The cornea and cranial dura mater share sensory innervation. This link raises the possibility that pathological impulses mediated by corneal injury may be transmitted to the cranial dura, trigger dural perivascular/connective tissue nociceptor responses, and induce vascular and stromal alterations affecting dura mater blood and lymphatic vessel functionality. In this study, using a mouse model, we demonstrate for the first time that two weeks after the initial insult, alkaline injury to the cornea leads to remote pathological changes within the coronal suture area of the dura mater. Specifically, we detected significant pro-fibrotic changes in the dural stroma, as well as vascular remodeling characterized by alterations in vascular smooth muscle cell (VSMC) morphology, reduced blood vessel VSMC coverage, endothelial cell expression of the fibroblast specific protein 1, and significant increase in the number of podoplanin-positive lymphatic sprouts. Intriguingly, the deficiency of a major extracellular matrix component, small leucine-rich proteoglycan decorin, modifies both the direction and the extent of these changes. As the dura mater is the most important route for the brain metabolic clearance, these results are of clinical relevance and provide a much-needed link explaining the association between ophthalmic conditions and the development of neurodegenerative diseases. Cranial dura mater (DM), a highly innervated and vascularized outermost meningeal layer, represents the most important site for the brain venous blood and cerebrospinal fluid (CSF) outflow. Compromised dura vascular integrity within both blood and lymphatic vessels conceivably contributes to the development of neurological disorders through the impairment of the brain metabolic waste clearance and alteration of homeostatic functions –3. The iAnatomical studies have shown that dura mater vasculature receives sensory innervation from the trigeminal nerve originating from the ophthalmic part of the trigeminal ganglion (TG) , which aAccording to several studies, a link between ophthalmic conditions (including cataract and diabetes-related eye disease) and cognitive impairment have been suggested . Shang XThe underlying hypothesis for the present study is that pathological events occurring in the cornea can impact distant vascular cells and the extracellular matrix (ECM) within dura mater blood and lymphatic system. Here, we investigated whether injury to the cornea and/or changes in ECM composition (decorin knockout) can induce alterations within pachymeningeal tissue harboring, in addition to blood and lymphatic vessels, mast cells, resident macrophages, and mesenchymal stem cells, as such alterations can potentially lead to compromised microvascular integrity and local immune homeostasis thus creating the background for the development of neurodegenerative conditions.-/-) mice, generated as previously described [-/- female mice were subjected to cornea alkali injury to investigate whether this injury could be associated with distant changes within cranial dura mater two weeks after initial insult. For this study, animals were divided into four groups: WT naive, 5 mice; WT with cornea injury (WT injury), 5 mice; Dcn-/-, 6 mice; and Dcn-/- with cornea injury (DCN-/- injury), 5 mice. The size of experimental groups was determined based on our previous experiences and Power Analysis. WT naïve animals, which did not have any genetic modifications and did not undergo any procedures, were used as control for all other groups.In this study, C57BL/6J wild type (WT) from Jackson Laboratory  and decorin-deficient  index. PDPL-positive lymphatic sprouts were counted by two independent observers in all photomicrographs followed by discussing and reaching a consensus on all sprouts in question. LV index was determined by creating a point array graticule using the Grid tool of ImageJ2 software and calculating the number of grid points that hit PDPL+ vessels. FSP1 and α-SMA positivity were used as the markers of activated fibroblasts. This choice was based on several studies that confirmed FSP1 and α-SMA as markers for post-injury activated fibroblasts [Two weeks after corneal injury mice were sacrificed with CO2 inhalation. Immediately following sacrifice, the chest cavity was opened, and the entire body of the mouse was perfused through the heart with 1 ml of Kreb’s/BSA containing 20 μg/ml AlexaFluor 594-conjugated wheat germ agglutinin (WGA) lectin  and AlexaFluor 488-conjugated anti-mouse LYVE1  antibody  to identify blood microvessels and lymphatic structures respectively . Dorsal roblasts –19 showi+ sprout and LYVE1+ cell counts in each individual sample.One-way analysis of variance (ANOVA) with Tukey post hoc test were used for statistical analysis. The data were expressed as fold change in fluorescence intensity compared with control. GraphPad Prism 9  software was used for statistical analysis and p ≤ 0.05 was used as the level of significance. See -/- mice. As WGA lectin is used to detect blood vessel endothelial cells and α-SMA to detect vascular smooth muscle cells, this implies that no major changes in the overall vascular density of the investigated dura regions occurred within two weeks of the initial insult.In our experiments, two weeks post corneal injury, we did not detect statistically significant changes in WGA lectin- or α-SMA-associated fluorescence in the investigated dura mater areas in either WT or DCN-/- mice  modify these responses.In this study, we investigated select aspects of the late  responses of fibrous dura mater connective tissue and meningeal vascular system to alkaline corneal injury in WT and DCNIt has been shown that alkaline corneal injury can stimulate inflammation propagating to the trigeminal ganglion (TG) through the cornea-trigeminal axis . This ea-/- animals  than WT animals  cells  to myofi animals .-/- mice FSP1 responses within dura stroma two weeks following cornea injury were blunted compared with WT mice. However, morphological changes within blood vessel walls were more evident in DCN-/- animals  was challenged by the alkaline injury, the stromal and vascular changes in DM were not ipsilateral and two weeks post injury were detected on both sides. Mechanistically, the described dural responses to corneal injury depend on ECM composition (DCN expression). While these results may have important clinical implications, the study itself has some limitations. Only female animals were used, so whether there are any sex differences in these responses could not be established. Also, only one time point (2 weeks post injury) was investigated. Further longitudinal studies will be performed to investigate more immediate dural responses to corneal injury as well as long term consequences to find out whether these changes are permanent or resolve over time similar to changes in DM lymphatics following traumatic brain injury [In summary, this study demonstrates for the first time that two weeks post initial insult alkaline corneal injury induces pathological processes in CS area of mouse dura mater manifested by significant pro-fibrotic changes in dural stroma, vascular remodeling characterized by alterations in VSMC morphology, reduced blood vessel wall VSMC coverage and endothelial cell FSP1 expression, as well as significant increase in the number of PDPLn injury . Also, iS1 FigRepresentative immunofluorescence images of FSP1 expression from investigation area 3 taken with 20x objective. Note significantly elevated stromal FSP1 expression in WT injury group (B) compared with WT naïve (A), DCN-/- (C) and DCN-/- injury (D) animals. Also note endothelial  FSP1 expression in WT injury (B) and DCN-/- injury mice two weeks post initial insult. Area marked with the white square in D was imaged using 40x objective (see (PDF)Click here for additional data file.S2 FigRepresentative immunofluorescence images of PDPL expression from investigation area 3 taken with 20x objective. While there was no statistically significant difference between the groups in the overall PDPL expression, there was a significant increase in PDPL+ lymphatic vessel index in WT injury (B) group compared with WT naïve animals (A), as well as the number of PDPL+ lymphatic sprouts in WT injury (B) and DCN-/- (C) groups, but not in DCN-/- injury (D) mice compared with WT naïve (A) mice (see (PDF)Click here for additional data file.S3 FigRepresentative immunofluorescence images of α-SMA expression from investigation area 3 taken with 20x objective. Note the loss of VSMC coverage of the blood vessels (white arrows) and acquisition of bead-like morphology by VSMCs (white asterisk). Area marked with the white square in D was imaged using 40x objective (see (PDF)Click here for additional data file.S1 File(XLSX)Click here for additional data file.


ERBB2-amplified mucinous ovarian carcinoma  who underwent optimal secondary cytoreduction followed by 6 cycles of carboplatin/paclitaxel/trastuzumab and 1-year maintenance trastuzumab. This patient remains without radiologic or biochemical evidence of disease for more than 3 years after secondary cytoreduction. This case supports routine assessment of HER2 status in patients with advanced or recurrent mucinous ovarian carcinoma and highlights the potential of HER2-targeted therapy with trastuzumab in combination with standard carboplatin and paclitaxel in this disease. This case also raises the possibility that expansile mucinous ovarian carcinomas with ERBB2 amplification and p53 mutant immunohistochemical staining pattern (as this patient had) may be associated with a more aggressive behavior and higher risk of relapse.Patients with advanced stage or recurrent mucinous ovarian carcinoma exhibit poor response to standard platinum- and taxane-based chemotherapy and poor prognosis. We report a 29-year-old patient with recurrent  Trastuzumab is a humanized monoclonal antibody against HER2 that was first approved by the Food and Drug Administration in HER2 overexpressing metastatic breast cancer either as a single agent in women who have received one or more chemotherapy regimens or in combination with paclitaxel for first-line treatment. It is also FDA approved for HER2 overexpressing gastric cancers in combination with cisplatin and capecitabine or 5-fluorouracil. Pan-cancer analyses show that this oncogenic driver event is found in up to 3.4% of all human solid cancers, which has led to increased interest in expanding the usage of trastuzumab beyond these tumor types . Her family history included a father diagnosed with a kidney tumor at age 63, a maternal grandmother diagnosed with breast cancer at age 68, a paternal grandfather diagnosed with prostate cancer and a paternal grandmother diagnosed with a brain tumor.Molecular profiling of the ovarian tumor was performed using a targeted 447 gene next generation sequencing panel, as previously described . SequencERBB2 amplification (estimated copy number 41) and KRAS p.G12D with a more complex array of copy number alterations compared to the prior testing including chromosomal level loss of chromosome 9, and arm level loss of chromosome 17p including the TP53 locus.Post-surgical CA125 was 97 U/mL . She received 3 cycles of adjuvant capecitabine/oxaliplatin with nadir CA125 of 18 U/mL. Follow up CT abdomen pelvis 5 months after completion of chemotherapy showed increase in size of the left ovary with pelvic peritoneal nodularity and free fluid, concerning for metastatic recurrence. CA125 at that time was 249 U/mL. Exploratory laparotomy revealed free fluid in the pelvis and mucinous implants diffusely involving the left round ligament, anterior cul-de-sac, posterior wall of the uterus and both uterosacral ligaments. Biopsies were obtained and showed metastatic mucinous adenocarcinoma involving the left ovary, rectosigmoid colon and uterus. Immunohistochemistry demonstrated diffuse basolateral positivity for HER2 B and intOptimal secondary cytoreductive surgery including total abdominal hysterectomy and left salpingo-oophorectomy was performed. Post-operative CA125 was 23 U/mL. She received 6 cycles of carboplatin, paclitaxel and trastuzumab followed by 1 year of maintenance trastuzumab. CA125 was stable at 12–14 U/mL following initial chemotherapy. She remains without radiologic or biochemical evidence of disease more than 3 years after secondary cytoreduction (2 years after completion of trastuzumab maintenance). This patient consented to allow discussion of her case and inclusion of pertinent images in this report.3ERBB2-amplified mucinous ovarian adenocarcinoma following optimal secondary cytoreduction and carboplatin/paclitaxel/trastuzumab followed by one year of maintenance trastuzumab. This study highlights the therapeutic potential of HER2-directed therapies specifically in mucinous ovarian carcinomas. Trastuzumab monotherapy or combinations of trastuzumab with carboplatin or weekly paclitaxel or lapatinib as single agents have been previously reported in patients with recurrent ERBB2-amplified or overexpressing recurrent mucinous ovarian carcinomas but responses in all these cases were relatively short in duration  (We describe durable remission in a 29-year-old woman with recurrent metastatic duration . To our (18–26%) , the potERBB2 amplification may be associated with a more aggressive behavior in the setting of an expansile growth pattern; further studies are needed to answer this question.At initial resection, this patient had an expansile mucinous carcinoma, with surface ovarian involvement and positive pelvic wash cytology (FIGO stage IC3). National Comprehensive Cancer Network (NCCN) guidelines (which do not incorporate the distinction between expansile vs infiltrative pattern of invasion) suggest monitoring or chemotherapy in this setting while the ESMO-ESGO guidelines (which incorporate the distinction between expansile vs infiltrative pattern of invasion) suggest that adjuvant chemotherapy is optional for stage IC3, expansile mucinous ovarian carcinomas. Determining when to opt for systemic therapy for these patients can be driven by multiple factors, in particular the histologic pattern of invasion (expansive vs infiltrative). Prior studies suggest a recurrence rate of 3–4% in patients with stage I disease and expansile histology as opposed to 15–30% with stage I disease and infiltrative histology . In thisERBB2-amplified mucinous ovarian carcinomas).One of the few mucinous ovarian carcinoma-specific randomized controlled trials compared the efficacy of capecitabine/oxaliplatin versus paclitaxel/carboplatin plus or minus bevacizumab . Preliminary results based on a limited number of patients showed no significant differences between objective response rate in the experimental arms and the trial was ultimately halted due to poor accrual . GOG 241MUTYH p.G396D germline alteration. MUTYH encodes a DNA glycosylase involved in the repair of mismatched adenines incorporated opposite damaged 8-hydroxyguanine during DNA replication. This variant is annotated as pathogenic in ClinVar (VCV000005294.90) and is associated with familial adenomatous polyposis 2, an autosomal recessive cancer predisposition syndrome characterized by multiple colorectal adenomas and an increased risk of colorectal cancer, urinary bladder cancer and ovarian cancer  in our patient’s tumor suggest biallelic MUTYH deficiency was likely not a distinctive driver of her mucinous ovarian carcinoma. However, the role of her carrier status with regard to her overall risk of developing this tumor is uncertain.Of note, our patient possesses a germline n cancer  (OMIM #6n cancer . There hERBB2 amplification, suggesting that evaluation for these alterations may be useful to guide clinical decision making. Proposed scoring algorithms exist for immunohistochemical assessment of these alterations with high levels of genetic concordance (ERBB2-amplified tumors.This case raises multiple lingering questions regarding the management of patients with mucinous ovarian carcinoma, including the role of HER2-targeted therapy in the treatment of advanced stage disease, the ideal management and prognostication of patients with stage IC disease, and the genetic and environmental risk factors specific to mucinous ovarian tumors. From a precision oncology standpoint, two molecular alterations in this patient’s tumor impacted the course of her care – the finding of p53 mutant immunohistochemistry after initial resection and the cordance  but havecordance  and bothcordance , it will4Informed consent was obtained from the patient for discussion of her case in this report.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Differential methylation of imprinting control regions in mammals is essential for distinguishing the parental alleles from each other and regulating their expression accordingly. To ensure parent of origin-specific expression of imprinted genes and thereby normal developmental progression, the differentially methylated states that are inherited at fertilization must be stably maintained by DNA methyltransferase 1 throughout subsequent somatic cell division. Further epigenetic modifications, such as the acquisition of secondary regions of differential methylation, are dependent on the methylation status of imprinting control regions and are important for achieving the monoallelic expression of imprinted genes, but little is known about how imprinting control regions direct the acquisition and maintenance of methylation at these secondary sites. Recent analysis has identified mutations that reduce DNA methyltransferase 1 fidelity at some genomic sequences but not at others, suggesting that it may function differently at different loci. We examined the impact of the mutant DNA methyltransferase 1 P allele on methylation at imprinting control regions as well as at secondary differentially methylated regions and non-imprinted sequences. We found that while the P allele results in a major reduction in DNA methylation levels across the mouse genome, methylation is specifically maintained at imprinting control regions but not at their corresponding secondary DMRs. This result suggests that DNA methyltransferase 1 may work differently at imprinting control regions or that there is an alternate mechanism for maintaining methylation at these critical regulatory regions and that maintenance of methylation at secondary DMRs is not solely dependent on the methylation status of the ICR. Parent of origin-specific DNA methylation at imprinting control regions (ICRs) is established during gametogenesis, inherited at fertilization, maintained throughout development, and serves as the primary imprinting mark; as such, it is responsible for distinguishing the parental alleles from each other and regulating their expression accordingly  promoter  that function as ICRs and are essential for regulating imprinted expression, some imprinted genes also acquire distinct regions of differential methylation during post-implantation development . Acquisipromoter , highligpromoter .Despite the demonstrated importance of differential methylation at secondary DMRs in the regulation of the individual imprinted genes with which they are associated, DNA methylation is less consistent at secondary DMRs than at primary DMRs . Investide novo methyltransferases while Dnmt1 functions as the maintenance methyltransferase . Dnmt3a and Dnmt3b function as nsferase . Dnmt1 pc lethal . Dnmt1 hc lethal . Mutatioce versa . These mce versa .Dnmt1 P allele. The P allele is a mutation in the mouse Dnmt1 IDD that replaces six codons with the corresponding rat sequence . Natural matings were also used to generate offspring in order to maintain the Dnmt1 P allele in the colony. Ethical approval for procedures involving animals was granted by the Bryn Mawr College Institutional Animal Care and Use Committee, PHS Welfare Assurance Number A3920-01.Sv/129 mice heterozygous for the mutation  were obtet al. . Chi-square goodness of fit tests were conducted in Microsoft Excel, using the raw number of Dnmt1+/+, Dnmt1P/+ and Dnmt1P/P embryos or pups collected at each developmental stage, to determine whether the observed values deviated significantly from the Mendelian ratios expected from crosses between heterozygous pairs.Genotypes were determined using a PCR-based assay described by Shaffer et al. . BrieflyGenomic DNA was isolated from 9.5, 12.5, 15.5 and 18.5 dpc embryo heads following proteinase K digestion and a series of phenol/chloroform extractions as described previously . PurifieDnmt1+/+ and Dnmt1P/P embryos was ranked and assessed for statistically significant differences using a Mann-Whitney U test (http://vassarstats.net/utest.html).Downsampling of NGS data was performed using Galaxy tools to obtain 20–25 sequencing reads for each locus analyzed. Percent methylation for each strand was calculated and the raw data from each allele in et al.   . The Dnm. Rattus .Dnmt1 P allele have dramatically reduced levels of global methylation but methylation was observed to be better maintained at primary DMRs associated with imprinted genes , and further illustrated that methylation was generally well maintained across the sequences analyzed , with inconsistent methylation remaining . Cmtm4 displayed a dramatic and dispersed loss of methylation in Dnmt1P/P embryos . Overall, these data suggest that methylation is poorly maintained across loci in Dnmt1P/P embryos rather than lost entirely from specific sequences.The lower levels of DNA methylation observed in  embryos . Methylade novo and maintenance methylation, with Dnmt1 primarily functioning as the maintenance methyltransferase and de novo methylation resulting from the activity of Dnmt3a and Dnmt3b , we fouDnmt3a/b , mutant Dnmt3a/b . FailureDnmt1 P allele has dramatically different effects at different loci within the mouse genome. This mutation is located within an N-terminal intrinsically disordered domain that interacts with at least 8 different proteins that may play roles in regulating Dnmt1 activity both broadly and at specific sequences . Additional analyses will be necessary to further test this hypothesis.Given the dispersed pattern of methylation at imprinted and non-imprinted loci in Dnmt1P/P mice, embryonic development appears to progress relatively normally although Dnmt1P/P individuals are unable to survive after birth, presumably as a consequence of altered gene expression patterns. While DNA methylation at promoters correlates with gene silencing (Despite the dramatic loss of global methylation in ilencing , the preilencing , but in


Active extravasation into the upper aerodigestive tract is a dramatic and potentially life-threatening complication in patients with head and neck cancers. It prompts presentation to the emergency room and subsequent urgent imaging to identify the source of hemorrhage. Imaging of these patients may be complicated by treatment-altered anatomy, posing a challenge to the emergency radiologist who needs to rapidly identify the presence of active hemorrhage and the potential source vessel. This retrospective review summarizes the clinical and imaging findings of 6 oropharyngeal and oral cavity squamous cell cancer (SCC) patients with active upper aerodigestive tract hemorrhage. Most patients had advanced stage disease and prior radiation therapy. All CECT or CTA exams on presentation demonstrated the “dot-in-sludge” sign of active extravasation, as demonstrated by a “dot” of avidly enhancing extravasated contrast material layered against a background “sludge” of non-enhancing debris in the lumen of the upper aerodigestive tract. Common sources of hemorrhage included the lingual, facial, and superior thyroidal arteries. Familiarity with these findings will help radiologists increase their accuracy and confidence in interpreting these urgent, complex examinations. Oropharyngeal and oral cavity squamous cell cancers (SCCs) affect over 54,000 new patients yearly in the USA . RadiothGiven the inherent complexities of treatment-altered head and neck anatomy as well as the potential presence of tumor and radiation necrosis, interpretation of these exams may seem intimidating to any radiologist, especially when under the pressures of an emergent setting. The goal of this paper is to familiarize radiologists with characteristic findings of active aerodigestive tract hemorrhage and relevant external carotid artery (ECA) anatomy, so that one could accurately and rapidly detect the presence and source of hemorrhage.Knowledge of ECA branch anatomy is important for patients with aerodigestive tract hemorrhage to detect the source of hemorrhage and to improve communication with surgeons and interventionalists Fig. . The firAn IRB-approved, HIPAA-compliant retrospective search of neck CECT and CTA reports from the past 15 years from a tertiary academic center was conducted. Patients with prior head and neck cancer suspected to have active hemorrhage in the upper aerodigestive tract on imaging were identified. Exclusion criteria included hemorrhage in the thoracic trachea, esophagus, or elsewhere in the neck. Patient imaging and medical records were reviewed to characterize imaging findings of active hemorrhage and key clinical features.Six patients with head and neck SCC were identified Table . Five paAll six patients were hospitalized, and five required transfusions. Active extravasation was visualized on imaging at the site of either the primary tumor or adjacent radiation field. Three patients required embolization, while three self-resolved after packing. The facial or lingual arteries were primary sources of suspected active extravasation.A 67-year-old male with a history of T3N1 right base of tongue (BOT) oropharyngeal SCC presented with hemoptysis 6 months after completion of treatment. CTA demonstrated hypoattenuating intraluminal debris in the right oropharynx with a focus of contrast enhancement, compatible with active hemorrhage, contiguous with an irregular right facial artery branch Figs.  and 3. AA 54-year-old male with a history of recurrent left oropharyngeal SCC presented with hemoptysis after incomplete radiation therapy 3 months prior. CECT showed a necrotic left oropharyngeal mass with signs of active hemorrhage adjacent to an irregular left lingual artery Fig. . PatientA 77-year-old female with a history of T3N1 right tonsillar SCC treated with surgery and CRT 28 years prior presented with hemoptysis. CECT neck demonstrated a recurrent right oropharyngeal mass, active hemorrhage in the oral cavity and oropharynx, and irregularity of the right ECA and lingual arteries Fig. .Fig. 8PaA 64-year-old female with a history of T2aN3b oral cavity SCC of the right retromolar trigone (RMT) presented with hematemesis 1 week after undergoing surgical resection and reconstruction. CECT demonstrated active hemorrhage in the right oropharyngeal lumen, near the presumed anastomotic site at the posteroinferior flap margin Fig. . While tA 67-year-old male with a remote history of laryngeal SCC treated with total laryngectomy and CRT developed a right BOT anastomotic site recurrence 15 months prior and presented with fever and epistaxis while on CRT. CECT showed a recurrent tumor at the BOT with a pharyngocutaneous fistula Fig. . An areaA 71-year-old male with a history of T4N2B right oropharyngeal SCC, originally treated 9 years prior with CRT, developed recurrent disease in the right BOT which was treated with surgery one year prior. The patient presented with hematemesis, and CECT showed recurrent tumor in the BOT and contralateral left hypopharynx, with active contrast extravasation in the left piriform sinus which subsequently self-resolved Fig. . Repeat Active extravasation into the upper aerodigestive tract is a potentially life-threatening complication in patients with treated or recurrent head and neck cancers. Existing literature is limited to case reports and focuses on its treatment and management rather than imaging diagnosis –7. In thAlthough active extravasation can be identified on both CECT and CTA, CTA is the modality for detecting its source , 9. CaseIn the setting of head and neck cancer, vascular complications occur most commonly due to radiation vasculopathy or invasion by hypervascular, friable tumor –12. In tAccurate rapid detection of upper aerodigestive tract extravasation is critical in both preventing further deterioration of an unstable patient and localizing the source vessel as a potential treatment target. This is especially important in advanced stage oropharyngeal and oral cavity SCC patients who are at higher risk of having this complication. The “dot-in-sludge” sign, indicating active contrast extravasation against a background of non-enhancing blood products and debris, is an emergent imaging finding that should alert radiologists of a nearby source vessel. Familiarity with ECA branch anatomy is crucial to help detect the source of hemorrhage and guide further treatment decision-making.


Stent thrombosis, a life-threatening complication of percutaneous coronary intervention (PCI) continues to occur despite effective antiplatelet regimens and improved stenting methods. Noncompliance with dual antiplatelet therapy is the most common etiology; however, in spite of timely and their optimum administration the rates of recurrent myocardial infarction (MI) and stent thrombosis remain high. Clopidogrel resistance is increasingly evoked with elevated risk of anterothrombotic events particularly in the setting of stent implantation. In this case report, we present a case of subacute stent thrombosis associated with clopidogrel resistance in a resource-constrained setting.A 60 year old man with a long standing history of hypertension presented with a 6-month history of progressive shortness of breath. Initial electrocardiogram (ECG) revealed T-wave inversion on lateral leads and echocardiogram revealed akinetic basal lateral wall and hypokinetic mid lateral wall with reduced systolic functions. An elective coronary angiography (CAG) revealed a 90% stenosis of mid left anterior descending (LAD) artery and an 80% stenosis on the proximal left circumflex artery. He underwent a successful PCI with a drug-eluting stent implantation to mid LAD. He was discharged in a stable state 48 h post revascularization with dual antiplatelet . Seven days later, he presented with a crushing substernal chest pain. Cardiac enzymes were elevated and ECG revealed anterior ST-elevation MI. An emergency CAG revealed a high thrombus burden with 100% occlusion of mid LAD. Following unsuccessful ballooning, intravenous and intracoronary thrombolysis with tenecteplase was given. A TIMI II flow was achieved and the patient was sent to the coronary care unit. However, 14 h later there was yet a new onset of severe chest pain. A 12-lead ECG previewed anterior ST-elevation MI and the cardiac enzymes were high. Urgent CAG revealed in-stent thrombotic total occlusion of mid LAD. A stent in stent was then implanted and TIMI III flow was restored. Clopidogrel resistance was suspected and the patient was transitioned to ticagrelol. There were no further ischemic events during the remainder of hospitalization and the patient was discharged in a hemodynamically stable state three days later. During follow-up after one and three months, he was fairly stable without any further cardiac events.Owing to clopidogrel resistance, stent thrombosis in the setting of dual antiplatelet therapy compliance may occur. While in a situation of clopidogrel resistance newer and more potent antiplatelet drugs should be used, their availability and cost remains a significant barrier particularly in the developing world. Nonetheless, a high index of suspicion and timely revascularization is fundamental to restore patency of the thrombosed vessel and confer better risk-adjusted survival rates. Since Jacques Puel implanted the first stainless steel stent in 1986, the dramatic evolution of stents has incrementally improved prognosis following percutaneous coronary intervention (PCI) and adamantly revolutionized the management of coronary artery disease (CAD) –12 yet lDual antiplatelet therapy with acetylsalicylic acid (ASA) and clopidogrel is the cornerstone of modern pharmacotherapy for preventing aberrant platelet activation in patients undergoing coronary angioplasty with stent implantation –27. HoweA 60-year-old man of African origin from Northern Tanzania presented with a 6-month history of progressive shortness of breath (SOB). He had a 13-years history of systemic hypertension; however, he denied a family history of premature coronary artery disease (CAD). Troponin-I was 1.8 ng/ml, initial electrocardiogram (ECG) revealed T-wave inversion on lateral leads Fig.  and an 8He presented seven days following discharge with a crushing substernal chest pain and ECG at this point showed anterior STEMI, Fig. However, 14 h later there was yet a new onset of severe chest pain. A 12-lead ECG previewed anterior STEMI Fig.  and the Acute coronary syndromes (ACS) and attributable complications remain one of the most daunting challenges facing the medical fraternity across the globe. However, PCI, the commonest therapeutic procedure in contemporary medical practice has significantly improved clinical outcomes and survival prospects of ACS patients worldwide –6. In coNoncompliance with dual antiplatelet therapy is the most frequent cause of stent thrombosis; however, other factors including inadequate stent deployment, stent malapposition and unrecognized coronary dissection are usually implicated –20. RepeSimilar to many other countries in the SSA region, none of the newer antiplatelet agents  is currently licensed in Tanzania and although ticagrelol is limitedly sold in Dar es Salaam, the current cost of $236 for 30 tablets is unbearably high to most people living in such impoverished settings. With the current state where newer antiplatelet drugs are not licensed  and relatively expensive , patients like this one remain at high risk of recurrent stent thrombosis and sudden cardiac death. Furthermore, with the increasing catheterizations in the developing world, unavailability and high cost of newer antiplatelet drugs particularly in the setting of clopidogrel resistance leads to overutilization of scarce medical resources and undermines the revascularization efforts. Moreover, as a result of the extreme scarcity of interventional cardiology facilities in SSA amidst the sharp rise of ischemic heart disease (IHD) , such seOwing to clopidogrel resistance, stent thrombosis in the setting of dual antiplatelet therapy compliance may occur. While preprocedural testing for clopidogrel resistance might be of value, there is insufficient evidence to support routine screening in clinical practice. Moreover, in a situation of clopidogrel resistance newer and more potent antiplatelet drugs should be used; however, their availability and cost remains a significant barrier particularly in the developing world. Nonetheless, a high clinical suspicion and prompt revascularization measures are fundamental to restore patency of the thrombosed vessel and confer better risk-adjusted survival rates.


Balloon pulmonary angioplasty (BPA) improves hemodynamics by dilating organized thrombi using a balloon and is becoming a therapeutic method for the distal type of chronic thromboembolic pulmonary hypertension (CTEPH) . In BPA,A 46-year-old man was referred to our hospital for treatment of CTEPH with dyspnea for six months. His mean pulmonary artery pressure (mPAP) was 43 mmHg, indicating distal type of CTEPH based on pulmonary angiography. BPA was selected as the therapeutic method after administration of vasodilator. Optical coherence tomography (OCT) can reveal the precise morphology of organized thrombi [In BPA, selecting the appropriate balloon size is crucial, as using a balloon that is too small can reduce treatment efficacy while using one that is too large can lead to pulmonary hemorrhage due to over-expansion . While tInitial angiogram of target vessel (MP4 1031 kb)Angiogram of target vessel after 4.0mm balloon dilatation (MP4 445 kb)Below is the link to the electronic supplementary material.


Dolutegravir (DTG), an integrase strand transfer inhibitor is currently the recommended first and second line anti-retroviral therapy (ART) anchor agent by the World Health Organization. This followed widespread reports of primary resistance to non-nucleoside reverse transcriptase inhibitors.Despite its very good side effect profile, there have been multiple case reports of ART experienced patients developing hyperglycemia within weeks to a few months after switching to DTG preceded by weight loss. At population level, however, dolutegravir as well as other integrase inhibitors have been demonstrated to have a reduced risk of incident diabetes mellitus (T2DM) compared to other HIV drug classes.Following multiple similar reports of accelerated hyperglycemia in Uganda during the first pilot year of DTG use, the Uganda Ministry of Health recommended withholding dolutegravir in all patients who develop diabetes. Whether this recommendation should be applied to all patients with incident T2DM remains to be demonstrated.We present a clinical case of an HIV positive ART naïve man who was diagnosed with T2DM after 36 weeks on dolutegravir. We describe changes in blood glucose, glycated hemoglobin, insulin resistance and pancreatic beta cell function before and after withholding DTG. We demonstrated that he was phenotypically different from the reported cases of accelerated hyperglycemia and he continued to have worsening insulin resistance despite withholding DTG. His blood glucose improved with dietary T2DM management. It is possible he had an inherent risk of developing T2DM independent of his exposure to DTG. This put in question whether DTG should universally be withheld in PLHIV with incident T2DM in Uganda. Integrase strand transfer inhibitors (INSTIs) have been demonstrated to have reduced risk of incident type 2 diabetes mellitus (T2DM) compared to non-nucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors (PIs) in different sub-populations in two meta-analyses, [2]. ThGLucose Metabolism changes in Ugandan HIV patients on Dolutegravir, GLUMED study) evaluating glucose metabolism changes in antiretroviral therapy (ART) naïve Ugandan people with HIV (PWH) on tenofovir/lamivudine/dolutegravir (TDF/3TC/ DTG) for 48 weeks. Th. Th2]. TThe patient we present had an asymptomatic onset of glucose intolerance over 36 weeks (diagnosed on routine screening) and gained weight before diabetes diagnosis in contrast to the above group of patients. Various factors such as immune reconstitution, improved appetite as well as dolutegravir itself could have contributed to the weight gain, 13]. O. O13]. OIn conclusion, this case report suggests that dolutegravir should not be universally withheld in ART naïve PWH who develop diabetes mellitus but the decision made on a case-by-case basis. More research is however needed to ascertain these findings. This is programmatically pertinent in sub-Saharan Africa given dolutegravir is first line treatment in majority HIV programs with millions of PWH on DTG due to wide spread primary resistance to NNRTIs.


Although drug formulary restrictions may reduce use of prescription medication and pharmacy costs, the effect of patient cost sharing on medication adherence and health care utilization and cost is unclear.To evaluate the relationship between patient cost sharing for novel type 2 diabetes mellitus (T2DM) medications and medication adherence, persistence, and health care utilization and cost.This retrospective study used medical and pharmacy claims linked to pharmacy benefit plan design data. Patients with T2DM were identified via ICD-9-CM codes , outpatient prescription fills (pharmacy claims), and pharmacy benefit design information. Patients with T2DM treated with novel T2DM medications (DPP4 or GLP-1) were enrolled in plans with fixed or coinsurance medication copayment structures and followed for 12-48 months. Endpoints included medication persistence and adherence and total all-cause health care cost. Multivariable regression analysis estimated the effect of benefit design parameters, adjusting for baseline patient characteristics.The integrated database included 36,475 patients with T2DM. The majority (83.1%) had fixed copayment plans, and 3-tier plans were common (93.1%). Higher third-tier copayment was associated with poorer medication adherence and persistence but not total health care cost during follow-up. A $10 higher third-tier copayment was associated with 11% greater risk of novel T2DM medication discontinuation and 3% lower adherence. A comparison of patients with fixed versus coinsurance plans found that fixed plans were associated with higher adjusted persistence and total all-cause health care costs.Higher medication copayment amounts were associated with lower patient medication adherence and persistence in T2DM but not total health care costs, as health plan costs decreased while patient out-of-pocket costs increased. We observed higher total all-cause health care costs among T2DM patients with a fixed copay (vs. coinsurance) pharmacy benefit. Additional research incorporating plan design information is needed to further examine this finding. What is already known about this subjectStrategies for containment of health care costs are important in type 2 diabetes mellitus (T2DM) management due to its high economic burden and the complex, progressive nature of the disease.The majority of previous studies in T2DM have been restricted by lack of availability of pharmacy benefit plan design data and have relied on observed patient-paid amount rather than copay and deductible information associated with specific drug tiers.Restrictive formulary designs have been shown to reduce medication use and associated pharmacy costs, but there is mixed evidence of their effect on medication adherence and health care utilization and cost.What this study addsHigher medication copayment amounts were associated with lower patient medication adherence and persistence in T2DM.Copayment amount was not associated with total health care costs, since health plan costs decreased while patient out-of-pocket costs increased.The use of pharmacy benefit plan design data integrated with medical and pharmacy claims data in this study provides a useful framework for future research into the effect of cost sharing.5 but there is mixed evidence of their effect on medication adherence and persistence and health care utilization and cost. A 2014 systematic review of formulary restriction identified 59 studies that evaluated the effect of patient access to medication on economic outcomes and found that 37% had neutral, 34% positive, and 29% negative association studies; 60% of included studies (n = 93) identified prescription cost sharing as a formulary management strategy.6 Thus, medication cost-sharing strategies are frequently used by managed care organizations, and pharmacy benefit designs may include patient prescription cost sharing via fixed copay amounts and coinsurance plans, in which patients pay a percentage of the total medication cost. Fixed copay and coinsurance plans may have different levels (tiers) of patient contribution. However, while lowering prescription patient cost sharing in chronic disease care may improve medication adherence, the effect of patient cost sharing on clinical and economic outcomes remains unclear.7Formulary designs may incorporate mechanisms such as patient cost sharing, prior authorization, step therapy, preferred drug lists, and quantity limits to control prescription costs. Formulary designs, which include these cost-containment mechanisms, have been shown to reduce medication use and associated pharmacy costs,8 As the number of Americans with diagnosed diabetes in the United States is projected to increase from 11 million (2000) to 29 million by 2050 (165%),9 costs are expected to rise. The goal of diabetes management with antihyperglycemic therapy is to lower blood glucose levels to as near normal as possible, and the American Diabetes Association recommends hemoglobin A1c testing at least twice a year among patients meeting glycemic treatment goals and quarterly among those not meeting goals.10 Poor glycemic control in T2DM has been associated with increased risk of complications12 and higher health care costs.14 Restrictive formularies may negatively affect T2DM medication adherence.19 Suboptimal adherence with prescribed T2DM medications has been linked to poorer glycemic control15,20,21 and increased health care costs.27Due to the considerable costs associated with type 2 diabetes mellitus (T2DM), evaluations of cost-containment strategies on patient outcomes may have important implications. Total estimated direct treatment costs among persons diagnosed with diabetes in the United States in 2012 was $176 billion, with 30% attributable to antihyperglycemic medications and supplies.Formulary management strategies are particularly important in the context of T2DM due to its high economic burden, the need for continuous drug treatment and patient management, and the complex, progressive nature of the disease. Novel T2DM medications (dipeptidyl peptidase-4 inhibitors and incretin mimetics) represent new classes of oral and injectable medications approved to manage T2DM. These medications are associated with relatively high medication costs compared to older T2DM medications, and thus, patients prescribed these medications may be directly affected by higher copayments and higher coinsurance costs. We hypothesized that more “generous” plans are associated with greater adherence, longer persistence, and lower total health care costs in T2DM, using the highest possible copay in the tier  and coinsurance as proxies of plan generosity .Our primary study objective was to evaluate the relationship between patient cost sharing for novel T2DM medications and patient medication adherence, health care utilization, and health care cost using linked medical and pharmacy claims and pharmacy benefit design data. Specifically, we sought to evaluate the association between the highest-tier pharmacy copayment and health care costs from the payer perspective , as well as the relationship between a fixed copay versus a coinsurance pharmacy benefit design on patient adherence and health care costs.International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 250.x0 and 250.x) between January 1, 2010, and December 31, 2012, (identification period) were identified for study eligibility. Patients were required to have filled a prescription for a specified novel T2DM medication between January 1, 2010, and December 31, 2012. The following novel T2DM medications were included: alogliptin, sitagliptin, saxagliptin, linagliptin, alogliptin/metformin, sitagliptin/metformin, saxagliptin/metformin, linagliptin/metformin, alogliptin/pioglitazone, sitagliptin/simvastatin, exenatide, and liraglutide. The date of the first qualifying prescription fill during the identification period was designated the study index date, and the specific agent prescribed was considered the index medication.This was a retrospective, observational cohort study that used Optum’s proprietary research database of medical and pharmacy claims linked to plan benefit design and enrollment information for commercially insured members of a large U.S. health plan. Patients who were aged 18 years or older and who had 2 or more medical claims at least 7 days apart for T2DM  and to be continuously enrolled in the health plan for at least 365 days preceding and subsequent to the index date. Study exclusion criteria included the use of the index medication during the study baseline period, which was defined as the 365-day period preceding the index date.Patients were followed for at least 12 months after the index date. The follow-up period began on the index date and terminated on the earliest date or the following: December 31, 2013; disenrollment from the health plan; or the date of a pharmacy benefit plan change. A pharmacy benefit plan change was defined as either a change in the cost-sharing structure, the multi-tier fixed copayment amount, or the coinsurance amount (percentage).29; the Diabetes Complications Severity Index (DCSI), calculated via ICD-9-CM codes during the 12-month baseline period31; and the total number of unique medications used during the baseline period. Pharmacy benefit design data elements included a fixed copayment structure, in which a member pays a predetermined dollar amount for a prescription fill, or a coinsurance structure, where a member pays a percentage of the total cost of a prescription fill. The number of pharmacy benefit tiers was captured for both fixed copayment and coinsurance plans, and both copayment amounts and coinsurance percentages were captured. Maximum copayment amount was defined as the copayment amount of the highest tier; for a 3-tiered plan, this would equal the copayment amount for a third-tier drug, that is, the highest dollar amount that patients could pay for a formulary covered drug on their plan.Study variables included these patient characteristics: patient age , gender, U.S. geographic region , and health plan funding type (self-insured employers or fully insured employers). Patient baseline health status was assessed using the following methods: the Quan-Charlson Comorbidity score, calculated based on the presence of ICD-9-CM diagnosis codes on medical claims during the study baseline periodStudy measures included medication adherence, measured using medication possession ratio (MPR). Adherence was calculated by dividing the sum of the number of days the index medication was supplied for all but the last fill in the observation period by the number of days between the first and the last refill. Patients were required to have at least 2 fills of the index medication. Patients who were perfectly compliant had an MPR of ≥ 1, while those who were less than fully compliant had an MPR < 1.Medication persistence was based on therapy discontinuation, defined as an index medication gap of ≥ 90 days. Medication persistence was assessed as the number of days from the index date to therapy discontinuation, which was identified as the run-out date based on days supply of the last prescription filled before the qualifying gap in therapy. Health care resource utilization was evaluated as > 1 emergency department (ED) admission, > 1 inpatient admission, and number of ambulatory visits during study follow-up.All-cause health care costs were calculated for the combined health plan paid and patient payment responsibility amounts for the study follow-up period. Medical , pharmacy, and other health care costs were included and summed to calculate total all-cause follow-up health care costs.32 to avoid potential difficulties introduced by transformation and retrans-formation of the dependent variable33; coefficients from a generalized linear model with a log link and gamma distribution are reported as cost ratios (exponentiated coefficients interpreted as the relative change in costs associated with a one-unit change in the variable). To estimate the relationship between a fixed copayment and coinsurance plan, similar analyses to the 3-tier fixed plan analysis for each endpoint were conducted, except that the analysis was limited to patients enrolled in a fixed or coinsurance plan (regardless of tier).Descriptive statistics were calculated as means and standard deviations (SD) for continuous variables and frequencies for categorical variables. Among patients with a 3-tier fixed copay pharmacy benefit, the relationship between maximum third-tier fixed copayment amount and medication adherence was evaluated using ordinary least squares (OLS) regression, controlling for patient demographic and clinical characteristics. Regression coefficients are interpreted as the change in adherence associated with a $10 change in maximum copay. Persistence was evaluated using parametric regression survival models based on maximum likelihood estimation to model the time to index medication discontinuation. The probabilities of > 1 inpatient or ED visit were modeled using logistic regression, and odds ratios and corresponding 95% confidence intervals (CI) were calculated. The number of ambulatory visits was modeled using a negative binomial regression with a log link to calculate incidence rate ratios and corresponding 95% CIs. Because health care costs are often skewed, estimated cost measures were modeled using the Manning and Mullahy formulationAll models included the following independent variables: patient age and gender, insured status (fully insured vs. administrative services only), high deductible medical plan, baseline health care cost , unique medication count, baseline Charlson comorbidity score, and DCSI; models did not include potential interaction effects. In addition, the analysis of 3-tier fixed copayment plan patients included maximum copay amount and maximum copay amount squared, to account for a possible decreasing (or increasing) effect of copay amount as maximum copayment amount increases . The analysis of all fixed copayment plan patients versus coinsurance patients included fixed versus coinsurance plan design.34 and corresponding 95% CIs were estimated by bootstrapping techniques (500 replicates).36The multivariate regression results were used to estimate predicted values  for each cohort (adjusted for covariates) using the recycled predictions method,Review/approval by an institutional review board was not required for this study as it used commercially available de-identified secondary data.Patients with ≥ 2 medical claims for T2DM at least 7 days apart, who also had ≥ 1 prescription claim for a specified novel T2DM medication, met continuous enrollment criteria, and who had all benefit design data were initially selected for study inclusion . Overall, 55.0% of study patients were male, and mean age was 54.3 years . Mean leThe adjusted effect of a higher third-tier pharmacy copayment for patients with a 3-tier fixed copayment plan is illustrated in P < 0.001; P < 0.001), as a $10 difference in third-tier copayment was associated with a 0.03 lower adherence. Higher third-tier copayment was also found to have a significant negative association with number of ambulatory visits , but not risk of hospitalizations  or risk of at least 1 ED visit . No statistically significant association was found between maximum third-tier index medication copayment amount and total all-cause health care costs . While total all-cause health care costs were not associated with cost sharing, we did observe that higher cost sharing was associated with lower health plan and higher patient out-of-pocket costs.Among 3-tier fixed medication copayment plans, a $10 higher copayment was associated with an 11% higher adjusted risk (hazard) of discontinuing the index study medication . Compared with coinsurance plans, a fixed pharmacy copay plan (regardless of tier) was associated with higher total all-cause health care costs. A fixed copayment structure was associated with 11% greater adjusted mean total health care costs compared with coinsurance plans adjusted mean total health care costs.Pharmacy benefit structure design (fixed medication copay vs. coinsurance) was associated with medication persistence, but not adherence. A fixed medication copayment plan was associated with a small but significantly lower risk (4%) of discontinuing the index study medication as compared to coinsurance plans  among patients with a 3-tier fixed plan, maximum copayment amount was not found to have a significant association with total all-cause health care costs. Further, a comparison of fixed copayment plans versus coinsurance plans, regardless of copayment tier, found that fixed copayment plans were associated with a lower risk of treatment discontinuation but higher total mean health care costs. The proportion of total unadjusted health care costs attributable to prescription medications were similar for patients with a 3-tier fixed plan (36.2%) and a coinsurance (36.7%) plan.19 Barron et al. (2008) found mean adherence for oral antihyperglycemic agents that ranged from 0.58 for patients with a copay of < $10 compared to 0.52 for patients whose copay was $20 or higher, and discontinuation that ranged from 55% in the lowest copay group (< $10) to 67% among those with a copay of $30 or more.15 In the current study, mean adherence was considerably higher and ranged from 0.76 for the lowest copay group ($25 copay) to 0.71 for the highest copay group ($100). Similar findings were reported by Colombi et al. (2008) as adherence to T2DM medications was highest for patients with the lowest copayments, regardless of patient age.17 Reynolds et al. (2016) found that higher medication copays were associated with T2DM medication discontinuation.37 Zeng et al. (2010) studied a value-based benefit design program that reduced the copayment for diabetes medications by 36.1% and correspondingly reduced the number of nonadherent patients by 30.0%.19 Another study by Zeng et al. (2013) of the effects of coverage gap reform on adherence to T2DM medications found that as patients experienced substantial copayment drops, adherence improved by approximately 0.03.38Our study found that a $10 higher third-tier copayment was associated with an 11% higher risk of discontinuing index novel T2DM medication and a 3% lower adherence. Consistent with these findings, previous investigations have demonstrated that formulary restrictions are associated with lower T2DM medication adherence and/or persistence.7 Among a broad Medicare health maintenance organization population not restricted to chronic medication users, Balkrishnan et al. (2001) found that increased patient prescription copayment was associated with higher health care costs.39 Campbell et al. (2011) demonstrated that an increase in prescription copayment > $5 (vs. < $5) was associated with more asthma-related outpatient and ED visits among a population with asthma.40 Patients with asthma may be more likely to experience immediacy of symptoms related to poor disease control compared with patients with diabetes. However, consistent with this finding among patients with asthma, Colombi et al. demonstrated that among patients with diabetes aged < 65 years, total health care costs were 22% lower for patients with low (< $10) copays compared with high copays (> $10), resulting in an average savings of $3,116 per patient per year.17 This difference in all-cause health care costs was observed despite significantly higher pharmacy costs among patients with low copays.Fewer studies have investigated the effect of formulary restrictions on health care utilization and cost or patient outcomes. Two recent systematic reviews that evaluated the relationship between formulary restrictions and health care resource utilization and cost across therapeutic areas found mixed results.41 Similarly, Fairman et al. (2003) found similar rates of inpatient, ED, and outpatient utilization among chronic medication users with a 3-tier (vs. 2-tier) medication formulary structure.42 While our results suggest that higher maximum third-tier copay was associated with decreased health care utilization (ED and ambulatory visits), we did not observe a significant relationship between third-tier copayment and health care cost during our 1- to 3-year follow-up period.In contrast, Brixner et al. (2007) found no effect of pharmacy benefit design change (defined as a second- or third-tier copayment increase > $5 or a change from a fixed copayment to coinsurance) on overall health care costs within 1 year across 5 chronic conditions, including diabetes.41 1 year of follow-up may not be sufficient to evaluate the effect of medication adherence on overall health care costs. This may be particularly true for diabetes, as the potential effect of reduced medication adherence on glycemic control and its subsequent effect on the development of diabetes complications may not be fully measurable in the short term. Furthermore, as indicated by DCSI, the majority of the study’s patients had no evidence of diabetic complications, indicating a less severe cohort of patients with diabetes.Since diabetes is a chronic disease that usually progresses to complications slowly, the effects of medication utilization on medical resources use may take time to manifest. Thus, as others have suggested,41 However, due to the chronic progressive nature of diabetes, it is plausible that these increased short-term costs may be associated with improved patient care and glycemic control, and any associated longer-term cost consequences of this may not be evident in the short term, that is, during our study’s follow-up period. As relatively few studies have investigated this relationship, additional research is warranted to understand the relationship between formulary restrictions and overall health care utilization and cost.Most literature reviews conducted to date have not been condition-specific and have synthesized literature for both symptomatic  and relatively asymptomatic  chronic conditions, and the effect of copayment changes may be different based on the underlying chronic disease. Our study, however, did find that a fixed prescription copay plan was associated with higher total health care costs during a mean of approximately 2.3 years of follow-up compared to a coinsurance plan suggesting an effect of pharmacy benefit design on costs.This retrospective study of a geographically diverse commercial population enabled the assessment of usual care in a large cohort of patients with T2DM. Furthermore, our study used pharmacy benefit design information linked to medical and prescription claims. This allowed the evaluation of maximum patient copay amount without relying on the use of administrative claims as a proxy to this information and also facilitated the evaluation of fixed-versus-coinsurance plan designs’ associations with patient outcomes.Despite these strengths, it is important to consider our study’s findings in the context of some study limitations. Only the effect of pharmacy benefit design information was evaluated, and medical plan benefit design may also be associated with outcomes, particularly health care utilization and cost. Patients with a pharmacy benefit with lower patient cost sharing may be likely to have a similarly generous medical plan benefit, and we did not distinguish between these factors. Patient health status may have been correlated with plan design, as it is plausible that patients who may have selected a coinsurance plan may have elected to take on greater financial risk due to perceived health status, which could have led to selection bias in our study.It is also important to consider that most coinsurance plans in this study were associated with self-insured employers; these employers may differ qualitatively from fully ensured employers, but we were unable to examine other employer characteristics beyond type of funding, which was included in multivariate models for adjustment of outcome variables.Patient plan benefit design may also correlate with unmeasured patient characteristics and other social determinants of health, such as education level and socioeconomic status; it is also possible that these unmeasured characteristics are associated with some outcome variables of interest, such as medication adherence.While our study did control for patient age, diabetes severity (DCSI), and Quan-Charlson comorbidity score, information regarding patient duration of disease (diabetes) was not available for analysis, and longer duration of disease may be associated with higher medical care costs.Finally, since a cross-sectional, observational study design was used, we should be cognizant that correlations between benefit design and measured medication adherence and health care utilization do not imply that one causes the other.Pharmacy benefit designs with higher copayment amounts may have an effect on patient adherence and persistence to novel medications used to treat T2DM. While we observed higher total all-cause health care costs among patients with a fixed copay pharmacy benefit compared with a coinsurance plan, we observed no difference in all-cause health care costs across levels of copayment among those with a fixed copay benefit. Additional research incorporating plan design information over a longer time period is needed to further examine this finding.Our study is unique in its use of specific plan design information to examine associations between formulary design and provides important precedent in the use of this type of information to subsequent research in this area. Although there is some research examining the relationship between patient cost sharing on health care resource utilization and associated costs in T2DM, few studies have addressed clinical outcomes  in T2DM, and additional research is warranted for both clinical and economic endpoints.


Our purpose was to identify patient characteristics and visit components that affect patient satisfaction with virtual new patient visits in an outpatient hand surgery clinic as measured by the Press Ganey Outpatient Medical Practice Survey (PGOMPS) total score (primary outcome) and provider subscore (secondary outcome).Adult patients evaluated through virtual new patient visits at a tertiary academic medical center between January 2020 and October 2020 who completed the PGOMPS for virtual visits were included. Data regarding demographics and visit characteristics were collected via chart review. Factors associated with satisfaction were identified using a Tobit regression model on the continuous score outcomes  to account for substantial ceiling effects.A total of 95 patients were included: 54% were men and the mean age was 54 ± 16 years. Mean area deprivation index was 32 ± 18, and the mean driving distance to the clinic was 97 ± 188 mi. Common diagnoses include compressive neuropathy (21%), hand arthritis (19%), hand mass (12%), and fracture/dislocation (11%). Treatment recommendations included small joint injection (20%), in-person evaluation (25%), surgery (36%), and splinting (20%). Multivariable Tobit regressions showed notable differences in satisfaction by the provider on the Total Score but not on the Provider Subscore. Other factors known to affect the PGOMPS scores for in-person visits were not notably associated with the Total or Provider Sub-Scores for virtual visits  other than the body mass index.Virtual clinic visit satisfaction was affected by the provider. Wait time strongly affects satisfaction with in-person visits but is not accounted for by the PGOMPS scoring system for virtual visits, which is a limitation of their survey. Further work is required to determine how to improve the patient experience with virtual visits.Prognostic IV. With the increased prevalence of broadband internet connection across the country, some providers have offered patients telemedicine encounters in lieu of an in-person visit. This has historically been particularly useful in connecting patients in socially deprived or medically isolated regions; nevertheless, telemedicine use surged in response to restrictions placed by the recent COVID-19≥18 years old) who were evaluated by six hand surgery providers (4 surgeons and one physician assistant) between January 2020 and October 2020 for virtual NPV driven by COVID-19 pandemic–related precautions at a single tertiary academic medical center were considered for inclusion pending completion of the survey. Exclusion criteria included patients <18 years old, those without corresponding video visits, and those with a virtual follow-up visit instead of NPV.In this institutional review board-approved study, all adult patients , area deprivation index (ADI), insurance type, smoking status, and primary diagnosis. Visit characteristics were also collected, such as distance from the clinic and the treatments offered . ADI is a measure calculated by the Health Resources and Services Administration and adapted to the Census by researchers at the University of Wisconsin-Madison.,Summary statistics of patient demographics, clinical characteristics, and outcomes were provided for the overall study cohort. Mean with standard deviation and median with interquartile range were provided for continuous outcome variables, and frequency with percentage was provided for categorical variables. Univariate and multivariable regression analyses were performed to identify the factors determining the PGOMPS Total Score using the Tobit model accounting the high ceiling effect.After excluding patients who were <18 years old (2), those without corresponding video visits (11), and those with virtual follow-up visits rather than an NPV (27), a total of 95 new hand patients were included (70% inclusion). Mean age was 54 ± 16 years; 54% (52) were men, and 87% (83) were identified as White (non-Hispanic). Most (62%) had commercial insurance, and 65% never smoked. Approximately two-thirds of the patients were overweight or obese (34% overweight and 41% obese). Primary diagnoses included compressive neuropathy (21%), hand arthritis (19%), fracture/dislocation (11%), hand mass (12%), and Dupuytren disease (6%). Common treatment recommendations included a small joint injection (20%), in-person evaluation to further elucidate the pathology (25%), surgery (36%), and splinting (20%). The average national percentile for ADI was 32 ± 18 with the average distance to a nearby clinic being 97 ± 188 miles .Table 1BFor the included patients, the PGOMPS Total Score was 84 ± 20 and the Subscore was 88 ± 22. Univariate and multivariable regression analyses were performed to identify the patient factors influencing the PGOMPS Total Score . AccordiUnivariate and multivariable regression analyses were also performed to identify the patient factors influencing the PGOMPS Provider Subscore . UnivariGiven the increasing use of telemedicine in health care, this study sought to identify the patient characteristics and/or visit components that affect patient satisfaction with virtual NPVs in a hand and upper-extremity clinic as documented by the PGOMS Total Score and Subscore. Both overweight BMI status and the surgeon providing care were associated with a notably higher Press Ganey Total Score. No patient covariates were notably associated with the Provider Subscore. Variables such as ADI, distance from the nearest clinic, age, and diagnosis did not statistically influence the patient satisfaction with virtual NPV.,a priori above the 33rd percentile threshold.,,,During the COVID-19 pandemic, health care underwent a series of changes that led to increased usage of telemedicine—including virtual visits and telephone calls. Under the Coronavirus Preparedness and Response Supplemental Appropriations Act and Section 1135 waiver authority,,,,Understanding the different variables and how it contributes to patient satisfaction within the clinical encounter has recently been of interest for provider and payers alike,,,In addition, patient satisfaction has been found to be notably impacted by surgeon empathy, rather than visit duration or patient expectation of the visit length.,,,,,,,Factors such as increasing patient age, the offer of surgery or injection, and decreased wait time have a notable influence patient satisfaction in the hand surgery clinic setting.,,,,,Socioeconomic data through the Neighborhood Atlas have provided additional factors that allow us to understand different predictors of satisfaction.Finally, it is important to consider the fact that patient satisfaction can be multifaceted. Graham et al brought up the concept of dividing it into patient satisfaction with the clinical process  versus satisfaction with the clinical outcome.,,,,67Limitations that warrant mention include the fact that we did not assess for patient mental health diagnosis because patients with documented depression have been shown to be less satisfied in the sports medicine clinic setting.


Right coronary artery intervention is usually accomplished with a Judkins right (JR) coronary guide catheter. Abnormal right coronary artery take-off from the right coronary sinus poses difficulty in engaging the right coronary artery with a conventional JR guide catheter. We report a rare case of primary percutaneous intervention of the right coronary artery which was performed with a multipurpose catheter as the patient had an extremely low-lying coronary artery from the coronary sinus where conventional catheters could not engage the right coronary artery in an octogenarian with acute inferior wall ST-elevation myocardial infarction in cardiogenic shock. The right coronary artery during the percutaneous coronary intervention (PCI) is usually engaged with a Judkins right (JR) guide catheter 6F 3.5 . The dif2) of 94% in room air. Baseline electrocardiogram (EKG) revealed ST elevation in inferior leads  with reciprocal ST depression in aVL and anterior leads (V1-4). Echocardiography revealed regional wall motion abnormality in the inferior posterior wall with left ventricular mild systolic dysfunction with an ejection fraction (EF) of 42% and mild ischemic mitral regurgitation. As she was in cardiogenic shock, she was infused with 1 liter of normal saline for over 1 hour, noradrenaline infusion was started and was rushed immediately to the cath lab for PPCI. Injection of the coronaries revealed a normal left coronary system with acute subtotal thrombotic occlusion of the right coronary artery. Interestingly, the right coronary artery was extremely low-lying in nature almost originating from the bottom of the coronary sinus. Right coronary ostium could not be engaged with conventional JR, AL, AR, and Ikari guide catheters. As the coronary ostium was low-lying almost in the bottom of the coronary sinus, we engaged it with a 6F MPA with a down-pointing tip which effectively engaged and provided good support during coronary intervention (Figure An 84-year-old female presented to the emergency department with acute-onset retrosternal chest discomfort with diaphoresis and shortness of breath for the last hour without any palpitation, presyncope, or syncope. She has been diabetic and hypertensive for the last 30 years on oral hypoglycemic agents and angiotensin receptor blockers. She had no history of effort angina in the past, but her exercise capacity was limited due to her elderly age. She had a blood pressure of 80/40 mm Hg in the right arm supine position and she had a heart rate of 56 beats per minute. She had ongoing angina with oxygen saturation (SpOr leads V-4. EchocAnomalous origin of the right coronary artery is most often engaged with AL, AR, and Ikari catheters . HoweverWe present a rare case of PPCI in a low-lying tortuous right coronary artery where an MPA effectively engaged the right coronary artery with good support and resulted in successful coronary intervention in an octogenarian with cardiogenic shock. The use of an MPA can be life-saving during the intervention in a low-lying right coronary artery from the coronary sinus.


The aim of this study was to determine whether viral shedding from the fecal RV vaccine strain RotarixQuantitative reverse transcription polymerase chain reaction specific to RV vaccine strain RV1 was used to monitor fecal RV1 viral shedding. RV IgG and IgA titers were measured using an in-house enzyme-linked immunosorbent assay. Fecal RV1 viral shedding and immune responses were compared between twins and singletons with mixed effects and fixed effects models.P=0.049) and RV IgG titers during the entire observation period (P=0.015) had a significantly better fit in the fixed effect model that assumed that twins have the same response versus the model that assumed that twins have a different response.A total of 347 stool and 54 blood samples were collected from four pairs of twins and twelve singletons during the observation period. Although the kinetics of fecal RV1 viral shedding and immune responses differed among vaccinated individuals, they appeared to be similar within twin pairs. RV shedding after the first dose (The similarity of RV vaccine viral replication in intestine and host immune responses in twin pairs was demonstrated using statistical analysis. RV vaccines are highly effective in countries with low mortality but are insufficient in those with medium to high levels of mortality.3 These differences can be explained by several mechanisms, including high titers of RV-specific IgA antibodies derived from breast milk4 and of maternal RV-specific IgG antibodies,5 variations in histo-blood group antigens that are RV genotype-dependent receptors,6 and differences in the gut microbiome.7Live attenuated rotavirus (RV) vaccines can decrease RV-related morbidity and mortality,8 A cohort study to assess whether there is an association between RV vaccine viral shedding in stool samples and host immune responses is ongoing. Fecal RV vaccine viral shedding can vary by vaccine recipient as demonstrated in a clinical study using a RV5-specific quantitative revere transcription polymerase chain reaction (qRT-PCR).9 As research progressed, the number of twin pairs enrolled in this study increased gradually, and fecal RV vaccine viral shedding and host immune responses appeared to be similar within those twin pairs. Levels of maternal antibodies and IgA antibodies derived from breast milk appeared to be similar within the twin pairs. In addition, host factors, including the composition of the gut microbiome, were also similar within the twin 12pairs. As mentioned above, these factors have been associated with host immune responses against RV vaccines, and fecal RV vaccine viral shedding and immune responses are likely to be similar within twin pairs. Therefore, the aim of this study was to determine whether fecal RV1 viral shedding and RV IgG and IgA responses are similar in twin pairs.Our institute conducted a prospective study to assess the safety of RV vaccines in neonatal intensive care units by monitoring fecal vaccine viral shedding. We demonstrated that RV vaccination can be performed safely in neonatal intensive care units with contact precaution measures.To examine the association between fecal RV vaccine viral shedding and vaccine-induced immune responses, we conducted a prospective cohort study of infants admitted to the neonatal intensive care unit of Fujita Health University Hospital. Twenty vaccinated infants (four pairs of twins and twelve singletons) born between November 2018 and June 2020 were enrolled in this study. This study was approved by the review board of our university . The infants’ guardians consented to their participation.To monitor RV1 vaccine strain viral shedding, stool samples were collected daily from day 0  until day 8 after the second of two vaccination doses. A 1-mL blood sample was obtained before the first vaccine dose, at 1 month after the first dose, and at 1 month after the second dose.13 The ELISA plate was coated with 25 μL of purified human rotavirus strain Wa virions (1 μg/mL) overnight at 4°C. After blocking and washing with Tris-buffered saline containing Tween 20, 25 μL of diluted samples (1:10–1:106) were added to each well and incubated at room temperature for 1 h. After washing, detection of anti-RV IgG or IgA was performed at room temperature over 1 h using 25 μL of peroxidase-labeled goat anti-human IgG (0.1 μg/mL) or anti-human IgA (0.5 μg/mL) . The antigen–antibody complexes were detected using 1-Step Ultra TMB-ELISA Substrate Solution  according to the manufacturer’s instructions. Five RV antibody-negative serum samples were used to determine cutoff values. The cutoff optical density value for negative anti-RV IgG and IgA was defined as the mean+three standard deviations of negative samples . Serum IgG and IgA titers were calculated as the highest dilution that gave a mean optical density greater than the cutoff value. A four-fold or higher increase in IgG or IgA titers during the first or second dose samples compared with the before samples was defined as a significant increase.An enzyme-linked immunosorbent assay (ELISA) was performed to measure serum anti-RV IgG and IgA titers as previously described with modifications.g. Next, 140 μL of the supernatant was used for RNA extraction. using the QIAamp viral RNA MiniKit . RV1-specific qPCR was used to monitor fecal RV1 viral shedding.14For each stool sample, 1 mL of a 10% solution was prepared in physiological saline solution. Each suspension was clarified by centrifugation for 20 min at 4,000 15 When the goodness of fit of the model including random effects was high  and significant differences could be detected with the likelihood ratio test, the twins were considered to be similar. All analyses were performed using R software version 4.1.1 .Baseline characteristics are presented as the medians and interquartile range (IQR) for continuous variables. For categorical variables, frequency and proportion are presented. To assess the similarity in RV IgG and IgA responses and viral shedding in twins, the goodness of fit models were compared. One model (twin model) was a mixed-effects model in which random effects were incorporated with the assumption that the data obtained from twins are correlated. The other model (without twin model) was a fixed effects model in which data from twins was assumed to be independent. The similarity within a twin pair was examined during two periods: (1) before and after the first dose of vaccination and (2) before the first dose of vaccination and after the second dose of vaccination. The goodness of fit of the models was assessed using Akaike information criterion (AIC).A total of 347 stool specimens were collected from 20 vaccinated infants as described above during the observation period. There were 143 samples collected from twins with 72 samples collected before and after the first dose and 71 samples collected before and after the second dose. One twin could not be sampled at day 8 after the second dose. There were 204 samples collected from singletons, of which 105 were samples collected before and after the first dose (three singletons failed to provide a single stool sample) and 99 samples were collected before and after the second dose (nine singletons failed to provide a single stool sample). A blood sample could not be collected from one pair of twins (pair D) and four singletons at 1 month after the second vaccination. All other blood samples (54 samples) were serially collected as per the study protocol.P=0.023). Generally, singleton infants have a higher birth weight than twin infants do. However, in this study, five singletons had fetal growth restriction caused by several complications such as excess torsion of the cord, subchorionic hematoma, pregnancy-induced hypertension, and single umbilical artery, whereas none of the twins had fetal growth restriction. Thus, the body weight of the singletons was significantly lower than that of the twins. All infants were delivered by cesarean section. Pair A consisted of monochorionic monoamniotic twins, pair B consisted of monochorionic diamniotic twins, and pairs C and D consisted of dichorionic diamniotic twins. There were no statistical differences in feeding procedures between twins and singletons. All infants received two doses of the RV1 vaccine.The baseline characteristics of the twins and singletons are summarized in The fecal RV1 RNA shedding from the singletons for 8 days after the first and second doses of the vaccine is shown in The fecal RV1 RNA shedding of the twins is shown in The kinetics of RV IgG and IgA antibodies in singletons and twins are shown in The kinetics of RV IgG C and IgAP=0.049), there was no significant differences in AIC values for RV IgG (P=0.057) or IgA titers (P=0.207) based on the likelihood ratio test for the first dose models. Conversely, no significant differences in AIC values between either model for viral shedding (P=0.248) or RV IgA antibody titers (P=0.058) were observed over the entire observation period, but there was a significant difference in AIC values for RV IgG titers (P=0.015)  .9 Herein, as similarly reported,14 study participants exhibited variable fecal RV shedding after vaccination, with several quickly decreasing in fecal RV1 viral shedding while others had prolonged fecal shedding after the first dose. In general, viral RNA loads in stool samples appeared to be lower after the second dose compared with that after the first dose. The kinetics of fecal RV1 viral shedding that showed lower viral shedding after the second dose were also consistent with previous studies,16 suggesting that the host immune response induced by the first vaccine dose suppressed RV1 replication after the second dose.Our previous studies suggested that the kinetics of RV vaccine viral shedding vary among vaccine recipients.P=0.049). However, the similarity in RV1 viral shedding in twins was not confirmed during the period from prevaccination to after the second RV vaccine dose. The model of RV IgG responses that assumed twins have the same response had a significantly better fit than the model that assumed twins have a different response, indicating a similarity in IgG responses from prevaccination to post-second vaccination within a twin pair (P=0.015). Therefore, these data show that RV1 viral shedding after the first vaccination and the IgG response before and after two vaccine doses were statistically similar within twin pairs. Meanwhile, the RV IgA antibody responses during the entire observation period tended to be similar in twins, although this was not significant different (P=0.058). Increasing the number of twins in a future study may uncover a significant relationship for the RV IgG antibody responses. Therefore, this is the first report showing significant similarities in RV vaccine viral replication and host immune response within twin pairs.We found that the kinetics of fecal RV1 RNA shedding after the first and second vaccine doses were similar within each pair of twins  and that20 In addition, the gut microbiome is thought to be involved in the development of both innate and adaptive immune training during early infancy.21 Many factors are involved in vaccine viral replication and host immune responses induced by RV vaccination, and it would be challenging to elucidate the mechanisms responsible for the similarities in RV vaccine viral replication and host immune responses between twins. However, understanding the precise mechanism underlying similar RV vaccine viral shedding and immune responses in pairs of twins may be valuable in improving the efficacy of RV vaccines in countries with medium- and high-mortality rates.Feeding was the same in each pair of twins but was diverse across singletons. Although the gut microbiome was not analyzed in this study, it has been suggested that the gut microbiomes in pairs of twins have greater similarities than those between two randomly selected infants. Delivery and feeding, which are generally identical within twin pairs, may influence the composition of the infant gut microbiome.5 and animal model experiments22 have suggested that maternal or transferred RV IgG antibodies suppress RV vaccine viral replication and weaken the host immune response. In this study, although high levels of maternal RV IgG antibody titers were detected in sera obtained before vaccination from pair A, both twins in pair A had more fecal RV1 viral shedding than that in the three other pairs. In addition, the maternal RV IgG antibody titers were relatively low in pairs C and D, but we did not observe high RV1 viral shedding in these pairs. Thus, although RV vaccine viral replication and host immune response were similar in each pair of twins in this study, the levels of viral replication and immune response differed from theoretical values based on previous studies.The complexity of the various factors involved in fecal RV shedding and host-immune responses among singletons impedes understanding the precise mechanisms involved in viral replication, vaccination, and host immune responses within a singleton cohort. However, studies targeting twins are considered helpful to simplify these analyses because of the similarity of their backgrounds. Indeed, although pairs B and D were breastfed, the RV IgG and IgA levels increased significantly after the second dose in these two pairs, despite slightly lower fecal RV1 viral shedding than in pair A. Several human studies23 and a low replication of RV1 in twin two of pair C may have contributed to a lower level of immune responses induced by vaccination. RV IgA antibody titers after the second dose are significantly correlated with RV vaccine efficacy.24 Therefore, to improve RV vaccine efficacy, it will be important to develop measures to promote RV vaccine viral replication in intestinal tissue. In addition, precise determination of how to evaluate viral replication is important. Several cases with positive RV1 shedding before the second vaccination dose appeared to have long-term RV1 viral replication. Therefore, the duration of the RV1 shedding may be useful for assessing vaccine virus replication in intestinal tissue.We only analyzed four pairs of twins were in this study, and it is difficult to establish an association between fecal RV vaccine viral shedding and immune responses, even if the similarities between the twins were statistically confirmed. However, high levels of RV vaccine viral shedding were observed in pair A, and the highest RV IgG and IgA antibody titers after the second dose of RV vaccine were observed in these two infants. In contrast to pair A, in one twin of pair C (indicated with open squares), RV IgA antibody titers after the second dose of the RV vaccine were low (×128) (indicated with open squares in We compared random and fixed effects models and demonstrated significant similarities in RV vaccine viral replication and immune responses in twins. Since many of the factors associated with RV vaccine viral replication and host immune responses will be similar between twin pairs, these findings are reasonable. Although several factors such as maternal antibody titers and feeding procedure have already been analyzed, the influence of the intestinal microbiome remains unclear in this study. Analysis of gut microbiomes is currently underway in this cohort to elucidate the role of the microbiome in influencing RV vaccine viral replication and host immune responses.


This cross-sectional study assesses declared data sharing in publications for a recent set of pediatric clinical trials funded by the US National Institutes of Health (NIH). Sharing of individual participant data promotes transparency and trust in scientific findings, enables replication and validation of results, and facilitates data reuse in future studies. Most recently, effective January 25, 2023, the NIH began requiring data management and sharing plans in grant applications to increase sharing of scientific data generated from research supported by the NIH.3 Each trial publication was reviewed by 2 authors to identify data sharing statements describing access to clinical trial data; any discrepancies were resolved by consensus. Information was collected on the type of data available and type of access provided. Journals were categorized according to affiliation with the International Committee of Medical Journal Editors (ICMJE), which has developed guidance and policies to promote data sharing for clinical trials and maintains a list of journals reporting compliance with ICMJE recommendations.5 Differences based on ICMJE affiliation were evaluated with 2-sided χ2 tests, with significance set at P < .05. The study followed STROBE reporting guidelines and was deemed exempt from review by the Boston Children’s Hospital institutional review board, as it relied on publicly available information.This cross-sectional study analyzed NIH-funded pediatric clinical trials with grants completed in 2017-2019 and with trial results published in a peer-reviewed publication by June 30, 2022. Methods for identification of trials enrolling pediatric patients (aged <18 years) and linkage to trial publications have been previously described.Among 213 pediatric clinical trial publications, 69 (32.4%) included a data sharing statement and 62 (29.1%) declared that data were available . For theP = .15). Similarly, data availability and type of data access did not differ according to ICMJE affiliation.Publications in ICMJE-affiliated journals were not more likely to provide a data sharing statement than those in non–ICMJE-affiliated journals (29 of 75 [38.7%] vs 40 of 138 [29.0%]; 5 Limitations of the study include potential lack of generalizability to trials studying adults and those funded by non-NIH entities. We also were not able to confirm data sharing for trials requiring data requests, which could have resulted in overestimation of actual data availability.6This study’s findings suggest that data for most NIH-funded pediatric clinical trials were not readily available for reuse. These findings are consistent with prior studies indicating that access to individual trial participant data remains limited, even among trials published in ICMJE-affiliated journals.This analysis provides a benchmark for future assessments of clinical trial data sharing as the NIH’s new policy goes into effect. Such evaluations should include specific measures to capture data sharing for patient populations that may have more limited clinical trial data, including pediatric patients or those with rare diseases. Furthermore, monitoring activities should focus not only on data availability and ease of access but also on measuring effective data reuse and benefits of secondary studies in advancing scientific knowledge.


Retinoic acid (RA) is a potent epigenetic regulator that directly controls transcription of key genes during development. This article addresses concerns about recently published data suggesting that RA influences the timing and scaling of limb development. RA gain-of-function (GOF) studies in chick embryos where RA is added at pharmacological levels were used to conclude that RA signaling controls the timing and scaling of limb development. However, previous RA loss-of-function (LOF) studies in mouse contradict the conclusions derived from chick GOF studies, instead demonstrating that endogenous RA is not required for timing, scaling, and patterning of limbs during development. As genetic LOF studies are generally considered superior to GOF studies for determining the normal functions of genes, proteins, and signaling molecules (such as RA), readers need to be aware that chick studies do not provide conclusive evidence on the normal function of endogenous RA during limb development.Meis1/Meis2 to extend from its normal proximal position to a distal position; this observation led to the conclusion that RA normally controls limb proximodistal patterning by activating Meis1/Meis2 in the proximal limb  that performs the final step of RA synthesis ; however, Aldh1a2−/− embryos were not able to verify the RA limb proximodistal hypothesis as these embryos completely lack trunk RA and undergo lethality prior to limb bud formation. Subsequently, an article was published in 2007 by Rdh10 encoding retinol dehydrogenase 10 (RDH10) that performs the first step of RA synthesis ; Rdh10 mutant embryos survive long enough to develop limbs because they retain a small amount of trunk RA activity (probably due to another unknown retinol-metabolizing enzyme), but limb buds do not exhibit RA signaling activity and proximodistal patterning of hindlimbs is normal whereas forelimbs are stunted. Interestingly, a recent genetic LOF study shows that conditional incomplete loss of all three mouse RA receptors results in embryos with a stunted forelimb but a hindlimb of normal size similar to Rdh10 mutants  in the forelimb field  still expresses Meis1/Meis2 in forelimbs and hindlimbs, the original hypothesis for control of limb proximodistal patterning  Meis1/Meis2 expressed in trunk mesoderm fated to become the limb field functions instructively along with Tbx5 to initiate limb budding; (c) after limb outgrowth begins, Meis1/Meis2 expression is activated in proximal limb by a signal other than RA; (d) Meis1/Meis2 expression is limited to the proximal limb due to expression of Fgf8 distally in the apical ectodermal ridge; (e) Meis1/Meis2 but not RA then functions to control limb proximodistal patterning  may lead to side-effects that prevent insight into how endogenous signaling systems function.