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There is an established supply/demand problem in addressing behavioral health needs. A proposed solution is to have primary care providers respond to patients' behavioral health challenges directly. The current study describes the adaptation and evaluation process of Precision Behavioral Health (PBH), a digital-first behavioral health care model with provider-referral to an ecosystem of digital interventions. User-centered design strategies used to adapt the PBH program included applying process to system-level behaviors, defining target users and their needs, defining workflows, rapid prototyping cycles, and a complimentary mixed-methods iterative development phase with a pilot trial. Twenty-one primary care providers, 164 medical assistants and check out staff, and 45 nursing staff were trained as part of the pilot. The RE-AIM implementation framework was used for evaluation. Fourteen primary care providers participated in a semi-structured interview to provide feedback on their experience. The adapted PBH program reached 39.54% of primary care patients seen by the pilot providers during the timeframe. Providers offered PBH to 76.63% of the patients reached, and 26.10% accepted the PBH referral. Out of the accepted patients, 78.15% registered, 73.95% activated their digital intervention, and 59.09% showed clinical improvement in outcomes. Nineteen (90.48%) pilot providers adopted PBH and referred a median of 2 patients each week. Medical assistants/check out staff scheduled 5% of digital care navigator appointments and 84.03% of provider follow up appointments. Primary care providers used the program's clinical decision support tool to aid their discussion and referral process with 95.33% of patients that accepted PBH and selected one of the top 3 recommended tools 95% of the time. Qualitative results identified six broad content categories: Overall PBH referral experience, PBH training, PBH eligibility flag, PBH follow-up appointment workflow, impacts of PBH program on providers, and future modifications. Providers described a positive experience with PBH elements, low burden, positive impact on their jobs, and PBH enhancing treatment options for their patients. Primary care providers identified several adaptations, such as expanding PBH to other types of visits (e.g., sick visits), and optimizing workflow for check-out staff when booking follow-up appointments. Primary care providers are willing and able to successfully refer patients to behavioral health digital interventions with minimal training time for onboarding. Patients referred through primary care demonstrate high acceptance rates, and comparable rates of improvement to those that are referred by licensed behavioral health providers. The results have the potential to impact public health, by increasing behavioral health access for patients without adding burden to providers, and providing healthcare organizations an alternative pathway to address increasing needs without having to increase personnel or introduce major organizational changes., Competing Interests: Declarations. Conflict of Interest: Samuel S. Nordberg has a financial relationship with Mental Health Informatics, which owns the Norse Feedback mea­sure, a measurement-based care tool that has been integrated within routine care at Reliant Medical Group as part of the Precision Behav­ioral Health initiative described in this paper. Samuel S. Nordberg de­clares a potential conflict of interest. Dr. Nordberg has a plan in place with OptumCare and Reliant Medical Group to monitor that the poten­tial conflict of interest does not impact methods, results, and publica­tions related to the Norse Feedback measure or Precision Behavioral Health. No other authors have a conflict of interest to disclose., (© 2025. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Ticagrelor, a P2Y12 inhibitor, offers a rapid onset and consistent platelet inhibition, making it a viable alternative for dual antiplatelet therapy (DAPT). The optimal ticagrelor dose for neurointerventional procedures, however, remains unclear. We report our experience with ticagrelor 60 mg twice daily plus aspirin 81 mg daily compared with the standard aspirin and clopidogrel regimen for intracranial stenting., Methods: We conducted a retrospective analysis of a prospectively maintained database, identifying consecutive patients who underwent intracranial stenting for aneurysm treatment or intracranial atherosclerosis. Patients received either ticagrelor 60 mg with aspirin or aspirin with clopidogrel 75 mg daily. Primary outcomes included peri-procedural ischemic and/or hemorrhagic events within 30 days. Secondary outcomes were the median P2Y12 reaction unit and in-stent stenosis rates at 6-month follow-up., Results: Among 119 patients, 59 received ticagrelor and 60 (50.4%) received clopidogrel. Baseline characteristics including age and gender were comparable between the two groups, although the ticagrelor group had a higher proportion of African-American patients. The majority of patients underwent aneurysm treatment (n=105; 88.23%), while the remainder received stenting for intracranial atherosclerosis (n=14; 11.77%). No ischemic events occurred in either group and intracranial hemorrhage rates were comparable (1.7% in both groups). The median P2Y12 reaction unit was significantly lower in the ticagrelor group (69 vs 126, P<0.001). In-stent stenosis rates were lower with ticagrelor (5% vs 21%)., Conclusion: Ticagrelor 60 mg for DAPT in intracranial stenting is safe and effective. Larger prospective studies may be required to validate these findings., Competing Interests: Competing interests: JM and JF are members of the Society of Neurointerventional Surgery Board of Directors. The authors have no other relevant disclosures., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Stent development has focused recently on low-profile, self-expandable stents compatible with 0.0165 inch microcatheters. The LVIS EVO is the second-generation version of the Low-Profile Visualized Intraluminal Support (LVIS) with improved visibility and resheathability. The LVIS EVO underwent a limited premarket release (PMR) in December 2023. This study aims to report the early safety and feasibility experience with the LVIS EVO stent for the treatment of intracranial aneurysms in the United States (US)., Methods: This was a multicenter, retrospective, observational study evaluating patients who underwent treatment of an intracranial aneurysm with an LVIS EVO stent after the limited PMR. All physicians who had placed an LVIS EVO stent were asked to input their cases after institutional review board approval was obtained. The data were then sent to a single center for analysis. Any patient aged 18 years or older who underwent treatment of an intracranial aneurysm with a LVIS EVO stent in the US was included from the initial PMR in December 2023 until April 2024. Patient age (or ≤90 years old), sex, preoperative modified Rankin Scale (mRS), aneurysm location, aneurysm measurements, and information about preoperative antiplatelet management were all collected. Data on periprocedural complications, 30-day mortality, discharge mRS, and length of stay were also collected., Results: Some 53 patients with 55 aneurysms underwent treatment with the LVIS EVO stent at 15 institutions. All aneurysms were unruptured. The most common location was the anterior communicating artery (35%) followed by the middle cerebral artery bifurcation (31%). All patients were on dual antiplatelet therapy. The average aneurysm size was 5.2 mm with a neck size of 3.7 mm. The smallest distal parent vessel size was 1.2 mm and 36% of stents were deployed in distal parent vessels <2 mm. All (100%) cases had successful deployment and the stent was repositioned in 10% of cases. A single stent was utilized in 91% of cases. Coils were placed in 48 cases (87.2%) and a microcatheter was jailed in 98% of those cases. Immediate Raymond Roy (RR) Class I occlusion was obtained in 33%, Class II in 22%, Class IIIa in 37%, and Class IIIb in 8% of cases. There were no delayed thromboembolic or hemorrhagic complications., Conclusions: The LVIS EVO is a braided, self-expanding, retrievable stent with enhanced visibility and smaller cell size. The drawn filled tube (DFT) technology results in improved visibility of the stent, allowing for more controlled stent positioning and visualization of vessel wall apposition. All cases in our series had complete neck coverage and good wall apposition. There were no thromboembolic or hemorrhagic complications., Competing Interests: Competing interests: BY is a consultant for Imperative Care and Q’Apel Medical, Inc., and has received speaking honoria from Penumbra. EAS is a consultant for MicroVention, Medtronic, Rapid Medical, iSchemaview, and Cerenovus. AS is a consultant/advisory board member for Amnis Therapeutics, Apellis Pharmaceuticals, Inc., Asahi Intecc Co. Ltd., Boston Scientific, Canon Medical Systems USA, Inc., Cardinal Health 200, LLC, Cerebrotech Medical Systems, Inc., CerebrovaKP, Cerenovus, Contego Medical, Cordis, Corindus, Inc., Endostream Medical, Ltd, Hyperfine Operations, Inc., Imperative Care, InspireMD, Ltd., Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Inc., Peijia Medical, Penumbra, Piraeus Medical, Inc., Q’Apel Medical, Inc., Rapid Medical, Serenity Medical, Inc., Shockwave Medical, Inc., Silk Road Medical, StimMed, LLC, Stryker Neurovascular., Synchron Australia Pty Ltd., VasSol, Vesalio, Viz.ai, Inc., WL Gore, and an investor in Adona Medical, Inc., Bend IT Technologies, Ltd., BlinkTBI, Inc., Borvo Medical, Inc., Cerebrotech Medical Systems, Inc., CerebrovaKP, Code Zero Medical, Inc., Cognition Medical, Collavidence, Inc., Contego Medical, CVAID Ltd., E8, Inc., Endostream Medical, Ltd., Galaxy Therapeutics, Inc., Hyperion Surgical, Inc., Imperative Care, Inc., InspireMD, Ltd., Instylla, Inc., Launch NY, Inc., Neurolutions, Inc., NeuroRadial Technologies, Inc. (sold to Medtronic in 2021), Neurovascular Diagnostics, Inc., Peijia Medical, PerFlow Medical, Ltd., Piraeus Medical, Inc., Q’Apel Medical, Inc., QAS.ai, Inc., Radical Catheter Technologies, Inc., Rebound Therapeutics Corp. (purchased 2019 by Integra Lifesciences, Corp.), Rist Neurovascular, Inc. (purchased 2020 by Medtronic), Sense Diagnostics, Inc., Serenity Medical, Inc., Silk Road Medical, Sim & Cure, Spinnaker Medical, Inc., StimMed, LLC, Synchron, Inc., Tulavi Therapeutics, Inc., Vastrax, LLC, Viseon, Inc., Whisper Medical, Inc., Willow Medtech, Inc. OG is a consultant for MicroVention, Stryker, and Route 92. CM is a consultant and proctor for Cerevasc and Silk Road Medical, and a consultant for MicroVention, Medtronic, Stryker, Navigantis, and Hyerbia. MRG is a consultant for Stryker and Rapid Medical. ARP is a consultant for Microvention, IRRAS, Penumbra, and NICO., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)