A Comparative Analysis of Catheter Directed Thrombolysis with Anticoagulation Alone or Systemic tPA in Acute Pulmonary Embolism with Cor Pulmonale.

BACKGROUND: Pulmonary embolism (PE) with cor pulmonale causes considerable mortality and morbidity. Randomized trials have failed to show a mortality difference between treatment modalities including anticoagulation (AC), Catheter directed thrombolysis (CDT) and systemic tPA (tissue plasminogen activator). METHODS: This is a cross-sectional retrospective case-control study utilizing the 2017 National Inpatient Sample (NIS). Patients admitted with acute PE with cor pulmonale were divided into groups based on whether they received anticoagulation, CDT or systemic tPA based on appropriate ICD-10 PCS codes. The AC group and CDT group were compared using univariate and multivariate analyses after adjusting for age, gender, race, comorbidities, insurance status and Charlson comorbidity index (CCI). Secondary outcomes included factors influencing length of stay (LOS) and total charges incurred. Similar analyses were done to compare the CDT group with the tPA group. RESULTS: In 2017, 13240 patients were admitted with acute PE and cor pulmonale, of whom 18% underwent CDT, 10% underwent systemic tPA and 72% underwent AC alone. Patients who received CDT over AC alone were significantly younger (61.5 vs. 65.5, p = 0.00). Mortality rate overall was 4.8% with tPA group, CDT group and AC alone group having a 11.2%, 3.0% and 4.4% mortality rate respectively. On multivariate analyses, there was no significant mortality difference between the CDT and AC groups (aOR 0.61, 0.34-1.1 95%CI, p = 0.103). Patients with liver disease had significantly higher mortality while obese patients had a significantly lower mortality after adjusting for treatment strategy and confounders. Length of stay (LOS) was not significantly different between the groups however, compared to AC alone, patients who underwent CDT or tPA incurred significantly higher total hospital charges. CONCLUSIONS: CDT offers an attractive alternative to tPA therapy; however, our study does not show an in-hospital mortality benefit. More studies are required to guide patient selection prior to establishing treatment protocols.

Using the Shapes of Clinical Data Trajectories to Predict Mortality in ICUs.

1) To show how to exploit the information contained in the trajectories of time-varying patient clinical data for dynamic predictions of mortality in the ICU; and 2) to demonstrate the additional predictive value that can be achieved by incorporating this trajectory information. DESIGN: Observational, retrospective study of patient medical records for training and testing of statistical learning models using different sets of predictor variables. SETTING: Medical ICU at the Yale-New Haven Hospital. SUBJECTS: Electronic health records of 3,763 patients admitted to the medical ICU between January 2013 and January 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Six-hour mortality predictions for ICU patients were generated and updated every 6 hours by applying the random forest classifier to patient time series data from the prior 24 hours. The time series were processed in different ways to create two main models: 1) manual extraction of the summary statistics used in the literature (min/max/median/first/last/number of measurements) and 2) automated extraction of trajectory features using machine learning. Out-of-sample area under the receiver operating characteristics curve and area under the precision-recall curve ("precision" refers to positive predictive value and "recall" to sensitivity) were used to evaluate the predictive performance of the two models. For 6-hour prediction and updating, the second model achieved area under the receiver operating characteristics curve and area under the precision-recall curve of 0.905 (95% CI, 0.900-0.910) and 0.381 (95% CI, 0.368-0.394), respectively, which are statistically significantly higher than those achieved by the first model, with area under the receiver operating characteristics curve and area under the precision-recall curve of 0.896 (95% CI, 0.892-0.900) and 0.905 (95% CI, 0.353-0.379). The superiority of the second model held true for 12-hour prediction/updating as well as for 24-hour prediction/updating. CONCLUSIONS: We show that statistical learning techniques can be used to automatically extract all relevant shape features for use in predictive modeling. The approach requires no additional data and can potentially be used to improve any risk model that uses some form of trajectory information. In this single-center study, the shapes of the clinical data trajectories convey information about ICU mortality risk beyond what is already captured by the summary statistics currently used in the literature.

Neogene fallout tuffs from the Yellowstone hotspot in the Columbia Plateau region, Oregon, Washington and Idaho, USA.

Sedimentary sequences in the Columbia Plateau region of the Pacific Northwest ranging in age from 16-4 Ma contain fallout tuffs whose origins lie in volcanic centers of the Yellowstone hotspot in northwestern Nevada, eastern Oregon and the Snake River Plain in Idaho. Silicic volcanism began in the region contemporaneously with early eruptions of the Columbia River Basalt Group (CRBG), and the abundance of widespread fallout tuffs provides the opportunity to establish a tephrostratigrahic framework for the region. Sedimentary basins with volcaniclastic deposits also contain diverse assemblages of fauna and flora that were preserved during the Mid-Miocene Climatic Optimum, including Sucker Creek, Mascall, Latah, Virgin Valley and Trout Creek. Correlation of ashfall units establish that the lower Bully Creek Formation in eastern Oregon is contemporaneous with the Virgin Valley Formation, the Sucker Creek Formation, Oregon and Idaho, Trout Creek Formation, Oregon, and the Latah Formation in the Clearwater Embayment in Washington and Idaho. In addition, it can be established that the Trout Creek flora are younger than the Mascall and Latah flora. A tentative correlation of a fallout tuff from the Clarkia fossil beds, Idaho, with a pumice bed in the Bully Creek Formation places the remarkably well preserved Clarkia flora assemblage between the Mascall and Trout Creek flora. Large-volume supereruptions that originated between 11.8 and 10.1 Ma from the Bruneau-Jarbidge and Twin Falls volcanic centers of the Yellowstone hotspot in the central Snake River Plain deposited voluminous fallout tuffs in the Ellensberg Formation which forms sedimentary interbeds in the CRBG. These occurrences extend the known distribution of these fallout tuffs 500 km to the northwest of their source in the Snake River Plain. Heretofore, the distal products of these large eruptions had only been recognized to the east of their sources in the High Plains of Nebraska and Kansas.