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Giant intracranial aneurysms represent a complex pathology that pose challenges for management, especially in the pediatric population. With emerging endovascular techniques, combined endovascular and open surgical approaches may be a favorable alternative for complex cases. In this systematic review, we characterize the treatment modalities of giant aneurysms in the pediatric population and provide an update on the number of giant aneurysms reported in the literature by anatomic location. We conducted a literature search of PubMed, Embase, and Medline databases with the following terms: ‘pediatric’ AND ‘giant’ AND ‘intracranial aneurysm.’ Studies were included if data on treatment modality and aneurysm location were available for pediatric patients with giant intracranial aneurysms. The literature search yielded a total of 188 papers, with 82 pediatric patients from 33 articles ultimately meeting inclusion criteria. There were significantly more male than female patients (p = 0.011), with 52 and 29 respectively. Patients presenting with a ruptured aneurysm were significantly younger than patients presenting without rupture (p = 0.018), with a median age of 8.0 and 12.0 years, respectively. There were 45 giant aneurysms reported in the anterior circulation and 37 in the posterior circulation. Anterior aneurysms were most often treated with surgical approaches, while posterior aneurysms were typically treated with endovascular interventions (p = 0.002). Although combined surgical and endovascular approaches were the least frequently utilized, we suggest a combined approach may be particularly useful for patients with complex cases that require a management plan tailored to their needs.

We are colleagues and friends working together in busy emergency departments in Washington DC. As Black physicians working in urban America, we do not find the recent deluge of news reports chronicling the disproportionate effect that the coronavirus disease (COVID‐19) pandemic is having on the disenfranchised and minority populations in our country shocking. We have long been witness to and are in a constant state of alarm over the legal, medical, educational, social and economic inequities faced by the most vulnerable residents of this country.

Objective: Most persons who undergo total knee replacement (TKR) do not increase their physical activity following surgery. We assessed whether financial incentives and health coaching would improve physical activity in persons undergoing TKR. Methods: We designed a factorial randomized controlled trial among persons undergoing TKR for osteoarthritis. Subjects underwent normal perioperative procedures, including post-operative physical therapy, and were assigned to one of four arms: attention control, telephonic health coaching (THC), financial incentives (FI), or THC+FI. We objectively measured step counts and minutes of physical activity with a commercial accelerometer (Fitbit Zip) and compared the changes from pre-TKR to 6 months post-TKR across the four study arms. Results: Of the 202 randomized subjects, 150 (74%) provided both pre-TKR and 6 months post-TKR accelerometer data. Among completers, the average daily step count at 6 months ranged from 5619 (SD 381) in the THC arm to 7152 (SD 407) in the THC+FI arm (adjusting for baseline values). Daily step count 6 months post-TKR increased by 680 (95% CI: -94 – 1,454) in the control arm, 274 (95% CI: -473 – 1021) in the THC arm, 826 (95% CI: 89 – 1563) in the FI arm, and 1808 (95% CI: 1010 – 2606) in the THC+FI arm. Physical activity increased by 14 (SD 10), 14 (SD 10), 16 (SD 10), and 39 (SD 11) minutes in the control, THC, FI, and THC+FI arms, respectively. Conclusions: A dual THC+FI intervention led to substantial improvements in step count and physical activity following TKR. This article is protected by copyright. All rights reserved.

Background We designed and implemented the Brigham and Women’s Wellness Initiative (B-Well), a single-arm study to examine the feasibility of a workplace program that used individual and team-based financial incentives to increase physical activity among sedentary hospital employees. Methods We enrolled sedentary, non-clinician employees of a tertiary medical center who self-reported low physical activity. Eligible participants formed or joined teams of three members and wore Fitbit Flex activity monitors for two pre-intervention weeks followed by 24 weeks during which they could earn monetary rewards. Participants were rewarded for increasing their moderate-to-vigorous physical activity (MVPA) by 10% from the previous week or for meeting the Centers for Disease Control and Prevention (CDC) physical activity guidelines (150 min of MVPA per week). Our primary outcome was the proportion of participants meeting weekly MVPA goals and CDC physical activity guidelines. Secondary outcomes included Fitbit-wear adherence and factors associated with meeting CDC guidelines more consistently. Results B-Well included 292 hospital employees. Participants had a mean age of 38 years (SD 11), 83% were female, 38% were obese, and 62% were non-Hispanic White. Sixty-three percent of participants wore the Fitbit ≥4 days per week for ≥20 weeks. Two-thirds were satisfied with the B-Well program, with 79% indicating that they would participate again. Eighty-six percent met either their personal weekly goal or CDC physical activity guidelines for at least 6 out of 24 weeks, and 52% met their goals or CDC physical activity guidelines for at least 12 weeks. African Americans, non-obese subjects, and those with lower impulsivity scores reached CDC guidelines more consistently. Conclusions Our data suggest that a financial incentives-based workplace wellness program can increase MVPA among sedentary employees. These results should be reproduced in a randomized controlled trial. Trial registration Clinicaltrials.gov, NCT02850094 . Registered July 27, 2016 [retrospectively registered].

Study objective We examine adult emergency department (ED) admission rates for the top 15 most frequently admitted conditions, and assess the relative contribution in admission rate variation attributable to the provider and hospital. Methods This was a retrospective, cross-sectional study of ED encounters (≥ 18 years) from 19 EDs and 603 providers (January 2012–December 2013), linked to the Area Health Resources File for county-level information on healthcare resources. “Hospital admission” was the outcome, a composite of inpatient, observation, or intra-hospital transfer. We studied the 15 most commonly admitted conditions, and calculated condition-specific risk-standardized hospital admission rates (RSARs) using multi-level hierarchical generalized linear models. We then decomposed the relative contribution of provider-level and hospital-level variation for each condition. Results The top 15 conditions made up 34% of encounters and 49% of admissions. After adjustment, the eight conditions with the highest hospital-level variation were: 1) injuries, 2) extremity fracture (except hip fracture), 3) skin infection, 4) lower respiratory disease, 5) asthma/chronic obstructive pulmonary disease (A&C), 6) abdominal pain, 7) fluid/electrolyte disorders, and 8) chest pain. Hospital-level intra-class correlation coefficients (ICC) ranged from 0.042 for A&C to 0.167 for extremity fractures. Provider-level ICCs ranged from 0.026 for abdominal pain to 0.104 for chest pain. Several patient, hospital, and community factors were associated with admission rates, but these varied across conditions. Conclusion For different conditions, there were different contributions to variation at the hospital- and provider-level. These findings deserve consideration when designing interventions to optimize admission decisions and in value-based payment programs.

A 5-year-old girl was brought to the clinic because of chronic intermittent left-sided headaches. The patient underwent computed tomographic angiography, which demonstrated a giant aneurysm that involved the P2 segment of the left posterior cerebral artery. Before treatment proceeded, consent was obtained from the patient's legal guardian. A trapping-evacuation technique was used for proximal control and decompression so that a clip could be placed on the proximal inflow artery of the aneurysm. First, embolization was performed for aneurysm trapping and for sacrifice of the parent vessel. Two days later, the patient was taken to the operating room for open surgical decompression, clipping, and reconstruction. Heparin was administered during the embolization stage of the operation. The patient did well postoperatively and was discharged home. The 3-month follow-up evaluation demonstrated a right superior homonymous quadrantanopia and no other neurologic deficits. The patient's clinical course is summarized in Video 1.

Summary Objective Studies suggest nerve growth factor inhibitors (NGFi) relieve pain but may accelerate disease progression in some patients with osteoarthritis (OA). We sought cost and toxicity thresholds that would make NGFi a cost-effective treatment for moderate-to-severe knee OA. Design We used the Osteoarthritis Policy (OAPol) model to estimate the cost-effectiveness of NGFi compared to standard of care (SOC) in OA, using Tanezumab as an example. Efficacy and rates of accelerated OA progression were based on published studies. We varied the price/dose from $200 to $1000. We considered self-administered subcutaneous (SC) injections (no administration cost) vs provider-administered intravenous (IV) infusion ($69–$433/dose). Strategies were defined as cost-effective if their incremental cost-effectiveness ratio (ICER) was less than $100,000/quality-adjusted life year (QALY). In sensitivity analyses we varied efficacy, toxicity, and costs. Results SOC in patients with high levels of pain led to an average discounted quality-adjusted life expectancy of 11.15 QALYs, a lifetime risk of total knee replacement surgery (TKR) of 74%, and cumulative discounted direct medical costs of $148,700. Adding Tanezumab increased QALYs to 11.42, reduced primary TKR utilization to 63%, and increased costs to between $155,400 and $199,500. In the base-case analysis, Tanezumab at $600/dose was cost-effective when delivered outside of a hospital. At $1000/dose, Tanezumab was not cost-effective in all but the most optimistic scenario. Only at rates of accelerated OA progression of 10% or more (10-fold higher than reported values) did Tanezumab decrease QALYs and fail to represent a viable option. Conclusions At $100,000/QALY, Tanezumab would be cost effective if priced ≤$400/dose in all settings except IV hospital delivery.

Historically, persons scheduled for total knee arthroplasty (TKA) have reported severe pain with low demand activities such as walking, but recent data suggests that TKA recipients may have less preoperative pain. Little is known about people who elect TKA with low levels of preoperative pain. To better understand current TKA utilization, we evaluated the association between preoperative pain and difficulty performing high demand activities, such as kneeling and squatting, among TKA recipients. We used baseline data from a randomized control trial designed to improve physical activity following TKA. Prior to TKA, participants were categorized according to Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain scores: Low (0–25), Medium (26–40), and High (41–100). Within each group, limitations in both low demand and high demand activities were assessed. The sample consisted of 202 persons with a mean age of 65 (SD 8) years; 21 %, 34 %, and 45 % were categorized in the Low, Medium, and High Pain groups, respectively. Of the Low Pain group, 60 % reported at least one of the following functional limitations: limited flexion, limp, limited walking distance, and limitations in work or housework. While only 12 % of the Low Pain group reported at least moderate pain with walking on a flat surface, nearly all endorsed at least moderate difficulty with squatting and kneeling. A substantial number of persons scheduled for TKA report Low WOMAC Pain (≤25) prior to surgery. Persons with Low WOMAC Pain scheduled for TKA frequently report substantial difficulty with high demand activities such as kneeling and squatting. Studies of TKA appropriateness and effectiveness for patients with low WOMAC Pain should include measures of these activities. Identifier NCT01970631 ; Registered 23 October 2013.

Objective: Young adults, in general, are not aware of their risk of knee osteoarthritis (OA). Understanding risk and risk factors is critical to knee OA prevention. We tested the efficacy of a personalized risk calculator on accuracy of knee OA risk perception and willingness to change behaviors associated with knee OA risk factors. Methods: We conducted a randomized controlled trial of 375 subjects recruited using Amazon Mechanical Turk. Subjects were randomized to either a) use a personalized risk calculator based on demographic and risk factor information (intervention) or b) view general OA risk information (control). At baseline and after the intervention, subjects estimated their 10-year and lifetime risk of knee OA and responded to contemplation ladders measuring willingness to change diet, exercise, or weight-control behaviors. Results: Subjects in both arms had an estimated 3.6% 10-year and 25.3% lifetime chance of developing symptomatic knee OA. Both arms greatly overestimated knee OA risk at baseline, estimating a 10-year risk of 26.1% and a lifetime risk of 47.8%. After the intervention, risk calculator subjects' perceived 10-year risk decreased by 12.9 percentage points to 12.5% and perceived lifetime risk decreased by 19.5 percentage points to 28.1%. Control subjects' perceived risks remained unchanged. Risk calculator subjects were more likely to move to an action stage on the exercise contemplation ladder (RR = 2.1). There was no difference between the groups for diet or weight-control ladders. Conclusions: The risk calculator is a useful intervention for knee OA education and may motivate some exercise-related behavioral change. This article is protected by copyright. All rights reserved.

Solid-state batteries have many enticing advantages in terms of safety and stability, but the solid electrolytes upon which these batteries are based typically lead to high cell resistance. Both components of the resistance (interfacial, due to poor contact with electrolytes, and bulk, due to a thick electrolyte) are a result of the rudimentary manufacturing capabilities that exist for solid-state electrolytes. In general, solid electrolytes are studied as flat pellets with planar interfaces, which minimizes interfacial contact area. Here, multiple ink formulations are developed that enable 3D printing of unique solid electrolyte microstructures with varying properties. These inks are used to 3D-print a variety of patterns, which are then sintered to reveal thin, nonplanar, intricate architectures composed only of Li7 La3 Zr2 O12 solid electrolyte. Using these 3D-printing ink formulations to further study and optimize electrolyte structure could lead to solid-state batteries with dramatically lower full cell resistance and higher energy and power density. In addition, the reported ink compositions could be used as a model recipe for other solid electrolyte or ceramic inks, perhaps enabling 3D printing in related fields.

Summary Objective We sought to investigate risk perception among an online cohort of younger US adults compared with calculated risk estimates. Design We recruited a population-based cohort 25–44 years of age with no history of knee osteoarthritis (OA) using Amazon's Mechanical Turk, an online marketplace used extensively for behavioral research. After collecting demographic and risk factor information, we asked participants to estimate their 10-year and lifetime risk of knee OA. We compared perceived risk with risk derived from the OA risk calculator (OA Risk C), an online tool built on the basis of the validated OA Policy Model. Results 375 people completed the study. 21% reported having 3+ risk factors for OA, 25% reported two risk factors, and 32% reported one risk factor. Using the OA Risk C, we calculated a mean lifetime OA risk of 25% and 10-year risk of 4% for this sample. Participants overestimated their lifetime and 10-year OA risk at 48% and 26%, respectively. We found that obesity, female sex, family history of OA, history of knee injury, and occupational exposure were all significantly associated with greater perceived lifetime risk of OA. Conclusions Risk factors are prevalent in this relatively young cohort. Participants consistently overestimated their lifetime risk and showed even greater overestimation of their 10-year risk, suggesting a lack of knowledge about the timing of OA onset. These data offer insights for awareness and risk interventions among younger persons at risk for knee OA.

Background The incidence of knee osteoarthritis (OA) is rising. While several risk factors have been associated with the development of knee OA, this information is not readily accessible to those at risk for osteoarthritis. Risk calculators have been developed for several prevalent chronic conditions but not for OA. Using published evidence on established risk factors, we developed an interactive, personalized knee OA risk calculator (OA Risk C) and conducted a pilot study to evaluate its acceptability and feasibility. Methods We used the Osteoarthritis Policy (OAPol) Model, a validated, state-transition simulation of the natural history and management of OA, to generate data for OA Risk C. Risk estimates for calculator users were based on a set of demographic and clinical factors (age, sex, race/ethnicity, obesity) and select risk factors (family history of knee OA, occupational exposure, and history of knee injury). OA Risk C presents personalized risk of knee OA in several ways to maximize understanding among a wide range of users. We conducted a study of 45 subjects in a primary care setting to establish the feasibility and acceptability of the OA risk calculator. Pilot study participants were asked several questions regarding ease of use, clarity of presentation, and clarity of the graphical representation of their risk. These questions used a five-level agreement scale ranging from strongly disagree to strongly agree. Results OA Risk C depicts information about users’ risk of symptomatic knee OA in 5 year intervals. Study participants estimated their lifetime risk at 38 %, while their actual lifetime risk, as estimated by OA Risk C, was 25 %. Eighty-four percent of pilot study participants reported that OA Risk C was easy to understand, and 89 % agreed that the graphs depicting their risk were clear and comprehensible. Conclusions We have developed a personalized, computer-based OA risk calculator that is easy to use. OA Risk C may be utilized to estimate individuals’ knee OA risk and to deliver educational and behavioral interventions focused on osteoarthritis risk reduction.

s / Osteoarthritis and Cartilage 23 (2015) A82eA416 A394 findings clearly indicate that even in low-risk group, it is cost-effective to co-prescribe PPIs along with traditional or COX-2-selective NSAIDs. Our results should be interpreted with caution due to their short time horizon and may not generalize beyond 3 months. 655 COULD NERVE GROWTH FACTOR INHIBITORS HAVE A PLACE IN THE TREATMENT OF KNEE OSTEOARTHRITIS?: IMPACT OF JOINT DESTRUCTION AND MEANS OF ADMINISTRATION OSSN THE VALUE OF TANEZUMABS E. Losina y, G. Michl y, J. Collins y, D.J. Hunter z, J.M. Jordan x, E. Yelin k, A.D. Paltiel ¶, J.N. Katz y. yBrigham and Women's Hosp., Boston, MA, USA; zUniv. of Sydney, Sydney, Australia; xUNC Sch. of Med., Chapel Hill, NC, USA; kUniv. of California, San Francisco, San Francisco, CA, USA; Yale Sch. of Publ. Hlth., New Haven, CT, USA Purpose: Tanezumab is a nerve growth factor inhibitor in development as an analgesic for patients with knee osteoarthritis (OA). While several studies show promising pain relief with Tanezumab, reports of joint destruction have led to temporary suspension of further studies. We sought to establish cost and toxicity (joint destruction) thresholds that would make Tanezumab a cost-effective treatment for moderate to severe knee OA. Methods: We used the Osteoarthritis Policy (OAPol) model, a validated computer simulation model of the natural history and management of knee OA, to estimate the cost-effectiveness of using Tanezumab in patients with persistent pain despite currently available pharmacologic therapy. Population characteristics and efficacy were derived from Lane et al. (2010). Mean age was 59 years, 59% were female and 88% were white. Baseline WOMAC Pain (0-100, with 1001⁄4worst) was 67 (SD 13). Mean pain reduction from Tanezumabwas 34 (SD 20) in the first year of treatment. In the absence of long-term data, we estimated Tanezumab annual discontinuation rate after the first year at 10% using data on Enbrel in RA. In the base case, we assumed joint destruction in 1% of subjects based on data from Pfizer’s 2012 Arthritis Advisory Committee Briefing Document. In subjects with a destroyed joint, we assumed a 50% decrease in pain reduction and structural efficacy for primary and revision total knee replacement surgery (TKR). We included drug, administration, and monitoring costs of Tanezumab. The price of one dose of Tanezumab (delivered every 8 weeks) was varied from $200 to $1,000. For each dose price, we considered self-administered subcutaneous injections vs. provider-administered IV infusion. The cost of an IV infusion varies by setting (non-hospital vs. hospital) and by whether it is billed as chemotherapy. Administrative costs therefore varied from $0 to $346 per dose in this analysis. Annual monitoring costs for IV infusions were fixed at $250 and included 2x/yr MD visits, 1x/yr blood tests, and biannual X-rays to check for OA progression. Monitoring costs for subcutaneous injections were $442, for two additional MD visits/yr. Cost-effectiveness was estimated as the ratio of incremental costs to incremental effectiveness (quality-adjusted life years, QALYs) when Tanezumab was added to current treatment for knee OA prior to primary TKR. Costs and QALYs were discounted at 3% per year. We defined a program as “cost-effective” if its cost-effectiveness ratio was below $100,000/QALY. In sensitivity analyses we varied efficacy, discontinuation, joint destruction rates and costs of Tanezumab. Results: In the base case analysis, Tanezumab led to an additional 0.27 quality-adjusted life years. It reduced primary TKR utilization by 17% and revision TKR utilization by 29%, and increased mean age at TKR from 67 to 70 years. Green shading in the Table indicates scenarios in which Tanezumab was cost-effective. Subcutaneous Tanezumab at $600/dose remained cost-effective when efficacy decreased by 20% and when discontinuation increased to 20%. Subcutaneous Tanezumab at $600/dose also remained cost-effective at a 2% joint destruction rate, but not when the joint destruction rate was increased to 5%. At joint destruction rates above 10%, Tanezumab decreased quality-adjusted life expectancy and did not represent a viable treatment option. Conclusions: Tanezumab (a promising NGF inhibitor in development) could be a cost-effective treatment for moderate to severe knee OA pain depending on the price of the drug and the delivery means. The value of Tanezumab depends on the rate of joint destruction. 656 EFFECTS OF DOXYCYCLINE AS AN ADJUVANT THERAPY ON THE WOMAC INDEX OF PATIENTS WITH PRIMARY KNEE OSTEOARTHRITIS S. Salman, A.M. Ahmed. Coll. of Med., Baghdad, Iraq Purpose: To examine the short-term effects of doxycycline compared with placebo on the WOMAC index (Western Ontario and McMaster Universities) of knee osteoarthritis during a 3-month treatment course. Methods:One hundred forty patients were enrolled in this randomized, placebo-controlled, double blind study. Half the patients (70) were randomly assigned to receive oral doxycycline capsule 100 mg twice daily in the drug group and the other half received a starch containing capsule (the placebo group). The efficacy outcome measure was the change in the WOMAC index. Results: There were no significant differences between the drug and placebo groups in pain score at the baseline visit (P1⁄40.63) or at the first visit one month later (P1⁄40.29). However, at the second visit, there was a significant reduction in pain score in the drug group compared to both placebo group (P1⁄40.028) and the baseline scores. At the third visit, three months later, the difference between both groups became more significant (P1⁄40.013). Stiffness and physical function scores in all comparisons in different visits showed no significant differences between both study groups.Mean WOMAC scores were reduced at each visit compared to its baseline value in drug group compared to the placebo group, and the reduction in mean score of baseline vs. third visit was significantly much higher in the treatment group (8.37±2.1) vs. (3.83±3.1) respectively, P

The emergence of recognition the operational level of warfare and the increased emphasis on joint operations within the U.S. military during the past decade has improved the country's warfighting capability and national security. The refinement of the operational art has progressed rapidly. The corresponding development of operational level logistics has lagged however. Logistics policy continues to be focused, at the strategic and tactical levels to the detriment of the operational level. More over, logistics issues tend to be viewed as scientific or quantitative exercises when the operational level demands a more artistic interpretation. Current logistics doctrine contains seven logistics principles as a corollary to the principles of war. The logistics principles span the three levels of warfare and thus do little to focus commanders' and logisticians' thought on the operational level. It is possible however, to construct a broad conceptual framework of four pillars that can help focus the thinking of operational commanders and theater logisticians. Examples of theater logistics from the Gulf War are cited to illustrate the conceptual framework.

SummaryThe prevalence of psychiatric morbidity (PM) was studied among general hospital out-patients in a rural and in a semi-urban area of Kenya. There were no significant differences in the demographic features of psychiatric patients from the two areas, so the results were pooled: this gave a PM prevalence rate of 29 per cent among 388 patients. Anxiety and depression were the most frequent diagnostic categories. Alcoholism was more common in the rural than in the semi-urban area. There was no sex difference in the prevalence of PM and possible reasons for this, which is in contrast to western findings, are discussed.Psychiatric symptoms could be readily elicited when present. Patients showing them had been ill longer than non-PM patients.The study suggests that clinic staff not psychiatrically trained should be able to identify and treat psychiatric morbidity, even when it is presented as somatic illness.

Salinity gradient heat engines represent an innovative and promising way to convert low-grade heat into electricity by employing salinity gradient technology in a closed-loop configuration. Among the aqueous solutions which can be used as working fluid, ammonium bicarbonate-water solutions appear very promising due to their capability to decompose at low temperature. In this work, an experimentally validated model for a reverse electrodialysis heat engine fed with ammonium bicarbonate-water solutions was developed. The model consists of two validated sub-models purposely integrated, one for the reverse electrodialysis unit and the other for the stripping/absorption regeneration unit. The impact of using current commercial membranes and future enhanced membranes on the efficiency of the system was evaluated, along with the effect of operating and design parameters through sensitivity analyses. Results indicated that exergy efficiency up to 8.5% may be obtained by considering enhanced future membranes and multi-column regeneration units.