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Objectives: Controlling elevated intracranial pressure following brain injury with hyperosmolar agents is one of the mainstay treatments in traumatic brain injury patients. In this study, we compared the effects of hypertonic saline (HS) and mannitol in reducing increased intracranial pressure. Methods: A total of 637 patients from 15 studies were included in our meta-analysis. The primary outcomes were mortality, the length of stay in the hospital and ICU, and the Glasgow Outcome Scale at follow-up. Results: The mortality in the mannitol group was not statistically different compared to the HS group (RR = 1.55; 95% CI = [0.98, 2.47], p = 0.06). The length of stay in the ICU was significantly shorter in the HS group (MD = 1.18, 95% CI = [0.44, 1.92], p < 0.01). In terms of favorable neurological outcomes, there was no significant difference between the two agents (RR = 0.92, 95% CI = [0.11, 7.96], p = 0.94). The duration of the effect was shorter in the mannitol group than in the HS group (MD = -0.67, 95% CI = [−1.00, −0.33], p < 0.01). Discussion: The results showed that HS and mannitol had similar effects in reducing ICP. Although the HS was associated with a longer duration of effect and shorter ICU stay, other secondary outcomes including mortality rate and favorable neurological outcomes were similar between the two drugs. In conclusion, considering the condition of each patient individually, HS could be a reasonable option than mannitol to reduce ICP in TBI patients. [ABSTRACT FROM AUTHOR]

A number of tools exist to aid surgeons in risk assessment, including the Charlson Comorbidity Index (CCI), the Elixhauser Comorbidity Index (ECI), and various measures of frailty, such as the Hospital Frailty Risk Score (HFR). While all of these tools have been validated for general use, the best risk assessment tool is still debated. Risk assessment is particularly important in elective surgery, such as total joint arthroplasty. The aim of this study is to compare the predictive power of the CCI, ECI, and HFR in the setting of total knee arthroplasty (TKA). All patients who underwent TKA were identified via International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code from the National Readmissions Database, years 2016 to 2019. Patient demographics, perioperative complications, and hospital-associated outcomes were recorded. Receiver operating characteristic (ROC) curves were created and area under the curves (AUCs) evaluated to gauge the predictive capabilities of each risk assessment tool (CCI, ECI, and HFR) across a range of outcomes. A total of 1,930,803 patients undergoing TKA were included in our analysis. For mortality, ECI was most predictive (0.95 AUC), while HFR and CCI were 0.75 and 0.74 AUC, respectively. For periprosthetic fractures, ECI was 0.78 AUC, HFR was 0.68 AUC, and CCI was 0.66 AUC. For joint infections, the ECI was 0.78 AUC, the HFR was 0.63 AUC, and the CCI was 0.62 AUC. For 30-day readmission, ECI was 0.79 AUC, while HFR and CCI were 0.6 AUC. For 30-day reoperation, ECI was 0.69 AUC, while HFR was 0.58 AUC and CCI was 0.56 AUC. Our analysis shows that ECI is superior to CCI and HFR for predicting 30-day postoperative outcomes following TKA. Surgeons should consider assessing patients using ECI prior to TKA. [ABSTRACT FROM AUTHOR]

A micro-grid consisting of distributed generation resources (DGRs) with a hybrid energy storage system (HESS) composed of batteries and super-capacitors was studied. A control strategy based on the particle swarm optimization (PSO) and energy management algorithms was proposed to facilitate power distribution in the micro-grid and to improve the reliability, control levels, and penetration of micro-grids in the current electrical grids. The proposed operational strategy is based on the power predicted using the load profile and power generation resources. Energy management strategies were then presented by solving a multi-objective problem by the PSO algorithm and submitting the optimization results to the fuzzy controller and power distribution management (PDM) unit. The optimizer, the PDM unit, and the fuzzy controller provide a comprehensive operating procedure for the islanded and grid-connected micro-grids, taking into account their stability against grid fluctuations. In another part of this strategy, an auxiliary power control unit (APCU) was proposed for supporting the HESS and increasing the reliable performance of this unit. The proposed structure was applied to the net power (P net) of the islanded and grid-connected micro-grids. The net power was divided into high-frequency (super-capacitor) and low-frequency (battery and APCU) components. The proposed algorithm and simulation results were analyzed using MATLAB/Simulink • The optimization unit and fuzzy controller generate optimal values for the HESS units. • The PDM unit sends control signals to storage system and APC unit. • Calculation of optimal charge and discharge ( T c & T d ) thresholds of HESS unit. • The proposed model compensates the power estimation error by the optimization unit. [ABSTRACT FROM AUTHOR]

Highlights • Is Severe Traumatic Brain Injury (TBI) a Risk Factor for the Development of Pulmonary Embolism? • Why severe TBI is a risk factor for the development of PE? • What is the true incidence of PE in the context of severe TBI? • What are the implications that PE does have in severe TBI? • Should all severe TBI patients receive prophylaxis for DVT and PE? Abstract Introduction Pulmonary emboli (PE) is a significant source of morbidity and mortality in the trauma patients. The use of chemical prophylaxis to prevent deep venous thrombosis and subsequent PE is still controversial given its risk of increased intracranial hemorrhage expansion. Objective In the present study, we evaluated the incidence of PE in severe traumatic brain injury. Methods Retrospective review of patients who were admitted to a Neurosurgery unit from 2011 to 2013 with severe TBI who developed PE. Results 155 patients met the study criteria. The incidence of PE was 2.58%. The cohort was mainly composed of white (71.6%), male (76.77%) with the mean age of 23.03 ± 15.79. There was no statistical difference between the patients who developed PE with prophylaxis and without (p = 0.58). Hospital length of stay was significantly increased by the development of a PE (27.82 ± 21.78 vs. 61.24 ± 25.74 days, p = 0.01). Conclusion Our data is limited by a low incidence of PE in this cohort, but does show an increased hospital length of stay. The true incidence of PE is unknown, so large-scale population studies are urgently needed and a high index of suspicion is required for diagnosis. [ABSTRACT FROM AUTHOR]

Background The objective of this study was to identify the neurosurgical MS-DRGs highest national bills and to analyze economic, demographic, and patient outcome trends. Methods This retrospective cohort study used the Nationwide Inpatient Sample (NIS) database to achieve the results. All MS-DRG codes for the years 2014 were ranked based on total aggregate charges. The highest ranked relevant to neurosurgery were identified and retrospectively reviewed to 2008. The data was analyzed by Z-test. Results In 2014, NIS reported the MS-DRG with the highest national bill of $22,894,340,928 was “Spinal Fusion Except Cervical without MCC,” which also had the largest rise over the cohort period, increasing from $15,853,679,222 in 2008 (p < .001). It was also the MS-DRG with the highest incidence, totaling 1,443,112 discharges and increasing from 190,692 in 2008 to 214,100 in 2014 (p < .10). “Craniotomy with major Device Implant/Acute Complex CNS Procedure w/MCC or Chemo Implant” had the longest length of stay (LOS) with a mean patient stay of 12.9 days. This MS-DRG also had the oldest patient population mean age of 57.5 years old. “Craniotomy & Endovascular Intracranial Procedures with MCC” had the most in-hospital deaths totaling 28,707 increasing significantly from 3602 in 2008 to 4410 in 2014 (p < .05). Conclusions “Spinal fusion except cervical without MCC,” had the highest national bill in the USA over the period of the cohort. Healthcare organizations can benefit from awareness of this information by using it to establish the most efficient healthcare investments and preparing a health-care roadmap for the following decades. [ABSTRACT FROM AUTHOR]

Objective This study examined the distribution of spinal fusion usage among payer groups in the United States. Methods Using the National Inpatient Sample (NIS) database, total discharges, length of stay, and mean hospital charges of patients who underwent spinal fusion from 1997 to 2014 in the United States were determined and analyzed. Results 5,715,625 total discharges with spinal fusion were reported. Among them, 2,875,188 (50.3%) were covered by private insurance, 1,710,182 by Medicare (29.9%), 342,638 (6.0%) by Medicaid, and 91,990 (1.6%) were uninsured. A statistically significant increase in spinal fusion usage occurred within each payer group over the study period ( P  < 0.001). For every year of the study period, private insurance patients had the most number and uninsured patients had the least number of total discharges with spinal fusion. Furthermore, annual growth in spinal fusion usage was greatest among private insurance patients, and smallest among uninsured patients. Conclusions Total discharges with spinal fusion increased significantly across all payer groups between 1997 and 2014, but not equally. Further inquiry is indicated to determine the etiology of spinal fusion usage discrepancies between payer groups. [ABSTRACT FROM AUTHOR]

Paroxysmal Supraventricular Tachycardia (SVT) is an arrhythmia with sudden onset and termination, characterized by a fast heart rate and a narrow QRS complex. There are several remedies that have been described to convert the SVT, such as the Valsalva maneuver, holding the breath for a few seconds, or putting cold water on the face. Here we are presenting a case of SVT, which we converted to sinus rhythm instantly by using a novel tool that has been designed and patented at the University of Texas. This device is named "Forced Inspiratory Suction and Swallow Tool" (FISST) and is branded as "HiccAway," which is primarily designed to stop hiccups and is available as an over-the-counter tool. It works by drinking water forcibly through a pressure valve, and it follows "Bernoulli's Principle": applications of the law of conservation energy. [ABSTRACT FROM AUTHOR]

Background: For patients diagnosed with stroke, the association between socioeconomic status and patient outcomes is poorly understood. Our objective was to define the impact of patients' socioeconomic status on their prognosis after stroke in the United States.Methods: Utilizing the Nationwide Inpatient Sample, we identified discharges involving a diagnosis of stroke from 2008 to 2013. Cohort was dichotomized to low-income patients (L-patients) and not-low-income patients (NL-patients). Z-test statistic was used to test the impact of income on stroke outcome.Results: The reported annual total in-hospital mortality for L-patients and NL-patients diagnosed with stroke at U.S. hospitals decreased significantly during the study period (P < .001). The mortality of L-patients decreased significantly from 1759 (4.16%) to 955 (2.54%) during study period. Similarly, NL-patients' mortality decreased significantly from 4818 (4.52%) to 2300 (2.47%) during the same period. The difference between the annual total in-hospital mortality for L-patients and NL-patients due to stroke was statistically significant throughout the entire study period (P < .0001). Notably, from 2008 to 2013, the annual total routine discharges, annual total discharges to short-term hospital, annual total discharges to another institution, and annual total discharges to home health care were statistically significantly different between the 2 populations of patients (P < .0001).Conclusions: Socioeconomic status has an impact on patient outcome after treatment of stroke in hospitals in the United States. Further study is needed to investigate the etiology of these differences between patients' socioeconomic status and their clinical outcomes after stroke. [ABSTRACT FROM AUTHOR]

Objective: This study investigates the effect of aneurysm circulation on mortality and patient outcomes after aneurysmal subarachnoid hemorrhage (SAH) within the United States.Methods: A retrospective cohort study was conducted using the Nationwide Inpatient Sample (NIS), a part of the Healthcare Cost and Utilization Project (HCUP), with ICD-10 codes for non-traumatic SAH between 2015-2016. Aneurysms were stratified as either anterior or posterior circulation. Multivariate logistic regression was used to find the impact of selected variables on the odds of mortality.Results: The NIS reported 1,892 cases of non-traumatic SAH within the study period that were predominantly anterior circulation (82.6%), female (68.6%), white (57.7%), with mean age of 59.07 years, and in-hospital mortality of 21.4%. Anterior circulation aneurysms were associated with lower severity of initial illness (p = 0.014) but higher likelihood of vasospasm (p = 0.0006) than those of the posterior circulation. In a multivariate logistic regression analysis, mortality was associated with posterior circulation aneurysms (OR: 1.42; CI 95% 1.005-20.10, p = 0.047), increasing age (OR: 1.035; 95% CI 1.022-1.049; p < 0.0001), and shorter hospital stays (OR: 0.7838; 95% CI 0.758-0.811; p < 0.0001). Smoking history (OR: 0.825; 95% CI 0.573-1.187, p > 0.05) and vasospasm (OR: 1.005; 95% CI 0.648-1.558; p > 0.05) were not significantly associated with higher odds of mortality.Conclusions: Mortality following aneurysmal SAH is associated with posterior circulation aneurysms, and increasing age, but not smoking history or vasospasm. These findings may be useful for prognostication and counseling patients and families. [ABSTRACT FROM AUTHOR]

• Optimal reward-penalty demand response (DR) program is designed. • Optimal values of reward and penalty are determined to maximize DISCOs' profit. • Penalty can mitigate the peak rebound and decrease the load deviation. • Customers' profit increases in comparison with conventional IDRPs. • Line congestions are eliminated in the presence of penalties in the DR program. In smart and sustainable power grids, incentive-based demand response programs (DRPs) encourage customers to shift their demand from peak load periods. Broad participation of customers in these programs may lead to a peak rebound and the distribution system congestion in lower load periods, endangering the supply of reliable and sustainable electricity to urban consumers. To tackle these issues, this paper proposes a reward-penalty DRP for customers in smart distribution networks. In the proposed program, the customers receive rewards as they reduce or shift their demands in requested hours. The customers may also be penalized if their demands exceed predefined thresholds. An optimization problem is proposed to determine the optimal penalty and reward values. The objective function is to maximize the distribution company's profit, considering operational constraints of the distribution system. The proposed program is examined on a test system, and the results are compared with the broad application of conventional incentive-based DRPs. The results indicate that the proposed reward-penalty DRP can improve the network operational characteristics and mitigate the peak rebound, without imposing more costs on customers. [ABSTRACT FROM AUTHOR]

Introduction: Transient ischemic attack (TIA) is a temporary event of neurological dysfunction. Patients with TIA may be discharged from the Emergency Department or following an observational admission since their symptoms have resolved. Some portion of these patients, however, return to the hospital due to various reasons. The aim of our study is to find the trend of TIA readmissions in the United States.Materials and Methods: Using the Healthcare Cost and Utilization Project (HCUP) database, we analyzed TIA discharges and TIA readmissions between 2009-2014 using the statistical z-test.Results and Statistical Analysis: We recorded a total of 985,851 hospitalizations of patients discharged with TIA with a significant decrease from 2009 to 2014 (p<0.001). Patients had a mean age of 70.4 years and were mainly women (58.43%, P<0.01). HCUP reported 34,503 discharges due to TIA readmissions within 7 days (3.73%) and 91,261 discharges due to readmissions within 30 days (9.83%); both values showed a significant decrease during the study period. Summation of the TIA readmissions found that acute cerebrovascular disease was the leading cause of readmission, followed by another TIA in both seven and thirty days.Conclusion: Between 2009-2014 the rate of TIA and TIA readmissions has significantly decreased in the United States, especially in the female gender. Acute cerebrovascular disease and another TIA have been the leading cause of hospital readmissions. With a better understanding of the risk factors associated with hospital readmissions, it is possible to reduce the impending burden of these patients on the healthcare system. [ABSTRACT FROM AUTHOR]