A field study of factors and variables regarding tour destination loyalty of Cox’s Bazar in Bangladesh

It is a generally held belief that a tourism destination gets maximum benefit from loyal visitors compared to nonloyal visitors. Although literature on loyalty covers different issues, it lacks a comprehensive study of factors and variables that influence destination loyalty. Therefore, this article aims to investigate the main factors affecting destination loyalty in adopting and applying it to the world's longest beach, Cox's Bazar in Bangladesh. Initially a conceptual destination loyalty framework was developed based on the literature. An exploratory field study utilizing a deductive methodological approach was undertaken by conducting field interviews with 10 experienced visitors from multiple disciplines. Then, we utilized a content analysis based on transcription of the interviews to extract the factors and variables and further developed a loyalty framework. The outcomes of the field interviews identify three new factors (Religious Belief, Seasonal Variation, and Level of Income) that play important roles in destination loyalty judgment. In addition, nine variables (natural beauty, longest beach, reputed place, adjacent attractions, nontraditional items, time, rational price of tourism products, recommendable place, and visit again) are also found to be common and of utmost importance. The article concludes by highlighting the methodological, theoretical, managerial implications, and future research directions

Potential Perioperative Complications Due To Difference In Timing Of Systemic Heparinization During Ruptured Aneurysm Coiling

Potential Perioperative Complications Due To Differences in Timing Of Systemic Heparin Distribution During Ruptured Aneurysm Coiling Introduction: In general, systematic heparin anticoagulation is standard in regards to neurovascular intervention. When coiling ruptured aneurysms, many neurointerventionalists have their own protocol as to timing of systemic heparinization. There is ample research and literature reviewing the frequency of perioperative events, predictors and outcomes, as well as the efficacy in the use of anticoagulants and/or antiplatelets before, during, and after neurovascular procedures to prevent adverse outcomes. However, there currently exists a dearth of research in regards to timing of distribution of heparin intraoperatively and its potential effects on adverse patient outcomes. We performed this analysis to evaluate the effect on the frequency of perioperative complications in relation to when systemic heparin is given to patients intraoperatively, particularly if earlier administration increases bleeding diathesis and if later administration increases ischemic events. Methods: We used a single hospital retrospective study of patients with a primary diagnosis of subarachnoid hemorrhage due to ruptured aneurysm to assess the relationship between the timing of intraoperative systemic heparin distribution during coiling. Patients were subdivided into two groups: those who received heparin at the start of the procedure and those that received heparin after deployment of first coil. Outcomes of interest were perioperative re-rupture of aneurysm and/or stroke. Other factors analyzed were age, sex, Hunt and Hess Scale, modified Fisher Scale, and aneurysm size at presentation. Continuous variables were expressed as the mean with standard error of the mean (±SE). Categorical variables are expressed as percentages. Comparisons between groups were performed using ANOVA for continuous variables and either the Chi-squared test or the Fisher’s exact test for categorical parameters. P \u3c 0.05 was considered statistically significant. Results: We analyzed 246 patients with ruptured aneurysms undergoing endovascular coiling (mean age 57.70 ± 1.00). Perioperative complications were seen in a total of 17 patients (6.91%). In univariate analysis, patients who received systemic heparin at the beginning of the procedure vs. those who received it after placement of first coil did not have worse outcomes both in re-rupture of aneurysm (1.08% vs. 6.54%, p= 0.056) or perioperative stroke (2.15% vs. 2.61%, p= 1). In our analysis, timing of systemic heparin did not seem to influence the rate of intraoperative complications regardless of hemorrhagic vs, thromboembolic. Conclusion: Timing of systemic heparin distribution and its potential effects on perioperative events remains an understudied area of interventional neurology. However, our data suggests that the different timepoints that are currently regarded as standard for its distribution have little bearing on adverse patient outcomes intraoperatively. This can lead us to rethink time guidelines for patients and decrease the apprehension in heparin distribution with regards to adverse outcomes

Primary Middle Meningeal Artery Embolization for a Chronic Subdural Hematoma After Non-Accidental Trauma in a Child: A Case Report

Chronic subdural hematoma in children can be pathognomonic of abusive head trauma. Treatment options for these range from observation to surgical evacuation depending on clinical circumstance and presenting features, which can include mental status changes, headaches, focal neurologic deficits, or asymptomatic presentation. Standalone endovascular treatments represent an area of growing interest in the adult population as an effective treatment modality. However, embolization as a singular treatment approach has not been reported in the pediatric population. We report the first case of stand-alone middle meningeal artery (MMA) embolization of a chronic subdural hematoma as a sequela of abusive head trauma in a two-year-old child, resulting in complete resolution on non-contrast CT head at six months post embolization

Frequency of ICU Specific Interventions After Middle Meningeal Artery

Background: Middle meningeal artery embolization (MMAE) is increasingly performed for the treatment of chronic subdural hematomas. Some authors have described managing minimally symptomatic patients with MMAE in the outpatient setting. Our practice, however, has been to routinely admit patients after MMAE to the neuro-intensive care setting. Objective of this research is to analyze the frequency of ICU level interventions after MMAE in the neuro-intensive care unit. Methods: A consecutive series of MMA embolizations for cSDH were retrospectively reviewed from 2020 to 2022 at Valley Baptist Medical Center in Harlingen, TX, USA. Frequency of ICU specific interventions such as need for post procedural mechanical ventilation, need for intravenous vasopressor or antihypertensive medications was recorded. Results: A total of 50 MMA embolizations were performed during the study period. The average age of patients included in the study was 63 years old +/- 16 years with 30% being female. 34% patients did not receive any sort of ICU level intervention at all. Among the remaining who did, 32% required mechanical ventilation post procedurally. 14% needed a vasopressor and 48% required intravenous antihypertensives to maintain systolic blood pressure within goal parameters. Conclusions: 34% of patients who underwent MMAE did not require any ICU level interventions afterwards. The most common reason for an ICU intervention after MMAE was for correction of blood pressure to maintain within specified goal. Further investigation is warranted but it suggests that liberalizing blood pressure parameters could reduce the need for ICU utilization after MMAE

STEPS-T Program Improves Endovascular Treatment Outcomes of Acute Ischemic Stroke; A 6-Year Study

Background: Early endovascular recanalization of occluded vessels in acute ischemic stroke (AIS) is a major contributor to good clinical outcome. We report the analysis of all AIS patients throughout a 6-year experience following the deployment of a quality initiative aiming at improving care, speed and maintaining quality for AIS treatment. Methods: Using a prospectively collected endovascular database at a comprehensive stroke center between 2012 and 2017, workflow/outcomes were recorded. There were no exclusion criteria. During the first year, a quality program employing “digital-object” technology, staff education, and workflow improvement was implemented to reduce time-to-treatment. Using electronic recording, workflow times were collected for onset (TO), CT (TCT), door (TD), angiography-suite (TA), groin puncture (TG), DSA (TDSA), and recanalization (TR). Recanalization time (TG-TR) and workflow intervals were compared at Year 1 and 6. Results: Analysis of 382 patients (aged 71.3 ± 12.9) undergoing mechanical thrombectomy for AIS (206 male and 176 female) was performed. Recanalization time was significantly reduced from 82min in 2012 to 34min by 2017 (IQR 52–117min and 23–49min), a 59% reduction (P \u3c 0.001). Further, consistent year-over-year reductions in setup time (TA-TG) (44% improvement) and TCT to TA times were observed. During the same period, clinical outcome significantly improved year-over-year as measured with the modified Rankin Scale 0–2 (33, 37, 38, 41, 53, and 58%). Conclusions: Significant improvements were observed following the deployment of a quality initiative enabling iterative evidence-based process improvements, thereby sustaining significant reductions in time-to-treat and improved clinical outcomes for AIS patients

Utilization of the Ballast Long Guiding Sheath for Neuroendovascular Procedures: Institutional Experience in 68 Cases

Background: The rise of neurointerventional devices has created a demand for guide systems capable of navigating to the carotid artery consistently regardless of tortuosity. The shift toward large distal access catheters (DACs) and desire for greater trackability have inspired the creation of flexible, supportive, large-lumen long guiding sheaths. Recently, the Ballast long guiding sheath was introduced to provide stability and flexibility while navigating neurointerventional devices through tortuous intracranial anatomy. Objective: To report our experience using the Ballast long guiding sheath in a series of patients undergoing a variety of neuroendovascular procedures. Methods: We retrospectively identified all patients who underwent neuroendovascular treatment with a long guiding sheath were selected from a prospectively maintained endovascular database from January 2019 to November 2019. Baseline clinical characteristics and procedural details were collected. Results: A total of 68 patients were included, mean patient age 67.6 ± 13.6 years. Of the patients treated, 52.9% (36/68) presented with stenosis, 25% (17/68) with aneurysms, 13.2% (9/68) with stroke or emboli, 1.5% (1/68) with a tumor, 1.5% (1/68) with an arteriovenous fistula (AVF), and 4.4% (3/68) with a carotid web. Of the patients with stenosis, 20/36 (55.6%) were extracranial, and 16/36 (44.4%) were intracranial. The Ballast long guiding sheath was used to deliver treatment devices for stenting (37/68, 54.4%), flow diversion (12/68, 17.6%), mechanical thrombectomy (8/68, 11.8%), endovascular coiling (5/68, 7.4%), liquid embolization (3/68, 4.4%), balloon angioplasty (2/68, 2.9%), and balloon angioplasty with stenting (1/68, 1.5%). No Ballast-related complications or adverse events were encountered. Conclusions: We demonstrate the feasibility of the Ballast long guiding sheath to successfully deliver modern neurointerventional treatment devices through tortuous anatomy

Seroprevalence of Salmonella Gallinarum Infection in Chicken Population of parts of Tigray and Addis Ababa by Plate Agglutination and Micro-agglutination Tests

Ethiopia owns a large poultry population whose growth is highly constrained by diseases. Fowl typhoid is a serious concern in growing and adult poultry and results from infection by Salmonella Gallinarum (Salmonella enterica subsp. enterica serovar Gallinarum biovar Gallinarum). Knowledge of the prevalence of the disease with confirmatory diagnosis is of paramount importance to embark on a control or prevention program. Seroprevalence of this infection in chicken population of Ethiopia has been reported from some parts of this country but in most of the reports it is based exclusively on a rapid slide agglutination test without further confirmation by another specific test. This study screened 279 sera samples of poultry for S. Gallinarum infection by employing plate agglutination test using colored antigen of S. Gallinarum that revealed 125(44.80%) of 279 sera samples positive. However, when plate positive samples were further tested for confirmation by microagglutination test by employing plain antigen of S. Gallinarum, only 55 (19.71%) were serologically positive lowering the prevalence rate from 44.8% to 19, 71%. The study reveals the serological prevalence of Salmonella gallinarum infection in poultry population of the study areas and recommends that the initial screening of this infection by a test like plate agglutination must always be followed by another specific test to get an accurate estimate of this infection.Keywords: Micro-agglutination test, Plate agglutination test, Poultry population, Salmonella gallinarum, Seroprevalence, Addis Ababa, Tigray, Ethiopia

Initial Experience With the Next-Generation Resolute Onyx Zotarolimus-Eluting Stent in Symptomatic Intracranial Atherosclerotic Disease

Background and Purpose: Intracranial atherosclerotic disease (ICAD) is a common cause of stroke worldwide. Although there are different endovascular options for the treatment of symptomatic ICAD (sICAD), it is still controversial. Herein, we aim to study the safety and efficacy of a new generation of drug-eluting balloon-mounted stent (DES); Resolute (R) onyx DES in the treatment of sICAD. Methods:A prospectively maintained neuroendovascular procedures database in a high-volume comprehensive stroke center was reviewed from October 2019 through January 2020. Patients were included if they had sICAD (≥70% stenosis), failed medical management, and underwent intracranial stenting with R-onyx DES. Technical success was defined as the ability to deploy the device at the desired location and achievement of Results: A total of 18 consecutive patients (mean age, 66.6 years; 44.4% were females and 94.4% were Hispanic) were eligible for the analysis. Indication for treatment was recurrent strokes in 13 and recurrent transient ischemic attack (TIA) in 5. A total of 22 symptomatic lesions with a mean baseline stenosis percent (84.9 ± 9.6) were treated using 23 R-onyx DES in 19 procedures. All procedures were done under general anesthesia with 100% technical success, and no reported periprocedural strokes or death. Among 13 patients who had clinical follow-up, 1 (7.7%) patient had TIA. There were no reported ischemic or hemorrhagic strokes. Angiographic follow-up for 9 (50%) patients showed no in-stent restenosis. Conclusion: The use of R-onyx DES in the treatment of sICAD is safe with high technical success rates. Large prospective multicenter trials with long-term follow-up are warranted

There Is No Association Between the Number of Stent Retriever Passes and the Incidence of Hemorrhagic Transformation for Patients Undergoing Mechanical Thrombectomy

Background: Previous research has focused on the association between hemorrhagic transformation (HT) incidence and pre-procedural variables (i.e., baseline variables) rather than the association between HT incidence and endovascular treatment (EVT) procedural variables (e.g., stent retriever passes). Objective: To assess the association, if any, that exists between the number of stent retriever passes per procedure and the incidence of HT for patients undergoing mechanical thrombectomy. Methods: An endovascular database from a comprehensive stroke center was used to collect data on EVT patients treated with Trevo, Solitaire, or Penumbra stent retrievers from the years 2012 to 2017. Statistical analyses were conducted on the stent retriever passes, demographics, morbidities, medication usage, and outcomes and their association with HT. Results: Of the 329 total patients, 46 (14%) had HT. The HT group had an average [SD] of 1.65 [0.67] and range of [1–3] passes per procedure while the non-HT group had an average [SD] of 1.63 [0.86] and range of [1–5] passes per procedure. Admission NIHSS score (p = 0.0003) and the incidence of diabetes mellitus (DM) (p = 0.05) were significantly higher in the HT group. Subdividing HT into symptomatic and asymptomatic ICH groups failed to display significant differences in the distribution of the stent retriever passes (p = 0.969). The number of passes failed to show any association with HT (p = 0.804) while admission NIHSS score was found to have an OR of 1.07 (95%CI: 1.029–1.121, p = 0.001) with HT incidence. Conclusion: No significant association was found between HT incidence and the stent retriever passes. Further multicenter studies are warranted to corroborate our results

An artificial intelligence (AI)-based approach to clinical trial recruitment: The impact of Viz RECRUIT on enrollment in the EMBOLISE trial

Background EMBOLISE (NCT 04402632) is an ongoing randomized controlled trial investigating the safety and efficacy of middle meningeal artery embolization for the treatment of subacute or chronic subdural hematoma (SDH). Viz RECRUIT SDH is an artificial intelligence (AI)-based software platform that can automatically detect SDH in noncontrast computed tomography (NCHCT) images and report the volume, maximum thickness, and midline shift. We hypothesized that the mobile recruitment platform would aid enrollment and coordinate communication and image sharing among the entire research team. Materials and methods Patient enrollment in EMBOLISE prior to and after implementation of Viz RECRUIT SDH at a large comprehensive stroke center was compared along with the performance of the software platform. The EMBOLISE trial was activated on May 5, 2021, and Viz RECRUIT SDH was activated on October 6, 2021. The pre-AI cohort consisted of all patients from EMBOLISE to AI activation (153 days), and the post-AI cohort consisted of all patients from AI activation until August 18, 2022 (316 days). All alerts for suspected SDH candidates were manually reviewed to determine the positive predictive value (PPV) of the algorithm. Results Prior to AI-software implementation, there were 5 patients enrolled (0.99 patients/month) and one screen failure. After the implementation of the software, enrollment increased by 36% to 1.35 patients/month (14 total enrolled), and there were no screen failures. Over the entire post-AI period, a total of 6244 NCHCTs were processed by the system with 207 total SDH detections (3% prevalence). 35% of all alerts for suspected SDH were viewed within 10 min, and 50% were viewed within an hour. The PPV of the algorithm was 81.4 (CI [75.3, 86.7]). Conclusion The implementation of an AI-based software for the automatic screening of SDH patients increased the enrollment rate in the EMBOLISE trial, and the software performed well in a real-world, clinical trial setting