Blinded Physician Research Articles

Adverse Events in Patients Transitioning From the Emergency Department to the Inpatient Setting.

The objective of this study was to determine the incidence and types of adverse events (AEs), including preventable and ameliorable AEs, in patients transitioning from the emergency department (ED) to the inpatient setting. A second objective was to examine the risk factors for patients with AEs. This was a prospective cohort study of patients at risk for AEs in 2 urban academic hospitals from August 2020 to January 2022. Eighty-one eligible patients who were being admitted to any internal medicine or hospitalist service were recruited from the ED of these hospitals by a trained nurse. The nurse conducted a structured interview during admission and referred possible AEs for adjudication. Two blinded trained physicians using a previously established methodology adjudicated AEs. Over 22% of 81 patients experienced AEs from the ED to the inpatient setting. The most common AEs were adverse drug events (42%), followed by management (38%), and diagnostic errors (21%). Of these AEs, 75% were considered preventable. Patients who stayed in the ED longer were more likely to experience an AE (adjusted odds ratio = 1.99, 95% confidence interval = 1.19-3.32, P = 0.01). AEs were common for patients transitioning from the ED to the inpatient setting. Further research is needed to understand the underlying causes of AEs that occur when patients transition from the ED to the inpatient setting. Understanding the contribution of factors such as length of stay in the ED will significantly help efforts to develop targeted interventions to improve this crucial transition of care.

Efficacy and safety of non-cross-linked hyaluronic acid compound in the treatment of keratosis pilaris: A split-body randomized clinical trial.

Keratosis pilaris (KP) is a prevalent benign dermatological condition characterized by small bumps at the hair follicles alongside surrounding redness, significantly impacting both aesthetics and mental well-being. This study investigated the potential benefits of a non-cross-linked hyaluronic acid (HA) compound for treating KP. A split-body, investigator-blinded, randomized, intraindividual comparative clinical trial was conducted. The non-cross-linked HA compound was injected into KP-affected regions on both upper arms. The treatment was delivered across four sessions scheduled at 4-week intervals. Blinded physicians and patients assessed differences in erythema, skin roughness, and overall scores between treated and control areas at the final follow-up visit. At the 12th and 24th weeks post-treatment, a four-point scale was utilized to assess subjects' perceived treatment efficacy. Additionally, dermoscopic images, histological alterations, and adverse events were monitored. Physician assessments revealed a significant reduction in roughness and overall scores for treated areas compared to controls. Patient self-assessments also reflected improvements in roughness, redness, and overall scores for treated sides at the final visit, with 35.71% of patients demonstrating sustained improvement in redness and 71.43% reporting persistent improvements in roughness at 24th weeks post-treatment. The dermatoscopic examinations revealed a notable enhancement in both the quantity of follicular plugs and the extent of erythema among the subjects in the treatment group. Histopathological outcomes also demonstrated improvement. This study suggests that the non-cross-linked HA compound effectively improves skin roughness and promotes hair shaft growth in KP treatment, demonstrating a favorable safety profile. These findings position it as a potentially viable alternative therapy in clinical practice.

Currently Available Large Language Models Do Not Provide Musculoskeletal Treatment Recommendations That Are Concordant With Evidence-Based Clinical Practice Guidelines

PurposeTo determine whether leading, commercially-available LLMs provide treatment recommendations concordant with evidenced-based clinical practice guidelines (CPGs) developed by the American Academy of Orthopedic Surgeons (AAOS). MethodsAll CPGs concerning the management of rotator cuff tears(n=33) and anterior cruciate ligament (ACL) injuries(n=15) were extracted from the AAOS. Treatment recommendations from Chat-generative pretrained transformer version-4 [ChatGPT-4; OpenAI], Gemini (Google), Mistral-7B (Mistral AI), and Claude-3 (Anthropic) were graded by two blinded physicians as being “concordant,” “discordant,” or “indeterminate” (i.e., neutral response without definitive recommendation) with respect to AAOS CPGs. The overall concordance between LLM and AAOS recommendations were quantified, while the comparative overall concordance of recommendations amongst the four LLMs was evaluated through the Fischer’s-exact test. ResultsOverall 135(70.3%) responses were concordant, 43(22.4%) indeterminate, and 14(7.3%) discordant. Inter-rater reliability for concordance classification was excellent (Kappa=0.92). Concordance with AAOS CPGs was most frequently observed with ChatGPT-4 (n=38, 79.2%), and least frequently with Mistral-7B (n=28,58.3%). Indeterminate recommendations were most frequently observed with Mistral-7B (n=17,35.4%) and least frequently with Claude-3 (n=8, 6.7%). Discordant recommendations were most frequently observed with Gemini (n=6,12.5%) and least frequently with ChatGPT-4 (n=1,2.1%). Overall, no statistically significant differences in concordant recommendations was observed across LLMs (p=0.12). Only 20 (10.4%) of all recommendations were transparent and provided references with full bibliographic details or links to specific peer-reviewed content to support recommendations. ConclusionAmong leading commercially-available LLMs, more than one-in-four recommendations concerning the evaluation and management of rotator cuff and ACL injuries do not reflect current evidenced-based CPGs. Although ChatGPT-4 demonstrated the highest performance, clinically significant rates of recommendations without concordance or supporting evidence were observed. Only 10% of responses by LLMs were transparent, precluding users from fully interpreting the sources from which recommendations were provided. Clinical RelevanceWhile leading LLMs generally provide recommendations concordant with CPGs, a substantial error-rate exists, and the proportion of recommendations that do not align with these CPGs suggest that LLMs are not trustworthy clinical support tools at this time. Each off-the-shelf, closed-source LLM has strengths and weaknesses. Future research should evaluate and compare multiple LLMs to avoid bias associated with narrow evaluation of few models as observed in current literature.

Evaluation of a Novel Dermal Cooling System for the Treatment of Benign Pigmented Lesions in Asians.

Our study aimed to evaluate the efficacy of this novel dermal cooling system (DCS) in reducing pigmentation in benign pigmented lesions in Asian patients and its potential side effects. It was a prospective open-label single-center study. Asian patients, with the presence of benign pigmented lesions mainly including lentigines, melasma, nevus spilus, ephelides, café au lait, and seborrheic keratosis were recruited for a novel DCS. The DCS provided localized cooling of the epidermal layer below freezing but was less intense than cryotherapy. Each patient received DCS at Week 0 and repeated at 4-week intervals up to 10 sessions. Global aesthetic improvement scores (GAIS) by blinded physicians and subjects were recorded at 2, 6, and 12 months posttreatment follow-up. Eighty-one patients were recruited with a total of 305 sessions performed and 1716 lesion sites treated. At 2-month posttreatment, 76.5% and 58.6% treatment sites showed obvious to marked improvement respectively and the improvement sustained at 6 and 12 months. Only minor adverse events were reported. Erythema and edema were the most commonly anticipated effects immediately after treatment. The pain was minimal. Postinflammatory hyperpigmentation was only reported in 2.2% (38/1716) treated sites. To our knowledge, this study was the first study to demonstrate that this novel DCS was an effective, safe, and well-tolerated treatment for benign pigmented lesions in Asians.

Effect of Lifestyle Counselling via a Mobile Application on Disease Activity Control in Inflammatory Arthritis: A Single-Blinded, Randomized Controlled Study.

Mobile applications (apps) are a resource for information on lifestyle and nutrition which are associated to improved outcomes in inflammatory arthritis. The aim of this study was to explore whether targeted lifestyle counselling via an app improves disease activity in arthritis patients. Patients with rheumatoid arthritis (RA), spondyloarthritis (SpA), psoriatic arthritis (PsA) were randomized to 12 weeks of lifestyle counselling via an app (Mida, Midaia GmbH, Germany) pertaining to a healthy Mediterranean Diet, physical activity, and mental health. Disease activity was measured with specific instruments by a blinded physician and categorized (remission, low, moderate, high). Dietary adherence was assessed by the Mediterranean Diet Adherence Screener (MEDAS). Mixed effects logistic regression adjusted to baseline disease activity, age, and sex were calculated. Of 158 patients included (73% female, 53.3 ± 11.7 years), 74 were in the active counselling group (ACG). All showed improvement in low disease activity or remission. ACG patients had an odds ratio (OR) of 2.8 (95%-CI 1.1-7.2, p = 0.035), while OR in the control group was not significant OR = 2.1 (0.9-5.0, p = 0.097). The control group was less likely to reach a MEDAS >= 4 (OR = 0.16 (0.03-0.77), p = 0.02), while this was not seen in the ACG (OR = 0.54 (0.06-4.63), p = 0.6). Patients in the ACG showed a tendency towards improved adhesion to a Mediterranean Diet (MEDAS) (β = 0.35 (-0.05-0.74), p = 0.086). This tendency was not observed in the control group (β = 0.09 (-0.29-0.46), p = 0.64). Individualized lifestyle and dietary counselling via app may help to improve disease control in inflammatory arthritis patients.

Sestamibi as an alternative to mebrofenin for the diagnosis of acute cholecystitis: An alternative option during supply chain disruption

PurposeTo determine the accuracy of Tc-99 m sestamibi for the diagnosis of acute cholecystitis during a supply chain disruption of mebrofenin. Material and methodsDuring a national shortage of Tc-99 m mebrofenin in 2019, our institution initiated sestamibi imaging for suspected cases of acute cholecystitis using a standard hepatobiliary imaging protocol. Forty-one patients underwent hepatobiliary imaging with sestamibi, 39 to assess for acute cholecystitis. The examinations were initially interpreted by one nuclear medicine physician and subsequently overread by 5 blinded nuclear medicine physicians (8–30 years’ experience). SPECT/CT was obtained for 8 of these patients at the discretion of the primary interpreter. An additional 23 asymptomatic patients (6 with prior cholecystectomy) underwent abdominal scintigraphy as a negative control to determine the normal time to sestamibi accumulation in the gallbladder. A composite reference standard was used (chart review by 3 physicians). Sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values were calculated with and without SPECT/CT (mean ± 95%CI). ResultsOf 39 symptomatic patients, 17/39 had acute cholecystitis and 22 did not. The sensitivity, specificity, PPV and NPV for acute cholecystitis at planar imaging were 97.6 ± 4.6, 62.7 ± 5.2, 67.0 ± 3.6, and 97.3 ± 5.2 % (N = 39). The values changed to 95.7 ± 4.7, 77.9 ± 4.7, 72.1 ± 4.1, and 97.0 ± 3.3 % when control patients were included (N = 62). With SPECT/CT, these mildly improved to 98.8 ± 2.3 %, 69.1 ± 4.4 %, 71.3 ± 3.2 %, and 98.7 ± 2.6 % (N = 39), but not significantly different. On average, sestamibi activity was detected in the gallbladder in negative controls within 1 h. ConclusionTc-99 m sestamibi has excellent sensitivity and NPV for diagnosing acute cholecystitis and can serve as an alternative when mebrofenin is unavailable for evaluating cystic duct obstruction during shortages of standard agents.

Blending Hyaluronic Acid and Calcium Hydroxylapatite for Injectable Facial Dermal Fillers: A Clinical and Ultrasonography Assessment

Both hyaluronic acid (HA) and calcium hydroxylapatite (CaHA) fillers have well-established indications in cosmetic medicine. Nevertheless, limited data are available on the effectiveness of combining CaHA and HA. The purpose of this report was to demonstrate the safety, tolerability, and clinical and ultrasonographic improvement of facial skin laxity using a blending technique that admixes HA and CaHA. Fifteen regular patients, including three men, between 25 and 71 years of age were reported. The participants were subjects who came regularly to the dermatologic office seeking a lifting effect without surgery. They were submitted to injection of an admixture of HA and CaHA and followed for 180 days. The clinical assessment consisted of photographic evaluation by two blind investigators, and a consensual subjective evaluation was performed by the physicians (PGAIS) using the five-point Global Aesthetic Improvement Scale. Dermal thickness was analyzed in jaw areas using high-frequency ultrasound. Subjects completed a satisfaction questionnaire with responses scored according to the five-point Global Aesthetic Improvement Scale (GAIS) to evaluate patient satisfaction. After 180 days of follow-up, clinical assessments by blinded physicians found that all patients improved. All the participants were highly satisfied with the results and reported exceptional improvement. Dermal thickness increased by 9.4% (8.2–10.8%), 14.0% (12.2–15.9%), and 18.8% (16.2–21.9%) at D90, D120, and D180, respectively, by ultrasonography. In conclusion, an injection technique using an admixture of CaHA and HA fillers was well tolerated, offering high satisfaction and long-lasting progressive benefits. The authors believe that this procedure optimizes the treatment time and results because HA promotes early volume restoration and CaHA stimulates long-term dermal remodeling through the synthesis of collagen and elastin.

Validating the anatomical landmark technique for bedside tunneled central venous catheter placement in the medical intensive care unit.

A non-tunneled dialysis catheter (nTDC) is often the vascular access of choice to initiate dialysis in an intensive care unit (ICU). In the absence of contraindications, if a patient remains dialysis dependent beyond 2-weeks, the options are either to replace the nTDC with another nTDC or convert to a tunneled dialysis catheter (TDC). As a standard of care, TDCs are placed under fluoroscopic guidance. To determine if TDCs and other tunneled central venous catheters (tCVC) can be placed safely using anatomical landmark techniques without the use of fluoroscopy. Subjects that met a predetermined selection criteria underwent placement of tunneled catheters with the use of the anatomical landmark technique. We looked at various outcomes to determine the safety and effectiveness of this technique. One hundred eleven TDCs and other tCVCs were placed using the anatomical landmark technique in the intensive care unit. All but one (110/111) of the catheters placed had recommended tip placement confirmed by at least one blinded physician. Major complications encountered were bleeding (two cases), pneumothorax (one case), and line associated blood stream infection (one case). We did find a higher-than-expected rate of "unnecessary procedures" with 18/111 lines placed in patients who did not survive beyond 7 days after placement of the catheter. Using the anatomical landmark technique for bedside tunneled catheter placement can be an effective approach in the right population.

Automated contouring, treatment planning, and quality assurance for VMAT craniospinal irradiation (VMAT-CSI).

Create a comprehensive automated solution for pediatric and adult VMAT-CSI including contouring, planning, and plan check to reduce planning time and improve plan quality. Seventy-seven previously treated CSI patients (age, 2-67 years) were used for creation of an auto-contouring model to segment 25 organs at risk (OARs). The auto-contoured OARs were evaluated using the Dice Similarity Coefficient (DSC), 95% Hausdorff Distance (HD95), and a qualitative ranking by one physician and one physicist (scale: 1-acceptable, 2-minor edits, 3-major edits). The auto-planning script was developed using the Varian Eclipse Scripting API and tested with 20 patients previously treated with either low-dose VMAT-CSI (12 Gy) or high-dose VMAT-CSI (36 Gy + 18 Gy boost). Clinically relevant metrics, planning time, and blinded physician review were used to evaluate significance of differences between the auto and manual plans. Finally, the plan preparation for treatment and plan check processes were automated to improve efficiency and safety of VMAT-CSI. The auto-contours achieved an average DSC of 0.71 ± 0.15, HD95 of 4.81 ± 4.68, and reviewers' ranking of 1.22 ± 0.39, indicating close to "acceptable-as-is" contours. Compared to the manual CSI plans, the auto-plans for both dose regimens achieved statistically significant reductions in body V50% and Dmean for parotids, submandibular, and thyroid glands. The variance in the dosimetric parameters decreased for the auto-plans as compared to the manual plans indicating better plan consistency. From the blinded review, the auto-plans were marked as equivalent or superior to the manual-plans 88.3% of the time. The required time for the auto-contouring and planning was consistently between 1-2 hours compared to an estimated 5-6 hours for manual contouring and planning. Reductions in contouring and planning time without sacrificing plan quality were obtained using the developed auto-planning process. The auto-planning scripts and documentation will be made freely available to other institutions and clinics.

Proposal for Diagnostic Criteria of Y-Shaped Dysmorphic Uterus Based on 3-Dimensional Transvaginal Ultrasound Measurements

Study ObjectiveTo define objective and readily applied diagnostic criteria for Y-shaped uteri using 3-dimensional transvaginal ultrasound (3D-TVUS) volume recordings. DesignA retrospective case-control diagnostic measurements study. SettingA tertiary university hospital's reproductive health and research center. PatientsTwo hundred thirteen patients who presented with infertility between January 2020 and December 2022. InterventionsTwo blinded physicians re-evaluated the 3D-TVUS images of all patients for the presence of a uterine abnormality. The images of patients with a Y-shaped uterus were re-evaluated, and descriptive measurements were done. Measurements and Main ResultsThe most common uterine abnormality in this cohort was the Y-shaped uterus with a prevalence of 12.2%, followed by the arcuate, T-shaped, and septate uteri, respectively. Reviewers identified 26 and 28 Y-shaped uteri, respectively, and came to a consensus on 25 images. Diagnostic criteria for the Y-shaped uterus based on 3D-TVUS findings have been specified as: lateral indentation depths between 4 and 7 mm, fundal indentation depth between 5 and 9 mm, lateral indentation angles between 121° and 149°, fundal indentation angle between 121° and 145°, and Y-angles 25° to 46°. ConclusionSome subtypes of dysmorphic uteri, such as the Y-shaped uterus, whose clinical significance is unknown and may be variants of the normal, may actually be more common than thought. Determining objective diagnostic criteria with 3D-TVUS will allow standard research on these anomalies and their clinical significance.

A Crossover Trial Evaluating Coconut Oil as an Alternative to Commercial Ultrasound Gel in Obstetrical Ultrasounds.

Our objective was to evaluate the quality of obstetrical ultrasound images obtained with coconut oil compared with commercial ultrasound gel and to assess patient acceptability. This was a randomized two-period crossover study in which 40 pregnant patients had standard biometry images obtained with both coconut oil and commercial ultrasound gel during their growth or anatomy ultrasound. All images were then rated by two blinded maternal-fetal medicine physicians on quality, resolution, and detail using a 0 to 100 scale. Contrasts obtained from linear mixed models were used to estimate the differences in image parameters between the agents. Participant experience was evaluated with an acceptability survey which included five items measured on a five-point Likert scale. Image quality, as rated by physicians, was found to be equivalent between commercial ultrasound gel and coconut oil. Additionally, there was not a statistically significant difference in image resolution or detail between the two coupling agents. The overall patient experience was significantly lower for commercial ultrasound gel when compared with coconut oil (mean difference = - 5.48, 95% confidence interval = [-6.89, -4.06]). Ultrasound images collected with coconut oil as the coupling agent are equivalent in quality to those collected using commercial ultrasound gel. Patients also preferred the use of coconut oil during their ultrasound, making its use a possible way to improve the patient ultrasound experience. Coconut oil has the potential as an alternative coupling agent that could significantly increase access to ultrasound use in resource-limited settings. · Coconut oil produces quality images during obstetrical ultrasounds.. · Patients prefer the use of coconut oil to standard ultrasound gel during obstetrical ultrasounds.. · Coconut oil is a coupling agent that could increase ultrasound use in resource-limited settings..

Evaluation of vital signs through a mobile application in patients with heart failure: a opportunity for remote titration?

Virtual consultations have increased exponentially, but a limitation is the inability to assess vital signs (VS). This is particularly useful in patients with heart failure (HF) for titrating prognosis-modifying medication. This issue could potentially be addressed by a tool capable of measuring blood pressure (BP) and heart rate (HR) accurately, remotely, and conveniently. Mobile phones equipped with transdermal optical imaging technology could meet these requirements. To evaluate the accuracy of a transdermal optical imaging-based app for estimating VS compared to clinical assessment in patients with HF. A prospective cohort study included patients evaluated in an HF outpatient unit between February and April 2022. BP and HR were simultaneously assessed using the app and clinical examination (BP with an automated sphygmomanometer and HR by brachial palpation). Three measurements were taken by both the app and clinic for each patient, by two independent blinded physicians. Thirty patients were included, with 540 measurements of BP and HR. The mean age was 66 (± 13) years, 53.3% were male. The mean left ventricular ejection fraction was 37 ± 15, with 63.3% having previous hospitalizations for HF, and 63.4% in NYHA class II-III. The mean difference between the app measurement and its clinical reference measurement was 3.6 ± 0.5 mmHg for systolic BP (SBP), 0.9 ± -0.2 mmHg for diastolic BP (DBP), and 0.2 ± 0.4 bpm for HR. When averaging the paired mean differences for each patient, the mean across the 30 patients was 2 ± 6 mmHg for SBP, -0.14 ± 4.6 mmHg for DBP, and 0.23 ± 4 bpm for HR. The estimation of BP and HR by an app with transdermal optical imaging technology was comparable to non-invasive measurement in patients with HF and met the precision criteria for BP measurement in this preliminary study. The use of this new transdermal optical imaging technology provides promising data, which should be corroborated in larger cohorts.

The value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism: A cross sectional analysis

IntroductionPulmonary embolism (PE) is a significant global cause of mortality, ranking third after myocardial infarction and stroke. ECG findings may play a valuable role in the prognostication of patients with PE, with various ECG abnormalities proving to be reasonable predictors of haemodynamic decompensation, cardiogenic shock, and even mortality. This study aims to assess the value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism, as diagnosed with computed tomography pulmonary angiogram. MethodThis study was a cross sectional analysis based at Tygerberg Hospital, Cape Town, South Africa. Eligible patients were identified from all CT-PA performed between 1 January 2017 and 31 December 2019 (2 years). The ECGs were independently screened by two blinded emergency physicians for predetermined signs that are associated with right heart strain and higher pulmonary artery pressures, and these findings were analysed to in-hospital mortality. ResultsOf the included 81 patients, 61 (75 %) were female. Of the 41 (51 %) patients with submassive PE and 8 (10 %) with massive PE, 7 (17 %) and 3 (38 %) suffered inpatient mortality (p = 0.023) respectively. Univariate ECG analysis revealed that complete right bundle branch block (OR, 8.6; 95 % CI, 1.1 to 69.9; p = 0.044) and right axis deviation (OR, 5.6; 95 % CI, 1.4 to 22.4; p = 0.015) were significant predictors of inpatient mortality. ConclusionEarly identification of patients with pulmonary embolism at higher risk of clinical deterioration and in-patient mortality remains a challenge. Even though no clinical finding or prediction tool in isolation can reliably predict outcomes in patients with pulmonary embolism, this study demonstrated two ECG findings at presentation that were associated with a higher likelihood of inpatient mortality. This single-centre observational study with a small sample precludes concrete conclusions and a large follow-up multi-centre study is advised.

Full-face and neck resurfacing with a novel ablative fractional 2910 nm erbium-doped fluoride glass fiber laser for advanced photoaging.

Ablative fractional lasers have long been considered the gold standard for facial resurfacing for advanced photoaging. These lasers offer an improved safety profile compared to traditional ablative lasers but typically require more treatment sessions given their fractional approach. In this study, we evaluate a new novel 2910 nm erbium-doped fluoride glass fiber laser (2910 nm fiber laser) (UltraClear; Acclaro Medical) for full-face and neck resurfacing for the treatment of advanced photoaging. Twenty-two healthy subjects aged 44-80 years presenting for advanced facial photoaging and rhytides were enrolled in the study. All subjects received three full-face and neck, multipass treatments utilizing the 2910 nm fiber laser spaced 6-8 weeks apart. Subjects were asked to rate the average level of pain during the treatment. At 90 days following subjects' third treatment subjects evaluated their improvement using a Global Aesthetic Improvement Scale (GAIS) and rated their satisfaction with the treatment. Evaluation of pretreatment and posttreatment photos was completed by two blinded physician reviewers. Reviewers were asked to identify the pretreatment and posttreatment photographs and to rate the degree of improvement utilizing a GAIS. Fifteen participants completed the study; six were exited from the study (withdrew or lost to follow-up). The average subject GAIS score for overall appearance was 3.8. The average subject satisfaction level at follow-up was 4.8. The average subject pain score was 4.9. One blinded physician reviewer correctly identified 100% of subjects' posttreatment photographs, while the second blinded reviewer correctly identified 93%. Blinded evaluation of digital photographs revealed an average GAIS score of 3.2. Posttreatment skin responses included pin-point hemorrhage, erythema, edema, and soft tissue crusting lasting 5-7 days. There were no instances of infection, scarring or hypopigmentation. There were two instances of temporary hyperpigmentation. Treatment with the novel 2910 nm fiber laser is safe and effective in treating advanced photoaging and rhytides. Three treatments produced moderate to marked improvement with high patient satisfaction and treatment was associated with less discomfort and downtime compared to conventional fractional ablative lasers.

Mixed-reality improves execution of templated glenoid component positioning in shoulder arthroplasty: a CT imaging analysis

Glenoid placement is critical for successful outcomes in total shoulder arthroplasty (TSA). Preoperative templating with three-dimensional imaging has improved implant positioning, but deviations from the planned inclination and version still occur. Mixed-Reality (MR) is a novel technology that allows surgeons intra-operative access to three-dimensional imaging and templates, capable of overlaying the surgical field to help guide component positioning. The purpose of this study was to compare the execution of preoperative templates using MR vs.standard instruments (SIs). Retrospective review of 97 total shoulder arthroplasties (18 anatomic, 79 reverse) from a single high-volume shoulder surgeon between January 2021 and February 2023, including only primary diagnoses of osteoarthritis, rotator cuff arthropathy, or a massive irreparable rotator cuff tear. To be included, patients needed a templated preoperative plan and then a postoperative computed tomography scan. Allocation to MR vs. SI was based on availability of the MR headset, industry technical personnel, and the templated preoperative plan loaded into the software, but preoperative or intraoperative patient factors did not contribute to the allocation decision. Postoperative inclination and version were measured by two independent, blinded physicians and compared to the preoperative template. From these measurements, we calculated the mean difference, standard deviation (SD), and variance to compare MR and SI. Comparing 25MR to 72 SI cases, MR significantly improved both inclination (P<.001) and version (P<.001). Specifically, MR improved the mean difference from preoperative templates (by 1.9° inclination, 2.4° version), narrowed the SD (by 1.7° inclination, 1.8° version), and decreased the variance (11.7-3.0 inclination, 14.9-4.3 version). A scatterplot of the data demonstrates a concentration of MR cases within 5° of plan relative to SI cases typically within 10° of plan. There was no difference in operative time. MR improved the accuracy and precision of glenoid positioning. Although it is unlikely that 2° makes a detectable clinical difference, our results demonstrate the potential ability for technology like MR to narrow the bell curve and decrease the outliers in glenoid placement. This will be particularly relevant as MR and other similar technologies continue to evolve into more effective methods in guiding surgical execution.

Chatbot Performance in Defining and Differentiating Palliative Care, Supportive Care, Hospice Care

ContextArtificial intelligence (AI) chatbot platforms are increasingly used by patients as sources of information. However, there is limited data on the performance of these platforms, especially regarding palliative care terms. ObjectivesWe evaluated the accuracy, comprehensiveness, reliability, and readability of three AI platforms in defining and differentiating “palliative care,” “supportive care,” and “hospice care.” MethodsWe asked ChatGPT, Microsoft Bing Chat, Google Bard to define and differentiate “palliative care,” “supportive care,” and “hospice care” and provide three references. Outputs were randomized and assessed by six blinded palliative care physicians using 0–10 scales (10 = best) for accuracy, comprehensiveness, and reliability. Readability was assessed using Flesch Kincaid Grade Level and Flesch Reading Ease scores. ResultsThe mean (SD) accuracy scores for ChatGPT, Bard, and Bing Chat were 9.1 (1.3), 8.7 (1.5), and 8.2 (1.7), respectively; for comprehensiveness, the scores for the three platforms were 8.7 (1.5), 8.1 (1.9), and 5.6 (2.0), respectively; for reliability, the scores were 6.3 (2.5), 3.2 (3.1), and 7.1 (2.4), respectively. Despite generally high accuracy, we identified some major errors (e.g., Bard stated that supportive care had “the goal of prolonging life or even achieving a cure”). We found several major omissions, particularly with Bing Chat (e.g., no mention of interdisciplinary teams in palliative care or hospice care). References were often unreliable. Readability scores did not meet recommended levels for patient educational materials. ConclusionWe identified important concerns regarding the accuracy, comprehensiveness, reliability, and readability of outputs from AI platforms. Further research is needed to improve their performance.

Increased Thyroidal Activity on Routine FDG-PET/CT after Combination Immune Checkpoint Inhibition: Temporal Associations with Clinical and Biochemical Thyroiditis.

FDG-PET/CT used for immune checkpoint inhibitor (ICI) response assessment can incidentally identify immune-related adverse events (irAEs), including thyroiditis. This study aimed to correlate the time course of FDG-PET/CT evidence of thyroiditis with clinical and biochemical evolution of thyroid dysfunction. A retrospective review was performed by two independent blinded nuclear medicine physicians (NMPs) of thyroidal FDG uptake in 127 patients who underwent PET/CT between January 2016 and January 2019 at baseline and during treatment monitoring of combination ICI therapy for advanced melanoma. Interobserver agreement was assessed and FDG-PET/CT performance defined by a receiver-operating characteristic (ROC) curve using thyroid function tests (TFTs) as the standard of truth. Thyroid maximum standardized uptake value (SUVmax) and its temporal changes with respect to the longitudinal biochemistry were serially recorded. At a median of 3 weeks after commencing ICI, 43/127 (34%) had a diagnosis of thyroiditis established by abnormal TFTs. FDG-PET/CT was performed at baseline and at a median of 11 weeks (range 3-32) following the start of therapy. ROC analysis showed an area under the curve of 0.87 (95% CI 0.80, 0.94) for FDG-PET/CT for detection of thyroiditis with a positive predictive value of 93%. Among patients with biochemical evidence of thyroiditis, those with a positive FDG-PET/CT were more likely to develop overt hypothyroidism (77% versus 35%, p < 0.01). In the evaluation of the index test, there was an almost perfect interobserver agreement between NMPs of 93.7% (95% CI 89.4-98.0), kappa 0.83. Increased metabolic activity of the thyroid on routine FDG-PET/CT performed for tumoral response of patients undergoing ICI therapy is generally detected well after routine biochemical diagnosis. Elevation of FDG uptake in the thyroid is predictive of overt clinical hypothyroidism and suggests that an ongoing robust inflammatory response beyond the initial thyrotoxic phase may be indicative of thyroid destruction.

Abstract 13686: An Implementation Science Informed, Patient Activation Intervention for Depression Treatment in Coronary Heart Disease Patients: Impact on Clinician Referral and Prescribing Behaviors

Intro: Implementation strategies are integral to addressing gaps in AHA depression treatment guidelines in coronary heart disease (CHD) patients. Methods: From 2019 to 2023, we randomized 12 Columbia University affiliated primary care and cardiology clinics to timing of receiving a multi-level intervention. We enrolled separate pre and post EHR eligible patients/site (≥21 years old, English or Spanish speaking, CHD ICD10 and upcoming cardiologist/PCP index visit) with Patient Health Questionnaire(PHQ)9≥10 and not seeing a psychiatrist. Pre-implementation patients and their providers/sites received usual care. Post-implementation, a theory-informed intervention included problem-solving meetings for mental health social workers (MHSW), cardiologist/PCP [“provider”] education and a patient psychoeducation, activation, and treatment selection tool (with patient treatment preferences sent to MHSW/providers via EPIC). Blinded physicians extracted index visit pre vs. post provider behavior (i.e., documented CHD risk factor or mental health counseling, therapy/cardiac rehab referral, and/or antidepressant prescribing vs. none). We conducted a pre-post analysis using descriptive statistics and thematically analyzed any MHSW/provider responses to EPIC reports. Results: Of 10,625 EHR eligible CHD patients; 1759 patients were screened, 304 (16.5%) eligible and 253 (82.9%) enrolled; 52.0% were female, 56.1% Hispanic, 14.6% Black; mean age was 67.8 years old, PHQ9 13.1. Overall, all (n=71) intervention providers received EPIC messages with 67.8% of patients selecting ≥1 treatment; 29.7% of reports prompted a MHSW/provider response (themes: thinking, talking, action) ; more cardiologists acknowledged receipt/relayed plans than PCPs as did providers caring for commercially insured (vs. Medicaid) patients; 25% of providers optimized treatment pre- vs. 40% post-implementation. Conclusion: A multi-level strategy centered around patient activation may marginally improve provider guideline adherence. Key limitations are pre-post design and descriptive analyses without adjustment for temporal trends. Our ongoing study will adjust for temporality and examine impact on depressive symptoms and patient behavior.

Evaluation of eyebrow position and upper eyelid laxity after endolift laser treatment.

The periorbital area is one of the most sensitive areas in the face, and many techniques are used to change the eyelid laxity and position of the eyebrows. Recently the use of noninvasive or minimally invasive techniques is developed so, the amount of surgical procedures has decreased. In the present study. We evaluate the effect of Endolift laser as a non-invasive method on upper eyelid laxity and eyebrow position. Nine patients underwent Endolift laser and evaluated for eyelid laxity and change in eyebrow position. Two blinded physicians assessed the cosmetic outcome of improvement in upper eyelid tightening via photography 6 months post-treatment. The physicians evaluated the patient's improvement degree using the photographs by two clinical factors: skin laxity and total cosmetic result. Also, eyebrow height from the center of the pupil (CPEBH), Central eyebrow height (CEBH), Lateral eyebrow height (LEBH), Medial eyebrow height (MEBH) were measured by ImagJ before and 6 months post Endolift laser treatment. Our results showed eyelid laxity and eyebrow height were significantly changed after treatment.

Dermoscopy of acute radiation-induced dermatitis in patients with head and neck cancers treated with radiotherapy

Head and neck cancer (HNC) was the seventh most common cancer in the world in 2018. Treatment of a patient may include surgery, radiotherapy (RT), chemotherapy, targeted therapy, immunotherapy, or a combination of these methods. Ionizing radiation used during RT covers relatively large volumes of healthy tissue surrounding the tumor. The acute form of radiation-induced dermatitis (ARD) are skin lesions that appear usually within 90 days of the start of RT. This is a prospective study which compares 2244 dermoscopy images and 374 clinical photographs of irradiated skin and healthy skin of 26 patients at on average 15 time points. Dermoscopy pictures were evaluated independently by 2 blinded physicians. Vessels in reticular distribution, white, yellow or brown scale in a patchy distribution, perifollicular pigmentation and follicular plugs arranged in rosettes were most often observed. For these dermoscopic features, agreement with macroscopic features was observed. Two independent predictors of severe acute toxicity were identified: gender and concurrent chemotherapy. Knowledge of dermoscopic features could help in the early assessment of acute toxicity and the immediate implementation of appropriate therapeutic strategies. This may increase the tolerance of RT in these groups of patients.