Detection of Endoleaks Following Thoracic and Abdominal Aortic Endovascular Aortic Repair—: A Comparison of Standard and Dynamic 4D-Computed Tomography Angiography

Purpose: Endoleaks are a common complication after endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR). The detection and correct classification of endoleaks is essential for the further treatment of affected patients. However, standard computed tomography angiography (CTA) provides no hemodynamic information on endoleaks, which can result in misclassification in complex cases. The aim of this study was to compare standard CTA (sCTA) with dynamic, dual-energy CTA (dCTA) for detection and classification of endoleaks following EVAR or TEVAR. Materials and Methods: This retrospective evaluation compared 69 sCTA diagnostic examinations performed on 50 different patients with 89 dCTA diagnostic examinations performed on 69 different patients. Results: In total, 15.9% of sCTA examinations and 49.4% of dCTA examinations led to the detection of endoleaks. With sCTA, 20.0% of patients were diagnosed with endoleaks, while with dCTA, 37.7% of patients were diagnosed with endoleaks. With sCTA, mainly Type 1 endoleaks were detected, whereas, with dCTA, the types of detected endoleaks were more evenly distributed. In comparison with the literature, the frequencies of endoleak types detected with dCTA better reflect the natural distribution than the frequencies detected with standard CTA. Conclusion: Based on the retrospective comparative evaluation, dCTA could pose a valuable supplementary diagnostic tool resulting in a more accurate and realistic detection and classification of suspected endoleaks

Comparison of unruptured intracranial aneurysm treatment score and PHASES score in subarachnoid hemorrhage patients with multiple intracranial aneurysms

Objective: Unruptured Intracranial Aneurysm (UIA) Treatment Score (UIATS) and PHASES score are used to inform treatment decision making for UIAs (treatment or observation). We assessed the ability of the scoring systems to discriminate between ruptured aneurysms and UIAs in a subarachnoid hemorrhage (SAH) cohort with multiple aneurysms.Methods: We retrospectively applied PHASES and UIATS scoring to the aneurysms of 40 consecutive patients with SAH and multiple intracranial aneurysms.Results: PHASES score discriminated better between ruptured aneurysms and UIAs than UIATS. PHASES scores and the difference between the UIATS subscores were higher for ruptured aneurysms compared with UIAs, which reached significance for the PHASES score. PHASES score estimated a low 5-year rupture risk in a larger proportion of the UIAs (≤0.7% in 62.3%, ≤1.7% in 98.4%) than of the ruptured aneurysms (≤0.7% in 22.5%, ≤1.7% in 82.5%). In the 40 ruptured aneurysms, UIATS provided recommendation for treatment in 11 (27.5%), conservative management in 14 (35.0%), and was inconclusive in 15 cases (37.5%). In the 61 UIAs, UIATS recommended treatment in 16 (26.2%), conservative management in 29 (47.5%), and was inconclusive in 16 (26.2%) cases.Conclusion: Similar to previous SAH cohorts, a significant proportion of the ruptured aneurysms exhibited a low-rupture risk. Nevertheless, PHASES score discriminated between ruptured aneurysms and UIAs in our cohort; the lower discriminatory power of UIATS was due to high weights of aneurysm-independent factors. We recommend careful integration of the scores for individual decision making. Large-scale prospective trials are required to establish score-based treatment strategies for UIAs

Comparing a common clavicle maturation-based age estimation method to ordinary regression analyses with quadratic and sex-specific interaction terms in adolescents

Established methods of age estimation are based on correlating defined maturation stages of bony structures with tables representing the observed range of biological ages in the majority of cases. In this retrospective monocentric study in southwestern Germany, common age estimation methodology was assessed in n = 198 subjects at the age of 25 or younger by analyzing the influence of age, quadratic age, biological sex and age-sex interaction on the ossification stages of the medial epiphysis fugue. Three readers (ICC ≥ 0.81 for left/right side) evaluated routine care computed tomography images of the clavicle with a slice thickness of 1 mm. By using least square regression analyses, to determine the real biological age a quadratic function was determined corrected for the age estimated by established methods and sex (R2 = 0.6 each side), reducing the mean absolute error and root mean squared error in the age estimation of women (2.57 and 3.19) and men (2.57 and 3.47) to 1.54 and 1.82 for women, and 1.54 and 2.25 for men. In women, the medial clavicle epiphysis seem to fuse faster, which was particularly observable from approximately 18 years of age. Before that age, the estimation method was relatively close to the ideal correlation between assessed and real age. To conclude, the presented new method enables more precise age estimation in individuals and facilitates the determination and quantification of additional variables, quantifying their influence on the maturation of the medial clavicle epiphysis based on the established ossification stages

Germany’s fourth COVID-19 wave was mainly driven by the unvaccinated

Background While the majority of the German population was fully vaccinated at the time (about 65%), COVID-19 incidence started growing exponentially in October 2021 with about 41% of recorded new symptomatic cases aged twelve or above being symptomatic breakthrough infections, presumably also contributing to the dynamics. So far, it remained elusive how significant this contribution was and whether targeted non-pharmaceutical interventions (NPIs) may have stopped the amplification of the crisis. Methods We develop and introduce a contribution matrix approach based on the next-generation matrix of a population-structured compartmental infectious disease model to derive contributions of respective inter- and intragroup infection pathways of unvaccinated and vaccinated subpopulations to the effective reproduction number and new infections, considering empirical data of vaccine efficacies against infection and transmission. Results Here we show that about 61%–76% of all new infections were caused by unvaccinated individuals and only 24%–39% were caused by the vaccinated. Furthermore, 32%–51% of new infections were likely caused by unvaccinated infecting other unvaccinated. Decreasing the transmissibility of the unvaccinated by, e. g. targeted NPIs, causes a steeper decrease in the effective reproduction number R than decreasing the transmissibility of vaccinated individuals, potentially leading to temporary epidemic control. Reducing contacts between vaccinated and unvaccinated individuals serves to decrease R in a similar manner as increasing vaccine uptake. Conclusions A minority of the German population—the unvaccinated—is assumed to have caused the majority of new infections in the fall of 2021 in Germany. Our results highlight the importance of combined measures, such as vaccination campaigns and targeted contact reductions to achieve temporary epidemic control.Peer Reviewe

Real world data in mechanical thrombectomy : who are we losing to follow-up?

Background: Missing outcome data (MOD) is a common problem in clinical trials and registries, and a potential bias when drawing conclusions from these data. Identifying factors associated with MOD may help to increase follow-up rates and assess the need for imputation strategies. We investigated MOD in a multicenter, prospective registry study of mechanical thrombectomy (MT) in large vessel occlusion ischemic stroke. Methods: 13 082 patients enrolled in the German Stroke Registry-Endovascular Treatment from May 2015 to December 2021 were analyzed with regard to MOD (90 day modified Rankin Scale, mRS). Univariate logistic regression analyses identified factors unbalanced between patients with and without MOD. Subgroup analyses were performed to identify patients for whom increased efforts to perform clinical follow-up after hospital discharge are needed. Results: We identified 19.7% (2580/13 082) of patients with MOD at the 90 day follow-up. MOD was more common with higher pre-stroke disability (mRS 3–5, 32.2% vs mRS 0–2, 13.7%; P<0.001), absence of bridging intravenous thrombolysis, longer time to treatment, and in patients with high post-stroke disability at discharge (mRS 3–5 vs 0–2: OR 1.234 (95% CI 1.107 to 1.375); P<0.001). In contrast, MOD was less common with futile recanalization (thrombolysis in cerebral infarction (TICI) score of 0–2a, 12.4% vs TICI 2b–3, 15.0%; P=0.001). In patients discharged alive with well documented baseline characteristics, shorter hospital stay (OR 0.992 (95% CI 0.985 to 0.998); P=0.010) and discharge to institutional care or hospital (OR 1.754 (95% CI 1.558 to 1.976); P<0.001) were associated with MOD. Conclusion: MOD in routine care MT registry data was not random. Increased efforts to perform clinical follow-up are needed, especially in the case of higher pre-stroke and post-stroke disability and discharge to hospital or institutional care

Improvement of neurovascular imaging using ultra-high-resolution computed tomography angiography

Objective To evaluate diagnostic image quality of ultra-high-resolution computed tomography angiography (UHR-CTA) in neurovascular imaging as compared to normal resolution CT-angiography (NR-CTA). Material and Methods In this retrospective single-center study brain and neck CT-angiography was performed using an ultra-high-resolution computed tomography scanner (n = 82) or a normal resolution CT scanner (NR-CTA; n = 73). Ultra-high-resolution images were reconstructed with a 1024 × 1024 matrix and a slice thickness of 0.25 mm, whereas NR-CT images were reconstructed with a 512 × 512 matrix and a slice thickness of 0.5 mm. Three blinded neuroradiologists assessed overall image quality, artifacts, image noise, overall contrast and diagnostic confidence using a 4-point Likert scale. Furthermore, the visualization and delineation of supra-aortic arteries with an emphasis on the visualization of small intracerebral vessels was assessed using a cerebral vascular score, also utilizing a 4-point Likert scale. Quantitative analyses included signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), noise and the steepness of gray value transition. Radiation exposure was determined by comparison of computed tomography dose index (CTDIvol), dose length product (DLP) and mean effective dose. Interrater agreement was evaluated via determining Fleiss-Kappa. Results Ultra-high-resolution CT-angiography (UHR-CTA) yielded excellent image quality with superior quantitative (SNR: p < 0.001, CNR: p < 0.001, steepness of gray value transition: p < 0.001) and qualitative results (overall image quality: 4 (Inter quartile range (IQR) = 4–4); p < 0.001, diagnostic confidence: 4 (IQR = 4–4); p < 0.001) compared to NR-CT (overall image quality: 3 (IQR = 3–3), diagnostic confidence: 3 (IQR = 3–4)). Furthermore, UHR-CT enabled significantly superior delineation and visualization of all vascular segments, from proximal extracranial vessels to the smallest peripheral cerebral branches (e.g., UHR-CTA PICA: 4 (3–4) vs. NR-CTA PICA: 3 (2–3); UHR-CTA P4: 4 (IQR = 3–4) vs. NR-CTA P4: 2 (IQR = 2–3); UHR-CTA M4: 4 (IQR = 4–4) vs. NR-CTA M4: 3 (IQR = 2–3); UHR-CTA A4: 4 (IQR = 3–4) vs. NR-CTA A4: 2 (IQR = 2–3); all p < 0.001). Noteworthy, a reduced mean effective dose was observed when applying UHR-CT (NR-CTA: 1.8 ± 0.3 mSv; UHR-CTA: 1.5 ± 0.5 mSv; p < 0.001). Conclusion Ultra-high-resolution CT-angiography improves image quality in neurovascular imaging allowing the depiction and evaluation of small peripheral cerebral arteries. It may thus improve the detection of pathologies in small cerebrovascular lesions and the resulting diagnosis

Brain connectivity networks underlying resting heart rate variability in acute ischemic stroke

Acute strokes can affect heart rate variability (HRV), the mechanisms how are not well understood. We included 42 acute stroke patients (2–7 days after ischemic stroke, mean age 66 years, 16 women). For analysis of HRV, 20 matched controls (mean age 60.7, 10 women) were recruited. HRV was assessed at rest, in a supine position and individual breathing rhythmus for 5 min. The coefficient of variation (VC), the root mean square of successive differences (RMSSD), the powers of low (LF, 0.04–0.14 Hz) and high (HF, 0.15–0.50 Hz) frequency bands were extracted. HRV parameters were z-transformed related to age- and sex-matched normal subjects. Z-values -1). No different connectivity could be found for the respective VC groups. Our results suggest that HRV alteration after acute stroke might be due to affecting resting-state brain networks

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Estrategias y coordinación en el subsistema de agronegocios de cacao orgánico en la región de San Martín : el caso ACOPAGRO

Actualmente grandes cambios en las cadenas agroalimentarias causadas por los consumidores, han generado el desarrollo de productos diferenciados, que en su mayoría son producidos por pequeños productores, tal es el caso del cacao orgánico. Durante los últimos años el Perú se ha consolidado como un importante exportador de cacao fino, aromático y orgánico, siendo San Martín una de las principales regiones productoras. Este subsistema de agronegocios, presentaba serias perturbaciones, tales como, inacceso a créditos para productores, inexistencia de alianzas estratégicas, y una baja coordinación entre los actores del sistema, así mismo la existencia de intermediarios que generaban gran oportunismo e incertidumbre por el precio del cacao que percibían los productores; todo ello ocasionaba elevados costos en las transacciones. Es en este contexto que se crea la Cooperativa Agraria Cacaotera ACOPAGRO, que se ha desempeñado de manera exitosa en los últimos años, siendo líder en la exportación de cacao orgánico. De aquí parte el objetivo de esta investigación, la cual es conocer las nuevas estrategias y formas de coordinación en agronegocios, utilizando el caso ACOPAGRO. La metodología utilizada fue la epistemología fenomenológica a través de un estudio de caso. Sustentada teóricamente en la Nueva Economía Institucional aplicada a los Negocios Agroalimentarios, fundamentalmente la economía de los costos de transacción. Los resultados obtenidos definen a ACOPAGRO como subsistema estrictamente coordinado, producto de la acción colectiva, con objeto de abastecer al mercado internacional exigente. Pues esta cooperativa se ha desarrollado eficientemente, adaptándose a las distintas perturbaciones y oportunidades de mercado; estratégicamente con una innovación en su diseño organizacional que permitió implementar tecnología, crear incentivos y poder adecuar controles. Además de convertirse en el coordinador del subsistema, ACOPAGRO optó en nuevas formas de gobernancia en sus transacciones, alineándolas de tal forma que permitan salvaguardar los activos específicos invertidos por los productores y reducir la incertidumbre, bajando así los costos de transacción