MedStar Health

BACKGROUND:Whether anticoagulation alone is an adequate treatment for acute, intermediate-risk pulmonary embolism is uncertain. METHODS:We conducted a multinational, adaptive-design trial with blinded outcome adjudication. Patients with intermediate-risk pulmonary embolism (with a ratio of right ventricular end-diastolic diameter to left ventricular end-diastolic diameter of ≥1.0 and an elevated troponin level) were eligible if they had at least two indicators of cardiorespiratory distress (systolic blood pressure of ≤110 mm Hg, a heart rate of ≥100 beats per minute, or a respiratory rate of >20 breaths per minute). Patients were randomly assigned to undergo ultrasound-facilitated, catheter-directed fibrinolysis with alteplase plus anticoagulation (the intervention group) or anticoagulation alone (the control group) according to prespecified treatment protocols. The primary outcome was a composite of pulmonary embolism-related death, cardiorespiratory decompensation or collapse, or symptomatic recurrence of pulmonary embolism within 7 days. RESULTS:The intention-to-treat population comprised 544 patients: 273 in the intervention group and 271 in the control group. The mean (±SD) age was 58.2±13.5 years, and 42.6% of the patients were women. A primary-outcome event occurred in 11 patients (4.0%; 95% confidence interval [CI], 2.3 to 7.1) in the intervention group and 28 (10.3%; 95% CI, 7.2 to 14.5) in the control group (relative risk, 0.39; 95% CI, 0.20 to 0.77; P = 0.005). The effect was driven primarily by a lower risk of cardiorespiratory decompensation or collapse in the intervention group. Major bleeding occurred within 7 days after randomization in 11 patients (4.1%) in the intervention group and 6 (2.2%) in the control group (P = 0.32); major bleeding occurred within 30 days in 11 patients (4.1%) and 8 patients (3.0%), respectively (P = 0.64). No substantial between-group differences in the incidence of other serious adverse events were observed up to 30 days after randomization; no intracranial hemorrhage occurred. CONCLUSIONS:In patients with acute, intermediate-risk pulmonary embolism, ultrasound-facilitated, catheter-directed fibrinolysis plus anticoagulation led to a lower risk of the composite of pulmonary embolism-related death, cardiopulmonary decompensation or collapse, or symptomatic recurrence of pulmonary embolism within 7 days than anticoagulation alone. (Funded by Boston Scientific; HI-PEITHO ClinicalTrials.gov number, NCT04790370.).

Liver infections comprise a large category of hepatic diseases which vary in etiology and geographic distribution. They remain a significant cause of morbidity and mortality globally and require prompt diagnosis and management. Because clinical and laboratory findings may not be definitive, imaging often plays an important role in the diagnosis, characterization, and follow-up of hepatic infections. Advanced imaging techniques increase accuracy of diagnosis of specific infectious pathogens and in some cases provide the means of differentiation of various infections from other hepatic pathologies and conditions, most notably, neoplasms. Radiologists must be familiar with the key imaging findings and differential features in the multimodality approach to these conditions. This review provides a comprehensive overview of common and uncommon hepatic infections, highlighting key imaging features, characteristic signs, differential diagnoses, complications, and treatment considerations. Advanced techniques utilizing major cross-sectional modalities, including but not limited to contrast-enhanced ultrasound, dual energy computed tomography, and diffusion-weighted and contrast-enhanced magnetic resonance imaging will be discussed. A summary table that combines clinical, laboratory, demographic data and imaging findings will also be provided to guide diagnostic evaluation. This article aims to equip radiologists with essential tools for accurate diagnosis and timely clinical guidance.

Inconsistencies in healthcare access, varying infrastructure, resource constraints and diverse local practices as well as practical and political issues restrict the global applicability of currently available guidelines. There is a need for universal recommendations that address the unique challenges faced by patients and healthcare providers worldwide. Our iCARDIO Alliance Global Implementation Guidelines emphasize the incorporation of novel therapies, while integrating standard of care with the most up-to-date evidence to enable clinicians to optimize patient care. This document is about heart failure (HF), including acute and chronic heart failure, heart failure with reduced ejection fraction and heart failure with preserved ejection fraction as well as cardiomyopathies. Context-specific recommendations tailored to individual patient needs are highlighted providing a thorough evaluation of the risks, benefits, and overall value of each therapy, aiming to establish a standard of care that improves patient outcomes and reduces the burden of hospitalization in this susceptible population. These guidelines provide evidence-based recommendations that represent a group consensus considering the many other published guidelines that have reviewed many of the issues discussed here, but they also make new recommendations where new evidence has recently emerged. Most importantly these guidelines also provide recommendations on a number of issues where resource limitations may put constraints on the care provided to HF patients. Such "economic adjustment" recommendations aim to provide guidance for situations when "Resources are somewhat limited" or when "Resources are severely limited". Hence, this document presents not only a comprehensive but also concise update to HF management guidelines thereby aiming to provide a unified strategy for the pharmacological, non-pharmacological, invasive and interventional management of this significant global health challenge that is applicable to the needs of healthcare around the globe.

Objective: This multicenter, prospective, single-arm study evaluated the safety and preliminary clinical performance of a flowable porcine urinary bladder matrix (UBM) particulate for managing tunneling and undermining features in complex wounds. These features are associated with delayed healing, chronic inflammation, and infection risk. Flowable UBM enables targeted delivery into wound tunnels and cavities. Method: Twenty-five subjects from 3 United States (U.S.) sites were enrolled, with 21 meeting protocol criteria for analysis (15 with undermining and 6 with tunneling wounds). Participants received flowable UBM applied directly to tunneling or undermining areas, along with additional UBM particulate or sheet forms applied to the wound surface. The primary endpoint was the percentage reduction in tunneling volume or undermining depth at 12 weeks, with secondary assessment of reduction in overall wound volume. Safety was evaluated through evaluation of device-related adverse events. Results: At 12 weeks, 90.5% of wounds demonstrated positive response, with mean ± standard deviation and median reduction in tunneling or undermining dimensions of 84.6 ± 29.3% and 100.0%, respectively. Complete resolution of these features occurred in 52.4% of wounds (53.3% in undermining and 50.0% in tunneling wounds) with higher closure rates in non-pressure wounds compared to pressure injuries. No device-related adverse events were reported. Conclusions: Overall, flowable UBM was well tolerated and associated with favorable clinical trajectories demonstrated by reduction in tunneling and undermining dimensions; however, comparative effectiveness cannot be inferred from this limited single-arm pilot study. Further controlled studies are needed to confirm comparative effectiveness and optimize clinical use.

Depression is common and often difficult to monitor for clinical worsening in real-world settings where structured symptom scales are inconsistently captured. Electronic health records allow large cohort analyses. Diagnostic-code based definitions offer a practical way to identify patients at risk for progression. We used a multi-institutional dataset (MedStar Health) to study adults with mild depression and evaluated whether machine learning models could predict progression to moderate or severe depression within two years. The cohort included 803 individuals with two years of continuous follow-up. A broad set of demographics, clinical, laboratory, socioeconomic, and healthcare utilization features was available. Models included logistic regression, random forest, gradient boosted trees, and a deep neural network (DNN). Gradient boosted trees showed balanced performance, defined as a trade-off between sensitivity and specificity with a modest improvement over baseline prevalence, while logistic regression demonstrated the strongest overall discrimination and generalization. The DNN showed lower accuracy than null classifier. These findings demonstrate that real-world EHR data can support risk prediction of depression worsening with stable and clinically relevant performance. These models may support earlier identification of patients who warrant closer monitoring or targeted follow-up.