Deaconess Hospital

Artificial intelligence-derived macular thinning patterns were associated with central visual field progression in glaucoma and outperformed global thickness metrics in predicting progression across disease severities. To provide spatial patterns of ganglion cell complex thickness and assess their associations with central visual field progression in glaucoma. Macular patterns from the ganglion cell complex were determined using an artificial intelligence algorithm termed archetypal analysis (AA). The diagnostic accuracy of spatial patterns for detecting 10-2 central visual field progression in eyes with at least five 10-2 visual field tests was calculated and compared with the mean global ganglion cell complex thickness. Eyes with progression on either of 2 trend-based methods (significant MD slope less than -0.5dB/y or clustered pointwise linear regression) were classified as "progressors." A total of 4031 macular scans of 1093 eyes (611 patients) were included, with a mean (SD) age of 67.8 (12.7) years. Eleven distinct spatial patterns were identified. While the macular vulnerable zone was preferentially affected in 4 patterns, most of the less vulnerable zones were preserved. The AA models at baseline achieved AUROC [0.73 (95% CI, 0.62-0.84)] and outperformed global ganglion cell complex thickness [0.55 (95% CI, 0.46-0.61), P =0.01] for predicting central VF progression in eyes with early disease at baseline. The AA models AUROC [0.70 (95% CI, 0.59-0.80)] also outperformed ganglion cell complex thickness [0.55 (95% CI, 0.48-0.60), P =0.02] for predicting central VF progression across all severities. Using unsupervised artificial intelligence, characteristic patterns of macular thinning were identified and associated with progression in the central visual field. Spatial macular pattern analysis may enhance individualized care and improve risk stratification for those at risk of central VF damage.

INTRODUCTION: Urinary incontinence is a widely prevalent, yet undertreated condition. High-intensity focused electromagnetic (HIFEM) devices offer patients a non-invasive, non-pharmacologic alternative treatment for urinary incontinence. There is a paucity of non-industry-sponsored studies of the efficacy of HIFEM devices for the treatment of urinary incontinence. OBJECTIVE: The primary objective was to assess the efficacy of HIFEM for the treatment of overactive bladder and stress urinary incontinence. METHODS: Eligible patients with stress or urge-predominant urinary incontinence were enrolled in a double-blind, stratified block randomized sham-controlled trial and assigned in a 1:1 ratio. Participants received a total of six HIFEM sessions delivered at either therapeutic or sham (subtherapeutic) intensity. The primary outcome was treatment success defined as a response of “little better,” “much better,” or “very much better” on the PGI-I questionnaire. Secondary outcomes included changes in validated questionnaires: Pelvic Floor Disability Index (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ), Female Sexual Function Index (FSFI), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ) scores, which were administered at baseline, two weeks, and three months after completion of treatment. Continuous variables were evaluated using Student t-test and categorical variables were assessed with chi-square or Fishers exact t-test, as needed. Variables with a p-value of less than 0.05 were considered to be significant. RESULTS: A total of 34 patients were enrolled and randomized: 19 to treatment and 15 to sham protocol. Baseline demographics including average age, BMI, and parity did not significantly differ between groups (Table 1). At the conclusion of the three-month follow-up, 12 patients completed the treatment protocol, and 12 patients completed the sham protocol. In the primary analysis at two weeks, more patients in the treatment protocol reported symptom improvement based on PGI-I compared to sham protocol (p=0.04). This improvement was sustained at three months, with PGI-I scores indicating improvement for those in the treatment protocol when compared to sham protocol (p=0.04). The secondary outcomes of PFDI-20, PFIQ-7, FSFI, or PISQ scores showed no difference between those in the treatment protocol and those in the sham protocol at either two weeks or three months (Table 2). After completing the study, a total of 12 patients, 2 (22%) from the sham protocol and 10 (83%) from the treatment protocol, opted for further treatment of their urinary symptoms. This included pelvic floor physical therapy (n=3), incontinence pessary (n=1), midurethral sling (n=3), beta-3-agonist (n=5), intradetrusor onabotulinumtoxina (n=2), or sacral neuromodulation device (n=1). CONCLUSIONS: Although underpowered, this randomized controlled trial demonstrated significantly improved patient-reported outcomes following HIFEM treatment for urinary incontinence. However, as most patients sought additional treatments, larger trials are needed to confirm these efficacy results.Table 1Table 2

OBJECTIVE Use of glucagon-like peptide 1 receptor agonists (GLP-1 RAs) for diabetes or weight management may affect pregnancy outcomes. We sought to estimate the number of U.S. women of reproductive age eligible for GLP-1 RA therapy. RESEARCH DESIGN AND METHODS Using 2017–2023 nationally representative survey data, we identified nonpregnant U.S. women aged 18–44 years who met trial-based eligibility criteria for diabetes, weight management, or secondary cardiovascular prevention. RESULTS Among 3,218 participants, 1,447 were eligible for GLP-1 RAs, representing 24.6 million U.S. women. Among GLP-1 RA–eligible women, mean BMI was 34.8 kg/m2, 8.3% had diabetes, and 1.9% had prior cardiovascular disease. Eligibility was primarily for weight management (24.1 million), followed by diabetes (2.0 million) and cardiovascular prevention (0.34 million). CONCLUSIONS Nearly half of U.S. reproductive-age women are eligible for GLP-1 RAs. Given limited pregnancy safety data and rising cardiometabolic burden in reproductive-age women, research is needed to guide counseling and coverage of preconception GLP-1 RA use.

Sepsis remains a leading cause of mortality, and optimizing treatment is challenging due to patient heterogeneity. Identification of cardiac phenotypes may inform precision medicine approaches and guide resuscitation. We performed a clustering analysis of patients with sepsis using echocardiographic data without using any a priori definitions of cardiac dysfunction or outcomes to establish the subgroups. This was a retrospective cohort study of patients admitted to the hospital with sepsis at a single academic center. Patients were identified using sepsis-related ICD codes, and those who had echocardiogram performed within 14days of admission underwent chart review to ensure sepsis-3 criteria were met. Those with preexisting heart disease were excluded. Clustering by echocardiographic variables was performed using latent profile analysis. Clinical features such as patient characteristics, laboratory studies, sepsis source, and outcomes were compared across the clusters. There were 2,071 patients included in the analysis. Our cluster analysis yielded five phenotypes: cluster 1, elevated mean E/e' 24.5 (SD 9.6); cluster 2, reduced ejection fraction, mean 33.1% (SD 10.6), and cardiac index 2.6 L/min/m2 (SD 0.9); cluster 3, right ventricular dilation with right ventricular basal diameter 4.5cm (SD 0.9) and elevated tricuspid regurgitation gradient 60.0mmHg (SD 13.5); cluster 4, hyperdynamic with mean left ventricular ejection fraction 75% (SD10.9) and mean cardiac index 6.6 L/min/m2 (SD 2.6); and lastly cluster 5, normal echocardiographic parameters. Group 3 had the highest mortality compared to the normal group (36.9% vs. 19.6%, p = 0.002), with an odds ratio of 2.3 (95%CI 1.4-3.9). Using an unsupervised clustering analysis, we identified five phenotypes of cardiac function in sepsis based on commonly recorded echocardiographic data: diastolic dysfunction, left ventricular systolic dysfunction with low cardiac index, right ventricular dilation with elevated tricuspid regurgitation gradient, hyperdynamic cardiac function, and normal. The right ventricular dilation group had the highest mortality. Future research should explore mechanisms and potential treatment implications for these groups.

Resistant hypertension is associated with adverse cardiovascular outcomes and mortality. In the past decade, management guidelines have shifted to target lower blood pressures (BP). Current prevalence and prescribing patterns among adults with resistant hypertension are not well characterized. We used data from the National Health and Nutrition Examination Survey from 2003 to 2020. Apparent treatment-resistant hypertension (aTRH) was defined as patients on a diuretic, either with a systolic BP ≥130 or diastolic BP ≥80 mm Hg while on 3 medications or those on ≥4 medications regardless of BP. Medications were identified through pill bottle review. Of 24 579 adults with hypertension, 1939 had aTRH (42.4% male, 19.9% Black), corresponding to a weighted total of 6 989 821 US patients. Among hypertensive adults, the prevalence of aTRH was 6.41% (95% CI, 5.97%-6.88%) and remained stable over time. Over the study duration, aTRH prevalence among adults on treatment decreased from 17.7% to 12.6%. The overall prevalence of hypertension rose from 50.1% to 54.0%, while the prevalence of uncontrolled BP decreased from 75.0% to 68.7%. Over time, use of 3 drug regimens for aTRH decreased (57.8%-42.9%), while 4 drug regimens increased (34.0%-51.8%). aTRH was most strongly associated with older patients, those of Black race, higher body mass index, and more advanced cardiovascular comorbidities. The prevalence of aTRH has remained stable over the past 2 decades despite the rising incidence of hypertension. Use of multidrug treatment regimens has increased, aligning with national guidelines. However, uncontrolled hypertension remains high.

Despite improving abdominal aortic aneurysm (AAA) outcomes in the United States, significant disparities exist. Smaller studies found that women experienced worse outcomes after endovascular aortic aneurysm repair (EVAR), yet few larger analyses have confirmed this. This study aimed to characterize sex-related differences in outcomes among patients who underwent infrarenal EVAR. Medicare fee-for-service beneficiaries ⩾ 66 years old who underwent infrarenal EVAR for intact AAA between January 1, 2011 and December 31, 2019 were included in this retrospective cohort study. The primary outcome was a composite of late aneurysm rupture, aortic reintervention, conversion to open repair, or all-cause mortality. Cox regression and Fine-Gray models were used. Among 111,381 patients, the mean age was 76.63 ± 6.60 years, 92.88% were White, and 21.19% were women. The maximum follow-up was 3283 days. The hazard of the primary outcome was higher in women in the adjusted model (p = 0.013). When mortality was excluded, the association with sex persisted (p < 0.0010 [adjusted subdistribution model]; p < 0.0010 [adjusted cause-specific model]). Women experienced a lower frequency of postprocedural office visits, but a higher frequency of emergency department visits and hospital readmissions. Women undergoing EVAR had a greater risk of adverse outcomes and unexpected healthcare utilization. Further investigation is warranted to determine the drivers of these outcomes.

Retatrutide and survodutide exhibit the most favourable efficacy profiles for obesity and T2DM, with acceptable safety. These findings support their potential clinical use and highlight the need for future head-to-head trials.

To examine the determinants of unmet transcatheter aortic valve replacement (TAVR) needs and their impact on patient survival among Medicare beneficiaries with aortic stenosis. We developed a county-level mismatch score measuring the gap between actual TAVR procedures performed and expected need based on population differences. Counties were classified as metropolitan, semiurban, or rural. Factors associated with larger mismatches were identified, and mortality rates among aortic stenosis (AS) patients were examined in relation to mismatch scores. We analyzed Medicare data from 2016 to 2022 across 3129 US counties. The mismatch score was developed to account for population differences and county urbanicity classification. Statistical analyses identified factors associated with TAVR mismatch and its relationship to mortality outcomes. We found substantial geographic variation in TAVR delivery. Counties with higher TAVR mismatch scores showed associations with fewer TAVR-providing hospitals, less market concentration, higher AS prevalence, and lower household incomes. Counties with greater gaps between needed and actual TAVR procedures were also associated with higher mortality rates. This relationship between mismatch and mortality was particularly strong in semiurban counties. Our findings identify associations between TAVR access gaps and patient outcomes, as well as factors linked to these access patterns. Counties with higher TAVR mismatch scores showed correlations with healthcare capacity constraints, geographic location, and socioeconomic factors. These associations suggest that mismatches may be addressed through targeted approaches based on local needs to improve care delivery for patients with AS in regions currently experiencing access challenges.

Purpose There are currently no standardized medical protocols for mass gathering events. This study sought to close that gap by creating a disaster preparedness program for the Boston Marathon, including bleeding control training and bleeding control kits for all medical tents. Design/methodology/approach All medical volunteers at the Boston Marathon are encouraged to complete online training prior to the race. Medical volunteers for the 2025 Boston Marathon completed a pre- and post-video trauma first aid training knowledge test. Medical volunteers were also graded on two simulation scenarios. Descriptive statistics, the Wilcoxon signed rank and McNemar's tests were performed. Findings Of the 1800 medical volunteers, 879 chose to complete the DLP training. Of those, 56 (6.4%) participated in the video-training study, but only 32 completed both the pre- and post-video surveys. After watching the video, overall knowledge scores increased from 8 (IQR 6, 9) to 10 (IQR 9, 10) (p-value <0.001). Of the 23 who participated in the simulation, 11 (48%) had completed the DLP trauma training video. Those who watched the training video scored better on the tourniquet (p = 0.035) and direct pressure simulation (p = 0.18). Originality/value Implementation of trauma first aid training and bleeding control kits to events such as the Boston Marathon is not only feasible but also increases the disaster preparedness confidence and knowledge of medical volunteers. This type of disaster preparedness in event medicine is crucial in mitigating future terrorist attacks at mass gatherings.

Emergency department (ED) crowding, constrained inpatient capacity, and long waits for outpatient cardiology delay care for patients with urgent cardiac symptoms. In 2016, the Beth Israel Deaconess Medical Center opened a non–ED-based, cardiologist-staffed Cardiac Direct Access Clinic with examination rooms, an infusion room, and six overnight observation beds to provide rapid specialty evaluation and short-stay care. Using administrative data and contribution-margin analyses, the authors assessed operational, clinical, and financial outcomes and summarized implementation strategies. Of 11,121 total patients seen in the clinic, 4239 patients — those most likely to have otherwise been sent to the ED — were admitted on the same day of referral. Of those patients, 59% were discharged home, 39% were managed in the Cardiac Direct Access Clinic’s overnight unit, and 7% ultimately were admitted to inpatient floors. Among 1467 patients discharged from the overnight unit, the 30-day return rate to the ED was 6.4%. Overall patient experience scores were higher for the clinic than for the ED — 84.7 versus 56.9. Annual labor and supply costs for the clinic totaled approximately US$1.8 million. The contribution margin derived from the clinic’s operations (US$245,000), admissions originating from the clinic (US$303,000), and inpatient capacity created (US$1.34 million) produced an estimated US$2.4 million annual contribution margin, underscoring financial sustainability. Key enablers included centralized prior-authorization teams, state approval to operate as an alternative care space for inpatient-level services, and codified diversion pathways for the ED and urgent care.