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Background and aims Percutaneous endoscopic gastrostomy (PEG) is an essential procedure for patients who require long-term enteral nutrition but are unable to eat orally. However, it carries a risk of bleeding, particularly in patients on anticoagulation or dual antiplatelet therapy (DAPT). This study aimed to assess the bleeding risk associated with continuing anticoagulation or DAPT during PEG placement. Methods Using the TriNetX US Collaborative Network Database, we analyzed four cohorts: patients on anticoagulants, patients not on anticoagulants, patients on DAPT, and patients on aspirin (ASP), focusing on gastrostomy-related bleeding within 7 and 30 days, along with secondary outcomes such as mortality and the need for blood transfusion or endoscopic reintervention. Results Our analysis showed no statistically significant difference in the 7-day bleeding risk between the anticoagulant and no anticoagulant groups. However, a higher 30-day bleeding risk was observed in the anticoagulant group (0.9 vs. 0.4%, P = 0.007). There was no significant difference in the incidence of severe bleeding events requiring endoscopic intervention or blood transfusion. In addition, the difference in the bleeding risk between the DAPT and ASP groups was not statistically significant within 7 and 30 days. Conclusion These findings suggest that while anticoagulant use increases the risk of minor post-PEG bleeding, it does not lead to a higher incidence of severe bleeding. Additionally, the continuation of DAPT was not associated with statistically significant increase in bleeding risk. This study provides valuable insights into the management of antithrombotic therapy in patients undergoing PEG.

Hazardous alcohol use remains a major contributor to acute and chronic liver disease, while alcohol-associated liver disease (ALD) is a leading indication for liver transplantation. In recent years, embedded, interprofessional ALD clinics have improved access to alcohol use disorder care within hepatology and liver transplantation, but more work is needed to meet this challenge. The literature is lacking regarding scaling procedures to provide services for increasingly large ill patient populations. This article begins to fill this gap by describing “expanded ALD care”: broad, innovative, longitudinal, interprofessional care delivery strategies surpassing standalone clinics. Drawing from analogous patient populations served by collaborative models in primary care and comprehensive eating disorder treatment, the expanded ALD care framework proposes practical strategies toward specific innovations: equipoise between biomedical and psychosocial care elements, increased clinician number and reach, long-term patient relationships, harm reduction and palliative care, outreach to external agencies and clinicians, and enhanced support for patients and families. The article also defines attributes of innovative healthcare systems that support expanded ALD care.

Abstract Introduction: Chronic obstructive pulmonary disease (COPD) represents a significant global health challenge, particularly in its moderate to severe cases, where effective management is crucial to improving patient outcomes. The integration of inhaled corticosteroids with long-acting β2-adrenoceptor agonists and long-acting muscarinic antagonists in fixed-dose combinations has emerged as a cornerstone of therapy. This study evaluates the efficacy of two triple therapy regimens — Glycopyrrolate, Budesonide, and Formoterol Fumarate (GLY/BUD/FOR) and Fluticasone Furoate, Vilanterol, and Umeclidinium (FF/VI/UMEC) —in adults aged 45 and older with diagnosed COPD with FEV1/FVC < 70% to assess the impact of these regimens on the preventing COPD exacerbations and acute hypoxemic respiratory failure. Methods: A retrospective cohort analysis was conducted using the TriNetX database. Patients with moderate to severe COPD and FEV1/FVC < 70% were identified based on ICD codes, and two cohorts were formed based on the prescribed inhaler therapy: GLY/BUD/FOR and FF/VI/UMEC. Patients with comorbid asthma, heart failure, or pneumonia were excluded. A 1:1 propensity-score matching (PSM) analysis was performed to balance covariates such as age, gender, smoking status, and baseline lung function to minimize confounding and bias. Post-matching, both had 16,052 patients. Ultimately, 23,331 patients (FF/VI/UMEC: 11,234, GLY/BUD/FOR: 12,097) with a mean age of 67.4 ± 10.1 years and 55.3% males were included. Results: Among groups, 10.4% of patients on FF/VI/UMEC experienced COPD exacerbations compared to 6.7% on GLY/BUD/FOR (Risk Ratio: 1.55, 95% CI: 1.42-1.69, p < 0.001). Kaplan-Meier analysis showed a lower survival probability in the FF/VI/UMEC group (77.7% vs. 83.9%, p < 0.001). For acute respiratory failure, 3.5% of patients on FF/VI/UMEC experienced this outcome compared to 2.8% on GLY/BUD/FOR (Risk Ratio: 1.28, 95% CI: 1.12-1.45, p = 0.003). Conclusion: Our study suggests that FF/VI/UMEC demonstrated an increased risk of COPD exacerbations and acute hypoxic respiratory failure compared to the group receiving GLY/BUD/FOR. This indicates that GLY/BUD/FOR may provide enhanced protective benefits in patients with moderate to severe COPD, improving disease management and minimizing healthcare resource utilization. Further studies are warranted to explore the long-term benefits and potential mechanisms underlying the observed differences.

Abstract RATIONALE: As technology for biopsy of peripheral pulmonary nodules advances, the size of suspicious nodules referred for biopsy has decreased. This can be partly attributed to tools such as shape-sensing robotic-assisted bronchoscopy (ssRAB), which can increase the likelihood of a diagnostic result. Literature describing the biopsy of sub-centimeter nodules is primarily single center with a reported diagnostic yield for robotic bronchoscopy of 67%1, and 71%2 for CT-guided percutaneous biopsy; robust prospective multi-center data is needed to further understand the feasibility and clinical value of <1cm nodule biopsies. Herein, we report data from the prospective Ion Registry describing outcomes for patients with sub-centimeter nodules biopsied using ssRAB. METHODS: Patients with at least one (1) nodule <1cm that underwent ssRAB biopsy were identified from those enrolled in the Ion Registry. Subjects with multiple lesions were included if all nodules were <1cm in largest diameter. Nodule and procedure characteristics are reported with descriptive statistics; diagnostic yield was assessed using the ATS/ACCP recommended guidelines of index biopsy results only. Safety was assessed as the rate of pneumothorax requiring intervention and Nashville Grade ≥3 bleeding. RESULTS: Fifty-four (54) subjects and 57 sub-centimeter nodules were identified across 9 centers and 15 investigators; procedures were completed October 2023 through September 2024. The majority of nodules (47.4%) were incidental findings. Median nodule diameter was 8 mm (IQR: 7,9; range: 4.0-9.7 mm) with 66.7% of nodules located in the outer-third of the lung, and predominantly (57.9%) in the upper lobes. CT bronchus sign was present in 24.6% of nodules, and most (89.5%) nodule were solid. Median procedure time was 34.5 mins (IQR: 26,47; range: 9-89 mins); fixed or mobile CBCT was utilized for 80.7% (46/57) of nodules. The flexision biopsy needle and cryoprobe were used in 91% and 49% of biopsies, respectively. Diagnostic yield was 83% (45/54) using index biopsy results, 59% of which were malignant. No (0%) pneumothorax requiring intervention, Nashville Grade ≥3 bleeding events. CONCLUSION: Preliminary results from this prospective, multi-center registry cohort demonstrate peripheral nodules <1cm can be safely and effectively diagnosed through ssRAB biopsy and highlight the impact of ssRAB in enhancing lung nodule diagnosis, particularly when combined with CBCT. These findings suggest ssRAB may be considered a viable option for the biopsy of suspicious sub-centimeter nodules, further optimizing the management of patients with suspected lung cancer. REFERENCES:1. 10.1016/j.chest.2021.07.2169 2. https://doi.org/10.1016/j.clinimag.2020.04.040

Abstract RATIONALE: 4G4G/4G5G SERPINE1 genotypes produce high concentrations of plasminogen activator inhibitor-1 and are associated with worse asthma outcomes. A secondary analysis of the American Lung Association (ALA) SOYA trial showed that soy isoflavones significantly reduced asthma exacerbations versus placebo among patients with 4G4G/4G5G SERPINE1 genotypes. We hypothesized that baseline characteristics predict optimal responders to soy isoflavones among this subgroup. METHODS: ALA-SOYA was a randomized controlled trial that tested the efficacy of soy isoflavones vs. placebo for reducing asthma exacerbations among adolescents and adults with symptomatic asthma. In this responder analysis among participants with 4G4G/4G5G SERPINE1 genotypes, baseline demographic and clinical characteristics were tested for effect modification of the treatment assignment (soy/placebo) on the primary outcome of annualized number of asthma exacerbations using interaction terms in negative binomial regression models, with a significance threshold of p-interaction=0.15. RESULTS: Data were available for n=168 participants. Soy reduced the annualized number of asthma exacerbations relative to placebo among patients with 4G4G/4G5G SERPINE1 genotypes (incident rate ratio (IRR)=0.37, 95% confidence interval (CI): 0.15-0.90, p=0.028). Self-reported adherence to baseline controller therapy was the only significant effect modifier of this association (interaction p=0.115), with those using inhaled corticosteroid (ICS)/long-acting beta-agonist (LABA) controller therapy at least twice weekly experiencing reductions in asthma exacerbations with soy versus placebo (IRR = 0.25, 95% CI: 0.09-0.69; p= 0.007) but not among those using ICS/LABA controller therapy less frequently (IRR = 1.33, 95% CI: 0.22-8.02; p= 0.757). CONCLUSION: Soy isoflavones reduce asthma exacerbations among patients with the 4G4G/4G5G SERPINE1 genotypes and are most effective in those with greater adherence to asthma controller therapy regimens.

Background: Noninvasive tests (NITs) are used to risk-stratify metabolic dysfunction–associated steatotic liver disease. The aim was to survey global patterns of real-world use of NITs. Methods: A 38-item survey was designed by the Global NASH Council. Providers were asked about risks for advanced fibrosis, which NITs (cutoff values) they use to risk-stratify liver disease, monitor progression, and which professional guidelines they follow. Results: A total of 321 participants from 43 countries completed the survey (54% hepatologists, 28% gastroenterologists, and 18% other). Of the respondents, 85% would risk-stratify patients with type 2 diabetes, obesity (82%), or abnormal liver enzymes (73%). Among NITs to rule out significant or advanced fibrosis, transient elastography (TE) and fibrosis-4 (FIB-4) were most used, followed by NAFLD Fibrosis Score, Enhanced Liver Fibrosis, and magnetic resonance elastography. The cutoffs for ruling out significant fibrosis varied considerably between practices and from guidelines, with only 50% using TE <8 kPa, 65% using FIB-4 <1.30 for age <65, and 41% using FIB-4 <2.00 for age ≥65. Similar variability was found for ruling in advanced fibrosis, where thresholds of FIB-4 ≥2.67 and TE ≥10 kPa were used by 20% and 17%, respectively. To establish advanced fibrosis, 48% would use 2 NITs while 23% would consider 1 NIT, and 17% would confirm with liver biopsy. TE was used by >75% to monitor, and 66% would monitor (intermediate or high risk) annually. Finally, 65% follow professional guideline recommendations regarding NITs. Conclusions: In clinical practice, there is variability in NIT use and their thresholds. Additionally, there is suboptimal adherence to professional societies’ guidelines.

Abstract Background Instruments to assess patient-reported outcomes (PRO) should generate high-quality evidence. Reliable PRO evidence is essential to policymakers, in conjunction with outcomes such as survival and radiological response, to understand the net clinical benefit of antitumor treatments. This study aimed to establish the content validity of 215 identified PRO measures used in patients with brain tumors. Methods A survey (n = 148 items) was developed reflecting aspects of the WHO International Classification of Functioning, Disability, and Health (ICF) framework. Patients with brain tumors, their proxies, and healthcare professionals (HCPs) were asked to rate each survey item on relevance. An item was considered a relevant issue if ≥25% of the patients or proxies or ≥50% of the HCPs considered that item to be an issue. Next, all items in the identified PRO measures were linked to ICF and relevant items in the survey, and the percentage of content coverage was calculated. Results In total, 114 patients, 71 proxies, and 65 HCPs from different countries completed the survey. Fifty-six of 148 (37.8%) items in the survey were considered relevant. The most important aspects mentioned by both patients and proxies were difficulty concentrating, difficulty remembering, multitasking, and handling stress. Depending on the definition, between 35% and 49% of PRO measures were considered to have sufficient content validity (≥80% coverage). Conclusion The content validity was insufficient in more than half of the identified PRO measures, particularly multidimensional measures. Future research should investigate whether different approaches to PRO assessment better meet the needs of all stakeholders.

Abstract The benefits of photon-counting detector (PCD) CT include improved spatial resolution, increased radiation dose efficiency, and the elimination of electronic noise. Unlike traditional energy-integrating-detector (EID) CT systems, PCDs have inherent spectral capabilities, which support “always-on” dual energy and multi-energy imaging acquisition. PCD-CT directly converts X-ray photons into electrical signals and captures their individual energy levels. Current commercially available PCD-CT scanners, all from one manufacturer, include 2 models that incorporate dual-source geometry. This innovation is particularly advantageous for paediatric imaging by enabling rapid scans that reduce motion artifact and therefore the need for sedation and can now be combined in the current model with multi-energy imaging or ultra-high-resolution acquisition. This review article explores how the technical benefits of PCD CT improve the diagnostic quality of images and opens the field of paediatric radiology up to future opportunities for research and new applications.