2 Minute Medicine Rewind October 9, 2023
1. This randomized clinical trial demonstrated that multigenetic pharmacogenomics-guided treatment (MPGT) had higher response and remission rates in the treatment of schizophrenia compared with treatment as usual (TAU).
Evidence Rating Level: 1 (Excellent)
Schizophrenia—a condition characterized by disruptions in various mental modalities—affects approximately 24 million people globally and imposes a significant disease burden. First-line treatment with antipsychotics is effective for only 20-50% of patients, often leading to a trial-and-error approach to finding an effective treatment. This randomized clinical trial aims to evaluate the efficacy of MPGT in hospitalized men with schizophrenia compared with TAU. 210 male inpatients in Guiyang, China with a diagnosis of schizophrenia were enrolled and randomized in a 1:1 ratio, with both participants and raters masked to the allocation. 113 patients received MPGT, medication regimens tailored to their genetic profiles, and 97 received TAU. MPGT was associated with a significantly greater reduction in the Positive and Negative Syndrome Scale (PANSS) score than TAU at week 12 (83.5% vs 76.1%; P = .001). The response rates, defined as a 20% or greater reduction in PANSS scores, at the end of week 6 were significantly higher in the MPGT group compared to the TAU group (adjusted odds ratio, 2.48; 95% CI, 1.28-4.80; P = .01). Symptomatic remission rates, defined as a PANSS total score of 70 or less, were also higher in the MPGT group (adjusted odds ratio, 2.03; 95% CI, 1.11-3.60; P = .02). While this study is limited by the inclusion of only male Chinese Han patients, these findings suggest that MPGT proved superior to TAU in treating schizophrenia patients, indicating that multigenetic pharmacogenomic testing could be a valuable tool for guiding schizophrenia treatment.
Generative Artificial Intelligence for Chest Radiograph Interpretation in the Emergency Department
1. Generative artificial intelligence (AI) and radiologist reports received comparable ratings of clinical accuracy and report quality, that were significantly greater than teleradiology report ratings.
Evidence Rating Level: 1 (Excellent)
Timely diagnostic imaging interpretation in the ED is crucial for patient care. Immediate radiologist interpretation minimizes errors, but some EDs lack consistent radiology services. Generative AI methods may bridge this gap by offering near-instant, fatigue-free interpretations of medical imaging. This study aimed to develop a generative AI tool for chest radiograph interpretation and evaluate its performance in the ED. The study data set comprised 500 randomly sampled chest radiographs of patients (mean [SD] age 53.3 [21.6] years, 56.4% female, 32.8% abnormal radiographs) evaluated in an ED. Radiologist, teleradiologist, and AI-generated reports for each radiograph were deidentified and rated on a Likert scale by 6 practicing board-certified emergency medicine physicians for report quality and clinical accuracy. AI and radiologist reports received significantly higher ratings than teleradiology (AI: mean [SE] 3.22 [0.34], P < .001; radiologist: 3.34 [0.34], P < .001; teleradiology: 2.74 [0.34]). AI and radiologist report ratings were not significantly different. There was no significant difference in the probability that each report type would generate a non-clinically discrepant report for normal and abnormal studies, even after stratifying by the presence of cardiomegaly, pulmonary edema, pleural effusion, infiltrate, pneumothorax, and support devices. When using radiologist reports as the standard, the sensitivity and specificity of AI reports for detecting any abnormality were 84.8% and 98.5%, respectively, and 91.5% and 97.0% for teleradiology reports. Overall, these findings suggest that the generative AI model produced reports similar in performance to a radiologist and better than a teleradiology service in a representative sample of ED chest radiographs.
1. The fracture reduction quality, functional outcomes, and overall patient satisfaction were comparable between patients in the wide-awake local anesthesia with no tourniquet (WALANT) and balanced anesthesia (BA) groups
Evidence Rating Level: 2 (Good)
DRF is a common injury that can require surgical intervention. As elderly patients with comorbidities increasingly opt for surgery to achieve quicker recovery and preserved functionality after injury, more suitable anesthetic options are being explored. WALANT offers various benefits including, cost-effectiveness, improved patient satisfaction, and reduced risks associated with systemic anesthesia. BA, involving multimodal pain management, has gained popularity and lowered the need for gas anesthetics and opioids. This retrospective cohort study aimed to investigate patient characteristics, surgical outcomes, intraoperative pain, anxiety, and satisfaction in patients (n=93) with DRF undergoing plating surgery via BA (n=55) or WALANT (n=38) techniques. In the WALANT group, patients were older (mean age [SD] 63.0 [16.5] vs. 54.4 [16/7], P=0.007) and had fewer intraarticular fractures (p=0.009) compared to the BA group. Surgical time was shorter in the WALANT group (MD, − 19.8 [ − 33.8 to − 5.9]; P < 0.01). Postoperative radiographs indicated similar reduction and plating quality in both groups. 3- and 6-month pronation was worse in the WALANT group (P=0.05; P=0.03), while 12-month flexion was better (P=0.02). Other outcomes, including remaining wrist and forearm range of motion, grip strength, QuickDASH scores, and patient satisfaction, showed no significant differences. These findings demonstrate that the WALANT and BA groups had comparable reduction quality, functional outcomes, and overall satisfaction, suggesting that the WALANT technique could serve as an alternative for DRF plating surgery in specific patient cases.
1. There was a steady increase in daily step counts, improvement in health-related quality of life scores, and a decrease in fatigue scores in the postpartum period.
2. There was no significant difference in daily step counts between women who used neuraxial labor analgesia and those who did not.
Evidence Rating Level: 1 (Excellent)
Early mobilization plays a vital role in enhanced recovery after surgery (ERAS), reducing thromboembolism and complications while improving physical recovery and pain relief. These benefits extend to postpartum patients, aiding in their physical and psychological recovery while caring for newborns. This study aims to evaluate postpartum recovery, utilizing activity trackers, questionnaires, and diaries, with a focus on identifying factors influencing recovery and the impact of neuraxial labor analgesia. 300 women anticipating a vaginal delivery were enrolled in the study, with 95 having a vaginal delivery without neuraxial analgesia (NCB group), and 116 opting for neuraxial labor analgesia (EPL group). At the 1-month postpartum visit, the EPL group reported slightly higher pain scores (median [interquartile range] 1 [0,6] versus 3 [0,12.5]; P=0.01), but demonstrated no other significant differences in pain scores at other time points. Both groups showed consistent increases in adjusted daily step counts, with no significant differences. Receiving neuraxial labor analgesia was not associated with increased or decreased odds of achieving adequate ambulation, defined as >3500 steps between 48 and 72 hours postpartum. Health-related quality of life scores, as measured by the validated EuroQol 5 Dimension 5 Level questionnaire (EQ-5D-5L), were lowest on postpartum day 1, gradually returning to pre-pregnancy levels by one month postpartum. Multidimensional Fatigue Inventory (MFI) scores increased during hospitalization compared to the antenatal period but improved by one month postpartum. Overall, these findings suggest epidural analgesia did not lead to poorer postpartum recovery outcomes.
1. Patients with centrally located breast cancer (CLBC) had higher breast cancer-specific survival (BCSS) and overall survival (OS) rates.
2. There was no significant difference in BCSS and OS between CLBC and non-CLBC patients who underwent BCS.
Evidence Rating Level: 2 (Good)
CLBC refers to breast cancer localized in the nipple, areola, or central region of the breast. While breast-conserving treatment is the standard of care for early-stage breast cancer, literature on its efficacy and safety in CLBC patients is lacking. In this large retrospective cohort study, data from 210,409 patients (median age [interquartile range]: 56 [48-63] years) with stage T1-2 non-metastatic breast cancer as their first malignancy was extracted from the US Surveillance, Epidemiology, and End Results (SEER) database, to evaluate the overall and cancer-specific survival between BCS and mastectomy in CLBC patients, and between CLBC and non-CLBC patients treated with BCT. Among these patients, 7.14% were diagnosed with CLBC, while 92.86% had non-CLBC. CLBC patients with less aggressive characteristics (lower histological grade, smaller tumor size, none or limited lymph node metastasis, or positive ER or PR status) often underwent BCS. Over a median follow-up of 91 months, 11.73% of patients died, with 6.10% being due to breast cancer. Multivariable analysis showed better BCSS (HR = 0.67, 95%CI: 0.55–0.80, p < 0.001) and OS (HR = 0.78, 95%CI: 0.68–0.90, P=0.001) in patients who received BCS compared to those who received mastectomy. These results remained consistent after propensity score matching, although the improved OS was non-significant (HR = 0.82, 95%CI: 0.65–1.04, P=0.110). BCSS and OS were comparable between CLBC and non-CLBC patients opting for BCS. Overall, these findings support BCS as a preferable alternative to mastectomy for early-stage CLBC patients.
Image: PD
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