Tufts Medical Center

AL amyloidosis is a rare, complex and often challenging disease for both patients and healthcare providers. The availability of accurate medical information is crucial for effective diagnosis and management. In recent years, artificial intelligence (AI) has emerged as a potential tool for providing medical information. This study aims to assess the accuracy of AI ChatGPT responses for AL amyloidosis related common questions and compare them to expert opinions. A scoring system was developed to evaluate responses provided by five participating expert physicians. AI ChatGPT demonstrated an overall accuracy rate of 82% in answering AL amyloidosis‐related questions. Responses on prognosis and patient support received the highest scores (100%), while questions related to treatment options showed lower accuracy (30%–60%). The results indicate that while the AI ChatGPT demonstrates overall accuracy, there are areas for improvement and potential discrepancies compared to expert opinions. These findings highlight the importance of ongoing refinement and validation of AI‐powered medical tools and cannot yet replace the advice of experts in the disease.

Background: Despite their central role in hospital care, little research has explored medical-surgical nurses’ perspectives on the rewarding aspects of and significant influences on caring for adults with intellectual disabilities, even though they are key to understanding this population’s inequitable hospital outcomes. Methods: A qualitative descriptive design was used, and interviews were conducted with 13 medical-surgical nurses from the United States. Manifest content analysis was used to analyze the interview transcripts and categorize findings. Results: Five categories of significant influences: Preparedness to Care for People with Intellectual Disabilities, Communication, Caregiver Involvement, Ethical Concerns, and Context of Care, and four categories of rewards: Connecting, Making a Difference, Enjoyment, and Learning Opportunity, were revealed. Conclusion: Medical-surgical nurses derive meaning from connecting with and making a difference in the lives of hospitalized adults with intellectual disabilities, but face barriers to providing high-quality nursing care, resulting in dehumanized, delayed, or missed care.

Background: Two common surgical approaches for breast cancer are breast-conserving surgery and mastectomy with implant-based breast reconstruction (MIBR). However, for large tumors, an alternative to MIBR is oncoplastic surgery with volume replacement (OPSVR). We performed a comprehensive analysis comparing OPSVR with MIBR, with our aim to focus on the 30-days post-operative complications between these two techniques. Methods: We conducted a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2020. Only breast cancer patients were included and were divided according to the surgical technique: OPSVR and MIBR. Logistic regression analysis was used to assess independent risk factors for total, surgical, and wound complications. Results: A cohort of 8,403 breast cancer patients was analyzed. 683 underwent OPSVR and 7,720 underwent MIBR. From 2005 to 2020, the adoption of OPSVR gradually increased over the years (p<0.001), whereas MIBR decreased. OPSVR patients were older (57.04 vs. 51.89 years, p<0.001), exhibited a higher BMI (31.73 vs. 26.93, p<0.001), had a greater prevalence of diabetes mellitus (11.0% vs. 5.0%, p<0.001). They also had a higher ASA classification (2.33 vs. 2.15, p<0.001), shorter operative time (173.39 vs. 216.20 min, p<0.001), and a higher proportion of outpatient procedures (83.7% vs 39.5%, p<0.001). Outcome analysis demonstrated fewer total complications in the OPSVR patients, (4.2% vs. 10.9%, p<0.001), including lower rates of surgical complications (2.2% vs 8.0%, p<0.001) and wound complications (1.9% vs. 4.8%, p=0.005) compared to MIBR patients. Multivariate analysis identified OPSVR as an independent protective factor for total, surgical, and wound complications. Conclusion: OPSVR has become a favorable technique for patients with breast cancer. Even in patients with higher comorbidities, OPSVR demonstrates safe and better outcomes when compared to MIBR. It should be considered a reasonable and safe breast surgical option in the appropriate patient.

Antibiotic resistance is a major cause of morbidity and mortality. However, a better understanding of the relationship between bacterial genetic markers, phenotypic resistance, and clinical outcomes is needed. We performed whole-genome sequencing on five medically important pathogens ( Acinetobacter baumannii , Enterobacter cloacae , Escherichia coli , Klebsiella pneumoniae , and Pseudomonas aeruginosa ) to investigate how resistance genes impact patient outcomes. A total of 168 isolates from 162 patients with Gram-negative infections admitted to Beilinson Hospital at Rabin Medical Center in Israel were included for final analysis. Genomes were analyzed for resistance determinants and correlated with microbiologic and clinical data. Thirty-day mortality from time of culture was 26.5% (43/162). Twenty-nine patients had carbapenem-resistant isolates (29/168, 17.2%), while 63 patients had multidrug-resistant isolates (63/168, 37.5%). Albumin levels were inversely associated with mortality and length of stay, while arrival from a healthcare facility and cancer chemotherapy predicted having a multidrug-resistant isolate. Sequencing revealed possible patient-to-patient transmission events. bla CTX-M-15 was associated with multidrug-resistance in E. coli (OR = 3.888, P = 0.023) on multivariate analysis. Increased bla OXA-72 copy number was associated with carbapenem-resistance in A. baumannii ( P = 0.003) and meropenem minimum inhibitory concentration ( P = 0.005), yet carbapenem-resistant isolates retained sensitivity to cefiderocol and sulbactam–durlobactam. RJX84154 was associated with multidrug-resistance across all pathogens ( P = 0.0018) and in E. coli ( P = 0.0024). Low albumin levels were associated with mortality and length of stay in this sample population. bla CTX-M-15 was correlated with multidrug-resistance in E. coli , and bla OXA-72 depth predicted meropenem minimum inhibitory concentration in A. baumannii . RJX84154 may play a role in multidrug-resistance. IMPORTANCE While there have been several studies that attempt to find clinical predictors of outcomes in patients hospitalized with bacterial infections, less has been done to combine clinical data with genomic mechanisms of antibiotic resistance. This study focused on a hospitalized patient population in Israel with infections due to medically important bacterial pathogens as a way to build a framework that would unite clinical data with both bacterial antibiotic susceptibility and genomic data. Merging both clinical and genomic data allowed us to find both bacterial and clinical factors that impact certain clinical outcomes. As genome sequencing of bacteria becomes both rapid and commonplace, near real-time monitoring of resistance determinants could help to optimize clinical care and potentially improve outcomes in these patients.

Otitis externa is an infection and inflammation involving the external auditory canal and may include the auricle and tympanic membrane. It is characterized by otorrhea, canal inflammation, otalgia, pruritus, tinnitus, and hearing loss. It is frequently caused by acute bacterial infections but can also be attributed to chronic bacterial inflammation, fungal infections, myringitis, or viral infections. The differential diagnosis includes otitis media, malignant otitis externa, neoplasm, and autoimmune or dermatologic conditions. Treatment includes topical medications (e.g., topical antibiotics, antiseptics, and corticosteroids), aural toilet, and in some cases surgical debridement. It is important to recognize the underlying diagnosis and common pathogens to appropriately treat the disease. In addition, the integrity of the tympanic membrane must be considered, as many topical medications are potentially ototoxic. This chapter reviews the etiology, clinical features, diagnosis, and treatment of various external otologic infections.

The gut‐derived peptide hormones glucagon‐like peptide‐1 (GLP‐1) and glucose‐dependent insulinotropic polypeptide (GIP) play important physiological roles including glucose homeostasis and appetite suppression. Stabilized agonists of the GLP‐1 receptor (GLP‐1R) and dual agonists of GLP‐1R and GIP receptor (GIPR) for the management of type 2 diabetes and obesity have generated widespread enthusiasm and have become blockbuster drugs. These therapeutics are refractory to the action of dipeptidyl peptidase‐4 (DPP4), that catalyzes rapid removal of the two N‐terminal residues of the native peptides, in turn severely diminishing their activity profiles. Here we report that a single atom change from carbon to nitrogen in the backbone of the entire peptide makes them refractory to DPP4 action while still retaining full potency and efficacy at their respective receptors. This was accomplished by use of aza‐amino acids, that are bioisosteric replacements for α‐amino acids that perturb the structural backbone and local side chain conformations. Molecular dynamics simulations reveal that aza‐amino acid can populate the same conformational space that GLP‐1 adopts when bound to the GLP‐1R. The insertion of an aza‐amino acid at the second position from the N‐terminus in semaglutide and in a dual agonist of GLP‐1R and GIPR further demonstrates its capability as a viable alternative to current DPP4 resistance strategies while offering additional structural variation that may influence downstream signaling.

Geographic atrophy (GA) is the advanced stage of non-neovascular (dry) age-related macular degeneration, defined by the presence of sharply demarcated atrophic lesions of the outer retina. The complement system is integral to the body’s natural immune response, and hence its overactivation can lead to tissue damage and inflammation. It has been shown to play a significant role in GA lesion development and progression, and therefore, complement inhibition is emerging as a promising avenue for therapeutic intervention. With the recent approval by the Food and Drug Administration of drugs like SYFOVRE™ (pegcetacoplan injection) and IZERVAY™ (avacincaptad pegol intravitreal solution), there is hope for the development of interventions capable of slowing down or arresting the progression of GA. In particular, gene therapy intervention is gaining traction for halting GA atrophy at the source of our genes. The concept is to insert a gene into the eye that will act as an ocular “bio-factory,” producing a desired protein. This can either lead to overproduction of an already available protein or produce a substance not typically generated in the eye. This review aims to provide an overview of the present understanding of GA, encompassing risk factors, prevalence, pathophysiology, and genetic associations. It will also highlight the current landscape of GA treatment, with particular emphasis on gene therapy intervention.

Splenic artery embolization (SAE) has emerged as a promising alternative for managing variceal bleeding secondary to portal hypertension (PH). This study aims to elucidate the significance of SAE in managing esophageal variceal bleeding in patients with PH, providing an overview of its efficacy, safety, and role in PH management. A systematic review and meta-analysis were conducted in accordance with PRISMA standards. EMBASE, PubMed, Scopus, and Web of Science databases were searched from inception until April 14, 2024. Original observational and clinical studies on SAE in managing variceal bleeding due to PH were included. Meta-analyses were performed using a random-effects model, and publication bias was assessed using regression and rank correlation tests for funnel plot asymmetry. Eighteen studies met the inclusion criteria, encompassing 531 patients. The meta-analysis revealed a significant reduction in variceal bleeding post-SAE (RD = -0.86; 95% CI: -0.97, -0.75; p < 0.001). Complete resolution of varices was observed in 26% of patients (95% CI: 11%, 45%; p = 0.006), and 78% showed improvement in variceal grade (95% CI: 43%, 88%; p < 0.001). SAE significantly increased platelet counts (SMD = 1.15; 95% CI: 0.63, 1.68; p < 0.001). Common complications included post-embolization syndrome, and the overall complication rate was low. This systematic review and meta-analysis study supports the efficacy and safety of SAE in managing variceal bleeding due to PH, demonstrating significant reductions in bleeding, improvements in variceal grade, and increases in platelet counts.

The Autosomal Dominant Polycystic Kidney Disease (ADPKD) Centers of Excellence Program, launched by the Polycystic Kidney Disease Foundation in 2022, aims to bridge the gap in specialized care for individuals with ADPKD. This program seeks to enhance the availability of specialized clinicians and simplify the process for patients seeking expert care. It is founded on three pillars: improving care for all individuals with ADPKD, educating and empowering the community, and advancing PKD research. The program draws inspiration from successful models in other diseases, such as cystic fibrosis and muscular dystrophy, which have demonstrated the effectiveness of standardized care centers in improving patient outcomes. Patient and clinician stakeholder interviews have identified key areas where a national program could make a significant impact, including the need for a core care team with defined referral processes, mentorship and shared care models, patient navigation services, and education around expert consensus and care guidelines. The program introduces two designations: "Center of Excellence" and "Partner Clinic" to accommodate diverse care settings and enhance patient access to specialists. The Partner Clinic designation ensures that patients in smaller community practices have access to specialized care through mentorship and guidance from experts at Centers of Excellence. The program also emphasizes the importance of specialized services, especially in underserved communities experiencing health disparities, to manage the complexities of ADPKD care. Patient focus groups have highlighted the need for care navigation services, centralized sources of knowledge, and access to local care. The program aims to address these needs by providing a structured framework for care coordination, enhancing patient self-advocacy, and improving overall outcomes for individuals with ADPKD.

Purpose The impact of Aortic Stenosis (AS) on the left ventricle (LV) extends beyond the influence of the pressure drop across the stenotic valve, but also includes the additional serial afterload imposed by the vascular system. Aortic input impedance is the gold standard for comprehensively studying the contribution of the vascular system to total myocardial afterload, but in the past measurement has been challenging arising from the need for invasive catheterization or specialized equipment to precisely record time-resolved blood pressure and flow signals. The goal of this work was to develop and validate a novel simulation-based method for determining aortic input impedance using only clinically available echocardiographic data and a simple blood pressure measurement. Methods A simulation-based method to determine vascular impedance was developed using echocardiographic data and a brachial blood pressure measurement. Simulation-based impedance was compared to impedance calculated from echocardiographic flow data and pressure data from a non-invasive central pressure measurement device. Results In validation analysis comparing patient-specific simulation-based vascular impedance to non-invasively measured impedance, correlation between methods across a range of vascular parameters varied between R ² = 0.40 and 0.99. A tendency was seen toward underestimation of pressure waveforms in point-by-point comparison of measured and simulated waveforms with an overall mean difference of 4.01 mmHg. Conclusions Requiring only non-invasive clinical data that are widely available, simulation-based vascular impedance has the potential to allow for easier, more widespread, and larger-scale investigation of the effect of vascular impedance on total LV afterload.

Background The rising prevalence of pretreatment drug resistance (PDR) to non-nucleoside reverse-transcriptase inhibitors threatens the effectiveness of ART. In response, the WHO recommends dolutegravir-based ART regimens due to their high genetic barrier to resistance and better treatment outcomes. This is expected to contribute to achieving the Joint United Nations Programme on HIV/AIDS (UNAIDS) target of 95% viral suppression in people on ART. Objectives To estimate the prevalence of PDR among adults initiating ART and assess viral suppression and acquired HIV drug resistance (ADR) among individuals receiving ART in Belize. Patients and methods Nationally representative cross-sectional PDR and ADR surveys were conducted between 2021 and 2022. Sixty-seven adults were included in the PDR survey, and 43 children and adolescents and 331 adults were included in the ADR survey. Demographic and clinic data and blood specimens were collected. HIV drug resistance (HIVDR) was predicted using the Stanford HIVdb tool. Results The prevalence of PDR to efavirenz or nevirapine in adults was 49.3% (95% CI 42.2%–56.4%) and was significantly higher in those with previous antiretroviral exposure (OR: 7.16; 95% CI 2.71–18.95; P = 0.002). Among children and adolescents receiving ART, 50.0% had viral suppression, with better rates for those receiving dolutegravir-based ART (OR: 5.31; 95% CI 3.02–9.34; P < 0.001). In adults, 79.6% achieved viral suppression. No resistance to integrase inhibitors was observed in those on dolutegravir-based ART. Conclusions Prioritizing dolutegravir-based ART is critical for achieving HIV epidemic control in Belize. Efforts should focus on retention in care and adherence support to prevent HIVDR.

Objective To report 52‐week safety and efficacy of ianalumab from phase 2b dose‐finding study in patients with Sjögren's disease (SjD). Methods Patients randomly received (1:1:1:1) ianalumab (5, 50, or 300 mg) or placebo subcutaneously every 4 weeks till week 24 (treatment period [TP]1). At week 24, patients on 300 mg were re‐randomized to continue 300 mg or receive placebo till week 52 (TP2), patients on placebo were switched to ianalumab 150 mg, while patients on 5 and 50 mg directly entered post treatment safety follow‐up. Patients who discontinued treatment early or completed treatment entered safety follow‐up (≥20 weeks). Results During TP1, 190 patients were randomized (placebo=49, 5 mg=47, 50 mg=47, 300 mg=47). Of these 190 patients, 90 (47.4 %; 43 continued 300 mg and 47 received placebo) entered TP2, and 81/90 (90.0%) completed the study treatment. By week 52, efficacy was sustained in patients who continued 300 mg in TP2 (ESSDAI, ESSPRI, PaGA, PhGA change from week 24: −1.45, −0.46, −4.69, −6.86, respectively). Stimulated salivary flow rates and autoantibody levels numerically improved in the 300 mg group. Treatment‐emergent adverse events were not dose‐dependent, except for injection‐site reactions. Cases of decreased neutrophil counts (CTCAE v4.03 grade 3 according to laboratory listings) were observed in 3 patients during the post‐treatment follow‐up, occurring at 3.5, 5.5, and 3 months, after the last ianalumab administration. None were associated with infection except one incidental finding of asymptomatic cytomegalovirus infection (IgM+). Conclusion In patients with SjD, ianalumab 300 mg demonstrated sustained efficacy through week 52 and a favorable safety profile up to two years of follow‐up.

Introduction: Due to the hormonal changes that occur during the menopause period, postmenopausal women (PMW) experience symptoms that can affect their quality of life. This study aimed to investigate the prevalence of menopausal symptoms and its related factors in Iranian PMW. Methods: In this cross-sectional study, a total number of 300 participants from Neyshabur health centers were recruited, using stratified random sampling in 2022. Data were collected using the demographic characteristics and Menopause Rating Scales. Descriptive statistics, Pearson correlation test, and stepwise regression analysis were employed for data analysis using SPSS software version 22. Results: The mean (standard deviation) age of menopause was 49.4 (3.3). The most common menopausal symptoms were muscle or joint pain 239 (79.7%), hot flashes/sweating 232(77.3%), and anxiety 219 (73%), and sexual problems 214 (71.3%). Independent predictors of menopausal symptoms were: the spouse’s education level for physiological and total menopausal symptoms; chronic diseases for somatic total menopausal symptoms; age, economic status, and the number of children for uranological menopausal symptoms; and family structure for physiological menopausal symptoms (P<0.05). Conclusion: Women education about menopause, including its associated symptoms and the underlying factors influencing symptomatology, is essential for enhancing their quality of life both during and after this transitional phase. Additionally, providing them with information on effective strategies and interventions for mitigating and managing menopausal symptoms can significantly contribute to improving women’s overall well-being during this life stage.

Background The incidence of obesity in patients with inflammatory bowel disease (IBD) is increasing and there are limited data on the impact of obesity on perianal fistulas in Crohn’s disease (CD). Aims We aim to examine the relationship between obesity and the prevalence and complications of Crohn’s perianal fistulas. Methods We conducted a cross-sectional study of CD patients treated at a tertiary care center from 2012 to 2022. Obesity was defined as maximum BMI > 30 kg/m² and further subdivided into 5 BMI categories. The prevalence of perianal fistulas was defined by any history of perianal fistula. The complications of perianal fistulas were measured by five variables including complex fistulas, history of perianal fistula surgery, number of perianal surgeries, history of fecal diversion, and median time to first anal surgery. Results In all, 704 patients with CD were included; 31.1% were obese. There was no significant association between obesity and prevalence of perianal fistulas (p = 0.719), complex fistulas (p = 0.144), history of perianal surgery (p = 0.146), ≥ 1 perianal surgeries (p = 0.220), fecal diversion (p = 0.705), or median time to first perianal surgery (p = 0.192). Increasing BMI category was not associated with the prevalence of perianal fistulas (p = 0.944), complex fistulas (p = 0.089), perianal surgery (p = 0.583), ≥ 1 perianal surgeries (p = 0.114), fecal diversion (p = 0.542), or median time to first perianal surgery (p = 0.486). When comparing those with perianal fistulas to those without, there was no significant difference in rates of obesity (p = 0.876). Conclusion There was no association between obesity and the prevalence and complications of Crohn’s perianal fistulas.

Prenatal stress (PS) impacts early behavioral, neuroimmune, and cognitive development. Pregnant rat models have been very valuable in examining the mechanisms of such fetal programming. A pregnant sheep model of maternal stress offers the unique advantages of chronic in utero monitoring and manipulation. This chapter presents the techniques used to model single and multigenerational stress exposures and their pleiotropic effects on the offspring.

JAK inhibitors (JAKi) are increasingly being utilized for both FDA-approved and off-label treatments in dermatology. However, JAKi carry a black box warning concerning major side effects, including serious infections, cardiovascular events, thrombosis, malignancy, and mortality. Given that there is an absence of large-scale studies examining the adverse event (AE) profile of multiple JAKi for dermatologic conditions in real-world settings, our study aimed to bridge this gap by evaluating AEs of dermatology patients on oral JAKi at two academic medical centers.

Acute right ventricular failure (RVF) is a common finding in cardiogenic shock (CS), yet the optimal method of supporting the failing RV remains unclear. This study aimed to describe CS patients receiving percutaneous right ventricular assist devices (pRVADs) using the multicenter Cardiogenic Shock Working Group (CSWG) registry. Among 6,201 patients with CS, 152 (2.4%) received pRVADs, with ProtekDuo and Impella RP being used in 71% and 29% of cases, respectively. The average age of this group was 58.5 years, with a higher proportion of men (66.4%). Heart failure–associated CS (HF-CS) was observed in 48% of patients, while myocardial infarction–associated CS (MI-CS) was seen in 27% (HF-CS versus MI-CS: 52.8% vs. 21.3% for ProtekDuo; 36.4% vs. 40.9% for Impella RP; p = 0.01). The overall in-hospital mortality rate was 54.6%, bleeding complications were more prevalent among ProtekDuo recipients (64.8% vs. 43.2%, p = 0.008), whereas Impella RP recipients had shorter hospital stays (20.4 ± 18.7 vs. 41.9 ± 31.5 days, p < 0.001). ProtekDuo was more commonly used in patients with HF-CS and was associated with higher rates of bleeding and longer hospital stays compared with Impella RP, although overall mortality was similar. Further investigation is required to determine the ideal timing and clinical conditions warranting pRVAD deployment in CS.

Introduction Preeclampsia remains a formidable public health challenge, particularly in low- and middle-income countries (LMICs), where it significantly contributes to the high rates of maternal and neonatal morbidity and mortality. The advent of mobile health (mHealth) applications presents a promising avenue for enhancing the management of preeclampsia. This review protocol is designed to systematically assess the effectiveness and equity of mHealth apps in managing preeclampsia within LMICs, with a focus on clinical outcomes and the broader implications for accessibility, affordability, and cultural relevance. Materials and methods To achieve the objectives of this review, a rapid review methodology will be employed, encompassing a structured search strategy to identify pertinent studies from databases such as PubMed, Cochrane Library, and Google Scholar, as well as grey literature. The inclusion criteria are set to encompass randomized controlled trials (RCTs), controlled clinical trials (CCTs), observational studies, and qualitative studies that offer insights into the effectiveness and user experience of mHealth apps for preeclampsia management. Participants in these studies will include pregnant women at risk for or diagnosed with preeclampsia, healthcare providers, and app developers. The quality of the included studies will be critically appraised using standardized tools, and data extraction will focus on study characteristics, interventions, outcomes, and equity considerations. Discussion The implications of this review are far-reaching, offering the potential to inform stakeholders including policymakers, healthcare providers, and app developers about the deployment and development of mHealth solutions for preeclampsia management in LMICs. Ultimately, the anticipated findings of this review are expected to contribute significantly to the understanding of mHealth apps’ role in improving preeclampsia management and addressing healthcare disparities, thereby guiding future strategies to enhance maternal and neonatal health outcomes in LMICs.