Prediction of outcomes after cardiac arrest by a generative artificial intelligence model.

Aims: To investigate the prognostic accuracy of a non-medical generative artificial intelligence model (Chat Generative Pre-Trained Transformer 4 - ChatGPT-4) as a novel aspect in predicting death and poor neurological outcome at hospital discharge based on real-life data from cardiac arrest patients. Methods: This prospective cohort study investigates the prognostic performance of ChatGPT-4 to predict outcomes at hospital discharge of adult cardiac arrest patients admitted to intensive care at a large Swiss tertiary academic medical center (COMMUNICATE/PROPHETIC cohort study). We prompted ChatGPT-4 with sixteen prognostic parameters derived from established post-cardiac arrest scores for each patient. We compared the prognostic performance of ChatGPT-4 regarding the area under the curve (AUC), sensitivity, specificity, positive and negative predictive values, and likelihood ratios of three cardiac arrest scores (Out-of-Hospital Cardiac Arrest [OHCA], Cardiac Arrest Hospital Prognosis [CAHP], and PROgnostication using LOGistic regression model for Unselected adult cardiac arrest patients in the Early stages [PROLOGUE score]) for in-hospital mortality and poor neurological outcome. Results: Mortality at hospital discharge was 43% (n = 309/713), 54% of patients (n = 387/713) had a poor neurological outcome. ChatGPT-4 showed good discrimination regarding in-hospital mortality with an AUC of 0.85, similar to the OHCA, CAHP, and PROLOGUE (AUCs of 0.82, 0.83, and 0.84, respectively) scores. For poor neurological outcome, ChatGPT-4 showed a similar prediction to the post-cardiac arrest scores (AUC 0.83). Conclusions: ChatGPT-4 showed a similar performance in predicting mortality and poor neurological outcome compared to validated post-cardiac arrest scores. However, more research is needed regarding illogical answers for potential incorporation of an LLM in the multimodal outcome prognostication after cardiac arrest.

Misconceptions and do-not-resuscitate preferences of healthcare professionals commonly involved in cardiopulmonary resuscitations: A national survey.

Aims: To assess the DNR preferences of critical care-, anesthesia- and emergency medicine practitioners, to identify factors influencing decision-making, and to raise awareness for misconceptions concerning CPR outcomes. Methods: A nationwide multicenter survey was conducted in Switzerland confronting healthcare professionals with a case vignette of an adult patient with an out-of-hospital cardiac arrest (OHCA). The primary outcome was the rate of DNR Code Status vs. CPR Code Status when taking the perspective from a clinical case vignette of a 70-year-old patient. Secondary outcomes were participants' personal preferences for DNR and estimates of survival with good neurological outcome after in- and out-of-hospital cardiac arrest. Results: Within 1803 healthcare professionals, DNR code status was preferred in 85% (n = 1532) in the personal perspective of the case vignette and 53.2% (n = 932) when making a decision for themselves. Main predictors for a DNR Code Status regarding the case vignette included preferences for DNR Code Status for themselves (n [%] 896 [58.5] vs. 87 [32.1]; adjusted odds ratio [OR] 2.97, 95% confidence interval [CI] 2.25-3.92; p < 0.001) and lower estimated OHCA survival (mean [±SD] 12.3% [±11.8] vs. 14.7%[±12.8]; adjusted OR 0.98, 95% CI 0.97-0.99; p = 0.001). Physicians chose a DNR order more often when compared to nurses and paramedics. Conclusions: The estimation of outcomes following cardiac arrest and personal living conditions are pivotal factors influencing code status preferences in healthcare professionals. Healthcare professionals should be aware of cardiac arrest prognosis and potential implications of personal preferences when engaging in code status- and end-of-life discussions with patients and their relatives.

[Integrative medicine: what's new in 2023]. / Médecine intégrative : ce qui a changé en 2023.

To illustrate the news of 2023 in integrative medicine, the authors summarized four particularly relevant studies. The first highlights one of the foundational principles of integrative medicine, describing the importance of respecting patient preference in the choice of a therapeutic approach, promoting their «empowerment¼. The second article proposes methodological recommendations to improve the scientific value of studies assessing the efficacy and mechanisms of non-pharmacological approaches. Finally, the last two articles are randomized studies designed to either demonstrate the feasibility and effect of hypnosis in geriatrics, or evaluate the efficacy of a several combined complementary approaches for cancer-related fatigue.

Dans cette nouvelle édition consacrée aux nouveautés en médecine intégrative, les auteurs ont choisi de résumer quatre études particulièrement pertinentes parmi les articles publiés en 2023. La première souligne l'un des principes fondateurs de la médecine intégrative en décrivant l'importance du respect de la préférence du patient dans le choix d'une approche thérapeutique, favorisant leur « empowerment ¼. La deuxième propose des recommandations méthodologiques afin d'améliorer la valeur scientifique des études de l'efficacité et des mécanismes d'approches non pharmacologiques. Enfin, les deux dernières sont des études randomisées visant à démontrer, d'une part, la faisablité et l'effet de l'hypnose en gériatrie et, d'autre part, l'efficacité d'une combinaison d'approches complémentaires pour lutter contre la fatigue liée au cancer.

Red blood cell distribution width for the prediction of outcomes after cardiac arrest.

The red blood cell distribution width (RDW) is a routinely available blood marker that measures the variation of the size/volume of red blood cells. The aim of our study was to investigate the prognostic value of RDW in cardiac arrest patients and to assess whether RDW improves the prognostic value of three cardiac arrest-specific risk scores. Consecutive adult cardiac arrest patients admitted to the ICU of a Swiss university hospital were included. The primary outcome was poor neurological outcome at hospital discharge assessed by Cerebral Performance Category. Of 702 patients admitted to the ICU after cardiac arrest, 400 patients (57.0%) survived, of which 323 (80.8%) had a good neurological outcome. Higher mean RDW values showed an independent association with poor neurological outcomes at hospital discharge (adjusted OR 1.27, 95% CI 1.14 to 1.41; p < 0.001). Adding the maximum RDW value to the OHCA- CAHP- and PROLOGUE cardiac arrest scores improved prognostic performance. Within this cohort of cardiac arrest patients, RDW was an independent outcome predictor and slightly improved three cardiac arrest-specific risk scores. RDW may therefore support clinical decision-making.

Extrapulmonary tuberculosis in HIV-infected patients in rural Tanzania: The prospective Kilombero and Ulanga antiretroviral cohort.

BACKGROUND: In sub-Saharan Africa, diagnosis and management of extrapulmonary tuberculosis (EPTB) in people living with HIV (PLHIV) remains a major challenge. This study aimed to characterize the epidemiology and risk factors for poor outcome of extrapulmonary tuberculosis in people living with HIV (PLHIV) in a rural setting in Tanzania. METHODS: We included PLHIV >18 years of age enrolled into the Kilombero and Ulanga antiretroviral cohort (KIULARCO) from 2013 to 2017. We assessed the diagnosis of tuberculosis by integrating prospectively collected clinical and microbiological data. We calculated prevalence- and incidence rates and used Cox regression analysis to evaluate the association of risk factors in extrapulmonary tuberculosis (EPTB) with a combined endpoint of lost to follow-up (LTFU) and death. RESULTS: We included 3,129 subjects (64.5% female) with a median age of 38 years (interquartile range [IQR] 31-46) and a median CD4+ cell count of 229/µl (IQR 94-421) at baseline. During the median follow-up of 1.25 years (IQR 0.46-2.85), 574 (18.4%) subjects were diagnosed with tuberculosis, whereof 175 (30.5%) had an extrapulmonary manifestation. Microbiological evidence by Acid-Fast-Bacillus stain (AFB-stain) or Xpert® MTB/RIF was present in 178/483 (36.9%) patients with pulmonary and in 28/175 (16.0%) of patients with extrapulmonary manifestations, respectively. Incidence density rates for pulmonary Tuberculosis (PTB and EPTB were 17.9/1000person-years (py) (95% CI 14.2-22.6) and 5.8/1000 py (95% CI 4.0-8.5), respectively. The combined endpoint of death and LTFU was observed in 1058 (33.8%) patients, most frequently in the subgroup of EPTB (47.2%). Patients with EPTB had a higher rate of the composite outcome of death/LTFU after TB diagnosis than with PTB [HR 1.63, (1.14-2.31); p = 0.006]. The adjusted hazard ratios [HR (95% CI)] for death/LTFU in EPTB patients were significantly increased for patients aged >45 years [HR 1.95, (1.15-3.3); p = 0.013], whereas ART use was protective [HR 0.15, (0.08-0.27); p <0.001]. CONCLUSIONS: Extrapulmonary tuberculosis was a frequent manifestation in this cohort of PLHIV. The diagnosis of EPTB in the absence of histopathology and mycobacterial culture remains challenging even with availability of Xpert® MTB/RIF. Patients with EPTB had increased rates of mortality and LTFU despite early recognition of the disease after enrollment.

[CME: Extrapulmonary Tuberculosis]. / CME: Extrapulmonale Tuberkulose CME-Fragen.

CME: Extrapulmonary Tuberculosis Abstract. While tuberculosis mostly manifests as pulmonary infection, a dissemination in any extrapulmonary organ is possible. Extrapulmonary tuberculosis mostly affects lymph nodes, pleura and bones. Patients with immunosuppressive conditions such as an HIV co-infection or immunosuppressive therapies like TNF-alpha-inhibitors have a higher risk of a dissemination of tuberculosis. Diagnosis of extrapulmonary tuberculosis is difficult, as microbiological testing mostly requires invasive procedures to obtain a sample for direct proof of tuberculosis by microscopy, culture, molecular methods (e.g. Xpert® MTB/RIF) or histology. Treatment follows guidelines of pulmonary tuberculosis with a two-month regimen consisting of four drugs (rifampicin, isoniazide, pyrazinamide and ethambuthol), followed by a four-month therapy with two drugs (rifampicin and isoniazide). Duration of therapy is extended in tuberculous meningitis to one year and in a skeletal dissemination up to six to nine months. Corticosteroids are recommended in cerebral and pericardial tuberculosis.

Niacin for primary and secondary prevention of cardiovascular events.

BACKGROUND: Nicotinic acid (niacin) is known to decrease LDL-cholesterol, and triglycerides, and increase HDL-cholesterol levels. The evidence of benefits with niacin monotherapy or add-on to statin-based therapy is controversial. OBJECTIVES: To assess the effectiveness of niacin therapy versus placebo, administered as monotherapy or add-on to statin-based therapy in people with or at risk of cardiovascular disease (CVD) in terms of mortality, CVD events, and side effects. SEARCH METHODS: Two reviewers independently and in duplicate screened records and potentially eligible full texts identified through electronic searches of CENTRAL, MEDLINE, Embase, Web of Science, two trial registries, and reference lists of relevant articles (latest search in August 2016). SELECTION CRITERIA: We included all randomised controlled trials (RCTs) that either compared niacin monotherapy to placebo/usual care or niacin in combination with other component versus other component alone. We considered RCTs that administered niacin for at least six months, reported a clinical outcome, and included adults with or without established CVD. DATA COLLECTION AND ANALYSIS: Two reviewers used pre-piloted forms to independently and in duplicate extract trials characteristics, risk of bias items, and outcomes data. Disagreements were resolved by consensus or third party arbitration. We conducted random-effects meta-analyses, sensitivity analyses based on risk of bias and different assumptions for missing data, and used meta-regression analyses to investigate potential relationships between treatment effects and duration of treatment, proportion of participants with established coronary heart disease and proportion of participants receiving background statin therapy. We used GRADE to assess the quality of evidence. MAIN RESULTS: We included 23 RCTs that were published between 1968 and 2015 and included 39,195 participants in total. The mean age ranged from 33 to 71 years. The median duration of treatment was 11.5 months, and the median dose of niacin was 2 g/day. The proportion of participants with prior myocardial infarction ranged from 0% (4 trials) to 100% (2 trials, median proportion 48%); the proportion of participants taking statin ranged from 0% (4 trials) to 100% (12 trials, median proportion 100%).Using available cases, niacin did not reduce overall mortality (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.97 to 1.12; participants = 35,543; studies = 12; I2 = 0%; high-quality evidence), cardiovascular mortality (RR 1.02, 95% CI 0.93 to 1.12; participants = 32,966; studies = 5; I2 = 0%; moderate-quality evidence), non-cardiovascular mortality (RR 1.12, 95% CI 0.98 to 1.28; participants = 32,966; studies = 5; I2 = 0%; high-quality evidence), the number of fatal or non-fatal myocardial infarctions (RR 0.93, 95% CI 0.87 to 1.00; participants = 34,829; studies = 9; I2 = 0%; moderate-quality evidence), nor the number of fatal or non-fatal strokes (RR 0.95, 95% CI 0.74 to 1.22; participants = 33,661; studies = 7; I2 = 42%; low-quality evidence). Participants randomised to niacin were more likely to discontinue treatment due to side effects than participants randomised to control group (RR 2.17, 95% CI 1.70 to 2.77; participants = 33,539; studies = 17; I2 = 77%; moderate-quality evidence). The results were robust to sensitivity analyses using different assumptions for missing data. AUTHORS' CONCLUSIONS: Moderate- to high-quality evidence suggests that niacin does not reduce mortality, cardiovascular mortality, non-cardiovascular mortality, the number of fatal or non-fatal myocardial infarctions, nor the number of fatal or non-fatal strokes but is associated with side effects. Benefits from niacin therapy in the prevention of cardiovascular disease events are unlikely.

Cardiovascular effects and safety of long-term colchicine treatment: Cochrane review and meta-analysis.

Colchicine is an old anti-inflammatory drug that has shown substantial cardiovascular benefits in recent trials. We systematically reviewed cardiovascular benefits and harms of colchicine in any population and specifically in patients with high cardiovascular risk. We evaluated randomised controlled trials comparing colchicine over at least 6 months versus any control in any adult population. Primary outcomes were all-cause mortality, myocardial infarction and adverse events. Cardiovascular mortality was a secondary outcome. We included 39 trials with 4992 patients. The quality of evidence for mortality outcomes and myocardial infarction was moderate but lower for adverse events. Colchicine had no effect on all-cause mortality (RR 0.94, 95% CI 0.82 to 1.09; I(2)=27%; 30 trials). Cardiovascular mortality was reduced in some but not all meta-analytical models (random-effects RR 0.34, 0.09 to 1.21, I(2)=9%; Peto's OR 0.24, 0.09 to 0.64, I(2)=15%; Mantel-Haenszel fixed-effect RR 0.20, 0.06 to 0.68, I(2)=0%; 7 trials). The risk for myocardial infarction was reduced (RR 0.20, 0.07 to 0.57; 2 trials). There was no effect on total adverse events (RR 1.52, 0.93 to 2.46, I(2)=45%; 11 trials) but gastrointestinal intolerance was increased (RR 1.83, 1.03 to 3.26, I(2)=74%; 11 trials). Reporting of serious adverse events was inconsistent; no event occurred over 824 patient-years (4 trials). Effects in high cardiovascular risk populations were similar (4 trials; 1230 patients). We found no evidence supporting colchicine doses above 1 mg/day. Colchicine may have substantial cardiovascular benefits; however, there is sufficient uncertainty about its benefit and harm to indicate the need for large-scale trials to further evaluate this inexpensive, promising treatment in cardiovascular disease.

Colchicine for prevention of cardiovascular events.

BACKGROUND: Colchicine is an anti-inflammatory drug that is used for a wide range of inflammatory diseases. Cardiovascular disease also has an inflammatory component but the effects of colchicine on cardiovascular outcomes remain unclear. Previous safety analyses were restricted to specific patient populations. OBJECTIVES: To evaluate potential cardiovascular benefits and harms of a continuous long-term treatment with colchicine in any population, and specifically in people with high cardiovascular risk. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, ClinicalTrials.gov, WHO International Clinical Trials Registry, citations of key papers, and study references in January 2015. We also contacted investigators to gain unpublished data. SELECTION CRITERIA: Randomised controlled trials (parallel-group or cluster design or first phases of cross-over studies) comparing colchicine over at least six months versus any control in any adult population. DATA COLLECTION AND ANALYSIS: Primary outcomes were all-cause mortality, myocardial infarction, and adverse events. Secondary outcomes were cardiovascular mortality, stroke, heart failure, non-scheduled hospitalisations, and non-scheduled cardiovascular interventions. We conducted predefined subgroup analyses, in particular for participants with high cardiovascular risk. . MAIN RESULTS: We included 39 randomised parallel-group trials with 4992 participants. Colchicine had no effect on all-cause mortality (RR 0.94, 95% CI 0.82 to 1.09; participants = 4174; studies = 30; I² = 27%; moderate quality of evidence). There is uncertainty surrounding the effect of colchicine in reducing cardiovascular mortality (RR 0.34, 95% CI 0.09 to 1.21, I² = 9%; participants = 1132; studies = 7; moderate quality of evidence). Colchicine reduced the risk for total myocardial infarction (RR 0.20, 95% CI 0.07 to 0.57; participants = 652; studies = 2; moderate quality of evidence). There was no effect on total adverse events (RR 1.52, 95% CI 0.93 to 2.46; participants = 1313; studies = 11; I² = 45%; very low quality of evidence) but gastrointestinal intolerance was increased (RR 1.83, 95% CI 1.03 to 3.26; participants = 1258; studies = 11; I² = 74%; low quality of evidence). Colchicine showed no effect on heart failure (RR 0.62, 95% CI 0.10 to 3.88; participants = 462; studies = 3; I² = 45%; low quality of evidence) and no effect on stroke (RR 0.38, 95% CI 0.09 to 1.70; participants = 874; studies = 3; I² = 45%; low quality of evidence). Reporting of serious adverse events was inconsistent; no event occurred over 824 patient-years (4 trials). Effects on other outcomes were very uncertain. Summary effects of RCTs specifically focusing on participants with high cardiovascular risk were similar (4 trials; 1230 participants). AUTHORS' CONCLUSIONS: There is much uncertainty surrounding the benefits and harms of colchicine treatment. Colchicine may have substantial benefits in reducing myocardial infarction in selected high-risk populations but uncertainty about the size of the effect on survival and other cardiovascular outcomes is high, especially in the general population from which most of the studies in our review were drawn. Colchicine is associated with gastrointestinal side effects based on low-quality evidence. More evidence from large-scale randomised trials is needed.