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Journal of Neurosurgery. Spine Jun 2024Obtaining timely postoperative radiotherapy (RT) following separation surgery is critical to avoid local recurrence of disease yet can be a challenge due to scheduling...
OBJECTIVE
Obtaining timely postoperative radiotherapy (RT) following separation surgery is critical to avoid local recurrence of disease yet can be a challenge due to scheduling conflicts, insurance denials, and travel arrangements. In patients undergoing metastatic spine surgery for spinal cord compression, the authors sought to: 1) report the rate of postoperative RT, 2) describe reasons for patients not receiving postoperative RT, and 3) investigate factors that may predict whether a patient receives postoperative RT.
METHODS
A single-center retrospective case series was undertaken of all patients who underwent metastatic spine surgery for extradural disease between January 2010 and January 2021. Inclusion criteria were patients with intermediate or radioresistant tumors with evidence of spinal cord compression who underwent surgery. The primary outcome was the occurrence of RT within 3 months following surgery. Multivariable logistic regression analysis was performed controlling for age, BMI, race, total number of decompressed levels, tumor size, other organ metastasis, and preoperative RT or chemotherapy to predict patients receiving postoperative RT.
RESULTS
Of 239 patients undergoing spine surgery for metastatic disease, 113 (47.3%) received postoperative RT while 126 (52.7%) did not. In the postoperative RT group, 24 (21.2%) received stereotactic body radiation therapy while 89 (78.8%) received conventional external-beam radiation therapy. The most common reasons for patients not receiving postoperative RT included death or transfer to hospice (31.0%), RT not being recommended by radiation oncology (30.2%), and loss to follow-up (23.8%). On critical review with the radiation oncology department, the authors estimated that 101 of 126 (80.2%) patients who did not receive postoperative RT were potential candidates for postoperative RT. Patients who received postoperative RT had more documented inpatient (48.7% vs 32.5%, p < 0.001) and outpatient (100.0% vs 65.1%, p < 0.001) radiation oncology consultations than those who did not. Additionally, patients who received postoperative RT had a higher rate of postoperative chemotherapy (53.1% vs 25.4%, p < 0.001), while patients who did not receive postoperative RT had a higher rate of preoperative RT (7.1% vs 31.0%, p < 0.001). Multivariable analysis confirmed that patients who received preoperative RT had lower odds of undergoing postoperative RT (OR 0.14, 95% CI 0.06-0.34; p < 0.001), and patients who underwent postoperative chemotherapy had higher odds of undergoing postoperative RT (OR 3.83, 95% CI 2.05-7.17; p < 0.001).
CONCLUSIONS
In the current study reflecting real-world care of patients with metastatic spine disease after undergoing separation surgery, 47% of patients did not receive postoperative RT, and 80% of those patients were potential candidates for postoperative RT. Radiation oncology consultation and postoperative chemotherapy were significantly associated with receiving postoperative RT, whereas preoperative RT was significantly associated with not receiving postoperative RT. The lack of timely postoperative RT highlights a potential gap in metastatic spine tumor care and underscores the necessity for prompt radiation oncology consultation and effective planning.
PubMed: 38941648
DOI: 10.3171/2024.4.SPINE231254 -
Endocrine Practice : Official Journal... Jun 2024Following its FDA approval in January 2020, we examined the impact of teprotumumab on thyroid eye disease (TED) clinical practices.
BACKGROUND
Following its FDA approval in January 2020, we examined the impact of teprotumumab on thyroid eye disease (TED) clinical practices.
METHODS
Across three referral centers from January 1, 2018, to December 30, 2022, we retrospectively analyzed demographics, clinical features, treatment choices, and insurance status of patients with active, moderate to severe TED.
RESULTS
Of 74 patients recommended for medical therapy, 53% received collaborative recommendations from endocrinologists and ophthalmologists in a TED clinic. Prior to teprotumumab availability, 19 patients were recommended medical therapy, and all received medical therapy (100%), which consists of corticosteroids (14, 73.7%) or tocilizumab (5, 26.3%). After teprotumumab became available, out of 55 patients that were recommended medical therapy, only 41 (74.6%) received medical therapy, mostly teprotumumab (33, 60%), followed by corticosteroids (5, 9.1%) or tocilizumab (3, 5.4%), while 14 (25.4%) did not receive medical therapy. Discordance between physicians' recommendations and therapy received or lack thereof was explained by patients' refusal (9, 64.3%), mostly due to side effect concerns (8, 88.9%), and insurance denial (5, 35.7%). Teprotumumab use was mostly associated with otic changes (10, 30.3%), weight loss (9, 27.3%), and hyperglycemia (6, 18.2%), but 2 (6.1%) patients developed serious infections. Corticosteroids were associated with insomnia (4, 21.1%), and one patient in the tocilizumab group had an infusion reaction requiring hospitalization.
CONCLUSION
Teprotumumab introduction increased TED therapy evaluations, yet not all received recommended treatment due to safety concerns or accessibility issues. Enhancing collaborative care, medication accessibility, and adverse effect management is crucial.
PubMed: 38936546
DOI: 10.1016/j.eprac.2024.06.010 -
IEEE Transactions on Cybernetics Jun 2024This article investigates the fully distributed resilient practical leader-follower bipartite output consensus (LFBOC) problem for heterogeneous linear multiagent...
This article investigates the fully distributed resilient practical leader-follower bipartite output consensus (LFBOC) problem for heterogeneous linear multiagent systems (MASs) with denial-of-service (DoS) attacks and actuator faults. To estimate the leader matrix and state in the presence of DoS attacks, two novel adaptive event-triggered observers are proposed based on newly developed lemmas, and then the adaptive event-triggered fault-tolerant controller without chattering behavior is developed to solve the LFBOC problem. Different from most existing resilient practical LFBOC working with DoS attacks and actuator faults, our method does not rely on any global information, event-triggered communication between neighbors and discrete update controllers are implemented simultaneously. Finally, an example is presented to well illustrate the effectiveness of developed method.
PubMed: 38935465
DOI: 10.1109/TCYB.2024.3404010 -
JAMA Ophthalmology Jun 2024Anti-vascular endothelial growth factor (VEGF) intravitreal injections, a mainstay of treatment for many retinal diseases to optimize visual outcomes, have been included...
IMPORTANCE
Anti-vascular endothelial growth factor (VEGF) intravitreal injections, a mainstay of treatment for many retinal diseases to optimize visual outcomes, have been included in prior authorization (PA) initiatives. However, if clinicians are extremely accurate in their use of anti-VEGF medications, such administrative burdens may need reconsideration.
OBJECTIVE
To quantify PA for anti-VEGF medications (aflibercept, ranibizumab, and bevacizumab) that were approved and determine associated administrative burdens experienced by retina practices.
DESIGN, SETTING, AND PARTICIPANTS
Prospective multicenter quality improvement study conducted from January 2022 through June 2022, and participants were 9 private retina practices across the US.
MAIN OUTCOMES AND MEASURES
Overall rate of approval of PA requests, reasons for requesting PA, and overall rate of delay of care resulting from PA procedures.
RESULTS
In total, 2365 PA requests were recorded, 2225 of which met inclusion criteria. Overall, 2140 (96.2%) requests were approved. The most common reason for requesting PA, at 64% (1423 of 2225 requests), was reauthorization for a previously utilized medication. Of the 2140 approvals, 59.6% (1277) resulted in a delay in care greater than 24 hours, and 40% (863) were given on the date of service. In a granular analysis of a subset of delayed approvals, 23.9% (173 of 725) were approved within 1 day, 15.9% (115 of 725) were approved within 2 to 3 days, 21.5% (156 of 725) were approved within 4 to 7 days, 26.3% (191 of 725) were approved within 8 to 31 days, and 12.4% (90 of 725) were approved within more than 31 days. Overall, PA denial for step therapy was 2.9% (65 of 2225) of requests and uncovered diagnoses was 0.9% (20 of 2225) of requests. The median staff time spent to obtain a single PA was 100 (range, 0-200) minutes.
CONCLUSIONS AND RELEVANCE
In this study, PA requests were almost always approved but led to a delay in patient care in most patients. The current study suggests that the PA process may not be effective for retina specialists if these results can be generalized to other practices in the US and if less burdensome and less costly approaches could result in similar approval rates. Potential short-term solutions may include eliminating the PA process for bevacizumab and reauthorizations for established patients.
PubMed: 38935350
DOI: 10.1001/jamaophthalmol.2024.2217 -
Sensors (Basel, Switzerland) Jun 2024Cyber-physical systems (CPS) are vital in automating complex tasks across various sectors, yet they face significant vulnerabilities due to the rising threats of...
Cyber-physical systems (CPS) are vital in automating complex tasks across various sectors, yet they face significant vulnerabilities due to the rising threats of cybersecurity attacks. The recent surge in cyber-attacks on critical infrastructure (CI) and industrial control systems (ICSs), with a 150% increase in 2022 affecting over 150 industrial operations, underscores the urgent need for advanced cybersecurity strategies and education. To meet this requirement, we develop a specialised cyber-physical testbed (CPT) tailored for transportation CI, featuring a simplified yet effective automated level-crossing system. This hybrid CPT serves as a cost-effective, high-fidelity, and safe platform to facilitate cybersecurity education and research. High-fidelity networking and low-cost development are achieved by emulating the essential ICS components using single-board computers (SBC) and open-source solutions. The physical implementation of an automated level-crossing visualised the tangible consequences on real-world systems while emphasising their potential impact. The meticulous selection of sensors enhances the CPT, allowing for the demonstration of analogue transduction attacks on this physical implementation. Incorporating wireless access points into the CPT facilitates multi-user engagement and an infrared remote control streamlines the reinitialization effort and time after an attack. The SBCs overwhelm as traffic surges to 12 Mbps, demonstrating the consequences of denial-of-service attacks. Overall, the design offers a cost-effective, open-source, and modular solution that is simple to maintain, provides ample challenges for users, and supports future expansion.
PubMed: 38931707
DOI: 10.3390/s24123923 -
Sensors (Basel, Switzerland) Jun 2024Cyber-physical systems (CPSs), which combine computer science, control systems, and physical elements, have become essential in modern industrial and societal contexts.... (Review)
Review
Cyber-physical systems (CPSs), which combine computer science, control systems, and physical elements, have become essential in modern industrial and societal contexts. However, their extensive integration presents increasing security challenges, particularly due to recurring cyber attacks. Therefore, it is crucial to explore CPS security control. In this review, we systematically examine the prevalent cyber attacks affecting CPSs, such as denial of service, false data injection, and replay attacks, explaining their impacts on CPSs' operation and integrity, as well as summarizing classic attack detection methods. Regarding CPSs' security control approaches, we comprehensively outline protective strategies and technologies, including event-triggered control, switching control, predictive control, and optimal control. These approaches aim to effectively counter various cyber threats and strengthen CPSs' security and resilience. Lastly, we anticipate future advancements in CPS security control, envisioning strategies to address emerging cyber risks and innovations in intelligent security control techniques.
PubMed: 38931599
DOI: 10.3390/s24123815 -
Sensors (Basel, Switzerland) Jun 2024With the escalation in the size and complexity of modern Denial of Service attacks, there is a need for research in the context of Machine Learning (ML) used in attack...
With the escalation in the size and complexity of modern Denial of Service attacks, there is a need for research in the context of Machine Learning (ML) used in attack execution and defense against such attacks. This paper investigates the potential use of ML in generating behavioral telemetry data using Long Short-Term Memory network and spoofing requests for the analyzed traffic to look legitimate. For this research, a custom testing environment was built that listens for mouse and keyboard events and analyzes them accordingly. While the economic feasibility of this attack currently limits its immediate threat, advancements in technology could make it more cost-effective for attackers in the future. Therefore, proactive development of countermeasures remains essential to mitigate potential risks and stay ahead of evolving attack methods.
Topics: Machine Learning; Computer Security; Memory, Short-Term; Humans; Telemetry; Computer Communication Networks; Algorithms
PubMed: 38931520
DOI: 10.3390/s24123735 -
Sensors (Basel, Switzerland) Jun 2024In order to reduce the position errors of the Global Positioning System/Strapdown Inertial Navigation System (GPS/SINS) integrated navigation system during GPS denial,...
In order to reduce the position errors of the Global Positioning System/Strapdown Inertial Navigation System (GPS/SINS) integrated navigation system during GPS denial, this paper proposes a method based on the Particle Swarm Optimization-Back Propagation Neural Network (PSO-BPNN) to replace the GPS for positioning. The model relates the position information, velocity information, attitude information output by the SINS, and the navigation time to the position errors between the position information output by the SINS and the actual position information. The performance of the model is compared with the BPNN through an actual ship experiment. The results show that the PSO-BPNN can obviously reduce the position errors in the case of GPS signal denial.
PubMed: 38931505
DOI: 10.3390/s24123722 -
Journal of General Internal Medicine Jun 2024Congressional hearings and public reports have drawn attention to problems afflicting Medicare Advantage (MA), the privatized version of Medicare. Private plans became a...
Congressional hearings and public reports have drawn attention to problems afflicting Medicare Advantage (MA), the privatized version of Medicare. Private plans became a staple of Medicare through the passage of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA). Congress passed this law during a furor of privatization, when think tanks and powerful financial interests emphasized the power of corporations' profit incentive to improve the efficiency and quality of social enterprise. Yet the surging criticism of MA suggests a misalignment between the financial interest of some MA plans and the well-being of their patient populations. The criticisms range from deceptive marketing, ghost networks, and patient cherry-picking to unethical prior authorization denials and defrauding the government. In total, MA plans cost the federal government 22% more per patient than if these patients in question were enrolled in traditional Medicare. Moreover, it is not clear that this additional funding is producing proportional benefits. These developments raise questions about the presence of a profit incentive in Medicare, and perhaps health care more broadly.
PubMed: 38926321
DOI: 10.1007/s11606-024-08876-7 -
Risk Management and Healthcare Policy 2024Growing cyberattacks have made it more challenging to maintain healthcare information system (HIS) security in medical institutes, especially for hospitals that provide...
BACKGROUND
Growing cyberattacks have made it more challenging to maintain healthcare information system (HIS) security in medical institutes, especially for hospitals that provide patient portals to access patient information, such as electronic health record (EHR).
OBJECTIVE
This work aims to evaluate the patient portal security risk of Taiwan's EEC (EMR Exchange Center) member hospitals and analyze the association between patient portal security, hospital location, contract category and hospital type.
METHODS
We first collected the basic information of EEC member hospitals, including hospital location, contract category and hospital type. Then, the patient portal security of individual hospitals was evaluated by a well-known vulnerability scanner, UPGUARD, to assess website if vulnerable to high-level attacks such as denial of service attacks or ransomware attacks. Based on their UPSCAN scores, hospitals were classified into four security ratings: absolute low risk, low to medium risk, medium to high risk and high risk. Finally, the associations between security rating, contract category and hospital type were analyzed using chi-square tests.
RESULTS
We surveyed a total of 373 EEC member hospitals. Among them, 20 hospital patient portals were rated as "absolute low risk", 104 hospital patient portals as "low to medium risk", 99 hospital patient portals as "medium to high risk" and 150 hospital patient portals as "high risk". Further investigation revealed that the patient portal security of EEC member hospitals was significantly associated with the contract category and hospital type (<0.001).
CONCLUSION
The analysis results showed that large-scale hospitals generally had higher security levels, implying that the security of low-tier and small-scale hospitals may warrant reinforcement or strengthening. We suggest that hospitals should pay attention to the security risk assessment of their patient portals to preserve patient information privacy.
PubMed: 38910900
DOI: 10.2147/RMHP.S463408