Incorporating Patient Values in Large Language Model Recommendations for Surrogate and Proxy Decisions.

BACKGROUND: Surrogates, proxies, and clinicians making shared treatment decisions for patients who have lost decision-making capacity often fail to honor patients' wishes, due to stress, time pressures, misunderstanding patient values, and projecting personal biases. Advance directives intend to align care with patient values but are limited by low completion rates and application to only a subset of medical decisions. Here, we investigate the potential of large language models (LLMs) to incorporate patient values in supporting critical care clinical decision-making for incapacitated patients in a proof-of-concept study. METHODS: We simulated text-based scenarios for 50 decisionally incapacitated patients for whom a medical condition required imminent clinical decisions regarding specific interventions. For each patient, we also simulated five unique value profiles captured using alternative formats: numeric ranking questionnaires, text-based questionnaires, and free-text narratives. We used pre-trained generative LLMs for two tasks: 1) text extraction of the treatments under consideration and 2) prompt-based question-answering to generate a recommendation in response to the scenario information, extracted treatment, and patient value profiles. Model outputs were compared with adjudications by three domain experts who independently evaluated each scenario and decision. RESULTS AND CONCLUSIONS: Automated extractions of the treatment in question were accurate for 88% (n = 44/50) of scenarios. LLM treatment recommendations received an average Likert score by the adjudicators of 3.92 of 5.00 (five being best) across all patients for being medically plausible and reasonable treatment recommendations, and 3.58 of 5.00 for reflecting the documented values of the patient. Scores were highest when patient values were captured as short, unstructured, and free-text narratives based on simulated patient profiles. This proof-of-concept study demonstrates the potential for LLMs to function as support tools for surrogates, proxies, and clinicians aiming to honor the wishes and values of decisionally incapacitated patients.

A case of ocular diffuse large B-cell lymphoma unveiled through Pars Plana Vitrectomy: surgical insight and multidisciplinary management.

We present a rare case of ocular diffuse large B-cell lymphoma (DLBCL) unveiled through Pars Plana Vitrectomy in a 74-year-old immunocompromised male, highlighting the surgical insight and multidisciplinary management required for similar cases. The patient's progressive vision impairment led to a Pars Plana Vitrectomy, which confirmed DLBCL through cytogenetic analysis. Initial intraocular rituximab treatment showed promise; however, the lymphoma's systemic progression necessitated a shift to more aggressive chemotherapy, underscored by pleural and pericardial effusions and central nervous system involvement. This case emphasizes the critical role of surgical techniques in diagnosing ocular lymphomas and the importance of a multidisciplinary approach in managing the disease's ocular and systemic manifestations. The complexities introduced by the patient's immunosuppression highlight the necessity for individualized treatment strategies. This case calls for further research into ocular lymphomagenesis and exploring therapies with enhanced efficacy and reduced toxicity, and emphasizes the importance of early diagnosis in ocular DLBCL cases.

Pandemic effect on national hospitalizations for acute hyperglycemic complications.

Objective: This study aimed to describe the effect of the pandemic on epidemiologic trends and disparities in outcomes for patients hospitalized with acute hyperglycemic complications (AHC). Methods: This was a retrospective study of the National Inpatient Sample (NIS) database from 2016 to 2020. The population included adults hospitalized with AHCs as a principal diagnosis using the Clinical Classifications Software Refined code. Results: There was a decrease in the AHC hospitalization rate per 100,000 admissions for type 1 diabetes (T1D) during the pandemic (577 vs 600). However, there was an increase for type 2 diabetes (T2D) (117 vs 125). The mean age during the pandemic versus prepandemic was 34.8 ± 14.1 vs 34.7 ± 14.2 (P = 0.41) and 59.1 ± 14.4 vs 58.8 ± 14.7 (P = 0.51) for T1D and T2D, respectively. No statistically significant difference was observed in mortality in T1D (0.20 vs 0.23; P = 0.42) or T2D (1.1 vs 0.8; P = 0.09). There was no difference in mortality after stratifying results by gender, race, median household income, or hospital region. During the pandemic, COVID-19 was the principal diagnosis in 5.5% of those with AHC in T1D and 9.1% in those with AHC in T2D. Conclusion: The pandemic had a significant impact on the hospitalization rate for both T1D and T2D.

Bilateral Renal Infarct in a Young Adult: Unveiling an Autoimmune Enigma.

A man in his late 20s presented to the emergency department with sudden-onset abdominal pain. Urinalysis was significant for hematuria and slightly elevated creatinine. A computed tomography (CT) scan with IV contrast revealed bilateral renal infarcts, which was corroborated by a computed tomography angiogram (CTA). Further evaluation by an autoimmune panel demonstrated a positive antinuclear antibody, while echocardiography showed left ventricular non-compaction cardiomyopathy. The workup included consultations with multiple specialities and additional investigations to assess hypercoagulability, vasculitis, and infectious etiologies. Following supportive care, the patient was discharged in stable condition with a plan for outpatient follow-up and further workup, including screening of first-degree family members for left ventricular non-compaction and associated cardiovascular risks. Here we describe a report of a rare case of bilateral renal infarct of possible thromboembolic etiology due to an underlying rare genetic cardiovascular condition.

Gender disparities and predictors of in-hospital mortality with Takotsubo cardiomyopathy.

BACKGROUND: Takotsubo cardiomyopathy (TCM) is classically associated with significant gender disparities, such that it is more prevalent in females, but the clinical outcomes are worse for male patients. The goal of this study was to assess contemporary gender disparities in clinical outcomes of TCM hospitalizations and to determine predictors of male in-hospital mortality. METHODS: This was a retrospective analysis involving adult hospitalizations for TCM in the U.S between 2016 and 2020. Multivariable Logistic regression was used to estimate Odds Ratio (OR) for in-hospital mortality between the two genders. Univariable Cox regression was performed to identify predictors associated with in-hospital mortality for male hospitalizations. All factors from the univariable analysis with p < 0.20 were included in a multivariable Cox regression model. RESULTS: A total of 199,920 patients with TCM were identified. Female patients with TCM had 50% lower risk of in-hospital mortality compared to male patients (Adjusted OR 0.50, 95% CI 0.46-0.55, p < 0.001). Older age, higher Charlson comorbidity index, history of intracranial hemorrhage, cardiac arrest, need for vasopressor agents, mechanical intubation, and cardiogenic shock without the use of temporary mechanical circulatory support (MCS) were associated with higher in-hospital male mortality. CONCLUSIONS: Although TCM is more prevalent among females, gender disparities exist in the clinical outcomes of TCM patients. Cardiac arrest and cardiogenic shock without the use of temporary MCS were found to be the most significant predictors of male in-hospital mortality. Cardiogenic shock with use of temporary MCS did not lead to higher male in-hospital mortality.

Acute Lung Injury As Severe Acute Respiratory Distress Syndrome After Fentanyl Overdose.

Acute lung injury following fentanyl overdose is an unusual presentation. Pulmonary edema has been associated with opioid and naloxone use. However, to our knowledge, there have been no previous reports of inhaled fentanyl-associated acute lung injury presenting with acute hypoxic respiratory failure secondary to severe acute respiratory distress syndrome. We report a case of inhaled fentanyl-related severe acute respiratory distress syndrome which presented immediately after snorting fentanyl. This patient developed hypoxia requiring 100% oxygen on non-rebreather mask, and acute respiratory distress syndrome was confirmed on chest X-ray and computed tomography on admission. He was successfully treated with steroids with recovery in 48 hours. Naloxone was used in this patient, which has been associated with pulmonary edema in case reports and series, but clinical findings were more consistent with acute respiratory distress syndrome rather than pulmonary edema. The mechanism for this clinical presentation is not well known. Proposed mechanisms include lung injury from inhalation against an obstruction in a manner similar to post-obstructive pulmonary edema. Although our patient rapidly responded to symptomatic treatment and steroid course, our case also highlights the need for further study to elucidate the various clinical presentations associated with fentanyl use-related lung toxicity including acute respiratory distress syndrome.