Changes in inpatient brain arteriovenous malformation management in the United States following the ARUBA trial: analysis of an interrupted time series design.

The November 2013 online publication of ARUBA, the first multi-institutional randomized controlled trial for unruptured brain arteriovenous malformations (AVMs), has sparked over 100 publications in protracted debates METHODS: This study sought to examine inpatient management patterns of brain AVMs from 2009 to 2016 and observe if changes in U.S. inpatient management were attributable to the ARUBA publication using interrupted time series of brain AVM studies from the National Inpatient Sample data 2009-2016. Outcomes of interest were use of embolization, surgery, combined embolization and microsurgery, radiotherapy, and observation during that admission. An interrupted time series design compared management trends before and after ARUBA. Segmented linear regression analysis tested for immediate and long-term impacts of ARUBA on management. RESULTS: Elective and asymptomatic patient admissions declined 2009-2016. In keeping with the ARUBA findings, observation for unruptured brain AVMs increased and microsurgery decreased. However, embolization, radiosurgery, and combined embolization and microsurgery also increased. For ruptured brain AVMs, treatment modality trends remained positive with even greater rates of observation, embolization, and combined embolization and microsurgery occurring after ARUBA (data on radiosurgery were scarce). None of the estimates for the change in trends were statistically significant. CONCLUSIONS: The publication of ARUBA was associated with a decrease in microsurgery and increase in observation for unruptured brain AVMs in the US. However, inpatient radiotherapy, embolization, and combined embolization and surgery also increased, suggesting trends moved counter to ARUBA's conclusions. This analysis suggested that ARUBA had a small impact as clinicians rejected ARUBA's findings in managing unruptured brain AVMs.

Flexible-circuit-based 3-D aware modular optical brain imaging system for high-density measurements in natural settings.

Significance: Functional near-infrared spectroscopy (fNIRS) presents an opportunity to study human brains in everyday activities and environments. However, achieving robust measurements under such dynamic condition remains a significant challenge. Aim: The modular optical brain imaging (MOBI) system is designed to enhance optode-to-scalp coupling and provide real-time probe 3-D shape estimation to improve the use of fNIRS in everyday conditions. Approach: The MOBI system utilizes a bendable and lightweight modular circuit-board design to enhance probe conformity to head surfaces and comfort for long-term wearability. Combined with automatic module connection recognition, the built-in orientation sensors on each module can be used to estimate optode 3-D positions in real-time to enable advanced tomographic data analysis and motion tracking. Results: Optical characterization of the MOBI detector reports a noise equivalence power (NEP) of 8.9 and 7.3 pW / H z at 735 nm and 850 nm, respectively, with a dynamic range of 88 dB. The 3-D optode shape acquisition yields an average error of 4.2 mm across 25 optodes in a phantom test compared to positions acquired from a digitizer. Results for initial in vivo validations, including a cuff occlusion and a finger-tapping test, are also provided. Conclusions: To the best of our knowledge, the MOBI system is the first modular fNIRS system featuring fully flexible circuit boards. The self-organizing module sensor network and automatic 3-D optode position acquisition, combined with lightweight modules (18 g/module) and ergonomic designs, would greatly aid emerging explorations of brain function in naturalistic settings.

Compact breast shape acquisition system for improving diffuse optical tomography image reconstructions.

Diffuse optical tomography (DOT) has been investigated for diagnosing malignant breast lesions, but its accuracy relies on model-based image reconstructions, which in turn depends on the accuracy of breast shape acquisition. In this work, we have developed a dual-camera structured light imaging (SLI) breast shape acquisition system tailored for a mammography-like compression setting. Illumination pattern intensity is dynamically adjusted to account for skin tone differences, while thickness-informed pattern masking reduces artifacts due to specular reflections. This compact system is affixed to a rigid mount that can be installed into existing mammography or parallel-plate DOT systems without the need for camera-projector re-calibration. Our SLI system produces sub-millimeter resolution with a mean surface error of 0.26 mm. This breast shape acquisition system results in more accurate surface recovery, with an average 1.6-fold reduction in surface estimation errors over a reference method via contour extrusion. Such improvement translates to 25% to 50% reduction in mean squared error in the recovered absorption coefficient for a series of simulated tumors 1-2 cm below the skin.

Association of venous thromboembolism following pediatric traumatic spinal injuries with injury severity and longer hospital stays.

OBJECTIVE: Venous thromboembolism (VTE) can cause significant morbidity and mortality in hospitalized patients, and may disproportionately occur in patients with limited mobility following spinal trauma. The authors aimed to characterize the epidemiology and clinical predictors of VTE in pediatric patients following traumatic spinal injuries (TSIs). METHODS: The authors conducted a retrospective cohort analysis of children who experienced TSI, including spinal fractures and spinal cord injuries, encoded within the National Trauma Data Bank from 2011 to 2014. RESULTS: Of the 22,752 pediatric patients with TSI, 192 (0.8%) experienced VTE during initial hospitalization. Proportionally, more patients in the VTE group (77%) than in the non-VTE group (68%) presented following a motor vehicle accident. Patients developing VTE had greater odds of presenting with moderate (adjusted odds ratio [aOR] 2.6, 95% confidence interval [CI] 1.4-4.8) or severe Glasgow Coma Scale scores (aOR 4.3, 95% CI 3.0-6.1), epidural hematoma (aOR 2.8, 95% CI 1.4-5.7), and concomitant abdominal (aOR 2.4, 95% CI 1.8-3.3) and/or lower extremity (aOR 1.5, 95% CI 1.1-2.0) injuries. They also had greater odds of being obese (aOR 2.9, 95% CI 1.6-5.5). Neither cervical, thoracic, nor lumbar spine injuries were significantly associated with VTE. However, involvement of more than one spinal level was predictive of VTE (aOR 1.3, 95% CI 1.0-1.7). Spinal cord injury at any level was also significantly associated with developing VTE (aOR 2.5, 95% CI 1.8-3.5). Patients with VTE stayed in the hospital an adjusted average of 19 days longer than non-VTE patients. They also had greater odds of discharge to a rehabilitative facility or home with rehabilitative services (aOR 2.6, 95% CI 1.8-3.6). CONCLUSIONS: VTE occurs in a low percentage of hospitalized pediatric patients with TSI. Injury severity is broadly associated with increased odds of developing VTE; specific risk factors include concomitant injuries such as cranial epidural hematoma, spinal cord injury, and lower extremity injury. Patients with VTE also require hospital-based and rehabilitative care at greater rates than other patients with TSI.

Non-diagnostic sonography may reduce negative appendicectomy rate in women when combined with abbreviated Alvarado score.

BACKGROUND: The diagnosis of acute appendicitis (AA) remains a clinical one, with selective use of adjunct imaging. Patients with equivocal clinical presentation often undergo a diagnostic laparoscopy. To help reduce negative appendicectomy rates in women, we aimed to develop a simple scoring system based on the Alvarado score (AS) and ultrasound scan (US), as a diagnostic aid for AA in females. METHODS: All patients who underwent appendicectomy for AA at The Alfred Hospital Melbourne between 1 July 2012 and 30 June 2017 were included for this case-control study. Logistic regression was used to identify pre-operative parameters predictive of AA. Histopathological identification of AA was interpreted as the gold standard. Statistical analysis was performed using IBM SPSS Statistics V26. RESULTS: A total of 1194 patients were included, with 26% negative appendicectomy rate in women. Of the 8 parameters in the AS, logistic regression identified migratory pain, leukocytosis and leukocyte left shift as most significant predictors for AA. These three parameters were used in a 3-point test which carried a sensitivity of 92.1% and specificity of 28.7%. In women, a negative or non-diagnostic US improved the negative predictive value of the 3-point test from 57% to 82%. CONCLUSION: The 3-point abbreviated AS in combination with US may be clinically useful in women to exclude appendicitis without diagnostic laparoscopy. Further large-scale prospective studies are required to validate the utility across different subgroups.

Impact of insurance on hospital course and readmission after resection of benign meningioma.

INTRODUCTION: Surgical outcomes and healthcare utilization have been shown to vary based on patient insurance status. We analyzed whether patients' insurance affects case urgency for and readmission after craniotomy for meningioma resection, using benign meningioma as a model system to minimize confounding from the disease-related characteristics of other neurosurgical pathologies. METHODS: We analyzed 90-day readmission for patients who underwent resection of a benign meningioma in the Nationwide Readmission Database from 2014-2015. RESULTS: A total of 9783 meningioma patients with private insurance (46%), Medicare (39%), Medicaid (10%), self-pay (2%), or another scheme (3%) were analyzed. 72% of all cases were elective; with 78% of cases in privately insured patients being elective compared to 71% of Medicare (p > 0.05), 59% of Medicaid patients (OR 2.3, p < 0.001), and 49% of self-pay patients (OR 3.4, p < 0.001). Medicare (OR 1.5, p = 0.002) and Medicaid (OR 1.4, p = 0.035) were both associated with higher likelihood of 90-day readmission compared to private insurance. In comparison, 30-day analyses did not unveil this discrepancy between Medicaid and privately insured, highlighting the merit for longer-term outcomes analyses in value-based care. Patients readmitted within 30 days versus those with later readmissions possessed different characteristics. CONCLUSIONS: Compared to patients with private insurance coverage, Medicaid and self-pay patients were significantly more likely to undergo non-elective resection of benign meningioma. Medicaid and Medicare insurance were associated with a higher likelihood of 90-day readmission; only Medicare was significant at 30 days. Both 30 and 90-day outcomes merit consideration given differences in readmitted populations.

Noninvasive assessment of abdominal adipose tissues and quantification of hepatic and pancreatic fat fractions in type 2 diabetes mellitus.

The purpose of this study was to evaluate adipose tissue distributions and hepatic and pancreatic fat contents using a 6-point Dixon MRI technique in type 2 diabetes mellitus (T2DM), and to assess associations between fat distributions and biochemical markers of insulin resistance. Intra-abdominal MRI was investigated in 14 T2DM patients, 13 age- and sex-matched healthy controls (HC) and 11 young HC using a 3 T Prisma MRI scanner. All T2DM subjects completed a fasting comprehensive metabolic panel, and demographic measurements were taken according to standardized methodologies. We observed excellent correlation (R2 = 0.94) between hepatic fat fraction quantified using 6-point Dixon MRI and gold standard MRS, establishing the accuracy and reliability of the Dixon technique. Significantly increased visceral adipose tissue (VAT) volumes were found in T2DM patients compared to age-matched HC (1569.81 ± 670.62 cm3 vs. 1106.60 ± 566.85 cm3, p = .04). We also observed a trend of increasing subcutaneous adipose tissues (SAT), and total abdominal fat (TAT) volumes in T2DM compared to age-matched HC. Hepatic fat fraction percentage (HFF%) was 44.6% higher in T2DM compared to age-matched HC and 64.4% higher compared to young HC. Pancreatic fat fractions in the head and body/tail were higher in T2DM patients compared to both healthy cohorts. We also observed correlations between fat contents of the liver and pancreas in T2DM patients, and association between biochemical markers of T2DM with HFF, indicating a risk for non-alcoholic fatty liver disease among T2DM. In summary, this study provides evidence of T2DM patients having increased liver and pancreatic fat, as well as increased adipose tissues.

Morbidity after traumatic spinal injury in pediatric and adolescent sports-related trauma.

OBJECTIVE: Sports injuries present a considerable risk of debilitating spinal injury. Here, the authors sought to profile the epidemiology and clinical risk of traumatic spinal injuries (TSIs) in pediatric sports injuries. METHODS: The authors conducted a retrospective cohort analysis of pediatric patients who had experienced a sports-related TSI, including spinal fractures and spinal cord injuries, encoded in the National Trauma Data Bank in the period from 2011 to 2014. RESULTS: Included in the analysis were 1723 cases of pediatric sports-related TSI, which represented 3.7% of all pediatric sports-related trauma. The majority of patients with TSI were male (81%), and the median age was 15 years (IQR 13-16 years). TSIs arose most often from cycling accidents (47%) and contact sports (28%). The most frequently fractured regions were the thoracic (30%) and cervical (27%) spine. Among patients with spinal cord involvement (SCI), the cervical spine was involved in 60% of cases.The average length of stay for TSIs was 2 days (IQR 1-5 days), and 32% of the patients required ICU-level care. Relative to other sports-related trauma, TSIs without SCI were associated with an increased adjusted mean length of stay by 1.8 days (95% CI 1.6-2.0 days), as well as the need for ICU-level care (adjusted odds ratio [aOR] 1.6, 95% CI 1.3-1.9). Also relative to other sports-related trauma, TSIs with SCI had an increased length of stay by 2.1 days (95% CI 1.8-2.6 days) and the need for ICU-level care (aOR 3.6, 95% CI 2.6-4.8).TSIs without SCI were associated with discharge to or with rehabilitative services (aOR 1.7, 95% CI 1.5-2.0), as were TSIs with SCI (aOR 4.0, 95% CI 3.2-4.9), both relative to other sports-related trauma. Among the patients with TSIs, predictors of the need for rehabilitation at discharge were having a laminectomy or fusion, concomitant lower-extremity injury, head injury, and thoracic injury. Although TSIs affected 4% of the study cohort, these injuries were present in 8% of patients discharged to or with rehabilitation services and in 17% of those who died in the hospital. CONCLUSIONS: Traumatic sports-related spinal injuries cause significant morbidity in the pediatric population, especially if the spinal cord is involved. The majority of TSI cases arose from cycling and contact sports accidents, underscoring the need for improving education and safety in these activities.

Assessment of Lipid and Metabolite Changes in Obese Calf Muscle Using Multi-Echo Echo-planar Correlated Spectroscopic Imaging.

Obesity-related conditions including heart disease, stroke, and type 2 diabetes are leading causes of preventable death. Recent evidence suggests that altered myocellular lipid metabolism in obesity may lead to increased insulin resistance (IR) that predisposes to these disorders. To test the hypothesis that muscles rich in type I vs. type II muscle fibers would exhibit similar changes in intramyocellular lipid (IMCL) and extramyocellular lipid (EMCL) content in obesity, we utilized a new four-dimensional multi echo echo-planar correlated spectroscopic imaging technique that allows separate determination of IMCL and EMCL content in individual calf muscles in obese vs. normal healthy human subjects. Calf muscles were scanned in 32 obese and 11 healthy subjects using a 3T MRI/MRS scanner, and IR in the obese subjects was documented by glucose tolerance testing. In obese subjects, elevation of both IMCL and EMCL content was observed in the gastrocnemius and tibialis anterior muscles (with mixed type I and II fiber content), while a significant increase in only IMCL content (+48%, p < 0.001) was observed in the soleus muscle (predominantly type I fibers). These observations indicate unexpected differences in changes in myolipid metabolism in type I vs. type II rich muscle regions in obesity, perhaps related to IR, and warrant further investigation.

Effects of alendronate and alfacalcidol on the femoral bone mass and bone strength in orchidectomized rats.

The purpose of the present study was to compare the effects of alendronate (ALN) and alfacalcidol (ALF) on the femoral bone mass and bone strength in orchidectomized rats and to clarify the skeletal benefits of combined administration of ALN and ALF. Fifty male Sprague-Dawley rats, 3 months of age, were randomized by the stratified weight method into five groups: the age-matched control (CON), orchidectomy (ORX), ORX + ALN (2.5 microg/kg, s.c., 5 times a week), ORX + ALF (0.1 microg/kg, p.o., 5 times a week), and ORX + ALN + ALF groups. After 12 weeks of feeding, the femoral distal metaphysis and mid-diaphysis were processed for peripheral quantitative tomographic analysis and biomechanical testing. In the femoral distal metaphysis, ALN prevented the ORX-induced reduction in the trabecular volumetric bone mineral density (vBMD) and breaking energy, and ALF prevented the ORX-induced reduction in the trabecular vBMD and increased the breaking energy to values above those observed in the CON group. Both ALN and ALF increased the maximum load to values above those observed in the ORX group. The improvements in parameters described above were more pronounced when ALN and ALF were administered in combination. In the femoral mid-diaphysis, on the other hand, ALN did not significantly affect the cortical bone parameters, whereas ALF increased the cortical area and maximum load to values above those observed in the ORX group. Furthermore, no apparent benefit of combined administration of ALN and ALF was observed. These findings suggest differential effects of ALN and ALF on femoral bone mass and the beneficial effects of combined administration of ALN and ALF on the trabecular bone of the femur in ORX rats.