Stand-alone Approach Research Articles

Preparing culturally responsive teachers: a systematic review

Abstract As the world continues to ponder issues of equity and diversity, U.S. public schools face an expanding demographic divide between teachers and students. While diverse groups of public school students show an increase in population, the teaching workforce in the U.S. remains overwhelmingly White. The purpose of this systematic review is to examine how preservice teachers (PST) are being prepared to be culturally responsive. A total of 26 studies published between 2006 and 2020 were reviewed. The results indicate that PSTs’ learning experiences are varied and tend to be stand-alone approaches focused on changing the attitudes and beliefs of PSTs. Findings also bring to light the vagueness of terminology used in the research to define cultural groups of students, the conspicuous absence of studies related to LGBTQ+ populations, and the lack of study replications. Implications for future research are discussed.

Forensic identity SNPs: Characterisation of flanking region variation using massively parallel sequencing.

Single nucleotide polymorphisms (SNPs) can be analysed for identity or kinship applications in forensic genetics to either provide an adjunct to traditional STR typing or as a stand-alone approach. The advent of massively parallel sequencing technology (MPS) has provided a useful opportunity to more easily deploy SNP typing in a forensic context, given the ability to simultaneously amplify a large number of markers. Furthermore, MPS also provides valuable sequence data for the targeted regions, which enables the detection of any additional variation seen in the flanking regions of amplicons. In this study we genotyped 977 samples across five UK-relevant population groups (White British, East Asian, South Asian, North-East African and West African) for 94 identity-informative SNP markers using the ForenSeq DNA Signature Prep Kit. Examination of flanking region variation allowed for the identification of 158 additional alleles across all populations studied. Here we present allele frequencies for all 94 identity-informative SNPs, both including and excluding the flanking region sequence of these markers. We also present information on the configuration of these SNPs in the ForenSeq DNA Signature Prep Kit, including performance metrics for the markers and investigation of bioinformatic and chemistry-based discordances. Overall, the inclusion of flanking region variation in the analysing workflow for these markers reduced the average combined match probability 2175 times across all populations, with a maximum reduction of 675,000-fold in the West African population. The gain due to flanking region-based discrimination increased the heterozygosity of some loci above that of some of the least useful forensic STR loci; thus demonstrating the benefit of enhanced analysis of currently targeted SNP markers for forensic applications.

Rapid analysis of titer, aggregate, and intact mass of antibody therapeutics using automated multi-dimensional liquid chromatography coupled with native mass spectroscopy.

Monoclonal antibodies are tetrameric complex proteins, primarily produced using mammalian cell culture. Attributes such as titer, aggregates, and intact mass analysis are monitored during process development/optimization. In the present study, a novel workflow such that the Protein-A affinity chromatography is performed in the first dimension for purification and titer estimation, whereas size exclusion chromatography is employed in the second dimension to characterize size variants using native mass spectrometry. The present workflow offers a significant advantage over the traditionally used standalone Protein-A affinity chromatography followed by size exclusion chromatography analysis in that it can monitor these four attributes in 8 min while requiring a minimal sample size (10-15μg) and not requiring any manual peak collection. In contrast, the traditional standalone approach requires manual collection of eluted peaks in Protein-A affinity chromatography followed by buffer exchange to a mass-compatible buffer, which can take up to 2-3h with considerable risk of sample loss, degradation, and induced modifications. As the biopharma industry moves to make analytical testing efficient, we believe that the approach proposed here would be of significant interest due to its ability to monitor multiple process and product quality attributes in a single workflow and via rapid analysis.

Bayesian monitoring of substructures under unknown interface assumption

Structural Health Monitoring (SHM) enables assessing in-service structures’ performance by localizing structural anomaly instances immediately after their occurrence. Typical SHM approaches monitor the entire structural spatial domain aggravating the required density and cost of instrumentation. Further, with model-based approaches, the entire structural domain is needed to be defined with high dimensional, compute-intensive models rendering the SHM approaches ill-posed and slow especially when the instrumentation is limited and system observability is compromised. Moreover, in absence of high-fidelity models, oversimplification and subsequent model inaccuracies may lead to inaccurate estimation and possibly false alarms even if a subdomain is modeled inaccurately, e.g. support boundaries. To mitigate such issues, stand-alone monitoring focusing only on a subdomain of interest may be a computationally cheaper and prompt approach while being substantially robust to false alarms. Typically, such stand-alone substructure monitoring approaches demand extensive measurement of the interface, which can be a challenge in real-life applications. This paper presents a novel filtering-based online time domain approach for estimating substructure parameters without the need to measure or estimate the substructure interfaces. The proposed component-wise estimation is stand-alone so that the health estimation of the complete structural domain can be undertaken in parallel and later coupled through post-processing. The requirement of the interface measurement has been alleviated by employing an output injection approach. The proposal has been validated on a numerical beam structure subjected to arbitrary forces and subsequently, the sensitivity against noise and damage severity of the proposal has been investigated. Finally, the proposal is validated on a real beam to illustrate its real-life applicability and significance.

A Critical Review of Remote Sensing Approaches and Deep Learning Techniques in Archaeology

To date, comprehensive reviews and discussions of the strengths and limitations of Remote Sensing (RS) standalone and combination approaches, and Deep Learning (DL)-based RS datasets in archaeology have been limited. The objective of this paper is, therefore, to review and critically discuss existing studies that have applied these advanced approaches in archaeology, with a specific focus on digital preservation and object detection. RS standalone approaches including range-based and image-based modelling (e.g., laser scanning and SfM photogrammetry) have several disadvantages in terms of spatial resolution, penetrations, textures, colours, and accuracy. These limitations have led some archaeological studies to fuse/integrate multiple RS datasets to overcome limitations and produce comparatively detailed outcomes. However, there are still knowledge gaps in examining the effectiveness of these RS approaches in enhancing the detection of archaeological remains/areas. Thus, this review paper is likely to deliver valuable comprehension for archaeological studies to fill knowledge gaps and further advance exploration of archaeological areas/features using RS along with DL approaches.

Determination of fracture toughness and traction–separation relation in Mode I/II of a natural quasi-brittle orthotropic composite using multi-specimen approach

The fracture behavior of quasi-brittle naturally occurring composites is characterized by the presence of fracture process zone (FPZ), which is attributed by crack bridging and micro-cracking in wood. The FPZ limits the use of existing standards for fracture toughness. Also, the repeated loading–unloading approach using single specimen is difficult due to crack face interference. Further, the crack growth monitoring is difficult since the crack tip may be buried inside FPZ. So far, the compliance based beam method (CBBM) has offered a reasonable solution to these challenges. However, the CBBM is not an absolutely independent approach as it uses elastic constant and compliance determined from other experiments. Naturally occurring materials, like wood, exhibits large variations in its properties. Therefore, the use of parameters from multiple other experiments decreases the confidence in measured fracture toughness. Considering this, the present work evaluates the fracture toughness attributed by critical energy release rate of New Zealand Pine wood. Firstly, the research method follows a stand-alone multi-specimen approach to evaluate fracture toughness without any requirement for crack growth monitoring. Secondly, it experimentally establishes the traction–separation relation for both Mode I and II. This work has a general applicability to other natural quasi-brittle orthotropic solids like bone.

Multilevel anterior cervical fusion with standalone cage or cage-and-plate after cervical discectomy: Benefits and drawbacks

PurposeMultilevel anterior cervical discectomy and fusion (ACDF), especially two-level ACDF, has been usually performed in the cervical degenerative disease, and the incidence rate of complications is controversial. This study aimed to compare the outcomes of ACDF approach with cage alone and with plate fixation in multilevel discectomy. MethodsPatients who had undergone multilevel ACDF by the Smith-Robinson methods were included from 2018 to 2020. Data were collected using a questionnaire containing demographic characteristics, surgical complications, and outcome. All the patients were followed for 18 months post-surgery. Visual Analogue Scale (VAS), Neck Disability Index (NDI) and Nurick Grading scale were used to measure the pain degree, neck pain effect, and myelopathy grade, respectively. Bone fusion rate, subsidence and instrument failure were checked through radiography. Data were analyzed using SPSS, and the significant level was considered 0.05. Results24 patients were included. There was no significant difference between the mean blood losses in the two groups. The rate of subsidence was much higher in group B after 18 months (60% vs 14.3%). As to the VAS score, NDI, and Nurick scale, trend change overtime was significantly improved in each group, but there was no significant difference between the groups. There was no significant difference between the two groups regarding bony fusion rate. DiscussionACDF with plate leads to a more prolonged surgery with no significant benefits. Stand-alone cage approach could be suggested as the gold standard for anterior cervical discectomy.

Combining Remote Sensing Approaches for Detecting Marks of Archaeological and Demolished Constructions in Cahokia’s Grand Plaza, Southwestern Illinois

Remote sensing data are increasingly being used in digital archaeology for the potential non-invasive detection of archaeological remains. The purpose of this research is to evaluate the capability of standalone (LiDAR and aerial photogrammetry) and integration/fusion remote sensing approaches in improving the prospecting and interpretation of archaeological remains in Cahokia’s Grand Plaza. Cahokia Mounds is an ancient area; it was the largest settlement of the Mississippian culture located in southwestern Illinois, USA. There are a limited number of studies combining LiDAR and aerial photogrammetry to extract archaeological features. This article, therefore, combines LiDAR with photogrammetric data to create new datasets and investigate whether the new data can enhance the detection of archaeological/ demolished structures in comparison to the standalone approaches. The investigations are implemented based on the hillshade, gradient, and sky view factor visual analysis techniques, which have various merits in revealing topographic features. The outcomes of this research illustrate that combining data derived from different sources can not only confirm the detection of remains but can also reveal more remains than standalone approaches. This study demonstrates that the use of combination remote sensing approaches provides archaeologists with another powerful tool for site analysis.

Minimal-access video-assisted retroperitoneal and/or transperitoneal debridement (VARTD) in the management of infected walled-off pancreatic necrosis with deep extension: initial experience from a prospective single-arm study

BackgroundThe currently preferred minimally invasive approaches have substantially improved outcomes of infected walled-off pancreatic necrosis (iWON). However, iWON with deep extension (iWONde) still poses a tricky challenge for sufficient necrosis evacuation by one stand-alone approach, often requiring repeated interventions. The aim of this study was to assess the effectiveness and safety of a minimal-access video-assisted retroperitoneal and/or transperitoneal debridement (hereafter called VARTD) in the management of iWONde.MethodsPatients who had developed an iWONde were recruited to receive the VARTD in this prospective single-arm study. The primary efficacy endpoint was clinical improvement up to day 28 after the VARTD, defined as a ≥ 75% reduction in size of necrotic collection (in any axis) on CT and clinical resolution of sepsis or organ dysfunction. The primary safety endpoint was a composite of major complications or death during follow-up. Six-month postdischarge follow-up was available.ResultsBetween July 18, 2018, and November 12, 2020, we screened 95 patients with necrotizing pancreatitis; of these, 21 iWONde patients (mean [SD] age, 42.9 [11.7] years; 10 [48%] women) were finally enrolled. The primary efficacy endpoint was achieved by most participants (14/21, 67%). No participants required repeated interventions. The primary safety endpoint occurred in six patients (29%). Except one in-hospital death attributable to repeated intra-abdominal hemorrhage, others were discharged without any major complication.ConclusionsThe VARTD approach appears to have a reasonable efficacy with acceptable complication rates and thus might be an option for improving clinical management of iWONde.Trial registrationThis study is registered with Chinese Clinical Trial Registry (chictr.org.cn number, ChiCTR1800016950).

From the Editors

From the Editors

The Use of a Discrete Choice Experiment Including Both Duration and Dead for the Development of an EQ-5D-5L Value Set for Australia.

Discrete choice experiments (DCEs) with either duration included an attribute or with dead included as an option can be used as a stand-alone approach to value health states. This paper reports on a DCE with both of these features to develop an EQ-5D-5L value set for Australia. A DCE was undertaken using a large Australian panel of internet respondents, from which a sample of more than 4000 Australian adults was chosen, stratified to be population representative on age and gender. The DCE contained 500 choice triplets, with two EQ-5D-5L health states with duration, and dead as the third option. Each respondent answered 12 choice sets from the 500, stating both the best and worst options from the three available. The design was constructed to estimate a utility algorithm with main effects plus some key interaction terms. A variety of approaches to parameterising interactions, and to anchoring the value set on the required 0-1 scale, were tested. A preferred Australian adult utility algorithm for use in cost-utility analysis was then generated. In total, 4477 people completed at least one choice set and were included in the analysis. The results reflected the monotonic structure of the EQ-5D-5L, in that moving from no problems to extreme problems led to worsening utility in each dimension. Inclusion of interaction terms demonstrates that the disutility of the first dimension moving to a poor level (defined as either level 5, or level 4 or 5) had a large impact, but subsequent dimensions moving to a poor level had a relatively smaller disutility. This work develops a value set for the EQ-5D-5L in Australia, and also provides a range of methodological insights which can inform future work using a stand-alone DCE to value health in other countries.

Intelligent process optimisation based on cutting-edge emotional learning for performance evaluation of NF/RO of seawater desalination plant

As decision-makers, researchers encounter highly dynamic, complex problems requiring suitable nature-based and industrial quantitative tools for performance analyses, syntheses, and modelling. This study employed a new-generation emotional artificial neural network (EANN) and other stand-alone approaches to model the performance of hybrid nanofiltration (NF) and reverse osmosis (RO) desalination plants in terms of permeate recovery (PR) (%) and permeate flow rate (PFR) (m3/h). With the obtained experimental data, augmented Dickey-Fuller (ADF) and Philip Perron tests, evaluated using the Akaike information criterion and Schwarz information criterion, were employed to assess stability and stationarity. Nonlinear input-variable feature selection based on mutual information and neuro-sensitivity analysis (NSA) was conducted on several input variables before modelling. The EANN was compared with stand-alone predictive models: backpropagation neural network and classical stepwise regression. Predictive simulations were evaluated using the Nash–Sutcliffe model efficiency coefficient (NSE), correlation coefficient (CC), mean absolute error (MAE), determination coefficient (DC), root mean square error (RMSE), and two-dimensional Taylor graphical visualisation. For PR, in the calibration phase, the NSE and MAE (%) were 27–99 % and 0.0064–0.1410, respectively. For PFR, NSE and MAE (m3/h) were 50–99 % and 0.0064–0.1410, respectively. The bibliography review indicated the popularity of artificial intelligence (AI) applications in desalination. Results revealed that this new-generation EANN demonstrated superior accuracy over all models; accordingly, it can serve as a reliable tool for evaluating the performance of NF/RO hybrid seawater desalination plants.

Local Antibiotics in the Treatment of Diabetic Foot Infections: A Narrative Review.

Along with the increasing global burden of diabetes, diabetic foot infections (DFI) and diabetic foot osteomyelitis (DFO) remain major challenges for patients and society. Despite progress in the development of prominent international guidelines, the optimal medical treatment for DFI and DFO remains unclear as to whether local antibiotics, that is, topical agents and local delivery systems, should be used alone or concomitant to conventional systemic antibiotics. To better inform clinicians in this evolving field, we performed a narrative review and summarized key relevant observational studies and clinical trials of non-prophylactic local antibiotics for the treatment of DFI and DFO, both alone and in combination with systemic antibiotics. We searched PubMed for studies published between January 2000 and October 2022, identified 388 potentially eligible records, and included 19 studies. Our findings highlight that evidence for adding local antibiotic delivery systems to standard DFO treatment remains limited. Furthermore, we found that so far, local antibiotic interventions have mainly targeted forefoot DFO, although there is marked variation in the design of the included studies. Suggestive evidence emerging from observational studies underscores that the addition of local agents to conventional systemic antibiotics might help to shorten the clinical healing time and overall recovery rates in infected diabetic foot ulcers, although the effectiveness of local antibiotics as a standalone approach remains overlooked. In conclusion, despite the heterogeneous body of evidence, the possibility that the addition of local antibiotics to conventional systemic treatment may improve outcomes in DFI and DFO cannot be ruled out. Antibiotic stewardship principles call for further research to elucidate the potential benefits of local antibiotics alone and in combination with conventional systemic antibiotics for the treatment of DFI and DFO.

Lead isotope analysis for provenancing ancient materials: a comparison of approaches.

Lead isotope analysis has been used to determine the provenance of metals such as lead, silver and bronze for many decades. Nevertheless, different approaches to interpret lead isotopic ratios have been proposed. In this study, three methods to couple the lead isotopic signature of archaeological artefacts to their possible mineral resources will be compared: the conventional assessment of biplots, a clustering method combined with calculating model ages (as applied by F. Albarède et al., J. Archaeol. Sci., 2020, 121, 105194), and relative probability calculations using kernel density estimates (as proposed by De Ceuster and Degryse, Archaeometry, 2020, 62(1), 107-116). The three different approaches will be applied to a dataset of lead isotopic analyses of 99 Roman Republican silver coins previously analyzed, pointing to a primary origin of the silver in the mining regions of Spain, NW-Europe and the Aegean, but showing signs of mixing and/or recycling. The interpretations made through the different approaches are compared, indicating the strengths and weaknesses for each one. This study argues that, although the conventional biplot method gives valid visual information, it is no longer feasible due to ever growing datasets. Calculating the relative probabilities via kernel density estimation provides a more transparent and statistically correct approach that generates an overview of plausible provenance candidates per artefact. The geological perspective introduced in the cluster and model age method by F. Albarède et al., J. Archaeol. Sci., 2020, 121, 105194 broadens the analytical spectrum with geologically informed parameters and improved visualization. However, the results when applying their method as a stand-alone approach are of low resolution and may lose archaeological relevance. Their approach regarding clustering should be revised.

E-Learning Platforms Analysis – Modern Review

E-learning is a novel instructional technique for imparting necessary information and skills to students. This article gives a thorough examination of the current state of e-learning approaches in organizations. The authors also assess the efficacy of e-learning by analyzing the current research articles. This study is presented and evaluated in several models to explain student intention to use an e-learning system as a substitute for traditional classroom learning or as a stand-alone distant education approach. The results of a survey related to eLearning platforms were reviewed by other researchers to determine the identified discoveries and uncover the research gaps. This work is unique as it contributes to the current literature discussion. The article's scientific uniqueness also includes a large-scale investigation that describes the author's theoretical and practical prerequisites. A critical examination of the literature is offered in this paper to establish a more realistic foundation for e-learning success. This paper reviews various e-learning tools and presents visualizations of web search data that display the popularity of electronic learning systems. Keywords: e-learning, Moodle, Blackboard, Top Hat, Google Classroom. DOI: https://doi.org/10.55463/hkjss.issn.1021-3619.60.89

Ionosphere Delay Extraction in GNSS using DSP Algorithm

With multiple GNSS availability and wider applications, many positioning modes like SPS, DGNSS, RTK and PPP have been developed to cover these flexible employments. Currently, some intricate influences such as ionosphere delays and environmental interference have caused obvious impacts to accurate positioning, and they are therefore formed highlighted research points for worldwide researchers and scholars. To deal with the ionosphere delay, this submission has proposed an intrinsic approach to identify and extract the ionospheric disturbance from GNSS observations in which Digital Signal Process (DSP) is employed to form an adaptive band pass filter for combined observations in the form of either code minus phase (CMP) or double differential (DD) carrier phase. Related mechanism for identification and extraction of the ionosphere delay using DSP are introduced and analyzed. We have also discussed the separation of ionosphere delay with multipath caused by signal reflections from nearby surroundings when deformation monitoring is conducted on some restricted environments. Effects achieved by DSP have been verified combining with typical SPS and carrier based relative positioning conducted in Guangzhou metro construction sites. Results exhibit that the suggested standalone approach to extract ionosphere delays is an innovative technical frame to achieve accurate positioning regardless of assistant messages from base stations or satellite navigation broadcast.

High or hot-Perspectives on altitude camps and heat-acclimation training as preparation for prolonged stage races.

Adaptation to heat stress and hypoxia are relevant for athletes participating in Tour de France or similar cycling races taking place during the summertime in landscapes with varying altitude. Both to minimize detrimental performance effects associated with arterial desaturation occurring at moderate altitudes in elite athletes, respectively, reduce the risk of hyperthermia on hot days, but also as a pre-competition acclimatization strategy to boost blood volume in already highly adapted athletes. The hematological adaptations require weeks of exposure to manifest, but are attractive as an augmented hemoglobin mass may improve arterial oxygen delivery and hence benefit prolonged performances. Altitude training camps have in this context a long history in exercise physiology and are still common practice in elite cycling. However, heat-acclimation training provides an attractive alternative for some athletes either as a stand-alone approach or in combination with altitude. The present paper provides an update and practical perspectives on the potential to utilize hypoxia and heat exposure to optimize hematological adaptations. Furthermore, we will consider temporal aspects both in terms of onset and decay of the adaptations relevant for improved thermoregulatory capacity and respiratory adaptations to abate arterial desaturation during altitude exposure. From focus on involved physiological mechanisms, time course, and responsiveness in elite athletes, we will provide guidance based on our experience from practical implementation in cyclists preparing for prolonged stage races such as the Tour de France.

Using Wearable Sensors to Estimate Mechanical Power Output in Cyclical Sports Other than Cycling-A Review.

More insight into in-field mechanical power in cyclical sports is useful for coaches, sport scientists, and athletes for various reasons. To estimate in-field mechanical power, the use of wearable sensors can be a convenient solution. However, as many model options and approaches for mechanical power estimation using wearable sensors exist, and the optimal combination differs between sports and depends on the intended aim, determining the best setup for a given sport can be challenging. This review aims to provide an overview and discussion of the present methods to estimate in-field mechanical power in different cyclical sports. Overall, in-field mechanical power estimation can be complex, such that methods are often simplified to improve feasibility. For example, for some sports, power meters exist that use the main propulsive force for mechanical power estimation. Another non-invasive method usable for in-field mechanical power estimation is the use of inertial measurement units (IMUs). These wearable sensors can either be used as stand-alone approach or in combination with force sensors. However, every method has consequences for interpretation of power values. Based on the findings of this review, recommendations for mechanical power measurement and interpretation in kayaking, rowing, wheelchair propulsion, speed skating, and cross-country skiing are done.

Teaching Histology Using Self-Directed Learning Modules (SDLMs) in a Blended Approach.

New technologies like virtual microscopy have revolutionized histology education. However, first-year students often require additional assistance with virtual slides. Online self-directed learning modules (SDLMs) were developed to provide such support to learners by offering them short instructional videos that are uploaded to YouTube and the instructional website. The purpose of this study was to determine the effectiveness of SDLMs and to sample students' opinions about SDLMs. Over a 3-year time span, SDLMs were used to augment histology lessons, and their effectiveness (on learning outcomes) was measured by using traditional steeple-chase and/or virtual slide assessments. Average percentage scores for both methods of assessment were compared using paired or independent t-tests. Student opinions about SDLMs were collected using an anonymous survey. The survey results were analyzed by average scores and thematic analysis of the narrative responses. Using SDLMs in a blended approach showed significant improvement in students' academic performance - irrespective of the method of assessment. There was a strong positive correlation with the performance when students wereassessed using the virtual slide method. However, a standalone approach using SDLMs did not positively impact learning outcomes. Survey results indicated that most students perceived the videos as helpful for understanding the subject better and as quick review opportunities. The results support the use of SDLMs in a blended instructional approach and as an adjunct resource to conventional microscopy. This use of SDLMs was positively received by learners and significantly improved the learning outcome. The online version contains supplementary material available at 10.1007/s40670-022-01669-9.

Flow diversion in direct carotid-cavernous fistula refractory to multiple coil embolizations: case report and review of the literature

ObjectivesDirect carotid-cavernous fistulas are high-flow abnormal connections between the carotid artery and cavernous sinus, which are associated with significant morbidity and mortality if left untreated. In addition to endovascular coil embolization, there is an evolving role for alternative stand-alone or adjunctive treatment approaches. We describe a case of flow diversion as an adjunctive treatment approach in a treatment-resistant direct carotid-cavernous fistula and review the literature on the use of flow diversion in this clinical context. Materials and methodsWe describe the clinical course, imaging findings, and outcome of a patient who developed a traumatic carotid-cavernous fistula requiring multiple interventions. We also performed an updated literature review of all published cases of flow diversion use in the treatment of direct CCFs. ResultsOur patient achieved angiographic cure and significant improvement in symptoms at 6-month follow-up. A total of 53 cases of flow diversion use in direct carotid-cavernous fistulas were identified from a literature search. In one third of cases, flow diversion was used as a stand-alone treatment modality. Angiographic resolution was achieved in 90% of cases at a median follow-up duration of 6 months. One half of reported cases had complete resolution of symptoms and a further third noted clinical improvement in at least some of their symptoms. ConclusionsThere is an emerging role for flow diversion as a safe and effective stand-alone or adjunctive treatment option for direct carotid-cavernous fistulas. Our case further supports a role for flow diversion in treatment-resistant fistulas with high-risk features. As treatment approaches continue to evolve, prospective, randomized data will be needed to establish the role of flow divertors in the hierarchy of available treatments for carotid-cavernous fistulas.