Tufts Medical Center

Left ventricular (LV) dysfunction is a potential cardioembolic source of ischemic stroke, but its role in recurrent stroke risk and treatment response remains unclear. We explore whether LV injury associates with the risk of recurrent stroke and modifies the association between anticoagulation and stroke recurrence using real-world data. We performed a multicenter, retrospective study of Cardiac Abnormalities in Stroke Prevention and Recurrence cohort across 27 US sites. Patients with LV ejection fraction ≥20% were included. LV injury, defined as LV ejection fraction 20% to 40% and wall motion abnormality, was the primary exposure and treatment effect modifier. The treatment of interest was anticoagulant versus antiplatelet therapy. The composite outcome included recurrent stroke, major bleeding, or death. Outcomes were evaluated using unadjusted and inverse probability weighting adjusted Cox proportional hazards models, with treatment effect modification tested by LV injury status. Among 2685 patients enrolled, 2328 with complete data were analyzed (median age, 65 years; 49.8% female; median follow-up, 1.6 years). LV injury was present in 310 patients (13.3%). Overall, 535 events occurred: 258 recurrent ischemic strokes, 28 hemorrhagic strokes, 67 major hemorrhages, and 256 deaths. LV injury was associated with a higher unadjusted risk of the primary outcome (hazard ratio [HR], 1.51 [95% CI, 1.21-1.87]), though nonsignificant after inverse probability weighting adjustment (adjusted HR, 1.29 [95% CI, 0.97-1.70]). In the LV injury subgroup, anticoagulation versus antiplatelet therapy was associated with a lower risk of the primary outcome (adjusted HR, 0.24 [95% CI, 0.10-0.59]), relative to the non-LV injury subgroup (adjusted HR, 1.28 [95% CI, 0.83-1.95]; p[LV-interaction], 0.001). Similar interactions were seen for EF 20% to 40% (versus >40%; adjusted HR, 0.19 [95% CI, 0.04-0.86]; p[LV-interaction], 0.001) and wall motion abnormality (versus no wall motion abnormality; adjusted HR, 0.33 [95% CI, 0.15-0.73]). After cryptogenic stroke, anticoagulation in those with LV injury was associated with lower rates of recurrent stroke, major bleeding, and death. These findings warrant confirmation in a dedicated randomized controlled trial. URL: https://www.clinicaltrials.gov; Unique identifier: NCT06398366.

To evaluate the effectiveness and safety of platelet-rich plasma (PRP) for acute hamstring injuries, with attention to return-to-play (RTP) time, reinjury rates and adverse events. Systematic review and meta-analysis of randomised controlled trials (RCTs). Risk of bias was assessed using the Cochrane tool; certainty of evidence was evaluated using GRADE (Grading of Recommendations Assessment, Development and Evaluation). Databases included Embase, MEDLINE, Web of Science, Elsevier and Cochrane Central searched through March 2025. RCTs comparing PRP to control treatments for acute hamstring injuries were included. Non-randomised and chronic tendinopathy studies were excluded. Six RCTs (n=277) were included. PRP reduced RTP time versus control (mean difference -8.6 days; 21.4 vs 30.0 days; 95% CI -3.04 to -0.03; p=0.045), though heterogeneity was high (I²=94.1%). Reinjury (15% vs 16%; p=0.722) and adverse event rates (1% vs 0%; p=0.687) did not differ. Certainty of evidence was rated as low to moderate due to risk of bias and imprecision. PRP may shorten RTP in acute hamstring injuries, especially when image-guided. Reinjury risk appears unchanged. Further trials are needed to confirm these findings and standardise biological use in muscle injuries. CRD420251109346.

To support high-quality, patient-centered care for systemic lupus erythematosus (SLE), the American College of Rheumatology (ACR) developed evidence-based measures incorporating clinical and patient-reported outcome measures (PROMs). Using the Consolidated Framework for Implementation Research (CFIR), we conducted semistructured interviews with rheumatologists and support staff who piloted these measures. Insights from these interviews informed development of the SLE Quality Measures Implementation Guide for national dissemination. Five rheumatology practices were selected to pilot workflows for collecting SLE PROMs recommended in recent ACR guidelines for at least 50 consecutive patients. Measures included physical function (PF) and depression. After data collection, representatives from each practice participated in virtual semistructured interviews. Interviews were recorded, transcribed verbatim, and analyzed thematically using both deductive and inductive techniques. Findings were used to develop the SLE Quality Measures Implementation Guide. A total of 31 clinicians across five practices participated in the pilot. Interviews with eight participants identified key themes related to innovations, resources, best practices, and challenges in collecting and using SLE PROMs, mapped to CFIR domains. Despite barriers related to workflow, engagement, and resources, PROM implementation in SLE care was well accepted and supported standardized assessment of mental health and PF through communication and electronic health records integration. These insights informed development of the SLE Quality Measures Implementation Guide, featuring guidelines, workflow recommendations, best practices, and educational resources to improve workflow efficiency and enhance patient care. This study evaluated the implementation of ACR-recommended SLE PROMs and provides actionable recommendations and resources to address challenges through the SLE Quality Measures Implementation Guide.

People who use drugs face barriers to accessing HIV prevention tools. The status-neutral model for HIV care starts with the HIV test and offers linkage to HIV treatment if the person tests positive and linkage to pre-exposure prophylaxis (PrEP) if the person tests negative. The goal of this study was to evaluate barriers and facilitators impacting the implementation of a status-neutral HIV model of care in the jail setting. Between June and August 2024, we recruited people working in and incarcerated in the jails operated by the Suffolk County Sheriff’s Department (Jail and House of Correction) for in-depth interviews. The Consolidated Framework for Implementation Research (CFIR) 2.0 guided interview development. Interviews were recorded, transcribed, coded, and analyzed using rapid thematic analysis (RTA) methods. Relevant themes were mapped onto CFIR domains. We conducted 28 interviews: 13 with correctional and clinical staff and 15 with incarcerated people. Clinical and administrative staff members indicated that strong relationships with state and local agencies and the state’s proactive approach to preventative carceral healthcare helped facilitate HIV treatment and prevention pathways. Incarcerated individuals identified issues in the system used to report health needs and unreliable test result delivery mechanisms as major barriers. Staff also identified barriers, including understaffing, but overwhelmingly endorsed the jails’ existing systems of accessing and delivering care. Findings identified multiple potential intervention targets to enhance a status-neutral approach to HIV testing and treatment in jail settings, including leveraging existing partnerships, and educational opportunities for staff. Strategies that reinforce a patient-centered institutional culture (with a focus on incarcerated individuals’ health), improve care continuity for transitions into and out of jail, and highlight gaps in healthcare delivery are critical for successful implementation of status-neutral HIV care in jails.

There are currently no established strategies for early identification and primary prevention of chronic kidney disease (CKD). Automatic reporting of estimated glomerular filtration rate (eGFR) allows opportunistic CKD screening. Here, we hypothesized that comparison with population-based eGFR distributions may further help identify individuals at elevated risk. A population-based observational cohort study including adults aged 40 to 100 years with routine serum/plasma creatinine tests (Stockholm CREAtinine Measurements project) between 2006 and 2021 was conducted. The cohort captured 1,179,501 unique individuals (80% of the population in the region) with 6,914,993 repeated annual eGFR measurements. After computing eGFR distributions by age and sex, cause-specific Cox regressions evaluated the associations between eGFR percentiles and risks of kidney failure with replacement therapy (KFRT) and death. Median eGFR (2009 CKD-EPI) was lower at higher age, from 104-106 ml/min per 1.73 m2 (men-women) at age 40 to 45-50 ml/min per 1.73 m2 at age 100. Exclusion of individuals with selected comorbid conditions or adjustment for the non-tested population had minimal impact on eGFR distributions. Compared to the central percentiles (47.5-52.5th), eGFR percentiles below the 25th were significantly associated with increased risk of KFRT, and both low and high eGFR percentiles were associated with increased mortality. Associations were consistent across age groups. Among 421,547 individuals with eGFR 60 ml/min per 1.73 m2 or more who were below the 25th percentile, only 24% underwent albuminuria/proteinuria testing in the adjacent year and could have benefited from additional diagnostic work-up. Our study shows that eGFR values below the 25th percentile of the population distribution are associated with increased risks of kidney failure and death. Population-based eGFR charts may complement current automatic reporting systems and provide opportunities for early identification and primary prevention of CKD.

Previous single-center studies conducted in the United States in women with suspected preeclampsia indicated that serum soluble fms-like tyrosine kinase 1-to-placental growth factor ratio values of >38 measured on a widely available Elecsys immunoassay platform during the third trimester of pregnancy predicted the development of preeclampsia with severe features and adverse outcomes within 2 weeks of testing. This study aimed to validate the Elecsys soluble fms-like tyrosine kinase 1-to-placental growth factor ratio test for the prediction of preeclampsia with severe features in a United States population using the prospective Preeclampsia Risk Assessment: Evaluation of Cut-offs to Improve Stratification cohort that recruited women with a hypertensive disorder of pregnancy (gestational hypertension, chronic hypertension, de novo and superimposed preeclampsia) across 18 tertiary and community hospitals throughout the United States. We measured soluble fms-like tyrosine kinase 1-to-placental growth factor ratios using the Elecsys platform in archived serum samples from the Preeclampsia Risk Assessment: Evaluation of Cut-offs to Improve Stratification study that recruited hospitalized women with a hypertensive disorder of pregnancy between 23 0/7 and 34 6/7 weeks of gestation. The primary study outcome was prediction of preeclampsia with severe features within 2 weeks after testing. The secondary outcomes included a composite of adverse maternal and fetal/neonatal outcomes and prediction of delivery within 2 weeks. In the validation cohort of the Preeclampsia Risk Assessment: Evaluation of Cut-offs to Improve Stratification study (556 enrollments), the serum soluble fms-like tyrosine kinase 1-to-placental growth factor ratio at a cutoff value of >38 demonstrated a 67% positive predictive value (95% confidence interval, 61-73) and a 95% negative predictive value (95% confidence interval, 92-97) for the progression to preeclampsia with severe features within 2 weeks. Among women at <30 weeks of gestation (n=188), serum soluble fms-like tyrosine kinase 1-to-placental growth factor ratio at a cutoff value of >38 demonstrated a 78% positive predictive value (95% confidence interval, 68-86) and a 100% negative predictive value (95% confidence interval, 96-100) for the progression to preeclampsia with severe features within 2 weeks. The Elecsys soluble fms-like tyrosine kinase 1-to-placental growth factor ratio test performed better than standard-of-care clinical measures, with an area under the receiver operating characteristic curve of 0.92 (95% confidence interval, 0.89-0.90) for soluble fms-like tyrosine kinase 1-to-placental growth factor ratio vs <0.70 for standard-of-care tests, such as liver enzymes, platelet count, and serum creatinine (P<.001). Compared with women with a ratio of ≤38, those with a ratio of >38 had a higher risk of developing adverse maternal (relative risk, 4.9 [95% confidence interval, 2.6-9.9]; P<.001) and fetal/neonatal (relative risk, 3.2 [95% confidence interval, 2.6-4.0]; P<.001) outcomes and were more likely to deliver within 2 weeks (adjusted hazard ratio, 3.3 [95% confidence interval, 2.7-4.0]; P<.001). The soluble fms-like tyrosine kinase 1-to-placental growth factor ratio of >38 measured on the Elecsys platform predicted the development of preeclampsia with severe features, delivery, and adverse maternal and fetal/neonatal outcomes within 2 weeks of testing among preterm pregnant women hospitalized with a hypertensive disorder of pregnancy.

The aim of this study was to perform a detailed clinical and pathologic analysis of biopsies from 180 BE patients with the goal of understanding the clinical significance and outcome of patients diagnosed with crypt dysplasia (CD). Biopsies from 58 progressors and 122 nonprogressors (372 biopsies) were graded by 3 gastrointestinal pathologists. A consensus biopsy diagnosis (agreement by ≥2 pathologists) was used for outcome analysis. The overall diagnostic agreement among all 3 observers was high (0.75) and was observed in 83.9% cases, with a moderate level of agreement (0.44) noted for CD. BE progressors had a significantly higher proportion of index biopsies with CD (17% vs. 2%) and LGD (9% vs. 0%; overall P <0.0001) compared with nonprogressors. Compared with an index consensus biopsy diagnosis of NDBE, a consensus biopsy diagnosis of IND, CD, and LGD had significantly increased odds of developing HGD/EAC by univariable (OR: 4.05; P <0.0001) as well as multivariable analysis (OR: 10.3; P =0.01). Furthermore, Kaplan-Meier analysis showed that patients diagnosed with CD or LGD on an index biopsy had a higher probability of developing HGD/EAC than those with NDBE ( P <0.0001), and the timeline for progression among patients with CD was found to be intermediate between those diagnosed with NDBE and LGD. BE patients with an index biopsy diagnosis of CD are more likely to develop HGD/EAC compared with those without dysplasia, and these patients may benefit from surveillance and management strategies, similar to LGD.