Citations

Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) have become increasingly utilized in patients undergoing percutaneous coronary intervention (PCI). Despite these purported advantages, prior reports regarding the use of IVUS and OCT have indicated that contemporary use of intravascular imaging remains low with significant regional variation. Here, we present the findings of an updated contemporary analysis regarding the use of IVUS/OCT-guided PCI versus angiography-guided PCI in the United States. We also evaluated in-hospital mortality and clinical outcomes between IVUS/OCT-guided PCI versus angiography-guided PCI-only over million patients in the United States. There has been a significant decrease in the number of PCIs performed, while there has been increasing in the trend of IVUS/OCT-guided PCI over this period. Most importantly, we found that IVUS/OCT-guided PCI was associated with better clinical outcomes in terms of in-hospital mortality, compared with angiography-guided PCI.

PURPOSE BRAF and MEK inhibitors are standard treatments in histiocytic disorders, such as Erdheim-Chester disease (ECD). Some patients lack MAPK-pathway alterations, making these treatments less effective. METHODS We describe three patients with histiocytic disorders who have novel non-MAPK pathway alterations. These alterations were studied through genomic and in silico analyses when applicable, then treated with off-label medications rationally selected on the basis of genomic alterations. RESULTS Patient 1 had rapidly progressive ECD involving the CNS. A CSF1R in-frame deletion (p.S560_P566del) was identified, and in silico modeling predicted a gain-of-function mutation. This alteration was targeted with pexidartinib, which led to a clinical complete response (CR) within 2 months, and a partial response (PR) on imaging after 3 months. After 15 months, the disease became resistant to pexidartinib and transformed to histiocytic sarcoma. Patient 2 has skin-only involvement of a xanthogranuloma disorder. A KIF5B-FGFR1 fusion was identified on RNA sequencing and targeted with pemigatinib. At 24 months of follow-up, she remains in a clinical PR. Patient 3 has ECD involving the bone marrow, gastrointestinal tract, and subcutaneous tissues. A MEF2C-FLT3 fusion was identified and targeted with sorafenib. He achieved a clinical CR and radiographic PR within 3 months, which has continued for 30 months. CONCLUSION We report three patients with histiocytic disorders harboring novel alterations who had sustained responses to off-label kinase inhibitors specific to their histiocytic disorder. Pathogenic variants outside of the MAPK pathway, including variants of unknown significant, may be targeted with readily available small molecules.

A 40 year old woman who underwent combined heart-lung transplant for familial severe pulmonary hypertension experienced episodes of nonsustained ventricular tachycardia followed by sudden ventricular fibrillation arrest 8 days after transplant. Postarrest investigations revealed left lower lobe herniation into the right lower hemithorax, prompting emergent reoperation, and hernia reduction. Arrhythmias resolved following reduction of the herniated lung and facilitated rapid weaning from vasopressor and ventilatory support. To our knowledge, this is the first reported case of cardiac arrest due to lung herniation after combined heart-lung transplantation. Herein, we describe this rare presentation and offer insights and management strategies for the cardiac intensivist.

Purpose To compare Medicaid and Medicare rates for the 20 most commonly billed orthopaedic sports medicine procedures. Methods Medicaid reimbursement rates were obtained from state‐specific fee schedules. Medicare rates were collected from the Centers for Medicare & Medicaid Services Physician Fee Schedule, along with relative value units for each procedure. State rates were compared using averages and dollar differences. Reimbursement rates were adjusted for cost of living using the Medicare Wage Index. Variability between states and between procedures was assessed using coefficients of variation. Results Mean Medicaid reimbursement was lower than that of Medicare for 19 of the 20 procedures. In total, Medicaid reimbursed surgeons 14.9% less when data were unadjusted and 26.0% less when data were adjusted for cost of living. Variation in Medicare rates between states was constant, with a coefficient of variation of 0.06. For Medicaid, the coefficients of variation ranged from 0.27 to 0.70 for unadjusted data and from 0.35 to 0.69 for adjusted data. Conclusions On average, Medicaid reimburses orthopaedic sports medicine specialists less than does Medicare, with substantial variability between states. Adjustment for cost of living increases the percentage difference and the variability between states’ Medicaid reimbursement rates. Level of Evidence Level IV, economic analysis.

Preoperative anemia is common and associated with worse outcomes in cardiac surgery including acute kidney injury, red blood cell transfusion, cardiovascular complications, stroke, infection, and death. Patient blood management programs, which include dedicated clinical programs to diagnose and treat anemia in advance of surgery (ie, preoperative anemia programs), have been highlighted as a means to optimize the blood health of each patient, thereby decreasing risk for allogeneic transfusion and improving clinical outcomes. However, there remain implementation challenges for preoperative anemia programs, including difficulties with education of patients and staff, short lead times to address anemia, infrastructure and staffing limitations, lack of clear leadership or ownership of preoperative anemia, the need to develop treatment algorithms and ensure appropriate infusion therapy support, lack of capital support, and insurance/reimbursement concerns, amongst others. The purpose of this advisory from the Society of Cardiovascular Anesthesiologists (SCA) Clinical Practice Improvement Committee and the Subcommittee on Patient Blood Management with endorsement from the Society for the Advancement of Patient Blood Management (SABM) is to provide guidance on the development and implementation of a preoperative anemia clinic or service line, including identification and navigation through potential logistical barriers. A detailed analysis of financial incentives is highlighted in our companion article in this edition focuses on the return on investment of anemia management. Although originating with a focus on anemia before cardiac surgery, this advisory is broadly applicable to all perioperative patients.

Abstract BACKGROUND Recurrent anaplastic astrocytoma (AA), a grade 3 brain cancer, remains an unmet medical need. STELLAR was a phase III randomized, open-label trial of eflornithine (ornithine decarboxylase inhibitor) with lomustine versus lomustine alone, originally for patients with recurrent AA. However, as the WHO definition of AA evolved during trial conduct (e.g., excluding IDH wild-type disease), we determined results in both the original ITT population and by revised molecularly defined WHO 2021 diagnoses in pre-planned analyses. METHOD Key eligibility: age ≥ 18, AA (2016 WHO criteria), first recurrence ≥ 6 months after radiation and temozolomide, KPS ≥ 70, no imaging findings consistent with grade 4 glioblastoma. Stratification: IDH, age, resection extent, and geography. Patients were randomized to Arm A: eflornithine (2.8 g/m2 TID Q 2/3 weeks) with lomustine (90 mg/m2 Q 6 weeks) or Arm B: lomustine (110 mg/m2 Q 6 weeks). Primary endpoint was OS. The pre-specified hazard ratio (HR) goal was 0.667 based on projected median OS (mOS) increase to 18 months from 12 months. RESULTS 343 pts (172/171 Arms A/B) were randomized (105 sites, 8 countries). ITT analysis found no difference between arms (mOS 23.4 vs. 20.3 months, HR = 0.94). However, a pre-specified subset analysis in IDH mutant, 2021 WHO-defined grade 3 astrocytoma (n=194), showed significant improvement with eflornithine (mOS 34.9 vs. 23.5 months, HR = 0.64, log rank p = 0.016) and PFS (15.8 vs. 7.2 months, HR = 0.58, log rank p = 0.015). No difference was observed in the IDH wild-type subset. AEs were consistent with historic data. CONCLUSION There was no difference in OS between arms in the ITT analysis. However, medically meaningful and statistically significant OS and PFS benefits were observed with eflornithine in the pre-planned analysis of patients with molecularly defined 2021 WHO CNS grade 3 astrocytoma.