Artificial Intelligence in Identifying Patients With Undiagnosed Nonalcoholic Steatohepatitis.

Background: Although increasing in prevalence, nonalcoholic steatohepatitis (NASH) is often undiagnosed in clinical practice. Objective: This study identified patients in the Veterans Affairs (VA) health system who likely had undiagnosed NASH using a machine learning algorithm. Methods: From a VA data set of 25 million adult enrollees, the study population was divided into NASH-positive, non-NASH, and at-risk cohorts. We performed a claims data analysis using a machine learning algorithm. To build our model, the study population was randomly divided into an 80% training subset and a 20% testing subset and tested and trained using a cross-validation technique. In addition to the baseline model, a gradient-boosted classification tree, naïve Bayes, and random forest model were created and compared using receiver operator characteristics, area under the curve, and accuracy. The best performing model was retrained on the full 80% training subset and applied to the 20% testing subset to calculate the performance metrics. Results: In total, 4 223 443 patients met the study inclusion criteria, of whom 4903 were positive for NASH and 35 528 were non-NASH patients. The remainder was in the at-risk patient cohort, of which 514 997 patients (12%) were identified as likely to have NASH. Age, obesity, and abnormal liver function tests were the top determinants in assigning NASH probability. Conclusions: Utilization of machine learning to predict NASH allows for wider recognition, timely intervention, and targeted treatments to improve or mitigate disease progression and could be used as an initial screening tool.

The association between weight loss medications and cardiovascular complications.

OBJECTIVE: Obesity and its cardiovascular complications are major causes of morbidity and mortality. Little is known in real-world settings about the effect of newly approved antiobesity medications (AOMs) on cardiovascular complications among patients with obesity. METHODS: This retrospective cohort study examined the association between newly approved AOM use and cardiovascular events among Medicare patients with obesity using data from 2020 to 2022. Patient age, gender, comorbidity scores, socioeconomic status, and baseline cardiovascular comorbidities were compared descriptively. Subgroup analysis compared variables by medication type. Relative risk and absolute risk of cardiovascular disease (CVD) events were estimated using Cox and Aalen regression models. RESULTS: The analysis included 5926 patients treated with semaglutide and tirzepatide, including Ozempic (5404 patients), Wegovy (375 patients), or Mounjaro (147 patients). Hypertension, type 2 diabetes, and hyperlipidemia were the most common comorbidities. For patients with AOMs, less incidence of heart failure (4.89% vs. 6.13%, p < 0.0001), atrial fibrillation (3.83% vs. 5.17%, p < 0.0001), arrhythmia (3.59% vs. 4.14%, p < 0.0153), and peripheral vascular disease (3.44% vs. 2.94%, p < 0.0395) was found versus patients without AOMs. Patients receiving AOMs showed an 8% risk reduction in any CVD. Protective effect on CVD was apparent over the first 375 days. CONCLUSIONS: Results suggest that utilization of AOMs effectively alleviates the high prevalence of CVD.

Cardiovascular events among patients with prostate cancer treated with abiraterone and enzalutamide.

BACKGROUND AND PURPOSE: There is growing concern about the adverse metabolic and cardiovascular effects of abiraterone acetate (AA) and enzalutamide (ENZ), two standard hormonal therapies for prostate cancer. We analysed the risk of cardiovascular adverse events among patients treated with AA and ENZ. PATIENTS AND METHODS: We used Kythera Medicare data from January 2019 to June 2023 to identify patients with at least one pharmacy claim for AA or ENZ. The index date was the first prescription claim date. Patients were required to have 1 year of data pre- and post-index date. New users excluded those with prior AA or ENZ claims and pre-existing cardiovascular comorbidities. Demographic and clinical variables, including age, socioeconomic status (SES), comorbidity score, prostate-specific comorbidities, and healthcare costs, were analysed . Propensity score matching was employed for risk adjustment. RESULTS: Of the 8,929 and 8,624 patients in the AA and ENZ cohorts, respectively, 7,647 were matched after adjusting for age, sociodemographic, and clinical factors. Between the matched cohorts (15.54% vs. 14.83%, p < 0.05), there were no statistically significant differences in any cardiovascular event after adjusting for these factors. The most common cardiovascular event in both cohorts was heart failure (5.20% vs. 4.49%), followed by atrial fibrillation (4.42% vs. 3.60%) and hypotension (2.93% vs. 2.48%). INTERPRETATION: This study provides real-world evidence of the cardiovascular risk of AA and ENZ that may not appear in clinical trial settings. Adjusting for age, baseline comorbidities, and SES, the likelihood of a cardiovascular event did not differ between treatment groups.

Use of Open Claims vs Closed Claims in Health Outcomes Research.

Background: Closed claims are frequently used in outcomes research studies. Lately, the availability of open claims has increased the possibility of obtaining information faster and on a larger scale. However, because of the possibility of missing claims and duplications, these data sets have not been highly utilized in medical research. Objective: To compare frequently used healthcare utilization measures between closed claims and open claims to analyze if the possibility of missing claims in open claims data creates a downward bias in the estimates. Methods: We identified 18 different diseases using 2022 data from 2 closed claims data sets (MarketScan® and PharMetrics® Plus) and 1 open claims database (Kythera). After applying an algorithm that removes possible duplications from open claims data, we compared healthcare utilizations such as inpatient, emergency department, and outpatient use and length of stay among these 3 data sets. We applied standardized differences to compare the medians for each outcome. Results: The sample size of the open claims data sets was 10 to 65 times larger than closed claims data sets depending on disease type. For each disease, the estimates of healthcare utilization were similar between the open claims and closed claims data. The difference was statistically insignificant. Conclusions: Open claims data with a bigger sample size and more current available information provide essential advantages for healthcare outcomes research studies. Therefore, especially for new medications and rare diseases, open claims data can provide information much earlier than closed claims, which usually have a time lag of 6 to 8 months.

Relationship between Body Mass Index and Diagnosis of Overweight or Obesity in Veterans Administration Population.

Background: This paper examined the gap between obesity and its diagnosis for cohorts of patients with overweight, obesity, and morbid obesity in the Veterans Administration (VA) population. Using the risk adjustment models, it also identified factors associated with the underdiagnosis of obesity. Methods: Analysis was performed on a VA data set. We identified diagnosed patients and undiagnosed patients (identified through BMI but not diagnosed using ICD-10 codes). The groups' demographics were compared using nonparametric chi-square tests. We used logistic regression analysis to predict the likelihood of the omission of diagnosis. Results: Of the 2,900,067 veterans with excess weight, 46% were overweight, 46% had obesity, and 8% of them had morbid obesity. The overweight patients were the most underdiagnosed (96%), followed by the obese (75%) and morbidly obese cohorts (69%). Older, male, and White patients were more likely to be undiagnosed as overweight and obese; younger males were more likely to be undiagnosed as morbidly obese. (p < 0.05) Comorbidities significantly contributed to diagnosis. Conclusions: The underdiagnosis of obesity continues to be a significant problem despite its prevalence. Diagnosing obesity accurately is necessary to provide effective management and treatment.

Efficacy of a Point-of-Care Transthoracic Echocardiography Workshop for Medical Students.

OBJECTIVE: To assess the efficacy of a 5-week point-of-care transthoracic echocardiography workshop for medical students. DESIGN: Prospective, time-series design. SETTING: A single institution, including students at one US medical school. PARTICIPANTS: The study comprised eight second- and third-year medical students. INTERVENTIONS: Subjects enrolled in a voluntary educational workshop designed to teach basic point-of-care transthoracic echocardiography. MEASUREMENTS AND MAIN RESULTS: The primary outcome was change on the total examination score (0-100) that assessed hands-on performance of four basic transthoracic echocardiography views, identification of relevant anatomy, and echocardiography knowledge. Secondary outcomes were scores on the practical (0-40) and written (0-60) subsections of the examination. Mean and standard deviation (±SD) total examination scores increased to 83.6 (±5.2) after the workshop versus 54 (±7.1) at baseline (p < 0.0001). Mean (±SD) practical examination scores increased to 38 (±2.5) after the workshop versus 22 (±4.6) at baseline (p < 0.0001). Mean (±SD) written examination scores increased to 46 (±4.8) after the workshop versus 32 (±5.8) at baseline (p = 0.0003). CONCLUSIONS: Results of this pilot study indicated that the workshop curriculum may be an effective way to teach basic point-of-care transthoracic echocardiography to medical students.

Assessment of Didactic Transesophageal Echocardiography Education During Anesthesia Residency.

BACKGROUND: Transesophageal echocardiography can be a useful monitor during noncardiac surgery, in patients with comorbidities and/or undergoing procedures associated with substantial hemodynamic changes. The goal of this study was to investigate if transesophageal-echocardiography-related knowledge could be acquired during anesthesia residency. METHODS: After institutional review board approval, a prospective observational study was performed in two anesthesiology residency programs. After a 41-week didactic transesophageal-echocardiography-education curriculum residents' exam scores were compared to baseline. The educators' examination was validated against the National Board of Echocardiography's Examination of Special Competence in Advanced Perioperative Transesophageal Echocardiography. RESULTS: After the 41-week course, clinical anesthesia (CA)-3 exam scores increased 12% compared to baseline (P = .03), CA-2 scores increased 29% (P = .007), and CA-1 scores increased 25% (P = .002). Pearson correlation coefficient between the educators' exam score and the special competence exam percentile rank was 0.69 (P = .006). Pearson correlation coefficient between the educators' exam score and the special competence exam scaled score was 0.71 (P = .0045). CONCLUSIONS: The 41-week course resulted in significant increases in exam scores in all 3 CA-classes. While didactic knowledge can be learned by anesthesiology residents during training, it requires significant time and effort. It is important to educate residents in echocardiography, to prepare them for board examinations and to care for the increasingly older and sicker patient population. Further work needs to be done to determine optimal methods to provide such education.

Development of a community-based intervention for the control of Chagas disease based on peridomestic animal management: an eco-bio-social perspective.

BACKGROUND: Integrated vector management strategies depend on local eco-bio-social conditions, community participation, political will and inter-sectorial partnership. Previously identified risk factors for persistent Triatoma dimidiata infestation include the presence of rodents and chickens, tiled roofs, dirt floors, partial wall plastering and dog density. METHODS: A community-based intervention was developed and implemented based on cyclical stakeholder and situational analyses. Intervention implementation and evaluation combined participatory action research and cluster randomized pre-test post-test experimental designs. The intervention included modified insecticide application, education regarding Chagas disease and risk factors, and participatory rodent control. RESULTS: At final evaluation there was no significant difference in post-test triatomine infestation between intervention and control, keeping pre-test rodent and triatomine infestations constant. Knowledge levels regarding Chagas disease and prevention practices including rodent control, chicken management and health service access increased significantly only in intervention communities. The odds of nymph infection and rat infestation were 8.3 and 1.9-fold higher in control compared to intervention communities, respectively. CONCLUSION: Vector control measures without reservoir control are insufficient to reduce transmission risk in areas with persistent triatomine infestation. This integrated vector management program can complement house improvement initiatives by prioritizing households with risk factors such as tiled roofs. Requirement for active participation and multi-sectorial coordination poses implementation challenges.