What does this study add to the field?Using latent class analysis (LCA), we identified two subgroups among a cohort of 483 patients with COVID-19-related ARDS. Class 2 patients had higher inflammatory markers and lactate and corresponded with the previously identified hyperinflammatory subphenotype, whereas Class 1 corresponded with the hypoinflammatory subphenotype. Class 2 had significantly higher 90-day mortality compared with Class 1 (75% vs 48%; p<0•0001). Differential response to corticosteroid treatment was observed, with decreased mortality in steroid-treated patients in Class 2 but not Class 1. SARS-CoV-2 polymerase chain reaction cycle threshold was a predictor of mortality in Class 1, but not Class 2, suggesting distinct drivers of mortality among classes.

Intermediate-risk pulmonary embolism is common and carries a risk of progression to hemodynamic collapse and death. Catheter-directed thrombolysis is an increasingly used treatment option, based largely on the assumptions that it is more efficacious than anticoagulation alone and safer than systemic thrombolysis. In this review, we critically analyze the published data regarding catheter-directed thrombolysis for the treatment of intermediate-risk pulmonary embolism. Catheter-directed thrombolysis reduces right heart strain and lowers pulmonary artery pressures more quickly than anticoagulation alone. The mortality for patients with intermediate-risk pulmonary embolism treated with catheter-directed thrombolysis is low, between 0% and 4%. However, similarly low mortality is seen with anticoagulation alone. Catheter-directed thrombolysis appears to be safer than systemic thrombolysis, and procedural complications are uncommon. Bleeding risk appears to be slightly higher than with anticoagulation alone. Randomized, controlled trials are needed to compare the efficacy and safety of catheter-directed thrombolysis versus anticoagulation for intermediate-risk pulmonary embolism. There is no evidence that catheter-directed thrombolysis decreases the incidence of chronic thromboembolic pulmonary hypertension. There is no evidence from clinical studies that ultrasound-assisted thrombolysis is more effective or safer than standard catheter-directed thrombolysis.

Background: Interventions to optimize blood culture (BCx) practices in adult inpatients are limited. Methods: Before-after study evaluating the impact of a diagnostic stewardship program to optimize BCx use in a medical intensive care unit (MICU) and five medicine units at a large academic center. The program included implementation of an evidence-based algorithm detailing indications for BCx use and education and feedback to providers about BCx rates and indication inappropriateness. Neutropenic patients were excluded. BCx rates from contemporary control units were obtained for comparison. The primary outcome was the change in BCx ordered with the intervention. Secondary outcomes included proportion of inappropriate BCx, solitary BCx and positive BCx. Balancing metrics included compliance with Centers for Medicare and Medicaid Services (CMS) SEP-1 BCx component, 30-day readmission, and all-cause in-hospital and 30-day mortality. Results: After the intervention, BCx rates decreased from 27.7 to 22.8 BCx/100 patient-days (PD) in the MICU (P=0.001) and from 10.9 to 7.7BCx/100 PD for the 5 medicine units combined (P<0.001). BCx rates in the control units did not decrease significantly (surgical ICU, P=0.06, surgical units, P=0.15). The proportion of inappropriate BCx did not significantly change with the intervention (30% in the MICU and 50% in medicine units, respectively). BCx positivity increased in the MICU (from 8% to 11%, P<0.001). Solitary BCx decreased by 21% on the medicine units (P<0.001). Balancing metrics were similar before and after the intervention. Conclusions: BCx use can be optimized with clinician education and practice guidance without affecting sepsis quality metrics or mortality.