The University of Maryland Medical System (also known as UMMS) is a private, not-for-profit corporation founded in 1984 and based in Baltimore, Maryland. It owns and operates 13 hospitals (as of 2018) in Maryland, and has more than 2,500 licensed beds, 122,300 annual admissions and gross patient revenues of $4.4 billion annually. UMMS physicians and care teams work with University of Maryland School of Medicine specialists to provide primary and specialty care at more than 150 locations across the state, including a network of academic, community and specialty hospitals..
Background Collateral circulation influences clinical outcomes in patients with acute ischemic stroke due to anterior circulation large-vessel occlusion (LVO). While both arterial and venous collateral assessments on single-phase computed tomography angiography (CTA) have prognostic value, they have traditionally been evaluated independently. Purpose We developed the CTA Collateral Impairment Score (CCIS), a composite measure incorporating arterial (Tan) and venous (Cortical Venous Opacification Score (COVES)) scores, and investigated its association with 90-day functional outcomes. Materials and methods We conducted a retrospective cohort study including 1080 patients with anterior circulation LVO stroke across four comprehensive stroke centers. Patients were assigned a CCIS of 0 (preserved), 1 (moderate impairment), or 2 (severe impairment) based on predefined thresholds for Tan and COVES scores. Results Favorable outcomes (modified Rankin Scale (mRS) score 0-2) occurred in 66% of patients with CCIS 0, 32% with CCIS 1, and 17% with CCIS 2 (P<0.001). Mortality increased with higher CCIS (11%, 25%, and 36% for CCIS 0, 1, and 2 respectively; P<0.001). In multivariable models, CCIS 0 and 1 were independently associated with greater odds of favorable outcomes compared with CCIS 2 (adjusted odds ratio (aOR) 5.77 (95% confidence interval (CI), 3.78 to 8.82) and 1.72 (95% CI, 1.14 to 2.60), respectively). CCIS also predicted mortality (aOR for CCIS 0 vs 2: 0.39 (95% CI, 0.25 to 0.61); P<0.001). The predictive performance of CCIS (area under the curve (AUC) 0.73) exceeded that of the Alberta Stroke Program Early CT Score (ASPECTS) and occlusion site and approximated National Institutes of Health Stroke Scale (NIHSS); inclusion of CCIS improved multivariable model discrimination (AUC 0.84). Conclusion CCIS, a composite arterial and venous collateral score derived from single-phase CTA, was strongly and independently associated with 90-day outcomes in anterior circulation LVO stroke. Its integration into acute stroke imaging assessment may improve risk stratification and guide therapeutic decisions.
BACKGROUND:Hydrocephalus is commonly treated using invasive surgical shunt placement with associated morbidity and frequent revision in children. The eShunt System, an endovascular miniature transdural shunt implanted via the inferior petrosal sinus (IPS), has shown promise in adults, but its pediatric application remains undefined because of limited data on IPS and cerebellopontine angle cistern (CPAC) morphometry. MATERIALS AND METHODS:Consecutive patients from two pediatric hospitals with high-resolution brain MRI were retrospectively analyzed. IPS and CPAC measurements were evaluated against adult anatomical criteria for safe implantation (IPS size ≥2 mm, IPS angle <150, and ≥5 mm distance from the dural access point to the brainstem or major artery). Regression analyses assessed the relationship between age and IPS/CPAC measurements. RESULTS:One hundred patients were included: 20 toddlers (1-2 years), 24 preschool age (3-5), 27 school age (6-11), and 29 adolescents (12-18). Median IPS size was 2.8 mm (2.4-3.3 mm) and 2.8 (2.5-3.4 mm) while median CPAC depth was 7.6 mm (5.6-9.0 mm) and 6.8 mm (5.5-8.5 mm) for the right and left side, respectively. While younger age was associated with smaller IPS diameter (P<0.001 for both), the correlation was weak (R² = 13.9% and 13.5% for right and left, respectively). Age was not associated with differences in other metrics after multivariable adjustments. Endovascular shunt placement was deemed feasible based on adult criteria in 67% of patients, with no age-based differences in eligibility (P=0.57). CONCLUSION:A majority of patients over 1 year of age met IPS and CPA anatomical criteria for placement of the eShunt System.
BACKGROUND:Although there are data describing the onset of neurocognitive toxicity following radiation for patients with brain metastases, less is known about the potential for functional cognitive recovery (CR). This study sought to evaluate CR following neurocognitive function failure (NCF) in patients treated with stereotactic radiosurgery (SRS), whole-brain radiotherapy (WBRT), and hippocampal avoidance (HA)-WBRT. METHODS:A pooled analysis of 3 (NCCTG N107C/CEC.3, NCCTG N0574, and NRG CC001) clinical trials was performed. Patients with trial-defined NCF and longitudinal cognitive testing were included. The primary endpoint was time to CR, defined as patients no longer exhibiting a 1 or more standard deviation decline from baseline on any cognitive test. RESULTS:A total of 288 patients were included, with a median follow-up of 12.2 months. The cumulative incidence of CR was 38% (95% confidence interval [CI] = 32.5% to 43.9%) at 6 months after NCF. Incidence of CR was significantly improved with post-op SRS vs WBRT (hazard ratio [HR] = 2.68, 95% CI = 1.43 to 5.03, P = .002) and with SRS vs SRS+WBRT (HR = 2.35, 95% CI = 1.16 to 4.79, P = .008). On multivariable analysis, SRS was highly prognostic of CR compared with WBRT (HR = 2.42, 95% CI = 1.70 to 3.45, P < .0001). Meta-analysis demonstrated that conformal RT techniques (SRS or HA-WBRT) conferred a significantly higher rate of CR compared with WBRT (pooled HR = 2.12, 95% CI = 1.49 to 3.02, P < .001); 68% of patients had long-term sustained CR. CONCLUSIONS:A sizeable proportion of patients who experience NCF following brain radiation eventually attain full and sustained CR, thereby highlighting that neurocognitive decline may not be permanent. The use of conformal radiation techniques results in greater rates of neurocognitive recovery.
BACKGROUND:Respiratory illness is the most frequent reason for unnecessary antibiotic use among hospitalized adults. In randomized trials, procalcitonin and respiratory virus testing without guidance on test interpretation do not influence antibiotic decision-making. METHODS:We conducted a pragmatic, randomized, controlled trial of antimicrobial stewardship-guided test interpretation versus usual care among hospitalized adults receiving antibiotics for suspected respiratory infection with either low procalcitonin or positive respiratory virus testing at 2 hospitals. The intervention involved a templated note in the electronic health record interpreting test results in terms of the post-test probability of bacterial pneumonia and antibiotic decision-making. When probability of bacterial pneumonia was low, discontinuation of antibiotic therapy was recommended. The primary outcome was in-hospital antibiotic days of therapy. RESULTS:Between 1 November 2023 and 10 January 2025, 107 adults were enrolled, including 65% with low procalcitonin, 30% with positive respiratory virus testing, and 5% with both. The intervention decreased antibiotic use by an average of 4.1 in-hospital days of therapy (7.5 versus 11.6, P = .006). All respiratory antibiotics were discontinued within 5 days of initiation for 76% of intervention patients versus 49% with usual care (P = .004). Length of stay (5.5 days intervention versus 6.6 days usual care, P = .16) and 30-day readmission (7% intervention versus 19% usual care, P = .079) did not significantly differ between groups. CONCLUSIONS:In this proof-of-concept study, antimicrobial stewardship-guided interpretation of laboratory tests for viral infection using a simple template safely decreased unnecessary antibiotic use for hospitalized adults with community-acquired respiratory illness. Clinical Trial Registration. NCT05976581.
No targeted therapy combinations have achieved regulatory approval for the treatment of biomarker-positive resistance in non-small cell lung cancer (NSCLC). Given the widespread availability of next-generation sequencing (NGS) to detect resistance, we reviewed the real-world experience of using off-label targeted therapy combinations to treat advanced NSCLC at our academic safety-net hospital. Pharmacy records from the Hematology/Oncology Department at Boston Medical Center during the years 2017 to 2024 were reviewed. One hundred eleven patients received oral, targeted therapy during this time. Our study focused on those patients who received an off-label combination of targeted therapies for advanced NSCLC. We reviewed their demographics, treatment history, molecular data, and published evidence to support the combination. Eight patients were treated with nine combination regimens. The median age was 69 years (age 29–89 years). Six patients had EGFR exon 19 deletions and two had EML4-ALK fusions. The nine combination regimens included addition of a MET inhibitor (n = 3), a RET inhibitor (n = 2), a MEK inhibitor (n = 2), an ALK inhibitor (n = 1), and an EGFR antibody (n = 1). The median duration of treatment was 7 months (range: 1–35 months), and was longest for alectinib and capmatinib (15 months ongoing and 25 months, ongoing) and gefitinib and selpercatinib (35 months, ongoing). Available supporting evidence included retrospective cohort studies (n = 5), published case reports/series (n = 2), and a prospective cohort study (n = 1). Off-label combination therapy to treat targeted therapy resistance in advanced NSCLC is feasible in routine clinical practice. Additional real-world evidence is needed to clarify best practices with this emerging approach.
