Analysis of the Vascular Quality Initiative registry shows equivalent unadjusted rates of in-hospital death and stroke across different approaches to shunting and cerebral monitoring with the exception of the awake monitoring group, which has lower unadjusted mortality compared with the routine shunting group. In the risk-adjusted analysis, however, there are no differences across any of the groups. Given the clinical equivalence of approaches to shunting and cerebral monitoring, further work should evaluate the relative cost of these techniques.

This colossal increase attracted renewed attention to generic pharmaceutical price spikes, prompting public outrage and a new round of proposals to address this issue. Over the past few years, increasing drug shortages and price spikes have affected generic drugs, which now account for 86% of prescriptions and 29% of pharmaceutical spending. 1 A stable supply of affordable generic pharmaceuticals is crucial to improve health care access and appropriate utilization for many Americans. A 2014 report from the US Government Accountability Office found that the number of active drug shortages increased steadily from 154 in 2007 to 456 in 2012, and the majority of the affected drugs were generic. 2 According to a recent Senate subcommittee investigation, many generic drugs prices have increased substantially as producers have left the market; for example, the price of albuterol sulfate tablets, used for asthma and other lung diseases, increased 4014% between October 2013 and April 2014 from $11 to $434. 3 These generic drug shortages and price spikes are adverse outcomes of a malfunctioning marketplace. Two features of the US generic drug market make it more prone to price swings and shortages than other commodity markets. First, entry into the generic drug market is restricted, including financial barriers (the cost of product formulation, quality assurance, and bioequivalence testing) and a time barrier due to the need for abbreviated clinical testing and the uncertainty of the Abbreviated New Drug Application (ANDA) review cycle. Second, again in contrast to more efficient commodity markets, there are barriers to the substitution of other products for a given generic drug molecule. The economics of the generic drug market are driven by the opportunity for 180 days of market exclusivity for the first generic product on the market. These products are available at prices only slightly reduced from those of the originator products. Generic manufacturers may enter the market after 180 days in the hope of a substantial financial return in the short period of time before the price of the product declines. Firms take a calculated risk in financing bioequivalence studies and in entering the marketplace without knowing how many competitors will enter the market nor how quickly the price of the product will decline. As other firms enter the market and the price of a product approaches its marginal cost, the incentive to remain a supplier diminishes. 4 At that time, firms make decisions about exiting the market without knowledge of the actions of other firms.

This study provides a pathway for using NASBA in developing POC diagnostic assays.

Case We describe the case of a dorsalis pedis artery pseudoaneurysm that developed following a repeat ankle arthrotomy for persistent bony impingement. The patient underwent attempted fluid aspiration for a presumed effusion, and ultimately experienced rupture of the aneurysm with significant blood loss and need for emergent vascular repair. Conclusion Anterior tibial or dorsalis pedis artery pseudoaneurysms are relatively rare but well-documented complications of ankle arthroscopy; however, their clinical significance is poorly understood. To our knowledge, this is the first reported case of a ruptured dorsalis pedis artery pseudoaneurysm following ankle surgery, and it highlights the need for timely diagnosis.

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We reviewed the published report 1 with great interest and commend the authors on seeking to complete an analysis of such a large cohort. Protection against hypoperfusion injury offered by shunting in carotid endarterectomy remains a topic around which there is much debate. There is wide variation not only nationally and internationally but between surgeons within individual units. There is conflicting evidence to support and to disparage intraoperative shunt use. Larger scale reviews have been unable to make definitive conclusions to support either standpoint as there is insufficient strong evidence. 2 This lack of clear evidence to guide best practice combined with potentially catastrophic sequelae of perioperative stroke may have contributed to clinicians' adopting a single surgical approach as evidenced in this article by the number of surgeons performing >90% of their endarterectomies a single way. The relatively small size of the never shunt cohort highlights surgeons' adversity to exposing patients to perceived increased procedural risk despite little evidence.Our unit has published experimental biochemical data, using purine nucleosides (adenosine inosine and hypoxanthine) as real-time indicators of cerebral ischemia in local anesthetic (awake) endarterectomy. 3 Purines are a highly sensitive biomarker and in this context could be used to assess evolving intraoperative cerebral ischemia. Results of the study repeated using general anesthetic revealed no increase in purine concentration during carotid cross-clamping (as yet unpublished results). These findings combined with studies of cerebral metabolism during endarterectomy as well as anesthesia literature 4,5 indicate that general anesthesia causes loss of the cerebral metabolism-blood flow (demand and supply) coupling. This causes "luxury perfusion" of cerebral tissue. Our conclusions from this are that general anesthesia serves to decrease cerebral metabolic rate to a degree whereby hypoperfusion-related ischemic injury is unlikely even without shunt use, and shunting may well be unnecessary in many patients. This is supported by the noninferior outcomes of no shunt compared with selective or routine shunting published here. A prospective study of sufficient size with sufficient power to conclusively demonstrate this and to effect change in shunting practice remains a significant challenge.

statistically significant correlation with positive family history of CBT (P < .0001), earlier age of presentation (P < .0001), symptomatic presentation of CBT (P < .0001), and postoperative complications after CBT excision (P < .0001). Mean age at diagnosis of patients with SDH mutations was 38.8 years, whereas patients without SDH mutations presented at a mean age of 51.3 years. In patients with SDH mutations, mean tumor diameter, average operating time, average operative blood loss, and distribution of Shamblin type 1, 2, and 3 lesions were not significantly different from patients without SDH mutations.Conclusions: Carotid body tumors can be treated with minimal morbidity and mortality; however, the subgroup of patients with positive SDH mutations may represent a variant group of younger patients with greater postoperative morbidity. Vascular surgeons should be aware of genetic testing to identify patients who may be at greater risk of operative morbidity. Concomitant lymph node excision does not appear to add value in the absence of clinic suspicion for malignancy.