Hirsh and Meyers espouse that same party line of the many private non -governmental agencies (and academics who will personally benefit from this program) who wish to impose private interest group-unproven corporate interests upon practicing physicians. They continue to state MOC is "voluntary" and then describe the many ways these "non-profit" corporations (who earn handsomely and have over $400 million in assets and as great yearly gross receipts!) will see this product forced on physicians. HOWEVER, Working physicians do not want or even see any value in this unproven imposition:

The American Medical Association (AMA) developed the Physician's Recognition Award (PRA) in the late 1960's as the validation program for Continuing Medical Education (CME), embraced by most, but not all states, to validate physician "lifelong learning" as the educational component of re-licensure. Recently, the Federation of State Medical Boards (FSMB), Inc., a multimillion dollar, non-profit and non-governmental corporation, targeted the State of Ohio as the first of 11 pilot states to implement their corporate brand of MOL (Ohio., Calif., Colo., Del., Iowa, Mass., Mississippi, Okla., Ore., Va., Wis.). On May 19, 2012, the Ohio State Medical Association, as the first Ohio physician organization, formally resolved at the state meeting to oppose the FSMB MOL program. (1) OSMA recognized early that FSMB MOL was the unwarranted regulatory capture of physician licensure: the act of securing corporate income through legislation. (2) An intense battle over FSMB MOL ensued within the State Medical Board of Ohio (SMBO), zealously led by two FSMB board members, who also occupied the SMBO Executive Director and one senior Board member positions. On October 5, 2012, the OSMA drafted with 10 other state medical associations, representing over 15,000 physicians, a formal resolution of opposition directed to the SMBO. (3) The defeat of the FSMB MOL proposal by SMBO vote followed on October 11, 2012. In the aftermath, the two FSMB board members serving on the SMBO were formally reviewed. The Executive Director of the SMBO was ousted October 12th and formal investigations regarding violations of conflict of interests continue regarding the senior SMBO member. (4) Subsequent communications with legal offices of the SMBO and OSMA concluded that: 1) FSMB MOL was not advocated by any other corporate, government or consumer groups, no deficiency of AMA PRA CME programs or physician competency issues were identified in Ohio and 2) FSMB MOL initiative appeared solely promulgated by the FSMB as a corporate mandate. It continues to be actively advocated by FSMB in 9 states and must be either fought or approved in each state. FSMB MOL serves primarily corporate coffers and false reassurance through testing vs CME. Effective physician opposition is primarily possible via grass-roots resolutions at state level. We must inform and support all state organizations at this time regarding FSMB MOL, using this "Ohio experience" as evidence and instruction in opposing this regulatory capture of physicians, solely for corporate profits. (5) The assertions by the Certification industrial complex including the ABMS that MOC and MOL are "Done deals" is simple propaganda-nothing more!

References: 1) Ohio State Medical Association Statement on MOL. Available at: http://www.osma.org/files/pdf/facts-maintenance-of-licensure-final-.pdf Accessed 10/27/12

2)Kempen PM: Maintenance of Certification (MOC), Maintenance of Licensure (MOL), and Continuing Medical Education (CME):the Regulatory Capture of Medicine. Journal of American Physicians and Surgeons 2012; 17:72-5. Available at: http://www.jpands.org/vol17no3/kempen.pdf Accessed 10/27/12 3) Kumar D et al: Joint letter from 11 medical societies to the SMBO. Available at: http://www.itraumaohio.org/aws/OACEP/asset_manager/get_file/54757/2012.10.5_joint_mol_letter_to_medical_board.pdf Accessed 10/27/12 4) Alan Johnson In The Columbus Dispatch Thursday October 18, 2012 6:07 AM: State medical board ousts chief Available at: http://www.dispatch.com/content/stories/local/2012/10/18/state-medical- board-ousts-chief.html Accessed 10/27/12 5)Kempen PM: What to do about MOC and MOL? Available at: http://www.youtube.com/watch?v=WRS15Dmsk7E Accessed Nov 1, 2012

Conflict of Interest:

None declared

Dear Sir,

We thank the authors for their letter entitled, "Caution during use of DDAVP in IPSS," by Drs. Pecori Giraldi, Federici, and Cavagnini. The authors suggest that because of the hypercoagulable state that characterizes Cushing disease, DDAVP may not be safe since it has been shown to increase the level of von Willebrand factor (vWF) and could therefore lead to platelet adhesion and cause thromboembolism. The authors point to their own published work suggesting this effect (1). In this paper, the authors show that not only vWF levels increase, but also t-PA, likely to achieve a balance by activating fibrinolytic pathways. Therefore, increased risk of thromboembolic events in Cushing disease patients in the context of DDAVP administration is a theoretical consideration.

Thromboembolism is a rare complication of BIPSS and when reported, has been linked to lack of prophylaxis with IV heparin (2, 3). In our practice, we routinely heparinize patients undergoing BIPSS, whether they receive CRH or DDAVP to stimulate the pituitary (4). The case series previously reported where DDAVP was used rather than CRH do not indicate an increased risk of thromboembolic events (5-8). As the increased risk of thromboembolism is only a theoretical consideration, we can only use this available clinical data. Because the sensitivity of BIPSS is significantly increased by the use of CRH or DDAVP, the benefits of using DDAVP appear at this point to outweigh the theoretical risks. One possible positive outcome of the CRH shortage is that more data will be accumulated to determine whether there are unexpected negative effects of using DDAVP.

1. Pecori Giraldi F, Ambrogio AG, Fatti LM, Rubini V, Cozzi G, Scacchi M et al. Von Willebrand factor and fibrinolytic parameters during the desmopressin test in patients with Cushing's disease. Br.J.Pharmacol. 2011;71:132-6.

2. Blevins LS Jr, Clark RV, Owens DS. Thromboembolic complications after inferior petrosal sinus sampling in patients with Cushing's syndrome. Endocr Pract 1998; 4:365-367.

3. Obuobie K, Davies JS, Ogunko A, Scanlon MF. Venous thrombo- embolism following inferior petrosal sinus sampling in Cushing's disease. J Endocrinol Invest 2000; 23:542-544.

4. Deipolyi...Oklu et al. The role of bilateral inferior petrosal sinus sampling in the diagnostic evaluation of Cushing syndrome. Diagn Interv Radiol 2012; 18:132-138

5. Castinetti F, Morange I, Dufour H, et al. Desmopressin test during petrosal sinus sampling: a valuable tool to discriminate pituitary or ectopic ACTH-dependent Cushing's syndrome. Eur J Endocrinol 2007;157:271- 7.

6. Machado MC, de Sa SV, Domenice S, et al. The role of desmopressin in bilateral and simultaneous inferior petrosal sinus sampling for differential diagnosis of ACTH-dependent Cushing's syndrome. Clin Endocrinol (Oxf) 2007;66:136-42.

7. Malerbi DA, Mendonca BB, Liberman B, et al. The desmopressin stimulation test in the differential diagnosis of Cushing's syndrome. Clin Endocrinol (Oxf) 1993;38:463-72.

8. Salgado LR, Mendon??a BB, Pereira MAA, et al. Use of Desmopressin in Bilateral and Simultaneous Inferior Petrosal Sinus Sampling for Differential Diagnosis of ACTH-Dependent Cushing's Syndrome. The Endocrinologist 1997;7:135-40.

Conflict of Interest:

None declared

The reply from Perez et al to my letter of March 2012 is misleading and wrong in two important regards.1 First, they state that their report of the use of the solitaire stent for thrombectomy was just a case report, "nothing else". 2 This is not true. In fact, they explicitly use this report, both in the abstract and conclusion to lay claim for developing the stentreiever concept for thrombectomy: "This was the first .. use of the Solitaire stent for this purpose and the ignition spark for the development of a whole new generation of devices". In addition, this report was titled a "Historical Vignette". This report was written to take credit for the development of stentreivers for acute stroke. To state, as they do in their response to my letter, that their paper makes no claims is clearly disingenuous.

Second, they dismiss the idea that the prior publication by Kelly et al -- reporting the use of an Enterprise stent (Codman Neurovascular, Rayhnam, MA) as a temporary endovascular bypass to achieve successful revascularization in a patient with an acute ischemic stroke and large vessel occlusion -- had any influence on their work. This claim is disingenuous as well. In their response, they state that " ... temporary bypass might have been a local and ephemeral phenomenon; however it did not cause to much commotion, at least in Europe." However, the technique of stent-retrieval, or any kind of temporary stenting for acute stroke is, in fact, part and parcel of "temporary endovascular bypass". The best evidence of this is that the authors presented their own original experience with the Solitaire at the 2010 International Stroke Conference in an abstract entitled "Temporary Endovascular Bypass for the treatment of ischemic stroke: Experience After 50 Patients". Clearly their work with the Solitaire stent in acute stroke was influenced by this prior report.

In summary, despite their claims, the concept of temporary stenting for acute stroke treatment preceded the authors' 2008 case. In their Historical Vignette and subsequent response to my prior letter, the authors are attempting to rewrite history. They do deserve credit for taking this concept and rapidly moving it forward in clinical practice, however. References: 1. Re: Perez et al 'Intracranial thrombectomy using the Solitaire stent: a historical vignette'. Derdeyn CP. J Neurointerv Surg. 2012 Mar;4(2):153-4; Author Response 154 2. Intracranial thrombectomy using the Solitaire stent: a historical vignette. P?rez MA, Miloslavski E, Fischer S, B?zner H, Henkes H. J Neurointerv Surg. 2011 Dec 14. 3. Kelly ME, Furlan AJ, Fiorella D. Recanalization of an acute middle cerebral artery occlusion using a self-expanding, reconstrainable, intracranial microstent as a temporary endovascular bypass. Stroke 2008;39:1770-3. 4. Liebig T, Lockau H, Stehle S, Dorn F, Prothmann S, Henkes HH. Temporary Endovascular Bypass in Acute Stroke: Experience After 50 Patients. Stroke 2010 Vol 41,1:e259-260.

Conflict of Interest:

None declared

We would like to thank Dr Hirsch and colleagues from Massachusetts General Hospital for their insightful comment on our paper.1 The authors advocate a more cautious conclusion regarding the efficacy of endovascular stroke intervention in the elderly since a control group of younger patients is lacking in our study. Although comparison to a younger group of patients is interesting, such data can hardly be used for drawing definitive conclusions regarding the efficacy of endovascular therapy. A clinical comparison between young and older patients is unfortunately not possible due to tremendous differences between the two study populations, such as pre-existing medical comorbidities and dementia. Randomized controlled studies comparing patient outcomes with intra-arterial therapy versus intravenous thrombolysis or best medical management will be needed to provide definitive information on the best therapeutic approach in this patient population.

In patients with NIHSS of 8 or above who have failed or were not eligible for intravenous thrombolysis, such as in our study population, medical therapy is unfortunately limited to supportive management. Most of these patients are destined to end of life care or are neurologically devastated from their stroke. In an era of FDA-approved intra-arterial thrombolysis, there is an ethical dilemma in randomizing patients that meet criteria to such life-saving interventions to medical therapies, regardless of their age group. It is therefore extremely challenging to obtain level-one evidence data in the elderly or any other age population comparing medical and endovascular stroke therapies.

Timely recanalization in acute ischemic stroke improves patient outcomes.2-4 Arterial recanalization can be achieved by intravenous or intraarterial means. Evidence suggests that treatment benefit with intravenous tissue plasminogen activator (IV-tPA) extends to patients older than 80 years.5 It is therefore plausible that intra-arterial thrombolysis could confer a similar benefit in elderly patients. In our study, almost a third of elderly patients achieved favorable outcomes with intraarterial thrombolysis, and similar rates were also reported by other investigators.6-7 In our opinion, such rates can be regarded as satisfactory considering the compromised collateral circulation, the reduced neuronal reserve, as well as the high frequency of pre-stroke comorbid conditions in this age group. However, we agree with Dr Hirsch and colleagues that this would require further confirmation by prospective controlled data.

In a recently published study by Chandra and colleagues8 from Massachusetts General Hospital, 49 elderly and 130 nonelderly patients treated between 2005 and 2010 were rigorously compared with respect to angiographic reperfusion, rate of parenchymal hematoma, and 90-day clinical outcome. The authors report comparable rates of reperfusion and hemorrhage between the two groups but favorable outcomes in only 2% of elderly patients and conclude that recanalization in this group "may be futile". In our view, these results warrant a more cautious conclusion than the one advocated in their report not only because comparison to a control group treated with medical therapy is lacking but also for the following reasons. 1) Nearly 33% of elderly patients in their study were disabled at baseline (mRS score 2 or greater), which makes the prospect of a favorable outcome nearly impossible in as many as one-third of their cohort. 2) Medical care was withdrawn in 55% of elderly patients, which obviously complicates any assessment of outcome. 3) CT perfusion data was not used to select patients for acute stroke intervention, which could possibly suggest that some patients with little or no salvageable brain tissue may have undergone endovascular treatment. In fact, CT perfusion can optimize patient selection for endovascular recanalization based on an individual's physiological parameters rather than an arbitrary time frame and may be of greater value in this specific population by helping identify "the subset of elderly patients who may benefit" from treatment.9 -11

Finally, we agree with Dr Hirsch and colleagues that endovascular stroke intervention in elderly patients is safe. Although the question of its efficacy requires more investigation, we believe that elderly patients should not be excluded from consideration for treatment especially if perfusion studies indicate adequate penumbra. The significance of proper patient selection for endovascular recanalization cannot be overstressed.

References

1.Ghobrial GM, Chalouhi N, Rivers L, et al. Multimodal endovascular management of acute ischemic stroke in patients over 75 years old is safe and effective. J Neurointerv Surg. Jul 11 2012.

2.Meyers PM, Schumacher HC, Connolly ES, Jr., Heyer EJ, Gray WA, Higashida RT. Current status of endovascular stroke treatment. Circulation. Jun 7 2011;123(22):2591-2601.

3.Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. Dec 14 1995;333(24):1581-1587.

4.Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. Sep 25 2008;359(13):1317-1329.

5.Mishra NK, Diener HC, Lyden PD, Bluhmki E, Lees KR. Influence of age on outcome from thrombolysis in acute stroke: a controlled comparison in patients from the Virtual International Stroke Trials Archive (VISTA). Stroke. Dec 2010;41(12):2840-2848.

6.Loh Y, Kim D, Shi ZS, et al. Higher rates of mortality but not morbidity follow intracranial mechanical thrombectomy in the elderly. AJNR Am J Neuroradiol. Aug 2010;31(7):1181-1185.

7.Kim D, Ford GA, Kidwell CS, et al. Intra-arterial thrombolysis for acute stroke in patients 80 and older: a comparison of results in patients younger than 80 years. AJNR Am J Neuroradiol. Jan 2007;28(1):159-163.

8.Chandra RV, Leslie-Mazwi TM, Oh DC, et al. Elderly Patients Are at Higher Risk for Poor Outcomes After Intra-Arterial Therapy. Stroke. Jun 28 2012.

9.Abou-Chebl A. Endovascular treatment of acute ischemic stroke may be safely performed with no time window limit in appropriately selected patients. Stroke. Sep 2010;41(9):1996-2000.

10.Jovin TG, Liebeskind DS, Gupta R, et al. Imaging-based endovascular therapy for acute ischemic stroke due to proximal intracranial anterior circulation occlusion treated beyond 8 hours from time last seen well: retrospective multicenter analysis of 237 consecutive patients. Stroke. Aug 2011;42(8):2206-2211.

11.Natarajan SK, Snyder KV, Siddiqui AH, Ionita CC, Hopkins LN, Levy EI. Safety and effectiveness of endovascular therapy after 8 hours of acute ischemic stroke onset and wake-up strokes. Stroke. Oct 2009;40(10):3269-3274.

Conflict of Interest:

None declared