Queen's Medical Center

ABSTRACT Cognition is an animal's real‐time adaptation system for responding to change. Rapid environmental change, often anthropogenic, is expanding the range and severity of challenges confronting wild animals. Effective conservation requires a multifaceted approach that includes animals' capacities. Large‐brained, long‐lived animals such as marine mammals often have extensive capability to adaptively modify their behavior due to their cognition, which comprises the mechanisms of information acquisition, processing, and flexible action. Consequently, current behavior need not be a final predictor of future behavior for these animals. This flexibility provides an underutilized and under examined point of leverage for humans interested in improving life outcomes for wild animals. In this team‐written, interdisciplinary paper, we argue that application of cognitive approaches may facilitate many conservation efforts directed toward marine mammals. Starting with a workshop on this topic at the 24th Biennial Conference on the Biology of Marine Mammals, scientists representing a wide range of disciplinary expertise addressed eight different conservation concerns for six marine mammal species and provided potential cognitive explanations of and interventions aimed at related behavior. Our treatment highlights the value of integrated laboratory and field research, and the importance of tight lines of communication between scientists and conservation managers.

BackgroundAs large language models (LLMs) become increasingly accessible to the public, patients are turning to these tools for medical guidance - including in highly specialized fields like interventional neuroradiology. Despite their growing use, the safety, completeness, and reliability of LLM-generated information in subspecialty medicine remain unclear.MethodsFive publicly available LLMs - ChatGPT, Gemini, Claude, Perplexity, and DeepSeek - were prompted with four neurointerventional patient-facing clinical questions spanning ischemic stroke, hemorrhagic stroke, venous disorders, and procedural device use. Each model was queried three times per question to generate unique responses. Eight blinded raters scored each response on accuracy, completeness, safety, and actionability using Likert scales. Plagiarism analyses were also performed.ResultsDeepSeek consistently outperformed other LLMs in accuracy, completeness, and actionability across four prompts, while Gemini frequently ranked worse, including in plagiarism levels. ChatGPT performed well in accuracy. Physicians were more critical than non-physicians across accuracy, completeness, and safety, whereas non-physicians rated actionability significantly lower. Overall, LLMs were rated relatively high (median of >4 on a 5-point scale) in medical safety, suggesting low risk of overtly harmful advice.ConclusionRecent-generation LLMs offer medically safe, though often incomplete or imprecise, information in response to patient-oriented neurointerventional queries. Including non-physician raters revealed valuable differences in perception that are relevant to how patients may interpret LLM outputs. As benchmark frameworks like HealthBench improve LLM evaluation, inclusion of lay perspectives and subspecialty contexts remains essential. Responsible use by clinicians and ongoing patient education will be critical as LLM use in healthcare expands.

Abdominal aortic aneurysm (AAA) rupture remains a significant cause of morbidity and mortality, but predictors of continued growth and rupture risk remain limited. The aim of this study was to investigate the relationship between abdominal aortic calcification and AAA growth via a secondary cohort analysis of the Non-Invasive Treatment of Abdominal Aortic Aneurysm Clinical Trial (N-TA3CT), a prospective multicenter randomized study. Arterial calcification Agatston scores and maximum transverse diameter were measured in non-contrast computed tomography (CT) scans in patients enrolled in N-TA3CT. Uni- and multi-variable linear regression were used to assess the association of anatomic calcium burden and comorbid conditions with rate of aneurysm growth. Of the 261 randomized patients in the trial, 136 patients met inclusion criteria for analysis. On univariable analysis, baseline calcium score at all assessed anatomic locations- the superior mesenteric artery (spearman correlation coefficient (SCC) -0.20, p = 0.0176), renal artery (-0.22, p = 0.0120, infrarenal aorta (-0.26, p = 0.0020), common iliac artery (-0.19, p = 0.024), external iliac artery (-0.26, p = 0.003), and sum of all measured sites (-0.28, p = 0.001)- was significantly associated with lower AAA diameter growth rates. Of individually measured sites, baseline infrarenal aortic calcification had the strongest negative association with aneurysm growth. Interestingly, infrarenal calcium score was not significantly associated with baseline aneurysm diameter (R2 0.0001, spearman correlation p = 0.94), or diabetes status (p = 0.59). In a multivariable regression model, factors significantly associated with faster diameter growth included baseline volume and current tobacco use. Factors associated with reduced growth rate included diabetes and baseline infrarenal aorta calcium score thereby establishing aneurysmal calcification as a marker for slower aneurysm growth.

Introduction: Transcatheter percutaneous aortic valve replacement (TAVR) was FDA-approved as an alternative to surgical aortic valve replacement (SAVR) in high (2012), intermediate (2016) and low-risk (2019) pts with aortic stenosis (AS). We assessed the impact of TAVR on SAVR in a marjority-minority population in Hawaii. Methods: We used data from The Queen’s Medical Center STS/ACC TVT and STS Adult Cardiac Surgery registries to identify all pts who underwent TAVR or isolated SAVR from 2012-23. We compared demographics, comorbidities, pre-op risk of mortality (ROM) score, procedural data and in-hospital outcomes. We used SPSS for descriptive analyses and parametric and non-parametric tests as appropriate. Results: From 2012-23, 1,732 pts had aortic valve replacement (AVR): 489 (28.2%) isolated SAVR and 1,243 (71.8%) TAVR. Whites, Asians, and Native Hawaiians underwent 38.1%, 47.6%, and 11.3% of procedures respectively. Total volume decreased during COVID-19 pandemic (2020-2023), with TAVR also negatively impacted in 2018-19 by changes in staffing. From 2012-23, each additional year was associated with a 21.0% increase in the odds of receiving TAVR vs. SAVR (OR 1.2, p < 0.001) - a corresponding 17.4% annual decrease in the odds of undergoing SAVR. The odds of receiving TAVR were 2.3 times higher during 2020-23 than before (p < 0.001). SAVR ROM significantly decreased with time (r = -0.170, p< 0.001). SAVR pts were younger (64.3 ± 12.5 vs. 79.1 ± 9.8 yrs, p < .001) with lower ROM (2.2 ± 3.2 vs 5.4 ± 4.2, p < .001) and more urgent procedures (14.7% vs 3.6%, p < 0.001). Conversely, TAVR pts were more often women (39.3% vs 28.8%, p < .001), with more diabetes (40.4% vs 31.3%, p < 0.001), prior MI (19.2% vs 9.4%, p < 0.001), and Medicaid/Medicare (84.8% vs 57.3%, p < 0.001). In-hospital mortality was significantly lower in TAVR vs SAVR (1.6% vs 3.3%, p = 0.02). Overall, the total number of AVRs increased 30.9% between 2013-14 (116.5 procedures/yr) and 2022-23 (152.5 procedures/yr). Among pts <65y, TAVR increased from 2013-14 to 2022-23 (9.1% vs. 42.6%) and SAVR decreased (90.9% vs.57.4%). Conclusion: With expanding indications for TAVR to include low-risk pts, annual TAVR volume has started to rebound following the COVID-19 pandemic. Despite fewer SAVRs, the annual number of all AVRs has substantially increased over the past decade, suggesting that TAVR has expanded access to AVRs to a broader range of pts.

Topiramate is a widely prescribed medication for epilepsy, migraine prophylaxis, and weight management, but it can rarely cause acute bilateral angle closure with myopic shift. We describe a healthy 35-year-old woman who developed sudden bilateral painful red eyes, blurred vision, and a myopic shift within one week of initiating topiramate. Examination revealed shallow anterior chambers, elevated intraocular pressure, and iridocorneal touch bilaterally.Prompt discontinuation of topiramate led to full resolution. Laser peripheral iridotomies (LPIs) were performed while the etiology was uncertain, and are not typically required in medication-induced effusion-related angle closure. This case underscores that cycloplegia and drug cessation are the key interventions, while LPI may be performed only when the underlying mechanism is unclear.This case highlights the importance of recognizing medication-induced angle closure and distinguishing it from primary pupillary-block mechanisms to ensure timely, vision-saving management.

Squamous cell carcinoma in situ (SCCIS), also known as Bowen's disease, is a precancerous intradermal lesion that commonly arises in sun-exposed areas. Other risk factors include radiation, inflammation, carcinogen exposure, and human papilloma virus exposure. Its presentation on the nipple-areolar complex is extremely rare with 14 cases reported in literature. We report a case of a postmenopausal woman with remote history of breast cancer and DCIS treated with bilateral breast conserving surgery followed by adjuvant radiation. She developed SCCIS of the right nipple nearly 30 years later. Associated symptoms included bloody nipple discharge, nipple rash, and nipple pruritus for 1.5 years. A punch biopsy of the right nipple lesion identified epithelioid cells in the intradermal space staining CK7 (+) and p40 (+)/p63 (+), classifying the lesion as Paget's disease. The patient elected to proceed with bilateral mastectomies without reconstruction. Final surgical pathology revealed radiation induced atypia and atypical keratinocytes that focally extend throughout the full epidermal thickness. Immunohistochemical staining demonstrated CK7 (-), CK5/6 (+), p40 (+), HER2 (-) and GCDFP15 (-) consistent with the diagnosis of SCCIS. Paget's disease of the nipple and SCCIS may present with similar clinical and histopathologic features; however, they are managed differently. Nipple lesions in the setting of prior radiation should raise concern for SCCIS. Clinicians should be aware of this rare, but potential sequelae in patients with a history of breast cancer treated with breast conserving therapy and nipple complaints.

To evaluate the relationship between the duration of pre-extracorporeal membrane oxygenation (ECMO) mechanical ventilation and mortality in acute respiratory distress syndrome (ARDS) patients undergoing venovenous ECMO. Retrospective cross-sectional study using the National Inpatient Sample database. National Inpatient Sample database from January 2019 to December 2022. Inclusion criteria were: 1) adults (age ≥ 18 yr old) who received venovenous ECMO and 2) ARDS diagnosis. Exclusion criteria were: 1) receipt of venovenous ECMO before intubation, 2) receipt of lung transplant, and 3) missing data for regression analysis variables. None. Survey-weighted multivariable logistic regression to assess the association between in-hospital mortality and time from mechanical ventilation to venovenous ECMO initiation was performed. A national estimate of 9090 patients were identified. The duration of pre-ECMO mechanical ventilation was not significantly associated with in-hospital mortality (odds ratio [OR], 1.02; 95% CI, 0.98-1.06; p = 0.367). Late initiation of venovenous ECMO (pre-ECMO mechanical ventilation > 7 d) was not associated with an increased risk of in-hospital mortality (OR, 1.18; 95% CI, 0.91-1.54; p = 0.216). Our study suggests that pre-ECMO mechanical ventilation duration does not independently predict mortality in patients with ARDS. This challenges the conventional belief that ECMO must be initiated within 7 days and supports a more individualized approach to ECMO candidacy.