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Introduction The Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis (SAMMPRIS) trial published in 2010 showed aggressive medical therapy is superior to percutaneous transluminal angioplasty and stenting (PTAS) for intracranial atherosclerotic disease (ICAD). Following the pivotal positive mechanical thrombectomy (MT) trials in 2015, MT utilization in the United States (US) has increased. Rescue ICAD stenting may be needed in MT patients with underlying ICAD but it remains uncertain whether PTAS use for ICAD has changed over this time. The aim of this study is to describe national trends in the utilization of PTAS for ICAD in the US before and after SAMMPRIS and following the pivotal MT trials. Methods We used a constellation of International Classification of Diseases ninth and tenth revision diagnostic/procedural codes to identify all elective and non‐elective adult (> = 18 years) ICAD admissions with or without infarction containing concomitant codes for PTAS in the 2007–2019 National Inpatient Sample. Admissions containing codes for subarachnoid hemorrhage, unruptured intracranial aneurysms or benign intracranial hypertension were excluded. We combined weighted counts of PTAS admissions with annual US adult census data to obtain prevalence of PTAS. We used joinpoint regression to evaluate trends in PTAS use over time. Results Across the study period, there were 16,477 weighted admissions for ICAD undergoing PTAS in the US. 52.4% of these admissions were in patients 60–79years and 43.2% were in women. 74.3% of these admissions were non‐elective and this proportion increased over time (P = 0.019). 26.5% of all admissions had concurrent codes for MT but this proportion increased by almost ten‐fold over time from 4.3% in 2007 to 40.0% in 2019. On join point regression, PTAS utilization increased but insignificantly from 3.0/million population in 2007 to 5.7/million population in 2010 (Annualized percentage change, APC 11.2%, 95%CI ‐11.8 to 40.3, p = 0.290), declined also insignificantly from 2010–2013 (APC ‐13.2, 95%CI ‐48.4 to 45.8, p = 0.514) and increased significantly from 3.55/million in 2013 to 3.80/million in 2014 and exponentially across the rest of the period to 8.4 cases/million in 2019 (APC 15.4, 95%CI 9.2 to 22.0, p = 0.001). Upon stratification by admission type, most of the increase across the period 2013/2014 to 2019 occurred in non‐elective admissions (Figure 1). Utilization in elective admissions varied from 0.92 to 1.96 cases per million population but this did not change significantly across the study period. Conclusions PTAS utilization for ICAD declined in the US after SAMMPRIS but has increased following publication of pivotal MT trials mainly in non‐elective admissions. PTAS utilization increased significantly following publication of pivotal MT trials likely in ICAD patients who required rescue stenting.. Additional prospective studies are needed to determine the long‐term outcomes of concurrent PTAS and MT as this is not a group of patients that was studied in SAMMPRIS.

BackgroundEffects of major dietary macronutrients on glucose-insulin homeostasis remain controversial and may vary by the clinical measures examined. We aimed to assess how saturated fat (SFA), monounsaturated fat (MUFA), polyunsaturated fat (PUFA), and carbohydrate affect key metrics of glucose-insulin homeostasis.Methods and findingsWe systematically searched multiple databases (PubMed, EMBASE, OVID, BIOSIS, Web-of-Knowledge, CAB, CINAHL, Cochrane Library, SIGLE, Faculty1000) for randomised controlled feeding trials published by 26 Nov 2015 that tested effects of macronutrient intake on blood glucose, insulin, HbA1c, insulin sensitivity, and insulin secretion in adults aged ≥18 years. We excluded trials with non-isocaloric comparisons and trials providing dietary advice or supplements rather than meals. Studies were reviewed and data extracted independently in duplicate. Among 6,124 abstracts, 102 trials, including 239 diet arms and 4,220 adults, met eligibility requirements. Using multiple-treatment meta-regression, we estimated dose-response effects of isocaloric replacements between SFA, MUFA, PUFA, and carbohydrate, adjusted for protein, trans fat, and dietary fibre. Replacing 5% energy from carbohydrate with SFA had no significant effect on fasting glucose (+0.02 mmol/L, 95% CI = -0.01, +0.04; n trials = 99), but lowered fasting insulin (-1.1 pmol/L; -1.7, -0.5; n = 90). Replacing carbohydrate with MUFA lowered HbA1c (-0.09%; -0.12, -0.05; n = 23), 2 h post-challenge insulin (-20.3 pmol/L; -32.2, -8.4; n = 11), and homeostasis model assessment for insulin resistance (HOMA-IR) (-2.4%; -4.6, -0.3; n = 30). Replacing carbohydrate with PUFA significantly lowered HbA1c (-0.11%; -0.17, -0.05) and fasting insulin (-1.6 pmol/L; -2.8, -0.4). Replacing SFA with PUFA significantly lowered glucose, HbA1c, C-peptide, and HOMA. Based on gold-standard acute insulin response in ten trials, PUFA significantly improved insulin secretion capacity (+0.5 pmol/L/min; 0.2, 0.8) whether replacing carbohydrate, SFA, or even MUFA. No significant effects of any macronutrient replacements were observed for 2 h post-challenge glucose or insulin sensitivity (minimal-model index). Limitations included a small number of trials for some outcomes and potential issues of blinding, compliance, generalisability, heterogeneity due to unmeasured factors, and publication bias.ConclusionsThis meta-analysis of randomised controlled feeding trials provides evidence that dietary macronutrients have diverse effects on glucose-insulin homeostasis. In comparison to carbohydrate, SFA, or MUFA, most consistent favourable effects were seen with PUFA, which was linked to improved glycaemia, insulin resistance, and insulin secretion capacity.