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Boisseau W, Benomar A, Ducroux C, Fahed R, Smajda S, Diestro JDB, Charbonnier G, Ognard J, Burel J, Ter Schiphorst A, Boulanger M, Nehme A, Boucherit J, Marnat G, Volders D, Holay Q, Forestier G, Bretzner M, Roy D, Vingadassalom S, Elhorany M, Nico L, Jacquin G, Abdalkader M, Guedon A, Seners P, Janot K, Dumas V, Olatunji R, Gazzola S, Milot G, Zehr J, Darsaut TE, Iancu D, Raymond J. The Management of Persistent Distal Occlusions after Mechanical Thrombectomy and Thrombolysis: An Inter- and Intrarater Agreement Study. AJNR Am J Neuroradiol 2024:ajnr.A8149. [PMID: 38388684 DOI: 10.3174/ajnr.a8149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/24/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND AND PURPOSE The best management of patients with persistent distal occlusion after mechanical thrombectomy with or without IV thrombolysis remains unknown. We sought to evaluate the variability and agreement in decision-making for persistent distal occlusions. MATERIALS AND METHODS A portfolio of 60 cases was sent to clinicians with varying backgrounds and experience. Responders were asked whether they considered conservative management or rescue therapy (stent retriever, aspiration, or intra-arterial thrombolytics) a treatment option as well as their willingness to enroll patients in a randomized trial. Agreement was assessed using κ statistics. RESULTS The electronic survey was answered by 31 physicians (8 vascular neurologists and 23 interventional neuroradiologists). Decisions for rescue therapies were more frequent (n = 1116/1860, 60%) than for conservative management (n = 744/1860, 40%; P < .001). Interrater agreement regarding the final management decision was "slight" (κ = 0.12; 95% CI, 0.09-0.14) and did not improve when subgroups of clinicians were studied according to background, experience, and specialty or when cases were grouped according to the level of occlusion. On delayed re-questioning, 23 of 29 respondents (79.3%) disagreed with themselves on at least 20% of cases. Respondents were willing to offer trial participation in 1295 of 1860 (69.6%) cases. CONCLUSIONS Individuals did not agree regarding the best management of patients with persistent distal occlusion after mechanical thrombectomy and IV thrombolysis. There is sufficient uncertainty to justify a dedicated randomized trial.
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Affiliation(s)
- W Boisseau
- From the Department of Interventional Neuroradiology (W.B., S.S.), Fondation Rothschild Hospital, Paris, France
- Department of Radiology (W.B., A.B., D.R, D.I., J.R.), Centre Hospitalier de l'Université de Montréal Montréal, Canada
| | - A Benomar
- Department of Radiology (W.B., A.B., D.R, D.I., J.R.), Centre Hospitalier de l'Université de Montréal Montréal, Canada
| | - C Ducroux
- Department of Neurology (C.D., R.F.), Ottawa Hospital Research Institute & University of Ottawa, Ottawa, Canada
| | - R Fahed
- Department of Neurology (C.D., R.F.), Ottawa Hospital Research Institute & University of Ottawa, Ottawa, Canada
| | - S Smajda
- From the Department of Interventional Neuroradiology (W.B., S.S.), Fondation Rothschild Hospital, Paris, France
| | - J D B Diestro
- Division of Diagnostic and Therapeutic Neuroradiology (J.D.B.D., R.O.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - G Charbonnier
- Interventional Neuroradiology Department (G.C.), Besançon University Hospital, Besançon, France
| | - J Ognard
- Interventional Neuroradiology Department (J.O.), Hôpital de la Cavale Blanche, Brest, Bretagne, France
| | - J Burel
- Department of Radiology (J. Burel), Rouen University Hospital, Rouen, France
| | - A Ter Schiphorst
- Neurology Department (A.T.S.), CHRU Gui de Chauliac, Montpellier, France
| | - M Boulanger
- Department of Neurology (M. Boulanger, A.N.), Caen University Hospital, Caen, France
| | - A Nehme
- Department of Neurology (M. Boulanger, A.N.), Caen University Hospital, Caen, France
| | - J Boucherit
- Department of Radiology (J. Boucherit), Rennes University Hospital, Rennes, France
| | - G Marnat
- Department of Neuroradiology (G. Marnat), University Hospital of Bordeaux, Bordeaux, France
| | - D Volders
- From the Department of Interventional Neuroradiology (W.B., S.S.), Fondation Rothschild Hospital, Paris, France
| | - Q Holay
- Radiology Department (Q.H.), Hôpital d'Instruction des armées Saint-Anne, Toulon, France
| | - G Forestier
- Neuroradiology Department (G.F.), University Hospital of Limoges, Limoges, France
| | - M Bretzner
- Neuroradiology Department (M. Bretzner), CHU Lille, University Lille, Inserm, U1172 Lille Neuroscience & Cognition, F-59000, Lille, France
| | - D Roy
- Department of Radiology (W.B., A.B., D.R, D.I., J.R.), Centre Hospitalier de l'Université de Montréal Montréal, Canada
| | - S Vingadassalom
- Interventional Neuroradiology Department (S.V.), CHRU Marseille, La Timone, France
| | - M Elhorany
- Department of Neuroradiology (M.E.), Groupe Hospitalier de Pitié Salpêtrière, Paris, France
- Department of Neurology (M.E.), Tanta University, Tanta, Egypt
| | - L Nico
- Department of Radiology (L.N.), University Hospital of Padova, Padova, Italy
| | - G Jacquin
- Neurovascular Health Program (G.J.), Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - M Abdalkader
- Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - A Guedon
- Department of Neuroradiology (A.G.), Lariboisière Hospital, Paris, France
| | - P Seners
- Neurology Department (P.S.), Hôpital Fondation A. de Rothschild, Fondation Rothschild Hospital, Paris, France
- Institut de Psychiatrie et Neurosciences de Paris (P.S.), UMR_S1266, INSERM, Université de Paris, Paris, France
| | - K Janot
- Interventional Neuroradiology (K.J.), University Hospital of Tours, Tours, France
| | - V Dumas
- Radiology Department (V.D.), University Hospital of Poitiers, Poitiers, France
| | - R Olatunji
- Division of Diagnostic and Therapeutic Neuroradiology (J.D.B.D., R.O.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - S Gazzola
- From the Department of Interventional Neuroradiology (W.B., S.S.), Fondation Rothschild Hospital, Paris, France
- From the Department of Interventional Neuroradiology (W.B., S.S.), Fondation Rothschild Hospital, Paris, France
| | - G Milot
- Department of Radiology (W.B., A.B., D.R, D.I., J.R.), Centre Hospitalier de l'Université de Montréal Montréal, Canada
- Department of Radiology (W.B., A.B., D.R, D.I., J.R.), Centre Hospitalier de l'Université de Montréal Montréal, Canada
| | - J Zehr
- Department of Neurology (C.D., R.F.), Ottawa Hospital Research Institute & University of Ottawa, Ottawa, Canada
- Department of Neurology (C.D., R.F.), Ottawa Hospital Research Institute & University of Ottawa, Ottawa, Canada
| | - T E Darsaut
- Division of Diagnostic and Therapeutic Neuroradiology (J.D.B.D., R.O.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Division of Diagnostic and Therapeutic Neuroradiology (J.D.B.D., R.O.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D Iancu
- Department of Radiology (W.B., A.B., D.R, D.I., J.R.), Centre Hospitalier de l'Université de Montréal Montréal, Canada
| | - J Raymond
- Department of Radiology (W.B., A.B., D.R, D.I., J.R.), Centre Hospitalier de l'Université de Montréal Montréal, Canada
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Darsaut TE, Raymond J. Clinical decisions based on reasons that reason should ignore. Neurochirurgie 2023; 69:101496. [PMID: 37742488 DOI: 10.1016/j.neuchi.2023.101496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/19/2023] [Indexed: 09/26/2023]
Affiliation(s)
- T E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, 8440 112 St NW, Edmonton, Alberta, Canada
| | - J Raymond
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
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Chan VKY, Darsaut TE, Raymond J. Cross-overs and design issues in lumbar discectomy trials. Neurochirurgie 2023; 69:101462. [PMID: 37419080 DOI: 10.1016/j.neuchi.2023.101462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/20/2023] [Indexed: 07/09/2023]
Affiliation(s)
- V K Y Chan
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, 8440 112 Street NW, Edmonton, Alberta, Canada
| | - T E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, 8440 112 Street NW, Edmonton, Alberta, Canada
| | - J Raymond
- Department of Radiology, Service of Neuroradiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada.
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Chapman R, Summersby S, Lang T, Raymond J, Ballantyne K. Novices cannot fill the examiners' shoes: Evidence of footwear examiners' expertise in shoe comparisons. Sci Justice 2023; 63:598-611. [PMID: 37718007 DOI: 10.1016/j.scijus.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/13/2023] [Accepted: 07/16/2023] [Indexed: 09/19/2023]
Abstract
The value of a footwear examiner's opinion centres on their ability to determine whether a particular shoe made an impression with greater accuracy than a novice. However, there has been limited research on the expertise of footwear examiners and the accuracy and reproducibility of their decisions. In the current study, we measured the accuracy and consensus of 31 footwear examiners versus a comparison group of 29 novices. Participants completed 20 ground truth known mock shoe comparisons. Results demonstrated that footwear examiners were more accurate than novices, regardless of comparison difficulty. Overall, on trials where probative decisions were given, examiners made false identifications and false exclusions on a total of 3% and 2% of trials, while novices made false identifications and false exclusions on a total of 19% and 17% of trials. Examiners also demonstrated better consensus in their opinions than novices, although both groups demonstrated low levels of agreement in their responses and variability in their interpretation of the conclusion scale. In summary, these findings support the proposition that footwear examiners show expert-level performance in matching known and unknown footwear impressions. These performance estimates may help the criminal justice system to appropriately value footwear examination evidence.
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Affiliation(s)
- R Chapman
- Major Crime Scene Unit, Victoria Police Forensic Services Department, 31 Forensic Drive Macleod, VIC 3085, Australia
| | - S Summersby
- Office of the Chief Forensic Scientist, Victoria Police Forensic Services Department, 31 Forensic Drive Macleod, VIC 3085, Australia.
| | - T Lang
- Major Crime Scene Unit, Victoria Police Forensic Services Department, 31 Forensic Drive Macleod, VIC 3085, Australia; Office of the Chief Forensic Scientist, Victoria Police Forensic Services Department, 31 Forensic Drive Macleod, VIC 3085, Australia
| | - J Raymond
- Forensic Evidence and Technical Service Command, New South Wales Police Force, 151-241 Goulburn Street Surry Hills, NSW 2010, Australia
| | - K Ballantyne
- Office of the Chief Forensic Scientist, Victoria Police Forensic Services Department, 31 Forensic Drive Macleod, VIC 3085, Australia
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Chan VKY, Darsaut TE, Bailey CS, Raymond J. Understanding crossovers and potential ways to mitigate the problem: Lessons from influential trials on lumbar microdiscectomy. Neurochirurgie 2023; 69:101461. [PMID: 37450957 DOI: 10.1016/j.neuchi.2023.101461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Lumbar microdiscectomy is the most frequent surgical intervention used in the treatment of sciatica from herniated lumbar discs. Many discectomy trials have been plagued with an excessive number of crossovers that have rendered results inconclusive. METHODS We review the design and results of influential lumbar microdiscectomy trials. We also discuss the various strategies that have been used to decrease the number of crossovers or to mitigate the effects of crossovers on analyses. RESULTS Randomized trials on lumbar discectomy were affected by crossover rates of 8% to 42%. Various strategies that have been used to decrease that number or to mitigate the effects on results include: patient selection, blinding (placebo-controlled trials), an immediate access to surgery for the surgical group (but limited access to surgery for the conservative group), shortening the follow-up period necessary to reach the primary outcome measure, postponing crossovers to surgery after determination of the primary outcome, and modifying the primary outcome measure to include treatment failures. Crossovers should be anticipated and compensated for by increasing the number of participants. CONCLUSION Non-adherence to randomly allocated management options can deprive trials of the statistical power needed to inform clinical care. Crossovers and ways to mitigate related problems should be anticipated at the time of trial design.
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Affiliation(s)
- V K Y Chan
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, 8440 112, Street NW, Edmonton, Alberta, Canada
| | - T E Darsaut
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, 8440 112, Street NW, Edmonton, Alberta, Canada
| | - C S Bailey
- Department of Surgery, London Health Sciences Centre, London, Ontario, Canada
| | - J Raymond
- Department of Radiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada.
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Raymond J, Darsaut TE. Reply. AJNR Am J Neuroradiol 2023; 44:E36-E37. [PMID: 37500283 PMCID: PMC10411846 DOI: 10.3174/ajnr.a7958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Affiliation(s)
- J Raymond
- Department of RadiologyCentre Hospitalier de l'Université de MontréalMontreal, Québec, Canada
| | - T E Darsaut
- University of Alberta HospitalEdmonton, Alberta, Canada
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Raymond J, Chan VKY, Darsaut TE. Understanding how the research question impacts trial design: Examples from discectomy trials. Neurochirurgie 2023; 69:101460. [PMID: 37413815 DOI: 10.1016/j.neuchi.2023.101460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Formulating a pertinent research question is of the utmost importance in clinical research. An ill-conceived question may lead to an erroneous trial design, which may adversely affect the care of patients and provide uninformative or even misleading results. METHODS We review the research question of a randomized trial on the timing of lumbar discectomy. We compare the resulting design with other trials, real or hypothetical, that would have been more appropriate. RESULTS The RCT we examine randomly allocated patients to early or delayed surgery to answer a theoretical question of the effect of time on the efficacy of surgery. The trial was interpreted to have shown that early surgery was associated with better clinical and functional outcomes as compared to delayed surgery. This conclusion is clinically misleading. Valid comparisons between groups should be performed on intent-to-treat analyses and at the same time points after randomization (and not at a fixed follow-up period after surgery). The clinically pertinent comparison is not between the theoretical efficacy of surgery performed at various times, but between surgery and conservative management in patients presenting at various times. Better-designed trials on the clinical benefits of lumbar discectomy, including the treatment of chronic sciatica, have been published. CONCLUSION Theoretical research questions inspired from observational data can lead to erroneous trial design. Prospective randomized trials impact practice immediately: they are unique occasions to address clinical problems and optimize care under uncertainty in real time. However, they require the research question to be formulated with great care.
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Affiliation(s)
- J Raymond
- Division of Neurosurgery, Department of Radiology, service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada.
| | - V K Y Chan
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - T E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Darsaut TE, Raymond J. 'It is not the answer which enlightens, but the question'. Neurochirurgie 2023; 69:101446. [PMID: 37178487 DOI: 10.1016/j.neuchi.2023.101446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 04/18/2023] [Indexed: 05/15/2023]
Affiliation(s)
- T E Darsaut
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, 8440 112 St NW, Edmonton, Alberta, Canada
| | - J Raymond
- Department of Radiology, Service of Neuroradiology, centre hospitalier de l'université de Montréal (CHUM), room D03.5462b, Montreal, H2X 0C1 Quebec, Canada.
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Darsaut TE, Findlay JM, Bojanowski MW, Chalaala C, Iancu D, Roy D, Weill A, Boisseau W, Diouf A, Magro E, Kotowski M, Keough MB, Estrade L, Bricout N, Lejeune JP, Chow MMC, O'Kelly CJ, Rempel JL, Ashforth RA, Lesiuk H, Sinclair J, Erdenebold UE, Wong JH, Scholtes F, Martin D, Otto B, Bilocq A, Truffer E, Butcher K, Fox AJ, Arthur AS, Létourneau-Guillon L, Guilbert F, Chagnon M, Zehr J, Farzin B, Gevry G, Raymond J. A Pragmatic Randomized Trial Comparing Surgical Clipping and Endovascular Treatment of Unruptured Intracranial Aneurysms. AJNR Am J Neuroradiol 2023; 44:634-640. [PMID: 37169541 PMCID: PMC10249696 DOI: 10.3174/ajnr.a7865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/10/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND AND PURPOSE Surgical clipping and endovascular treatment are commonly used in patients with unruptured intracranial aneurysms. We compared the safety and efficacy of the 2 treatments in a randomized trial. MATERIALS AND METHODS Clipping or endovascular treatments were randomly allocated to patients with one or more 3- to 25-mm unruptured intracranial aneurysms judged treatable both ways by participating physicians. The study hypothesized that clipping would decrease the incidence of treatment failure from 13% to 4%, a composite primary outcome defined as failure of aneurysm occlusion, intracranial hemorrhage during follow-up, or residual aneurysms at 1 year, as adjudicated by a core lab. Safety outcomes included new neurologic deficits following treatment, hospitalization of >5 days, and overall morbidity and mortality (mRS > 2) at 1 year. There was no blinding. RESULTS Two hundred ninety-one patients were enrolled from 2010 to 2020 in 7 centers. The 1-year primary outcome, ascertainable in 290/291 (99%) patients, was reached in 13/142 (9%; 95% CI, 5%-15%) patients allocated to surgery and in 28/148 (19%; 95% CI, 13%-26%) patients allocated to endovascular treatments (relative risk: 2.07; 95% CI, 1.12-3.83; P = .021). Morbidity and mortality (mRS >2) at 1 year occurred in 3/143 and 3/148 (2%; 95% CI, 1%-6%) patients allocated to surgery and endovascular treatments, respectively. Neurologic deficits (32/143, 22%; 95% CI, 16%-30% versus 19/148, 12%; 95% CI, 8%-19%; relative risk: 1.74; 95% CI, 1.04-2.92; P = .04) and hospitalizations beyond 5 days (69/143, 48%; 95% CI, 40%-56% versus 12/148, 8%; 95% CI, 5%-14%; relative risk: 0.18; 95% CI, 0.11-0.31; P < .001) were more frequent after surgery. CONCLUSIONS Surgical clipping is more effective than endovascular treatment of unruptured intracranial aneurysms in terms of the frequency of the primary outcome of treatment failure. Results were mainly driven by angiographic results at 1 year.
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Affiliation(s)
- T E Darsaut
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | - J M Findlay
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | | | | | - D Iancu
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - D Roy
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - A Weill
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - W Boisseau
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - A Diouf
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - E Magro
- Service of Neurosurgery (E.M.), Centre Hospitalier Universitaire Cavale Blanche, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1101 LaTIM, Brest, France
| | - M Kotowski
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - M B Keough
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | - L Estrade
- Interventional Neuroradiology (L.E., N.B.)
| | - N Bricout
- Interventional Neuroradiology (L.E., N.B.)
| | - J-P Lejeune
- Service of Neurosurgery (J.-P.L.), Centre Hospitalier Universitaire de Lille, Lille, France
| | - M M C Chow
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | - C J O'Kelly
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | - J L Rempel
- Department of Surgery, and Department of Radiology and Diagnostic Imaging (J.L.R., R.A.A.), Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - R A Ashforth
- Department of Surgery, and Department of Radiology and Diagnostic Imaging (J.L.R., R.A.A.), Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - H Lesiuk
- Section of Neurosurgery (H.L., J.S.)
| | | | - U-E Erdenebold
- Department of Surgery, and Department of Medical Imaging (U.-E.E.), Section of Interventional Neuroradiology, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - J H Wong
- Division of Neurosurgery (J.H.W.), Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - F Scholtes
- Departments of Neurosurgery (F.S., D.M.)
| | - D Martin
- Departments of Neurosurgery (F.S., D.M.)
| | - B Otto
- Medical Physics (B.O.), Division of Medical Imaging, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - A Bilocq
- Service of Neurosurgery (A.B., E.T.), Centre Hospitalier Régional de Trois-Rivières, Trois-Rivières, Québec, Canada
| | - E Truffer
- Service of Neurosurgery (A.B., E.T.), Centre Hospitalier Régional de Trois-Rivières, Trois-Rivières, Québec, Canada
| | - K Butcher
- Clinical Neurosciences (K.B.), Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia
| | - A J Fox
- Department of Medical Imaging (A.J.F.), University of Toronto, Toronto, Ontario, Canada
| | - A S Arthur
- Department of Neurosurgery (A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis, Tennessee
| | - L Létourneau-Guillon
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - F Guilbert
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - M Chagnon
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montréal, Québec, Canada
| | - J Zehr
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montréal, Québec, Canada
| | - B Farzin
- Research Centre of the University of Montreal Hospital Centre (B.F., G.G., J.R.), Interventional Neuroradiology Research Laboratory, Montreal, Québec, Canada
| | - G Gevry
- Research Centre of the University of Montreal Hospital Centre (B.F., G.G., J.R.), Interventional Neuroradiology Research Laboratory, Montreal, Québec, Canada
| | - J Raymond
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
- Research Centre of the University of Montreal Hospital Centre (B.F., G.G., J.R.), Interventional Neuroradiology Research Laboratory, Montreal, Québec, Canada
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Boisseau W, Darsaut TE, Fahed R, Drake B, Lesiuk H, Rempel JL, Gentric JC, Ognard J, Nico L, Iancu D, Roy D, Weill A, Chagnon M, Zehr J, Lavoie P, Nguyen TN, Raymond J. Stent-Assisted Coiling in the Treatment of Unruptured Intracranial Aneurysms: A Randomized Clinical Trial. AJNR Am J Neuroradiol 2023; 44:381-389. [PMID: 36927759 PMCID: PMC10084896 DOI: 10.3174/ajnr.a7815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/16/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND AND PURPOSE Stent-assisted coiling may improve angiographic results of endovascular treatment of unruptured intracranial aneurysms compared with coiling alone, but this has never been shown in a randomized trial. MATERIALS AND METHODS The Stenting in the Treatment of Aneurysm Trial was an investigator-led, parallel, randomized (1:1) trial conducted in 4 university hospitals. Patients with intracranial aneurysms at risk of recurrence, defined as large aneurysms (≥10 mm), postcoiling recurrent aneurysms, or small aneurysms with a wide neck (≥4 mm), were randomly allocated to stent-assisted coiling or coiling alone. The composite primary efficacy outcome was "treatment failure," defined as initial failure to treat the aneurysm; aneurysm rupture or retreatment during follow-up; death or dependency (mRS > 2); or an angiographic residual aneurysm adjudicated by an independent core laboratory at 12 months. The primary hypothesis (revised for slow accrual) was that stent-assisted coiling would decrease treatment failures from 33% to 15%, requiring 200 patients. Primary analyses were intent to treat. RESULTS Of 205 patients recruited between 2011 and 2021, ninety-four were allocated to stent-assisted coiling and 111 to coiling alone. The primary outcome, ascertainable in 203 patients, was reached in 28/93 patients allocated to stent-assisted coiling (30.1%; 95% CI, 21.2%-40.6%) compared with 30/110 (27.3%; 95% CI, 19.4%-36.7%) allocated to coiling alone (relative risk = 1.10; 95% CI, 0.7-1.7; P = .66). Poor clinical outcomes (mRS >2) occurred in 8/94 patients allocated to stent-assisted coiling (8.5%; 95% CI, 4.0%-16.6%) compared with 6/111 (5.4%; 95% CI, 2.2%-11.9%) allocated to coiling alone (relative risk = 1.6; 95% CI, 0.6%-4.4%; P = .38). CONCLUSIONS The STAT trial did not show stent-assisted coiling to be superior to coiling alone for wide-neck, large, or recurrent unruptured aneurysms.
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Affiliation(s)
- W Boisseau
- From the Department of Radiology (W.B., D.I., D.R., A.W., J.R.), Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - T E Darsaut
- Department of Surgery (T.E.D.), Division of Neurosurgery
| | - R Fahed
- Departments of Neurology (R.F.)
| | - B Drake
- Neurosurgery (B.D., H.L.), University of Ottawa, the Ottawa Hospital, Ottawa, Ontario, Canada
| | - H Lesiuk
- Neurosurgery (B.D., H.L.), University of Ottawa, the Ottawa Hospital, Ottawa, Ontario, Canada
| | - J L Rempel
- Department of Radiology and Diagnostic Imaging (J.L.R.), University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - J-C Gentric
- Department of Radiology (J.-C.G., J.O.), University Hospital of Brest, Brest, France
| | - J Ognard
- Department of Radiology (J.-C.G., J.O.), University Hospital of Brest, Brest, France
| | - L Nico
- Departement of Radiology (L.N.), Service of Interventional Neuroradiology, Centre Hospitalo-universitaire de Saint-Etienne, Saint-Etienne, France
| | - D Iancu
- From the Department of Radiology (W.B., D.I., D.R., A.W., J.R.), Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - D Roy
- From the Department of Radiology (W.B., D.I., D.R., A.W., J.R.), Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - A Weill
- From the Department of Radiology (W.B., D.I., D.R., A.W., J.R.), Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - M Chagnon
- Department of Mathematics and Statistics (M.C., J.Z.), Pavillon André-Aisenstadt, Montreal, Québec, Canada
| | - J Zehr
- Department of Mathematics and Statistics (M.C., J.Z.), Pavillon André-Aisenstadt, Montreal, Québec, Canada
| | - P Lavoie
- Department of Neurosurgery (P.L.), Centre Hospitalier Universitaire de Québec-Université Laval, Québec, Canada
| | - T N Nguyen
- Departments of Neurology (T.N.N.)
- Radiology (T.N.N.), Boston Medical Center, Boston, Massachusetts
| | - J Raymond
- From the Department of Radiology (W.B., D.I., D.R., A.W., J.R.), Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
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Raymond J, Rheaume AR, Olijnyk L, Lecaros NE, Darsaut TE. Understanding the difference between theory and practice: The extracranial-intracranial bypass trials in prevention of ischemic stroke. Neurochirurgie 2023; 69:101407. [PMID: 36689827 DOI: 10.1016/j.neuchi.2023.101407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Patients with atherosclerotic carotid or middle cerebral artery occlusions suffer ischemic events that might theoretically be preventable with a surgical extracranial-intracranial bypass, but theory by itself does not justify surgical interventions. METHODS We review landmark randomized trials on EC-IC bypass surgery for the treatment of ischemic stroke in patients with atherosclerotic stenoses or occlusions. RESULTS The initial EC-IC bypass trial from 1985 did not show any clinical benefit from surgery. The carotid occlusion surgery study (COSS) performed more than 20 years later included only patients highly selected to potentially benefit from bypass by using modern perfusion studies. While EC-IC bypasses were successfully created and they did improve cerebral perfusion, the COSS study also failed to show any clinical benefit to the participating patients. CONCLUSION Neurosurgical interventions must not only work in theory; they must improve patient outcomes in real practice.
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Affiliation(s)
- J Raymond
- Department of radiology, Service of neuroradiology, Centre hospitalier de l'université de Montréal (CHUM), Montréal, Québec, Canada.
| | - A R Rheaume
- Division of neurosurgery, Department of surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - L Olijnyk
- Department of radiology, Service of neuroradiology, Centre hospitalier de l'université de Montréal (CHUM), Montréal, Québec, Canada
| | - N E Lecaros
- Department of radiology, Service of neuroradiology, Centre hospitalier de l'université de Montréal (CHUM), Montréal, Québec, Canada
| | - T E Darsaut
- Division of neurosurgery, Department of surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Collins J, Benomar A, Iancu D, Farzin B, Darsaut TE, Raymond J. Research participants may not recall their participation but have a better understanding of alternative management options than patients in routine care. Neurochirurgie 2023; 69:101392. [PMID: 36669431 DOI: 10.1016/j.neuchi.2022.101392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/23/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Patient understanding of care interventions, of the clinical uncertainty, and of their participation in clinical research is often poor. We hypothesized that compared to routine care, patients would better understand the prevailing uncertainty when they participated in research. METHODS A questionnaire was administered to patients at the time they attended a follow-up neurovascular clinic 4 to 52 weeks after a care episode where they did or did not participate in a clinical trial. Patients were not reminded whether they had previously participated in a clinical trial. Questions concerned their understanding of the risks/benefits of interventions, the availability of alternative options, whether their personal opinion was taken into consideration, the reason for the final decision, their confidence at having received the best management, and whether they had been research participants. RESULTS Between June 2019 and June 2020, 167 patients were recruited; 71 had truly been research participants, while 96 had not. A greater proportion of research patients were aware of the existence of management alternatives (65% versus 44%; P=0.008). Patients of both groups believed their personal opinion counted in the final decision (76% versus 70%), and patients were equally confident that they had received the best management (94%). Research patients believed they had participated in research 46% of the time, compared to 12% of routine care patients (P=0.003). CONCLUSION Many patients do not recall that they participated in a clinical trial, but they have a better understanding of the clinical uncertainty and of the availability of alternative management options.
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Affiliation(s)
- J Collins
- Interventional Neuroradiology Research laboratory, CHUM Research Centre, Montreal, Quebec, Canada
| | - A Benomar
- Interventional Neuroradiology Research laboratory, CHUM Research Centre, Montreal, Quebec, Canada; Department of Radiology, service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - D Iancu
- Interventional Neuroradiology Research laboratory, CHUM Research Centre, Montreal, Quebec, Canada; Department of Radiology, service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - B Farzin
- Interventional Neuroradiology Research laboratory, CHUM Research Centre, Montreal, Quebec, Canada
| | - T E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - J Raymond
- Interventional Neuroradiology Research laboratory, CHUM Research Centre, Montreal, Quebec, Canada; Department of Radiology, service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
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13
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Rheaume AR, Olijnyk L, Lecaros NE, Darsaut TE, Raymond J. Understanding how the primary endpoint impacts the interpretation of trial results: The Japanese Adult Moyamoya bypass trial. Neurochirurgie 2023; 69:101408. [PMID: 36701981 DOI: 10.1016/j.neuchi.2023.101408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND The meaning of a clinical trial depends to a large extent on the choice of the primary outcome measure, which can be explanatory or pragmatic. METHODS We review the Japanese Adult Moyamoya (JAM) trial, that compared surgical extracranial to intracranial (EC-IC) bypass and medical management of hemorrhagic moyamoya disease. We also review some principles which guide the selection of the primary trial endpoint. DISCUSSION The main component of the primary outcome measure in JAM was rebleeding, a surrogate outcome that allowed investigators to demonstrate that surgical bypass had causal efficacy. However, the number of patients with a poor outcome, defined as those with a modified Rankin score (mRS)>2, would have been a more pragmatic choice. Unfortunately, the trial was too small to show that patients benefited from surgery. CONCLUSION The JAM trial showed that EC-IC bypass can decrease rebleeding in moyamoya patients, but whether patients have better outcomes with surgery remains uncertain. Hard pragmatic clinical primary outcome measures are necessary to guide surgical care.
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Affiliation(s)
- A R Rheaume
- Division of neurosurgery, department of surgery, university of Alberta Hospital, Mackenzie Health Sciences centre, Edmonton, Alberta, Canada
| | - L Olijnyk
- Department of radiology, service of neuroradiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada
| | - N E Lecaros
- Department of radiology, service of neuroradiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada
| | - T E Darsaut
- Division of neurosurgery, department of surgery, university of Alberta Hospital, Mackenzie Health Sciences centre, Edmonton, Alberta, Canada
| | - J Raymond
- Department of radiology, service of neuroradiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada.
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Raymond J, Olijnyk L, Lecaros NE, Rheaume AR, Darsaut TE. When successful surgery may not be beneficial to patients. Neurochirurgie 2023; 69:101406. [PMID: 36706512 DOI: 10.1016/j.neuchi.2023.101406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 01/26/2023]
Affiliation(s)
- J Raymond
- Centre hospitalier de l'université de Montreal, Montreal, Canada.
| | - L Olijnyk
- Centre hospitalier de l'université de Montreal, Montreal, Canada
| | - N E Lecaros
- Centre hospitalier de l'université de Montreal, Montreal, Canada
| | - A R Rheaume
- Division of neurosurgery, department of surgery, university of Alberta hospital, Mackenzie health sciences centre, Edmonton, Alberta, Canada
| | - T E Darsaut
- Division of neurosurgery, department of surgery, university of Alberta hospital, Mackenzie health sciences centre, Edmonton, Alberta, Canada
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Crayle J, Lutz M, Raymond J, Mehta P, Bedlack R. Study of "ALS reversals": LifeTime environmental exposures (StARLiTE). Amyotroph Lateral Scler Frontotemporal Degener 2023; 24:54-62. [PMID: 35775279 DOI: 10.1080/21678421.2022.2090846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
We previously reported on a series of patients diagnosed with ALS whom had an extraordinary course defined by substantial and sustained improvement in weakness and function. For this study, twenty-five of these "ALS Reversals" completed extensive environmental exposure questionnaires. These responses were then compared to a large database of prior responses from patients with typically progressive ALS (n = 6187). The results demonstrated that the "Reversal" participants have had a diverse number of exposures with substantial heterogeneity. In general, this was similar to the control group; however, there were a few specific differences that could be further explored in future research.
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Affiliation(s)
- J Crayle
- Department of Neurology, Washington University in Saint Louis, Saint Louis, MO, USA
| | - M Lutz
- Department of Neurology, Duke University, Durham, NC, USA
| | - J Raymond
- Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry, National ALS Registry, Atlanta, GA, USA
| | - P Mehta
- Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry, National ALS Registry, Atlanta, GA, USA
| | - R Bedlack
- Department of Neurology, Duke University, Durham, NC, USA
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Eneling J, Darsaut TE, Raymond J. Trying to learn research methodology from the vertebroplasty saga. Neurochirurgie 2023; 69:101400. [PMID: 36608448 DOI: 10.1016/j.neuchi.2022.101400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/09/2022] [Indexed: 01/06/2023]
Affiliation(s)
- J Eneling
- Department of Radiology, service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - T E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - J Raymond
- Department of Radiology, service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
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Darsaut TE, Collins J, Raymond J. Patients may be right: Clinical research should be designed in their best medical interest. Neurochirurgie 2023; 69:101391. [PMID: 36608449 DOI: 10.1016/j.neuchi.2022.101391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/23/2022] [Indexed: 01/05/2023]
Affiliation(s)
- T E Darsaut
- University of Alberta Hospital, Mackenzie Health Sciences Centre, Department of Surgery, Division of Neurosurgery, 112 Street, 8440 Edmonton, Alberta, Canada
| | - J Collins
- Centre hospitalier de l'université de Montréal - CHUM, Department of Radiology, Service of Interventional Neuroradiology, 1000, St-Denis street room, D03-5462B Montreal, Canada
| | - J Raymond
- Centre hospitalier de l'université de Montréal - CHUM, Department of Radiology, Service of Interventional Neuroradiology, 1000, St-Denis street room, D03-5462B Montreal, Canada.
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18
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Eneling J, Darsaut TE, Patel M, Raymond J. Understanding explanatory and pragmatic trials: Examples from randomized controlled trials on vertebroplasty. Neurochirurgie 2023; 69:101403. [PMID: 36566693 DOI: 10.1016/j.neuchi.2022.101403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/09/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To better understand the explanatory-pragmatic distinction in the design and interpretation of randomized controlled trials (RCTs). METHODS We review the explanatory-pragmatic distinction in clinical trial design. We use the PRECIS-2 tool to evaluate the trial design of selected RCTs on percutaneous vertebroplasty for osteoporotic vertebral compression fractures. We discuss difficulties in the selection of criteria and in the construction of PRECIS diagrams. We also examine how inconsistency in the selection of various items of trial design can cause confusion in the interpretation of results. RESULTS The selection of criteria and the scoring of multiple PRECIS domains were subjective and thus debatable. The pragmascope patterns of various vertebroplasty trials were heterogeneous. Many trials had both pragmatic and explanatory components. Some placebo-controlled trial goals seem to have been explanatory, but their design actually included enough pragmatic items such that the meaning of negative trial results remains ambiguous. CONCLUSION The results of a trial cannot be interpreted without understanding the various design choices made along the explanatory-pragmatic spectrum.
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Affiliation(s)
- J Eneling
- Department of radiology, service of neuroradiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada
| | - T E Darsaut
- Division of neurosurgery, department of surgery, university of Alberta hospital, Mackenzie health sciences centre, Edmonton, Alberta, Canada
| | - M Patel
- Division of neurosurgery, department of surgery, university of Alberta hospital, Mackenzie health sciences centre, Edmonton, Alberta, Canada
| | - J Raymond
- Department of radiology, service of neuroradiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada.
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Eneling J, Darsaut TE, Veilleux C, Raymond J. Understanding power in randomized trials: The example of vertebroplasty. Neurochirurgie 2023; 69:101402. [PMID: 36621210 DOI: 10.1016/j.neuchi.2022.101402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/09/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Randomized trials (RCTs) should include a sufficient number of patients to reduce the risk that the observed outcome is a result of chance rather than from a truly different treatment effect. Trials must be even larger to claim an absence of treatment effect in a placebo-controlled trial. To estimate the size of the trial and maximize power, it is often suggested to use a comparison between the means of a continuous variable. METHODS We examine the RCTs that have compared vertebroplasty and placebo for patients with osteoporotic fractures. Most trials compared the means of a continuous pain score to yield implausibly small trials, as small as 24 patients per group. RESULTS The minimally significant difference between groups has no precise clinical meaning for patients when it is based on a comparison of means of pain scores. A comparison of the proportions of patients reaching a per-patient outcome measure of treatment success is much more pertinent if the trial is to inform the care of future patients. The resulting trials will admittedly need to be larger, but they will be much less likely to fall prey to the 'evidence of absence' fallacy. Furthermore, trial size should also take into consideration harder clinical outcome measures, such as death and disability. CONCLUSION When the goal of a trial is to inform outcome-based medical care, comparing the proportions of patients reaching a clinically pertinent outcome is more appropriate than comparing the means of a continuous variable.
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Affiliation(s)
- J Eneling
- Department of radiology, service of neuroradiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada
| | - T E Darsaut
- Division of neurosurgery, department of surgery, university of Alberta hospital, Mackenzie health sciences centre, Edmonton, Alberta, Canada
| | - C Veilleux
- Division of neurosurgery, department of clinical neurosciences, university of Calgary, Alberta, Canada
| | - J Raymond
- Department of radiology, service of neuroradiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada.
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Darsaut TE, Chagnon M, Raymond J. Reply. AJNR Am J Neuroradiol 2023; 44:E9-E10. [PMID: 36574315 PMCID: PMC9835901 DOI: 10.3174/ajnr.a7732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- T E Darsaut
- Department of Surgery, Division of NeurosurgeryMackenzie Health Sciences CentreUniversity of Alberta HospitalEdmonton, Alberta, Canada
| | - M Chagnon
- Department of Mathematics and StatisticsUniversité de MontréalMontreal, Quebec, Canada
| | - J Raymond
- Department of Radiology, Service of Interventional NeuroradiologyCentre Hospitalier de l'Université de MontréalMontreal, Quebec, Canada
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Raymond J, Collins J, Darsaut TE. Understanding the research-care demarcation and why it must be revised. Neurochirurgie 2023; 69:101393. [PMID: 36566695 DOI: 10.1016/j.neuchi.2022.101393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/23/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND A clean-cut separation between research and care was artificially created at the time of the Belmont report more than 40 years ago. The demarcation was initially controversial but eventually was implemented for political reasons. We examine why it must be revised. METHODS We review historical research scandals as well as the theoretical basis for the Belmont demarcation. We then discuss consequences on medical practice and propose an alternative. DISCUSSION Most research scandals involved abusing human beings supposedly for the sake of science. Belmont commissioners were aware the research/care problem was double-headed. While research subjects should be protected from abuse in the research context, patients need to be protected from unvalidated medical and surgical interventions in the care context. For political reasons the Commission recommended the regulation of research but to leave medical practice untouched. Thus the Commission had to distinguish research from care. The notion of 'generalizable knowledge' was introduced to define and regulate research, but the inadvertent result was that by trying to protect research subjects, the regulation has not only failed to protect all other patients, but also encouraged the widespread practice of unvalidated interventions within the care context. The notion of validated care should be re-introduced into a proper analysis of the care-research demarcation, for care research is an integral ingredient of a good medical practice. CONCLUSION The research-care demarcation should be revised to leave room for the validated/unvalidated care distinction. Care research, essential to guide medical practice, should be facilitated at all levels.
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Affiliation(s)
- J Raymond
- Centre Hospitalier de l'Université de Montréal-CHUM, Department of Radiology, Service of Interventional Neuroradiology, 1000 St-Denis, Montreal H2X 0C1, Canada.
| | - J Collins
- Centre Hospitalier de l'Université de Montréal-CHUM, Department of Radiology, Service of Interventional Neuroradiology, 1000 St-Denis, Montreal H2X 0C1, Canada.
| | - T E Darsaut
- University of Alberta Hospital, Mackenzie Health Sciences Centre, Department of Surgery, Division of Neurosurgery, 8440 - 112 Street, Edmonton T6G 2B7, Alberta, Canada.
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Eneling J, Darsaut TE, Veilleux C, Raymond J. Understanding the choice of control group: A systematic review of vertebroplasty trials for osteoporotic vertebral compression fractures. Neurochirurgie 2023; 69:101401. [PMID: 36566694 DOI: 10.1016/j.neuchi.2022.101401] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/09/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To better understand the choice of the comparator intervention in the design of clinical trials and its impact on the meaning of results we review randomized trials on vertebroplasty. METHODS We conducted a systematic and narrative review of all randomized trials on vertebroplasty. Trials are categorized according to the comparator intervention (non-surgical management, placebo/sham vertebroplasty, and kyphoplasty). RESULTS All trials were too small to show a difference in objective clinical outcomes, and 20 of 23 RCTs used mean pain scores to compare interventions. Most trials comparing vertebroplasty with non-surgical management concluded that vertebroplasty was superior. Trials comparing kyphoplasty with vertebroplasty showed similar results for both interventions. However, 4 of 5 trials comparing vertebroplasty with placebo surgery failed to show a significant difference between groups. CONCLUSION The clinical results of an intervention cannot be interpreted without a comparison that involves a control group. The choice of comparator intervention can change the meaning of the trial. A large pragmatic trial, using hard clinical outcomes such as morbidity and mortality as a primary outcome measure, would be needed to assess the potential clinical benefits of vertebroplasty.
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Affiliation(s)
- J Eneling
- Department of Radiology, Service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
| | - T E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - C Veilleux
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - J Raymond
- Department of Radiology, Service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
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Waszczuk JR, Peacock L, Chadwick S, Maynard P, Raymond J, Roux C. Misidentifications of alphanumeric characters in serial number restorations. AUST J FORENSIC SCI 2022. [DOI: 10.1080/00450618.2022.2149855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- J. R Waszczuk
- Centre for Forensic Science, School of Mathematical and Physical Sciences, University of Technology Sydney, Ultimo, Australia
- Firearms Identification & Armoury Team, Australian Federal Police, Majura, Australia
| | - L. Peacock
- Centre for Forensic Science, School of Mathematical and Physical Sciences, University of Technology Sydney, Ultimo, Australia
| | - S. Chadwick
- Centre for Forensic Science, School of Mathematical and Physical Sciences, University of Technology Sydney, Ultimo, Australia
| | - P. Maynard
- Centre for Forensic Science, School of Mathematical and Physical Sciences, University of Technology Sydney, Ultimo, Australia
| | - J. Raymond
- Science and Research Unit, Forensic Evidence & Technical Services Command, New South Wales Police Force, Sydney, Australia
| | - C. Roux
- Centre for Forensic Science, School of Mathematical and Physical Sciences, University of Technology Sydney, Ultimo, Australia
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Raymond J, Obaid S, Darsaut TE. Why are surgical trials so difficult to accomplish, and then considered so definitive? Neurochirurgie 2022; 68:560-561. [PMID: 35787923 DOI: 10.1016/j.neuchi.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 02/06/2023]
Affiliation(s)
- J Raymond
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
| | - S Obaid
- Department of Neurosurgery, Comprehensive Epilepsy Center, Yale School of Medicine, New Haven, CT, USA
| | - T E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Ducroux C, Boisseau W, Poppe AY, Daneault N, Deschaintre Y, Diestro JDB, Eneling J, Gioia LC, Iancu D, Maier B, Nauche B, Nico L, Odier C, Raymond J, Roy D, Stapf C, Weill A, Jacquin G. Successful Reperfusion is Associated with Favorable Functional Outcome despite Vessel Perforation during Thrombectomy: A Case Series and Systematic Review. AJNR Am J Neuroradiol 2022; 43:1633-1638. [PMID: 36175082 PMCID: PMC9731237 DOI: 10.3174/ajnr.a7650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 07/17/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Arterial perforation is a potentially serious complication during endovascular thrombectomy. PURPOSE Our aim was to describe interventional approaches after arterial perforation during endovascular thrombectomy and to determine whether reperfusion remains associated with favorable outcome despite this complication. DATA SOURCES Data from consecutive patients with acute stroke undergoing endovascular thrombectomy were retrospectively collected between 2015 to 2020 from a single-center cohort, and a systematic review was performed using PubMed, EMBASE, and Ovid MEDLINE up to June 2020. STUDY SELECTION Articles reporting functional outcome after arterial perforation during endovascular thrombectomy were selected. DATA ANALYSIS Functional outcomes of patients achieving successful reperfusion (TICI 2b/3) were compared with outcomes of those with unsuccessful reperfusion in our single-center cohort. We then summarized the literature review to describe interventional approaches and outcomes after arterial perforation during endovascular thrombectomy. DATA SYNTHESIS In our single-center cohort, 1419 patients underwent endovascular thrombectomy, among whom 32 (2.3%) had vessel perforation and were included in the analysis. The most common hemostatic strategy was watchful waiting (71% of cases). Patients with successful reperfusion had a higher proportion of favorable 90-day mRS scores (60% versus 12.5%; P = .006) and a lower mortality rate (13.3% versus 56.3%, P = .01) than patients without successful reperfusion. Thirteen articles were included in the systematic review. Successful reperfusion also appeared to be associated with better outcomes. LIMITATIONS Given the low number of published reports, we performed only a descriptive analysis. CONCLUSIONS Arterial perforation during endovascular thrombectomy is rare but is associated with high mortality rates and poor outcome. However, successful reperfusion remains correlated with favorable outcome in these patients.
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Affiliation(s)
- C Ducroux
- From the Department of Neurosciences (C.D., A.Y.P., N.D., Y.D. L.C.G., C.O., C.S., G.J.), Faculté de médecine, Université de Montréal, Montréal, Quebec. Canada
- Departments of Medicine (Neurology) (C.D., A.Y.P., N.D., Y.D., L.C.G., C.O., C.S., G.J.)
- Division of Neurology (C.D.), Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - W Boisseau
- Radiology (W.B., J.D.B.D., J.E., D.I., B.M., L.N., J.R., D.R., A.W.)
- Department of Interventional Neuroradiology (W.B., B.M.), Hopital Fondation A. De Rothschild, Paris, France
| | - A Y Poppe
- From the Department of Neurosciences (C.D., A.Y.P., N.D., Y.D. L.C.G., C.O., C.S., G.J.), Faculté de médecine, Université de Montréal, Montréal, Quebec. Canada
- Departments of Medicine (Neurology) (C.D., A.Y.P., N.D., Y.D., L.C.G., C.O., C.S., G.J.)
- Neurovascular Group (A.Y.P., N.D., Y.D., L.C.G., C.O., C.S., G.J.), Neurosciences Axis, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - N Daneault
- From the Department of Neurosciences (C.D., A.Y.P., N.D., Y.D. L.C.G., C.O., C.S., G.J.), Faculté de médecine, Université de Montréal, Montréal, Quebec. Canada
- Departments of Medicine (Neurology) (C.D., A.Y.P., N.D., Y.D., L.C.G., C.O., C.S., G.J.)
- Neurovascular Group (A.Y.P., N.D., Y.D., L.C.G., C.O., C.S., G.J.), Neurosciences Axis, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Y Deschaintre
- From the Department of Neurosciences (C.D., A.Y.P., N.D., Y.D. L.C.G., C.O., C.S., G.J.), Faculté de médecine, Université de Montréal, Montréal, Quebec. Canada
- Departments of Medicine (Neurology) (C.D., A.Y.P., N.D., Y.D., L.C.G., C.O., C.S., G.J.)
- Neurovascular Group (A.Y.P., N.D., Y.D., L.C.G., C.O., C.S., G.J.), Neurosciences Axis, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - J D B Diestro
- Radiology (W.B., J.D.B.D., J.E., D.I., B.M., L.N., J.R., D.R., A.W.)
| | - J Eneling
- Radiology (W.B., J.D.B.D., J.E., D.I., B.M., L.N., J.R., D.R., A.W.)
| | - L C Gioia
- From the Department of Neurosciences (C.D., A.Y.P., N.D., Y.D. L.C.G., C.O., C.S., G.J.), Faculté de médecine, Université de Montréal, Montréal, Quebec. Canada
- Departments of Medicine (Neurology) (C.D., A.Y.P., N.D., Y.D., L.C.G., C.O., C.S., G.J.)
- Neurovascular Group (A.Y.P., N.D., Y.D., L.C.G., C.O., C.S., G.J.), Neurosciences Axis, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - D Iancu
- Radiology (W.B., J.D.B.D., J.E., D.I., B.M., L.N., J.R., D.R., A.W.)
| | - B Maier
- Radiology (W.B., J.D.B.D., J.E., D.I., B.M., L.N., J.R., D.R., A.W.)
- Department of Interventional Neuroradiology (W.B., B.M.), Hopital Fondation A. De Rothschild, Paris, France
- Université Paris-Cité (B.M.), Paris, France
| | - B Nauche
- Bibliothèque du Centre Hospitalier de l'Université de Montréal (B.N.), Montreal, Quebec, Canada
| | - L Nico
- Radiology (W.B., J.D.B.D., J.E., D.I., B.M., L.N., J.R., D.R., A.W.)
| | - C Odier
- From the Department of Neurosciences (C.D., A.Y.P., N.D., Y.D. L.C.G., C.O., C.S., G.J.), Faculté de médecine, Université de Montréal, Montréal, Quebec. Canada
- Departments of Medicine (Neurology) (C.D., A.Y.P., N.D., Y.D., L.C.G., C.O., C.S., G.J.)
- Neurovascular Group (A.Y.P., N.D., Y.D., L.C.G., C.O., C.S., G.J.), Neurosciences Axis, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - J Raymond
- Radiology (W.B., J.D.B.D., J.E., D.I., B.M., L.N., J.R., D.R., A.W.)
| | - D Roy
- Radiology (W.B., J.D.B.D., J.E., D.I., B.M., L.N., J.R., D.R., A.W.)
| | - C Stapf
- From the Department of Neurosciences (C.D., A.Y.P., N.D., Y.D. L.C.G., C.O., C.S., G.J.), Faculté de médecine, Université de Montréal, Montréal, Quebec. Canada
- Departments of Medicine (Neurology) (C.D., A.Y.P., N.D., Y.D., L.C.G., C.O., C.S., G.J.)
- Neurovascular Group (A.Y.P., N.D., Y.D., L.C.G., C.O., C.S., G.J.), Neurosciences Axis, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - A Weill
- Radiology (W.B., J.D.B.D., J.E., D.I., B.M., L.N., J.R., D.R., A.W.)
| | - G Jacquin
- From the Department of Neurosciences (C.D., A.Y.P., N.D., Y.D. L.C.G., C.O., C.S., G.J.), Faculté de médecine, Université de Montréal, Montréal, Quebec. Canada
- Departments of Medicine (Neurology) (C.D., A.Y.P., N.D., Y.D., L.C.G., C.O., C.S., G.J.)
- Neurovascular Group (A.Y.P., N.D., Y.D., L.C.G., C.O., C.S., G.J.), Neurosciences Axis, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
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Raymond J, Darsaut TE. Lessons from landmark studies on the treatment of ruptured intracranial aneurysms. Neurochirurgie 2022; 68:469-470. [PMID: 35272856 DOI: 10.1016/j.neuchi.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- J Raymond
- Department of Radiology, service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), room D03.5462b, H2X 0C1 Montreal, QC, Canada.
| | - T E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, 8440 112 St NW, Edmonton, Alberta, Canada
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Raymond J, Darsaut TE. Reporting the outcomes of medical or surgical treatments: The Tower of Babel. Neurochirurgie 2022; 68:483-484. [PMID: 35654612 DOI: 10.1016/j.neuchi.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 02/06/2023]
Affiliation(s)
- J Raymond
- Centre hospitalier de l'Université de Montréal (CHUM), Department of Radiology, room D03.5462b, Montreal H2X 0C1, Quebec, Canada.
| | - T E Darsaut
- University of Alberta hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Boisseau W, Darsaut TE, Fahed R, Findlay JM, Bourcier R, Charbonnier G, Smajda S, Ognard J, Roy D, Gariel F, Carlson AP, Shotar E, Ciccio G, Marnat G, Sporns PB, Gaberel T, Jecko V, Weill A, Biondi A, Boulouis G, Bras AL, Aldea S, Passeri T, Boissonneau S, Bougaci N, Gentric JC, Diestro JDB, Omar AT, Al-Jehani HM, Hage GE, Volders D, Kaderali Z, Tsogkas I, Magro E, Holay Q, Zehr J, Iancu D, Raymond J. Surgical or Endovascular Treatment of MCA Aneurysms: An Agreement Study. AJNR Am J Neuroradiol 2022; 43:1437-1444. [PMID: 36137654 PMCID: PMC9575541 DOI: 10.3174/ajnr.a7648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/28/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE MCA aneurysms are still commonly clipped surgically despite the recent development of a number of endovascular tools and techniques. We measured clinical uncertainty by studying the reliability of decisions made for patients with middle cerebral artery (MCA) aneurysms. MATERIALS AND METHODS A portfolio of 60 MCA aneurysms was presented to surgical and endovascular specialists who were asked whether they considered surgery or endovascular treatment to be an option, whether they would consider recruitment of the patient in a randomized trial, and whether they would provide their final management recommendation. Agreement was studied using κ statistics. Intrarater reliability was assessed with the same, permuted portfolio of cases of MCA aneurysm sent to the same specialists 1 month later. RESULTS Surgical management was the preferred option for neurosurgeons (n = 844/1320; [64%] responses/22 raters), while endovascular treatment was more commonly chosen by interventional neuroradiologists (1149/1500 [76.6%] responses/25 raters). Interrater agreement was only "slight" for all cases and all judges (κ = 0.094; 95% CI, 0.068-0.130). Agreement was no better within specialties or with more experience. On delayed requestioning, 11 of 35 raters (31%) disagreed with themselves on at least 20% of cases. Surgical management and endovascular treatment were always judged to be a treatment option, for all patients. Trial participation was offered to patients 65% of the time. CONCLUSIONS Individual clinicians did not agree regarding the best management of patients with MCA aneurysms. A randomized trial comparing endovascular with surgical management of patients with MCA aneurysms is in order.
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Affiliation(s)
- W Boisseau
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
| | - T E Darsaut
- Department of Surgery (T.E.D., J.M.F.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - R Fahed
- Department of Medicine (R.F.), Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - J M Findlay
- Department of Surgery (T.E.D., J.M.F.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - R Bourcier
- Department of Neuroradiology (R.B.), University Hospital of Nantes, Nantes, France
| | - G Charbonnier
- Departments of Interventional Neuroradiology (G. Charbonnier, A.B.)
| | - S Smajda
- Departments of Interventional Neuroradiology (S.S.)
| | - J Ognard
- Department of Interventional Neuroradiology (J.O., J.C.G.), Hôpital de la Cavale Blanche, Brest, Bretagne, France
| | - D Roy
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
| | - F Gariel
- Departments of Neuroradiology (F.G., G.M.)
| | - A P Carlson
- Department of Neurosurgery (A.P.C.), University of New Mexico Hospital, Albuquerque, New Mexico
| | - E Shotar
- Department of Neuroradiology (E.S.), Groupe Hospitalier de Pitié Salpêtrière, Paris, France
| | - G Ciccio
- Department of Interventional Neuroradiology (G. Ciccio), Centre Hospitalier de Bastia, Bastia, Corse, France
| | - G Marnat
- Departments of Neuroradiology (F.G., G.M.)
| | - P B Sporns
- Department of Neuroradiology (P.B.S., I.T.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
- Department of Diagnostic and Interventional Neuroradiology (P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - T Gaberel
- Department of Neurosurgery (T.G.), University Hospital of Caen, Caen, France
| | - V Jecko
- Neurosurgery (V.J.), University Hospital of Bordeaux, Bordeaux, France
| | - A Weill
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
| | - A Biondi
- Departments of Interventional Neuroradiology (G. Charbonnier, A.B.)
| | - G Boulouis
- Department of Neuroradiology (G.B.), University Hospital of Tours, Tours, Indre et Loire, France
| | - A L Bras
- Department of Radiology (A.L.B.), Groupement Hospitaliser Bretagne Atlantique-Hôpital Chubert, Vannes, Bretagne, France
| | - S Aldea
- Neurosurgery (S.A.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - T Passeri
- Department of Neurosurgery (T.P.), Lariboisière Hospital, Assistance Publique Hôpitaux de Paris, University of Paris, Paris, France
| | - S Boissonneau
- Department of Neurosurgery (S.B.), La Timone Hospital
- L'Institut National de la Santé et de la Recherche Médicale (S.B.), Institut de Neurosciences des Systèmes, Aix Marseille University, Marseille, France
| | - N Bougaci
- Neurosurgery (N.B.), Besançon University Hospital, Besançon, France
| | - J C Gentric
- Department of Interventional Neuroradiology (J.O., J.C.G.), Hôpital de la Cavale Blanche, Brest, Bretagne, France
| | - J D B Diestro
- Division of Diagnostic and Therapeutic Neuroradiology (J.D.B.D.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - A T Omar
- Division of Neurosurgery (A.T.O.), Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - H M Al-Jehani
- Department of Neurosurgery, Radiology and Critical Care Medicine (H.M.A.-J.), King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University, Alkhobar, Saudi Arabia
| | - G El Hage
- Department of Neurosurgery (G.E.H.), Centre Hospitalier de l'Université de Montréal,Montreal, Québec, Canada
| | - D Volders
- Department of Radiology (D.V.), Dalhousie University, Halifax, Nova Scotia, Canada
| | - Z Kaderali
- Division of Neurosurgery (Z.K.), GB1-Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - I Tsogkas
- Department of Neuroradiology (P.B.S., I.T.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - E Magro
- Department of Neurosurgery (E.M.), Centre Hospitalier Universitaire Cavale Blanche, UBO L'Institut National de la Santé et de la Recherche Médicale, LaTIM UMR 1101, Brest, France
| | - Q Holay
- Department of Radiology (Q.H.), Hôpital d'Instruction des Armées Saint-Anne, Toulon, France
| | - J Zehr
- Department of Mathematics and Statistics (J.Z.), Pavillon André-Aisenstadt,Montreal, Québec, Canada
| | - D Iancu
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
| | - J Raymond
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
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Raymond J, Iancu D, Boisseau W, Diestro JDB, Klink R, Chagnon M, Zehr J, Drake B, Lesiuk H, Weill A, Roy D, Bojanowski MW, Chaalala C, Rempel JL, O'Kelly C, Chow MM, Bracard S, Darsaut TE. Flow Diversion in the Treatment of Intracranial Aneurysms: A Pragmatic Randomized Care Trial. AJNR Am J Neuroradiol 2022; 43:1244-1251. [PMID: 35926886 PMCID: PMC9451626 DOI: 10.3174/ajnr.a7597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/28/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Flow diversion is a recent endovascular treatment for intracranial aneurysms. We compared the safety and efficacy of flow diversion with the alternative standard management options. MATERIALS AND METHODS A parallel group, prerandomized, controlled, open-label pragmatic trial was conducted in 3 Canadian centers. The trial included all patients considered for flow diversion. A Web-based platform 1:1 randomly allocated patients to flow diversion or 1 of 4 alternative standard management options (coiling with/without stent placement, parent vessel occlusion, surgical clipping, or observation) as prespecified by clinical judgment. Patients ineligible for alternative standard management options were treated with flow diversion in a registry. The primary safety outcome was death or dependency (mRS > 2) at 3 months. The composite primary efficacy outcome included the core lab-determined angiographic presence of a residual aneurysm, aneurysm rupture, progressive mass effect during follow-up, or death or dependency (mRS > 2) at 3-12 months. RESULTS Between May 2011 and November 2020, three hundred twenty-three patients were recruited: Two hundred seventy-eight patients (86%) had treatment randomly allocated (139 to flow diversion and 139 to alternative standard management options), and 45 (14%) received flow diversion in the registry. Patients in the randomized trial frequently had unruptured (83%), large (52% ≥10 mm) carotid (64%) aneurysms. Death or dependency at 3 months occurred in 16/138 patients who underwent flow diversion and 12/137 patients receiving alternative standard management options (relative risk, 1.33; 95% CI, 0.65-2.69; P = .439). A poor primary efficacy outcome was found in 30.9% (43/139) with flow diversion and 45.6% (62/136) of patients receiving alternative standard management options, with an absolute risk difference of 14.7% (95% CI, 3.3%-26.0%; relative risk, 0.68; 95% CI, 0.50-0.92; P = .014). CONCLUSIONS For patients with mostly unruptured, large, anterior circulation (carotid) aneurysms, flow diversion was more effective than the alternative standard management option in terms of angiographic outcome.
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Affiliation(s)
- J Raymond
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - D Iancu
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
- Departments of Radiology (D.I.)
| | - W Boisseau
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - J D B Diestro
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - R Klink
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - M Chagnon
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montreal, Canada
| | - J Zehr
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montreal, Canada
| | - B Drake
- Surgery (B.D., H.L.), Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
| | - H Lesiuk
- Surgery (B.D., H.L.), Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
| | - A Weill
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - D Roy
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - M W Bojanowski
- Department of Neurosurgery (M.W.B., C.C.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada
| | - C Chaalala
- Department of Neurosurgery (M.W.B., C.C.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada
| | | | - C O'Kelly
- Surgery (C.O., M.M.C., T.E.D.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - M M Chow
- Surgery (C.O., M.M.C., T.E.D.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - S Bracard
- Neuroradiology (S.B.), CHRU de Nancy, Nancy, Lorraine, France
| | - T E Darsaut
- Surgery (C.O., M.M.C., T.E.D.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Jentzer A, Attal A, Roué C, Raymond J, Lleixà C, Illa I, Querol L, Taieb G, Devaux J. IgG4 Valency Modulates the Pathogenicity of Anti–Neurofascin-155 IgG4 in Autoimmune Nodopathy. Neurol Neuroimmunol Neuroinflamm 2022; 9:9/5/e200014. [PMID: 35948442 PMCID: PMC9365386 DOI: 10.1212/nxi.0000000000200014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/18/2022] [Indexed: 12/03/2022]
Abstract
Background and Objectives IgG4 autoantibodies to neurofascin-155 (Nfasc155) are associated with a subgroup of patients with chronic inflammatory demyelinating polyneuropathy (CIDP), currently named autoimmune nodopathy. We previously demonstrated that those antibodies alter conduction along myelinated axons by inducing Nfasc155 depletion and paranode destruction. In blood, IgG4 have the potency to exchange their moiety with other unrelated IgG4 through a process called Fab-arm exchange (FAE). This process results in functionally monovalent antibodies and may affect the pathogenicity of autoantibodies. Here, we examined this issue and whether FAE is beneficial or detrimental for Nfasc155 autoimmune nodopathy. Methods The bivalency and monospecificity of anti-Nfasc155 were examined by sandwich ELISA in 10 reactive patients, 10 unreactive CIDP patients, and 10 healthy controls. FAE was induced in vitro using reduced glutathione and unreactive IgG4, and the ratio of the κ:λ light chain was monitored. To determine the pathogenic potential of bivalent anti-Nfasc155 IgG4, autoantibodies derived from patients were enzymatically cleaved into monovalent Fab and bivalent F(ab’)2 or swapped with unreactive IgG4 and then were injected in neonatal animals. Results Monospecific bivalent IgG4 against Nfasc155 were detected in the serum of all reactive patients, indicating that a fraction of IgG4 have not undergone FAE in situ. These IgG4 were, nonetheless, capable of engaging into FAE with unreactive IgG4 in vitro, and this decreased the levels of monospecific antibodies and modulated the ratio of the κ:λ light chain. When injected in animals, monovalent anti-Nfasc155 Fab did not alter the formation of paranodes; by contrast, both native anti-Nfasc155 IgG4 and F(ab’)2 fragments strongly impaired paranode formation. The promotion of FAE with unreactive IgG4 also strongly diminished the pathogenic potential of anti-Nfasc155 IgG4 in animals and decreased IgG4 clustering on Schwann cells. Discussion Our findings demonstrate that monospecific and bivalent anti-Nfasc155 IgG4 are detected in patients and that those autoantibodies are the pathogenic ones. The transformation of anti-Nfasc155 IgG4 into monovalent Fab or functionally monovalent IgG4 through FAE strongly decreases paranodal alterations. Bivalency thus appears crucial for Nfasc155 clustering and paranode destruction.
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Affiliation(s)
- Alexandre Jentzer
- From the Institute for Neurosciences of Montpellier (A.J., A.A., G.T., J.D.), INSERM U1051, Montpellier University, Hôpital Saint Eloi, France; Department of Immunology (A.J.), CHU Montpellier, France ; Department of Neurology (A.A., G.T.), CHU Montpellier, Hôpital Gui de Chauliac, France; Institut de Génomique Fonctionnelle (C.R., J.R., G.T., J.D.), CNRS UMR5203, France; and Neuromuscular Diseases Unit (C.L., I.I., L.Q.), Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Spain
| | - Arthur Attal
- From the Institute for Neurosciences of Montpellier (A.J., A.A., G.T., J.D.), INSERM U1051, Montpellier University, Hôpital Saint Eloi, France; Department of Immunology (A.J.), CHU Montpellier, France ; Department of Neurology (A.A., G.T.), CHU Montpellier, Hôpital Gui de Chauliac, France; Institut de Génomique Fonctionnelle (C.R., J.R., G.T., J.D.), CNRS UMR5203, France; and Neuromuscular Diseases Unit (C.L., I.I., L.Q.), Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Spain
| | - Clémence Roué
- From the Institute for Neurosciences of Montpellier (A.J., A.A., G.T., J.D.), INSERM U1051, Montpellier University, Hôpital Saint Eloi, France; Department of Immunology (A.J.), CHU Montpellier, France ; Department of Neurology (A.A., G.T.), CHU Montpellier, Hôpital Gui de Chauliac, France; Institut de Génomique Fonctionnelle (C.R., J.R., G.T., J.D.), CNRS UMR5203, France; and Neuromuscular Diseases Unit (C.L., I.I., L.Q.), Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Spain
| | - Julie Raymond
- From the Institute for Neurosciences of Montpellier (A.J., A.A., G.T., J.D.), INSERM U1051, Montpellier University, Hôpital Saint Eloi, France; Department of Immunology (A.J.), CHU Montpellier, France ; Department of Neurology (A.A., G.T.), CHU Montpellier, Hôpital Gui de Chauliac, France; Institut de Génomique Fonctionnelle (C.R., J.R., G.T., J.D.), CNRS UMR5203, France; and Neuromuscular Diseases Unit (C.L., I.I., L.Q.), Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Spain
| | - Cinta Lleixà
- From the Institute for Neurosciences of Montpellier (A.J., A.A., G.T., J.D.), INSERM U1051, Montpellier University, Hôpital Saint Eloi, France; Department of Immunology (A.J.), CHU Montpellier, France ; Department of Neurology (A.A., G.T.), CHU Montpellier, Hôpital Gui de Chauliac, France; Institut de Génomique Fonctionnelle (C.R., J.R., G.T., J.D.), CNRS UMR5203, France; and Neuromuscular Diseases Unit (C.L., I.I., L.Q.), Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Spain
| | - Isabel Illa
- From the Institute for Neurosciences of Montpellier (A.J., A.A., G.T., J.D.), INSERM U1051, Montpellier University, Hôpital Saint Eloi, France; Department of Immunology (A.J.), CHU Montpellier, France ; Department of Neurology (A.A., G.T.), CHU Montpellier, Hôpital Gui de Chauliac, France; Institut de Génomique Fonctionnelle (C.R., J.R., G.T., J.D.), CNRS UMR5203, France; and Neuromuscular Diseases Unit (C.L., I.I., L.Q.), Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Spain
| | - Luis Querol
- From the Institute for Neurosciences of Montpellier (A.J., A.A., G.T., J.D.), INSERM U1051, Montpellier University, Hôpital Saint Eloi, France; Department of Immunology (A.J.), CHU Montpellier, France ; Department of Neurology (A.A., G.T.), CHU Montpellier, Hôpital Gui de Chauliac, France; Institut de Génomique Fonctionnelle (C.R., J.R., G.T., J.D.), CNRS UMR5203, France; and Neuromuscular Diseases Unit (C.L., I.I., L.Q.), Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Spain
| | - Guillaume Taieb
- From the Institute for Neurosciences of Montpellier (A.J., A.A., G.T., J.D.), INSERM U1051, Montpellier University, Hôpital Saint Eloi, France; Department of Immunology (A.J.), CHU Montpellier, France ; Department of Neurology (A.A., G.T.), CHU Montpellier, Hôpital Gui de Chauliac, France; Institut de Génomique Fonctionnelle (C.R., J.R., G.T., J.D.), CNRS UMR5203, France; and Neuromuscular Diseases Unit (C.L., I.I., L.Q.), Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Spain
| | - Jérôme Devaux
- From the Institute for Neurosciences of Montpellier (A.J., A.A., G.T., J.D.), INSERM U1051, Montpellier University, Hôpital Saint Eloi, France; Department of Immunology (A.J.), CHU Montpellier, France ; Department of Neurology (A.A., G.T.), CHU Montpellier, Hôpital Gui de Chauliac, France; Institut de Génomique Fonctionnelle (C.R., J.R., G.T., J.D.), CNRS UMR5203, France; and Neuromuscular Diseases Unit (C.L., I.I., L.Q.), Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Spain.
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Powers C, Mack D, Raymond J. Advanced Stage Breast Cancer on Initial Presentation Following One Year Hiatus in Screening Mammography Due to COVID-19 Pandemic. S D Med 2022; 75:396-401. [PMID: 36881824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Breast cancer is the second most common cancer and second leading cause of cancer death affecting women in the U.S., behind only skin and lung cancers, respectively. Modern screening mammography methods have contributed, in part, to a 40 percent decrease in breast cancer mortality since it was introduced in 1976. Therefore, regular breast cancer screening is vital to women's health. The COVID-19 Pandemic posed many challenges to healthcare systems worldwide. One challenge was the discontinuation of routine screening tests. We present a female patient who consistently participated in annual screening mammography and was confirmed negative for malignancy between 2014 and 2019. She did not get her mammogram in 2020 due to the COVID-19 pandemic and was subsequently diagnosed with stage IIIB breast cancer when she resumed her screening mammogram in 2021. This case illustrates one of the consequences of delayed breast cancer screening.
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Affiliation(s)
- Colton Powers
- University of South Dakota Sanford School of Medicine, Rapid City, South Dakota
| | - Danielle Mack
- University of South Dakota Sanford School of Medicine, Rapid City, South Dakota
| | - Julie Raymond
- Department of General Surgery, Rapid City Medical Center, Rapid City, South Dakota
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Obaid S, Darsaut TE, Raymond J. Understanding the problems with recruitment in surgical randomized trials: A lesson from landmark trials on temporal lobe epilepsy. Neurochirurgie 2022; 68:612-617. [PMID: 35787925 DOI: 10.1016/j.neuchi.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Surgical randomized trials are difficult to accomplish. One major problem is recruitment of a sufficient number of patients to address the clinical problem. METHODS We review the various ways patient recruitment in surgical RCTs can be promoted. We examine two landmark trials on the surgical treatment of temporal lobe epilepsy (TLE), one that was successful, and one which did not attain the target number of participants. DISCUSSION Both designs of the Canadian and American trials of surgery for TLE included a benefit to participants: the Canadian trial gave a chance to have immediate access to investigation and treatment, as compared to a 1 year delay (considered 'standard care' in that center), while the American trial offered free surgical management to both arms. Patients were recruited and treatments randomly allocated prior to knowing for certain whether they were surgical candidates or not. This design choice may have helped circumvent the 'equipoise problem'. The Canadian trial offered participation to drug-resistant patients that were already routinely referred to surgical centers, while the success of the American trial which limited recruitment to the early period of drug resistance was dependent on a change of practice of referring clinicians which did not materialize. CONCLUSION The surgical treatment of drug-resistant temporal lobe epilepsy has been validated using RCT methods. Ways to promote participation in surgical trials should be further investigated.
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Affiliation(s)
- S Obaid
- Department of Neurosurgery, Comprehensive Epilepsy Center, Yale School of Medicine, New Haven, CT, USA
| | - T E Darsaut
- University of Alberta Hospital, Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - J Raymond
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
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Raymond J, Magro E, Darsaut TE. Understanding burden of proof and equipoise in the design of pragmatic clinical trials: An example from a trial on brain arteriovenous malformations. Neurochirurgie 2022; 68:608-611. [PMID: 35787924 DOI: 10.1016/j.neuchi.2022.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE The burden of proof principle is rarely discussed and poorly understood, but central to the proper design of pragmatic clinical trials. A better understanding of the principle could play an important role in the re-introduction of scientific methods within practice and in revising fundamental problems with the current research-care separation. METHODS We analyze the design of the ARUBA trial on the management of unruptured brain arteriovenous malformations. We also review how the concept of clinical equipoise was introduced to address a misconceived problem of research ethics. RESULTS The ARUBA trial hypothesis in favour of conservative management of brain arteriovenous malformations failed to take into account the fact that the burden of proof was on surgery, endovascular treatment or radiation therapy. Thus, results remained inconclusive and other trials are needed. The equipoise notion fails to take into account that the burden of proof is on unvalidated medical or surgical interventions, if we want to provide outcome-based medical care that patients can trust. CONCLUSION The burden of proof principle is essential to properly design pragmatic trials. This principle also explains why in certain circumstances optimal care is a randomized care trial.
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Affiliation(s)
- J Raymond
- Department of radiology, service of neuroradiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada.
| | - E Magro
- Service de neurochirurgie, CHU Cavale-Blanche, Inserm UMR 1101 LaTIM, Brest, France
| | - T E Darsaut
- Division of neurosurgery, department of surgery, university of Alberta hospital, Mackenzie Health Sciences Centre, 8440 112St NW, Edmonton, Alberta, Canada
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Raymond J, Benomar A, Darsaut TE. Understanding the reliability of trial outcome measures: The example of angiographic results of surgical or endovascular treatments of aneurysms. Neurochirurgie 2022; 68:485-487. [PMID: 35654613 DOI: 10.1016/j.neuchi.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The reliability of outcome measures is of central importance in clinical research. Studies of reliability remain rare in the neurovascular field. METHODS A narrative review of the history (1997-2021) of reporting angiographic results of the surgical or endovascular treatments of aneurysms serves to illustrate the importance of precisely defining outcome measures. We also review how the reliability of an angiographic classification system was studied. DISCUSSION Outcome measures are commonly used without precise definitions. When definitions or classification systems exist, they are rarely verified for their reliability. Twenty-five years following its introduction, a classification of angiographic results of aneurysm treatments is still being studied and modified. CONCLUSION The reliability of outcome measures should be made a research priority if we are to practice outcome-based medical or surgical care.
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Affiliation(s)
- J Raymond
- Department of Radiology, service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
| | - A Benomar
- Department of Radiology, service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - T E Darsaut
- Department of Surgery, division of Neurosurgery, University of Alberta hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Raymond J, Létourneau-Guillon L, Darsaut TE, Findlay JM, Chow MM, Keough MB, Chan AM, Farzin B, Gevry G, Chagnon M, Zehr J. Reply. AJNR Am J Neuroradiol 2022; 43:E4. [PMID: 35241423 PMCID: PMC8910809 DOI: 10.3174/ajnr.a7454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- J. Raymond
- Department of Radiology, Neuroradiology Service Centre Hospitalier de l’Université de Montréal (CHUM), Montreal Quebec, CanadaCHUM Research Centre, MontrealQuebec, Canada
| | - L. Létourneau-Guillon
- Department of Radiology, Neuroradiology Service Centre Hospitalier de l’Université de Montréal (CHUM), Montreal Quebec, CanadaCHUM Research Centre, MontrealQuebec, Canada
| | - T E Darsaut
- Department of Surgery, Division of Neurosurgery University of Alberta hospital, Mackenzie Health Sciences Center, EdmontonAlberta, Canada
| | - J M Findlay
- Department of Surgery, Division of Neurosurgery University of Alberta hospital, Mackenzie Health Sciences Center, EdmontonAlberta, Canada
| | - M M Chow
- Department of Surgery, Division of Neurosurgery University of Alberta hospital, Mackenzie Health Sciences Center, EdmontonAlberta, Canada
| | - M B Keough
- Department of Surgery, Division of Neurosurgery University of Alberta hospital, Mackenzie Health Sciences Center, EdmontonAlberta, Canada
| | - A M Chan
- Department of Surgery, Division of Neurosurgery University of Alberta hospital, Mackenzie Health Sciences Center, EdmontonAlberta, Canada
| | | | - G Gevry
- CHUM Research Centre, MontrealQuebec, Canada
| | - M Chagnon
- Department of Mathematics and Statistics Université de Montréal, Montreal Quebec, Canada
| | - J Zehr
- Department of Mathematics and Statistics Université de Montréal, Montreal Quebec, Canada
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Stahl JP, Castan B, Bonnet E, Bru JP, Cohen R, Diamantis S, Faye A, Hitoto H, Issa N, Lesprit P, Maulin L, Poitrenaud D, Raymond J, Strady C, Varon E, Verdon R, Vuotto F, Welker Y, Gauzit R. Utilization of macrolides: State of the art 2022 Spilf and GPIP. Infect Dis Now 2022; 52:252-266. [DOI: 10.1016/j.idnow.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Raymond J, Darsaut TE. Reprint of: We need less research, better research, and research done for the right reasons. Neurochirurgie 2022; 68:147. [PMID: 35074167 DOI: 10.1016/j.neuchi.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- J Raymond
- Department of radiology, service of neuroradiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada.
| | - T E Darsaut
- Division of neurosurgery, department of surgery, Mackenzie health sciences centre, university of Alberta hospital, 8440 112St NW, Edmonton, Alberta, Canada
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Darsaut T, Keough M, Chan A, Farzin B, Findlay J, Chow M, Chagnon M, Zehr J, Gevry G, Raymond J. Transcranial Doppler Velocities and Angiographic Vasospasm after SAH: A Diagnostic Accuracy Study. AJNR Am J Neuroradiol 2022; 43:80-86. [PMID: 34794947 PMCID: PMC8757545 DOI: 10.3174/ajnr.a7347] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/14/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE After aneurysmal SAH, transcranial Doppler is commonly used to monitor cerebral vasospasm. The diagnostic accuracy of transcranial Doppler flow velocity values in detecting angiographic vasospasm in patients requiring urgent endovascular intervention has not been established. MATERIALS AND METHODS We performed a retrospective analysis of a consecutive series of patients with aneurysmal SAH who underwent transcranial Doppler (index test) within 24 hours of conventional angiography (reference test). The judgment of 33%, 50%, and 66% degree of vessel narrowing on angiography was independently established by multiple neuroendovascular clinicians. Vessel-specific per-segment and per-patient transcranial Doppler velocities were studied using receiver operating characteristic curves, the Youden index, and minimal acceptable sensitivity models. Optimal mean flow-velocity thresholds were explored to calculate sensitivity and specificity using a per-patient judgment of vasospasm of at least 50% angiographic narrowing in any large arterial segment except A1. RESULTS In 221 patients, vasospasm was found in 15%, 8%, and 4% of arteries when the degree of reference angiographic luminal narrowing was 33%, 50%, and 66%, respectively. Mean flow velocities were significantly higher in vasospastic segments (P = . 001), but per-segment exploratory analyses yielded unsound mean flow velocity thresholds. The Youden and minimal acceptable sensitivity models proposed mean flow velocity thresholds of approximately 160 cm/s for the anterior circulation and 80 cm/s for the posterior circulation in the per-patient diagnosis of angiographic vasospasm (≥50%), yielding a sensitivity of 80%-90% (95% CI, 0.77-0.96), but with a corresponding specificity of 50% (95% CI, 0.40-0.56). CONCLUSIONS In this study, a threshold transcranial Doppler mean flow-velocity value that would accurately diagnose ≥50% angiographic vasospasm remained elusive.
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Affiliation(s)
- T.E. Darsaut
- From the Division of Neurosurgery (T.E.D., M.B.K., A.M.C., J.M.F., M.M.C.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - M.B. Keough
- From the Division of Neurosurgery (T.E.D., M.B.K., A.M.C., J.M.F., M.M.C.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - A.M. Chan
- From the Division of Neurosurgery (T.E.D., M.B.K., A.M.C., J.M.F., M.M.C.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - B. Farzin
- Department of Radiology (B.F., G.G., J.R.), Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | - J.M. Findlay
- From the Division of Neurosurgery (T.E.D., M.B.K., A.M.C., J.M.F., M.M.C.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - M.M. Chow
- From the Division of Neurosurgery (T.E.D., M.B.K., A.M.C., J.M.F., M.M.C.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - M. Chagnon
- Department of Mathematics and Statistics (M.C., J.Z.), Pavillon André-Aisenstadt, Montreal, Quebec, Canada
| | - J. Zehr
- Department of Mathematics and Statistics (M.C., J.Z.), Pavillon André-Aisenstadt, Montreal, Quebec, Canada
| | - G. Gevry
- Department of Radiology (B.F., G.G., J.R.), Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | - J. Raymond
- Department of Radiology (B.F., G.G., J.R.), Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
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Luizet JB, Raymond J, Lacerda TLS, Barbieux E, Kambarev S, Bonici M, Lembo F, Willemart K, Borg JP, Celli J, Gérard FCA, Muraille E, Gorvel JP, Salcedo SP. The Brucella effector BspL targets the ER-associated degradation (ERAD) pathway and delays bacterial egress from infected cells. Proc Natl Acad Sci U S A 2021; 118:e2105324118. [PMID: 34353909 PMCID: PMC8364137 DOI: 10.1073/pnas.2105324118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Perturbation of the endoplasmic reticulum (ER), a central organelle of the cell, can have critical consequences for cellular homeostasis. An elaborate surveillance system known as ER quality control ensures that cells can respond and adapt to stress via the unfolded protein response (UPR) and that only correctly assembled proteins reach their destination. Interestingly, several bacterial pathogens hijack the ER to establish an infection. However, it remains poorly understood how bacterial pathogens exploit ER quality-control functions to complete their intracellular cycle. Brucella spp. replicate extensively within an ER-derived niche, which evolves into specialized vacuoles suited for exit from infected cells. Here we present Brucella-secreted protein L (BspL), a Brucella abortus effector that interacts with Herp, a central component of the ER-associated degradation (ERAD) machinery. We found that BspL enhances ERAD at the late stages of the infection. BspL targeting of Herp and ERAD allows tight control of the kinetics of autophagic Brucella-containing vacuole formation, delaying the last step of its intracellular cycle and cell-to-cell spread. This study highlights a mechanism by which a bacterial pathogen hijacks ERAD components for fine regulation of its intracellular trafficking.
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Affiliation(s)
- Jean-Baptiste Luizet
- Laboratory of Molecular Microbiology and Structural Biochemistry, CNRS UMR5086, Université de Lyon, 69367 Lyon, France
| | - Julie Raymond
- Laboratory of Molecular Microbiology and Structural Biochemistry, CNRS UMR5086, Université de Lyon, 69367 Lyon, France
| | - Thais Lourdes Santos Lacerda
- Laboratory of Molecular Microbiology and Structural Biochemistry, CNRS UMR5086, Université de Lyon, 69367 Lyon, France
| | - Emeline Barbieux
- Department of Biology, Research Unit in Microorganisms Biology, Namur Research Institute for Life Sciences, 5000 Namur, Belgium
- Laboratory of Parasitology, Université Libre de Bruxelles Centre for Research in Immunology (UCRI), Université Libre de Bruxelles, 6041 Gosselies, Belgium
| | - Stanimir Kambarev
- Paul G. Allen School for Global Animal Health, Washington State University, Pullman, WA 99164
| | - Magali Bonici
- Laboratory of Molecular Microbiology and Structural Biochemistry, CNRS UMR5086, Université de Lyon, 69367 Lyon, France
| | - Frédérique Lembo
- Equipe labellisée Ligue 'Cell Polarity, Cell Signaling and Cancer', Centre de Recherche en Cancérologie de Marseille, Institut Paoli-Calmettes, Aix-Marseille Université, CNRS, INSERM, 13009 Marseille, France
| | - Kévin Willemart
- Department of Biology, Research Unit in Microorganisms Biology, Namur Research Institute for Life Sciences, 5000 Namur, Belgium
| | - Jean-Paul Borg
- Equipe labellisée Ligue 'Cell Polarity, Cell Signaling and Cancer', Centre de Recherche en Cancérologie de Marseille, Institut Paoli-Calmettes, Aix-Marseille Université, CNRS, INSERM, 13009 Marseille, France
- Institut Universitaire de France, 75231 Paris, France
| | - Jean Celli
- Paul G. Allen School for Global Animal Health, Washington State University, Pullman, WA 99164
| | - Francine C A Gérard
- Laboratory of Molecular Microbiology and Structural Biochemistry, CNRS UMR5086, Université de Lyon, 69367 Lyon, France
| | - Eric Muraille
- Department of Biology, Research Unit in Microorganisms Biology, Namur Research Institute for Life Sciences, 5000 Namur, Belgium
- Laboratory of Parasitology, Université Libre de Bruxelles Centre for Research in Immunology (UCRI), Université Libre de Bruxelles, 6041 Gosselies, Belgium
| | - Jean-Pierre Gorvel
- Centre d'Immunologie de Marseille-Luminy, CNRS, INSERM, Aix-Marseille Université, 13009 Marseille, France
| | - Suzana P Salcedo
- Laboratory of Molecular Microbiology and Structural Biochemistry, CNRS UMR5086, Université de Lyon, 69367 Lyon, France;
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Benomar A, Farzin B, Gevry G, Boisseau W, Roy D, Weill A, Iancu D, Guilbert F, Létourneau-Guillon L, Jacquin G, Chaalala C, Bojanowski MW, Labidi M, Fahed R, Volders D, Nguyen TN, Gentric JC, Magro E, Boulouis G, Forestier G, Hak JF, Ghostine JS, Kaderali Z, Shankar JJ, Kotowski M, Darsaut TE, Raymond J. Noninvasive Angiographic Results of Clipped or Coiled Intracranial Aneurysms: An Inter- and Intraobserver Reliability Study. AJNR Am J Neuroradiol 2021; 42:1615-1620. [PMID: 34326106 DOI: 10.3174/ajnr.a7236] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/28/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND PURPOSE Noninvasive angiography is commonly used to assess the outcome of surgical or endovascular treatment of intracranial aneurysms in clinical series or randomized trials. We sought to assess whether a standardized 3-grade classification system could be reliably used to compare the CTA and MRA results of both treatments. MATERIALS AND METHODS An electronic portfolio composed of CTAs of 30 clipped and MRAs of 30 coiled aneurysms was independently evaluated by 24 raters of diverse experience and training backgrounds. Twenty raters performed a second evaluation 1 month later. Raters were asked which angiographic grade and management decision (retreatment; close or long-term follow-up) would be most appropriate for each case. Agreement was analyzed using the Krippendorff α (αK) statistic, and the relationship between angiographic grade and clinical management choice, using the Fisher exact and Cramer V tests. RESULTS Interrater agreement was substantial (αK = 0.63; 95% CI, 0.55-0.70); results were slightly better for MRA results of coiling (αK = 0.69; 95% CI, 0.56-0.76) than for CTA results of clipping (αK = 0.58; 95% CI, 0.44-0.69). Intrarater agreement was substantial to almost perfect. Interrater agreement regarding clinical management was moderate for both clipped (αK = 0.49; 95% CI, 0.32-0.61) and coiled subgroups (αK = 0.47; 95% CI, 0.34-0.54). The choice of clinical management was strongly associated with the size of the residuum (mean Cramer V = 0.77 [SD, 0.14]), but complete occlusions (grade 1) were followed more closely after coiling than after clipping (P = .01). CONCLUSIONS A standardized 3-grade scale was found to be a reliable and clinically meaningful tool to compare the results of clipping and coiling of aneurysms using CTA or MRA.
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Affiliation(s)
- A Benomar
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| | - B Farzin
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| | - G Gevry
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| | - W Boisseau
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| | - D Roy
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| | - A Weill
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| | - D Iancu
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| | - F Guilbert
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| | - L Létourneau-Guillon
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| | - G Jacquin
- Department of Medicine, Division of Neurology (G.J.)
| | - C Chaalala
- Division of Neurosurgery (C.C., M.W.B., M.L.), Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - M W Bojanowski
- Division of Neurosurgery (C.C., M.W.B., M.L.), Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - M Labidi
- Division of Neurosurgery (C.C., M.W.B., M.L.), Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - R Fahed
- Division ofNeurology (R.F.), The Ottawa Hospital Ottawa, Ontario, Canada
| | - D Volders
- Department of Diagnostic Radiology (D.V.), Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - T N Nguyen
- Departments of Neurology, Neurosurgery, and Radiology (T.N.N.), Boston Medical Center, Boston, Massachusetts
| | - J-C Gentric
- Departments of Interventional Neuroradiology (J.-C.G.)
| | - E Magro
- Neurosurgery (E.M.), Hôpital de la Cavale Blanche, Centre Hospitalier Régional et Universitaire de Brest, Brest, France
| | - G Boulouis
- Department of Neuroradiology (G.B.), Centre Hospitalier Régional et Universitaire de Tours, Tours, France
| | - G Forestier
- Department of Neuroradiology (G.F.), University Hospital of Limoges, Limoges, France
| | - J-F Hak
- Department of Medical Imaging (J.-F.H.), University Hospital Timone Assistance Publique - Hôpitaux de Marseille, Marseille, France
| | - J S Ghostine
- Department of Radiology (J.S.G.), Jean-Talon Hospital, Montreal, Quebec, Canada
| | | | - J J Shankar
- Department of Radiology (J.J.S.), Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - M Kotowski
- Department of Neurosurgery (M.K.), Hôpital de la Providence, Neuchâtel, Switzerland
| | - T E Darsaut
- Department of Surgery (T.E.D.), Division of Neurosurgery,Walter C. Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - J Raymond
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
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Del Valle A, Acosta-Rivero N, Laborde RJ, Cruz-Leal Y, Cabezas S, Luzardo MC, Alvarez C, Labrada M, Rodríguez A, Rodríguez GL, Raymond J, Nogueira CV, Grubaugh D, Fernández LE, Higgins D, Lanio ME. Sticholysin II shows similar immunostimulatory properties to LLO stimulating dendritic cells and MHC-I restricted T cell responses of heterologous antigen. Toxicon 2021; 200:38-47. [PMID: 34237340 DOI: 10.1016/j.toxicon.2021.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 06/22/2021] [Accepted: 06/30/2021] [Indexed: 10/20/2022]
Abstract
Induction of CD8+ T cell responses against tumor cells and intracellular pathogens is an important goal of modern vaccinology. One approach of translational interest is the use of liposomes encapsulating pore-forming proteins (PFPs), such as Listeriolysin O (LLO), which has shown efficacy at priming strong and sustained CD8+ T cell responses. Recently, we have demonstrated that Sticholysin II (StII), a PFP from the sea anemone Stichodactyla helianthus, co-encapsulated into liposomes with ovalbumin (OVA) was able to stimulate, antigen presenting cells, antigen-specific CD8+ T cells and anti-tumor activity in mice. In the present study, we aimed to compare StII and LLO in terms of their abilities to stimulate dendritic cells and to induce major histocompatibility complex (MHC) class I restricted T cell responses against OVA. Interestingly, StII exhibited similar abilities to LLO in vitro of inducing dendritic cells maturation, as measured by increased expression of CD40, CD80, CD86 and MHC-class II molecules, and of stimulating OVA cross-presentation to a CD8+ T cell line. Remarkably, using an ex vivo Enzyme-Linked ImmunoSpot Assay (ELISPOT) to monitor gamma interferon (INF-γ) producing effector memory CD8+ T cells, liposomal formulations containing either StII or LLO induced comparable frequencies of OVA-specific INF-γ producing CD8+ T cells in mice that were sustained in time. However, StII-containing liposomes stimulated antigen-specific memory CD8+ T cells with a higher potential to secrete IFN-γ than liposomes encapsulating LLO. This StII immunostimulatory property further supports its use for the rational design of T cell vaccines against cancers and intracellular pathogens. In summary, this study indicates that StII has immunostimulatory properties similar to LLO, despite being evolutionarily distant PFPs.
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Affiliation(s)
- A Del Valle
- Center for Protein Studies, Faculty of Biology, Havana University (UH) and Lab UH-CIM, Cuba
| | - N Acosta-Rivero
- Center for Protein Studies, Faculty of Biology, Havana University (UH) and Lab UH-CIM, Cuba.
| | - R J Laborde
- Center for Protein Studies, Faculty of Biology, Havana University (UH) and Lab UH-CIM, Cuba
| | - Y Cruz-Leal
- Center for Protein Studies, Faculty of Biology, Havana University (UH) and Lab UH-CIM, Cuba
| | - S Cabezas
- Center for Protein Studies, Faculty of Biology, Havana University (UH) and Lab UH-CIM, Cuba
| | - M C Luzardo
- Center for Protein Studies, Faculty of Biology, Havana University (UH) and Lab UH-CIM, Cuba
| | - C Alvarez
- Center for Protein Studies, Faculty of Biology, Havana University (UH) and Lab UH-CIM, Cuba
| | - M Labrada
- Center of Molecular Immunology (CIM), Playa, La Habana, Cuba
| | - A Rodríguez
- Center of Molecular Immunology (CIM), Playa, La Habana, Cuba
| | - G L Rodríguez
- Center of Molecular Immunology (CIM), Playa, La Habana, Cuba
| | - J Raymond
- Center of Molecular Immunology (CIM), Playa, La Habana, Cuba
| | | | - D Grubaugh
- Harvard Medical School, Harvard University, USA
| | - L E Fernández
- Center of Molecular Immunology (CIM), Playa, La Habana, Cuba
| | - D Higgins
- Harvard Medical School, Harvard University, USA
| | - M E Lanio
- Center for Protein Studies, Faculty of Biology, Havana University (UH) and Lab UH-CIM, Cuba.
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Raymond J, Naggara O, Guilbert F, Darsaut TE. Douglas Altman's 2009 Grand Lecture: Can we trust our literature? Neurochirurgie 2021; 68:202-205. [PMID: 34186030 DOI: 10.1016/j.neuchi.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 06/19/2021] [Indexed: 11/18/2022]
Abstract
Recent studies of the medical literature have revealed numerous and serious problems. Errors in the design, methods and interpretation of studies can frequently be identified. A huge hidden problem is publication bias, the tendency for positive articles to be published, while negative articles are either not written or submitted. This can systematically lead to an overestimation of the value of treatments, of diagnostic or prognostic studies. Even more worrisome is selective reporting: only a subset of a wide array of tested hypotheses are presented (the ones that turned out to be positive with significance testing). This is particularly true for secondary endpoints and subgroup findings, but even the primary endpoints of trials have been modified when publications are compared to protocols. The peer-review process is fallible. Even if it were strengthened, reviewers cannot examine what is not reported. Hence many problems can only be mitigated with better reporting. Numerous initiatives have proposed guidelines to promote transparent reporting, but progress is slow.
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Affiliation(s)
- J Raymond
- Department of Radiology, Neuroradiology service, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
| | - O Naggara
- Department of Neuroradiology, Université Paris-Descartes, INSERM UMR 894, Centre hospitalier Sainte-Anne, Paris, Ile de France, France
| | - F Guilbert
- Department of Radiology, Neuroradiology service, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - T E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta hospital, Mackenzie Health Sciences Centre, 8440 112St NW, Edmonton, Alberta, Canada
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Raymond J, Darsaut TE. We need less research, better research, and research done for the right reasons. Neurochirurgie 2021; 67:413. [PMID: 34311988 DOI: 10.1016/j.neuchi.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- J Raymond
- Department of radiology, service of neuroradiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada.
| | - T E Darsaut
- Division of neurosurgery, department of surgery, Mackenzie health sciences centre, university of Alberta hospital, 8440 112St NW, Edmonton, Alberta, Canada
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Findler M, Turjman AS, Raymond J, White PM, Sadeh-Gonik U, Taschner CA, Mazighi M, Biondi A, Gory B, Turjman F. Interobserver Agreement in Scoring Angiographic Results of Basilar Artery Occlusion Stroke Therapy. AJNR Am J Neuroradiol 2021; 42:1458-1463. [PMID: 34117020 DOI: 10.3174/ajnr.a7182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/09/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The modified TICI Infarction grading system is a metric currently used to evaluate angiographic results of thrombectomy for large-vessel occlusion in ischemic stroke. Originally designed for evaluating MCA territories, it is currently used for other vessel occlusions, including the posterior circulation. We postulate that the modified TICI use for the posterior circulation is not accurate due to the different vascular territories supplied by vertebrobasilar vasculature, making grading more complex. MATERIALS AND METHODS We collected angiographic results from 30 patients who presented with acute posterior circulation occlusions between 2015 and 2018 and underwent thrombectomy in our institution. Eight observers were asked to evaluate the TICI scores before and after thrombectomy. The multirater statistics were computed using Fleiss κ analysis. Further data were collected regarding the potential brain territories at risk and the existence of atherosclerotic disease in the basilar artery. RESULTS The overall agreement κ reached 0.277 (SD, 0.013), which suggests a "fair" agreement among the raters. On average, 45% of observers achieved a high accuracy in predicting brain areas at risk of ischemia. As for the existence of basilar atherosclerotic disease, a high agreement (defined as at least 5 of 6 observers) was seen in 20 of the 30 patients. CONCLUSIONS Despite TICI being ubiquitous in stroke diagnostics, the high variability of posterior circulation TICI scores calls into question its use in these strokes. Other methods should be developed to assess recanalization in the posterior circulation.
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Affiliation(s)
- M Findler
- Department of Neurology and Interventional Neuroradiology (M.F.), Rabin Medical Center, Petah Tikva, Israel
| | - A S Turjman
- Cognition Medical Corporation (Alexis S. Turjman), Boston, Massachusetts
| | - J Raymond
- Département de Radiologie, Radio-Oncologie et Médecine Nucléaire (J.R.), Université de Montréal, Montreal, Quebec, Canada
| | - P M White
- Department of Neuroradiology (P.M.W.), Royal Victoria Infirmary, Newcastle, UK
| | - U Sadeh-Gonik
- Department of Radiology and Interventional Neuroradiology (U.S.-G.), Tel Aviv Medical Center, Tel-Aviv, Israel
| | - C A Taschner
- Department of Neuroradiology (C.A.T.), University Medical Centre Freiburg, Freiburg, Germany
| | - M Mazighi
- Department of Interventional Neuroradiology (M.M.), Fondation Rothschild Hospital, Paris, France
| | - A Biondi
- Department of Neuroradiology and Endovascular Therapy (A.B.), Besancon University Hospital, Besancon, France
| | - B Gory
- Department of Diagnostic and Therapeutic Neuroradiology (B.G.), Centre Hospitalier Régional Universitaire Nancy, Nancy, France
| | - F Turjman
- Department of Interventional Neuroradiology (Francis Turjman), Hospices Civils de Lyon, Lyon,France
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Darsaut TE, Fahed R, Raymond J. Unruptured aneurysms: Why observational studies fall short no matter how "Big" the Data. Neurochirurgie 2021; 67:330-335. [PMID: 33713661 DOI: 10.1016/j.neuchi.2021.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/09/2020] [Accepted: 02/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The best management of unruptured intracranial aneurysms (UIAs) remains unknown, despite multiple observational studies. A randomized trial (RCT) is in order. Yet, a National Institute Neurological Disorders and Stroke workshop has once again proposed to use prospective observational studies (POS) of large databases to address such problems. METHODS We review the historical misconceptions that have been associated with observations of UIAs and their treatments. We critically examine some recent methods that have been proposed to address shortcomings of observational studies. We finally review the ethical principles underlying the use of trial methods in the care of patients. RESULTS Replacing RCTs with POS submits patients to management options that have never been proven beneficial, while making them involuntary research subjects of studies that are inevitably biased. A science of practice cannot be an outsider's examination of the behavior of clinicians incapable of questioning their practice. The thesis we propose is that a science of practice must not only eventually determine what best practice will be; It must engage agents involved in medical practice to transparently reveal the uncertainty that calls for management options to be offered under the guidance of declared and controlled care research, to optimize patient outcomes in spite of the uncertainty. CONCLUSION To use POS rather than RCTs in medical practice is to renege on scientific and ethical principles that characterize modern medicine. Instead, we must learn to integrate care research into our practice to provide optimal medical care in real time.
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Affiliation(s)
- T E Darsaut
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Center, University of Alberta hospital, 8440 112th Street, Edmonton, T6G 2B7 Alberta, Canada.
| | - R Fahed
- Division of Neurology, Department of Medicine, The Ottawa Hospital-Civic Campus, 1053, Carling Avenue, K1Y 4E9 Ottawa, Ontario, Canada.
| | - J Raymond
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal, 1000, Saint-Denis, D03.5462B, H2X 0C1 Montreal, Quebec, Canada.
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Gauzit R, Castan B, Bonnet E, Bru JP, Cohen R, Diamantis S, Faye A, Hitoto H, Issa N, Lebeaux D, Lesprit P, Maulin L, Poitrenaud D, Raymond J, Strady C, Varon E, Verdon R, Vuotto F, Welker Y, Stahl JP. Anti-infectious treatment duration: The SPILF and GPIP French guidelines and recommendations. Infect Dis Now 2021; 51:114-139. [PMID: 34158156 DOI: 10.1016/j.idnow.2020.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/28/2020] [Indexed: 02/07/2023]
Affiliation(s)
- R Gauzit
- Infectiologie transversale, CHU Cochin, AP-HP, 75014 Paris, France.
| | - B Castan
- Maladies infectieuses et tropicales, CHG, 24000 Périgueux, France
| | - E Bonnet
- Équipe Mobile d'Infectiologie, Hôpital Joseph-Ducuing, Clinique Pasteur, 31300 Toulouse, France
| | - J P Bru
- Maladies Infectieuses, CH Annecy-Genevois, 74374 Pringy, France
| | - R Cohen
- Unité petits nourrissons, CHI, 94000 Créteil, France
| | - S Diamantis
- Maladies Infectieuses et Tropicales, groupe hospitalier Sud Île-de-France, 77000 Melun, France
| | - A Faye
- Pédiatrie Générale et maladies infectieuses, Hôpital Robert-Debré, Université de Paris, AP-HP, 75019 Paris, France
| | - H Hitoto
- Maladies Infectieuses et Tropicales, CH, 72037 Le Mans, France
| | - N Issa
- Réanimation médicale et maladies infectieuses, Hôpital Saint-André, CHU, 33000 Bordeaux, France
| | - D Lebeaux
- Université de Paris, 75006 Paris, France; Microbiologie, Unité Mobile d'Infectiologie, HEGP, AP-HP, 75015 Paris, France
| | - P Lesprit
- Unité transversale d'hygiène et d'infectiologie, Service de Biologie Clinique, Hôpital Foch, 92150 Suresnes, France
| | - L Maulin
- Maladies Infectieuses et tropicales, CHIAP, 13616 Aix-en-Provence, France
| | - D Poitrenaud
- Unité fonctionnelle d'Infectiologie Régionale, CH Ajaccio, 20303 Ajaccio, France
| | - J Raymond
- Bactériologie, Centre Hospitalier Bicêtre, 94270 Kremlin-Bicêtre, France
| | - C Strady
- Cabinet d'infectiologie, Groupe Courlancy, 51100 Reims, France
| | - E Varon
- Laboratoire de Biologie Médicale et Centre National de Référence des Pneumocoques, CHIC, 94000 Créteil, France
| | - R Verdon
- Maladies Infectieuses et Tropicales, CHU, 14033 Caen, France; Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0), Normandie Univ, UNICAEN, UNIROUEN, GRAM 2.0, 14000 Caen, France
| | - F Vuotto
- Maladies Infectieuses, CHU, Hôpital Huriez, 59000 Lille, France
| | - Y Welker
- Maladies Infectieuses, CHI, 78100 Saint-Germain-en-Laye, France
| | - J P Stahl
- Infectiologie, CHU Grenoble Alpes, 38043 Grenoble, France
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Darsaut TE, Derksen C, Farzin B, Keough MB, Fahed R, Boisseau W, Letourneau-Guillon L, Januel AC, Weill A, Roy D, Nguyen TN, Finitsis S, Gentric JC, Volders D, Carlson A, Chow MM, O'Kelly C, Rempel JL, Ashforth RA, Chagnon M, Zehr J, Findlay JM, Gevry G, Raymond J. Reliability of the Diagnosis of Cerebral Vasospasm Using Catheter Cerebral Angiography: A Systematic Review and Inter- and Intraobserver Study. AJNR Am J Neuroradiol 2021; 42:501-507. [PMID: 33509923 DOI: 10.3174/ajnr.a7021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/24/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Conventional angiography is the benchmark examination to diagnose cerebral vasospasm, but there is limited evidence regarding its reliability. Our goals were the following: 1) to systematically review the literature on the reliability of the diagnosis of cerebral vasospasm using conventional angiography, and 2) to perform an agreement study among clinicians who perform endovascular treatment. MATERIALS AND METHODS Articles reporting a classification system on the degree of cerebral vasospasm on conventional angiography were systematically searched, and agreement studies were identified. We assembled a portfolio of 221 cases of patients with subarachnoid hemorrhage and asked 17 raters with different backgrounds (radiology, neurosurgery, or neurology) and experience (junior ≤10 and senior >10 years) to independently evaluate cerebral vasospasm in 7 vessel segments using a 3-point scale and to evaluate, for each case, whether findings would justify endovascular treatment. Nine raters took part in the intraobserver reliability study. RESULTS The systematic review showed a very heterogeneous literature, with 140 studies using 60 different nomenclatures and 21 different thresholds to define cerebral vasospasm, and 5 interobserver studies reporting a wide range of reliability (κ = 0.14-0.87). In our study, only senior raters reached substantial agreement (κ ≥ 0.6) on vasospasm of the supraclinoid ICA, M1, and basilar segments and only when assessments were dichotomized (presence or absence of ≥50% narrowing). Agreement on whether to proceed with endovascular management of vasospasm was only fair (κ ≤ 0.4). CONCLUSIONS Research on cerebral vasospasm would benefit from standardization of definitions and thresholds. Dichotomized decisions by experienced readers are required for the reliable angiographic diagnosis of cerebral vasospasm.
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Affiliation(s)
- T E Darsaut
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - C Derksen
- Stroke Program (C.D.), Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - B Farzin
- Research Center (B.F., G.G., J.R.)
| | - M B Keough
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - R Fahed
- Department of Medicine (R.F.), Division of Neurology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - W Boisseau
- Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
| | - L Letourneau-Guillon
- Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
| | - A-C Januel
- Service de Neuroradiologie (A.-C.J.), Hôpital Purpan, Centre Hospitalier Universitaire Toulouse, Toulouse, France
| | - A Weill
- Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
| | - D Roy
- Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
| | - T N Nguyen
- Service of Interventional Neurology and Neuroradiology (T.N.N.), Boston Medical Center, Boston, Massachusetts
| | - S Finitsis
- Department of Radiology (S.F.), Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - J-C Gentric
- Department of Radiology (J.-C.G.), Division of Neuroradiology, Centre Hospitalier Universitaire Cavale Blanche, Brest, France
| | - D Volders
- Department of Radiology (D.V.), Dalhousie University, Halifax, Nova Scotia, Canada
| | - A Carlson
- Department of Neurosurgery (A.C.), University of New Mexico, Albuquerque, New Mexico
| | - M M Chow
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - C O'Kelly
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - J L Rempel
- Department of Radiology and Diagnostic Imaging (J.L.R., R.A.A.), University of Alberta hospital, Mackenzie Health Sciences Center, Edmonton, Alberta, Canada
| | - R A Ashforth
- Department of Radiology and Diagnostic Imaging (J.L.R., R.A.A.), University of Alberta hospital, Mackenzie Health Sciences Center, Edmonton, Alberta, Canada
| | - M Chagnon
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montreal, Province du Québec, Canada
| | - J Zehr
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montreal, Province du Québec, Canada
| | - J M Findlay
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - G Gevry
- Research Center (B.F., G.G., J.R.)
| | - J Raymond
- Research Center (B.F., G.G., J.R.) .,Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
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Darsaut TE, Chapot R, Raymond J. Changing the Rules of the Game: The Problem of Surrogate Angiographic Outcomes in the Evaluation of Aneurysm Treatments. AJNR Am J Neuroradiol 2020; 41:2174-2175. [PMID: 33033042 DOI: 10.3174/ajnr.a6825] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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49
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Darsaut T, Raymond J. Experience using pragmatic care trials to guide neurovascular practice under uncertainty. Neurochirurgie 2020; 66:423-428. [DOI: 10.1016/j.neuchi.2020.06.136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/03/2020] [Accepted: 06/19/2020] [Indexed: 01/04/2023]
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Veilleux C, Farzin B, Chaalala C, Labidi M, Raymond J, Bojanowski M. Les anévrismes du segment A1 de l’artère cérébrale antérieure : revue systématique de la littérature. Neurochirurgie 2020. [DOI: 10.1016/j.neuchi.2020.06.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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