The credibility of health economic models for health policy decision-making: the case of population screening for abdominal aortic aneurysm

<i>Objectives</i>: To review health economic models of population screening for abdominal aortic aneurysm (AAA) among elderly males and assess their credibility for informing decision-making. <i>Methods</i>: A literature review identified health economic models of ultrasound screening for AAA. For each model focussing on population screening in elderly males, model structure and input parameter values were critically appraised using published good practice guidelines for decision analytic models. <i>Results</i>: Twelve models published between 1989 and 2003 were identified. Converting costs to a common currency and base year, substantial variability in cost-effectiveness results were revealed. Appraisals carried out for the nine models focusing on population screening showed differences in their complexity, with the simpler models generating results most favourable to screening. Eight of the nine models incorporated two or more simplifying structural assumptions favouring screening; uncertainty surrounding these assumptions was not investigated by any model. Quality assessments on a small number of parameters revealed input values varied between models, methods used to identify and incorporate input data were often not described, and few sensitivity analyses were reported. <i>Conclusions</i>: Large variation exists in the cost-effectiveness results generated by AAA screening models. The substantial number of factors potentially contributing to such disparities means that reconciliation of model results is impossible. In addition, poor reporting of methods makes it difficult to identify the most plausible and thus most useful model of those developed

Correlations Between Intracranial Aneurysms And Thoracic Aortic Aneurysms

This project investigates the clinical occurrence of concurrent thoracic aortic aneurysms (TAA) and intracranial aneurysms (ICA). We hypothesized that patients with a TAA have an increased risk of harboring a concurrent ICA, and likewise that patients with an ICA have an increased risk of harboring a concurrent TAA relative to the general population. In a separate arm of this project, we hypothesized that a pre-defined gene expression profile, based on the expression levels of 41 specific genes measured in peripheral blood cells, will exhibit a characteristic expression pattern in ICA patients and thereby have utility in detecting the presence of ICA. To accomplish the first objective of this project, we reviewed the charts of patients with TAA who also had recent intracranial imaging to document the prevalence of concurrent ICA and compared this rate to the ICA prevalence in the general population. Likewise, we reviewed the charts of patients with ICA who also had recent thoracic imaging to document the prevalence of concurrent TAA. To investigate the gene expression profile for detecting ICA, we collected peripheral blood samples from ICA patients and non- aneurysmal controls and measured the expression levels of 39 pre-defined genes in a signature aneurysm profile using real-time PCR. The observed pattern of expression of these genes was compared to a pre-defined signature aneurysm pattern to predict the aneurysm status of each sample. We found that 9.0% of 212 TAA patients we studied harbor a concurrent ICA. Patients with descending TAA and hypertension had significantly higher rates of concurrent ICA. We also found that 4.5% of 359 ICA patients we studied harbor a concurrent TAA. ICA patients over 70 years of age had an increased rate of concurrent TAA. We also analyzed gene expression in the blood samples of 17 ICA patients and 15 controls. By comparing the observed pattern of gene expression to a predefined signature aneurysm pattern, we were able to detect ICA from a peripheral blood test with an 88% sensitivity and overall accuracy of 63%. In conclusion, this project finds that patients with TAA are at an increased risk relative to the general population of harboring a concurrent ICA. Likewise, patients with ICA are at an increased risk relative to the general population of harboring a concurrent TAA. Our early results show that a peripheral blood test based on the gene expression pattern of 39 genes holds promise as a sensitive screening test for ICA

Proposal for Numerical Benchmarking of Fluid-Structure Interaction in Cerebral Aneurysms

Computational fluid dynamics is intensively used to deepen the understanding of aneurysm growth and rupture in the attempt to support physicians during therapy planning. Numerous studies have assumed fully-rigid vessel walls in their simulations, whose sole hemodynamics may fail to provide a satisfactory criterion for rupture risk assessment. Moreover, direct in-vivo observations of intracranial aneurysm pulsation have been recently reported, encouraging the development of fluid-structure interaction for their modelling and for new assessments. In this work, we describe a new fluid-structure interaction benchmark setting for the careful evaluation of different aneurysm shapes. The studied configurations consist of three real aneurysm domes positioned on a toroidal channel. All geometric features, meshing characteristics, flow quantities, comparisons with a rigid-wall model and corresponding plots are provided. Reported results emphasize the alteration of flow patterns and hemodynamic descriptors when moving from the rigid-wall model to the complete fluid-structure interaction framework, thereby underlining the importance of the coupling between hemodynamics and the surrounding vessel tissue.Comment: 23 pages, 14 figure

New Insight into Cerebrovascular Diseases

“Brain circulation is a true road map that consists of large extended navigation territories and a number of unimagined and undiscovered routes.” Dr. Patricia Bozzetto Ambrosi This book combines an update on the review of cerebrovascular diseases in the form of textbook chapters, which has been carefully reviewed by Dr. Patricia Bozzetto Ambrosi, Drs. Rufai Ahmad and Auwal Abdullahi and Dr. Amit Agrawal, high-performance academic editors with extensive experience in neurodisciplines, including neurology, neurosurgery, neuroscience, and neuroradiology, covering the best standards of neurological practice involving basic and clinical aspects of cerebrovascular diseases. Each topic was carefully revised and prepared using smooth, structured vocabulary, plus superb graphics and scientific illustrations. In emphasizing the most common aspects of cerebrovascular diseases: stroke burden, pathophysiology, hemodynamics, diagnosis, management, repair, and healing, the book is comprehensive but concise and should become the standard reference guide for this neurological approach

Motor Evoked Potential Warning Criteria in Supratentorial Surgery: A Scoping Review.

During intraoperative monitoring of motor evoked potentials (MEP), heterogeneity across studies in terms of study populations, intraoperative settings, applied warning criteria, and outcome reporting exists. A scoping review of MEP warning criteria in supratentorial surgery was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Sixty-eight studies fulfilled the eligibility criteria. The most commonly used alarm criteria were MEP signal loss, which was always a major warning sign, followed by amplitude reduction and threshold elevation. Irreversible MEP alterations were associated with a higher number of transient and persisting motor deficits compared with the reversible changes. In almost all studies, specificity and Negative Predictive Value (NPV) were high, while in most of them, sensitivity and Positive Predictive Value (PPV) were rather low or modest. Thus, the absence of an irreversible alteration may reassure the neurosurgeon that the patient will not suffer a motor deficit in the short-term and long-term follow-up. Further, MEPs perform well as surrogate markers, and reversible MEP deteriorations after successful intervention indicate motor function preservation postoperatively. However, in future studies, a consensus regarding the definitions of MEP alteration, critical duration of alterations, and outcome reporting should be determined

Pulsatile Flow in Computational Modelling of Thrombosis in Cerebral Aneurysms

Ngoepe and Ventikos have developed one of a growing number of computational models of thrombosis of cerebral aneurysms designed with consideration towards clinical use and research. Their model, amongst many others, utilizes computationally inexpensive steady flow conditions. However, pulsatile flow better characterizes blood flow in-vivo. Steady flow is an acceptable approximation of pulsatile flow from a fluid dynamics perspective, but there is no prior evidence suggesting whether it is an acceptable approximation when considering clot formation within a flowing environment. To this end a pulsatile flow model has been created in ANSYS® Fluent, and a function from Ngoepe and Ventikos’s computational model that simulates the release of thrombin, a chemical responsible for clotting activation, has been implemented. The output of this simulation is compared to the output of an otherwise identical simulation utilizing Particle-Image-Velocimetry (PIV) validated steady flow conditions, to determine whether clotting outcome of Ngoepe and Ventikos’s model, amongst others, differs with pulsatile flow This experiment revealed that the concentration of thrombin required for clotting activation is generated in nearly half the time when utilizing pulsatile flow over steady flow. Pulsatile flow creates unsteady flow patterns within the aneurysm, which create an environment where less thrombin is carried out of the aneurysm and into the regular bloodstream. This indicates that steady flow approximations for realistic clotting in computational models of thrombosis of cerebral aneurysms without strong consideration for the effects of pulsatile flow are inaccurate

Diagnosis and Treatment of Abdominal and Thoracic Aortic Aneurysms Including the Ascending Aorta and the Aortic Arch

This book considers diagnosis and treatment of abdominal and thoracic aortic aneurysms. It addresses vascular and cardiothoracic surgeons and interventional radiologists, but also anyone engaged in vascular medicine. The book focuses amongst other things on operations in the ascending aorta and the aortic arch. Surgical procedures in this area have received increasing attention in the last few years and have been subjected to several modifications. Especially the development of interventional radiological endovascular techniques that reduce the invasive nature of surgery as well as complication rates led to rapid advancements. Thoracoabdominal aortic aneurysm (TAAA) repair still remains a challenging operation since it necessitates extended exposure of the aorta and reimplantation of the vital aortic branches. Among possible postoperative complications, spinal cord injury (SCI) seems one of the most formidable morbidities. Strategies for TAAA repair and the best and most reasonable approach to prevent SCI after TAAA repair are presented