Purpose of review

Multivessel coronary artery disease, defined as significant stenosis in two or more major coronary arteries, is associated with high morbidity and mortality. The diagnosis and treatment of multivessel disease have evolved in the PCI era from solely a visual estimation of ischemic risk to a functional evaluation during angiography. This review summarizes the evidence and discusses the commonly used methods of multivessel coronary artery stenosis physiologic assessment.

Recent findings

While FFR remains the gold standard in coronary physiologic assessment, several pressure-wire-based non-hyperemic indices of functional stenosis have been developed and validated as well as wire-free angiographically derived quantitative flow ratio. Identifying and treating functionally significant coronary atherosclerotic lesions reduce symptoms and major adverse cardiovascular events. Coronary physiologic assessment in multivessel disease minimizes the observer bias in visual estimates of stenosis, changes clinical management, and improves patient outcomes.

Background

The Cancer Center Cessation Initiative (C3I) was launched in 2017 as a part of the NCI Cancer Moonshot program to assist NCI-designated cancer centers in developing tobacco treatment programs for oncology patients. Participating centers have implemented varied evidence-based programs that fit their institutional resources and needs, offering a wide range of services including in-person and telephone-based counseling, point of care, interactive voice response systems, referral to the quitline, text- and web-based services, and medications.

Methods

We used a mixed methods comparative case study design to evaluate system-level implementation costs across 15 C3I-funded cancer centers that reported for at least one 6-month period between July 2018 and June 2020. We analyzed operating costs by resource category (e.g., personnel, medications) concurrently with transcripts from semi-structured key-informant interviews conducted during site visits. Personnel salary costs were estimated using Bureau of Labor Statistics wage data adjusted for area and occupation, and non-wage benefits. Qualitative findings provided additional information on intangible resources and contextual factors related to implementation costs.

Results

Median total monthly operating costs across funded centers were $11,045 (range: $5129-$20,751). The largest median operating cost category was personnel ($10,307; range: $4122-$19,794), with the highest personnel costs attributable to the provision of in-person program services. Monthly (non-zero) cost ranges for other categories were medications ($17-$573), materials ($6-$435), training ($96-$516), technology ($171-$2759), and equipment ($10-$620). Median cost-per-participant was $466 (range: $70-$2093) and cost-per-quit was $2688 (range: $330-$9628), with sites offering different combinations of program components, ranging from individually-delivered in-person counseling only to one program that offered all components. Site interviews provided context for understanding variations in program components and their cost implications.

Conclusions

Among most centers that have progressed in tobacco treatment program implementation, cost-per-quit was modest relative to other prevention interventions. Although select centers have achieved similar average costs by offering program components of various levels of intensity, they have varied widely in program reach and effectiveness. Evaluating implementation costs of such programs alongside reach and effectiveness is necessary to provide decision makers in oncology settings with the important additional information needed to optimize resource allocation when establishing tobacco treatment programs.

Background

The Cancer Center Cessation Initiative (C3I) is a National Cancer Institute (NCI) Cancer Moonshot Program that supports NCI-designated cancer centers developing tobacco treatment programs for oncology patients who smoke. C3I-funded centers implement evidence-based programs that offer various smoking cessation treatment components (e.g., counseling, Quitline referrals, access to medications). While evaluation of implementation outcomes in C3I is guided by evaluation of reach and effectiveness (via RE-AIM), little is known about technical efficiency-i.e., how inputs (e.g., program costs, staff time) influence implementation outcomes (e.g., reach, effectiveness). This study demonstrates the application of data envelopment analysis (DEA) as an implementation science tool to evaluate technical efficiency of C3I programs and advance prioritization of implementation resources.

Methods

DEA is a linear programming technique widely used in economics and engineering for assessing relative performance of production units. Using data from 16 C3I-funded centers reported in 2020, we applied input-oriented DEA to model technical efficiency (i.e., proportion of observed outcomes to benchmarked outcomes for given input levels). The primary models used the constant returns-to-scale specification and featured cost-per-participant, total full-time equivalent (FTE) effort, and tobacco treatment specialist effort as model inputs and reach and effectiveness (quit rates) as outcomes.

Results

In the DEA model featuring cost-per-participant (input) and reach/effectiveness (outcomes), average constant returns-to-scale technical efficiency was 25.66 (SD = 24.56). When stratified by program characteristics, technical efficiency was higher among programs in cohort 1 (M = 29.15, SD = 28.65, n = 11) vs. cohort 2 (M = 17.99, SD = 10.16, n = 5), with point-of-care (M = 33.90, SD = 28.63, n = 9) vs. no point-of-care services (M = 15.59, SD = 14.31, n = 7), larger (M = 33.63, SD = 30.38, n = 8) vs. smaller center size (M = 17.70, SD = 15.00, n = 8), and higher (M = 29.65, SD = 30.99, n = 8) vs. lower smoking prevalence (M = 21.67, SD = 17.21, n = 8).

Conclusion

Most C3I programs assessed were technically inefficient relative to the most efficient center benchmark and may be improved by optimizing the use of inputs (e.g., cost-per-participant) relative to program outcomes (e.g., reach, effectiveness). This study demonstrates the appropriateness and feasibility of using DEA to evaluate the relative performance of evidence-based programs.

Background

Physicians are not always comfortable deferring treatment of a stenosis in the left anterior descending (LAD) artery because of the perception that there is a high risk of major adverse cardiac events (MACE). The authors describe, using the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) trial, MACE rates when LAD lesions are deferred, guided by physiological assessment using fractional flow reserve (FFR) or the instantaneous wave-free ratio (iFR).

Objectives

The purpose of this study was to establish the safety of deferring treatment in the LAD using FFR or iFR within the DEFINE-FLAIR trial.

Methods

MACE rates at 1 year were compared between groups (iFR and FFR) in patients whose physiological assessment led to LAD lesions being deferred. MACE was defined as a composite of cardiovascular death, myocardial infarction (MI), and unplanned revascularization at 1 year. Patients, and staff performing follow-up, were blinded to whether the decision was made with FFR or iFR. Outcomes were adjusted for age and sex.

Results

A total of 872 patients had lesions deferred in the LAD (421 guided by FFR, 451 guided by iFR). The event rate with iFR was significantly lower than with FFR (2.44% vs. 5.26%; adjusted HR: 0.46; 95% confidence interval [CI]: 0.22 to 0.95; p = 0.04). This was driven by significantly lower unplanned revascularization with iFR and numerically lower MI (unplanned revascularization: 2.22% iFR vs. 4.99% FFR; adjusted HR: 0.44; 95% CI: 0.21 to 0.93; p = 0.03; MI: 0.44% iFR vs. 2.14% FFR; adjusted HR: 0.23; 95% CI: 0.05 to 1.07; p = 0.06).

Conclusions

iFR-guided deferral appears to be safe for patients with LAD lesions. Patients in whom iFR-guided deferral was performed had statistically significantly lower event rates than those with FFR-guided deferral.

A search for Higgs boson pair production in the bb¯ bb¯ final state is carried out with up to 36.1 fb−1 of LHC proton-proton collision data collected at s=13 TeV with the ATLAS detector in 2015 and 2016. Three benchmark signals are studied: a spin-2 graviton decaying into a Higgs boson pair, a scalar resonance decaying into a Higgs boson pair, and Standard Model non-resonant Higgs boson pair production. Two analyses are carried out, each implementing a particular technique for the event reconstruction that targets Higgs bosons reconstructed as pairs of jets or single boosted jets. The resonance mass range covered is 260–3000 GeV. The analyses are statistically combined and upper limits on the production cross section of Higgs boson pairs times branching ratio to bb¯ bb¯ are set in each model. No significant excess is observed; the largest deviation of data over prediction is found at a mass of 280 GeV, corresponding to 2.3 standard deviations globally. The observed 95% confidence level upper limit on the non-resonant production is 13 times the Standard Model prediction.[Figure not available: see fulltext.].

Abstract: The ratio of branching ratios of the W boson to muons and electrons, $$R^{\,\mu /e}_W={{\mathcal {B}}(W\rightarrow \mu u )}$$ R W μ / e = B ( W → μ ν ) /$${{\mathcal {B}}(W\rightarrow e u )}$$ B ( W → e ν ) , has been measured using $$140\,\text{ fb}^{-1}\,$$ 140 fb - 1 of pp collision data at $$\sqrt{s}=13$$ s = 13  $$\text {T}\text {e}\hspace{-1.00006pt}\text {V}$$ Te V collected with the ATLAS detector at the LHC, probing the universality of lepton couplings. The ratio is obtained from measurements of the $$t\bar{t}$$ t t ¯ production cross-section in the ee, $$e\mu $$ e μ and $$\mu \mu $$ μ μ dilepton final states. To reduce systematic uncertainties, it is normalised by the square root of the corresponding ratio $$R^{\,\mu \mu /ee}_Z$$ R Z μ μ / e e for the Z boson measured in inclusive $$Z\rightarrow ee$$ Z → e e and $$Z\rightarrow \mu \mu $$ Z → μ μ events. By using the precise value of $$R^{\,\mu \mu /ee}_Z$$ R Z μ μ / e e determined from $$e^+e^-$$ e + e - colliders, the ratio $$R^{\,\mu /e}_W$$ R W μ / e is determined to be $$\begin{aligned} R^{\,\mu /e}_W&= 0.9995\pm 0.0022\,\mathrm {(stat)}\,\pm 0.0036\,\mathrm {(syst)}\ &\quad \pm 0.0014\,\mathrm {(ext)} . \end{aligned}$$ R W μ / e = 0.9995 ± 0.0022 ( stat ) ± 0.0036 ( syst ) ± 0.0014 ( ext ) . The three uncertainties correspond to data statistics, experimental systematics and the external measurement of $$R^{\,\mu \mu /ee}_Z$$ R Z μ μ / e e , giving a total uncertainty of 0.0045, and confirming the Standard Model assumption of lepton flavour universality in W-boson decays at the 0.5% level.

A search for a long-lived, heavy neutral lepton (N) in 139  fb^{-1} of sqrt[s]=13  TeV pp collision data collected by the ATLAS detector at the Large Hadron Collider is reported. The N is produced via W→Nμ or W→Ne and decays into two charged leptons and a neutrino, forming a displaced vertex. The N mass is used to discriminate between signal and background. No signal is observed, and limits are set on the squared mixing parameters of the N with the left-handed neutrino states for the N mass range 3  GeV