Adjuvant proton beam therapy in patients with grade 2 meningiomas.

Background: The World Health Organization (WHO) grade 2 meningiomas behave aggressively with a high proclivity toward recurrence despite maximal surgical resection. Our institution, a pioneer of proton therapy, uses exclusively proton beam radiation, and thus, we present a retrospective cohort analysis of patients with WHO grade 2 meningiomas treated with adjuvant proton beam therapy (PBT) at our institution between 2007 and 2019. The effects of adjuvant PBT were evaluated. Methods: Data collected include diagnosis, gender, histological subtype, WHO grade, the extent of surgical resection, adjuvant PBT radiation, details of the PBT radiation, recurrence, any additional PBT radiation, systemic medical therapy, and disease-specific survival. Results: Among the WHO grade 2 meningiomas (n = 50) recommended PBT, 80% and 78% of patients with gross-total resection (GTR) and subtotal resection (STR), respectively, followed through with PBT. The median radiation dose of PBT was 59.5 Gy and 59.92 Gy for patients with GTR and STR, respectively, with a median of 33 fractions delivered in 1.8 Gy doses for both groups. Combined 3-year progression-free survival (PFS) was 96%, and 5-year PFS was 92%. Combined overall survival was 95% at five years. Minimal radiation side effects were reported with no grade 3 or higher toxicities. Conclusion: Our results suggest that adjuvant PBT is well tolerated with minimal radiation toxicity. Alternative to photon radiation, PBT may be considered at least as safe and effective for adjuvant treatment of WHO grade 2 meningiomas when it is available.

White Matter Hyperintensities as a Predictor of Aphasia Recovery.

OBJECTIVE: To examine the relation between baseline white matter hyperintensities (WMH) and change in naming, content production, and efficiency after treatment in subacute aphasia. We hypothesized that more severe baseline WMH would result in less improvement with treatment. DESIGN: Retrospective analysis of a cohort from a double-blind randomized controlled trial (RCT). SETTING: Outpatient clinical setting or participant home. PARTICIPANTS: We retrospectively reviewed imaging and behavioral data for 52 participants with subacute aphasia due to left-hemisphere ischemic stroke enrolled in the RCT. RCT inclusion criteria: English proficiency, normal/corrected-to-normal hearing/vision, and no history of neurologic conditions other than the stroke resulting aphasia. One participant with a chronic right-hemisphere lesion was retained as she presented with no residual deficits on neurologic examination. Individuals with scalp sensitivities or on medications that lower seizure threshold or any N-methyl-D-aspartate (NMDA) antagonists were excluded. Of the 52 participants, for this analysis, 2 were excluded for not having a magnetic resonance imaging, and 7 were excluded for not participating in treatment or pre/post assessment for at least 1 outcome, resulting in final sample of 43 participants (20 women sex, M [SD] age=64.4 [11.9] and M [SD] education=14.9 [3.1] years). INTERVENTIONS: Participants received 15 sessions (2-3 times/week) of computerized lexical-semantic (ie, verification) treatment with [sham/active] transcranial direct current stimulation (tDCS). Sessions were approximately 45 minutes each (tDCS for first 20 minutes). MAIN OUTCOME MEASURES: Naming accuracy, content units (CUs, a measure of semantically accurate production), and efficiency (ie, syllables/CU) on a picture description task. RESULTS: Periventricular WMH severity was independently associated with recovery in picture naming for the active tDCS group. Deep WMH severity was associated with recovery for CU production for the sham tDCS group. CONCLUSION: Baseline periventricular and deep WMH, among other factors, may be an important consideration for prognosis and treatment planning, especially when considered in conjunction with tDCS treatment.

Temporal change in aetiology and clinical characteristics of hepatocellular carcinoma in a large cohort of patients in New South Wales, Australia.

BACKGROUND: Viral hepatitis, alcohol-related liver disease (ARLD) and nonalcoholic fatty liver disease (NAFLD) are the main risk factors for hepatocellular carcinoma (HCC) in many countries. In Australia, given the access to hepatitis C virus (HCV) direct-acting antiviral (DAA) therapy since 2016, a temporal change in HCC aetiology was hypothesized. This study evaluated the temporal change in the aetiology and characteristics of HCC in New South Wales (NSW). METHODS: Patients diagnosed with HCC, admitted to three public hospitals in NSW between 2008 and 2021, were included in the analyses. We assessed the annual frequency of each HCC aetiology and the distribution of HCC characteristics in participants. RESULTS: Among 1370 patients, the most common HCC etiologies were HCV (n = 483, 35%), ARLD (n = 452, 33%), NAFLD (n = 347, 25%) and hepatitis B virus (n = 301, 22%). The proportion of HCV-related HCC was the highest in 2011-2016 (41%) and significantly declined to 30% in 2017-2021 (odds ratio [OR], 0.53 [95% confidence interval (CI), 0.35-0.79]; P = 0.002). The proportion of HCC diagnosed at an early stage (Barcelona Clinic Liver Cancer stage O/A) increased from 41% in 2008-2009 to 56% in 2020-2021 (OR per annum, 1.05 [95% CI, 1.02-1.08]; P = 0.002), and the proportion of patients receiving potentially curative HCC management increased from 29% in 2008-2009 to 41% in 2020-2021 (OR per annum, 1.06 [95% CI, 1.03-1.10]; P < 0.001). CONCLUSION: The contribution of HCV to HCC burden has been decreasing in the DAA era, suggesting the role of HCV elimination in decreasing HCC risk. Increasing frequency of less advanced HCC at diagnosis over time suggests improved HCC surveillance.

A phase II trial of gemcitabine and erlotinib followed by ChemoProton therapy plus capecitabine and oxaliplatin for locally advanced pancreatic cancer.

Background: Epidermal growth factor receptor (EGFR) is overexpressed in pancreatic cancer. EGFR expression plays a potentially important role in modulation of tumor sensitivity to either chemotherapy or radiotherapy. Erlotinib is a receptor tyrosine kinase inhibitor with specificity for EGFR/HER1. A phase II trial was conducted to explore the efficacy of a regimen utilizing erlotinib and proton therapy. Methods: Patients with unresectable or borderline resectable non-metastatic adenocarcinoma of the pancreas were included. Patients received 8-week systemic treatment with gemcitabine 1,000 mg/m2 and erlotinib 100 mg (GE). If there was no evidence of metastatic disease after GE, then patients preceded with proton therapy to 50.4 Gy in 28 fractions with concurrent capecitabine 825 mg/m2 (CPT). This was followed with oxaliplatin 130 mg/m2 and capecitabine 1,000 mg/m2 (CapOx) for 4 cycles. The primary study objective was 1-year overall survival (OS). The benchmark was 43% 1-year survival as demonstrated in RTOG/NRG 98-12. The Kaplan-Meier method was used to estimate the one-year OS and the median OS and progression-free survival (PFS). Results: The study enrolled 9 patients ages 47-81 years old (median 62) between January 2013 and March 2016, when the trial was closed due to low patient accrual. The 1-year OS rate was 55.6% (95% CI: 31% to 99%). The median OS was 14.1 months (95% CI: 11.4-NE) and the median PFS was 10.8 months (95% CI: 7.44-NE). A majority of patients completed CPT and GE, but only 33.3% completed the four cycles of CapOx. A third of patients experienced grade 3 toxicities, which were all hepatic along with one patient who also had grade 3 diarrhea. There were no grade 4 or 5 toxicities. Four patients were enrolled with borderline resectable disease, three of which were eligible for pancreaticoduodenectomy after GE and CPT treatment. One of two patients who underwent resection had a negative margin. Conclusions: This regimen for locally advanced pancreatic cancer (LAPC) exceeded the pre-specified benchmark and was safe and well tolerated. Additional investigations utilizing more current systemic treatment regimens with proton therapy are warranted. Trial Registration: ClinicalTrials.gov identifier (NCTNCT01683422).

Pharmacologic Treatment for Temporomandibular and Temporomandibular Joint Disorders.

Temporomandibular joint disorder is defined by pain and/or loss of function of the temporomandibular joint and its associated muscles and structures. Treatments include noninvasive pharmacologic therapies, minimally invasive muscular and articular injections, and surgery. Conservative therapies include nonsteroidal anti-inflammatory drugs, muscle relaxants, benzodiazepines, antidepressants, and anticonvulsants. Minimally invasive injections include botulinum toxin, corticosteroids, platelet-rich plasma, hyaluronic acid, and prolotherapy with hypertonic glucose. With many pharmacologic treatment options and modalities available to the oral and maxillofacial surgeon, mild to moderate temporomandibular joint disorder can be managed safely and effectively to improve symptoms of pain and function of the temporomandibular joint.

Reflection on the development of a patient case in twine.

PURPOSE: With technology becoming an essential component in classrooms, it is becoming more crucial for pharmacy faculty to explore innovative active learning strategies that engage students inside and outside the classroom. This manuscript discusses how two fourth-year students and their preceptor developed interactive patient cases using an open-source software application called Twine (www.twinery.org). DESCRIPTION: Two different cases were developed in Twine. The first patient case story was created by the fourth-year students and will be implemented in the future. The second patient case, consisting of two Twine stories, was created by the faculty preceptor and was implemented during new student orientation. ANALYSIS/INTERPRETATION: Resources for development as well as advantages and disadvantages of developing and implementing Twine stories into the curriculum are discussed. Implementation of the faculty's Twine stories into the pharmacy curriculum is also discussed. CONCLUSIONS: Twine is a user-friendly application and has the potential to be utilized in healthcare programs as an effective and engaging teaching strategy that both professor and students enjoy. IMPLICATIONS: While development of a Twine story could be time-consuming, the benefit of increasing student engagement outweighs the cost. Active learning is an essential component in the classroom, and finding new and innovative ways to enhance student learning is imperative.

Proton stereotactic body radiation therapy for liver metastases-results of 5-year experience for 81 hepatic lesions.

BACKGROUND: To report on our institutional experience using Proton stereotactic body radiation therapy (SBRT) for patients with liver metastases. METHODS: All patients with liver metastases treated with Proton SBRT between September 2012 and December 2017 were retrospectively analyzed. Local control (LC) and overall survival (OS) were estimated using the Kaplan-Meier method calculated from the time of completion of Proton SBRT. LC was defined according to Response Evaluation Criteria in Solid Tumors (RECIST) guidelines (version 1.1). Toxicity was graded according to Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. RESULTS: Forty-six patients with 81 lesions were treated with Proton SBRT. The median age was 65.5 years old (range, 33-86 years) and the median follow up was 15 months (range, 1-54 months). The median size of the gross tumor volume (GTV) was 2.5 cm (range, 0.7-8.9 cm). Two or more lesions were treated in 56.5% of patients, with one patient receiving treatment to a total of five lesions. There were 37 lesions treated with a biologically effective dose (BED) ≤60, 9 lesions with a BED of 61-80, 22 lesions with a BED of 81-100, and 13 lesions with a BED >100. The 1-year and 2-year LC for all lesions was 92.5% (95% CI, 82.7% to 96.8%). The grade 1 and grade 2 toxicity rates were 37% and 6.5%, respectively. There were no grade 3 or higher toxicities and no cases of radiation-induced liver disease (RILD). CONCLUSIONS: Proton SBRT for the treatment of liver metastases has promising LC rates with the ability to safely treat multiple liver metastases. Accrual continues for our phase II trial treating liver metastases with Proton SBRT to 60 GyE (Gray equivalent) in 3 fractions.

Anterior Cruciate Ligament Surgery Performed Less Than 3 Weeks After Injury Is Not Inferior to Delayed Surgery.

Performing anterior cruciate ligament (ACL) surgery in the immediate period after injury is controversial. However, there may be instances where the opportunity cost of delayed surgery for the patient may be unacceptable. Concomitant meniscus injuries may also prevent the patient from regaining range of motion in the preoperative period. Every week that surgery is delayed may increase pain and impair mobility for this group of patients. We investigate the functional and clinical outcomes in patients with ACL surgery in the immediate 3-week period following ACL injury. A cohort study was performed to compare the outcome of early ACL (less than 3 weeks after injury) and late ACL surgery (more than 3 weeks after surgery). A total of 58 patients were followed up at fixed time points over a 2-year period. Clinical measurements (range of motion and knee laxity scores) and functional outcome scores (International Knee Documentation Committee, Lysholm's Knee and Tegner's scores) were used to document outcomes over time. The mean time to surgery from the time of injury in the early ACL surgery group was 2 weeks (standard deviation [SD] = 0.45) and the 20 weeks (SD = 9.64) in the late ACL surgery group. The absence or presence of meniscal injuries had no significant effect on the improvement over time for both groups of patients (p > 0.05). Patients in the early ACL group had faster rates of improvement for clinical measurements and functional outcome scores but had started out initially with poorer outcomes at baseline. However, both groups had comparable outcomes (p > 0.05) at the 1- and 2-year mark postsurgery. Patients in both groups had no adverse outcomes. ACL Surgery within 3 weeks of injury (2 weeks SD = 0.45) is safe and has comparable outcomes compared to patients with delayed surgery (20 weeks SD = 9.64).

Subchondroplasty for Bone Marrow Lesions in the Arthritic Knee Results in Pain Relief and Improvement in Function.

Subchondroplasty is a relatively new joint preserving procedure, which involves the localized injection of calcium pyrophosphate bone substitute into the bone marrow lesion. The advent of magnetic resonance imaging (MRI) has greatly facilitated the identification of these bone marrow lesions. We investigated the clinical efficacy of subchondroplasty in the treatment of symptomatic bone marrow lesions in the knee, including knees with preexisting osteoarthritis. This study comprised of 12 patients whose knees were evaluated with standard radiographs and MRI to identify and localize the bone marrow lesions. They then underwent subchondroplasty under intraoperative radiographic guidance. Preoperative and postoperative visual analog scale (VAS) pain scores, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, and Knee Injury and Arthritis Outcome Scores (KOOS) were obtained. VAS scores improved significantly from 7.5 ± 1.8 before surgery to 5.2 ± 2.7 after surgery. This further improved to 2.1 ± 2.4 at the one-year follow-up. KOOS scores improved significantly from 38.5 ± 17.0 before surgery to 73.2 ± 19.0 at the one-year follow-up. WOMAC scores improved significantly from 47.8 ± 20.5 before surgery to 14.3 ± 13.2 at the one-year follow-up. Subchondroplasty offers an effective way to treat subchondral bone marrow lesions in the arthritic knee, resulting in improvement in symptoms and early return to activity. Long-term studies are required to evaluate if these benefits can last. This is a Level II study.

Identification of US Counties at Elevated Risk for Congenital Syphilis Using Predictive Modeling and a Risk Scoring System.

BACKGROUND: Although preventable through timely screening and treatment, congenital syphilis (CS) rates are increasing in the United States, occurring in 5% of counties in 2015. Although individual-level factors are important predictors of CS, given the geographic focus of CS, it is also imperative to understand what county-level factors are associated with CS. METHODS: This is a secondary analysis of reported county CS cases to the National Notifiable Diseases Surveillance System during the periods 2014-2015 and 2016-2017. We developed a predictive model to identify county-level factors associated with CS and use these to predict counties at elevated risk for future CS. RESULTS: Our final model identified 973 (31.0% of all US counties) counties at elevated risk for CS (sensitivity, 88.1%; specificity, 74.0%). County factors that were predictive of CS included metropolitan area, income inequality, primary and secondary syphilis rates among women and men who have sex with men, and population proportions of those who are non-Hispanic black, Hispanic, living in urban areas, and uninsured. The predictive model using 2014-2015 CS outcome data was predictive of 2016-2017 CS cases (area under the curve value, 89.2%) CONCLUSIONS: Given the dire consequences of CS, increasing prevention efforts remains important. The ability to predict counties at most elevated risk for CS based on county factors may help target CS resources where they are needed most.

Causal inference of latent classes in complex survey data with the estimating equation framework.

Latent class analysis (LCA) has been effectively used to cluster multiple survey items. However, causal inference with an exposure variable, identified by an LCA model, is challenging because (1) the exposure variable is unobserved and harbors the uncertainty of estimating parameters in the LCA model and (2) confounding bias adjustments need to be done with the unobserved LCA-driven exposure variable. In addition to these challenges, complex survey design features and survey weights must be accounted for if they are present. Our solutions to these issues are to (1) assess point estimates with the expected estimating function approach and (2) modify the survey design weights with LCA-based propensity scores. This paper aims to introduce a statistical procedure to apply the estimating equation approach to assessing the effects of LCA-driven cause in complex survey data using an example of the National Health and Nutrition Examination Survey.

Hypofractionated Proton Therapy in Early Prostate Cancer: Results of a Phase I/II Trial at Loma Linda University.

PURPOSE: To determine whether a hypofractionated proton therapy regimen will control early-stage disease and maintain low rates of side effects similar to results obtained using standard-fraction proton therapy at our institution. MATERIALS AND METHODS: A cohort of 146 patients with low-risk prostate cancer according to National Comprehensive Cancer Network guidelines (Gleason score <7, prostate-specific antigen [PSA] <10, tumor stage of T1-T2a) received 60 Gy (cobalt Gy equivalent) of proton therapy (20 fractions of 3.0 Gy per fraction) in 4 weeks, a dose biologically equivalent to standard fractionation (44-45 fractions of 1.8 Gy to a total of 79.2 to 81 Gy in 0 weeks). Patients were evaluated at least weekly during treatment, at which time documentation of treatment tolerance and acute reactions was obtained. Follow-up visits were conducted every 3 months for the first 1 years, every 6 months for the next 3 years, then annually. Follow-up visits consisted of history and physical examination, PSA measurements, and evaluation of toxicity. RESULTS: The median follow-up time was 42 months (range, 3-96 months). Acute grade 2 urinary toxicity occurred in 16% (20/120) of the patients; acute grade 2 or higher gastrointestinal toxicity was seen in 1.7% (2/120). At 9 months, 1 patient had late grade 3 urinary toxicity, which resolved by 12 months; no grade 3 gastrointestinal toxicities occurred. The 3-year biochemical survival rate was 99.3% (144/145). The median time to PSA nadir was 30 months. CONCLUSION: Hypofractionated proton therapy of 60 Gy in 20 fractions was safe and effective for patients with low-risk prostate cancer.

A phase I trial of Proton stereotactic body radiation therapy for liver metastases.

BACKGROUND: A phase I trial to determine the maximum tolerated dose (MTD) of Proton stereotactic body radiation therapy (SBRT) for liver metastases in anticipation of a subsequent phase II study. METHODS: An institutional IRB approved phase I clinical trial was conducted. Eligible patients had 1-3 liver metastases measuring less than 5 cm, and no metastases location within 2 cm of the GI tract. Dose escalation was conducted with three dose cohorts. The low, intermediate, and high dose cohorts were planned to receive 36, 48, and 60 respectively to the internal target volume (ITV) in 3 fractions. At least 700 mL of normal liver had to receive <15. Dose-limiting toxicity (DLT) included acute grade 3 liver, intestinal or spinal cord toxicity or any grade 4 toxicity. The MTD is defined as the dose level below that which results in DLT in 2 or more of the 6 patients in the highest dose level cohort. RESULTS: Nine patients were enrolled (6 male, 3 female): median age 64 years (range, 33-77 years); median gross tumor volume (GTV) 11.1 mL (range, 2.14-89.3 mL); most common primary site, colorectal (5 patients). Four patients had multiple tumors. No patient experienced a DLT and dose was escalated to 60 in 3 fractions without reaching MTD. The only toxicity within 90 days of completion of treatment was one patient with a grade 1 skin hyperpigmentation without tenderness or desquamation. Two patients in the low dose cohort had local recurrence and repeat SBRT was done to previously treated lesions without any toxicities. CONCLUSIONS: Biologically ablative Proton SBRT doses are well tolerated in patients with limited liver metastases with no patients experiencing any grade 2+ acute toxicity. Results from this trial provide the grounds for an ongoing phase II Proton SBRT study of 60 over 3 fractions for liver metastases.

Psychological Traits, Heart Rate Variability, and Risk of Coronary Heart Disease in Healthy Aging Women-The Women's Health Initiative.

OBJECTIVE: Psychological traits such as optimism and hostility affect coronary heart disease (CHD) risk, but mechanisms for this association are unclear. We hypothesized that optimism and hostility may affect CHD risk via changes in heart rate variability (HRV). METHODS: We conducted a longitudinal analysis using data from the Women's Health Initiative Myocardial Ischemia and Migraine Study. Participants underwent 24-hour ambulatory electrocardiogram monitoring 3 years after enrollment. Optimism (Life Orientation Test-Revised), cynical hostility (Cook-Medley), demographics, and coronary risk factors were assessed at baseline. HRV measures included standard deviation of average N-N intervals (SDNN); standard deviation of average N-N intervals for 5 minutes (SDANN); and average heart rate (HR). CHD was defined as the first occurrence of myocardial infarction, angina, coronary angioplasty, and bypass grafting. Linear and Cox regression models adjusted for CHD risk factors were used to examine, respectively, associations between optimism, hostility, and HRV and between HRV and CHD risk. RESULTS: Final analyses included 2655 women. Although optimism was not associated with HRV, hostility was inversely associated with HRV 3 years later (SDANN: adjusted ß = -0.54; 95% CI = -0.97 to -0.11; SDNN: -0.49; 95% CI = -0.93 to -0.05). HRV was inversely associated with CHD risk; for each 10-millisecond increase in SDNN or SDANN, there was a decrease in CHD risk of 9% (p = .023) and 12% (p = .006), respectively. CONCLUSIONS: HRV did not play a major role in explaining why more optimistic women seem to be somewhat protected from CHD risk. Although hostility was inversely associated with HRV, its role in explaining the association between hostility and CHD risk remains to be established.

Assessment of sexual health services at US colleges and universities, 2001 and 2014.

Background Approximately 19million students attend post-secondary institutions in the US. With rates of sexually transmitted infections (STIs) at unprecedented highs, the college and university setting can provide the opportunity to engage young adults in their sexual health and deliver recommended services. The purpose of this study was to compare the provision of sexual health services at US college and university health centres across studies conducted in 2001 and 2014. METHODS: We compared data from nationally representative surveys administered by the Centers for Disease Control and Prevention (2001, n=736 schools; 2014, n=482 schools), assessing the provision of services, including STI diagnosis and treatment, contraception, STI education, condom distribution and availability of health insurance. RESULTS: Compared with 2001, statistically significant increases were observed in 2014, including in the provision of contraceptive services (56.1% vs 65.0%), HIV testing (81.5% vs 92.3%) and gonorrhoea testing (90.7% vs 95.8%). Significant decreases were found in the number of schools offering health plans (65.5% vs 49.4%) and specific modes of offering STI education, such as health fairs (82.3% vs 69.9%) and orientation presentations (46.5% vs 29.8%; all P<0.001). CONCLUSIONS: From 2001 to 2014, there have been some improvements in sexual health services at colleges and universities, but there are areas that require additional access to services. Schools may consider regular assessments of service provision in order to further promote sexual health services on college campuses.

Laboratory Evaluation of a Commercially Available Rapid Syphilis Test.

Serological diagnosis of syphilis depends on assays that detect treponemal and nontreponemal antibodies. Laboratory certification and trained personnel are needed to perform most of these tests, while high costs and long turnaround time can hinder treatment initiation or linkage to care. A rapid treponemal syphilis test (RST) that is simple to perform, accessible, and inexpensive would be ideal. The Syphilis Health Check (SHC) assay is the only Food and Drug Administration (FDA)-cleared and Clinical Laboratory Improvement Amendments (CLIA)-waived RST in the United States. In this study, 1,406 archived human serum samples were tested using SHC and traditional treponemal and nontreponemal assays. Rapid test results were compared with treponemal data alone and with a laboratory test panel consensus defined as being reactive by both treponemal and nontreponemal assays for a given specimen, or nonreactive by both types of assays. The sensitivity and specificity of the SHC assay compared with treponemal tests alone were 88.7% (95% confidence interval [CI], 86.2 to 90.0%) and 93.1% (95% CI, 90.0 to 94.9%), respectively, while comparison with the laboratory test panel consensus showed 95.7% (95% CI, 93.6 to 97.2%) sensitivity and 93.2% (95% CI, 91.0 to 95.1%) specificity. The data were further stratified based on age, sex, pregnancy, and HIV status. The sensitivity and specificity of the SHC assay ranged from 66.7% (95% CI, 46.0 to 83.5%) to 91.7% (95% CI, 87.7 to 94.7%) and 88% (95% CI, 68.8 to 97.5%) to 100% (95% CI, 47.8 to 100%), respectively, across groups compared to traditional treponemal assays, generally increasing for all groups except the HIV-positive (HIV+) population when factoring in the laboratory test panel consensus. These data contribute to current knowledge of the SHC assay performance for distinct populations and may guide use in various settings.

Advanced endografting techniques: snorkels, chimneys, periscopes, fenestrations, and branched endografts.

The anatomy of aortic aneurysms from the proximal neck to the access vessels may create technical challenges for endovascular repair. Upwards of 30% of patients with abdominal aortic aneurysms (AAA) have unsuitable proximal neck morphology for endovascular repair. Anatomies considered unsuitable for conventional infrarenal stent grafting include short or absent necks, angulated necks, conical necks, or large necks exceeding size availability for current stent grafts. A number of advanced endovascular techniques and devices have been developed to circumvent these challenges, each with unique advantages and disadvantages. These include snorkeling procedures such as chimneys, periscopes, and sandwich techniques; "homemade" or "back-table" fenestrated endografts as well as manufactured, customized fenestrated endografts; and more recently, physician modified branched devices. Furthermore, new devices in the pipeline under investigation, such as "off-the-shelf" fenestrated stent grafts, branched stent grafts, lower profile devices, and novel sealing designs, have the potential of solving many of the aforementioned problems. The treatment of aortic aneurysms continues to evolve, further expanding the population of patients that can be treated with an endovascular approach. As the technology grows so do the number of challenging aortic anatomies that endovascular specialists take on, further pushing the envelope in the arena of aortic repair.

Exploring causality mechanism in the joint analysis of longitudinal and survival data.

In many biomedical studies, disease progress is monitored by a biomarker over time, eg, repeated measures of CD4 in AIDS and hemoglobin in end-stage renal disease patients. The endpoint of interest, eg, death or diagnosis of a specific disease, is correlated with the longitudinal biomarker. In this paper, we examine and compare different models of longitudinal and survival data to investigate causal mechanisms, specifically, those related to the role of random effects. We illustrate the methods by data from two clinical trials: an AIDS study and a liver cirrhosis study.

Men Who Have Sex With Men-Identification Criteria and Characteristics From the National Health and Nutrition Examination Survey, 1999 to 2014.

OBJECTIVES: This study aimed to provide identification criteria for men who have sex with men (MSM), estimate the prevalence of MSM behavior, and compare sociodemographics and sexually transmitted disease risk behaviors between non-MSM and MSM groups using data from a nationally representative, population-based survey. METHODS: Using data from men aged 18 to 59 years who took part in the National Health and Nutrition Examination Survey (NHANES), 1999 to 2014, detailed criteria were developed to estimate MSM behavior-at least one lifetime same-sex partner (MSM-ever), at least one same-sex partner in the past 12 months (MSM-current), and at least one lifetime and zero same-sex partners in the past 12 months (MSM-past). RESULTS: The estimated prevalence of MSM-ever was 5.5%-of these, 52.4% were MSM-current and 47.1% were MSM-past. Furthermore, MSM-ever are a nonhomogenous subpopulation, for example, 70.4% of MSM-current identified as homosexual and 71.2% of MSM-past identified as heterosexual (P < 0.001). CONCLUSIONS: The prevalence of MSM behavior identified here is similar to other published estimates. This is also the first article, to our knowledge, to use National Health and Nutrition Examination Survey data to compare MSM by 2 recall periods (recent vs. lifetime) of last same-sex sexual behavior.