Adopting a child perspective for exposome research on mental health and cognitive development - Conceptualisation and opportunities

Mental disorders among children and adolescents pose a significant global challenge. The exposome framework covering the totality of internal, social and physical exposures over a lifetime provides opportunities to better understand the causes of and processes related to mental health, and cognitive functioning. The paper presents a conceptual framework on exposome, mental health, and cognitive development in children and adolescents, with potential mediating pathways, providing a possibility for interventions along the life course. The paper underscores the significance of adopting a child perspective to the exposome, acknowledging children's specific vulnerability, including differential exposures, susceptibility of effects and capacity to respond; their susceptibility during development and growth, highlighting neurodevelopmental processes from conception to young adulthood that are highly sensitive to external exposures. Further, critical periods when exposures may have significant effects on a child's development and future health are addressed. The paper stresses that children's behaviour, physiology, activity pattern and place for activities make them differently vulnerable to environmental pollutants, and calls for child-specific assessment methods, currently lacking within today's health frameworks. The importance of understanding the interplay between structure and agency is emphasized, where agency is guided by social structures and practices and vice-versa. An intersectional approach that acknowledges the interplay of social and physical exposures as well as a global and rural perspective on exposome is further pointed out. To advance the exposome field, interdisciplinary efforts that involve multiple scientific disciplines are crucial. By adopting a child perspective and incorporating an exposome approach, we can gain a comprehensive understanding of how exposures impact children's mental health and cognitive development leading to better outcomes.

Protective effect of restorative possibilities on cognitive function and mental health in children and adolescents: A scoping review including the role of physical activity

Background The exposome approach can be a powerful tool for understanding the intertwining of social, physical, and internal influences that shape mental health and cognitive development throughout childhood. To distil conceptual models for subsequent analyses, the EU-funded project Early Environmental quality and Life-course mental health effects (Equal-Life) has conducted literature reviews on potential mediators linking the exposome to these outcomes. We report on a scoping review and a conceptual model of the role of restorative possibilities and physical activity. Methods Peer-reviewed studies published since the year 2000 in English, on the association between the exposome and mental health/cognition in children/adolescents, and quantitatively investigating restoration/restorative quality as a mediating variable were considered. Database searches were last updated in December 2022. We used an unstructured expert-driven approach to fill in gaps in the reviewed literature. Results Five records of three distinct studies were identified, indicating a scarcity of empirical evidence in this newly developing research area. Not only were these studies few in numbers, but also cross-sectional, lending only tentative support to the idea that perceived restorative quality of adolescent's living environment might mediate the association between greenspace and mental health. Physical activity emerged as a mediator leading to better psychological outcomes in restorative environments. We provide a critical discussion of potential caveats when investigating the restoration mechanism in children and propose a hierarchical model including restoration, physical activity, and relational dynamics between children and their environment, including social context, as well as restorative environments other than nature. Conclusions It is justified to further explore the role of restoration and physical activity as mediators in the association between early-life exposome and mental health/cognitive development. It is important to consider the child perspective and specific methodological caveats. Given the evolving conceptual definitions/operationalizations, Equal-Life will attempt to fill in a critical gap in the literature.

Comparing perspectives on research needs from stakeholders vs. researchers in an exposome project

Background

Exposome research looks into how combined exposures affect human health. The EU-funded Equal-Life project focuses on physical and social exposures in a child’s environment and its effects on children’s mental health and cognitive development in the life course. Perspectives and priorities on what to study in particular might differ between practitioners and researchers. Therefore, collaboration with external stakeholders from various fields is encouraged to integrate practical experience and link it to the researchers’ aims.

Methods

Two Delphi studies were conducted collecting and evaluating research questions to be studied in the project among a) the researchers within the project and b) among external stakeholders from various European countries. The exercise was to evaluate the research questions for group a) based on relevance and testability and for b) e.g. regarding practitioners’ work and options for policies. Involved stakeholders work in health care, and urban planning, among others. Prioritised questions are collated.

Findings

Within the researchers’ group, top-rated questions were mainly mechanism-directed in terms of how and to what extent certain factors affect children’s mental health and cognitive development, cumulative effects in different settings, among others. Stakeholders most value research questions on practical issues, e.g. effects of early experiences of discrimination, critical windows in children’s lives that are most sensitive regarding the impact of exposures on mental health and cognitive development, or impact of exposures in early stages of life.

Discussion

In comparing approaches of stakeholders and researchers, stakeholders’ input from the practical field can shape the approach of the research process. The second benefit is to derive implications for creating effective interventions and policies to prevent adverse effects of environmental exposures and to foster positive health in children and later on in life.

Key messages

• Bi-directional exchange between researchers and external stakeholders can make gaps visible.

• Engaging stakeholders into a research process can help sharpening the aim and outcome of a project.

Effect of the Shelving Technique on the Outcome of Embolization in Intracranial Bifurcation Aneurysms

BACKGROUND AND PURPOSE

Stent bulging technique has been introduced as a technique that improves the outcome of aneurysm coiling. Our aim was to evaluate the utility of this technique, which involves the intentional herniation of stents into the bifurcation aneurysms during coiling.

MATERIALS AND METHODS

Unruptured bifurcation aneurysms treated by stent-assisted coiling using a single type of low-profile braided (LEO Baby) stent between November 2012 and October 2018 were retrospectively evaluated. The clinical (age and sex) and morphologic characteristics (aneurysm size, neck size, proximal/distal diameters of the stented artery, incorporation of the origins of the side branches to the aneurysm neck, and bifurcation angle) and response to antiplatelet therapy were evaluated.

RESULTS

Sixty-one patients (29 men, 47.5%; mean age, 55.95 [SD, 12.33] years) with 66 aneurysms were included. There were 36 aneurysms in group A (treated with the stent bulging technique) and 30 aneurysms in group B (treated by classic stent-assisted coiling). There was no significant difference in the patient and aneurysm characteristics in the groups except for the larger size and wider neck of the aneurysms in group A (P = .02 and P = .04, respectively). At the mean follow-up of 27.30 (SD, 17.45) months, there was no significant difference in the complication rate, the occlusion status, and the early and long-term occlusion rates between the groups. The stent bulging technique did not predict total occlusion (Raymond-Roy I) at the final imaging follow-up.

CONCLUSIONS

The stent bulging technique enables the coiling of larger, wide-neck aneurysms; however, we did not observe an added flow-diversion effect with the stent bulging technique compared with conventional stent-assisted coiling. We, therefore, suggest that bifurcation aneurysms should be coiled as densely and as safely as possible using this technique.

Safety, Efficacy, and Durability of Stent-Assisted Coiling Treatment of M2 (Insular) Segment MCA Aneurysms

BACKGROUND AND PURPOSE

Most distal MCA aneurysms are located within the insular segment, which lies between the limen insulae and circular sulcus. However, experience is limited in the microsurgical and endovascular management of insular segment MCA aneurysms. In this multicenter retrospective case series, we aimed to investigate the safety, efficacy, and durability of stent-assisted coiling for treatment of insular segment MCA aneurysms.

MATERIALS AND METHODS

A retrospective review was performed to identify patients with insular MCA aneurysms that were treated with stent-assisted coiling. The technical success of the procedures and the initial and follow-up clinical and angiographic outcomes were assessed. Periprocedural and delayed complications were reviewed.

RESULTS

Twenty-seven aneurysms in 27 patients with a mean age of 53.3 (SD,11.3) years were included. The mean size of the aneurysms was 6.3 (SD 2.6) mm. Endovascular procedures were successfully performed in all patients. Immediate postprocedural angiography revealed complete aneurysm occlusions in 81.5%. Periprocedural complications developed in 7.4% without causing permanent morbidity. A delayed thromboembolic complication resulted in a minor permanent morbidity in 1 patient (3.7%). There was no mortality. The mean duration of angiographic follow-up was 19.5 (SD, 9.8)  months. The last follow-up examinations showed complete occlusion in 92.6%. During the follow-up period, none of the treated aneurysms showed recanalization.

CONCLUSIONS

The results of this study demonstrate that stent-assisted coiling with a low-profile self-expandable stent is a feasible and relatively safe technique for endovascular treatment of insular segment complex MCA aneurysms. Additionally, it provides an effective and durable treatment for insular MCA aneurysms.

Stakeholders’ involvement in identification of research and policy needs for children’s mental health

Background

The overarching aim of the Horizon 2020 Equal-Life project is to develop evidence-based guidance for policy-and decision-makers concerning child environment and long-term effects on mental health and cognitive development. Stakeholders at national and local level are crucial in improving the physical and social environments children grow up in. In this paper, we present preliminary results of a repeated survey on stakeholders' needs concerning environmental determinants of mental health and cognitive development of children and adolescents.

Methods

We invited potential stakeholders from relevant fields of expertise. Two of three rounds of the Delphi survey were performed by means of an on-line survey between November 2020 and February 2021.The questionnaire was aimed at identifying research questions, knowledge gaps and raised issues about data collection and analysis regarding improving mental health and cognitive development, policy needs related to environment and its role in children's mental health and the potential effectiveness of policy interventions.

Results and Conclusions

In the 1st survey round 34 stakeholders participated and in the 2nd survey round 51 stakeholders participated from 26 different countries and continents. Across both rounds of the survey most participants were from research institutes (21), public health organisations (8), civil society (6), national stakeholders (5) with only little involvement of local or regional authorities or child care organisations. Stakeholders identified several research priorities such as: instruments to improve children's mental health, preventive programs addressing mental health, integrated mental health care services, programs aimed at parenting skills and child care. Early life exposure to adverse social events and psychosocial stressors in the family and socioeconomic disadvantage were recognized as main factors for child development.

Key messages

The guidance from Equal-Life aims to include stakeholders in creation of intervention strategies and preventive measures for mental health and the cognitive development of children. Evidence-based policies and programmes can buffer the negative effects of adverse environments and create restorative ones, and by doing so improve mental health and cognitive development.

Childhood vaccination coverage in Australia: an equity perspective

BACKGROUND

This study describes trends in social inequities in first dose measles-mumps-rubella (MMR1) vaccination coverage in Western Australia (WA) and New South Wales (NSW). Using probabilistically-linked administrative data for 1.2 million children born between 2002 and 2011, we compared levels and trends in MMR1 vaccination coverage measured at age 24 months by maternal country of birth, Aboriginal status, maternal age at delivery, socio-economic status, and remoteness in two states.

RESULTS

Vaccination coverage was 3-4% points lower among children of mothers who gave birth before the age of 20 years, mothers born overseas, mothers with an Aboriginal background, and parents with a low socio-economic status compared to children that did not belong to these social groups. In both states, between 2007 and 2011 there was a decline of 2.1% points in MMR1 vaccination coverage for children whose mothers were born overseas. In 2011, WA had lower coverage among the Aboriginal population (89.5%) and children of young mothers (89.3%) compared to NSW (92.2 and 92.1% respectively).

CONCLUSION

Despite overall high coverage of MMR1 vaccination, coverage inequalities increased especially for children of mothers born overseas. Strategic immunisation plans and policy interventions are important for equitable vaccination levels. Future policy should target children of mothers born overseas and Aboriginal children.

Propensity Score Analysis of Flow Diverters Placed in Scaffolding Stents

BACKGROUND AND PURPOSE

Flow-diverter deployment within a stent remains controversial, but flow-diverter deployment within a scaffolding stent has been performed occasionally. To date, an analysis of this scaffolding technique has not been reported. We aimed to evaluate whether the scaffolding technique adversely affects the outcomes of flow diversion.

MATERIALS AND METHODS

Patients who had undergone intracranial aneurysm treatment using a Silk flow diverter with (scaffolding group) or without (bare flow-diverter group) a scaffolding stent were identified retrospectively and compared. Propensity score matching was used to match the aneurysms in both groups for variables with a significant difference between groups. Aneurysm occlusion rates and clinical outcomes were compared.

RESULTS

There were 84 patients (105 aneurysms) in the bare flow-diverter group and 21 patients (22 aneurysms) in the scaffolding group (using 20 LEO stents and 1 Enterprise stent). The aneurysms in the scaffolding group were larger (mean, 13.1 [SD, 10.7] versus 7 [SD, 4.5] mm, P = .001) and more likely to be fusiform (40.9% versus 5.7%, P < .001) than in the bare flow-diverter group. After 2:1 propensity score matching, 24 aneurysms in the bare flow-diverter group and 15 in the scaffolding group were matched. Aneurysm occlusion rates did not significantly differ between groups at 1-3 months (41.2 versus 33.3%, P > .99), 3-6 months (55.5 versus 75.0%, P = .44), 7-12 months (65.0 versus 90.0%, P = .21), or beyond 1 year (73.6 versus 91.6%, P = .36). There was no difference in complication rates between the groups (P > .99).

CONCLUSIONS

Placement of a scaffolding stent before flow diversion does not adversely affect aneurysm occlusion or complication rates.

Timing of paediatric orchidopexy in universal healthcare systems: international administrative data cohort study

BACKGROUND

International guidelines in 2008 recommended orchidopexy for undescended testis at 6-12 months of age to reduce the risk of testicular cancer and infertility. Using administrative data from England, Finland, Ontario (Canada), Scotland and Sweden (with data from Victoria (Australia) and Iceland in supplementary analyses), the aim of this study was to investigate compliance with these guidelines and identify potential socioeconomic inequities in the timing of surgery before 1 and 3 years.

METHODS

All boys born in 2003-2011 with a diagnosis code of undescended testis and procedure codes indicating orchidopexy before their fifth birthday were identified from administrative health records. Trends in the proportion of orchidopexies performed before 1 and 3 years of age were investigated, as were socioeconomic inequities in adherence to the guidelines.

RESULTS

Across all jurisdictions, the proportion of orchidopexies occurring before the first birthday increased over the study period. By 2011, from 7·6 per cent (Sweden) to 27·9 per cent (Scotland) of boys had undergone orchidopexy by their first birthday and 71·5 per cent (Sweden) to 90·4 per cent (Scotland) by 3 years of age. There was limited evidence of socioeconomic inequities for orchidopexy before the introduction of guidelines (2008). Across all jurisdictions for boys born after 2008, there was consistent evidence of inequities in orchidopexy by the first birthday, favouring higher socioeconomic position. Absolute differences in these proportions between the highest and lowest socioeconomic groups ranged from 2·5 to 5·9 per cent across jurisdictions.

CONCLUSION

Consistent lack of adherence to the guidelines across jurisdictions questions whether the guidelines are appropriate.

Relevance of Distal Arterial Collapse in Stenting of Atherosclerotic Near-Occlusion of the Carotid Artery

BACKGROUND AND PURPOSE

Carotid near-occlusion has been subclassified into near-occlusion with and without collapse. We aimed to compare the technical success and perioperative complication rates of carotid artery stent placement with special attention to these subtypes to see whether there is a clinical relevance of this subclassification.

MATERIALS AND METHODS

From January 2014 to January 2018, we retrospectively evaluated all patients with atherosclerotic extracranial carotid stenosis treated by carotid artery stent placement. Patients with near-occlusion were identified based on DSA findings. Patient characteristics, the presence of criteria for near-occlusion and collapse, arterial diameters, technical success rate, and perioperative (≤30 days) complications were analyzed.

RESULTS

We identified 59 near-occlusions in 58 (46 men, 11 with collapse) patients. Forty-one patients (70.7%) were symptomatic. Technical success rate was 98.3% (58 of 59 procedures). In 1 case of near-occlusion with collapse, we were not able to pass through the stenosis. Compared with patients without collapse (4.2% of 48 cases), those with collapse (30% of 10 stented patients) had significantly higher rates of postintervention hyperperfusion syndrome (P = .032). In the whole cohort, the permanent morbidity and mortality rate was 3.4% (1.7% permanent morbidity and 1.7% mortality). For asymptomatic and symptomatic near-occlusion groups, the rates were 0% and 4.9%, respectively. The composite risk of stroke, death, and myocardial infarction was similar between the groups with and without collapse (P = .682). Rate of hyperperfusion syndrome (with or without permanent deficit) was similar (P = 1) in preoperatively symptomatic patients versus asymptomatic patients (9.8% vs 5.9%). Internal carotid artery diameter consistently increased after carotid artery stent placement in patients with collapse and was not related to the development of hyperperfusion syndrome.

CONCLUSIONS

Care should be taken to minimize hyperperfusion risk in patients with near-occlusion undergoing CAS, especially in the subgroup of patients with collapse and in patients with both symptomatic and asymptomatic carotid stenosis.

Placement of a Stent within a Flow Diverter Improves Aneurysm Occlusion Rates

BACKGROUND AND PURPOSE

Placement of a stent within a flow diverter has been described previously but its consequences have not been analyzed. We evaluated the clinical and angiographic results of stent placement within a flow diverter during the same treatment session.

MATERIALS AND METHODS

All patients treated with a Surpass flow diverter were retrospectively evaluated. Patients with previously deployed stents and procedures in which scaffolding stents, a second flow diverter, or intrasaccular devices were used were excluded. Patient and aneurysm characteristics and clinical and imaging follow-up results were compared between stented and nonstented Surpass flow-diverter groups and stent assisted coiling.

RESULTS

Thirty-five patients (41 aneurysms) were treated with a Surpass flow diverter only (monotherapy group), and in 33 patients (35 aneurysms), a stent was placed within the Surpass flow diverter (stented group). Stents were placed inside the Surpass flow diverter for a variety of reasons at the operator's discretion. No statistical difference was noted between the 2 groups in age, body weight, sex, history of thromboembolic events, smoking, platelet inhibition levels, hypertension, hyperlipidemia, diabetes mellitus, malignancy, and aneurysm location. Aneurysms in the stented group were larger than those in the monotherapy group (14.8 versus 9.1 mm, P < .001). The rate of clinically significant adverse events and complete aneurysm occlusion rates at 0-3 and 3-6 months (73.3% versus 61.3%, P = .31, and 84.8% versus 70.2%, P = .14) were similar. At 9-12 months, a significantly higher proportion of aneurysms in the stented group achieved complete occlusion (93.9% versus 73.2%, P = .019). There was a trend toward a higher obliteration rate on final follow-up in the stented group (93.9% versus 82.9%, P = .14).

CONCLUSIONS

Placement of a stent within a flow diverter increases the rate of aneurysm occlusion. We propose that these results are from improved flow-diverter apposition due to the higher radial force of intracranial stents.

Organisation of preventive child health services: Key to socio-economic equity in vaccine uptake?

Background: Measles has made a comeback in Western Europe, with more cases being reported each year. One factor behind this development is low vaccination coverage in socially disadvantaged segments of the population in many countries. This study investigates whether socioeconomic patterns of uptake of the measles, mumps and rubella (MMR) vaccine in the Nordic countries differ by national organisation of preventive health services for children. Methods: MMR vaccine uptake before the age of two years was analysed in register data from Denmark, Finland, Iceland and Sweden, linked to family indicators of socio-economic status (SES) from national registers. Results: Denmark, a country where child vaccinations are administered by general practitioners, presented the lowest overall coverage of MMR at 83%. It also had the greatest difference between subpopulations of low and high SES at 14 percentage points. Finland, Iceland and Sweden, countries where preschool children are vaccinated in 'well-baby' clinics, had a higher overall coverage at 91-94%, with a more equal distribution between SES groups at 1-4 percentage points. Conclusions: This study suggests that the organisation of preventive health care in special units, 'well-baby' clinics, facilitates vaccine uptake among children with low SES in a Nordic welfare context.

Social inequities in vaccination coverage among infants and pre-school children in Europe and Australia - a systematic review

BACKGROUND

Herd immunity levels of vaccine uptake are still not reached in some high-income countries, usually in countries with persisting social inequities in uptake. Previous studies have focused on factors within one health care system. This study takes a broader health care systems approach by reviewing the socioeconomic distribution of vaccination coverage on the national level in light of structural and organizational differences of primary care for children.

METHODS

A systematic literature review of socio-economic patterns of uptake of Measles-Mumps-Rubella (MMR) and/or Diphteria-Tetanus-Pertusis (DTP) in population based studies of children 0-5 years of age living in the 30 European Economic Area (EEA) or European Free Trade Association (EFTA) countries and Australia, was carried out using the PRISMA guidelines. The health care system in the countries in the study were categorized by degree of freedom of the primary care provider (hierarchical or non-hierarchical) and whether preventive services were provided in a separate organization (well-baby clinics).

RESULTS

The review identified 15 studies from 10 European countries and Australia that fulfilled the criteria. Although the heterogeneity of the socio-economic indicators did not allow for a conclusive meta-analysis, the study pointed towards lower levels of inequities in primary care models with well-baby clinics. In non-hierarchical primary care organizations that also lacked well-baby clinics, socioeconomic gaps in uptake were often found to be large.

CONCLUSION

This review indicates that structural and organizational aspects of health care systems for young children are important for equity in vaccine uptake.

ADHD medication in offspring of immigrants - does the income level of the country of parental origin matter?

BACKGROUND

Child psychiatric treatment facilities vary greatly worldwide and are virtually non-existent in many low-income countries. One of the most common psychiatric disorders in childhood is ADHD, with an estimated prevalence of 3-5% in Sweden. Previous studies have shown a similar prevalence of ADHD in minority and majority children in Sweden and the UK. However, clinical studies demonstrated that children from immigrant families living in Sweden received less psychiatric care than those of native-born parents. We tested the hypothesis that the consumption of child psychiatric care in immigrant families would be determined by the availability of such treatment in the parents' country of origin. Patterns of medication for attention-deficit hyperactivity disorder (ADHD) were studied as a proxy for child psychiatric care.

METHODS

This was a register study of dispensed stimulant medication during 2013-2014 in Swedish national birth cohorts from 1995-2009. The study population, consisting of nearly 1.4 million children, was divided by national income of the parental country of origin and whether the parents were native Swedes, European immigrants, non-European immigrants or a mixture. Logistic regression was used to calculate the odds ratios of having been dispensed at least one ADHD drug during 2013, with adjustments for gender, family status indicating whether the child is living with both parents, household income and area of residence.

RESULTS

Having parents born in low-income (OR [95% confidence interval] 0.27 [0.24-0.29]) or middle-income (European: OR 0.23 [0.20-0.26], non-European: OR 0.39 [0.34-0.41]) countries was associated with lower ADHD treatment levels than having parents born in high-income countries (European: OR 0.60 [0.54-0.66], non-European: OR 0.68 [0.59-0.79]), when compared to children of parents born in Sweden. In families with a background in low or middle income countries, there was no significant association between household income and ADHD medication, while in children with Swedish and mixed backgrounds high level of disposable income was associated with lower levels of ADHD medication.

CONCLUSION

The use of child psychiatric care by immigrant families in Sweden was largely associated with the income level of the country of origin.

Flow Diverters in the Treatment of Pediatric Cerebrovascular Diseases

BACKGROUND AND PURPOSE

There is very limited data concerning utilization of flow diverters in children. Our aim is to report results for the treatment of complex intracranial aneurysms and carotid cavernous fistulas by using flow diverters in children.

MATERIALS AND METHODS

Retrospective review of children (17 years of age or younger) treated with flow diverters between May 2011 and July 2014 was performed. Clinical and laboratory data and angiographic findings were extracted. Seven patients (6 males, 1 female; mean age, 12.7 years; range, 3-16 years) were included. Two presented with posttraumatic fistulas. The remaining patients presented with traumatic aneurysms of the cavernous carotid artery or fusiform aneurysms of the distal vertebral artery, M1, or A2 segments. All patients were premedicated with clopidogrel (75 mg daily for patients with body weights of >45 kg, 37.5 mg daily for 1 small child with a body weight of <45 kg) and aspirin (300 mg daily for ≥45 kg, 100 mg daily for smaller children).

RESULTS

VerifyNow and Multiplate Analyzer values were higher than expected. No clinical complications were noted. Imaging performed at 7-52 months after the procedure (mean/median, 22.3/14 months) revealed occlusions of all aneurysms and fistulas. One patient had an asymptomatic occlusion of the parent artery; otherwise, no hemodynamically significant parent artery restenosis was observed. There were no clinically significant neurologic events during follow-up.

CONCLUSIONS

Although flow-diverter placement appears to be safe and effective on midterm follow-up in children, longer follow-up is critical. The current sizes of flow diverter devices and delivery systems cover the pediatric size range, obviating developing flow diverters specific to children.

Parental death in childhood and self-inflicted injuries in young adults-a national cohort study from Sweden

Previous studies have shown that parental death influences health and mortality in bereaved offspring. To date, few studies have examined whether exposure to parental bereavement in childhood is associated with suicidality later in life. The aim of the present research was to investigate whether parental death during childhood influences self-inflicted injuries/poisoning in young adulthood. A national cohort born during 1973-1982 (N = 871,402) was followed prospectively in the National Patient Discharge Register from age 18 to 31-40 years. Cox regression analyses of proportional hazards, with adjustment for socio-demographic confounders and parental psychosocial covariates, were used to test hypotheses regarding parental loss and hospital admission due to self-inflicted injuries/poisoning. Parental deaths were divided into deaths caused by (1) external causes/substance abuse and (2) natural causes. Persons who had lost a parent to an external cause/substance abuse-related death had the highest risk of being admitted to a hospital for a self-inflicted injury/poisoning; HRs 2.03 (1.67-2.46) for maternal death and 2.03 (1.84-2.25) for paternal death, after adjustment for socio-demographic confounders and risk factors among surviving parents. Risks were also increased for parental death due to natural causes, but at a lower level: 1.19 (1.01-1.39) and 1.28 (1.15-1.43), respectively. Losing a father before school age was associated with a higher risk of hospital admission for a self-inflicted injury/poisoning than was loss at an older age for both genders. Maternal loss before school age was associated with a higher risk only for men, particularly maternal death by natural causes (p < 0.01).

Stent-Assisted Coiling of Wide-Neck Intracranial Aneurysms Using Low-Profile LEO Baby Stents: Initial and Midterm Results

BACKGROUND AND PURPOSE

Low-profile self-expandable stents were recently introduced for the treatment of wide-neck intracranial aneurysms. This study investigated the initial and midterm clinical and angiographic results of LEO Baby stent-assisted coiling in the treatment of wide-neck intracranial aneurysms.

MATERIALS AND METHODS

A retrospective review was performed to identify patients who were treated with LEO Baby stent-assisted coiling. Eighty patients with 80 wide-neck intracranial aneurysms were included in the study. Eleven patients (13.8%) presented with subarachnoid hemorrhage. All patients were treated with LEO Baby stent-assisted coiling. Technical success and immediate postprocedural clinical and angiographic outcomes were evaluated. Seventy-three patients attended angiographic and clinical follow-up for a mean duration of 7.2 ± 3.8 months. Periprocedural and delayed complications were reviewed. Preprocedural and follow-up clinical statuses were assessed by using the modified Rankin Scale.

RESULTS

The technical success rate of the procedure was 97.5%. The immediate postprocedural angiography revealed a complete occlusion of the aneurysm in 75% of the 80 patients. The last follow-up angiograms showed complete occlusion in 85.7% of the 77 patients with an angiographic follow-up. Of the 77 patients with a follow-up angiography, 6.5% showed an increase in the filling status of the aneurysm and 5.2% required retreatment. The overall procedure-related complication rate, including asymptomatic complications, was 11.3%. The permanent morbidity rate was 3.8%. There was no mortality in this study.

CONCLUSIONS

This case series demonstrates the relative safety, efficacy, and midterm durability of the LEO Baby stent-assisted coiling procedure for the treatment of wide-neck intracranial aneurysms.

Dual stenting using low-profile LEO baby stents for the endovascular management of challenging intracranial aneurysms

BACKGROUND AND PURPOSE

Endovascular treatment of wide-neck, complex, and distally located cerebral aneurysms is a challenging issue. This study evaluated the safety and efficacy of dual stent placement by using a low-profile stent system (LEO Baby) for the treatment of challenging distal intracranial aneurysms.

MATERIALS AND METHODS

We retrospectively reviewed patients in whom at least 1 LEO Baby stent was used in the context of dual stent placement for the treatment of intracranial aneurysms. Patients who were treated with dual stent-assisted coil embolization and telescopic implantation of LEO Baby stents were included in the study. Clinical and angiographic findings, procedural data, and follow-up are reported.

RESULTS

Twelve patients were included in this study. Three patients presented with subarachnoid hemorrhage in the subacute-chronic phase, and the remaining patients had unruptured aneurysms. Nine patients were treated by using the dual stent-assisted coiling method. X- (nonintersecting), Y- (intersecting and reversible), T-, and parallel-stent configurations were performed for the dual stent-assisted coiling procedures. Three patients were treated by using telescopic stent placement for a flow diverter-like effect. The procedures were successful in all cases. Technical complications without a significant clinical adverse event developed in 2 patients. The 3- and 6-month control MRAs and DSAs demonstrated complete occlusion of the aneurysms in all patients except 1. All patients had good clinical outcomes on follow-up (mRS ≤1).

CONCLUSIONS

The results of this small study showed the feasibility of dual stent placement by using low-profile LEO Baby stents to treat distally located complex intracranial aneurysms.

Aneurysm ostium angle: a predictor of the need for stent as assistance for endovascular aneurysm coiling in internal carotid artery sidewall aneurysms

BACKGROUND AND PURPOSE

There is no satisfactory parameter that can predict the need for assistant devices for endovascular aneurysm coiling. Our aim was to evaluate the utility of MOA as a predictor of the need for stent-assisted coiling in ICA sidewall aneurysms.

MATERIALS AND METHODS

From a retrospective review of an internal data base, 55 consecutive ICA sidewall aneurysms were identified. Thirty-two of the aneurysms were treated by using endovascular techniques. Because 23 of the 55 aneurysms were either untreated or clipped, 3 experienced interventionalists reviewed the 3D images of these aneurysms and then made a decision as to whether stent-assisted coiling would have been required. Thirty-one of the 55 aneurysms would have required stent-assisted coiling, while 24 would not. Neck width, DNR, AR, and MOA were obtained from each aneurysm by using prototype software. These parameters were then correlated with the requirement of stent-assisted coiling.

RESULTS

MOA and neck width of aneurysms requiring stent-assisted coiling were significantly larger than those not requiring stent-assisted coiling (P < .001 and <0.001, respectively). Although the DNR and AR of aneurysms requiring stent-assisted coiling were smaller than those not requiring it, the difference was not significant (P = .22 and 0.12, respectively). ROC analysis revealed that MOA was the parameter that best correlated with the need for stent-assisted coiling. Inclusion of MOA with the rest of the parameters significantly increased the predictive performance regarding the need for stent-assisted coiling (P = .005).

CONCLUSIONS

In this small study, MOA was a useful parameter to predict the need for stent-assisted coiling in ICA sidewall aneurysms. Further prospective study of this parameter for aneurysms at multiple locations is required to determine its ultimate value.

Embolization of Cerebral Aneurysms with Spherically Shaped Detachable Microcoils (MicruSphere Microcoil System). A Single Centre Experience

SUMMARY

We present our initial experience of concentric-filling technique using MicruSphere 3D coils (Micrus Endovascular, San Jose, CA) in the treatment of intracranial aneurysms. 149 intracranial saccular aneurysms in 142 consecutive patients (mean age 56.6-/+12.7, ruptured in 54 (36.2%)) were treated with the concentric-filling technique. The mean aneurysm volume was 169.0-/+363.0 mm(3). Neck remodeling technique was used in 120 (80.5%). Procedure-related problems were recorded. Initial embolization results were evaluated, and the coil packing density was calculated. Clinical and angiographic follow-ups were performed after six months. Any changes in embolization status were classified as 'improved', 'unchanged', or 'worse'. The overall packing density was 40.1% (range 10.5-90.9%). The permanent morbidity and mortality rates were 4.0% and 1.3%, respectively. The initial Raymond and Roy classification results were class 1 in 37 aneurysms (24.8%), class 2 in 50 (33.6%), and class 3 in 62 (41.6%). On the mean follow-up examination of 8.2 months in 103 patients (72.5%), there were one transient ischemic attack, one minor stroke, and one instance of rebleeding. Angiographic follow-up in 101 aneurysms (67.8%) showed the change in embolization status as 'improved' in 42 aneurysms (41.6%), 'unchanged' in 42 (41.6%), and 'worse' in 17 (recanalisation rate, 16.8%). The concentric-filling technique using Micrusphere 3D coils was effective in achieving high packing density which in turn resulted in stable embolization in the majority of the aneurysms. Longer follow-up is warranted to determine the durability of these results.

Dual antiplatelet therapy monitoring for neurointerventional procedures using a point-of-care platelet function test: a single-center experience

BACKGROUND AND PURPOSE

Growing evidence of the relationship between poor antiplatelet response and occurrence of clinical events elicited the need of monitoring the response which has not been part of our daily practice. We present our initial experience with a new point-of-care antiplatelet-function test (VerifyNow assay) in neurointerventional procedures.

MATERIALS AND METHODS

Among the 106 consecutive patients from July 2006 to April 2007, ninety-eight met the inclusion criteria. Our preferred antiplatelet regimen was aspirin (325 mg daily) and clopidogrel (300 mg of loading dose followed by 75 mg daily) starting 5-10 days before the procedure. The test results were reported as aspirin-reaction unit (ARU) for aspirin and P2Y(12) reaction units (PRU), baseline (BASE), and percentage inhibition for the P2Y(12) assay and were summarized as mean +/- SD of the values. We analyzed the effects of several factors of poor clopidogrel response (<40% inhibition). The occurrence of thrombotic events was recorded.

RESULTS

The mean ARU of aspirin assays was 438.3 +/- 47.9 (range, 350-632), and the response was poor in 2 patients (2.1%). For clopidogrel, the mean of the BASE, PRU, and percentage inhibition was 356.8 +/- 56.3 (range, 234-495), 198.9 +/- 104.4 (range, 8-401), and 45.2 +/- 27.1% (range, 0-98), respectively. Forty-two patients (42.9%) showed poor response. Multivariate analysis showed greater body weight (81.9 Kg +/- 19.1 kg versus 69.9 +/- 15 kg) in the poor-response group. All 3 cases of intraprocedural thrombosis (3.1%) were observed only in the poor-response group.

CONCLUSION

We observed a high frequency of poor clopidogrel responses in the neurointerventional setting. Routine monitoring of the drug response would be helpful for the early identification of poor antiplatelet responders so that we may modify the regimen and/or treatment plan.

Emergent treatment of an Iatrogenic arterial injury at femoral puncture site With Symbiot self-expanding PTFE-covered coronary stent-graft

We report an intracranial stenting procedure complicated by active bleeding from the femoral puncture site because of high arterial puncture. The patient was treated by placement of two PTFE-covered self-expanding coronary stent-grafts. To our knowledge, there have been very few reports on stent-grafting of femoral artery in the literature. The low profile and flexibility of the coronary stent-graft enabled treatment via a six French sheath and 12th month patency is demonstrated with CT angiography.

Embolization of high-flow craniofacial vascular malformations with onyx

BACKGROUND AND PURPOSE

Various techniques and materials have been used for the endovascular treatment of craniofacial high-flow arteriovenous vascular malformations, because their rarity precludes standardization of their treatment. The aim of this retrospective review is to assess Onyx as the primary embolic agent in the treatment of these vascular malformations.

MATERIALS AND METHODS

Six patients with arteriovenous fistulas and 3 with arteriovenous malformations (AVMs) of the head and neck region were treated with intra-arterial (IA)/direct percutaneous injections of Onyx. Adjunctive maneuvers used during embolization included external compression of the arterial feeders or venous outflow (6 patients), balloon assist (4 patients), and direct embolization of the draining vein remote to the fistula site (1 patient). n-butyl-2-cyanoacrylate (n-BCA) was used in addition to Onyx for rapid induction of thrombosis in a large venous pouch (1 patient) and for cost containment purposes (1 patient). Four patients were treated surgically after the embolization.

RESULTS

There were no neurologic complications secondary to the embolization procedure. The arteriovenous shunt was eliminated in all of the fistulous lesions and 2 of the 3 AVMs. The embolization was incomplete in 1 patient with a large AVM who declined further endovascular or surgical procedures. Untoward events included 2 instances of catheter entrapment (of 9 IA injections), blackish skin discoloration necessitating surgical revision in 1 patient, and difficulty of balloon deflation/wire withdrawal during a balloon-assisted embolization.

CONCLUSION

Onyx appears to be a safe and effective liquid embolic agent for use in the treatment of craniofacial high-flow vascular malformations with distinct advantages and disadvantages compared with n-BCA.

Intimal Thickening after Placement of a Neuroform Stent. Its Incidence and Relation to Angiographic Follow-up Results of Aneurysm Embolization

SUMMARY

Little attention has been given to the intimal thickening of the parent artery associated with the use of Neuroform stent. The purposes of this study were are to analyze quantifyanalyze the incidence of the parent artery intimal thickening the incidence and pattern of luminal changes, to to see somedetermine possible predictors of the phenomenonof the intimal thickening, to to evaluate the its effectthe phenomenonrestenosis on the aneurysm treatment results. We reviewed the initial and six-month followup angiographic images in 32 intracranial aneurysm patients treated with Neuroform stent and coilsin wide-necked aneurysm treatment. The initial embolization results were evaluated by the Raymond and Roy classification. The angiographic changes from immediate post-embolization to the six-month follow-up were classified as 'improved', 'unchanged' and 'worse'. The occurrencerates of parent artery intimal thickening was observed. Any perceivable change in the stented segment of the parent artery was considered as 'intimal thickening' and any change of >/=50% as 'significant thickening'. Fisher exact tests and logistic regression analysis were applied to determine the relation between the occurrence of the intimal thickening and several variables. The incidence of the intimal thickening was 18.8% (6/32) and of significant thickening, 3.1% (1/32). The change in angiographic occlusion of the aneurysm was 'improved' in 40.6% (13/32), 'unchanged' in 37.5% (12/32), and 'worse' in 21.9% (7/32). Among the variables, patient's age (>/=55) and follow-up angiographic results ('improved') correlated with the occurrence of the intimal thickening. Of notable finding was all six cases with intimal thickening of the parent artery were associated with 'improved' in their followup angiographic result. Neuroform-associated intimal thickening usually occurs in younger patients and is frequently associated with improved angiographic result of the aneurysm embolization on follow-up.

Spinal dural arteriovenous fistula in a case with lipomyelodysplasia

Coexistence of a spinal dural arteriovenous fistula within a dysraphic spinal lesion is a very rare situation. We report a 40-year-old man who presented with low back pain and progressive paraparesis. MR images showed an intradural high signal intensity mass at the L2-L3 level containing irregular signal void structures. Spinal angiography revealed extradural arteriovenous fistula with three connections, drained by a tortuous perimedullary vein.

Methylation of histone H3 lysine-79 by Dot1p plays multiple roles in the response to UV damage in Saccharomyces cerevisiae

Various proteins have been found to play roles in both the repair of UV damaged DNA and heterochromatin-mediated silencing in the yeast Saccharomyces cerevisiae. In particular, factors that are involved in the methylation of lysine-79 of histone H3 by Dot1p have been implicated in both processes, suggesting a bipartite function for this modification. We find that a dot1 null mutation and a histone H3 point mutation at lysine-79 cause increased sensitivity to UV radiation, suggesting that lysine-79 methylation is important for efficient repair of UV damage. Epistasis analysis between dot1 and various UV repair genes indicates that lysine-79 methylation plays overlapping roles within the nucleotide excision, post-replication and recombination repair pathways, as well as RAD9-mediated checkpoint function. In contrast, epistasis analysis with the H3 lysine-79 point mutation indicates that the lysine-to-glutamic acid substitution exerts specific effects within the nucleotide excision repair and post-replication repair pathways, suggesting that this allele only disrupts a subset of the functions of lysine-79 methylation. The overall results indicate the existence of distinct and separable roles of histone H3 lysine-79 methylation in the response to UV damage, potentially serving to coordinate the various repair processes.

Endothelium and angiogenesis in white coat hypertension

Hypertensive patients are at particular risk of cardiovascular complications, possibly related to endothelial damage or dysfunction, or to abnormal angiogenesis. The aim of this study was to compare the risk conferred by white coat hypertension (WCH) vs sustained hypertension in the development of the endothelial dysfunction and abnormal angiogenesis by evaluating nitric oxide (NO=NO2+NO3), endothelin-1 (ET-1), vascular endothelial growth factor (VEGF), and E-selectin levels in plasma. The study group included 102 subjects, 34 with WCH (17 male and 17 female patients) aged 49+/-11 years, 34 sustained hypertensives (HT) (15 male and 19 female patients) aged 47+/-11 years and 34 normotensive control subjects (NT) (16 male and 18 female patients) aged 48+/-10 years. WCH was defined as clinical hypertension and daytime ambulatory blood pressure less than 135/85 mmHg. The subjects were matched for age, gender, body mass index and the patients with smoking habit, dyslipidaemia, and diabetes mellitus were excluded from the study. The NO, ET-1, VEGF and E-selectin levels were analysed by ELISA technique. The WCH subjects had significantly higher levels of NO than the HT (41.68+/-2.23 vs 32.18+/-2.68 micromol/l; P<0.001) and significantly lower values than the NT (48.24+/-4.29 micromol/l; P<0.001). ET-1 levels of the WCH group were significantly higher than the NT (8.10+/-0.92 vs 5.95+/-0.26 ng/ml; P<0.001) and significantly lower than the HT (11.46+/-0.59 ng/ml; P<0.001). Considering with VEGF, the WCH group had significantly higher levels than the NT (195.88+/-11.84 vs 146.26+/-18.67 pg/ml; P<0.001), but the difference from the HT group was not significant (203.35+/-7.48 pg/ml; P=0.062). E-selectin in the WCH group was significantly lower than the HT (4.77+/-0.52 vs 8.49+/-2.85; P<0.001), but the difference from the NT group was not significant (3.86+/-0.67; P=0.077). Our data demonstrate that WCH is associated with endothelial dysfunction and abnormal angiogenesis. The degree of these changes is not as severe as observed in hypertensive population.

Distal middle cerebral artery aneurysms. Endovascular treatment results with literature review

SUMMARY

Intracranial aneurysms of the distal intracranial arteries are uncommon lesions which are difficult to treat with surgical techniques. Distal middle cerebral artery (MCA) aneurysms constitute approximately 5% of all MCA aneurysms.We report the results of our coil embolization for the treatment of distal MCA aneurysms. Eleven patients (four men and seven women, average age 37 years) with distally located MCA aneurysms were treated. Four of the aneurysms were fusiform in shape and the remainder were saccular. Seven of the aneurysms were in the dominant hemisphere. Four of the seven patients who had saccular aneurysms were treated with selective aneurysm embolization. The remaining seven patients were treated with aneurysmal sac and parent artery coiling. All patients had good retrograde flow into the peripheral branches of the occluded artery. All the procedures were completed successfully without any additional neurological deficits. Coil embolization is a safe and effective technique for the treatment of distal MCA aneurysms. If the parent artery cannot be preserved, pial collaterals can supply adequate blood to prevent neurological deficits.

Target organ damage and changes in arterial compliance in white coat hypertension. Is white coat innocent?

The aim of this study was to perform an extensive evaluation of target organ status, metabolic abnormalities and hemodynamic alterations in white coat hypertension (WCH). Fifty normotensive (NT), 90 WCH (ambulatory daytime blood pressure < 135/85 mmHg) and 101 hypertensive (HT) subjects underwent extensive biochemical, echocardiographic, fundoscopic examination. In a subgroup study, arterial compliance and intima-media thickness (IMT) were measured by Doppler ultrasound in left common carotid artery. WCH subjects were found to have higher body mass index (BMI) than the NTs (p = 0.042). Left ventricle mass index (LVMI) was greater in the WCHs than the NTs (p < 0.001), but significantly less than the HTs (p < 0.001). Hypertensive retinopathy was observed in the WCHs, but was less severe and rare compared to the HTs (13% vs 27%). Both WCHs and HTs had high levels of urinary albumin excretion (UAE) (p = not significant). Total cholesterol was higher in WCHs than in the NTs (p = 0.04) The distensibility coefficient (DC) of the WCHs was significantly greater than the HTs (p < 0.01), while significantly smaller than the NTs (p < 0.01). The compliance coefficient (CC) of the WCHs was significantly higher than the HTs (p < 0.01), and significantly less than the NTs (p < 0.01). The IMT in the HTs was significantly higher than the WCHs (0.81 +/- 0.05 vs 0.70 +/- 0.04 mm; p < 0.001) and the NTs (p < 0.001). The difference between the NTs and the WCHs was not significant. Our data indicate that patients with WCH represent an intermediate group between NTs and sustained HTs where target organ damage and cardiovascular risk is concerned.

Giant cervical internal carotid artery pseudoaneurysm in a child: endovascular treatment

We report a child with a giant upper cervical internal carotid artery pseudoaneurysm presenting with dysphagia, respiratory distress and a sentinel mild epistaxis, then massive epistaxis. Rupture of the pseudoaneurysm during treatment occurred, as in one reported case. Prompt endovascular treatment yielded a good outcome.

Gadodiamide as an alternative contrast medium in cerebral angiography in a patient with sensitivity to iodinated contrast medium

The physical and pharmacological properties of gadolinium enable its chelates to be used as a contrast medium in digital subtraction angiography. We report the use of gadodiamide, a low-osmolar nonionic gadolinium chelate, for selective angiography in a patient with known sensitivity to iodinated contrast medium. No adverse effects were encountered during or after injection. Contrary to a single previous report of the use of these agents in cerebral angiography, contrast in the angiogram was not particularly good, especially in the distal circulation, but the angiogram was diagnostic.

A cardiac papillary fibroelastoma with chordal location

Papillary fibroelastomas, which were initially incidental findings at autopsy and surgery, are now being recognized with increasing frequency with the widespread use of echocardiography. Because of their embolic potential, an aggressive treatment approach is generally accepted. We report a papillary fibroelastoma located at the chorda of the anterior mitral leaflet that underwent conservative follow-up for 8 years without any complications. Because most of the cardiac papillary fibroelastoma cases reported are incidental findings, the question of whether symptomless fibroelastomas must be removed or other factors contribute to the embolic nature of the selected cases remains a challenge for the future.

Neuroblastoma with spermatic cord metastasis in a child: sonographic findings

We report a case of neuroblastoma in a patient who had no involvement of the spermatic cord at diagnosis but who developed spermatic cord metastasis 2 months later. The metastasis appeared on sonography as a hypoechoic, highly vascular, fusiform, hard, 14x10x7 mm mass located in the right inguinal canal and extending into the scrotum. The diagnosis of spermatic cord metastasis was confirmed by resection and histopathologic examination. We recommend that the scrotum and spermatic cord be evaluated by high-resolution sonography in children with neuroblastoma, both at the time of diagnosis and during follow-up.

Prevalence of risk factors of coronary heart disease in Turks living in Germany: The Giessen Study

Turkish people represent the majority of immigrants in Germany. Even though a high proportion of Turks has been living in Germany since about 20 years, little is known about risk factors of coronary heart disease (CHD) in this population. In this study a sample of 325 male and 155 female Turks are investigated, who voluntarily underwent a health check-up in Germany. Data about the presence of CHD, risk factors and blood parameters were collected. Mean residence time was 21 and 17 years (males/females). A low percentage of female participants was observed compared to the general Turkish population in Germany. Age adjusted prevalence of CHD reached 9.5% in males and 6.7% in females, respectively. Dyslipoproteinemia (DLP) showed the highest prevalence of all risk factors investigated in both genders. Total cholesterol (TC) levels were comparable to those of other western countries and remarkably higher than reported for the population in Turkey. Besides this, low high density lipoprotein-cholesterol (HDL-C) and apolipoprotein A-I (ApoA-I) levels could be found in the majority of the sample. The highest odds ratios for CHD were estimated for stress and hypertension in males and obesity in females. It is concluded that Turkish immigrants in Germany showed an assimilation of lipid pattern to western populations. However, reasons for low HDL-C levels remain unclear. Changes in the lipid metabolism chiefly seem to contribute to the risk factor pattern of Turkish immigrants in Germany.

Gallbladder duplication: imaging findings and differential considerations

Duplication of the gallbladder, a rare congenital anomaly, is important in clinical practice because it may cause some clinical, surgical, and diagnostic problems. We present imaging findings of a double gallbladder including coronal reformatted computed tomographic sections, to our knowledge not previously presented, and discuss the radiologic signs that may be helpful in diagnosis. We also present another case of a double gallbladder in which only one gallbladder was imaged 10 years after cholecystectomy.

Splenic calcifications in heterozygote sickle cell patients

A small, fibrotic, and even calcified spleen is the hallmark of homozygote sickle cell disease in adults. Such a condition is very rare in sickle-thalassemia and, to our knowledge, not previously reported in a sickle cell trait. We report two heterozygote sickle cell siblings with splenic calcifications, one sickle cell trait and one sickle-beta+-thalassemia, without any history suggestive of splenic vasooclusive-infarctive crisis.

Urethro-vaso-cutaneous fistula in a 5-year-old child

A 5-year-old boy with a 4-year history of urethro-vaso-cutaneous fistula is presented. This is the youngest patient reported to have an acquired urethro-vaso-cutaneous fistula. Fistulography is a convenient method for the demonstration of such entities.

Pulmonary involvement in adult Gaucher's disease: high resolution CT appearance

High resolution CT findings of pulmonary involvement are described in a patient with adult type Gaucher's disease. Although the reticular pattern on the chest radiograph was typical, appearance of pulmonary involvement on high resolution CT has not been demonstrated in the literature. High resolution CT demonstrated interlobular septal and intralobular interstitial thickening, irregular interfaces at the pleural surfaces and ground-glass appearance, corresponding to both the alveolar and the interstitial components of the pulmonary involvement.