Citations

Abstract Aims Type 2 myocardial infarction due to myocardial oxygen supply–demand imbalance is associated with poor outcomes. There are no guidelines to inform care for these patients. The consensus on the assessment and management of type 2 myocardial infarction is gained. Methods and results An international e-Delphi study including experts in type 2 myocardial infarction identified through systematic review was conducted. Participants were asked to describe their approach to (i) definition and diagnosis, (ii) risk stratification, (iii) assessment of coronary artery disease and cardiac function, (iv) specialty management, (v) treatment and secondary prevention, and (vi) communication and rehabilitation. Statements generated in round one were circulated, with consensus defined a priori as ≥70% agreement on a 5-point Likert scale. Where no consensus was reached, statements were amended and recirculated for a final round. The response rate was 56% (38/68), 54% (37/68), and 72% (49/68) in the first, second, and third rounds, respectively. Following the first round, 67 unique statements were generated across six domains. Overall, consensus was achieved on 64% (43/67) of statements. Consensus was achieved for 42% (5/12) of statements on the diagnosis of type 2 myocardial infarction, 75% (3/4) on risk stratification, 50% (9/18) on the assessment of coronary artery disease and cardiac function, 60% (6/10), on specialty management, 100% (9/9) on treatment and secondary prevention, and 79% (11/15) on communication and rehabilitation. Conclusion Consensus was obtained across a number of domains for the assessment and management of patients with type 2 myocardial infarction. However, there was limited agreement amongst experts on the diagnostic criteria, which may benefit from refinement.

ABSTRACT Background & Aims Pregnancy can be a complex and risk filled event for women with inflammatory bowel disease (IBD). High‐quality studies in this population are lacking, with limited data on medications approved to treat IBD during pregnancy. For patients, limited knowledge surrounding pregnancy impacts pregnancy rates, medication adherence, and outcomes. Limited provider knowledge leads to highly varied practices in care affected by local dogma, available resources, individual interpretation of the literature, and fear of harming the fetus. The variations in guidelines by different societies and countries reflect this and lead to confusion for physicians and patients alike. The Global Consensus Consortium is a group of 39 IBD and content experts and 7 patient advocates from 6 continents who convened to review and assess current data and come to an agreement on best practices based on these data. Methods The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) process was used when sufficient published data were available and the RAND process in those instances where expert opinion was needed to guide consistent practice. Recommendations were informed by the guiding principle that maternal health best supports infant health. Results The topics were divided into ten categories with 34 GRADE recommendations and 35 consensus statements. Conclusions Overall, the goal of the group was to provide data‐driven and practical guidance to improve the care of women with IBD around the globe based on the best available research.

Acute respiratory distress syndrome (ARDS) is a common and highly heterogeneous condition in the critically ill. The association between hyper- and hypo-inflammatory subphenotypes and clinical outcomes has generated significant interest in precise ARDS management. The value of identifying biomarkers to guide treatment and enrollment in future ARDS trials is undisputable. We describe multiple factors complicating the search for subphenotypes and their treatable traits. The observed heterogeneity seen in the clinical course of ARDS is dynamic and influenced by factors beyond lung pathophysiology, including variations in the delivery of best critical care practices, patient comorbidities, and functional status, and patient or family preferences. Current subphenotype definitions lack strong biological plausibility and without clear evidence of benefit from targeted treatments, their use in clinical practice is currently unwarranted.

Introduction: Pregnancy can be a complex and risk filled event for women with inflammatory bowel disease (IBD). High-quality studies in this population are lacking, with limited data on medications approved to treat IBD during pregnancy. For patients, limited knowledge surrounding pregnancy impacts pregnancy rates, medication adherence, and outcomes. Limited provider knowledge leads to highly varied practices in care affected by local dogma, available resources, individual interpretation of the literature, and fear of harming the fetus. The variations in guidelines by different societies and countries reflect this and lead to confusion for physicians and patients alike. The Global Consensus Consortium is a group of 39 IBD and content experts and 7 patient advocates from 6 continents who convened to review and assess current data and come to an agreement on best practices based on these data. Methods: The GRADE process was used when sufficient published data were available and the RAND process in those instances where expert opinion was needed to guide consistent practice. Recommendations were informed by the guiding principle that maternal health best supports infant health. Results: The topics were divided into 10 categories with 34 GRADE recommendations and 35 Consensus statements. Discussion: Overall, the goal of the group was to provide data-driven and practical guidance to improve the care of women with IBD around the globe based on the best available research.

Background Although telehealth cardiac rehabilitation (CR) may improve access, there are concerns about its long‐term effectiveness and impact on equity as compared with in‐person CR. Our objective was to tailor a patient‐centered telehealth CR program for diverse populations. Methods CR patients and caregivers were recruited between January and September 2023 from 4 US academic medical centers. Participants engaged in human‐centered design sessions to iteratively refine a telehealth CR program. Sessions had planned topics, but there was variation across sites to account for site‐specific needs and participant feedback. Sessions were qualitatively analyzed using rapid template analysis with preselected behavioral science constructs and other emergent codes. Results The study included 21 participants (71% aged ≥60 years, 48% women, 62% non‐Hispanic White individuals; 90% CR patients, 10% CR caregivers). Participants thought that telehealth CR could be helpful for personalized support at home and convenience but recognized that technology is not always easy to use. Some expressed concerns about the safety of telehealth CR, especially at the beginning, and desired monitoring through a mobile device or video observation of exercise. Safety protocols and technology training were developed, which addressed concerns about telehealth CR. Opportunities for social support with telehealth CR were also desired. From these findings, an implementation toolkit was developed, including a graphic program description, safety plan, home exercise plan for during and after CR, and scripts for technology training and individual and group telehealth visits. Conclusions A patient‐centered telehealth CR program and implementation toolkit were systematically tailored to address the needs of diverse populations.

Background and objectives Arteriovenous malformations (AVMs) with perinidal aneurysms and single draining vein are associated with an elevated risk of rupture and increased procedural complexity. The role of preoperative embolization in this high-risk anatomical subset remains unclear. This study aimed to evaluate the safety and efficacy of microsurgery with preoperative embolization, compared with microsurgery alone in patients with such AVMs. Methods We conducted a multicenter retrospective analysis of an AVM registry from the MISTA (Multicenter International Study for Treatment of Brain AVMs) consortium and included AVMs with perinidal aneurysms and a single draining vein. Baseline characteristics, angiographic outcomes, functional outcomes, and complication rates were compared. Propensity score weighting (PSW) using the covariate balancing method was applied to adjust for baseline differences. Results Out of a total of 1919 patients, 65 met the inclusion criteria; 45 patients underwent preoperative embolization followed by microsurgery, and 20 underwent microsurgery alone. After adjustment, complete obliteration rates were similar between groups (OR 0.87, 95% CI 0.04 to 16.33, P=0.92), as were rates of functional independence at discharge and follow-up. Overall complication, symptomatic complication, and mortality rates did not differ significantly between groups. However, permanent complications were significantly lower in patients with preoperative embolization (OR 0.06, 95% CI 0.004 to 0.84, P=0.03). Discussion In patients with AVMs featuring perinidal aneurysms and single draining vein, preoperative embolization followed by microsurgery was associated with fewer permanent complications and no increase in adverse outcomes compared with microsurgery alone. However, given the small number of events, this finding should be interpreted cautiously.

ABSTRACT Objective Despite the availability of approved treatments, a substantial proportion of patients with bipolar disorder experience treatment‐resistant bipolar depression (TRBD), characterized by persistent depressive symptoms unresponsive to standard therapies. However, a universally accepted definition of TRBD is lacking. This consensus document, developed by the International Society for Bipolar Disorders (ISBD) Task Force on TRBD, aims to provide a standardized definition of TRBD to facilitate clinical trials, research, and treatment strategies. Methods The Task Force employed a literature review, clinical trials analysis, and expert consensus meetings to define TRBD. Results TRBD was defined as the failure to achieve a significant and sustained clinical response after at least two approved and adequately dosed pharmacological treatments, administered for a sufficient duration with treatment adherence. For bipolar I (BD‐I) depression, approved treatments included quetiapine (300–600 mg/day for ≥ 8 weeks), lurasidone (20–120 mg/day for ≥ 6 weeks), the combination of olanzapine (6–12 mg/day) and fluoxetine (25–75 mg/day for ≥ 8 weeks), cariprazine (1.5–3 mg/day for ≥ 6 weeks), and lumateperone (42 mg/day for ≥ 6 weeks). For bipolar II (BD‐II) depression, approved treatments included quetiapine (300–600 mg/day for ≥ 8 weeks) and lumateperone (42 mg/day for ≥ 6 weeks). Conclusion This consensus definition aims to provide clarity for clinical trials, improve consistency in research, and guide treatment approaches and inform regulatory pathways. It represents a foundational step in addressing the unmet needs in TRBD and promoting the development of innovative therapeutic strategies. Future efforts will focus on adapting the definition to better align with real‐world clinical challenges and optimize patient care.

Background: Current understanding of associations between alcohol use and falls among people with HIV (PWH) is limited due to few and inconsistent studies. Given the prevalence of heavy episodic alcohol use reported among PWH, this remains an important question. Methods: Alcohol use was measured using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) and self-reported alcohol use treatment and/or diagnosis of alcohol use disorder (collectively AUD) among PWH at eight CFAR Network of Integrated Clinical Systems (CNICS) sites from 2021 to 2024. Falls were self-reported using the components of the Falls Risk for Older People in the Community (FROP-Com) questionnaire. Cross-sectional associations between alcohol use and falls were examined using relative risk models adjusted for age, sex, race/ethnicity, and geographic location. Results: Among 5729 PWH, mean age was 55 years; 42% reported White and 41% reported Black/African American race/ethnicity; and 81% were male. Mean AUDIT-C score was 1.9 (range: 0–12); 27% reported heavy episodic drinking; 22% had AUD; and 22% reported falling in the past year. Reporting at least one fall in the past year was not associated with any measure of current alcohol use. AUD was associated with reporting at least one fall [prevalence ratio = 1.54; 95% confidence interval (CI) 1.39–1.70] and number of falls [one fall: prevalence ratio = 1.27 (95% CI: 1.08–1.50); at least two falls: prevalence ratio = 1.84 (95% CI: 1.58–2.15)]. Conclusion: Among PWH, 22% reported falling, which was associated with AUD, but not current alcohol use, suggesting that a mechanism other than acute intoxication could be responsible. Further longitudinal research is warranted to explore mechanisms for why AUD, but not current alcohol use, is associated with falls.

BACKGROUND AND OBJECTIVES: Symptomatic hydrocephalus (HCP) requiring cerebrospinal fluid diversion by shunting is routinely performed through ventriculoperitoneal or ventriculoatrial (VA) shunting. The optimal method of distal catheter placement for a VA shunt is not well defined. We detail a novel surgical technique for VA shunt placement using intraoperative digital subtraction angiography (DSA). METHODS: The aim of this single-institution, retrospective review was to describe a unique technique of distal catheter placement in a series of the initial 50 consecutive adult patients who underwent VA shunt placement with DSA at our institution between 2021 and 2024. Detailed procedural techniques and outcomes are described. RESULTS: Accurate surgical placement of the distal VA shunt was achieved in 48 patients (96%). Five patients required shunt revisions for delayed shearing of distal catheter (1), suboptimal distal catheter placement (3), and suboptimal proximal catheter placement (1). Four instances of post-VA shunt bacteremia were found when patients were routinely cultured for febrile episodes; all completed appropriate antibiotic course, and none resulted in meningitis or required shunt revision. Kaplan-Meier analysis demonstrated overall VA shunt success of 92% at 3 years after initial surgery. CONCLUSION: This series of 50 consecutive patients demonstrated use of intraoperative DSA yields safe and accurate placement VA shunts with acceptable long-term outcomes. As more neurosurgeons have endovascular training, this surgical technique may be more readily adopted.