Anatomic Snuffbox (Distal Radial Artery) and Radial Artery Access for Treatment of Intracranial Aneurysms with FDA-Approved Flow Diverters

BACKGROUND AND PURPOSE:Transradial access for neurointerventional procedures has been proved a safer and more comfortable alternative to femoral artery access. We present our experience with transradial (distal radial/anatomic snuffbox and radial artery) access for treatment of intracranial aneurysms using all 3 FDA-approved flow diverters.MATERIALS AND METHODS:This was a high-volume, dual-center, retrospective analysis of each institution’s data base between June 2018 and June 2020 and a collection of all patients treated with flow diversion via transradial access. Patient demographic information and procedural and radiographic data were obtained.RESULTS:Seventy-four patients were identified (64 female patients) with a mean age of 57.5 years with a total of 86 aneurysms. Most aneurysms were located in the anterior circulation (93%) and within the intracranial ICA (67.4%). The mean aneurysm size was 5.5 mm. Flow diverters placed included the Pipeline Embolization Device (Flex) (PED, n = 65), the Surpass Streamline Flow Diverter (n = 8), and the Flow-Redirection Endoluminal Device (FRED, n = 1). Transradial access was successful in all cases, but femoral crossover was required in 3 cases (4.1%) due to tortuous anatomy and inadequate support of the catheters in 2 cases and an inability to navigate to the target vessel in a patient with an aberrant right subclavian artery. All 71 other interventions were successfully performed via the transradial approach (95.9%). No access site complications were encountered. Asymptomatic radial artery occlusion was encountered in 1 case (3.7%).CONCLUSIONS:Flow diverters can be successfully placed via the transradial approach with high technical success, low access site complications, and a low femoral crossover rate.

The transradial access (TRA), including distal radial artery (dRA) access in the anatomic snuffbox and radial artery (RA) access at the palmar surface of the wrist, is being increasingly used as primary vascular access for neurointerventional procedures. In prior years, large randomized trials in the field of interventional cardiology and more recent articles in neurointerventional surgery have shown higher patient preference for the TRA, cost reduction, as well as lower morbidity and mortality compared with the traditional transfemoral access (TFA).^1-11 Reduction in access site complications has been a particular advantage of wrist over femoral access and is an important consideration for vascular access choice in the treatment of intracranial aneurysms using flow diversion. Patients undergoing flow diversion are required to take dual-antiplatelet agents and receive heparin during the procedure, all of which increase the risk of bleeding from the access site.¹² Also, flow diverters (FDs) may require large-bore catheter assemblies for delivery and deployment, which may increase the risk of radial artery occlusion, access site bleeding, or vascular injury.^13,14To date, only a limited number of case reports and case series have described the safety and feasibility of TRA for the treatment of intracranial aneurysms using flow diverters.^15-22Recently, a large, retrospective multicenter study reported the safety of TRA for flow diversion, showing a lower access site (P = .039) and overall complication rate (P = .035).¹² This study, however, did not cover catheter systems, patient functional outcome, and aneurysm occlusion. Here, we report our experience with TRA (dRA [anatomic snuffbox] and RA) for the treatment of intracranial aneurysms using all 3 FDA-approved flow diverters, including technical feasibility, procedural safety, patient outcome, and aneurysm occlusion on follow-up. Additionally, we reviewed the current literature on use of flow diverters via TRA.     

Demonstration of pharmaceutical tablet coating process by injection molding technology

We demonstrate the coating of tablets using an injection molding (IM) process that has advantage of being solvent free and can provide precision coat features. The selected core tablets comprising 10% w/w griseofulvin were prepared by an integrated hot melt extrusion-injection molding (HME-IM) process. Coating trials were conducted on a vertical injection mold machine. Polyethylene glycol and polyethylene oxide based hot melt extruded coat compositions were used. Tablet coating process feasibility was successfully demonstrated using different coating mold designs (with both overlapping and non-overlapping coatings at the weld) and coat thicknesses of 150 and 300?μm. The resultant coated tablets had acceptable appearance, seal at the weld, and immediate drug release profile (with an acceptable lag time). Since IM is a continuous process, this study opens opportunities to develop HME-IM continuous processes for transforming powder to coated tablets.     

The influence of the veneering porcelain and different surface treatments on the biaxial flexural strength of a heat-pressed ceramic

STATEMENT OF PROBLEM: The strength of all-ceramic restorations can be adversely affected by surface defects, leading to restoration failures. Additionally, when a 2-layer all-ceramic restoration is required for esthetic purposes, part of the stronger ceramic core material is replaced by veneering porcelain. PURPOSE: This study evaluated the effect of different surface treatments on the strength of a ceramic core material and veneering porcelain, as well as the influence of veneering porcelain on the strength of a 2-layer ceramic structure. MATERIAL AND METHODS: Fifty heat-pressed ceramic cores and 30 veneering porcelain discs (17 mm diameter x 2 mm) were made. From the ceramic core group, 20 discs were selected and reduced to a thickness of 1 mm and veneered with 1 mm of porcelain. These specimens were divided into 2 groups of 10 each. The remaining 30 ceramic core and the 30 veneering porcelain discs were divided into 2 sets of 3 equal sized groups (n=10). Ceramic core groups were prepared for testing having the following surfaces: airborne-particle abrasion, ground, and overglazed. Veneering porcelain groups were tested: as fired (no additional treatment), ground, and overglazed. Biaxial flexural strength was measured using the ball-on-ring test method. All specimens were loaded to fracture. One and 2-way analysis of variance were used to analyze the data (alpha=.05). RESULTS: The ceramic core discs were significantly (P=.001) stronger than the veneering porcelain discs for the airborne-particle abrasion, as-fired, and ground surface treatments (82 +/- 11 MPa vs 51 +/- 8 MPa and 93 +/- 14 MPa vs 60 +/- 6 MPa, respectively). For the overglazed treatment, there was not a significant difference between the core (115 +/- 1 4 MPa) and the veneer materials (107 +/- 14 MPa). The ground 1-layer core was significantly (P=.015) stronger (93 +/- 14 MPa) than the 2-layer with the core tested in tension (72 +/- 19 MPa). There was no significant difference between 1-layer veneer overglazed (107 +/- 14 MPa) and 2-layer discs when tested with the veneer in tension (105 +/- 16 MPa). CONCLUSION: The overglazed surface treatment significantly improved the strength of the materials tested, as well as the strength of 2-layer discs with the veneer in tension. The veneering porcelain influenced the strength of 2-layer specimens only when tested with the ground ceramic core surface in tension.     

Predictable preparation, staining, and cementation procedures for chairside CAD/CAM dentistry

Although direct composite resin procedures yield acceptable results when used correctly, if a large quantity of resin is required, complications may arise. In such cases, an indirect protocol must be followed. Numerous CAD/CAM systems, both laboratory and chairside, are available for practitioner use. In a laboratory system, a traditional impression is made and sent to a dental laboratory, where the restoration is fabricated. A chairside system, however, utilizes a digital impression system, and the restoration can then be milled and cemented in a single visit.     

Comparative study to evaluate the efficacy of surgical and conservative techniques for apexification in young permanent teeth with open apices

The Study was conducted to compare and evaluate the effectiveness of surgical and conservative approach for apexification. Twenty-four non-vital permanent maxillary anterior teeth were selected for this study. The teeth selected were having wide apical foramen and definite radiolucent periapical area. Twelve teeth were treated under conservative method and another 12 teeth with surgical method using 'Renew' (A radioopaque calcium Hydroxide paste). The patient were recalled after 1 1/2, 3, 4 and 6 Months. The results of the study indicated that Calcific bridge formation is rapid in teeth treated with conservative technique. However, periapical repair is accelerated in teeth treated by surgical technique, though the results are comparable at the end of 6 months, So the conservative approach is preferred as it saves surgical trauma. In conservative technique, 75% of the teeth showed calcific bridge formation and 100% showed decrease in periapical radiolucent area by 3.56 mm (mean) after 6 months. In surgical technique the radiographic evidence of calcific bridge formation was noticed in 54.51% of teeth after 6 months. However in 100% of teeth there was decrease in periapical radiolucent area by 3.53 mm (mean) after 6 months.     

The effects of a triclosan/copolymer dentifrice on oral bacteria including those producing hydrogen sulfide

A clinical procedure was developed to examine the effects of short-term and extended use of a triclosan/copolymer dentifrice and a commercial fluoride dentifrice on oral bacteria, including those producing hydrogen sulfide. Healthy adults volunteered for this double-blind, crossover design clinical study and provided saliva samples for culturing on enriched and indicator media to enumerate all salivary bacteria and those producing hydrogen sulfide (odorigenic), respectively. Subjects brushed with an assigned dentifrice for 7 d and were sampled on day 8 to assess the long-term effects on bacteria. Extended use of the triclosan/copolymer dentifrice resulted in a 49% and 66% reduction of salivary and odorigenic bacteria, respectively, compared with the fluoride dentifrice. To examine short-term effects, subjects subsequently brushed with their assigned dentifrice and were sampled at 2 h and 4 h post-brushing. At 2 h and 4 h post-brushing, the triclosan/copolymer dentifrice resulted in a 62% and 52% decrease for salivary bacteria and 79% and 72% decrease for odorigenic bacteria, respectively, vs. the fluoride dentifrice. The results indicate a significant decrease of all salivary bacteria and hydrogen sulfide-producing odorigenic bacteria following use of the triclosan/copolymer dentifrice and explain previous results on the efficacy of this dentifrice on oral malodor.     

Case Report of Multiple Bilobar Hepatic Arterio-Portal Fistulas Post–Liver Transplantation Managed Conservatively

Multiple intrahepatic arterio-portal fistulas are rare. The majority are isolated and occur secondary to liver trauma including iatrogenic interventions such as liver biopsy. Post–liver transplantation 18 cases have been reported, all secondary to an interventional radiological procedure. We report multiple bi-lobar arterio-portal fistulas in a liver transplant recipient recognized 1 year after transplantation. The donor died due to intracerebral bleeding following blunt head and abdominal trauma. In the present case, the etiology is not very clear. The patient was managed conservatively and to date has not required intervention.     

Machine Learning and Primary Total Knee Arthroplasty: Patient Forecasting for a Patient-Specific Payment Model

Background

Value-based and patient-specific care represent 2 critical areas of focus that have yet to be fully reconciled by today’s bundled care model. Using a predictive naïve Bayesian model, the objectives of this study were (1) to develop a machine-learning algorithm using preoperative big data to predict length of stay (LOS) and inpatient costs after primary total knee arthroplasty (TKA) and (2) to propose a tiered patient-specific payment model that reflects patient complexity for reimbursement.