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Abstract Background Spinal cord stimulation (SCS) is an important modality for treating chronic pain in patients who have failed conservative therapy and a substantial portion of the population rely on fee-for-service Medicare or Medicaid for coverage. We aimed to determine physician professional fee reimbursement rates and the ratio of Medicaid to Medicare professional fee reimbursement (MMI) for three common Current Procedural Terminology (CPT) codes related to SCS therapy (63650, 63685, and 63655) across states. Secondarily, we explored trends in utilization and reimbursement of these procedures by Medicare at the national level between 2013 and 2023. Methods Medicaid professional fee reimbursement data were extracted from publicly available fee schedules where available for individual states, while Medicare reimbursement data were extracted from the Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule. Baseline and wage-adjusted MMI values were calculated for each state. Results Medicaid reimbursed 11.5–21.0% less than Medicare across the evaluated CPT codes after wage adjustment, with differences of 11.8% for CPT 63650 (facility), 18.0% for CPT 63650 (non-facility), 11.5% for CPT 63685 (facility), and 21.0% for CPT 63655 (facility). Medicaid MMI values ranged from 0.397–1.87 across codes and settings. State-level Medicaid professional fee reimbursement varied substantially, ranging from $194.52–$639.38 for CPT 63650 (facility), $978.72–$2,781.65 for CPT 63650 (non-facility), $160.82–$558.00 for CPT 63685 (facility), and $375.97–$1,045.15 for CPT 63655 (facility); Medicare reimbursement was substantially less variable. From 2013–2023, Medicare utilization, rendering providers, beneficiaries, and standardized payments generally increased, although trends varied by CPT code and site of service. Conclusions Medicare physician professional fee reimbursement largely exceeds Medicaid physician professional fee reimbursement for three of the most common SCS procedural codes, suggesting potential access barriers to chronic pain procedures. Medicaid reimbursement shows considerable variation across states and among procedural codes, suggesting substantial interstate heterogeneity in Medicaid rate-setting that may reflect differences in state policy priorities or other factors not analyzed in this study.

BACKGROUND: The impact of life-course blood pressure (BP) trajectories on later-life focal left ventricular (LV) fibrosis by late gadolinium enhancement (LGE) remains elusive. METHODS: MyoFit46 prospectively recruited ≈500 participants from a 1946 birth cohort for a cardiovascular magnetic resonance scan at 77 years, assessing LV LGE calculated using the 3-SD method or 5-SD method. Systolic BP (SBP) and diastolic BP were recorded at 36, 43, 53, 63, 69, and 77 years. For each participant, annual rates of BP change (steepness) and area under the BP trajectory (cumulative burden) for each age interval were calculated using mixed-effects models. Associations between life-course BPs and LGE were tested using generalized linear models, adjusted for antihypertensives, demographics, lifestyle, and comorbidities. Time-to-event associations between LGE and incident major adverse cardiovascular event (hospitalizations for coronary artery disease, stroke, heart failure, and atrial/ventricular arrhythmias; n=29) were also evaluated. RESULTS: Among 472 participants (54% male), each 10 mm Hg greater individual SBPs at 36 to 69 years were associated with 6% to 11% greater LV LGE calculated using the 3-SD method (all P ≤0.033), whereas each 10 mm Hg sustained greater SBPs on any age interval from 36 to 69 associated with 16% to 24% greater LGE calculated using the 3-SD method at 77(all P ≤0.005), independent of SBP at 77 years. Each 1 mm Hg/y steeper SBP rise during age intervals 36 to 43, 43 to 53, and 53 to 63 was associated with 6% to 12% greater LGE calculated using the 3-SD method at 77 years. LGE presence was associated with greater major adverse cardiovascular event rates (hazard ratio, 2.5 [95% CI, 1.2–5.2]). CONCLUSIONS: Higher life-course BPs, cumulative burden, and steeper increases were associated with greater older-age LV LGE, which was linked to incident major adverse cardiovascular events. BP trajectories, beyond single-point BP measurements, warrant further investigation as tools to guide BP management strategies.

Importance Effective interventions are needed to support the cocreation of diabetes care plans that are sensible, desirable, and feasible for the people living with diabetes (ie, care that fits). Objective To investigate whether an agenda-setting kit (ASK) added to usual primary care improves fit of care and glycemic control in adults with type 2 diabetes (T2D). Design, Setting, and Participants This single-center, clinician-level cluster randomized clinical trial was conducted from February 16, 2023, to July 26, 2024, with a 6-month follow-up, at a federally qualified health center in New Haven, Connecticut. Eligible clinicians were primary care physicians, nurse practitioners, and physician assistants who prescribed medication to treat patients with T2D. Eligible patients were English- or Spanish-speaking adults aged 18 years or older with T2D and hemoglobin (Hb) A 1c level greater than 8%. Patients were excluded if their clinician determined that an HbA 1c level 8% or lower was inconsistent with goals of care. Data were analyzed from November 7, 2024, to August 13, 2026. Intervention Clinicians were randomized 1:1 to the ASK plus usual primary care group (intervention group) or usual primary care only (control group). The ASK intervention consisted of 14 conversation cards about life with diabetes and its treatment. Prior to the clinical encounter, patients were asked to select 0 to 3 cards they wanted to prioritize for discussion. Main Outcomes and Measures The primary outcome was the 6-month change from baseline in illness intrusiveness measured with the Illness Intrusiveness Ratings Scale (IIRS; range: 13-91, with higher scores indicating greater intrusiveness) and HbA 1c level. Secondary outcomes included changes in treatment burden measured with the Treatment Burden Questionnaire (TBQ; range: 0-150, with higher scores indicating greater burden), diabetes distress measured with the 17-Item Diabetes Distress Scale (DDS-17; scores: indicate little or no distress [<2.0], moderate distress [2.0-2.9], and high distress [≥3.0]), and visit satisfaction. Results Eleven clinicians (6 [54.5%] female) were included in the trial along with 143 of their patients. The mean (SD) patient age was 56 (12) years; 87 participants (60.8%) were female and 88 (61.5%) reported Spanish as their primary language. Six-month survey data were available for 65 of 74 patients (87.8%) in the intervention group and 58 of 69 (84.0%) in the control group; data on HbA 1c level were available for 71 (95.9%) and 65 (94.2%), respectively. At 6 months, mean (SD) IIRS scores were 32.1 (15.1) and 37.1 (18.7) in the intervention and control groups (adjusted mean difference, −3.9; 95% CI, −10.4 to 2.6). The mean (SD) HbA 1c levels were 8.8% (1.8) in the intervention group and 9.1% (1.8) in the control group (adjusted mean difference, −0.2%; 95% CI, −0.9% to 0.5%). Mean (SD) TBQ scores in the intervention and control groups were 41.2 (44.8) and 46.8 (44.4) (adjusted mean difference, 1.0; 95% CI, −16.6 to 18.6), and mean (SD) DDS-17 scores were 2.0 (1.0) and 2.3 (1.0) (adjusted mean difference, −0.1; 95% CI, −0.4 to 0.2). Clinician-reported satisfaction was greater in the intervention group; patient satisfaction did not differ between groups. Conclusions and Relevance In this cluster randomized clinical trial of adults with T2D, use of the ASK with usual primary care was associated with greater clinician satisfaction but not with improvements in patients’ fit of care or glycemic control over 6 months. Larger studies should evaluate interventions that not only identify patients’ priorities and treatment burdens but also better support clinicians in addressing them. Trial Registration ClinicalTrials.gov Identifier: NCT05553912

ABSTRACT Introduction Changes in peripheral eosinophils follow endoscopic sinus surgery (ESS) in chronic rhinosinusitis with nasal polyps (CRSwNP), with and without aspirin sensitivity. Cytometry by time‐of‐flight (CyTOF) identifies more immune cell subsets than conventional assays or clinical testing. We hypothesized that ESS‐associated changes in peripheral immune cell subsets differ between aspirin‐tolerant (AT)‐CRSwNP and aspirin‐exacerbated respiratory disease (AERD) as measured by CyTOF. Methods Pre‐ and post‐ESS peripheral blood from patients with CRSwNP ( n = 13) or with AERD ( n = 15) was analyzed for immune cell populations using a 37‐marker CyTOF panel. CITRUS analysis identified cell clusters most predictive of patient group or sample timepoint. Results In the combined cohort of 28 patients, circulating CD4 + naïve T cells and CD194 + neutrophils increased after ESS, while eosinophils decreased. When stratified by disease, CD4 + naïve T cells increased in both AERD and CRSwNP post‐ESS; however, eosinophils decreased after ESS only in CRSwNP. Neutrophil subsets showed a mixed response in both patient groups after ESS. Dendritic cells increased in CRSwNP but not in AERD after ESS. Individual timepoint analyses showed more CD141 + monocyte‐derived DCs (moDCs) in CRSwNP than in AERD pre‐ and post‐ESS. Pre‐ESS, both CD185 + and CD194 + neutrophils were higher in AERD compared to CRSwNP. Conclusion CD141 + moDCs were more prevalent in CRSwNP versus AERD, both before and after ESS. Naïve CD4 + T cells increased, and neutrophil subsets changed in all groups after ESS, but eosinophils decreased only in CRSwNP. Our study points to possible systemic immune effects of ESS and candidate immune signatures in CRSwNP and AERD.

Study Design: Case presentation. Objective: The interlaminar endoscopic lateral recess decompression (IE-LRD) represents a novel surgical alternative to consider in carefully selected cases, particularly when patients do not respond to conservative treatment. Background: Lumbar spinal stenosis (LSS) constitutes one of the most prevalent spinal conditions in the elderly population around the world. A myriad of causes have been elucidated, and although infrequent, vertebral compression fractures (VCF) may also cause LSS. Conservative treatment might be the first option; however, patients often require surgery. Methods: A 76-year-old woman with a medical history of dementia consulted for radicular pain in her left leg during the past 6 months, without any favorable response to conservative treatment. Neurological examination revealed a positive straight leg raising test on the left. A spine MRI revealed a VCF in L5, linked with spondylolisthesis (grade I) at L5–S1. An IE-LRD was planned, as the patient did not consent to a classical open surgery. The incision was placed over the inferior medial edge of the left L4 lamina. Following sequential dilatators, the working channel was located on the inferomedial edge of the left L4 lamina. Lateral fluoroscopy (LF) guided the entire procedure. During the procedure, laminotomy was extended cranially and caudally to ensure sufficient vertebral decompression. Results: After surgery, the patient was mobilized in the first 6 hours and discharged in the next 24 hours. Her lower back pain score improved significantly to 2–3, while her leg VAS pain improved to 0–1. After a follow-up for 18 months, the patient did not manifest complications or recurrences, and no additional treatment was carried out. Conclusion: (1) IE-LRD might be a useful and safe surgical procedure for the surgical management of LSS caused by VCF. (2) Consider this surgical alternative for elderly patients without a previous response to conservative medical treatment.

T cell exhaustion is often viewed as a terminal state marked by irreversible loss of function during chronic infection and cancer. However, the rapid recovery of antitumor activity in clinical responders after PD-1 blockade suggests that some exhausted T cells retain hidden functional potential. To explain this paradox, we present a theoretical framework that separates latent effector capacity from active effector function. Latent effector capacity represents a history-dependent state reflecting preserved epigenetic accessibility and regulatory readiness, distinct from ongoing gene expression. In this model, PD-1 signaling acts as a reversible mask that suppresses effector function without eliminating the underlying effector capacity. The framework explains preserved chromatin accessibility, rapid reinvigoration after checkpoint blockade, and variable therapeutic responses. By incorporating nonlinear maintenance and erosion of latent effector capacity, the model predicts a bistable system with a point of no return beyond which exhaustion becomes irreversible. These principles may guide development of mechanistically informed biomarkers and artificial intelligence models predicting response to PD-1 therapy.

Purpose The purpose of this study was to identify risk factors and evaluate clinical outcomes associated with incidental left common iliac vein compression on CT imaging. Methods This is a retrospective study that reviewed venous-phase abdomen and pelvis CT scans to identify patients with incidental extrinsic compression of the left common iliac vein due to an overlying right common iliac artery. A total of 726 patients were included (364 females, 362 males; mean patient age: 61.9 ± 15.9 years). Board-certified radiologists reviewed all CT scans. Significant left iliac vein compression was defined as >50% luminal narrowing. Results Significant iliac vein compression was identified in 114 (15.7%) patients and was more common in females (19.5%) versus males (11.9%) ( p < 0.01). Patients with iliac vein compression >50% had significantly lower BMI than those without compression (24.8 ± 6.2 vs 28.7 ± 7.2 kg/m 2 , p < 0.01). Patients with incidental left iliac vein compression had a higher rate of prior left lower extremity DVT ( p = 0.02). Conclusion Incidental left common iliac vein compression was present in approximately 16% of patients and was more frequent among females. Compression was associated with lower BMI and more than twice the rate of ipsilateral DVT, despite no prior diagnosis of MTS. These findings suggest that incidental iliac vein compression could have more clinical significance than previously recognized.