Minneapolis VA Medical Center

Article Title: Global Consensus Statement on the Management of Pregnancy in Inflammatory Bowel Disease.

Background/Objectives: In populations with type 2 diabetes mellitus (T2DM), it is unknown whether the survival benefits of glucagon-like peptide-1 receptor agonists (GLP-1 RA) differ by estimated glomerular filtration rate (eGFR). To address this question and in the absence of definitive randomized controlled trials, we performed a retrospective observational study of US Veterans with T2DM to evaluate mortality hazard ratios associated with GLP-1 RA use at different eGFR levels. Methods: This administrative claims-based cohort included 1,188,052 U.S. Veterans with T2DM as of 1 January 2020. Initiation of GLP-1 RA was treated as a time-dependent variable and vital status of Veterans was followed until 31 December 2023. Results: A total of 31,676 Veterans met inclusion criteria. Over the study timeframe, 6.1% initiated treatment with GLP-1 RA and 57.7% died. Older age and eGFR < 15 mL/min/1.73 m2 were associated with a decreased likelihood of GLP-1 RA initiation. In contrast, younger age and lower comorbidity burden were associated with decreased mortality, a finding that persisted even after adjustment for several baseline covariates. Conclusions: Among those with T2DM and eGFR < 25 mL/min/1.73 m2, initiation of GLP-1 RA was associated with improved survival. This association remained significant with decreasing levels of kidney function, as well as among those receiving kidney replacement therapy (KRT). In conclusion, longer survival was observed both in participants on KRT and in those with eGFR 15–24 mL/min/1.73 m2 not on KRT, but these findings were not observed among those with eGFR ≤ 15 mL/min/1.73 m2.

Abstract Ageism is global and prevalent in healthcare. Previous studies have shown that ChatGPT generated gender and racial biased outputs. This study aimed to explore ChatGPT4.o geriatric attitude using validated UCLA geriatric attitude instrument and to compare it with health trainees and providers and to examine whether hospital social workers agree or disagree with ChatGPT 4.o responses to geriatric attitude statements. Six of 16 statements reflected positive geriatric attitudes, such as “Most old people are pleasant to be with”. Ten statements reflected negative geriatric attitudes, such as “Treatment of chronically ill old patients is hopeless”. ChatGPT4.o responses and social workers’ evaluation of ChatGPT4.o responses were graded on a Likert scale of 1-5 (1=strongly disagree, 5 =strongly agree). Positive and negative geriatric attitudes scores were calculated to compare them to the medical students, ED residents, and neurologists from the previously published studies. The positive geriatric attitude score by ChatGPT4.o was 4.2 and higher than humans (higher scores indicated a more positive geriatric attitude), which was agreed by 40 social workers as 4.1 on a Likert scale of 1-5. The negative geriatric attitude score by ChatGPT4.o was 1.8 and lower than humans (lower scores indicated a less biased aging attitude), which was slightly agreed by 40 social workers as 3.2 on a scale of 1-5. In conclusion, ChatGPT4.o had a better geriatric attitude than humans, which is consistent with our previous findings using ChatGPT3.5. Social workers had modest agreement with ChatGPT4.o geriatric attitude. It suggests ChatGPT4.o is less likely to generate age-biased outputs.

Abstract Motivational interviewing (MI) is a well-established strategy for promoting behavior change, but it has been understudied for older adults with complex health conditions. As part of a holistic patient-centered approach to the care of older patients with multi-complexity, such as those served by home-based primary care (HBPC), use of MI could be instrumental in identifying patients’ priorities, strengthening interdisciplinary care, and engaging patients in managing their own healthcare decisions. A multi-pronged approach to training a home-based primary care team in using MI was undertaken to train HBPC providers in practicing MI regularly during patient care. A gamification teaching strategy was utilized to train 24 members of an interprofessional HBPC in use of MI skills. A 90-minute workshop was comprised of a 30-minute didactic and a 60-minute skills-focused game, led by three MI experts within the team. Participants were asked to complete brief pre- and post-session knowledge checks. The number of participants correctly identifying the stages of behavior change and MI microskills increased from 54% and 75% respectively before the training, to 100% on both concepts after the session. Qualitative feedback was obtained from a focus group conducted with team members after the training highlighted collaboration and feeling valued as positive impacts of using MI. Sustainability efforts following the training included having time during team meetings to share of stories about using MI with patients and building in in-home coaching sessions by MI experts within the team to demonstrate MI skills with patients and help coach staff who requested additional learning.

The ideal resection strategy for rectal neoplasms extending to the dentate line (RNDLs) remains unclear. Transanal surgical approaches and endoscopic mucosal resection (EMR) have their limitations related to inadequate visualization, device maneuverability, and securing an adequate margin on the anal side. Endoscopic submucosal dissection (ESD) appears to overcome some of the limitations of transanal surgical and snare-based endoscopic techniques. Therefore, we evaluated the safety and efficacy of ESD for resection of distal rectal lesions within 2cm of the dentate line. This is a large-scale multicenter retrospective study of patients who underwent ESD for RNDLs between 2015 and 2023. The primary outcomes were the rates of R0 and en bloc resection. Secondary outcomes were immediate and delayed adverse events. A total of 255 patients across 20 institutions were included (mean age 63.60, women 52.20%). The median lesion size was 40mm (IQR: 30 to 55), and the median resection time was 110 minutes (IQR: 81 to 169). The en bloc resection rate was 93.70% (n=236), and the rate of R0 resection was 85.40% (n=216). The rate of overall adverse events was 8.70% (n=22, 95% CI: 5.22% to 12.17%), with 13 cases of bleeding (5.10%), 4 cases of full-thickness perforation, and 1 case of postprocedural pain requiring intervention. All AEs were managed conservatively without the need for subsequent surgical or endoscopic interventions. ESD is safe and effective for resecting RNDLs with high en bloc and R0 resection rates, offering the potential for complete resection with minimal morbidity. It offers advantages over TEN, TAMIS, and other forms of transanal surgery due to the anatomy being less conducive to the equipment required for these techniques, lower cost, and lower rates of complications. However, careful patient selection, meticulous procedural planning, and close follow-up are essential to ensure optimal outcomes and minimize the risk of complications. Long-term follow-up studies and additional prospective controlled trials are warranted.

We describe the case of a young 42-year-old female who suffered from cyclical right upper quadrant abdominal pain that led to an emergency department visit where an intrahepatic mass was found on imaging. Initial CT-guided biopsy led to the diagnosis of hepatic epithelioid hemangioendothelioma, and the patient was referred to a liver transplant center. She underwent hepatic segmentectomy with right nephrectomy and surgical pathology came to the correct diagnosis of hepatic endometriosis.