MedStar Washington Hospital Center is the largest private hospital in Washington, D.C. A member of MedStar Health, the not-for-profit Hospital Center is licensed for 926 beds. Health services in primary, secondary and tertiary care are offered to adult and neonatal patients. It also serves as a teaching hospital for Georgetown University School of Medicine.The Hospital Center occupies a 47-acre (19 ha) campus in Northwest Washington that it shares with three other medical facilities. Immediately adjacent to MedStar Washington Hospital Center are the National Rehabilitation Hospital and the central branch of Children's National Medical Center.C.C.C.
Pressure reactivity index (PRx) is a surrogate for cerebral autoregulation and has been used for prognostication in aneurysmal subarachnoid hemorrhage (SAH). We examined patient-specific temporal courses of PRx and identified time thresholds that optimized the accuracy of PRx monitoring. Comatose patients with SAH from two Comprehensive Stroke Centers were identified and received continuous ICP and PRx recordings. Outcomes were dichotomized into “poor” versus “good” based on disposition and modified Rankin score. Smoothed PRx trajectories were created to generate “candidate features”, looking at daily average PRx and cumulative first-order and second-order changes in PRx. “Candidate features” were used to perform penalized logistic regression analysis. Penalized logistic regression models that maximized specificity for poor outcome were iteratively generated and evaluated sensitivity changes over time. We evaluated 33 comatose SAH patients in this cohort. Average PRx trajectories for good and poor outcome groups diverged at post-ictus day 6. When targeting specificities ≥ 78.6
BACKGROUND AND AIMS:Immune checkpoint inhibitors (ICI) are associated with life-threatening myocarditis but milder presentations are increasingly recognized. The same autoimmune process that causes ICI myocarditis can manifest concurrent generalized myositis, myasthenia-like syndrome, and respiratory muscle failure. Prognostic factors for this 'cardiomyotoxicity' are lacking. The main aim of this study was to determine predictors and construct a risk score associated with negative outcomes in patients admitted for ICI myocarditis. METHODS:A multicentre registry collected data retrospectively from 17 countries between 2014 and 2023. A multivariable Cox regression model was used to determine risk factors for the primary composite outcome: time to severe arrhythmia, heart failure, respiratory muscle failure, and/or cardiomyotoxicity-related death. Covariates included demographics, comorbidities, cardiomuscular symptoms, diagnostics, and treatments. Time-dependent covariates were used, and missing data were imputed. A point-based prognostic risk score was derived and externally validated. RESULTS:In 748 patients (67% male, age 23-94 years), 30-day incidence of the primary composite outcome, cardiomyotoxic death, and overall death were 33%, 13%, and 17%, respectively. By multivariable analysis, the primary composite outcome was associated with active thymoma (hazard ratio [HR] 3.6, 95% confidence interval [CI] 1.7-7.7), presence of cardiomuscular symptoms (HR 2.6 [1.5-4.2]), low QRS voltage on presenting electrocardiogram (HR for ≤0.5 mV vs >1 mV 1.9 [1.1-3.1]), left ventricular ejection fraction (LVEF) < 50% (HR 1.7 [1.1-2.6]), and incremental troponin elevation (HR 1.8 [1.4-2.4], 2.9 [1.8-4.7], and 4.6 [2.3-9.3], for 20, 200, and 2000-fold above upper reference limit, respectively). A prognostic risk score developed using these parameters showed good performance; 30-day primary outcome incidence increased gradually from 4% (risk score = 0) to 81% (risk score ≥ 4). This risk score was externally validated in two independent French and US cohorts. This risk score was used prospectively in the external French cohort to identify low-risk patients who were managed with no immunosuppression resulting in no cardiomyotoxic events. CONCLUSIONS:ICI-associated myocarditis can manifest with high morbidity and mortality. Myocarditis severity is associated with magnitude of troponin, thymoma, low QRS voltage, depressed LVEF, and cardiomuscular symptoms. A risk score incorporating these features performed well. CLINICAL TRIAL REGISTRATION:NCT04294771 and NCT05454527.
Introduction There is increased recognition that diagnostic errors disproportionately affect marginalised and underserved patient populations in the USA. However, evidence on diagnostic inequities in mental disorders is sparse and not well integrated into the overall diagnostic safety literature.Objective We systematically reviewed and narratively synthesised evidence on inequities in diagnosis of mental disorders, guided by the Diagnostic Process Framework developed by The National Academies of Sciences, Engineering, and Medicine.Methods We conducted a systematic review and a narrative synthesis. Medline, Embase, PsycInfo and CINAHL were searched for studies published between 2015 and 2024. Studies were eligible if they reported on inequities in the diagnosis of mental disorders and applied a quantitative, qualitative or mixed-methods design. Studies had to be peer reviewed, US based and published in English. The Mixed-Methods Appraisal Tool was used for quality appraisal. Data were analysed with a descriptive intent, and inequities were mapped into the diagnostic process.Results 20 studies of varying methodological quality were included. Though not the initial focus, autism spectrum disorder (ASD) emerged as the most studied mental disorder (n=17). Of the diagnostic errors identified, most fell into the category of delayed diagnosis. 11 factors emerged as contributors to diagnostic inequities. Limited health literacy among patients and caregivers was the leading cause of diagnostic error in symptom recognition. Insurance coverage issues delayed patient engagement with the healthcare system. Provider bias during clinical history-taking and interviewing was seen as a key cause of delays and misdiagnoses. Within diagnostic testing and interpretation, culturally inequivalent assessment measures might cause misdiagnosis and delayed diagnosis for Black/African American and Hispanic/Latino patients. The use of medical jargon and lack of qualified language interpreters during communicating the diagnosis were associated with diagnostic errors impacting patients with limited health literacy and low English language proficiency.Conclusions Diagnostic inequities in ASD and other mental disorders persist across US patient populations. Multiple factors such as parental health literacy, provider bias and limited access interact and impact the diagnostic process. Addressing these interconnected barriers is essential to ensure timely, accurate and equitable care.PROSPERO registration number CRD42024581271.
BACKGROUND:Drug-eluting stents (DESs) are recommended treatment for coronary in-stent restenosis (ISR) but are not used in >20% of cases. OBJECTIVES:The aim of the SELUTION4ISR (SELUTION SLR 014 In-stent Restenosis) trial was to assess the safety and effectiveness of a novel sirolimus drug-eluting balloon (DEB). METHODS:After successful lesion predilation, patients with ISR were randomly assigned to the SELUTION Sustained Limus Release (MedAlliance) DEB or a control strategy of usual care, including any approved DES or balloon angioplasty (BA) on the basis of operator selection prerandomization. Randomization to selected BA control treatment was limited to 20% of patients. The primary outcome was target lesion failure (TLF) (cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization) assessed at 1 year in the per protocol group (all treated eligible patients with complete primary endpoint follow-up). Noninferiority was established if the upper limit of the 2-sided 95% credible interval was smaller than 10%. A sequential secondary hypothesis test was performed comparing DEB with DES in patients with single-layer ISR. RESULTS:From July 2020 to July 2024, 418 patients were randomly assigned to the DEB group (n = 210) or the control group (n = 208), with 390 patients per protocol (DEB, 197; control, 193 [154 DES; 39 BA]). TLF occurred in 32 (16.2%) of 197 patients in the DEB group and in 28 (14.5%) of 193 patients in the control group (difference: 1.7%; 95% credible interval: -5.5% to 8.9%; posterior probability of noninferiority: 98.80%). In the secondary hypothesis test, TLF occurred in 22 (14.2%) of 155 patients in the DEB group and in 9 (6.5%) of 138 patients in the DES control group (difference: 7.7%; 95% credible interval: 0.6%-14.6%, posterior probability for noninferiority: 76.07%). TLF according to operator selected control was higher for DEB compared with DES (15.3% vs 7.1%; difference: 8.1%; 95% credible interval: 1.4%-15.0%) and lower for DEB compared with BA (23.6% vs 43.6%; difference: 23.7%; 95% credible interval: -41.4% to -1.5%; Pforinteraction = 0.0026). CONCLUSIONS:The sirolimus DEB was noninferior to a usual care control strategy including 80% repeat DES but not noninferior to DES for single-layer ISR for TLF at 12 months. There was significant interaction on the basis of operator selection of DES vs BA. (SELUTION SLR 014 In-stent Restenosis [SELUTION4ISR]; NCT04280029).
BACKGROUND:For patients with atrial fibrillation, the use of oral anticoagulant therapy to prevent stroke is limited by the risk of bleeding. Left atrial appendage closure is considered for patients who are unsuitable candidates for long-term anticoagulation, but its role in patients who are eligible for anticoagulants has not been established. METHODS:In this ongoing, prospective, international, randomized trial involving patients with atrial fibrillation who were suitable candidates for anticoagulation, we randomly assigned patients in a 1:1 ratio to receive either device-based left atrial appendage closure (device group) or non-vitamin K antagonist oral anticoagulant (NOAC) therapy (anticoagulation group). The primary efficacy end point - a composite of death from cardiovascular causes, stroke, or systemic embolism - was tested for noninferiority (noninferiority margin, 4.8 percentage points) after 3 years of follow-up. The primary safety end point, non-procedure-related bleeding, was tested for superiority. RESULTS:Of the 3000 patients who underwent randomization, 1499 were assigned to the device group and 1501 to the anticoagulation group. The mean (±SD) age of the patients was 71.7±7.5 years, 31.9% of the patients were women, and the mean CHA2DS2-VASc score was 3.5±1.3. At 3 years, a primary efficacy end-point event had occurred in 81 patients (Kaplan-Meier estimate, 5.7%) in the device group and in 65 patients (Kaplan-Meier estimate, 4.8%) in the anticoagulation group (difference, 0.9 percentage points; 95% confidence interval [CI], -0.8 to 2.6; P<0.001 for noninferiority). Non-procedure-related bleeding occurred in 154 patients (Kaplan-Meier estimate, 10.9%) in the device group and in 260 patients (Kaplan-Meier estimate, 19.0%) in the anticoagulation group (hazard ratio, 0.55; 95% CI, 0.45 to 0.67; P<0.001 for superiority). CONCLUSIONS:Among patients with atrial fibrillation who were candidates for anticoagulation, device-based left atrial appendage closure was noninferior to NOAC therapy with respect to a composite of death from cardiovascular causes, stroke, or systemic embolism and was superior to NOAC therapy for non-procedure-related bleeding at 3 years. (Funded by Boston Scientific; CHAMPION-AF ClinicalTrials.gov number, NCT04394546.).
