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Background Advanced chronic kidney disease (CKD) complicates anticoagulant treatment because thromboembolic and bleeding risks compete. We compared treatment outcomes for apixaban and rivaroxaban in adults with atrial fibrillation (AF) and stage 4/5 CKD. Methods Deidentified TriNetX records for patients treated with apixaban (n=49,698) and rivaroxaban (n=2660) underwent 1:1 propensity score matching (demographics, medications, procedures, laboratory values); 2533 matched pairs were identified (absolute standardized mean difference <0.10, indicating adequate balance). The smaller rivaroxaban cohort constrained matching; findings apply only to the matched population. Outcomes were assessed at 1, 3, and 5 years. Myocardial infarction (MI) findings were exploratory. P values were not adjusted for multiplicity. Results Gastrointestinal bleeding was lower for apixaban vs rivaroxaban (5-year: 9.3% vs 10.9%; relative risk [RR], 0.86; 95% CI, 0.71-1.02; P=.09). Cerebrovascular events were significantly higher for apixaban vs rivaroxaban at 3 years only (9.8% vs 7.9%; RR, 1.24; 95% CI, 1.01-1.53; P=.04); this association may reflect chance. Cerebral infarction was significantly higher for apixaban vs rivaroxaban at 1 year (3.0% vs 1.8%; RR, 1.61; 95% CI, 1.09-2.37; P=.02) and attenuated at 3 and 5 years. Rates of MI were nominally higher in the apixaban group. Five-year mortality risk was significantly lower for apixaban vs rivaroxaban (33.3% vs 36.1%; RR, 0.92; 95% CI, 0.86-0.10; P=.04) but differences in time-to-event survival were not significant. Conclusion Apixaban did not have greater bleeding risk than rivaroxaban and may be associated with lower gastrointestinal bleeding, a finding that requires further study. Isolated cerebrovascular, MI, and mortality findings require cautious interpretation. A mortality advantage for either drug was not established.

ABSTRACT A previously healthy 29-year-old man presented with abdominal pain and was found to have a liver mass with periductal infiltration and a stricture of the common bile duct, concerning for cholangiocarcinoma. Hepatic function panel disclosed alanine transaminase 293 U/L, aspartate aminotransferase 122 U/L, γ-glutamyl transferase 2019 U/L, normal total bilirubin, carcinoembryonic antigen, and carbohydrate antigen 19-9. Biopsy established the diagnosis of diffuse large B-cell lymphoma, with no underlying hepatic disease. He was started on polatuzumab-rituximab-cyclophosphamide-doxorubicin-prednisone chemotherapy and achieved complete tumor response. This case highlights the importance of a thorough evaluation of liver tumors and the critical role of tissue diagnosis.

Background Pericarditis may be associated with significant morbidity and mortality and can be a clinically challenging entity to diagnose. There is a clinical need for automated artificial intelligence (AI) algorithms to act as a screening aid to assist with the early and accurate detection of pericarditis. Methods We developed p-Cal, a browser-based pericarditis risk calculator that fuses the patient clinical data and 12-lead ECG image to estimate risk for pericarditis. The ECG encoder was designed based on a pretrained MedCLIP Vision Transformer and random forest classifier was used for the clinical tabular data. These two modalities were fused at the decision-level using a meta classifier. Model reasoning for both modalities was assessed using advanced explainable AI techniques—attention maps from the transformer model were used to interpret ECG images, while SHapley Additive exPlanations (SHAP) force plots were applied to analyse the tabular data. Results A total of 6508 patients (mean age 54.8±16.1 years, 50.9% female) were used for training and internal validation of the AI model, of whom 902 patients had a confirmed diagnosis of pericarditis (13.8%) and the remainder were normal controls. On 1302 hold-out test patients, the Fusion Model demonstrated the best discriminatory performance, achieving an area under the curve (AUC) of 0.89, which surpassed the ECG (AUC = 0.85) and the clinical data only models (AUC = 0.74) performance. On external validation in the Medical Information Mart for Intensive Care (MIMIC) Database, the fusion model achieved an AUC of 0.81. Conclusion A late fusion AI model integrating tabular clinical electronic medical record data and ECG signal has robust predictive capability for pericarditis as a screening tool.

This slideshow presentation provides a practical image-based road map to essential spinal and pelvic radiographic measurements, with stepwise instructions and reference values, for assessment and management of spinal disorders.

Objective To evaluate the clinical effectiveness of sodium glucose cotransporter 2 (SGLT2) inhibitors in reducing the risk of hospital admission for heart failure and mortality in a contemporary nationwide cohort of patients with heart failure with preserved ejection fraction (HFpEF). Design Nationwide cohort study (REFINE-HFpEF). Setting 170 veteran health medical centres across the US, 1 January 2014 to 31 December 2021. Participants 2177 patients with type 2 diabetes and HFpEF; 1129 patients were newly prescribed SGLT2 inhibitors and 1048 were newly prescribed dipeptidyl peptidase 4 (DPP4) inhibitors or sulfonylureas. Main outcome measures The primary outcome was a composite of all cause mortality and hospital admission for heart failure. Secondary outcomes included all cause mortality only and serial changes in body weight. Hazard ratios were derived from Cox proportional hazards models, incorporating inverse probability of treatment weighting based on propensity scores to account for confounding. Results From a validated cohort of 179 288 patients with type 2 diabetes and HFpEF, the study included 1129 new users of SGLT2 inhibitors (active treatment) and 1048 new users of DPP4 inhibitors or sulfonylureas (comparators). After a median follow-up of 2.63 years, 46.4% of the study population had at least one hospital admission for heart failure (n=1011) and the overall mortality rate was 45.9% (n=1000). Use of SGLT2 inhibitors was associated with a relative risk reduction in the primary composite outcome of 18% compared with the use of DPP4 inhibitors or sulfonylureas (hazard ratio 0.82, 95% confidence interval 0.70 to 0.96; P=0.01). The adjusted hazard ratio for all cause mortality only was 0.73 (0.60 to 0.89; P=0.002). Weight loss was similar in the two groups. Conclusions In this large, contemporary, nationwide cohort of patients with HFpEF, type 2 diabetes, and high event rates, starting SGLT2 inhibitors was associated with a significantly lower risk of hospital admission for heart failure and all cause mortality compared with starting treatment with DPP4 inhibitors or sulfonylureas.

Abstract. Introduction: Preterm birth drives adverse perinatal maternal and infant health outcomes through heterogeneous symptoms, severity, and etiologies. Delivery prior to reaching 37 weeks of gestation may result from medically indicated intervention for pregnancy complications or spontaneously in the absence of prior symptoms. Placental tissue collected following preterm birth exhibits differential DNA methylation compared to full-term placentas and may indicate pregnancy health during gestation. Placental DNA currently has limited utility for assessing health of ongoing pregnancy, as sampling placental tissue during gestation increases the risk of infection and miscarriage. Risks associated with placental sampling during pregnancy limit the use of DNA methylation in clinical preterm birth prediction. Assessing preterm birth risk during gestation requires non-invasive methods for characterizing placental DNA methylation. Results: We quantified genome-wide DNA methylation patterns of hypermethylated cell-free DNA in pregnant (n = 99) and non-pregnant (n = 93) plasma using cell-free methylated DNA immunoprecipitation sequencing (cfMeDIP-seq). In each sample, we assessed DNA methylation status in 300-bp genomic windows, examining both sequencing read counts and calculated absolute molar DNA amount. Known hypermethylated placental regions, including RASSF1, STAT5A, and ERG promoters showed significantly increased odds of detection in pregnant samples, suggesting enrichment of cell-free placental DNA. Of the 536,444 300-bp windows examined, 173,071 (32%) showed significant enrichment in pregnant plasma. Linear modeling identified 107,505 differentially methylated regions (DMRs) associated with pregnancies later diagnosed with intrauterine growth restriction (IUGR) (n = 22). Alu elements showed increased representation in these DMRs than expected, while other repetitive elements exhibited underrepresentation. Discussion: These results demonstrate cfMeDIP-seq's ability to enrich for cell-free placental DNA and characterize cell-free DNA methylation signatures of pregnancies complicated by IUGR. Enrichment of cell-free placental DNA enables non-invasive profiling of placental DNA methylation from maternal plasma. Detectable epigenetic signatures in maternal plasma may identify pregnancies at elevated risk for preterm birth before clinical symptoms appear. Our findings further highlight the potential of cell-free placental DNA for monitoring pregnancy health.