Impact of ARUBA trial on trends and outcomes in symptomatic non-ruptured brain AVMs: A national sample analysis.

INTRODUCTION: The real-world evolution of management and outcomes of patients with unruptured brain arteriovenous malformations (AVMs) has not been well-delineated following the ARUBA trial findings of no general advantage of initial interventional (surgical/endovascular/radiotherapy) vs. initial conservative medical therapy. METHODS: We analyzed the National Inpatient Sample from 2009-2018, capturing 20% of all admissions in the U.S. Validated ICD-9 and -10 codes defined brain AVMs, comorbidities, and the use of interventional modalities. Analyses were performed by year and for the dichotomized periods of pre-ARUBA (2009-2013) vs. post-ARUBA (2014-2018). RESULTS: Among the national projected 88,037 AVM admissions, 72,812 (82.7%) were unruptured AVMs and 15,225 (17.3%) were ruptured AVMs. Among uAVMs, 51.4% admitted pre-ARUBA and 48.6% in post-ARUBA period. The post-ARUBA patients were mildly older (median age 53.3 vs. 51.8 (p = 0.001) and had more comorbidities including hypertension, diabetes, obesity, renal impairment, and smoking. Before the first platform report of ARUBA (2009-2012), rates of use of interventional treatments during uAVM admissions trended up from 31.8% to 35.4%. Thereafter, they declined significantly to 26.4% in 2018 (p = 0.02). The decline was driven by a reduction in the frequency of endovascular treatment from 18.8% to 13.9% and inpatient stereotactic radiosurgery from 0.5% to 0.1%. No change occurred in the frequency of microsurgery or combined endovascular and surgical approaches. Adjusted multivariable model of uAVMs showed increased odds of discharge to a long-term inpatient facility or in-hospital death [OR 1.14 (1.02-1.28), p = 0.020] in post-ARUBA. A significantly increased proportion of ruptured AVMs from 17.0% to 23.3% was observed consistently in post-ARUBA. CONCLUSION: Nationwide practice in the management of unruptured AVMs changed substantially with the publication of the ARUBA trial in a durable and increasing manner. Fewer admissions with the interventional treatment of unruptured AVMs occurred, and a corresponding increase in admission for ruptured AVMs transpired, as expected with a strategy of watchful waiting and treatment only after an index bleeding event. Further studies are needed to determine whether these trends can be considered to be ARUBA trial effect or are merely coincidental.

Machine Learning Applied to Datasets of Human Activity Recognition: Data Analysis in Health Care.

BACKGROUND: In order to remain active and productive, older adults with poor health require a combination of advanced methods of visual monitoring, optimization, pattern recognition, and learning, which provide safe and comfortable environments and serve as a tool to facilitate the work of family members and workers, both at home and in geriatric homes. Therefore, there is a need to develop technologies to provide these adults autonomy in indoor environments. OBJECTIVE: This study aimed to generate a prediction model of daily living activities through classification techniques and selection of characteristics in order to contribute to the development in this area of knowledge, especially in the field of health. Moreover, the study aimed to accurately monitor the activities of the elderly or people with disabilities. Technological developments allow predictive analysis of daily life activities, contributing to the identification of patterns in advance in order to improve the quality of life of the elderly. METHODS: The vanKasteren, CASAS Kyoto, and CASAS Aruba datasets were used to validate a predictive model capable of supporting the identification of activities in indoor environments. These datasets have some variation in terms of occupation and the number of daily living activities to be identified. RESULTS: Twelve classifiers were implemented, among which the following stand out: Classification via Regression, OneR, Attribute Selected, J48, Random SubSpace, RandomForest, RandomCommittee, Bagging, Random Tree, JRip, LMT, and REP Tree. The classifiers that show better results when identifying daily life activities are analyzed in the light of precision and recall quality metrics. For this specific experimentation, the Classification via Regression and OneR classifiers obtain the best results. CONCLUSION: The efficiency of the predictive model based on classification is concluded, showing the results of the two classifiers, i.e., Classification via Regression and OneR, with quality metrics higher than 90% even when the datasets vary in occupation and number of activities.

Interventional outcomes for patients eligible for entry into the ARUBA clinical trial: a systematic review and meta-analysis.

OBJECTIVE: A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) suggested that medical management afforded outcomes superior to those following intervention for unruptured arteriovenous malformations (AVMs), but its findings have been controversial. Subsequent studies of AVMs that would have met the eligibility requirements of ARUBA have supported intervention for the management of some cases. The present meta-analysis was conducted with the object of summarizing interventional outcomes for ARUBA-eligible patients reported in the literature. METHODS: A systematic literature search (PubMed, Web of Science, Google Scholar) for AVM intervention studies that used inclusion criteria identical to those of ARUBA (age ≥ 18 years, no history of AVM hemorrhage, no prior intervention) was performed. The primary outcome was death or symptomatic stroke. Secondary outcomes included AVM obliteration, hemorrhage, death, and poor outcome (modified Rankin Scale score ≥ 2 at final follow-up). Bias assessment was performed with the Newcastle-Ottawa Scale, and the results were synthesized as pooled proportions. RESULTS: Of the 343 articles identified through database searches, 13 studies met the inclusion criteria, yielding an overall study cohort of 1909 patients. The primary outcome occurred in 11.2% of patients (pooled = 11%, 95% CI 8%-13%). The rates of AVM obliteration, hemorrhage, poor outcome, and death were 72.7% (pooled = 78%, 95% CI 70%-85%), 8.4% (pooled = 8%, 95% CI 6%-11%), 9.9% (pooled = 10%, 95% CI 7%-13%), and 3.5% (pooled = 2%, 95% CI 1%-4%), respectively. Annualized primary outcome and hemorrhage risks were 1.85 (pooled = 2.05, 95% CI 1.31-2.94) and 1.34 (pooled = 1.41, 95% CI 0.83-2.13) per 100 patient-years, respectively. CONCLUSIONS: Intervention for unruptured AVMs affords acceptable outcomes for appropriately selected patients. The risk of hemorrhage following intervention compared favorably to the natural history of unruptured AVMs. The included studies were retrospective and varied in treatment and AVM characteristics, thereby limiting the generalizability of their data. Future studies from prospective registries may clarify patient, nidus, and intervention selection criteria that will refine the challenging management of patients with unruptured AVMs.

Elective intervention for unruptured cranial arteriovenous malformations in relation to ARUBA trial: a National Inpatient Sample study.

BACKGROUND: In 2014, A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) concluded that medical management alone for cranial arteriovenous malformations (AVMs) had better clinical outcomes than interventional treatment. The impact of the ARUBA study on changes in the rates of intervention and outcomes is unknown. Thus, we investigated whether the conclusions from ARUBA may have influenced treatment modalities and outcomes of unruptured AVMs. METHODS: The National Inpatient Sample (NIS) was queried between 2006 and 2018, for adult patients with an AVM who were admitted on an elective basis. Interventions included open, endovascular, and stereotactic surgeries. Join-point regression was used to assess differences in slopes of treatment rate for each modality before and after the time-point. Logistic regression was used to assess the odds of non-routine discharge and hemorrhage between the two time-points for each treatment modality. Linear regression was used to assess the mean length of stay (LOS) for each treatment modality between the two time-points. RESULTS: A total of 40,285 elective admissions for AVMs were identified between 2006 and 2018. The rate of intervention was higher pre-ARUBA (n = 15,848; 63.8%) compared to post-ARUBA (n = 6985; 45.2%; difference in slope - 8.24%, p < 0.001). The rate of open surgery decreased, while endovascular and stereotactic surgeries remained the same, after the ARUBA trial time-point (difference in slopes - 8.24%, p < 0.001; - 1.74%, p = 0.055; 0.20%, p = 0.22, respectively). For admissions involving interventions, the odds of non-routine discharge were higher post-ARUBA (OR 1.24; p = 0.043); the odds of hemorrhage were lower post-ARUBA (OR 0.69; p = 0.025). There was no statistical difference in length of stay between the two time-points (p = 0.22). CONCLUSION: The rate of intervention decreased, the rate of non-routine discharge increased, and rate of hemorrhage decreased post-ARUBA, suggesting that it may have influenced treatment practices for unruptured AVMs.

Contribution of amenable mortality to life expectancy differences between the Dutch Caribbean islands of Aruba and Curaçao and the Netherlands.

OBJECTIVE: To identify specific health care areas whose optimization could improve population health in the Dutch Caribbean islands of Aruba and Curaçao. METHODS: Comparative observational study using mortality and population data of the Dutch Caribbean islands and the Netherlands. Mortality trends were calculated, then analyzed with Joinpoint software, for the period 1988-2014. Life expectancies were computed using abridged life tables for the most recent available data of all territories (2005-2007). Life expectancy differences between the Dutch Caribbean and the Netherlands were decomposed into cause-specific contributions using Arriaga's method. RESULTS: During the period 1988-2014, levels of amenable mortality have been consistently higher in Aruba and Curaçao than in the Netherlands. For Aruba, the gap in amenable mortality with the Netherlands did not significantly change during the study period, while it widened for Curaçao. If mortality from amenable causes were reduced to similar levels as in the Netherlands, men and women in Aruba would have added, respectively, 1.19 years and 0.72 years to their life expectancies during the period 2005-2007. In Curaçao, this would be 2.06 years and 2.33 years. The largest cause-specific contributions were found for circulatory diseases, breast cancer, perinatal causes, and nephritis/nephrosis (these last two causes solely in Curaçao). CONCLUSIONS: Improvements in health care services related to circulatory diseases, breast cancer, perinatal deaths, and nephritis/nephrosis in the Dutch Caribbean could substantially contribute to reducing the gap in life expectancy with the Netherlands. Based on our study, we recommend more in-depth studies to identify the specific interventions and resources needed to optimize the underlying health care areas.

Microsurgery for Unruptured Cerebral Arteriovenous Malformations in the National Inpatient Sample is More Common Post-ARUBA.

BACKGROUND: The ARUBA trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformations) was the first randomized control trial to investigate unruptured cerebral arteriovenous malformation (cAVM) treatments and concluded that medical management was superior to interventional therapy for the treatment of unruptured cAVMs. This conclusion generated considerable controversy and was followed by rebuttals and meta-analyses of the ARUBA methodology and results. We sought to determine whether the ARUBA results altered treatment trends of cAVMs within the United States. METHODS: Using the National Inpatient Sample, the largest all-payer inpatient care database within the United States, we isolated patients who were admitted on an elective basis for cAVM treatment and determined the treatment modality undergone by these patients. The cohort was dichotomized separately at 2 ARUBA time points: the European Stroke Conference presentation in May 2013, and The Lancet publication in February 2014. RESULTS: We found that the overall treatment rate of unruptured cAVMs decreased after both time points. However, the rate of surgical excision alone, relative to other modalities, was significantly increased, and endovascular intervention demonstrated a nonsignificant decrease. CONCLUSIONS: Our findings suggest that the ARUBA trial has influenced unruptured cAVM treatment patterns within the United States. Although the overall treatment rate has decreased, unruptured cAVMs, when treated post-ARUBA, are most commonly approached with surgical excision alone.

Two distinct lineages of chikungunya virus cocirculated in Aruba during the 2014-2015 epidemic.

Chikungunya virus (CHIKV), a positive-sense, single-stranded RNA virus in the family Togaviridae, is transmitted by Aedes mosquitoes. Of three known CHIKV genotypes, the Asian genotype was introduced into the Caribbean islands and rapidly spread throughout Central and South Americas. We previously found patients with symptoms compatible with chikungunya fever in 2014-2015 in Aruba, a Caribbean island of 180 km2. We here describe the full genome sequences of eight CHIKV strains isolated from patient sera of the Aruban outbreak. Phylogenetic analysis revealed that two closely related but distinct lineages of Asian-genotype CHIKV circulated simultaneously during the epidemic in 2014-2015. These results suggested that CHIKV was introduced into Aruba more than once in a short period, reflecting the importance of Aruba as a travel hub within the region.

Contribution of amenable mortality to life expectancy differences between the Dutch Caribbean islands of Aruba and Curaçao and the Netherlands / Contribución de la mortalidad por causas evitables mediante la atención de salud a la diferencia de la esperanza de vida entre las islas del Caribe holandés de Aruba y Curaçao y los Países Bajos / Contribuição da mortalidade evitável para as diferenças na expectativa de vida entre as ilhas de Aruba e Curaçao, no Caribe holandês, e os Países Baixos

ABSTRACT Objective. To identify specific health care areas whose optimization could improve population health in the Dutch Caribbean islands of Aruba and Curaçao. Methods. Comparative observational study using mortality and population data of the Dutch Caribbean islands and the Netherlands. Mortality trends were calculated, then analyzed with Joinpoint software, for the period 1988-2014. Life expectancies were computed using abridged life tables for the most recent available data of all territories (2005-2007). Life expectancy differences between the Dutch Caribbean and the Netherlands were decomposed into cause-specific contributions using Arriaga's method. Results. During the period 1988-2014, levels of amenable mortality have been consistently higher in Aruba and Curaçao than in the Netherlands. For Aruba, the gap in amenable mortality with the Netherlands did not significantly change during the study period, while it widened for Curaçao. If mortality from amenable causes were reduced to similar levels as in the Netherlands, men and women in Aruba would have added, respectively, 1.19 years and 0.72 years to their life expectancies during the period 2005-2007. In Curaçao, this would be 2.06 years and 2.33 years. The largest cause-specific contributions were found for circulatory diseases, breast cancer, perinatal causes, and nephritis/nephrosis (these last two causes solely in Curaçao). Conclusions. Improvements in health care services related to circulatory diseases, breast cancer, perinatal deaths, and nephritis/nephrosis in the Dutch Caribbean could substantially contribute to reducing the gap in life expectancy with the Netherlands. Based on our study, we recommend more in-depth studies to identify the specific interventions and resources needed to optimize the underlying health care areas.(AU)

RESUMEN Objetivo. Determinar las áreas específicas de atención de salud cuya optimización podría mejorar la salud de la población en las islas del Caribe holandés de Aruba y Curaçao. Métodos. Estudio de observación comparativo en el que se utilizaron datos demográficos y de mortalidad de las islas del Caribe holandés y de los Países Bajos. Se calcularon las tendencias de mortalidad y luego se analizaron con programas de computación Jointpoint de regresión lineal segmentada, para el período 1988-2014. La esperanza de vida se calculó utilizando tablas de mortalidad abreviadas con los datos más recientes disponibles de todos los territorios (2005-2007). Las diferencias de esperanza de vida entre el Caribe holandés y los Países Bajos se desglosaron, usando el método de Arriaga, en contribuciones por causas específicas. Resultados. En el período 1988-2014, los niveles de mortalidad por causas evitables mediante la atención de salud han sido sistemáticamente mayores en Aruba y Curaçao que en los Países Bajos. En el caso de Aruba, la brecha en la mortalidad por causas evitables mediante la atención de salud con respecto a los Países Bajos no varió significativamente durante el período de estudio; en el caso de Curaçao, la brecha fue mayor. Si la mortalidad por causas evitables mediante la atención de salud se redujese a un nivel similar al de los Países Bajos, los hombres y las mujeres en Aruba habrían sumado, respectivamente, 1,19 años y 0,72 años a su esperanza de vida en el período 2005-2007. En Curaçao, el aumento hubiese sido de 2,06 años y de 2,33 años. Según el estudio, las causas específicas que más contribuyen a esta diferencia son las enfermedades circulatorias, el cáncer de mama, las complicaciones perinatales, y la nefritis/nefrosis (estas últimas dos causas solamente en Curaçao). Conclusiones. Una mejora en los servicios de salud en relación con las enfermedades circulatorias, el cáncer de mama, las complicaciones perinatales, y la nefritis/nefrosis en el Caribe holandés podría contribuir sustancialmente a la reducción de la brecha en la esperanza de vida con respecto a los Países Bajos. Por tanto, con base en nuestro estudio, recomendamos que se realicen más estudios exhaustivos a fin de determinar las intervenciones específicas y los recursos que se necesitan para optimizar las áreas de atención de salud involucradas.(AU)

RESUMO Objetivo. Identificar áreas específicas da atenção à saúde cuja otimização poderia melhorar a saúde da população nas ilhas de Aruba e Curaçao, no Caribe holandês. Métodos. Estudo observacional comparativo baseado em dados de mortalidade e populacionais das ilhas do Caribe holandês e dos Países Baixos. As tendências de mortalidade foram calculadas e então analisadas com o software Joinpoint, no período de 1988 a 2014. As expectativas de vida foram computadas usando tábuas de mortalidade resumidas com os dados disponíveis mais recentes de todos os territórios (2005-2007). As diferenças na expectativa de vida entre o Caribe holandês e os Países Baixos foram desagregadas segundo as contribuições específicas por causa usando o método de Arriaga. Resultados. No período de 1988 a 2014, os níveis de mortalidade evitável foram consistentemente mais elevados em Aruba e Curaçao do que nos Países Baixos. Em Aruba, a diferença na mortalidade evitável em comparação com os Países Baixos não mudou significativamente durante o período do estudo, enquanto que em Curaçao a diferença aumentou. Se a mortalidade por causas evitáveis fosse reduzida a níveis semelhantes aos dos Países Baixos, os homens e mulheres de Aruba teriam aumentos respectivos de 1,19 e 0,72 anos nas suas expectativas de vida durante o período 2005-2007. Em Curaçao, o aumento seria de 2,06 e 2,33 anos. As maiores contribuições de causas específicas foram as de doenças circulatórias, câncer de mama, causas perinatais e nefrite/nefrose (estas duas últimas causas somente em Curaçao). Conclusões. Melhorias nos serviços de saúde relacionados com doenças circulatórias, câncer de mama, mortes perinatais e nefrite/nefrose no Caribe holandês poderiam contribuir substancialmente para reduzir as disparidades na expectativa de vida em comparação com os Países Baixos. Com base neste trabalho, recomendamos estudos mais aprofundados para identificar as intervenções e recursos específicos necessários para otimizar estas áreas da atenção à saúde.(AU)

Multimodal cerebral arteriovenous malformation treatment: a 12-year experience and comparison of key outcomes to ARUBA.

OBJECTIVE: Curative treatment of unruptured brain arteriovenous malformations (AVMs) remains controversial after the only randomized controlled trial, A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA), was halted prematurely because interim analysis revealed superiority of the medical management group. In contrast, meta-analyses of retrospective cohorts suggest that intervention is much safer than was found in ARUBA. METHODS: The authors retrospectively analyzed 318 consecutive adult patients with brain AVMs treated at their institution with embolization, surgery, and/or proton beam radiosurgery. Analysis was performed in 142 ARUBA-eligible patients (baseline modified Rankin Scale [mRS] score 0-1, no history of hemorrhage), and results were compared to primary and secondary outcomes from ARUBA, as well as to natural history cohorts. RESULTS: The annualized stroke rate (hemorrhagic or ischemic) in this cohort was 1.8%, 4.9% in the first 12 months and 0.8% after the first 12 months, which was lower than in natural history studies and the ARUBA medical management arm (p = 0.001). The primary ARUBA endpoint of symptomatic stroke was reached in 13 patients (9.2%), which compares favorably to the ARUBA intervention arm (39.6%, p = 0.0001) and is similar to the ARUBA medical management arm (9.2%, p = 1.0). The secondary ARUBA endpoint (mRS score ≥ 2 at 5 years of follow-up) was reached in 14.3% of patients, compared to 40.5% in the ARUBA intervention arm (p = 0.002) and 16.7% in the ARUBA medical management arm (p = 0.6). CONCLUSIONS: This multimodal approach to the selection and treatment of patients with brain AVMs yields good clinical outcomes with key safety endpoints (stroke, death, and mRS score 0-1) better than the ARUBA intervention arm and similar to the ARUBA medical arm at 5 years of follow-up. Results compare favorably to natural history cohorts at longer follow-up times. This suggests that tertiary care centers with integrated programs, expertise in patient selection, and individualized treatment approaches may allow for better clinical outcomes than reported in ARUBA. It supports current registry studies and merits consideration of future randomized controlled trials in patients with brain AVMs.

Gamma Knife Radiosurgery for ARUBA-Eligible Patients with Unruptured Brain Arteriovenous Malformations.

BACKGROUND: A randomized trial of unruptured brain arteriovenous malformations (ARUBA) reported superior outcomes in conservative management compared to interventional treatment. There were numerous limitations to the study. This study aimed to investigate the efficacy of gamma knife radiosurgery (GKS) for patients with brain arteriovenous malformations (AVMs) by comparing its outcomes to those of the ARUBA study. METHODS: We retrospectively reviewed ARUBA-eligible patients treated with GKS from June 2002 to September 2017 and compared against those in the ARUBA study. AVM obliteration and hemorrhage rates, and clinical outcomes following GKS were also evaluated. RESULTS: The ARUBA-eligible cohort comprised 264 patients. The Spetzler-Martin grade was Grade I to II in 52.7% and III to IV in 47.3% of the patients. The mean AVM nidus volume, marginal dose, and follow-up period were 4.8 cm³, 20.8 Gy, and 55.5 months, respectively. AVM obliteration was achieved in 62.1%. The annual hemorrhage rate after GKS was 3.4%. A stroke or death occurred in 14.0%. The overall stroke or death rate of the ARUBA-eligible cohort was significantly lower than that of the interventional arm of the ARUBA study (P < 0.001) and did not significantly differ from that of the medical arm in the ARUBA study (P = 0.601). CONCLUSION: GKS was shown to achieve a favorable outcome with low procedure-related morbidity in majority of the ARUBA-eligible patients. The outcome after GKS in our patients was not inferior to that of medical care alone in the ARUBA study. It is suggested that GKS is rather superior to medical care considering the short follow-up duration of the ARUBA study.

Health systems strengthening for noncommunicable disease control and healthy aging: integrated actions in Aruba and Curaçao.

Caribbean countries are experiencing social, epidemiological, and demographic transitions shaped by the growing elderly population and the rise of noncommunicable diseases (NCDs)-now responsible for 78% of all deaths. These circumstances demand rethinking the model of care to improve health outcomes and build more sustainable health systems with new orientations in policy, service delivery, organization, training, technology, and financing. Policy must be aimed towards healthy living, leveraging interventions that ensure healthy aging. The health system must proactively structure interventions to reduce the incidence of new NCD cases and to prevent related complications. Interventions should be focused on optimizing the individual's capacity, functional ability, and autonomy within adapted environments, as well as with the necessary preventive, long-term care, self-care, community care, and health system support.

Los países del Caribe están experimentando transiciones sociales, epidemiológicas y demográficas como resultado del envejecimiento de la población y el aumento de la prevalencia de las enfermedades no transmisibles (ENT), que en la actualidad causan el 78% de todas las defunciones. Estas circunstancias exigen replantear el modelo de atención para mejorar los resultados de salud y establecer sistemas de salud más sostenibles mediante nuevos enfoques en políticas, prestación de servicios, organización, capacitación, tecnología y financiamiento. Las políticas deben tener como propósito procurar una vida saludable, aprovechando las intervenciones que garanticen el envejecimiento saludable. El sistema de salud debe ser proactivo, estructurando las intervenciones para reducir la incidencia de nuevos casos de ENT y para prevenir las complicaciones relacionadas. Las intervenciones deben centrarse en optimizar la capacidad funcional, la autonomía y el desenvolvimiento general de la persona dentro de un entorno adaptado y con el apoyo necesario del sistema de salud en materia de atención preventiva, cuidados a largo plazo, de autocuidado y de atención en la comunidad.

Os países do Caribe estão passando por transições sociais, epidemiológicas e demográficas configuradas pela população de idosos cada vez maior e a ascensão das doenças não transmissíveis (DNTs), já responsáveis por 78% de todas as mortes. Essas circunstâncias exigem repensar o modelo de atenção para melhorar os desfechos de saúde e construir sistemas de saúde mais sustentáveis, com novas orientações de política, prestação de serviços, organização, treinamento, tecnologia e financiamento. As políticas devem ser orientadas para a vida saudável, alavancando intervenções que asseguram o envelhecimento saudável. O sistema de saúde deve estruturar proativamente intervenções para reduzir a incidência de novos casos de DNT e a prevenir as complicações relacionadas. As intervenções devem se concentrar na otimização da capacidade do indivíduo, das habilidades funcionais e da autonomia dentro de ambientes adaptados, e também nas ações preventivas a para assistência de longa duração, no autocuidado, na atenção na comunidade e no apoio pelos sistemas de saúde.

Incidence of Obesity and Hypertension among Hyatt Employees in Aruba, 2012 / Incidencia de la Obesidad y la Hipertensión entre los Empleados de Hyatt en Aruba, 2012

ABSTRACT Objective: Obesity and hypertension, which are associated with cardiovascular disease and Type 2 Diabetes Mellitus (DM), have become a major health concern in Aruba. The present study was aimed to determine the incidence of obesity and potential hypertension among Hyatt employees in Oranjestad, Aruba. Method: On November 9, 2012, students from the Xavier University School of Medicine, Aruba, conducted a health fair for the employees of the Hyatt Hotel in Aruba - one of the largest hotels in the capital city of Oranjestad. The Medical students collected the information through questionnaire-based survey and physical examinations. This cross-sectional study measured the weight, height, random blood glucose, systolic and diastolic blood pressures of the participants. Results: One hundred and fourteen individuals (19%) participated out of the 509 Hyatt employees. Obesity, hypertensive readings and potential diabetes or pre-diabetes was noted among the majority of the participants; and 46% (52/114) of the respondents were overweight and 37% (43/114) were obese. Hypertensive BPs were detected in 33% (38/114) of the participants. Students' t-test showed no significant correlation between the subjects' gender and the following variables: BMI, random blood glucose, systolic/diastolic blood pressure, and the hypertensive findings. Based on the random blood sugar readings, 4/114 individuals were at risk for diabetes. The four individuals had a random blood sugar reading of 11.1 mmol/L or higher. Conclusion: Many of the participants in this study, presented with both obesity and possible hypertension. It is logical to expect a significant risk for cardiovascular disease and Type 2 DM in the participants' population.

RESUMEN Objetivo: La obesidad y la hipertensión, asociadas con las enfermedades cardiovasculares y la diabetes mellitus tipo 2 (DM), se han convertido en un importante problema de salud en Aruba. El presente estudio tuvo por objetivo determinar la incidencia de la obesidad y la hipertensión potencial entre los empleados de Hyatt en Oranjestad, Aruba. Método: El 9 de noviembre de 2012, estudiantes de la Escuela de Medicina de la Universidad Xavier, Aruba, realizaron una feria de salud para los empleados del Hotel Hyatt en Aruba -uno de los hoteles más grandes de la ciudad Oranjestad, la capital del país. Los estudiantes recopilaron la información mediante encuestas basadas en cuestionarios y exámenes físicos. Este estudio transversal midió el peso, la altura, la glucosa en sangre aleatoria, y la presión arterial sistólica y diastólica de los participantes. Resultados: De los 509 empleados de Hyatt, ciento catorce individuos (19%) participaron en el estudio. Obesidad, lecturas hipertensivas y diabetes potencial o prediabetes se observaron entre la mayoría de los participantes. El 46% (52/114) de los encuestados tenían sobrepeso y el 37% (43/114) eran obesos. Se detectó PA hipertensa en 33% (38/114) de los participantes. La prueba t de Student no mostró ninguna correlación significativa entre el género de los sujetos y las siguientes variables: IMC, glucosa en sangre aleatoria, presión arterial sistólica/diastólica, y los hallazgos de hipertensión. De acuerdo con las lecturas de azúcar en sangre aleatoria, 4/114 individuos corrían riesgo de padecer diabetes. Los cuatro individuos tenían una lectura de azúcar en sangre aleatoria de 11.1 mmol/L, o más. Conclusión: Muchos de los participantes en este estudio, presentaban obesidad y posible hipertensión. Es lógico esperar un riesgo significativo de enfermedad cardiovascular y DM tipo 2 en la población de participantes.

Treatment of Unruptured Brain Arteriovenous Malformations: A Single-Center Experience of 86 Patients and a Critique of the A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) Trial.

OBJECTIVE: The A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) trial has received fierce criticism, including considerable selection bias, poor generalizability, questionable clinical practices (only 15.8% underwent surgical resection, the gold standard for arteriovenous malformation [AVM] treatment), and short follow-up (33 months) for a disease process that carries a life-long risk. In this study, we sought to present our own experience treating unruptured brain AVMs to provide supporting evidence of the ARUBA trial criticism. METHODS: All cases of treated brain AVMs from 2004 to 2017 at our institution were retrospectively reviewed and included in the analysis if they met ARUBA trial inclusion criteria. The primary outcome was symptomatic stroke or death. Secondary outcomes included AVM obliteration, long-term clinical impairment (modified Rankin Scale score >1), and new major or minor postoperative deficit. RESULTS: Of the 245 reviewed cases, 86 met the ARUBA trial criteria. Treatment included microsurgical resection alone (2.3%), preoperative embolization followed by microsurgical resection (62.8%), stereotactic radiosurgery alone (10.5%), embolization followed by stereotactic radiosurgery (15.1%), and embolization alone (9.3%). The primary outcome was met in 8.3%, new perioperative major and minor complications occurred in 5.8% and 12.8%, and long-term clinical impairment in 4.5%. AVM obliteration was observed in 92.4% overall and in 100% of patients who underwent surgical resection. CONCLUSIONS: The criticism of the ARUBA trial is warranted, as our study found that treatment of unruptured brain AVMs has an acceptable safety profile when approached in a multidisciplinary manner at an experienced institution, using surgical resection as the primary treatment modality when applicable.

The benefit of radiosurgery for ARUBA-eligible arteriovenous malformations: a practical analysis over an appropriate follow-up period.

OBJECTIVE The authors of this study found that, given the latency period required for arteriovenous malformation (AVM) obliteration after stereotactic radiosurgery (SRS), a study with limited follow-up cannot assess the benefit of SRS for unruptured AVMs. METHODS The authors reviewed their institutional experience with "ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations)-eligible" AVMs treated with SRS between 1987 and 2016, with the primary outcome defined as stroke (ischemic or hemorrhagic) or death (AVM related or AVM unrelated). Patients with at least 3 years of follow-up in addition to those who experienced stroke or died during the latency period were included. Secondary outcome measures included obliteration rates, patients with new seizure disorders, and those with new focal deficits without stroke. RESULTS Of 233 patients included in this study, 32 had a stroke or died after SRS over the mean 8.4-year follow-up (14%). Utilizing the 10% stroke or death rate at a mean 2.8-year follow-up for untreated AVMs in ARUBA, the rate in the authors' study is significantly lower than that anticipated at the 8.4-year follow-up for an untreated cohort (14% vs 30%, p = 0.0003). Notwithstanding obliteration, in this study, annualized rates of hemorrhage and stroke or death after 3 years following SRS were 0.4% and 0.8%, respectively. The overall obliteration rate was 72%; new seizure disorders, temporary new focal deficits without stroke, and permanent new focal deficits without stroke occurred in 2% of patients each. CONCLUSIONS After a sensible follow-up period exceeding the latency period, there is a lower rate of stroke/death for patients with treated, unruptured AVMs with SRS than for patients with untreated AVMs.

Stereotactic Radiosurgery for ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations)-Eligible Spetzler-Martin Grade I and II Arteriovenous Malformations: A Multicenter Study.

OBJECTIVE: ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations) found better short-term outcomes after conservative management compared with intervention for unruptured arteriovenous malformations (AVMs). However, because Spetzler-Martin (SM) grade I-II AVMs have the lowest treatment morbidity, sufficient follow-up of these lesions may show a long-term benefit from intervention. The aim of this multicenter, retrospective cohort study is to assess the outcomes after stereotactic radiosurgery (SRS) for ARUBA-eligible SM grade I-II AVMs. METHODS: We pooled SRS data for patients with AVM from 7 institutions and selected ARUBA-eligible SM grade I-II AVMs with ≥12 months follow-up for analysis. Favorable outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes. RESULTS: The ARUBA-eligible SM grade I-II AVM cohort comprised 232 patients (mean age, 42 years). The mean nidus volume, SRS margin dose, and follow-up duration were 2.1 cm3, 22.5 Gy, and 90.5 months, respectively. The actuarial obliteration rates at 5 and 10 years were 72% and 87%, respectively; annual post-SRS hemorrhage rate was 1.0%; symptomatic and permanent radiation-induced changes occurred in 8% and 1%, respectively; and favorable outcome was achieved in 76%. Favorable outcome was significantly more likely in patients treated with a margin dose >20 Gy (83%) versus ≤20 Gy (62%; P < 0.001). Stroke or death occurred in 10% after SRS. CONCLUSIONS: For ARUBA-eligible SM grade I-II AVMs, long-term SRS outcomes compare favorably with the natural history. SRS should be considered for adult patients harboring unruptured, previously untreated low-grade AVMs with a minimum life expectancy of a decade.

Interventional therapy for brain arteriovenous malformations before and after ARUBA.

The ARUBA trial (2014) concluded that medical management alone is superior to medical management plus interventional therapy for the treatment of unruptured brain arteriovenous malformations (bAVMs). This sparked considerable controversy among involved healthcare providers. Here, we evaluated the impact of ARUBA on the volume, type, and treatment modality of bAVMs referred to a large tertiary care center. This was achieved by conducting a retrospective review of a prospectively maintained database of all bAVMs treated at Stanford Health Care and Stanford Children's Health from January 2012 through July 2015. The case volume of bAVMs treated at Stanford has been relatively unchanged in the period of time leading up to and after ARUBA. Furthermore, there has been no significant change in the proportion of unruptured AVMs treated. Although differences existed in types of interventions administered, these differences are best explained by variations in the SM grades of AVMs treated during each study period, rather than by underlying changes in treatment strategy. Additional research is warranted to more thoroughly characterize the impact of ARUBA on the treatment patterns of bAVMS.

Responses to ARUBA: a systematic review and critical analysis for the design of future arteriovenous malformation trials.

OBJECTIVE The ARUBA study (A Randomized Trial of Unruptured Brain Arteriovenous Malformations [AVMs]) on unruptured brain AVMs has been the object of comments and editorials. In the present study the authors aim to systematically review critiques, discuss design issues, and propose a framework for future trials. METHODS The authors performed a systematic review of the French and English literature on the ARUBA study published between January 2006 and February 2015. The electronic search, including the Cochrane Library, MEDLINE (PubMed and Ovid), CINAHL, and EMBASE databases, was complemented by hand searching and cross-referencing. The comments were categorized as items related to the design, the conduct, and the analysis and interpretation of the trial. RESULTS Thirty-one articles or letters were identified. The pragmatic design, with heterogeneity of patients and lack of standardization of the treatment arm, were frequently stated concerns. The choice of outcome measures was repeatedly criticized. During the trial, low enrollment rates, selection bias, and premature interruption of enrollment were frequent comments. The short follow-up period, the lack of subgroup analyses, the lack of details on the results of the various treatments, and a contentious interpretation of results were noted at the analysis stage. A fundamental problem was the primary hypothesis testing conservative management. The authors believe that other trials are needed. Future trials could be pragmatic, test interventions stratified at the time of randomization, and look for long-term, hard clinical outcomes in a large number of patients. CONCLUSIONS In the authors' view, the ARUBA trial is a turning point in the history of brain AVM management; future trials should aim at integrating trial methodology and clinical care in the presence of uncertainty.

Intervention for A randomized trial of unruptured brain arteriovenous malformations (ARUBA) - Eligible patients: An evidence-based review.

While intervention for ruptured arteriovenous malformations (AVMs) of the brain is typically warranted, the management of unruptured AVMs remains controversial. Despite numerous retrospective studies, only one randomized controlled trial has been conducted, comparing the role of medical management alone to medical management plus surgical and/or radiosurgical intervention in patients with unruptured AVMs: A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA). To great controversy, ARUBA concluded that medical management alone was superior to intervention for unruptured AVMs, which was subsequently challenged by various single-institution and multi-center studies analyzing outcomes of ARUBA-eligible patients. This review summarizes studies returned from a PubMed database search querying, 'ARUBA,' 'ARUBA-eligible,' 'surgery unruptured AVM,' and "radiosurgery unruptured AVM". The rates of the primary endpoint of symptomatic stroke or death were low among the analyzed studies (0-12.2%, mean 8.0%) and similar to the medically managed arm of ARUBA (10.1%). Likewise, the percentage of patients with impaired functional outcomes (modified Rankin score ≥2) in the reviewed studies was low (5.9%-13.1%; mean: 9.9%) and comparable to the 14.0% observed in the medically management arm of ARUBA. The key findings of ARUBA and subsequent work in its aftermath are overviewed and analyzed for the role of surgery and/or radiosurgery in patients with unruptured AVMs.

Outcome of microsurgical excision of unruptured brain arteriovenous malformations in ARUBA-eligible patients.

OBJECTIVES: To determine the outcome of microsurgical excision of selected unruptured brain arteriovenous malformations (AVMs), and to compare the results with those of the ARUBA trial. METHODS: Prospective data collection for all patients undergoing microsurgical excision of unruptured brain AVMs by two neurovascular surgeons. Outcome measures similar to those assessed in the ARUBA trial (death and stroke) as well as modified Rankin scores (mRS) at 6 months were assessed. RESULTS: Between September 2004 and September 2014, 45 patients with unruptured brain AVMs underwent microsurgical excision. 11 patients (eight children and three with mRS >2 at presentation) were excluded to match ARUBA eligibility criteria. 34 patients were included in this study. AVM characteristics closely matched those in the ARUBA trial with 70.5% Spetzler-Martin (SM) grade I or II AVMs, 68% AVM size <3 cm. However, compared to ARUBA, a larger proportion of our patients presented with seizures, and a lower proportion with headaches. 8(23%) had preoperative embolization. There were no deaths and no strokes (as defined in ARUBA). 5 (14.7%) had permanent neurological deficit related to surgery within/near eloquent cortex. At 6 months follow-up, 32 (94%) had mRS score of 0-1. Two (6%) had mRS 2 and none had mRS> 2. Postoperative digital DSA confirmed complete AVM excision in all cases. None of the patients have suffered intracranial hemorrhage during the follow-up period of 6-126 (median 69) months. CONCLUSIONS: Microsurgical excision of unruptured brain AVMs can be performed with low morbidity in selected cases. Our study has limitations particularly the small number of patients with selected AVMs for microsurgical excision. However, our results suggest that ARUBA results may not be applicable to microsurgical excision when cases are appropriately selected for this treatment modality.

Treatment and outcomes of ARUBA-eligible patients with unruptured brain arteriovenous malformations at a single institution.

OBJECT: Management of unruptured arteriovenous malformations (AVMs) is controversial. In the first randomized trial of unruptured AVMs (A Randomized Trial of Unruptured Brain Arteriovenous Malformations [ARUBA]), medically managed patients had a significantly lower risk of death or stroke and had better outcomes. The University of California, San Francisco (UCSF) was one of the participating ARUBA sites. While 473 patients were screened for eligibility, only 4 patients were enrolled in ARUBA. The purpose of this study is to report the treatment and outcomes of all ARUBA-eligible patients at UCSF. METHODS: The authors compared the treatment and outcomes of ARUBA-eligible patients using prospectively collected data from the UCSF brain AVM registry. Similar to ARUBA, they compared the rate of stroke or death in observed and treated patients and used the modified Rankin Scale to grade outcomes. RESULTS: Of 74 patients, 61 received an intervention and 13 were observed. Most treated patients had resection with or without preoperative embolization (43 [70.5%] of 61 patients). One of the 13 observed patients died after AVM hemorrhage. Nine of the 61 treated patients had a stroke or died. There was no significant difference in the rate of stroke or death (HR 1.34, 95% CI 0.12-14.53, p = 0.81) or clinical impairment (Fisher's exact test, p > 0.99) between observed and treated patients. CONCLUSIONS: The risk of stroke or death and degree of clinical impairment among treated patients was lower than reported in ARUBA. The authors found no significant difference in outcomes between observed and treated ARUBA-eligible patients at UCSF. Results in ARUBA-eligible patients managed outside that trial led to an entirely different conclusion about AVM intervention, due to the primary role of surgery, judicious surgical selection with established outcome predictors, and technical expertise developed at high-volume AVM centers.