Citations

Background Traditional endovascular treatments of giant intracranial aneurysms are associated with high rates of complications and retreatment. Our objective was to examine the safety and long-term efficacy of the Pipeline Embolization Device for treatment of these aneurysms. Methods This retrospective study using the IntrePED database included all patients with giant intracranial aneurysms treated with the Pipeline device between July 2008 and February 2013. Efficacy outcomes were stratified by using the Raymond-Roy Occlusion Classification. Predefined safety outcomes included spontaneous rupture of the target aneurysm; ipsilateral intracranial hemorrhage; ischemic stroke; parent artery stenosis; and sustained cranial neuropathy. Results Sixty-six embolizations were performed to treat 63 giant intracranial aneurysms (including 2 ruptured): 49 (77.8%) in the anterior and 14 (22.2%) in the posterior circulation. The median follow-up was 22.4 (0.1–60.5) months. Class I angiographic occlusion was achieved in 72.0% (36/50). The neurological morbidity/mortality rate was 23.8% (15/63), with higher rates in the posterior circulation than in the anterior circulation (22.4% vs. 28.6%). Among seven deaths, five had neurological causes. The procedure-related neurological morbidity and mortality rates were 22.7% (15/66) and 7.6% (5/66), respectively. The spontaneous rupture rate was 4.5% (3/66). Two spontaneous ruptures (1 death), 4/4 postprocedural intracranial hemorrhages, and 6/9 ischemic events occurred within 30 days. In-stent stenosis and new-onset cranial neuropathy were not observed during the angiographic follow-up period. Conclusions Although procedure-related neurological morbidity/mortality rates were not insignificant, this study confirms the feasibility and long-term efficacy of the Pipeline Embolization Device to treat giant intracranial aneurysms.

Abstract We identified resistance mechanisms to abiraterone acetate/prednisone (AA/P) in patients with metastatic castration-resistant prostate cancer (mCRPC) in the Prostate Cancer Medically Optimized Genome-Enhanced Therapy (PROMOTE) study. We analyzed whole-exome sequencing (WES) and RNA-sequencing data from 83 patients with metastatic biopsies before (V1) and after 12 weeks of AA/P treatment (V2). Resistance was determined by time to treatment change (TTTC). At V2, 18 and 11 of 58 patients had either short-term (median 3.6 months; range 1.4–4.5) or long-term (median 29 months; range 23.5–41.7) responses, respectively. Nonresponders had low expression of TGFBR3 and increased activation of the Wnt pathway, cell cycle, upregulation of AR variants, both pre- and posttreatment, with further deletion of AR inhibitor CDK11B posttreatment. Deletion of androgen processing genes, HSD17B11, CYP19A1 were observed in nonresponders posttreatment. Genes involved in cell cycle, DNA repair, Wnt-signaling, and Aurora kinase pathways were differentially expressed between the responder and non-responder at V2. Activation of Wnt signaling in nonresponder and deactivation of MYC or its target genes in responders was detected via SCN loss, somatic mutations, and transcriptomics. Upregulation of genes in the AURKA pathway are consistent with the activation of MYC regulated genes in nonresponders. Several genes in the AKT1 axis had increased mutation rate in nonresponders. We also found evidence of resistance via PDCD1 overexpression in responders. Implications: Finally, we identified candidates drugs to reverse AA/P resistance: topoisomerase inhibitors and drugs targeting the cell cycle via the MYC/AURKA/AURKB/TOP2A and/or PI3K_AKT_MTOR pathways.

AbstractHow to deliver best care in various clinical settings remains a vexing problem. All pertinent healthcare-related questions have not, cannot, and will not be addressable with costly time- and resource-consuming controlled clinical trials. At present, evidence-based guidelines can address only a small fraction of the types of care that clinicians deliver. Furthermore, underserved areas rarely can access state-of-the-art evidence-based guidelines in real-time, and often lack the wherewithal to implement advanced guidelines. Care providers in such settings frequently do not have sufficient training to undertake advanced guideline implementation. Nevertheless, in advanced modern healthcare delivery environments, use of eActions (validated clinical decision support systems) could help overcome the cognitive limitations of overburdened clinicians. Widespread use of eActions will require surmounting current healthcare technical and cultural barriers and installing clinical evidence/data curation systems. The authors expect that increased numbers of evidence-based guidelines will result from future comparative effectiveness clinical research carried out during routine healthcare delivery within learning healthcare systems.

In southwestern and western regions of the United States, at least half a million diagnostic tests for coccidioidomycosis (valley fever) are run annually. Enzyme immunoassays (EIAs) are blood tests which require precise dilution of patient serum prior to testing.

ABSTRACT Background Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). Methods Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence‐based review (EBR), or evidence‐based review with recommendations (EBR‐R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. Results The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA‐associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. Conclusion This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence‐based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Background: Plastic surgeons regularly perform injections for both cosmetic and functional purposes. This article examines the most common injections utilized by plastic surgeons under Medicare and how their usage and billing has changed between 2012 and 2019. Methods: Using the earliest and latest data available on the Centers for Medicare and Medicaid Services’ Provider Utilization and Payment Data File, we first determined Healthcare Common Procedure Coding System injection codes most billed to Medicare in 2012 and 2019. The number of services, amount of Medicare beneficiaries, and reimbursement rates were collected and analyzed for each Healthcare Common Procedure Coding System code from the Provider Utilization and Payment Data File for years 2012 and 2019. We compared the change in reimbursement rate for each injection to the rate of inflation in US dollars over the same period. Results: The unadjusted Medicare reimbursement rate for eight included injection types increased an average of 31.63% during the study period. This was not significantly different from the rate of inflation during the same period (+11.33%, P = 0.311). When all Medicare reimbursement data were adjusted for inflation to 2019 dollars, the average percentage change in reimbursement for all included injections in this study increased by 17.58% from 2012 to 2019. Conclusions: The findings from our study suggest that injections administered by plastic surgeons appear to be unique in their general stability in reimbursement rates as compared to rates in other fields. Further research should be performed to better understand the driving factors for usage and reimbursement changes.