Rapid suppression and sustained activation of distinct cortical regions for a delayed sensory-triggered motor response.

The neuronal mechanisms generating a delayed motor response initiated by a sensory cue remain elusive. Here, we tracked the precise sequence of cortical activity in mice transforming a brief whisker stimulus into delayed licking using wide-field calcium imaging, multiregion high-density electrophysiology, and time-resolved optogenetic manipulation. Rapid activity evoked by whisker deflection acquired two prominent features for task performance: (1) an enhanced excitation of secondary whisker motor cortex, suggesting its important role connecting whisker sensory processing to lick motor planning; and (2) a transient reduction of activity in orofacial sensorimotor cortex, which contributed to suppressing premature licking. Subsequent widespread cortical activity during the delay period largely correlated with anticipatory movements, but when these were accounted for, a focal sustained activity remained in frontal cortex, which was causally essential for licking in the response period. Our results demonstrate key cortical nodes for motor plan generation and timely execution in delayed goal-directed licking.

Integrating Academic and Community Cancer Care and Research through Multidisciplinary Oncology Pathways for Value-Based Care: A Review and the City of Hope Experience.

As the US transitions from volume- to value-based cancer care, many cancer centers and community groups have joined to share resources to deliver measurable, high-quality cancer care and clinical research with the associated high patient satisfaction, provider satisfaction, and practice health at optimal costs that are the hallmarks of value-based care. Multidisciplinary oncology care pathways are essential components of value-based care and their payment metrics. Oncology pathways are evidence-based, standardized but personalizable care plans to guide cancer care. Pathways have been developed and studied for the major medical, surgical, radiation, and supportive oncology disciplines to support decision-making, streamline care, and optimize outcomes. Implementing multidisciplinary oncology pathways can facilitate comprehensive care plans for each cancer patient throughout their cancer journey and across large multisite delivery systems. Outcomes from the delivered pathway-based care can then be evaluated against individual and population benchmarks. The complexity of adoption, implementation, and assessment of multidisciplinary oncology pathways, however, presents many challenges. We review the development and components of value-based cancer care and detail City of Hope's (COH) academic and community-team-based approaches for implementing multidisciplinary pathways. We also describe supportive components with available results towards enterprise-wide value-based care delivery.

Improvement in hemodynamics with a new, larger-volume (50 cc) intra-aortic balloon for high-risk percutaneous coronary intervention.

A primary cause of adverse outcomes among high-risk patients undergoing percutaneous coronary intervention (PCI) may be a diminished capacity to tolerate the hemodynamic and ischemic insults that can occur during the procedure. A common means of mechanical support during PCI has been the intra-aortic balloon pump (IABP). We describe successful periprocedural mechanical support with a new, 50 cc IABP in a patient with both severe left ventricular dysfunction and extensive coronary arteriosclerosis, for whom PCI with stenting was indicated. The prophylactic use of this 50 cc IABP, which traditionally would be contraindicated because of the patient's height (162.6 cm), markedly increased the diastolic aortic pressure (by approximately 110 mmHg) over the baseline level, while promptly reducing left-sided heart pressures. This finding appears to exceed the average diastolic augmentation reported for smaller-volume balloons. Although the role of the IABP in high-risk PCI remains controversial, further research is warranted to clarify and compare this new 50 cc IABP to smaller-volume balloons, and ascertain whether the observed hemodynamic benefits can translate into improved clinical outcomes among patients requiring mechanical support during PCI.

Effect of statin therapy prior to elective percutaneous coronary intervention on frequency of periprocedural myocardial injury.

This study evaluated whether pretreatment with statins was associated with a decreased incidence of periprocedural myocardial injury. Periprocedural myocardial injury occurs after percutaneous coronary intervention (PCI) and is associated with adverse outcomes. The pleiotropic properties of statins stabilize plaque and decrease the inflammatory milieu of atherosclerotic lesions. Accordingly, we hypothesized that preprocedural statin therapy would decrease periprocedural myocardial injury. We enrolled 425 patients who underwent successful PCI. The control arm (n = 150) included patients not on statin therapy at the time of PCI, and the statin arm (n = 275) included patients who were taking statin medication before PCI. All patients had serial enzymes measured, including creatine kinase (CK), CK-MB, and troponin I. The incidence of increased levels of CK and CK-MB >3 times normal and the absolute increase in CK and troponin I were compared between groups. The control arm had significantly higher periprocedural levels of CK. In the control group, 6% of patients had CK increases >3 times the upper limit of normal compared with 1.8% in the statin group (p = 0.02). The control arm had a higher frequency of CK-MB increases >3 times the upper limit of normal (7.3% vs 2.2%, p = 0.01). There was a trend toward higher levels of troponin I in the control group (3.21 vs 1.85 ng/ml, p = 0.06). Thus, statin therapy before elective PCI was associated with lower levels of periprocedural CK.