Application of REVEAL Lite 2 and COMPERA 2.0 risk scores to patients with pulmonary arterial hypertension switching to riociguat in the REPLACE study.

In Riociguat rEplacing PDE5i therapy evaLuated Against Continued PDE5i thErapy (REPLACE) (NCT02891850), improvements in risk status were observed in patients with pulmonary arterial hypertension (PAH) at intermediate risk switching to riociguat versus continuing phosphodiesterase-5 inhibitors (PDE5i). This post hoc study applied the Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL) Lite 2 and Comparative Prospective Registry of Newly Initiated Therapies for Pulmonary (COMPERA) 2.0 risk-assessment tools to REPLACE to investigate the impact of baseline risk status on clinical improvement. The proportions of riociguat- and PDE5i-treated patients achieving the primary end-point at REVEAL Lite 2 low, intermediate, and high baseline risk reflected the overall population. Proportions of riociguat-treated patients achieving the primary end-point were comparable between the COMPERA 2.0 intermediate-low risk (39%) and intermediate-high risk (43%) groups. Our findings show that patients in REPLACE achieved clinical improvement by switching from PDE5i to riociguat across all COMPERA 2.0 and most REVEAL Lite 2 baseline risk strata.

Disparities in postpartum readmission by patient- and hospital-level social risk factors in the United States: a retrospective multistate analysis, 2015-2020.

BACKGROUND: Postpartum readmission is an area of focus for improving obstetric care and reducing costs. We examined disparities in all-cause 30-day postpartum readmission by patient- and hospital-level factors in the United States. METHODS: We conducted a retrospective cohort study using 2015-2020 records from the State Inpatient Databases from four states. Generalized linear mixed models were constructed to estimate the effects of individual patient- and hospital-level factors on adjusted odds of 30-day readmission after controlling for confounders. Stratified analyses by delivery and anesthesia type (New York only) and interaction models were performed. RESULTS: Black mothers were more likely than White mothers to be readmitted within 30-days postpartum (aOR 1.57, 95% CI 1.52 to 1.61). Mothers with public insurance had increased odds of readmission compared with those with private insurance (Medicare: aOR 2.13, 95% CI 1.95 to 2.32; Medicaid: aOR 1.14, 95% CI 1.11 to 1.17). Compared with mothers in the lowest income quartile, those in the highest quartile experienced a 14% lower odds of readmission (aOR 0.86, 95% CI 0.83 to 0.89). There were no significant associations between hospital-level characteristics and readmission. Black mothers were more likely to be readmitted regardless of delivery type and most combinations of delivery and anesthesia type. Black mothers from the highest income quartile were more likely to be readmitted than White mothers from the lowest income quartile. CONCLUSION: Substantial disparities in 30-day postpartum readmissions by patient-level social factors were observed, particularly amongst Black mothers. Action is needed to address and mitigate disparities in postpartum readmission.

Cardiac effort and 6-min walk distance correlate with stroke volume measured by cardiac magnetic resonance imaging.

Right ventricular (RV) dysfunction in pulmonary arterial hypertension (PAH) is associated with poor outcomes. Cardiac magnetic resonance imaging (cMRI) is the gold standard for volumetric assessment, and few reports have correlated 6-min walk distance (6MWD) and cMRI parameters in PAH. Cardiac Effort, (the number of heart beats used during 6-min walk test)/(6MWD), incorporates physiologic changes into walk distance and has been associated with stroke volume (SV) measured by nuclear imaging and indirect Fick. Here, we aimed to interrogate the relationship of Cardiac Effort and 6MWD with SV measured by the gold standard, cMRI. This was a single-center, observational, prospective study in Group 1 PAH patients. Subjects completed 6-min walk with heart rate monitoring (Cardiac Effort) and cMRI within 24 h. cMRI was correlated to Cardiac Effort and 6MWD using Spearman Correlation Coefficient. Twenty-five participants with a wide range of RV function completed both cMRI and Cardiac Effort. There was a strong correlation between left ventricle SV index and both Cardiac Effort (r = -0.70, p = 0.0001) and 6MWD (r = 0.67, p = 0.0002). Cardiac Effort and 6MWD were statistically separated in patients at prognostically significant thresholds of left ventricle SV index (>31 ml/m2), RV Ejection Fraction (>35%), and SV/End Systolic Volume ( > 0.53). Cardiac Effort and 6MWD are noninvasive ways to gain insight into those with impaired SV. 6MWD may correlate better with SV than previously thought and heart rate monitoring provides physiologic context to the walk distance obtained.

Ruminal pH sensing for monitoring volatile fatty acid concentrations in response to short-term dietary disruption.

The purpose of this study was to investigate the potential of using ruminal pH measurements to track time-series ruminal volatile fatty acid (VFA) concentrations occurring in response to short-term dietary disruption. Four ruminally cannulated dry Holstein dairy cows were individually housed and assigned to 4 treatments in a Latin square design. Treatments differing in forage-to-concentrate (F:C) ratio (100:0 to 55:45) were used because they were expected to result in large differences in VFA concentration, over which the relationships between pH and VFA could be robustly evaluated. Each sampling period lasted 36 h. Animals were removed from pasture and fasted for 24 h, after which time they were fed their treatment ration for 2 h and sampled for rumen fluid hourly for 12 h. Rumen fluid samples were analyzed immediately for pH, frozen, and subsequently analyzed for VFA concentrations using gas chromatography. Animals were returned to pasture for 7 d between sampling periods. To confirm that the short-term dietary disruptions resulted in expected variation in VFA concentrations, mean VFA concentrations during each animal period (n = 16) were analyzed using a linear mixed effects model with fixed (linear and quadratic) effects for F:C ratio and random effects for animal and period. Results indicated significant changes in VFA concentration across F:C ratio, but no significant shifts in VFA molar proportions, perhaps due to the short-term nature of the feeding protocol. To explore opportunity to use pH measurements to explain variability in VFA concentrations in real time across dietary conditions, a linear mixed-effect model was used to link the time-series measurements (n = 207). The VFA concentrations were analyzed with linear mixed effect models using linear and quadratic terms for pH, and random effects for animal and period. These models had poor accuracy, with residual error variance ranging from 21% to 38%, and residuals patterning significantly with F:C ratio. The data suggest that pH may lack reliability for VFA prediction in short-term feeding scenarios differing considerably in F:C ratio.

Ability of three dairy feed evaluation systems to predict postruminal outflows of amino acids in dairy cows: A meta-analysis.

Adequate prediction of postruminal outflows of essential AA (EAA) is the starting point of balancing rations for EAA in dairy cows. The objective of this meta-analysis was to compare the performance of 3 dairy feed evaluation systems (National Research Council [NRC], Cornell Net Protein and Carbohydrate System version 6.5.5 [CNCPS], and National Academies of Sciences, Engineering and Medicine [NASEM]) to predict EAA outflows (Trp was not tested). The data set included a total of 354 treatment means from 70 duodenal and 24 omasal studies. To avoid Type I error, mean and linear biases were considered of concern if statistically significant and representing >5.0% of the observed mean. Analyses were conducted on raw observed values and on observations adjusted for the random effect of study. The analysis on raw data indicates the ability of the feed evaluation system to predict absolute values whereas the analysis on adjusted values indicates its ability to predict responses of EAA outflows to dietary changes. For the prediction of absolute values (based on raw data), NRC underpredicted outflows of all EAA, from 5.3% to 8.6% of the observed mean (%obs.mean) except for Leu, Lys, and Val; NASEM overpredicted Lys (10.8%obs.mean); and CNCPS overpredicted Arg, His, Lys, Met, and Val (5.2 to 26.0%obs.mean). No EAA had a linear bias of concern with NASEM, followed by NRC for His (6.8%obs.mean), and CNCPS for all EAA (5.6 to 12.2%obs.mean) except Leu, Phe, and Thr. In contrast, for the prediction of responses to dietary changes (based on adjusted data), NRC had 2 EAA presenting a linear bias of concern, followed by NASEM and CNCPS with 4 and 6 EAA, respectively. Predictions of His showed a linear bias of concern (5.3 to 9.6%obs.mean) with the 3 feed evaluation systems. Measured chemistry of crude protein and EAA were reported for 1 or more feed ingredients of the ration in 36% of the studies, and resulted in decreased linear biases in the 3 feed evaluation systems. The difference in mean biases of Met outflows was systematically positive when comparing omasal versus duodenal studies. Predictions of Met outflows with NRC had a higher concordance correlation coefficient in duodenal (used to develop NRC equations) versus omasal studies, whereas the opposite was observed with CNCPS, the latter showing the lowest mean bias for Met in omasal sampling studies. The 30% difference in Met mean biases between sampling sites appeared related to a similar difference found for observed Met versus nonammonia nitrogen outflows between duodenal and omasal studies, which is independent of predictions. In conclusion, NRC and NASEM yielded accurate predictions of EAA outflows, with a small superiority of NASEM to predict absolute values, and slight superiority of NRC to predict the responses to dietary changes. In comparison, CNCPS may present mean and linear biases of concern for many EAA. Moreover, it remains to determine which sampling site is more representative of the true supply of EAA to the cows.

Defining optimal dietary starch, oil, and amino acid inclusion levels for broilers experiencing a coccidiosis challenge.

Alternative methods to alleviate coccidiosis in broilers are of interest to producers, including dietary strategies to minimize disruptions in growth rate and efficiency when faced with health challenges. Our objective was to determine optimal combinations of dietary starch, amino acids (AA), and oil to benefit productivity of broilers experiencing Eimeria-induced immune activation. Two trials were conducted using 1,536 male Ross 308 broiler chicks in floor pens randomly assigned to 1 of 17 experimental treatments. All birds received common starter (d 0-10) and finisher (d 24-35) diets, and only differed based on their assigned experimental grower diet (d 10-24). Trial 1 experimental grower diets ranged from 2,700 to 3,300 kcal/kg AME. Trial 2 included 10 experimental grower diets following a simplex lattice design consisting of 3 basal lots formulated to have the highest starch (45.4%), oil (10.2%), or AA density (120, 1.33% digestible Lys) and mixed in 4 equally spaced levels for each component (0, 0.33, 0.67, 1). These mixtures enabled varying densities of AA (80-120% of recommendation), starch:oil (4:1-20:1), and AME (2,940-3,450 kcal/kg). Bird and feeder weights were collected on d 0, 10, 24, and 35, and birds were exposed to an Eimeria challenge on d 11 or 12. In trial 2, excreta samples were collected for AME determination and carcasses were processed on d 36. Data were analyzed using ANOVA, t test, or regression. In Trial 1, BW gain and feed conversion were improved (P < 0.05) by increasing dietary AME. In Trial 2, birds receiving diets containing AA at 93 to 107% of recommendations and higher oil exhibited improved (P < 0.05) performance, but increased starch at the expense of oil reduced performance (P < 0.05). Relative breast and fat pad weights were not influenced by diet in Trial 2. We determined that broilers mildly challenged with Eimeria would exhibit highest BW gain when receiving diets containing 35.8% starch, 8.9% oil, and 101.3% of AA recommendations, which can be utilized by producers to maintain productivity under health-challenged conditions.

Oral Treprostinil is Associated with Improved Survival in FREEDOM-EV and its Open-Label Extension.

INTRODUCTION: In the event-driven FREEDOM-EV trial, oral treprostinil delayed clinical worsening in patients with pulmonary arterial hypertension (PAH). Open-label extension studies offer additional data about tolerability, efficacy, and survival, especially for those initially assigned placebo. The aim of the current study was to determine if oral treprostinil changed survival when considering the parent and extension study, if treprostinil provides functional benefits for participants initially assigned to placebo, and if the benefits observed for those treated with treprostinil were durable. METHODS: Both active and placebo participants from FREEDOM-EV could enroll in the FREEDOM-EV open-label extension (OLE) study after experiencing an investigator-assessed clinical worsening event or after parent study closure. All participants in the OLE were offered open-label oral treprostinil. Previously assigned placebo participants titrated to maximally tolerated doses; previously assigned treprostinil participants continued dose titration. We repeated assessments including functional class and 6-min walk distance (6MWD) at 12-week intervals and measured N-terminal pro-brain natriuretic peptide (NT-proBNP) at week 48. Survival was estimated by Kaplan-Meier analysis, and we estimated hazard ratio (HR) using Cox proportional hazards. RESULTS: Of 690 FREEDOM-EV participants, 470 enrolled in the OLE; vital status was available for 89% of initial Freedom-EV participants. When considering the combined parent and open-label data, initial assignment to oral treprostinil reduced mortality (HR 0.64, 95% confidence interval 0.46-0.91, p = 0.013); absolute risk reduction was 9%. Participants randomized to placebo who initiated oral treprostinil after clinical worsening and tolerated treatment through week 48 demonstrated favorable shifts in functional class (p < 0.0001), 6MWD improvements of + 84 m (p < 0.0001), and a reduction in NT-proBNP of - 778 pg/mL (p = 0.02), compared to OLE baseline. Modest trends toward benefit were measured for those initially assigned placebo who did not have clinical worsening, and 132/144 (92%) of treprostinil assigned participants without clinical worsening remained on drug at week 48 in the OLE study. Adverse events were consistent with FREEDOM-EV. CONCLUSION: Initial treprostinil assignment improved survival in the entire data set; those who began treprostinil after a clinical worsening in the placebo arm and tolerated drug to week 48 enjoyed substantial functional gains. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT01560637.

Emergence and control of an outbreak of PVL-positive MRSA in a UK-based maternity setting.

This paper aims to describe the investigation and control of an outbreak of USA300 ST8 Panton-Valentine leucocidin (PVL)-positive meticillin-resistant Staphylococcus aureus (MRSA), confirmed by whole genome sequencing (WGS), within a maternity and neonatal setting in the UK. The identification of two linked PVL-MRSA cases led to an outbreak investigation. A lookback exercise conducted using the infection control surveillance database, typing of saved MRSA isolates, enhanced patient screening, and staff screening were used to identify further cases. Environmental screening was also performed. Genetic relatedness between isolates was assessed by WGS. During the outbreak, 18 cases were identified between 11th July 2021 and 22nd December 2022: 10 cases were infections and eight cases were colonizations. A healthcare worker (HCW) tested positive for colonization with the same strain, and environmental swabbing identified contaminated information technology equipment in the hospital. The outbreak was brought to an end by exclusion of the colonized HCW from work, and infection prevention and control measures. Since the end of the outbreak, cases of PVL-MRSA with similar molecular profiles have been found in the community. It is likely that the HCW played a role in the transmission of PVL-MRSA. Their exclusion from work and decolonization were key to preventing further cases. WGS was valuable in identifying and linking cases. The identification of community cases of PVL-MRSA with similar molecular profiles confirms transmission of the organism outside of healthcare settings.

Factors associated with emergency admission for people dying from cancer in Northern Ireland: an observational data linkage study.

BACKGROUND: Many people living with cancer are admitted as an emergency, some just prior to diagnosis and others in their last year of life. Factors associated with accessing emergency care for people dying of cancer are complex and not well understood. This can make it difficult to have the resources and staffing in place to best care for individuals in their last year of life and their families. METHODS: This study uses routinely collected administrative data from people who died of cancer in N. Ireland (NI) during 2015 and explores how personal characteristics (e.g., gender, age) and disease related factors (e.g., tumour site, cancer stage at initial diagnosis) were associated with having an emergency admission to hospital in the last year and the last 28 days of their lives, using multivariate logistic regression. RESULTS: Almost three in four people had at least one emergency admission in the last year of life, and over one in three had an emergency admission the last 28 days of life. Patterns were similar for both time outcomes with males, people with haematological, lung or brain cancers, younger persons, those diagnosed with late-stage cancer, and people diagnosed close to time of death, being significantly more likely to have an emergency admission. While there was no significant association between deprivation and emergency admission rates, those living in urban areas were more likely to have an emergency admission in their last month of life compared to rural dwellers. Late diagnosis was evident with 538 people (12.8% of all deaths from cancer) being diagnosed within one month of death and 1242 (29%) within 3 months of death. CONCLUSION: The high level of emergency admissions points to gaps in routine end-of-life care, and the need for additional training for hospital staff including frontline emergency department (ED) staff who are often the 'gatekeepers' to emergency inpatient care for people living with cancer. The levels of late diagnosis indicate a need for increased population awareness of cancer symptoms and system change to promote earlier diagnosis.

Regional Variation in Pulmonary Arterial Hypertension in the United States: The Pulmonary Hypertension Association Registry.

Rationale: Pulmonary arterial hypertension (PAH) is a heterogeneous disease within a complex diagnostic and treatment environment. Other complex heart and lung diseases have substantial regional variation in characteristics and outcomes; however, this has not been previously described in PAH. Objectives: To identify baseline differences between U.S. census regions in the characteristics and outcomes for participants in the Pulmonary Hypertension Association Registry (PHAR). Methods: Adults with PAH were divided into regional groups (Northeast, South, Midwest, and West), and baseline differences between census regions were presented. Kaplan-Meier survival analyses and Cox proportional hazards were used to estimate the association between region and mortality in unadjusted and adjusted models. Results: Substantial differences by census regions were seen in age, race, ethnicity, marital status, employment, insurance payor breakdown, active smoking, and current alcohol use. Differences were also seen in PAH etiology and baseline 6-minute walk distance test results. Treatment characteristics varied by census region, and mortality appeared to be lower in PHAR participants in the West (hazard ratio, 0.60; 95% confidence interval, 0.43-0.83, P = 0.005). This difference was not readily explained by differences in demographic characteristics, PAH etiology, baseline severity, baseline medication regimen, or disease prevalence. Conclusions: The present study suggests significant regional variation among participants at accredited pulmonary vascular disease centers in multiple baseline characteristics and mortality. This variation may have implications for clinical research planning and represent an important focus for further study to better understand whether there are remediable care aspects that can be addressed in the pursuit of providing equitable care in the United States.

Peak steps: Capacity for activity improves after adding approved therapy in pulmonary arterial hypertension.

Pulmonary arterial hypertension (PAH) patients have low activity. Activity intensity or duration could be a measure of clinical status or improvement. We aimed to determine whether standard or novel actigraphy measures could detect increases in activity after adding therapy. This was a prospective, single-center observational study evaluating activity after adding therapy in Group 1 PAH; we also report a validation cohort. For our study, two different accelerometers were used, a wrist (ActiGraph) and chest (MC10) device. Patients were analyzed in two groups, Treatment Intensification (TI, adding therapy) or Stable. Both groups had baseline monitoring periods of 7 days; the TI group had follow-up at 3 months, while Stables had follow-up within 4 weeks to assess stability. Activity time and steps were reported from both devices' proprietary algorithms. In ActiGraph only, steps in 1-min intervals throughout the day were ranked (not necessarily contiguous). Average values for each week were calculated and compared using nonparametric testing. Thirty patients had paired data (11 Stable and 19 TI). There was no between-group difference at baseline; we did not observe therapy-associated changes on average daily steps or activity time/intensity. The top 5 min of steps (capacity) increased after adding therapy; there was no difference in the stable group. This key finding was validated in a previously reported randomized trial studying a behavioral intervention to increase exercise. Total daily activity metrics are influenced by both disease and non-disease factors, making therapy-associated change difficult to detect. Peak minute steps were a treatment-responsive marker in both a pharmacologic and training intervention.

Ability of three dairy feed evaluation systems to predict postruminal outflows of nitrogenous compounds in dairy cows: A meta-analysis.

Adequate prediction of postruminal outflow of protein fractions is the starting point for the determination of metabolizable protein supply in dairy cows. The objective of this meta-analysis was to compare the performance of 3 dairy feed evaluation systems (National Research Council [NRC], Cornell Net Protein and Carbohydrate System [CNCPS], and National Academies of Sciences, Engineering and Medicine [NASEM]) to predict outflows (g/d) of nonammonia nitrogren (NAN), microbial N (MiN), and nonammonia nonmicrobial N (NANMN). Predictions of rumen degradabilities (% of nutrient) of protein (RDP), NDF, and starch were also evaluated. The data set included 1,294 treatment means from 312 digesta flow studies. The 3 feed evaluation systems were compared using the concordance correlation coefficient (CCC), the ratio of root mean square prediction error (RMSPE) on standard deviation of observed values (RSR), and the slope between observed and predicted values. Mean and linear biases were deemed biologically relevant and are discussed if higher than a threshold of 5% of the mean of observed values. The comparisons were done on observed values adjusted or not for the study effect; the adjustment had a small effect on the mean bias but the linear bias reflected a response to a dietary change rather than absolute predictions. For the absolute predictions of NAN and MiN, CNCPS had the best-fit statistics (8% greater CCC; 6% lower RMSPE) without any bias; NRC and NASEM underpredicted NAN and MiN, and NASEM had an additional linear bias indicating that the underprediction of MiN increased at increased predictions. For NANMN, fit statistics were similar among the 3 feed evaluation systems with no mean bias; however, the linear bias with NRC and CNCPS indicated underprediction at low predictions and overprediction at elevated predictions. On average, the CCC were smaller and RSR ratios were greater for MiN versus NAN indicating increased prediction errors for MiN. For NAN responses to a dietary change, CNCPS also had the best predictions, although the mean bias with NASEM was not biologically relevant and the 3 feed evaluation systems did not present a linear bias. However, CNCPS, but not the 2 other feed evaluation systems, presented a linear bias for MiN, with responses being overpredicted at increased predictions. For NANMN, responses were overpredicted at increased predictions for the 3 feed evaluation systems, but to a lesser extent with NASEM. The site of sampling had an effect on the mean bias of MiN and NANMN in the 3 feed evaluation systems. The mean bias of MiN was higher in omasal than duodenal studies in the 3 feed evaluation systems (from 55 to 61 g/d) and this mean bias was twice as large when 15N labeling was used as a microbial marker compared with purines. Such a difference was not observed for duodenal studies. The reasons underlying these systematic differences are not clear as the type of measurements used in the current meta-analysis does not allow to delineate if one site or one microbial marker is yielding the "true" postruminal N outflows. Rumen degradabilities of protein was underpredicted with CNCPS, and RDP responses to a dietary change was underpredicted by the 3 feed evaluation systems with increased RDP predictions. Rumen degradability of NDF was underpredicted and had poor fit statistics for NASEM compared with CNCPS. Fit statistics were similar between CNCPS and NASEM for rumen degradability of starch, but with an underprediction of the response with NASEM and absolute values being overpredicted with CNCPS. Multivariate regression analyses showed that diet characteristics were correlated with prediction errors of N outflows in each feed evaluation system. Globally, compared with NAN and NANMN, residuals of MiN were correlated with several moderators in the 3 feed evaluation systems reflecting the complexity to measure and model this outflow. In addition, residuals of NANMN were correlated positively with RDP suggesting an overestimation of this parameter. In conclusion, although progress is still to be made to improve equations predicting postruminal N outflows, the current feed evaluation systems provide sufficient precision and accuracy to predict postruminal outflows of N fractions.

United States rural residence is associated with increased acute maternal end-organ injury or mortality after birth: a retrospective multi-state analysis, 2007-2018.

BACKGROUND: Geographic-based healthcare determinants and choice of anesthesia have been shown to be associated with maternal morbidity and mortality. We explored whether differences in maternal outcomes based on maternal residence, and anesthesia type for cesarean and vaginal birth, exist. METHODS: This study was a retrospective multi-state analysis; patient residence was the predictor variable of interest and a composite binary measure of maternal end-organ injury or inpatient mortality was the primary outcome. Our secondary outcomes included a binary measure of anesthesia type for cesarean birth (general vs. neuraxial [NA]) and NA analgesia for vaginal birth (no NA vs. NA). Our predictor variable of interest was patient residency (reference category central metropolitan areas of >1 million population), fringe large metropolitan county, medium metropolitan, small metropolitan, micropolitan, and non-metropolitan or micropolitan county. RESULTS: Women residing in micropolitan (OR 1.17; 95% CI 1.09 to 1.27) and non-metropolitan or micropolitan counties (OR 1.14; 95% CI 1.04 to 1.24) had the highest adjusted increased odds of adverse maternal outcomes. Those residing in suburban, medium, and small metropolitan areas underwent general anesthesia less often during cesarean births than those residing in urban areas. Patients residing in micropolitan rural (OR 2.07; 95% CI 2.02 to 2.12) and non-metropolitan or micropolitan (2.25; 95% CI 2.16 to 2.34) counties underwent vaginal births without NA analgesia more than twice as often as those residing in urban areas. CONCLUSIONS: Rural-urban disparities in maternal end-organ damage and mortality exist and anesthesia choice may play an important role in these disparate outcomes.

Investigating Angiographic Injection Parameters for Cerebral Aneurysm Hemodynamic Characterization Using Patient-Specific Simulated Angiograms.

Cerebral aneurysm (CA) rupture is one of the major causes of hemorrhagic stroke. During endovascular therapy (ET), neurointerventionalists rely on qualitative image sequences and do not have access to crucial quantitative hemodynamic information. Quantifying angiographic image sequences can provide vital information, but it is not possible to perform this in a controlled manner in vivo. Computational fluid dynamics (CFD) is a valuable tool capable of providing high fidelity quantitative data by replicating the blood flow physics within the cerebrovasculature. In this work, we use simulated angiograms (SA) to quantify the hemodynamic interaction with a clinically utilized contrast agent. SA enables extraction of time density curves (TDC) within the desired region of interest to analyze hemodynamic parameters such as time to peak (TTP) and mean transit time (MTT) within the aneurysm. We present on the quantification of several hemodynamic parameters of interest for multiple, clinically-relevant scenarios such as variable contrast injection duration and bolus volumes for 7 patient-specific CA geometries. Results indicate that utilizing these analyses provides valuable hemodynamic information relating vascular and aneurysm morphology, contrast flow conditions and injection variability. The injected contrast circulates for multiple cardiac cycles within the aneurysmal region, especially for larger aneurysms and tortuous vasculature. The SA approach enables determination of angiographic parameters for each scenario. Together, these have the potential to overcome the existing barriers in quantifying angiographic procedures in vitro or in vivo, and can provide clinically valuable hemodynamic insights for CA treatment.

Boltzmann's equation at 150: Traditional and modern solution techniques for charged particles in neutral gases.

Seminal gas discharge experiments of the late 19th and early 20th centuries laid the foundations of modern physics, and the influence of this "golden era" continues to resonate well into the 21st century through modern technologies, medical applications, and fundamental scientific investigations. Key to this continuing success story has been the kinetic equation formulated by Ludwig Boltzmann in 1872, which provides the theoretical foundations necessary for analyzing such highly non-equilibrium situations. However, as discussed here, the full potential of Boltzmann's equation has been realized only in the past 50 years or so, with modern computing power and analytical techniques facilitating accurate solutions for various types of charged particles (ions, electrons, positrons, and muons) in gases. Our example of thermalization of electrons in xenon gas highlights the need for such accurate methods-the traditional Lorentz approximation is shown to be hopelessly inadequate. We then discuss the emerging role of Boltzmann's equation in determining cross sections by inverting measured swarm experiment transport coefficient data using machine learning with artificial neural networks.