Adenosine diphosphate released from stressed cells triggers mitochondrial transfer to achieve tissue homeostasis.

Cell-to-cell mitochondrial transfer has recently been shown to play a role in maintaining physiological functions of cell. We previously illustrated that mitochondrial transfer within osteocyte dendritic network regulates bone tissue homeostasis. However, the mechanism of triggering this process has not been explored. Here, we showed that stressed osteocytes in mice release adenosine diphosphate (ADP), resulting in triggering mitochondrial transfer from healthy osteocytes to restore the oxygen consumption rate (OCR) and to alleviate reactive oxygen species accumulation. Furthermore, we identified that P2Y2 and P2Y6 transduced the ADP signal to regulate osteocyte mitochondrial transfer. We showed that mitochondrial metabolism is impaired in aged osteocytes, and there were more extracellular nucleotides release into the matrix in aged cortical bone due to compromised membrane integrity. Conditioned medium from aged osteocytes triggered mitochondrial transfer between osteocytes to enhance the energy metabolism. Together, using osteocyte as an example, this study showed new insights into how extracellular ADP triggers healthy cells to rescue energy metabolism crisis in stressed cells via mitochondrial transfer in tissue homeostasis.

Treatment of cavitated non-small cell lung cancer presenting as "Halloween pumpkin" following the consecutive NEOADAURA and ADAURA2 strategy: A case report.

Osimertinib is a third-generation tyrosine kinase inhibitor that targets mutant epidermal growth factor receptor (EGFR). The success of FLAURA and ADAURA trials prompted the license of Osimertinib for the treatment of EGFR mutant non-small cell lung cancer (NSCLC) at advanced stage and for patients with stages IB to IIIA disease in post-operative setting. In the present study, we described neoadjuvant use of Osimertinib in an EGFR mutant NSCLC patient with locally metastatic disease (T2aN2M0). Intriguingly, the cavitated NSCLC resembled an impressive"Halloween pumpkin" appearance that dramatically responded to Osimertinib treatment. Downstaging of N2 metastatic disease was reached and surgical resection was scheduled. The post-operative clinical stage was IA3. The patient was recommended to continue Osimertinib adjuvant treatment and our follow-ups showed no signs of disease recurrence. Our case study underscored the feasibility of Osimertinib as a neoadjuvant and adjuvant therapy for patients with locally advanced EGFR mutant NSCLC.

Co-delivery of Siape1 and Melatonin by 125I-loaded PSMA-targeted Nanoparticles for the Treatment of Prostate Cancer.

BACKGROUND: Both apurinic/apyrimidinic endodeoxyribonuclease 1 (APE1) inhibition and melatonin suppress prostate cancer (PCa) growth. OBJECTIVE: This study evaluated the therapeutic efficiency of self-assembled and prostate-specific membrane antigen (PSMA)-targeted nanocarrier loading 125I radioactive particles and encapsulating siRNA targeting APE1 (siAPE1) and melatonin for PCa. METHODS: The linear polyarginine R12 polypeptide was prepared using Fmoc-Arg-Pbf-OH. The PSMA-targeted polymer was synthesized by conjugating azide-modified R12 peptide to PSMA monoclonal antibody (mAb). Before experiments, the PSMA-R12 nanocarrier was installed with melatonin and siAPE1, which were subsequently labeled by 125I radioactive particles. In vitro biocompatibility and cytotoxicity of nanocomposites were examined in LNCaP cells and in vivo biodistribution and pharmacokinetics were determined using PCa tumor-bearing mice. RESULTS: PSMA-R12 nanocarrier was ~120 nm in size and was increased to ~150 nm by melatonin encapsulation. PSMA-R12 nanoparticles had efficient loading capacities of siAPE1, melatonin, and 125I particles. The co-delivery of melatonin and siAPE1 by PSMA-R12-125I showed synergistic effects on suppressing LNCaP cell proliferation and Bcl-2 expression and promoting cell apoptosis and caspase-3 expression. Pharmacokinetics analysis showed that Mel@PSMA-R12-125I particles had high uptake activity in the liver, spleen, kidney, intestine, and tumor, and were accumulated in the tumor sites within the first 8 h p.i., but was rapidly cleared from all the tested organs at 24 h p.i. Administration of nanoparticles to PCa tumors in vivo showed that Mel@PSMA-R12- 125I/siAPE1 had high efficiency in suppressing PCa tumor growth. CONCLUSION: The PSMA-targeted nanocarrier encapsulating siAPE1 and melatonin is a promising therapeutic strategy for PCa and can provide a theoretical basis for patent applications.

Phosphorus-Water Interaction Drives Active Center Evolution into the Water-Adaptive Structure in the High-Humidity NH3-SCR Reaction.

The impact of water on catalyst activity remains inconclusive due to its dependence on the specific reaction environment. To maximize the exploitation of water's promoting effect, we employed ammonia selective catalytic reduction (NH3-SCR) as a probe reaction and proposed a phosphorus modification strategy for Cu-ZSM-5 catalysts. The objective of this approach was to construct water-adaptive microstructures through directional arrangement. To investigate the effect of phosphorus on the transformation of framework copper sites in humid environments, we conducted comprehensive characterizations and density functional theory calculation. Results reveal that water molecules cleave the oxygen bridges between phosphorus oxide and copper, leading to the formation of active isolated [Cu(OH)]+ groups and phosphate. The phosphate species weaken the interaction between exchanged Cu2+ groups and the zeolite framework, leading to the generation of highly migratory hydrated Cu2+ species. This work will potentially guide the rational design of water-adaptive catalysts for gas pollution abatement in a humid environment.

Deep learning in pulmonary nodule detection and segmentation: a systematic review.

OBJECTIVES: The accurate detection and precise segmentation of lung nodules on computed tomography are key prerequisites for early diagnosis and appropriate treatment of lung cancer. This study was designed to compare detection and segmentation methods for pulmonary nodules using deep-learning techniques to fill methodological gaps and biases in the existing literature. METHODS: This study utilized a systematic review with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching PubMed, Embase, Web of Science Core Collection, and the Cochrane Library databases up to May 10, 2023. The Quality Assessment of Diagnostic Accuracy Studies 2 criteria was used to assess the risk of bias and was adjusted with the Checklist for Artificial Intelligence in Medical Imaging. The study analyzed and extracted model performance, data sources, and task-focus information. RESULTS: After screening, we included nine studies meeting our inclusion criteria. These studies were published between 2019 and 2023 and predominantly used public datasets, with the Lung Image Database Consortium Image Collection and Image Database Resource Initiative and Lung Nodule Analysis 2016 being the most common. The studies focused on detection, segmentation, and other tasks, primarily utilizing Convolutional Neural Networks for model development. Performance evaluation covered multiple metrics, including sensitivity and the Dice coefficient. CONCLUSIONS: This study highlights the potential power of deep learning in lung nodule detection and segmentation. It underscores the importance of standardized data processing, code and data sharing, the value of external test datasets, and the need to balance model complexity and efficiency in future research. CLINICAL RELEVANCE STATEMENT: Deep learning demonstrates significant promise in autonomously detecting and segmenting pulmonary nodules. Future research should address methodological shortcomings and variability to enhance its clinical utility. KEY POINTS: Deep learning shows potential in the detection and segmentation of pulmonary nodules. There are methodological gaps and biases present in the existing literature. Factors such as external validation and transparency affect the clinical application.

Mitochondria from osteolineage cells regulate myeloid cell-mediated bone resorption.

Interactions between osteolineage cells and myeloid cells play important roles in maintaining skeletal homeostasis. Herein, we find that osteolineage cells transfer mitochondria to myeloid cells. Impairment of the transfer of mitochondria by deleting MIRO1 in osteolineage cells leads to increased myeloid cell commitment toward osteoclastic lineage cells and promotes bone resorption. In detail, impaired mitochondrial transfer from osteolineage cells alters glutathione metabolism and protects osteoclastic lineage cells from ferroptosis, thus promoting osteoclast activities. Furthermore, mitochondrial transfer from osteolineage cells to myeloid cells is involved in the regulation of glucocorticoid-induced osteoporosis, and glutathione depletion alleviates the progression of glucocorticoid-induced osteoporosis. These findings reveal an unappreciated mechanism underlying the interaction between osteolineage cells and myeloid cells to regulate skeletal metabolic homeostasis and provide insights into glucocorticoid-induced osteoporosis progression.

Styxl2 regulates de novo sarcomere assembly by binding to non-muscle myosin IIs and promoting their degradation.

Styxl2, a poorly characterized pseudophosphatase, was identified as a transcriptional target of the Jak1-Stat1 pathway during myoblast differentiation in culture. Styxl2 is specifically expressed in vertebrate striated muscles. By gene knockdown in zebrafish or genetic knockout in mice, we found that Styxl2 plays an essential role in maintaining sarcomere integrity in developing muscles. To further reveal the functions of Styxl2 in adult muscles, we generated two inducible knockout mouse models: one with Styxl2 being deleted in mature myofibers to assess its role in sarcomere maintenance, and the other in adult muscle satellite cells (MuSCs) to assess its role in de novo sarcomere assembly. We find that Styxl2 is not required for sarcomere maintenance but functions in de novo sarcomere assembly during injury-induced muscle regeneration. Mechanistically, Styxl2 interacts with non-muscle myosin IIs, enhances their ubiquitination, and targets them for autophagy-dependent degradation. Without Styxl2, the degradation of non-muscle myosin IIs is delayed, which leads to defective sarcomere assembly and force generation. Thus, Styxl2 promotes de novo sarcomere assembly by interacting with non-muscle myosin IIs and facilitating their autophagic degradation.

Aggressive vertebral hemangiomas contain no adipose tissue resulting in thoracic spine kyphosis: A case report.

RATIONALE: Aggressive vertebral hemangiomas (AVHs) destroy continuous vertebral bodies and intervertebral discs and resulting in spinal kyphosis is extremely rare. The very aggressive behavior was attributable to its significant vascular component and contained no adipose tissue. PATIENT CONCERNS: We report a case of thoracic spine kyphosis of AVHs with multiple vertebral bodies and intervertebral disc destruction in a 45-year-old woman. DIAGNOSES: Based on the imaging studies, the patient underwent surgical removal of this lesion and spinal reconstruction. Histopathology consistent with vertebral hemangioma and contained no adipose. INTERVENTIONS: The patient underwent surgical removal of the lesion and spinal reconstruction. After subperiosteal dissection of the paraspinal muscles and exposure of the laminae, the laminae of the T5-7 vertebrae were removed and exposing the lesion. The lesion was soft and showed cystic changes, completely curetted and autogenous bone was implanted. Vertebroplasty was performed through T3-T9 pedicles bilaterally. Pedicle screw fixation was performed for segmental fixation and fusion. OUTCOMES: After 9 days of operation, the incision healed cleanly and free of pain. She was discharged in good general condition. The patient remained asymptomatic after follow-up 6 months of postoperative. LESSONS: AVHs destroy multiple vertebral bodies and intervertebral discs and resulting in spinal kyphosis is extremely rare.

Scalable Approach to Molecular Motor-Polymer Conjugates for Light-Driven Artificial Muscles.

The integration of molecular machines and motors into materials represents a promising avenue for creating dynamic and functional molecular systems, with potential applications in soft robotics or reconfigurable biomaterials. However, the development of truly scalable and controllable approaches for incorporating molecular motors into polymeric matrices has remained a challenge. Here, it is shown that light-driven molecular motors with sensitive photo-isomerizable double bonds can be converted into initiators for Cu-mediated controlled/living radical polymerization enabling the synthesis of star-shaped motor-polymer conjugates. This approach enables scalability, precise control over the molecular structure, block copolymer structures, and high-end group fidelity. Moreover, it is demonstrated that these materials can be crosslinked to form gels with quasi-ideal network topology, exhibiting light-triggered contraction. The influence of arm length and polymer structure is investigated, and the first molecular dynamics simulation framework to gain deeper insights into the contraction processes is developed. Leveraging this scalable methodology, the creation of bilayer soft robotic devices and cargo-lifting artificial muscles is showcased, highlighting the versatility and potential applications of this advanced polymer chemistry approach. It is anticipated that the integrated experimental and simulation framework will accelerate scalable approaches for active polymer materials based on molecular machines, opening up new horizons in materials science and bioscience.

An entanglement association polymer electrolyte for Li-metal batteries.

To improve the interface stability between Li-rich Mn-based oxide cathodes and electrolytes, it is necessary to develop new polymer electrolytes. Here, we report an entanglement association polymer electrolyte (PVFH-PVCA) based on a poly (vinylidene fluoride-co-hexafluoropropylene) (PVFH) matrix and a copolymer stabilizer (PVCA) prepared from acrylonitrile, maleic anhydride, and vinylene carbonate. The entangled structure of the PVFH-PVCA electrolyte imparts excellent mechanical properties and eliminates the stress arising from dendrite growth during cycling and forms a stable interface layer, enabling Li//Li symmetric cells to cycle steadily for more than 4500 h at 8 mA cm-2. The PVCA acts as a stabilizer to promote the formation of an electrochemically robust cathode-electrolyte interphase. It delivers a high specific capacity and excellent cycling stability with 84.7% capacity retention after 400 cycles. Li1.2Mn0.56Ni0.16Co0.08O2/PVFH-PVCA/Li full cell achieved 125 cycles at 1 C (4.8 V cut-off) with a stable discharge capacity of ~2.5 mAh cm-2.

Anatomical distribution and clinical significance of translobar bronchi, arteries, and veins hidden in the interlobar fissure.

Background: The interlobar bronchovascular structures hidden in the incomplete interlobar fissures (IFs) are often inadvertently transected during pulmonary resections, which could inevitably lead to accidental injury and potentially compromise the function of the preserved area. A thorough examination of the anatomical distribution of translobar bronchi, arteries, and veins holds significant clinical importance. Methods: Three-dimensional computed tomography bronchography and angiography (3D-CTBA) data from patients who underwent pulmonary resection between December 2018 and November 2019 were retrospectively analyzed. The translobar bronchi, arteries, and veins were categorized based on their origin and distribution. Surgical results of patients who underwent surgery involving translobar structures were further reviewed. Results: Among the 310 enrolled patients, incomplete IFs (IIFs) were most frequently observed in horizontal fissures (68.7%), followed by right upper oblique fissures (42.3%), left lower oblique fissures (32.6%), left upper oblique fissures (12.9%), and right lower oblique fissures (11.0%). The incidence of bronchovascular structures was significantly higher in IIFs than in complete IFs (CIFs; 85.5% vs. 5.2%, χ2=1,021.1, P<0.001). A total of three subtypes of translobar bronchi, five subtypes of translobar arteries, and 14 subtypes of translobar veins were identified. Primary subtypes of translobar arteries (frequency >5%) included the left A4/5 (18.7%) that branched from A7/8/7+8 and the common trunk of right Asc.A2+A6 (6.1%). Primary subtypes of translobar veins (frequency >5%) included the right V2 draining into inferior pulmonary vein (IPV) (5.8%), the interlobar V3b (58.4%) within horizontal fissures, the right V4/5 draining into V2/3 (26.1%), the left V4/5 draining into IPV (7.4%), the right V6 draining into V2 (38.4%), and the common trunk of left IPV and superior pulmonary vein (SPV; 9.4%). Moreover, 12.0% of translobar arteries and 75.0% of translobar veins were mistransected during anatomical pulmonary resection, resulting in gas-exchanging dysfunction in the preserved territory. Conclusions: Translobar bronchovascular structures exhibited a high incidence and were more commonly present in IIFs. Surgeons should pay increased attention to these structures to prevent accidental injuries during anatomical pulmonary resection.

Osteocyte mitochondria regulate angiogenesis of transcortical vessels.

Transcortical vessels (TCVs) provide effective communication between bone marrow vascular system and external circulation. Although osteocytes are in close contact with them, it is not clear whether osteocytes regulate the homeostasis of TCVs. Here, we show that osteocytes maintain the normal network of TCVs by transferring mitochondria to the endothelial cells of TCV. Partial ablation of osteocytes causes TCV regression. Inhibition of mitochondrial transfer by conditional knockout of Rhot1 in osteocytes also leads to regression of the TCV network. By contrast, acquisition of osteocyte mitochondria by endothelial cells efficiently restores endothelial dysfunction. Administration of osteocyte mitochondria resultes in acceleration of the angiogenesis and healing of the cortical bone defect. Our results provide new insights into osteocyte-TCV interactions and inspire the potential application of mitochondrial therapy for bone-related diseases.

Description of two new Megistophylla Burmeister, 1855 species from China, with a redescription of M. andrewesi Moser, 1913 (Coleoptera: Scarabaeidae: Melolonthinae).

This study presents descriptions and illustrations of two new melolonthine species: Megistophylla brevivirgata Wang & Gao, new species and M. keithi Wang & Gao, new species from Yunnan province in China. Additionally, a detailed redescription and illustration of the male of M. andrewesi Moser, 1913, and a description of its previously unknown female are provided. Finally, a key to identification of Megistophylla Burmeister, 1855 species from China is added.

Robot-assisted thoracic surgery for benign tumors at the cervicothoracic junction: a propensity-matched study.

This study aimed to assess the feasibility and safety of robot-assisted thoracic surgery (RATS) for resecting benign tumors of the cervicothoracic junction. Between 2017 and 2021, a total of 54 patients with benign cervicothoracic junction tumors were included. Among them, 46 underwent RATS while 8 underwent open surgery. Using a propensity score based on four variables (age, sex, comorbidity, and tumor size). The outcomes compared included short-term outcomes such as blood loss, as well as long-term outcomes including respiratory function and patients' postoperative health-related quality of life. No operative deaths occurred in this study. RATS was associated with less intraoperative blood loss (102 < 380 ml, P = 0.001) and a shorter length of hospital stay (1.8 < 4.8, P < 0.001). After a median follow-up of 37 months, no recurrences were reported, and no statistically significant differences were found in the 3-year survival between the two groups. The postoperative respiratory function of patients with open surgery showed a significant decrease compared to preoperative levels and were lower than those of RATS patients. In terms of health-related quality of life, RATS was associated with a better mean EQ-5D-5L index than open surgery (0.808 > 0.650, P < 0.05). In RATS, tumor sizes > 5 cm (mean ± SD = 0.768 ± 0.111, P = 0.028) and neurogenic tumors (mean ± SD = 0.702 ± 0.082, P < 0.001) remained significantly and independently associated with a lower EQ-5D-5L index. This study demonstrated that robot-assisted thoracic surgery for benign tumors of the cervicothoracic junction is a safe and technically feasible procedure, particularly for tumors < 5 cm and non-neurogenic tumors.

Clinical Impact of Switching or Continuation of Apixaban or Rivaroxaban among Patients with Non-Valvular Atrial Fibrillation.

BACKGROUND: Real-world evidence on direct oral anticoagulant outcomes among Non-Valvular Atrial Fibrillation (NVAF) patients is limited. We aimed to evaluate stroke/systemic embolism (SE) and major bleeding (MB) risks among NVAF patients continuing or switching to different oral anticoagulants. METHODS: Using Optum's de-identified Clinformatics® Data Mart Database, we identified NVAF patients initiating apixaban or rivaroxaban between 1 January 2013 and 31 December 2021. Patients switching therapies within 30 days before or 90 days after discontinuing their initial DOAC and those who continued initial therapy were included. The index date was the switch date for switchers, while continuers were assigned a hypothetic index date. Switchers and continuers were propensity score matched based on pre-index characteristics. RESULTS: Among 167,868 apixaban and 65,888 rivaroxaban initiators, 2900 apixaban-to-rivaroxaban switchers were matched with 14,500 apixaban continuers, and 2873 rivaroxaban-to-apixaban switchers were matched with 14,365 rivaroxaban continuers. Apixaban-to-rivaroxaban switching was associated with higher stroke/SE risk (HR: 1.99, 95% CI: 1.38-2.88) and MB risk (HR:1.80, 95% CI: 1.46-2.23) than continuing apixaban. Rivaroxaban-to-apixaban switching had similar stroke/SE risk (HR: 0.74, 95% CI: 0.45-1.22) but lower MB risk (HR: 0.49, 95% CI: 0.38-0.65) than continuing rivaroxaban. CONCLUSIONS: These findings may aid physicians and patients in making informed decisions when considering a switch between apixaban and rivaroxaban.

The protective effect of social support on all-cause and cardio-cerebrovascular mortality among middle-aged and older adults in the US.

The relationship between social support and mortality, especially cardio-cerebrovascular mortality, still has some limitations in the assessment of social support, sample selection bias, and short follow-up time. We used the data from 2005 to 2008 National Health and Nutrition Examination Survey to examine this relationship. The study analyzed a total of 6776 participants, divided into Group 1, Group 2, and Group 3 according to the social support score (0-1; 2-3; 4-5). Multivariable adjusted COX regression analyses of our study showed that Group 3 and Group 2 had a reduced risk of all-cause and cardio-cerebrovascular mortality (Group 3 vs 1, HR: 0.55, P < 0.001; HR: 0.4, P < 0.001; Group 2 vs 1, HR: 0.77, P = 0.017; HR: 0.58, P = 0.014) compared with Group 1. The same results were observed after excluding those who died in a relatively short time. Additionally, having more close friends, being married or living as married, and enough attending religious services were significantly related to a lower risk of mortality after adjustment. In brief, adequate social support is beneficial in reducing the risk of all-cause mortality and cardio-cerebrovascular mortality in middle-aged and older adults, especially in terms of attending religious services frequency, the number of close friends, and marital status.

Influence of Oxygen Vacancy-Induced Coordination Change on Pd/CeO2 for NO Reduction.

The byproduct formation in environmental catalysis is strongly influenced by the chemical state and coordination of catalysts. Herein, two Pd/CeO2 catalysts (PdCe-350 and PdCe-800) with varying oxygen vacancies (Ov) and coordination numbers (CN) of Pd were prepared to investigate the mechanism of N2O and NH3 formation during NO reduction by CO. PdCe-350 exhibits a higher density of Ov and Pd sites with higher CN, leading to an enhanced metal-support interaction by electron transformation from the support to Pd. Consequently, PdCe-350 displayed increased levels of byproduct formation. In situ spectroscopies under dry and wet conditions revealed that at low temperatures, the N2O formation strongly correlated with the Ov density through the decomposition of chelating nitro species on PdCe-350. Conversely, at high temperatures, it was linked to the reactivity of Pd species, primarily facilitated by monodentate nitrates on PdCe-800. In terms of NH3 formation, its occurrence was closely associated with the activation of H2O and C3H6, since a water-gas shift or hydrocarbon reforming could provide hydrogen. Both bridging and monodentate nitrates showed activity in NH3 formation, while hyponitrites were identified as key intermediates for both catalysts. The insights provide a fundamental understanding of the intricate relationship among the local coordination of Pd, surface Ov, and byproduct distribution.

An Ultrasmall Ordered High-Entropy Intermetallic with Multiple Active Sites for the Oxygen Reduction Reaction.

Controlling multimetallic ensembles at the atomic level is significantly challenging, particularly for high-entropy alloys with more than five elements. Herein, we report an innovative ultrasmall (∼2 nm) PtFeCoNiCuZn high-entropy intermetallic (PFCNCZ-HEI) with a well-ordered structure synthesized by using the space-confined strategy. By exploiting these combined metals, the PFCNCZ-HEI nanoparticles achieve an ultrahigh mass activity of 2.403 A mgPt-1 at 0.90 V vs reversible hydrogen electrode for the oxygen reduction reaction, which is up to 19-fold higher than that of state-of-the-art commercial Pt/C. A proton exchange membrane fuel cell assembled with PFCNCZ-HEI as the cathode (0.03 mgPt cm-2) exhibits a power density of 1.4 W cm-2 and a high mass-normalized rated power of 45 W mgPt-1. Furthermore, theoretical calculations reveal that the outer electrons of the non-noble-metal atoms on the surface of the PFCNCZ-HEI nanoparticle are modulated to show characteristics of multiple active centers. This work offers a promising catalyst design direction for developing highly ordered HEI nanoparticles for electrocatalysis.

The Association between Direct Oral Anticoagulants Prescribing Behavior and Non-Valvular Atrial Fibrillation Outcomes: An Instrumental Variable Analysis of Real-World Data.

Several observational studies have compared apixaban with rivaroxaban in patients with non-valvular atrial fibrillation (NVAF), but these analyses may be confounded by unmeasured characteristics. This study used provider prescribing preference (PPP) as an instrumental variable (IV) to assess the association between prescriber choice of rivaroxaban vs. apixaban and the study outcomes of stroke/systemic embolism (SE), major bleeding, and death in a retrospective cohort of NVAF patients in the US. Initiators of either medication were linked to their prescribers and followed until the first of the study outcome, the end of rivaroxaban/apixaban use, or 365 days after initiation. PPP for each patient was the percent of rivaroxaban initiations issued by the provider for the prior 10 NVAF patients. Cox regression models tested associations between quintiles of PPP and each outcome. A total of 61,155 patients and 1726 providers were included. The IV was a strong predictor of rivaroxaban prescription (OR = 17.9; 95% CI: 16.6, 19.3). There were statistically significant associations between increasing preference for rivaroxaban and rates of major bleeding (ptrend = 0.041) and death (ptrend = 0.031), but not stroke/SE (ptrend = 0.398). This analysis provides evidence of the relative safety of apixaban over rivaroxaban for the risk of major bleeding and death.