfusion Acquisition for THrombectomy Scale (PATHS). We also compared the prognostic value of PATHS with a further 6 scales based on various techniques: CT-angiography, perfusion CT, and digital subtraction angiography. Additionally, we studied the relationship between the scores for the different scales. PATIENTS AND METHODS: We performed a retrospective study of consecutive patients with stroke and M1/terminal carotid occlusion treated with thrombectomy in our center. Leptomeningeal collateral circulation was prospectively evaluated using 7 scales: Tan and Miteff (CT Angiography); Calleja, Cao, American Society of Intervention and Therapeutic Neuroradiology/Society of Interventional Radiology, and PATHS (perfusion); and Christoforidis (Digital Subtraction Angiography). Correlations were studied using the Spearman method. RESULTS: The study population comprised 108 patients. All scales predicted the modified Rankin Scale at 3 months (P ≤ .02) and all but 1 (Christoforidis) correlated with 24-hour brain infarct volume (P ≤ .02). These correlations were higher with PATHS (rho = -0.47, P < .001 for 3-month modified Rankin Scale; rho = -0.35, P < .001 for follow-up infarct volume). The multivariate analysis showed PATHS to be an independent predictor of modified Rankin Scale at 3 months less than equal to 2. A crosscorrelation analysis revealed a better correlation between scales that used the same techniques. CONCLUSIONS: PATHS can be used to assess leptomeningeal collateral circulation. PATHS had better prognostic value than other scales; therefore, it might be considered for assessment of leptomeningeal collateral circulation in candidates for thrombectomy. The moderate correlation between scales suggests that scores are not interchangeable.

Serotonin Reuptake Inhibitor Drugs Are Associated with Contrast Extravasation and Clinical Outcome in Patients with Intracerebral Haemorrhage.

BACKGROUND: Antidepressants that inhibit the reuptake of serotonin (SRIs) have been related to the appearance of intracerebral haemorrhage (ICH). Some studies have described bigger haematoma volumes in these patients. So far, no studies have demonstrated an association between SRIs and contrast extravasation (CE). We propose to investigate the relationship of SRIs with CE and clinical outcome. PATIENTS AND METHODS: We aimed a prospective registry of 294 patients with ICH. All previous treatments were registered, including SRIs intake. The presence of CE and the number of spot sign in CT angiography were collected. Early neurological deterioration (END) and late neurological deterioration (LND) were registered. Follow-up was completed at day 90. RESULTS: Two hundred and ninety-four patients were included, mean age 66.5 years, 27.6% female. A total of 28 (9.5%) were taking SRIs at the time of the ICH. This group of patients presented statistically significantly more CE (46.4 vs. 19.9%, p = 0.012), ≥2 spot sign (25 vs. 6.8%, p = 0.017), END (46.4 vs. 25.2%, p = 0.018) and LND (14.3 vs. 4.9%, p = 0.032). In addition, this group of patients showed a tendency to have higher mortality (32.1 vs. 22.2%, p = 0.553) and a lower functional independence (modified Rankin Scale 0-2) at day 90 (25 vs. 36.5%, p = 0.230). In the multivariate analysis, SRIs intake was identified as an independent predictor of CE (adjusted OR 3.37; 95% CI 1.033-10.989; p = 0.044) together with hematoma volume at baseline and alcohol use. CONCLUSIONS: In our studied population, previous SRIs intake in patients with ICH was independently associated to CE. Further studies are needed to confirm this association.

What Are the Economic Arguments for Mandating LGBT+ Health Training for Healthcare Providers? An Economic Evaluation of the Impacts of LGBT+ Health Training on Cervical Screening.

Background: Equitable access to healthcare is a priority of many healthcare systems, aiming to ensure access is driven by need and not minority groups such as those defined by sexual orientation. However, there are healthcare areas where inequity in access across sexual orientation groups is found that are not justified based on need. Mandated LGBTQ+-specific training of the healthcare workforce may help address some barriers of access for these groups. The study aims to understand the potential economic implications for mandated LGBTQ+-specific healthcare training on the healthcare system in England, UK to inform commissioning of training provision. Methods: Cervical cancer screening was used as an exemplar case where there appears to be inequity in access for different sexual orientation groups. A decision model was developed and analysed that considered the impacts of greater uptake of screening for lesbian and bisexual women due to LGBTQ+ training. Costs took the perspective of the healthcare system and outcomes modelled were cancer cases averted in a timeframe of 5 years. Results: Based on cervical cancer screening alone, where training costs are fully attributed to this service, training would likely result in fewer cancer cases detected in the lesbian and bisexual populations, though this comes at a modest increase in healthcare sector costs, with this increase largely reflecting a greater volume of screens. Training costs do not appear to be a major component of the cost implications. Conclusions: In resource-constrained systems with increasing pressures for efficiency savings, the opportunity cost of delivering training is a realistic component of the commissioning decision. The findings in this paper provide a signal that mandated LGBTQ+ training in healthcare could lead to potentially greater outcomes and in breaking down barriers of access and could also enable the healthcare system to provide more equitable access to healthcare.

Classification of LAMOST spectra of B-type and hot subdwarf stars using kernel support vector machine.

Machine learning has emerged as a leading field in artificial intelligence, demonstrating expert-level performance in various domains. Astronomy has benefited from machine learning techniques, particularly in classifying and identifying stars based on their features. This study focuses on the spectra-based classification of 11,408 B-type and 2422 hot subdwarf stars. The study employs baseline correction using Asymmetric Least Squares (ALS) to enhance classification accuracy. It applies the Pan-Core concept to identify 500 unique patterns or ranges for both types of stars. These patterns are the foundation for creating Support Vector Machine (SVM) models, including the linear (L-SVM), polynomial (P-SVM), and radial basis (R-SVM) kernels. Parameter tuning for the SVM models is achieved through cross-validation. Evaluation of the SVM models on test data reveals that the linear kernel SVM achieves the highest accuracy (87.0%), surpassing the polynomial kernel SVM (84.1%) and radial kernel SVM (80.1%). The average calibrated accuracy falls within the range of 90-95%. These results demonstrate the potential of using spectrum-based classification to aid astronomers in improving and expanding their understanding of stars, with a specific focus on the identification of hot subdwarf stars. This study presents a valuable investigation for astronomers, as it enables the classification of stars based on their spectra, leveraging machine learning techniques to enhance their knowledge and insights in astronomy.

To evaluate the utility of Oxford classification in predicting renal outcome in IgA nephropathy patients.

BACKGROUND: Immunoglobulin A Nephropathy (IgAN) is a heterogeneous disorder. Multiple ethnicities conducted studies to assess the effectiveness of the Oxford classification of IgAN in prognostication. However, there is no study on the Pakistani population. We aim to identify its prognostic effectivity in our patients. METHODS: We retrospectively reviewed the medical records of 93 biopsy-proven cases of primary IgAN. We collected the clinical and pathological data at baseline and on follow-ups. The median follow-up period was 12 months. We defined the renal outcome as a ≥ 50% decline in eGFR or end-stage renal disease (ESRD). RESULTS: Of 93 cases, 67.7% were males with a median age of 29. Glomerulosclerosis was the most prevalent lesion (71%). The median MEST-C was 3. On follow-up, median serum creatinine worsened from 1.92 to 2.2 mg/dL, and median proteinuria reduced from 2.3 g/g to 1.072 g/g. The reported renal outcome was 29%. T and C scores and MEST-C scores above 2 were significantly associated with pre-biopsy eGFR. On Kaplan-Meier analysis, the T and C scores' association was significant with the renal outcome (p-value 0.000 and 0.002). In univariate and multivariate analyses, the association of T-score (p-value 0.000, HR 4.691), total MEST-C score (p-value 0.019), and baseline serum creatinine (p-value 0.036, HR 1.188) were significant with the outcome. CONCLUSION: We validate the prognostic significance of the Oxford classification. T and C scores, baseline serum creatinine, and total MEST-C score significantly affect the renal outcome. Furthermore, we recommend the inclusion of the total MEST-C score in determining the IgAN prognosis.

Y Stent-Assisted Coiling Technique for Bifurcation Aneurysms Using Double Neuroform® Stent: a Large Restrospective Series.

BACKGROUND: Stent assisted coiling technique have shown to be an effective and safe endovascular strategy for wide neck bifurcation aneurysms in achieving greater packing, allowing the closure of the aneurysm and preserving the parent arteries, compared to simple coiling. MATERIAL AND METHODS: We conducted a retrospective analysis of 79 patients with cerebral aneurysms treated using 'Y'-configuration double Neuroform® stent-assisted coiling at our center from July 2009 to July 2022. RESULTS: Of the 79 patients, 76% (60/79) were incidental unruptured cerebral aneurysm and 24% were patients treated for aneurysm recanalization of a previous ruptured aneurysm (19/79). The most frequent locations were anterior communicating artery (AComA) 44.3% (35/79) and middle cerebral artery (MCA) 32.9% (26/79). We found a complete and almost complete aneurysm occlusion (Raymond-Roy occlusion classification (RROC) 1 and 2): in 100% (79/79) in the angiography after procedure, in 97.6% (42/43) at the first follow-up at 6-8 months and 100% (57/57) at the first 1-2 years of follow-up. No mortality related to treatment was detected. We registered 2.5% (2/79) major ipsilateral strokes, one due to acute in stent thrombosis (patient had a mRS: 0 in follow up at 90 days) and a spinal anterior artery occlusion (patient had a mRS: 3 in follow up at 90 days). CONCLUSION: The 'Y' stent-assisted coiling technique with double Neuroform® is a safe and effective technique for the treatment of wide-neck bifurcation aneurysms, with high rates of complete occlusion, preserving the permeability of the afferent and efferent arteries and low rate of complications.

Economic evaluation of a water fluoridation scheme in Cumbria, UK.

OBJECTIVES: The addition of fluoride to community drinking water supplies has been a long-standing public health intervention to improve dental health. However, the evidence of cost-effectiveness in the UK currently lacks a contemporary focus, being limited to a period with higher incidence of caries. A water fluoridation scheme in West Cumbria, United Kingdom, provided a unique opportunity to study the contemporary impact of water fluoridation. This study evaluates the cost-effectiveness of water fluoridation over a 5-6 years follow-up period in two distinct cohorts: children exposed to water fluoridation in utero and those exposed from the age of 5. METHODS: Cost-effectiveness was summarized employing incremental cost-effectiveness ratios (ICER, cost per quality adjusted life year (QALY) gained). Costs included those from the National Health Service (NHS) and local authority perspective, encompassing capital and running costs of water fluoridation, as well as NHS dental activity. The measure of health benefit was the QALY, with utility determined using the Child Health Utility 9-Dimension questionnaire. To account for uncertainty, estimates of net cost and outcomes were bootstrapped (10 000 bootstraps) to generate cost-effectiveness acceptability curves and sensitivity analysis performed with alternative specifications. RESULTS: There were 306 participants in the birth cohort (189 and 117 in the non-fluoridated and fluoridated groups, respectively) and 271 in the older school cohort (159 and 112, respectively). In both cohorts, there was evidence of small gains in QALYs for the fluoridated group compared to the non-fluoridated group and reductions in NHS dental service cost that exceeded the cost of fluoridation. For both cohorts and across all sensitivity analyses, there were high probabilities (>62%) of water fluoridation being cost-effective with a willingness to pay threshold of £20 000 per QALY. CONCLUSIONS: This analysis provides current economic evidence that water fluoridation is likely to be cost-effective. The findings contribute valuable contemporary evidence in support of the economic viability of water fluoridation scheme.

Clinico-radiological features of intracranial atherosclerosis-related large vessel occlusion prior to endovascular treatment.

The identification of large vessel occlusion with underlying intracranial atherosclerotic disease (ICAS-LVO) before endovascular treatment (EVT) continues to be a challenge. We aimed to analyze baseline clinical-radiological features associated with ICAS-LVO that could lead to a prompt identification. We performed a retrospective cross-sectional study of consecutive patients with stroke treated with EVT from January 2020 to April 2022. We included anterior LVO involving intracranial internal carotid artery and middle cerebral artery. We analyzed baseline clinical and radiological variables associated with ICAS-LVO and evaluated the diagnostic value of a multivariate logistic regression model to identify ICAS-LVO before EVT. ICAS-LVO was defined as presence of angiographic residual stenosis or a trend to re-occlusion during EVT procedure. A total of 338 patients were included in the study. Of them, 28 patients (8.3%) presented with ICAS-LVO. After adjusting for confounders, absence of atrial fibrillation (OR 9.33, 95% CI 1.11-78.42; p = 0.040), lower hypoperfusion intensity ratio (HIR [Tmax > 10 s/Tmax > 6 s ratio], (OR 0.69, 95% CI 0.50-0.95; p = 0.025), symptomatic intracranial artery calcification (IAC, OR .15, 95% CI 1.64-26.42, p = 0.006), a more proximal occlusion (ICA, MCA-M1: OR 4.00, 95% CI 1.23-13.03; p = 0.021), and smoking (OR 2.91, 95% CI 1.08-7.90; p = 0.035) were associated with ICAS-LVO. The clinico-radiological model showed an overall well capability to identify ICAS-LVO (AUC = 0.88, 95% CI 0.83-0.94; p < 0.001). In conclusion, a combination of clinical and radiological features available before EVT can help to identify an ICAS-LVO. This approach could be useful to perform a rapid assessment of underlying etiology and suggest specific pathophysiology-based measures. Prospective studies are needed to validate these findings in other populations.

Enhancing the First-Pass Effect in Acute Stroke: The Impact of Stent Retriever Characteristics.

Introduction: Although stentrievers (SRs) have been a mainstay of mechanical thrombectomy (MT), and current guidelines recommend the use of SRs in the treatment of large vessel occlusion stroke (LVO), there is a paucity of studies in the literature comparing SRs directly against each other in terms of mechanical and functional properties. Timely access to endovascular therapy and the ability to restore intracranial flow in a safe, efficient, and efficacious manner have been critical to the success of MT. This study aimed to investigate the impact of contemporary SR characteristics, including model, brand, size, and length, on the first-pass effect (FPE) in patients with acute ischemic stroke. Methods: Consecutive patients with M1 occlusion treated with a single SR+BGC were recruited from the ROSSETTI registry. The primary outcome was the FPE that was defined as modified (mFPE) or true (tFPE) for the achievement of modified thrombolysis in cerebral infarction (mTICI) grades 2b-3 or 3 after a single device pass, respectively. We compared patients who achieved mFPE with those who achieved tFPE according to SR characteristics. Results: We included 610 patients (52.3% female and 47.7% male, mean age 75.1 ± 13.62 years). mFPE was achieved in 357 patients (58.5%), whereas tFPE was achieved in 264 (43.3%). There was no significant association between SR characteristics and mFPE or tFPE. Specifically, the SR size did not show a statistically significant relationship with improvement in FPE. Similarly, the length of the SR did not yield significant differences in the mFPE and tFPE, even when the data were grouped. Conclusions: Our data indicate that contemporary SR-mediated thrombectomy characteristics, including model, brand, size, and length, do not significantly affect the FPE.