Current Consensus Research Articles

Advancements in the diagnosis and management of premature ventricular contractions in pediatric patients.

Premature ventricular contractions (PVCs) are relatively common arrhythmias in the pediatric population, with implications that range from benign to potentially life-threatening. The management of PVCs in children poses unique challenges, and recent advancements in diagnostic and therapeutic options call for a comprehensive review of current practices. This review synthesizes the latest literature on pediatric PVCs, focusing on publications from the past decade. We evaluate studies addressing the epidemiology, pathophysiology, diagnosis, and treatment of PVCs in children, including pharmacological, non-pharmacological, and invasive strategies. The review identifies key advancements in the non-invasive detection of PVCs, the growing understanding of their genetic underpinnings, and the evolving landscape of management options. We discuss the clinical decision-making process, considering the variable significance of PVCs in different pediatric patient subgroups, and highlight the importance of individualized care. Current guidelines and consensus statements are examined, and areas of controversy or limited evidence are identified. Our review underscores the need for a nuanced approach to PVCs in children, integrating the latest diagnostic techniques with a tailored therapeutic strategy. We call for further research into long-term outcomes and the development of risk stratification tools to guide treatment. The potential of emerging technologies and the importance of multidisciplinary care are also emphasized to improve prognoses for pediatric patients with PVCs.

European consensus-based interdisciplinary guideline for diagnosis, treatment and prevention of actinic keratoses, epithelial UV-induced dysplasia and field cancerization on behalf of European Association of Dermato-Oncology, European Dermatology Forum, European Academy of Dermatology and Venereology and Union of Medical Specialists (Union Européenne des Médecins Spécialistes).

A collaboration of multidisciplinary experts from the European Association of Dermato-Oncology, the European Dermatology Forum, the European Academy of Dermatology and Venereology, and the European Union of Medical Specialists was formed to develop European recommendations on AK diagnosis and treatment, based on current literature and expert consensus. This guideline addresses the epidemiology, diagnostics, risk stratification and treatments in immunocompetent as well as immunosuppressed patients. Actinic keratoses (AK) are potential precursors of cutaneous squamous cell carcinoma (cSCC) and display typical histopathologic and immunohistochemical features of this malignancy in an early stage. They can develop into cSSC insitu and become invasive in a low percentage of cases. AK is the most frequent neoplasia in white populations, frequently occurring within a cancerous field induced by ultraviolet radiation. Since it cannot be predicted, which lesion will progress to cSCC and when treatment is usually recommended. The diagnosis of AK and field cancerization is made by clinical examination. Dermatoscopy, confocal microscopy, optical coherence tomography or line-field confocal-OCT can help in the differential diagnosis of AK and other skin neoplasms. A biopsy is indicated in clinically and/or dermatoscopically suspicious and/or treatment-refractory lesions. The choice of treatment depends on patients' and lesion characteristics. For single non-hyperkeratotic lesions, the treatment can be started upon patient's request with destructive treatments or topical treatments. For multiple lesions, field cancerization treatment is advised with topical treatments and photodynamic therapy. Preventive measures such as sun protection, self-examination and repeated field cancerization treatments of previously affected skin areas in high-risk patients are advised.

Surveying neurologist perspectives and knowledge of epilepsy surgery to identify barriers to surgery referral.

Epilepsy surgery is an effective means of treating medically refractory epilepsy (MRE), but it remains underused. We aimed to analyze the perspectives and knowledge of referring neurologists in the New York metropolitan area, who serve a large epilepsy population. We adapted a previous Canadian survey by Roberts etal. (2015), adding questions regarding demographic descriptors, insurance coverage, training and practice details, and perceived social barriers for patients. We surveyed neurologists directly affiliated with Montefiore Medical Center and those referring to Montefiore's Comprehensive Epilepsy Center. Participants had 10 weeks to fill out an online Qualtrics survey with weekly reminders. Of 117 neurologists contacted, 51 eligible neurologists completed the survey (63.8% Montefiore, 35.0% referring group). A high proportion of the results were from epilepsy-trained individuals (41.2%) and neurologists who graduated residency ≤19 years ago (80.4%). 80.4% of respondents felt that epilepsy surgery is safe, but only 56.9% would refer a patient for surgical workup after two failed trials of anti-seizure medications. Epileptologists and providers with a larger volume of epilepsy patients and electroencephalogram readings had better knowledge of the epilepsy surgery workup guidelines. When asked to rank social barriers to patients receiving surgery, participants were most concerned about lack of social support, financial insecurity, and a patient's dual role as a caregiver. Our study suggests continued reluctance of neurologists regarding epilepsy surgery, and deficiencies in the knowledge and adherence to the recommended guidelines. In the context of prior studies, these results showed improved understanding of the definition of MRE (80.4%) and an increased likelihood to refer eligible patients as early as possible (78.4%) in line with current consensus recommendations. The finding that epilepsy-trained and more epilepsy/electroencephalogram-facing neurologists showed better understanding of the guidelines suggests that increased education efforts should be targeted at non-epileptologists. Our study asked New York City doctors about their approach to epilepsy surgery. Many do not consider it as early as they could in treatment plans. The doctors with extra epilepsy training were better at knowing when to consider surgery.

Recurrent Esophageal Stricture in a Child Post Steven-Johnson Syndrome: A Case Report

Background: Esophageal stricture is an abnormal narrowing of the esophageal lumen, resulting in dysphagia. Despite its rarity, this condition could be caused by various etiologies, including Steven-Johnson Syndrome (SJS). In some cases, stricture could recur, which complicates the management. This case report presented a rare case of refractory esophageal stricture in children with Steven-Johnson Syndrome. Case: A 5-years-old boy with a prior history of SJS presented with dysphagia for one month. The patient experienced choking, blood vomiting, stomatitis, swelling on the lips, and difficulty in swallowing solid food. Barium meal and EGD test confirmed the diagnosis of esophageal strictures. The patient then underwent dilation using bougie dilator. However, he continued to experience dysphagia, resulting in a total of 15 serial dilation sessions. Discussion: Esophageal dysphagia is observed in patients who experience difficulty swallowing solid food. SJS can contribute to the development of esophageal dysphagia by causing inflammation of the esophageal mucosa, resulting in lesions and strictures. In patients with esophageal strictures, two types of dilation methods are available: bougie dilator with wire guidance (Savary-Gilliard) and balloon dilator, with the current consensus for dilation procedures supporting the rule of three. For patients with refractory strictures, other modalities such as mitomycin-C injection and stent placement are also available. Esophageal replacement surgery is considered as the last resort for refractory stricture patients who have not responded to previous treatments. Conclusion: Steven-Johnson Syndrome is a rare cause of esophageal strictures. The management of refractory esophageal stricture requires a comprehensive subspecialty care and long-term monitoring.

Rational synthesis of a heparan sulfate saccharide that promotes the activity of BMP2

Heparan sulfate (HS) is a glycosaminoglycan (GAG) found throughout nature and is involved in a wide range of functions including modulation of cell signalling via sequestration of growth factors. Current consensus is that the specificity of HS motifs for protein binding are individual for each protein. Given the structural complexity of HS the synthesis of libraries of these compounds to probe this is not trivial. Herein we present the synthesis of an HS decamer, the design of which was undertaken rationally from previously published data for HS binding to the growth factor BMP-2. The biological activity of this HS decamer was assessed in vitro, showing that it had the ability to both bind BMP-2 and increase its thermal stability as well as enhancing the bioactivity of BMP-2 in vitro in C2C12 cells. At the same time no undesired anticoagulant effect was observed. This decamer was then analysed in vivo in a rabbit model where higher bone formation, bone mineral density (BMD) and trabecular thickness were observed over an empty defect or collagen implant alone. This indicated that the HS decamer was effective in promoting bone regeneration in vivo.

A205 PRACTICE PATTERNS FOR EOSINOPHILIC ESOPHAGITIS IN ADULTS VARY WIDELY AMONG CANADIAN GASTROENTEROLOGISTS: INTERIM ANALYSIS OF A NATIONWIDE SURVEY

Abstract Background Eosinophilic esophagitis (EoE) is a chronic allergic, type 2 immune-mediated, condition of the esophagus with increasing prevalence in Canada. Practice patterns among Canadian gastroenterologists are not well described. Aims To identify practice variation among Canadian gastroenterologists who care for adults with EoE. Methods A cross-sectional, web-based survey was distributed to Canadian gastroenterologists through the Canadian Association of Gastroenterology as well as administrations at Canadian universities. Results Of 53 respondents, 68% currently work in an academic setting. 77% manage at least 6 patients with EoE per year, with 19% managing over 50 patients per year. 51% of respondents obtain biopsies in every new patient presenting with an acute food bolus, while 26% take biopsies in less than 50% of cases or never at all. 36% take less than 5 biopsies on initial endoscopy with 23% only taking biopsies from one location in the esophagus. 58% are either unaware of the EoE Endoscopic Reference Score (EREFS) or never use it in clinical practice. Most respondents (72%) prefer proton pump inhibitors as initial therapy while 17% prefer starting multiple treatment modalities. 9% use topical steroids initially. Only 6% keep their patients on topical steroids indefinitely, if started. Preferred dietary approach vary with 36% choosing 6-food elimination diet (FED), 23% 2-FED, 19% 4-FED, 13% milk-only elimination diet, 6% allergy test-directed diet, and 4% elemental diet. Only 17% feel very comfortable starting biologic therapies. When evaluating treatment effectiveness, 23% use improving patient symptoms alone, while 74% include repeat histological assessments. 42% do not regularly screen for adaptive behaviours, such as excessive chewing, or texture modification and avoidance. In those who perform repeat endoscopic evaluation, 13% do so in less than 3 months after starting therapy, 32% in 3-5.9 months, 28% in 6-11.9 months, and 8% after a year. 11% will only repeat endoscopic evaluation if a patient reports symptom recurrence. 64% do not regularly refer to an allergist. For guidance, 59% follow the American Gastroenterology Association 2020 guidelines, 34% American Society of Gastrointestinal Endoscopy 2022 guidelines, 4% British Society of Gastroenterology 2022 guidelines, while 21% do not use any guidelines. 83% feel Canadian guidelines would be useful in their practice. Conclusions EoE practice patterns among Canadian adult gastroenterologists vary widely, with management differing from the current consensus guidelines. Strategies aimed at decreasing these variations, such as the development of Canadian guidelines, are needed to standardize practice. Funding Agencies None

The Clear Value of Coronary Artery Calcification Evaluation on Non-Gated Chest Computed Tomography for Cardiac Risk Stratification.

To enhance risk stratification in patients suspected of coronary artery disease, the assessment of coronary artery calcium (CAC) could be incorporated, especially when CAC can be readily assessed on previously performed non-gated chest computed tomography (CT). Guidelines recommend reporting on patients' extent of CAC on these non-cardiac directed exams and various studies have shown the diagnostic and prognostic value. However, this method is still little applied, and no current consensus exists in clinical practice. This review aims to point out the clinical utility of different kinds of CAC assessment on non-gated CTs. It demonstrates that these scans indeed represent a merely untapped and underestimated resource for risk stratification in patients with stable chest pain or an increased risk of cardiovascular events. To our knowledge, this is the first review to describe the clinical utility of different kinds of visual CAC evaluation on non-gated unenhanced chest CT. Various methods of CAC assessment on non-gated CT are discussed and compared in terms of diagnostic and prognostic value. Furthermore, the application of these non-gated CT scans in the general practice of cardiology is discussed. The clinical utility of coronary calcium assessed on non-gated chest CT, according to the current literature, is evident. This resource of information for cardiac risk stratification needs no specific requirements for scan protocol, and is radiation-free and cost-free. However, some gaps in research remain. In conclusion, the integration of CAC on non-gated chest CT in general cardiology should be promoted and research on this method should be encouraged.

Anger at work

What happens when you express anger at work? A large body of work suggests that workers who express anger are judged to be competent and high status, and as a result are rewarded with more status, power, and money. We revisit these claims in four pre-registered, well-powered experiments (N = 3,852), conducted in the US, using the same methods used in previous work. Our findings consistently run counter to the current consensus regarding anger's positive role in obtaining status and power in the workplace. We find that when men and women workers express anger they are sometimes viewed as powerful but they are consistently viewed as less competent. Importantly, we find that angry workers are penalized with lower status compared to workers expressing sadness or no emotions. We explore the reasons for these findings both experimentally and descriptively and find that anger connotes less competence and warmth and that anger expressions at work are perceived as inappropriate, an overreaction, and as a lack of self-control. Moreover, we find that people hold negative attitudes toward workplace anger expressions, citing them as relatively more harmful, foolish, and worthless compared to other emotional expressions. When we further explore beliefs about what can be accomplished by expressing anger at work, we find that promoting one's status isn't one of them. We discuss the theoretical and applied implications of these findings and point to new directions in the study of anger, power, and the workplace.

Modeling of Human Rabies Cases in Brazil in Different Future Global Warming Scenarios.

Bat species have been observed to have the potential to expand their distribution in response to climate change, thereby influencing shifts in the spatial distribution and population dynamics of human rabies cases. In this study, we applied an ensemble niche modeling approach to project climatic suitability under different future global warming scenarios for human rabies cases in Brazil, and assessed the impact on the probability of emergence of new cases. We obtained notification records of human rabies cases in all Brazilian cities from January 2001 to August 2023, as reported by the State and Municipal Health Departments. The current and future climate data were sourced from a digital repository on the WorldClim website. The future bioclimatic variables provided were downscaled climate projections from CMIP6 (a global model ensemble) and extracted from the regionalized climate model HadGEM3-GC31-LL for three future socioeconomic scenarios over four periods (2021-2100). Seven statistical algorithms (MAXENT, MARS, RF, FDA, CTA, GAM, and GLM) were selected for modeling human rabies. Temperature seasonality was the bioclimatic variable with the highest relative contribution to both current and future consensus models. Future scenario modeling for human rabies indicated a trend of changes in the areas of occurrence, maintaining the current pace of global warming, population growth, socioeconomic instability, and the loss of natural areas. In Brazil, there are areas with a higher likelihood of climatic factors contributing to the emergence of cases. When assessing future scenarios, a change in the local climatic suitability is observed that may lead to a reduction or increase in cases, depending on the region.

State-of-the-art model for derivation of analytical performance specifications: how to define the highest level of analytical performance technically achievable.

To be accurate and equivalent among assays, laboratory results should be traceable to higher-order references and their quality should fulfill maximum allowable measurement uncertainty (MU) as defined to fit the intended clinical use. Accordingly, laboratory professionals should estimate and validate MU of performed tests using appropriate analytical performance specifications (APS). Current consensus supports the derivation of APS by using one of the three models established by the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Strategic Conference held in Milan in 2014. It is recognized that some models are better suited for certain measurands than for others and the attention should be primarily directed towards their biological and clinical characteristics. Among others, model 3 should reflect the state of the art of the measurements that can be defined as the best analytical performance that is technically achievable. Taking serum C-reactive protein and ferritin as examples, here we describe the theoretical premises and the experimental protocol to be used to derive APS for MU when a measurand is allocated to this model. Although the model lacks a direct relationship with clinical outcomes, useful information about the invitro diagnostic medical device performance and the average quality of provided results may be obtained.

Investigation of the Relationship Between Laparoscopic Sleeve Gastrectomy and Gastroesophageal Reflux Disease Using 24-hour Multichannel Intraluminal Impedance With pH Testing According to Current Consensus.

Laparoscopic sleeve gastrectomy (LSG) is a popular weight loss procedure with potential effects on gastroesophageal reflux disease (GERD). However, research on the association between LSG and GERD using objective evaluation criteria, such as multichannel intraluminal impedance combined with pH testing (MII-pH), is limited. This study aimed to investigate the impact of LSG on GERD using MII-pH and current consensus guidelines. It was conducted as a prospective clinical study on 33 patients who underwent LSG between January 2022 and August 2022. MII-pH and high-resolution manometry were performed preoperatively and 3 to 6 months postoperatively. GERD diagnosis was based on MII-pH results using the Lyon and Update Porto consensus guidelines. Postoperative MII-pH analysis revealed a significant increase in acid reflux time, acid exposure time, reflux index, esophageal clearance, total reflux time, and longest reflux period. Weak acid reflux episodes decreased, while Demeester score and alkaline reflux showed nonsignificant increases. Pathologic reflux significantly increased postoperatively based on MII-pH diagnosis. High-resolution manometry showed a significant increase in unsuccessful motility. Although the Demeester score calculation consists of 6 metrics, including acid exposure time, the acid exposure time is more specific in detecting pathologic reflux. Pathologic GERD increases significantly with LSG in the early period. Therefore, preoperative and postoperative endoscopy and MII-pH can provide valuable information regarding the need for closer follow-up after LSG.

Screen time and pediatric headache: A scoping review of the literature.

The aim of this study was to summarize the evidence regarding screen use as a contributing factor in pediatric headache and migraine. Screen exposure is often reported as a headache trigger, though there is no current consensus in terms of how screen type, duration, or frequency influences pediatric headache and the associated burden of disease. A systematic search in PubMed, Scopus, Cochrane Library, ProQuest Health and Medical Database, and Google Scholar was performed through November 2022 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. All English-language articles of pediatric patients aged ≤18 years evaluating screen use in relation to headache were included. A total of 48 studies were included. Nearly all studies were cross-sectional and represented international samples. The strongest association between screen use and headache found was for duration of use, and computer use emerged as the most common device type related to headache. While there were mixed findings related to screen use and specific headache diagnosis, migraine appeared to confer a higher risk. Across studies, there were insufficient data to assess the impact of screen use on headache frequency or headache-related disability. Several studies demonstrated changes in screen use and headache patterns related to the COVID-19 pandemic and computer vision syndrome was commonly reported. While there is preliminary evidence supporting possible associations between screen use and pediatric headache, there are several limitations in the present review including a lack of prospective and randomized controlled trials to better demonstrate causal relationships as well as methodological limitations with significant variability in how both headache and screen use are defined and measured. Future studies including real-time screen use and device monitoring are needed to better understand the influence of screen use behaviors on pediatric headache and to help further define best-use guidelines around these technologies.

ACR Lung-RADS v2022: Assessment Categories and Management Recommendations

The American College of Radiology created the Lung CT Screening Reporting and Data System (Lung-RADS) in 2014 to standardize the reporting and management of screen-detected pulmonary nodules. Lung-RADS was updated to version 1.1 in 2019 and revised size thresholds for nonsolid nodules, added classification criteria for perifissural nodules, and allowed for short-interval follow-up of rapidly enlarging nodules that may be infectious in etiology. Lung-RADS v2022, released in November 2022, provides several updates including guidance on the classification and management of atypical pulmonary cysts, juxtapleural nodules, airway-centered nodules, and potentially infectious findings. This new release also provides clarification for determining nodule growth and introduces stepped management for nodules that are stable or decreasing in size. This article summarizes the current evidence and expert consensus supporting Lung-RADS v2022.

Updating Angling Records to Advance Sport Fish Conservation: A Case Study of IGFA's Black Bass World Records

As taxonomic studies revise our understanding of biodiversity, both fisheries managers and the angling public must adapt to best conserve fisheries. Unfortunately, communication gaps between scientists and anglers may result in lags and inaccuracies in the taxonomic information available to anglers. We updated the International Game Fish Association (IGFA)'s black bass Micropterus spp. world records to current taxonomic consensus. Seven new species were acknowledged for all‐tackle world record availability, and four of seven existing species records were revised. Florida Bass M. salmoides (formerly M. floridanus), Neosho Bass M. velox, and four members of the Redeye Bass species complex (M. cahabae, M. chattahoochae, M. tallapoosae, and M. warriorensis) are now recognized. Additionally, Alabama Bass M. henshalli—an emerging invasive species—is now distinguished from the smaller, broadly distributed Spotted Bass M. punctulatus. A misidentified specimen resulted in vacant all‐tackle records for Shoal Bass M. cataractae and Redeye Bass M. coosae. Genetic verification is warranted in the future, but implementation may create accessibility barriers to record submissions. We hope these efforts will encourage anglers to learn more about black bass diversity, to pursue their own world record catches, and to gain awareness of the conservation challenges threatening this iconic group.

Ubiquitous acceleration in Greenland Ice Sheet calving from 1985 to 2022.

Nearly every glacier in Greenland has thinned or retreated over the past few decades1-4, leading to glacier acceleration, increased rates of sea-level rise and climate impacts around the globe5-9. To understand how calving-front retreat has affected the ice-mass balance of Greenland, we combine 236,328 manually derived and AI-derived observations of glacier terminus positions collected from 1985 to 2022 and generate a 120-m-resolution mask defining the ice-sheet extent every month for nearly four decades. Here we show that, since 1985, the Greenland Ice Sheet (GrIS) has lost 5,091 ± 72 km2 of area, corresponding to 1,034 ± 120 Gt of ice lost to retreat. Our results indicate that, by neglecting calving-front retreat, current consensus estimates of ice-sheet mass balance4,9 have underestimated recent mass loss from Greenland by as much as 20%. The mass loss we report has had minimal direct impact on global sea level but is sufficient to affect ocean circulation and the distribution of heat energy around the globe10-12. On seasonal timescales, Greenland loses 193 ± 25 km2 (63 ± 6 Gt) of ice to retreat each year from a maximum extent in May to a minimum between September and October. We find that multidecadal retreat is highly correlated with the magnitude of seasonal advance and retreat of each glacier, meaning that terminus-position variability on seasonal timescales can serve as an indicator of glacier sensitivity to longer-term climate change.

The role of large corporations in entrepreneurial ecosystems – a case study of Munich

ABSTRACT A critical omission in research on entrepreneurial ecosystems is the role of large firms. It is claimed that they are critical actors. However, the current consensus – which suggests that their effects are entirely beneficial – is superficial. We present evidence from a case study of Munich, a city that combines an emerging ecosystem with a strong corporate sector, which indicates that the reality is much more nuanced. We confirm the resource-enriching effects of corporations. However, we also identify adverse impacts on the entrepreneurial culture that arise from their conservative and risk-avoiding mindset.

Title-molecular diagnostics of dystrophinopathies in Sri Lanka towards phenotype predictions: an insight from a South Asian resource limited setting

BackgroundThe phenotype of Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) patients is determined by the type of DMD gene variation, its location, effect on reading frame, and its size. The primary objective of this investigation was to determine the frequency and distribution of DMD gene variants (deletions/duplications) in Sri Lanka through the utilization of a combined approach involving multiplex polymerase chain reaction (mPCR) followed by Multiplex Ligation Dependent Probe Amplification (MLPA) and compare to the international literature. The current consensus is that MLPA is a labor efficient yet expensive technique for identifying deletions and duplications in the DMD gene.MethodologyGenetic analysis was performed in a cohort of 236 clinically suspected pediatric and adult myopathy patients in Sri Lanka, using mPCR and MLPA. A comparative analysis was conducted between our findings and literature data.ResultsIn the entire patient cohort (n = 236), mPCR solely was able to identify deletions in the DMD gene in 131/236 patients (DMD-120, BMD-11). In the same cohort, MLPA confirmed deletions in 149/236 patients [DMD-138, BMD -11]. These findings suggest that mPCR has a detection rate of 95% (131/138) among all patients who received a diagnosis. The distal and proximal deletion hotspots for DMD were exons 45–55 and 6–15. Exon 45–60 identified as a novel in-frame variation hotspot. Exon 45–59 was a hotspot for BMD deletions. Comparisons with the international literature show significant variations observed in deletion and duplication frequencies in DMD gene across different populations.ConclusionDMD gene deletions and duplications are concentrated in exons 45–55 and 2–20 respectively, which match global variation hotspots. Disparities in deletion and duplication frequencies were observed when comparing our data to other Asian and Western populations. Identified a 95% deletion detection rate for mPCR, making it a viable initial molecular diagnostic approach for low-resource countries where MLPA could be used to evaluate negative mPCR cases and cases with ambiguous mutation borders. Our findings may have important implications in the early identification of DMD with limited resources in Sri Lanka and to develop tailored molecular diagnostic algorithms that are regional and population specific and easily implemented in resource limited settings.

A content-aware chatbot based on GPT 4 provides trustworthy recommendations for Cone-Beam CT guidelines in dental imaging.

To develop a content-aware chatbot based on GPT-3.5-Turbo and GPT-4 with specialized knowledge on the German S2 Cone-Beam CT (CBCT) dental imaging guideline and to compare the performance against humans. The LlamaIndex software library was used to integrate the guideline context into the chatbots. Based on the CBCT S2 guideline, 40 questions were posed to content-aware chatbots and early career and senior practitioners with different levels of experience served as reference. The chatbots' performance was compared in terms of recommendation accuracy and explanation quality. Chi-square test and one-tailed Wilcoxon signed rank test evaluated accuracy and explanation quality, respectively. The GPT-4 based chatbot provided 100% correct recommendations and superior explanation quality compared to the one based on GPT3.5-Turbo (87.5% vs. 57.5% for GPT-3.5-Turbo; P = .003). Moreover, it outperformed early career practitioners in correct answers (P = .002 and P = .032) and earned higher trust than the chatbot using GPT-3.5-Turbo (P = 0.006). A content-aware chatbot using GPT-4 reliably provided recommendations according to current consensus guidelines. The responses were deemed trustworthy and transparent, and therefore facilitate the integration of artificial intelligence into clinical decision-making.

Pregnancy-adapted YEARS Algorithm: A Retrospective Analysis.

Pulmonary embolism (PE) is an imperative diagnosis to make given its associated morbidity. There is no current consensus in the initial workup of pregnant patients suspected of a PE. Prospective studies have been conducted in Europe using a pregnancy-adapted YEARS algorithm, which showed safe reductions in computed tomography pulmonary angiography (CTPA) imaging in pregnant patients suspected of PE. Our objective in this study was 1)to measure the potential avoidance of CTPA use in pregnant patients if the pregnancy-adapted YEARS algorithm had been applied and 2)to serve as an external validation study of the use of this algorithm in the United States. This study was a single-system retrospective chart analysis. Criteria for inclusion in the cohort consisted of keywords: pregnant; older than 18; chief complaints of shortness of breath, chest pain, tachycardia, hemoptysis, deep vein thromboembolism (DVT), and D-dimer-from January 1, 2019- May 31,2022. We then analyzed this cohort retrospectively using the pregnancy-adapted YEARS algorithm, which includes clinical signs of a DVT, hemoptysis, and PE as the most likely diagnosis with a D-dimer assay. Patients within the cohort were then subdivided into two categories: aligned with the YEARS algorithm, or not aligned with the YEARS algorithm. Patients who did not receive a CTPA were analyzed for a subsequent diagnosis of a PE or DVT within 30 days. A total of 74 pregnant patients were included in this study. There was a PE prevalence of 2.7% (two patients). Of the 36 patients who did not require imaging by the algorithm, seven CTPA were performed. Of the patients who did not receive an initial CTPA, zero were diagnosed with PE or DVT within a 30-day follow-up. In total, 85.1% of all the patients in this study were treated in concordance with the pregnancy-adapted YEARS algorithm. The use of the pregnancy-adapted YEARS algorithm could have resulted in decreased utilization of CTPA in the workup of PE in pregnant patients, and the algorithm showed similar reductions compared to prospective studies done in Europe. The pregnancy-adapted YEARS algorithm was also shown to be similar to the clinical rationale used by clinicians in the evaluation of pregnant patients, which indicates its potential for widespread acceptance into clinical practice.

Multiparametric Monitoring of Disease Progression in Contemporary Patients with Wild-Type Transthyretin Amyloid Cardiomyopathy Initiating Tafamidis Treatment.

Recently, a disease modifying therapy has become available for transthyretin amyloid cardiomyopathy (ATTR-CM). A validated monitoring concept of treatment is lacking, but a current expert consensus recommends three clinical domains (clinical, biomarker and ECG/imaging) assessed by several measurable features to define disease progression. We retrospectively analyzed data of wild-type ATTR-CM patients initiating tafamidis therapy assessed within our local routine protocol at baseline and 6-months follow-up with respect to the frequency of values beyond the proposed thresholds defining disease progression. Additionally, associations of cardiac magnetic resonance (CMR) tomography with clinical domains were examined within a subgroup. Sixty-two ATTR-CM patients were included (88.7% male, mean age 79 years). In total, 16.1% of patients had progress in the clinical and functional domain, 33.9% in the biomarker domain and 43.5% in the imaging/electrocardiography (ECG) domain, with the latter driven by deterioration of the diastolic dysfunction grade and global longitudinal strain. In total, 35.5% of patients showed progress in none, 35.5% in one, 29.0% in two and no patient in three domains, the latter indicating overall disease progression. A subgroup analysis of twenty-two patients with available baseline and follow-up CMR data revealed an increase in CMR-based extracellular volume by more than 5% in 18.2% of patients, with no significant correlation with progress in one of the clinical domains. We provide first frequency estimates of the markers of disease progression according to a recent expert consensus statement, which might help refine the multiparametric monitoring concept in patients with ATTR-CM.