In 2017, the U.S. Centers for Medicare and Medicaid Services approved reimbursement for billing codes specific to the Collaborative Care Model (CoCM), an evidence-based practice for improving access and quality of behavioral health services in primary care. However, it remains unclear how reimbursement through these billing codes aligns with applications of CoCM for complex patient populations, such as those with co-occurring mental and substance use disorders. We examined the reimbursement potential of CoCM intervention activities documented during a pragmatic clinical trial of CoCM for patients with opioid use disorder co-occurring with depression and/or post-traumatic stress disorder. We defined reimbursement potential based on federal (i.e., Medicare) CoCM billing code rules and reimbursement rates, as of 2024. Across 381 patients and 10 care managers (i.e., the CoCM interventionists), we documented 90,996 total intervention activity minutes in the project’s care management registry. Under ideal conditions where all CoCM billing codes can be and are used, a maximum of 56
ObjectiveCognitive impairment is increasingly recognized in patients with cerebral venous congestion (CVC), yet the cognitive tools used are largely adapted from stroke and dementia research. This review examines current literature on cognitive function in CVC, including conditions such as cerebral venous sinus thrombosis (CVST), idiopathic intracranial hypertension (IIH), and dural arteriovenous fistulas (dAVFs). Special emphasis is placed on the limitations of common screening tools like the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE). Cognitive dysfunction-primarily affecting executive function, processing speed, and attention-is reported in up to 86% of CVC cases, yet only about 20% of studies use validated cognitive testing tools, most of which may lack sensitivity for CVC-specific deficits. Emerging techniques such as ocular motor testing and physiological markers show promise but require further validation. There is an urgent need for standardized, CVC-specific cognitive assessment protocols that reflect the unique pathophysiology of venous disorders. Future research should prioritize the development of targeted cognitive batteries and integrate objective physiological measures to enhance diagnostic accuracy.
Background The Monopoint reperfusion system (Monopoint; Route 92 Medical, San Mateo, California, USA) is a large bore (0.088 or 0.070 inch inner diameter) aspiration thrombectomy platform designed to minimize ledge effect and improve neurovascular navigation and embolectomy. We aimed to describe a multicenter, real world experience of the safety and performance of the Monopoint system in first line aspiration thrombectomy for large vessel occlusions (LVOs), outside of the recently completed SUMMIT MAX (A Randomized, Controlled Trial to Evaluate the Safety and Effectiveness of the Route 92 Medical Reperfusion System) clinical trial.Methods Adults with acute anterior circulation LVO stroke between January 2019 and December 2024 consecutively treated with first line aspiration thrombectomy using the Monopoint at 10 centers were retrospectively reviewed. The primary outcome was first pass effect (FPE, modified Thrombolysis in Cerebral Infarction (mTICI) 2C/3 on first pass) and modified FPE (mFPE, mTICI 2B/2C/3 on first pass). The primary safety outcome was the rate of intraprocedural complications attributed to the Monopoint system.Results In 193 included patients, median age was 67 years (IQR 67-78), and 46.6% (90/193) were women. Successful delivery of the aspiration catheter to the clot site occurred in 96.2% (185/193) of patients. FPE was achieved in 57.5% (111/193) and mFPE was achieved in 68.4% (132/193) of patients. Of 10 (5.2%) total complications, most were vasospasm treated with intra-arterial verapamil (8/193, 4.1%); major complications included one dissection (1/193, 0.5%) and one perforation (1/193, 0.5%).Conclusion This multicenter study of the Monopoint reperfusion system for LVO thrombectomy outside of the SUMMIT MAX trial demonstrated a high FPE rate and a low rate of major complications.
BACKGROUND:Hospital-based violence intervention programs (HVIPs) are widespread, but their effectiveness for violence prevention is unclear. OBJECTIVE:To determine the effects of Boston Medical Center's HVIP on future violence outcomes among violently injured young adults. DESIGN:Target trial emulation using observational data. SETTING:Boston, Massachusetts. PARTICIPANTS:Young adults aged 16 to 34 years who survived a shooting or stabbing. INTERVENTION:Target trials of 2 treatment strategies using the same eligibility criteria, time zero, and control group were emulated: 1) any treatment: engaging with the HVIP within 1 month of injury and 2) sustained treatment: initiating within 1 month and engaging more than 4 of the first 8 weeks. MEASUREMENTS:Combined measure of violent reinjury or violence perpetration at 1, 2, and 3 years, using hospital and police data. RESULTS:1328 patients met criteria; 565 (42.5%) initiated within 1 month. Of these, 58 (10.2%) sustained engagement. In the any-treatment analysis, estimated cumulative incidence was roughly equal between the treatment and control strategies at 1, 2, and 3 years. In the sustained engagement analysis, treatment was associated with considerably lower cumulative incidence (4.5% [95% CI, 1.1% to 9.3%] at 1 year; 5.1% [CI, 1.1% to 9.3%] at 2 years; 6.4% [CI, 1.4% to 12.9%] at 3 years) versus the control strategy (8.7% [CI, 6.6% to 10.0%] at 1 year; 12.3% [CI, 10.2% to 14.5%] at 2 years; 14.3% [CI, 11.8% to 16.6%] at 3 years), with corresponding risk reductions of 47.6% (CI, -19.8% to 86.7%), 58.5% (CI, 21.6% to 91.2%), and 55.3% (CI, 4.9% to 90.2%). Confidence intervals were wide. LIMITATION:Despite our target trial emulation approach, results could be confounded by unmeasured factors associated with program engagement. CONCLUSION:Although HVIPs can improve long-term violence outcomes, these effects seem to require intensive participant engagement. PRIMARY FUNDING SOURCE:Fund for a Safer Future.
BACKGROUND:Patients with extensive ischaemic change are often excluded from endovascular thrombectomy. We aimed to synthesise the evidence from recent trials in these patients by performing a systematic review and individual patient data meta-analysis to estimate treatment benefit, including within clinical and imaging subgroups. METHODS:In this systematic review and meta-analysis, we searched PubMed and Embase for randomised trials published between March 1, 2018, and March 1, 2025, that evaluated efficacy and safety of endovascular thrombectomy compared with medical management in patients with large-core ischaemic stroke (based on an Alberta Stroke Program Early CT Score [ASPECTS] of ≤5 or estimated ischaemic core ≥50 mL) presenting within 24 h of onset. Individual patient-level data from all eligible trials were obtained. A central imaging core laboratory readjudicated ASPECTS and reanalysed ischaemic core volume. A two-stage meta-analysis with random-effects model was used to evaluate the distribution of 90-day modified Rankin Scale (mRS) scores (the primary outcome) using adjusted pooled generalised odds ratios (aGenORs). Missing data were handled by multiple imputation. Safety outcomes were all-cause mortality within 90-day follow-up and neurological worsening within 24-48 h of randomisation, reported as adjusted pooled relative risk (aRR); and symptomatic intracerebral haemorrhage within 36 h of randomisation (reported as risk difference). Subgroup analyses based on clinical and imaging characteristics were done, including subgroups defined by ischaemic core volume, ASPECTS, and time window from onset to randomisation. The meta-analysis was registered with PROSPERO (CRD420251058584). FINDINGS:We included 1886 patients (944 assigned to endovascular thrombectomy and 942 assigned to medical management) from six trials. Baseline characteristics were similar between treatment groups. At day 90, the distribution of mRS scores was improved in patients in the endovascular thrombectomy group (median score 4 [IQR 3-6]; n=940) versus those in the medical management group (5 [4-6]; n=931; aGenOR 1·63 [95% CI 1·42-1·88], p<0·0001). The endovascular thrombectomy group also had reduced mortality (292 [31·1%]) compared with the medical management group (347 [37·3%]; aRR 0·82 [95% CI 0·70-0·97], p=0·022). No significant differences were observed in symptomatic intracranial haemorrhage (ten [1·1%] of 944 vs nine [1·0%] of 942 patients; pooled unadjusted risk difference -0·17 percentage points [95% CI -1·01 to 0·67], p=0·69) or neurological worsening (197 [22·0%] of 896 patients vs 161 [17·9%] of 899; aRR 1·19 [0·87-1·62], p=0·27). Improved functional outcomes with endovascular thrombectomy were consistent across clinical and imaging subgroups, except for those with an estimated ischaemic core volume of 150 mL or greater, in whom point estimates favoured endovascular thrombectomy, particularly in the early time window (0-6 h), but wide 95% CIs limited interpretation. INTERPRETATION:Endovascular thrombectomy was associated with improved functional outcomes and reduced mortality versus medical management in patients with large-core ischaemic stroke presenting within 24 h of onset. With the exception of very extensive ischaemic changes (core volume ≥150 mL) presenting beyond 6 h, where evidence remains limited, benefit was sustained across ASPECTS and ischaemic core strata for patients presenting up to 24 h after onset. FUNDING:None.
