ChatGPT4's Proficiency in Addressing Patients' Questions on Systemic Lupus Erythematosus: A Blinded Comparative Study with Specialists.

OBJECTIVES: The efficacy of artificial intelligence (AI)-driven chatbots like ChatGPT4 in specialized medical consultations, particularly in rheumatology, remains underexplored. This study compares the proficiency of ChatGPT4' responses with practicing rheumatologists to inquiries from patients with systemic lupus erythematosus (SLE). METHODS: In this cross-sectional study, we curated 95 frequently asked questions (FAQs), including 55 in Chinese and 40 in English. Responses for FAQs from ChatGPT4 and 5 rheumatologists were scored separately by a panel of rheumatologists and a group of patients with SLE across 6 domains (scientific validity, logical consistency, comprehensibility, completeness, satisfaction level, and empathy) on a 0-10 scale (a score of 0 indicates entirely incorrect responses, while 10 indicates accurate and comprehensive answers). RESULTS: Rheumatologists' scoring revealed that ChatGPT4-generated responses outperformed those from rheumatologists in satisfaction level and empathy, with mean differences of 0.537 (95% CI, 0.252-0.823; p < 0.01) and 0.460 (95% CI, 0.227-0.693 p < 0.01), respectively. From the SLE patients' perspective, ChatGPT4-generated responses were comparable to the rheumatologist-provided answers in all 6 domains. Subgroup analysis revealed ChatGPT4 responses were more logically consistent and complete regardless of language, and exhibited greater comprehensibility, satisfaction, and empathy in Chinese. However, ChatGPT4 responses were inferior in comprehensibility for English FAQs. CONCLUSION: ChatGPT4 demonstrated comparable, possibly better in certain domains, to address FAQs from patients with SLE, when compared with the answers provided by specialists. This study showed the potential of applying ChatGPT4 to improve consultation in SLE patients.

Federated Learning of Electronic Health Records Improves Mortality Prediction in Patients Hospitalized with COVID-19

Machine learning (ML) models require large datasets which may be siloed across different healthcare institutions. Using federated learning, a ML technique that avoids locally aggregating raw clinical data across multiple institutions, we predict mortality within seven days in hospitalized COVID-19 patients. Patient data was collected from Electronic Health Records (EHRs) from five hospitals within the Mount Sinai Health System (MSHS). Logistic Regression with L1 regularization (LASSO) and Multilayer Perceptron (MLP) models were trained using local data at each site, a pooled model with combined data from all five sites, and a federated model that only shared parameters with a central aggregator. Both the federated LASSO and federated MLP models performed better than their local model counterparts at four hospitals. The federated MLP model also outperformed the federated LASSO model at all hospitals. Federated learning shows promise in COVID-19 EHR data to develop robust predictive models without compromising patient privacy.

Liver Specification in the Absence of Cardiac Differentiation Revealed by Differential Sensitivity to Wnt/ß Catenin Pathway Activation.

Embryonic precursors of liver and heart, whilst not sharing cellular origin, develop in close proximity through a dynamic series of inductive signaling events. During gastrulation anterior endoderm (AE) provides cardiogenic signals that act on adjacent mesoderm, resulting in induction of cardiac precursors. Subsequently cardiogenic mesoderm generates a FGF signal that acts on adjacent AE to induce foregut organ specification. Additional signals such as BMP and Wnt provide further information required for liver specification. Most findings on liver specification were derived from mouse explant studies as well as experiments with Xenopus and zebrafish embryos. To address some of the limitations of these models, here we used two complementary ex vivo models based on Xenopus embryos: pluripotent animal cap explants expressing Gata4 transcription factor and conjugates of gastrula-stage AE with animal caps (AC). We show that in these models liver specification is not sensitive to Wnt signaling manipulation, in contrast to the requirement for Wnt antagonism shown in vivo. FGF pathway is not necessary for Gata4-induced liver specification in animal cap explants but is required for prolonged period in sandwiches of AE and AC. In contrast, BMP signaling is shown to be essential for Gata4-induced liver specification. Our findings may have implications for research on liver differentiation from embryonic stem cells.

A functional connectome: regulation of Wnt/TCF-dependent transcription by pairs of pathway activators.

BACKGROUND: Wnt/ß-catenin signaling is often portrayed as a simple pathway that is initiated by Wnt ligand at the cell surface leading, via linear series of interactions between 'core pathway' members, to the induction of nuclear transcription from genes flanked by ß-catenin/TCF transcription factor binding sites. Wnt/ß-catenin signaling is also regulated by a much larger set of 'non-core regulators'. However the relationship between 'non-core regulators' is currently not well understood. Aberrant activation of the pathway has been shown to drive tumorgenesis in a number of different tissues. METHODS: Mammalian cells engineered to have a partially-active level of Wnt/ß-catenin signaling were screened by transfection for proteins that up or down-regulated a mid-level of TCF-dependent transcription induced by transient expression of an activated LRP6 Wnt co-receptor (∆NLRP). RESULTS: 141 novel regulators of TCF-dependent transcription were identified. Surprisingly, when tested without ∆NLRP activation, most up-regulators failed to alter TCF-dependent transcription. However, when expressed in pairs, 27 % (466/1170) functionally interacted to alter levels of TCF-dependent transcription. When proteins were displayed as nodes connected by their ability to co-operate in the regulation of TCF-dependent transcription, a network of functional interactions was revealed. In this network, 'core pathway' components (Eg. ß-catenin, GSK-3, Dsh) were found to be the most highly connected nodes. Activation of different nodes in this network impacted on the sensitivity to Wnt pathway small molecule antagonists. CONCLUSIONS: The 'functional connectome' identified here strongly supports an alternative model of the Wnt pathway as a complex context-dependent network. The network further suggests that mutational activation of highly connected Wnt signaling nodes predisposed cells to further context-dependent alterations in levels of TCF-dependent transcription that may be important during tumor progression and treatment.

Simultaneous pancreas-kidney transplantation: lessons learned from the initial experience of a single center in Korea

PURPOSE: The purpose of this study is to report the results of simultaneous pancreas-kidney (SPK) transplantations and describe the lessons learned from the early experiences of a single center. METHODS: Between January 2002 and June 2013, a total of 8 patients underwent SPK transplantation. Clinical and radiologic data were reviewed retrospectively. RESULTS: Seven patients were diagnosed with type I diabetes mellitus and one patient became insulin-dependent after undergoing a total pancreatectomy because of trauma. Pancreas exocrine drainage was performed by enteric drainage in 4 patients and bladder drainage in 4 patients. Three patients required conversion from initial bladder drainage to enteric drainage due to urinary symptoms and duodenal leakage. Four patients required a relaparotomy due to hemorrhage, ureteral stricture, duodenal leakage, and venous thrombosis. There was no kidney graft loss, and 2 patients had pancreas graft loss because of venous thrombosis and new onset of type II diabetes mellitus. With a median follow-up of 76 months (range, 2-147 months), the death-censored graft survival rates for the pancreas were 85.7% at 1, 3, and 5 years and 42.9% at 10 years. The patient survival rate was 87.5% at 1, 3, 5, and 10 years. CONCLUSION: The long-term grafts and patient survival in the current series are comparable to previous studies. A successful pancreas transplant program can be established in a single small-volume institute. A meticulous surgical technique and early anticoagulation therapy are required for further improvement in the outcomes.

Effectiveness of Early Enteral Feeding in Major Burn Patient

PURPOSE: Early enteral feeding is recommended in cases of critical illness. However, it is unclear whether this recommendation is of most benefit to extremely ill patients. From our experiences, our authors believed that early enteral nutrition can lead to better prognosis of ICU patients. We aim to clarify the efficacy of early enteral feeding. METHODS: Eighty six critically ill patients were enrolled and grouped as "Early enteral feeding (EF)" and "Delayed enteral feeding (DF)" for this cross-sectional, prospective randomized observational study. To reduce the selection bias, we compare our groups to 20~39% (group A) TBSA (total body surface area, and 40~59% (group B) TBSA burned. BMI (body mass index), length of ICU stay, length of hospital stay, hospital mortality, serum prealbumin, serum transfferin and lymphocyte count data were collected over 28 days. RESULTS: There were no statistical differences in measured outcomes between early and late feeding groups. In serologic test; prealbumin, transferrin and lymphocyte, there is also no statistical difference except 2nd, 4th week of lymphocyte. EF group has higher lymphocyte than DF group. In the group A, however, prealbumin and transferrin was high in EF group during the whole 4 weeks of study. Comparing the ICU stay and hospital mortality, there was also no statistical significance. CONCLUSION: In this study, there is no significant association between hospital outcomes and timing of enteral feeding initiation. More active trials and many-sided studies will be needed to maximize the effect of early enteral nutritional support as a method to improve treatment for major burned patients.

Low-level microbial contamination of liquid in syringe hubs leads to an unacceptable risk to the end product.

OBJECTIVES: The aim of this study was to assess the risk associated with microbial contamination in the hub-fluid in Luer-lock syringes to the end-product, and ultimately patients. METHOD: The hub-fluid of 48 sterile syringes prefilled with broth was contaminated with a low number of Staphylococcus epidermidis or spores of Bacillus subtilis. After incubation for three weeks, the syringe fills were tested for the presence of bacterial contaminants and some syringes were used to inoculate an end product broth that was then investigated for the presence of microorganisms. KEY FINDINGS: After three weeks of incubation only 20.8% of syringe fills showed turbidity, although following further investigation 70.8% were positive for the presence of viable bacteria, whereas 95.6% of end products became contaminated following injection of the syringe fill. CONCLUSIONS: These findings add quantitative data that support the current practice of discarding syringes with residue around the cap.

Surgical Treatment of Acute Arterial Occlusion after Applying the Vascular Closure Device for Hemostasis of Femoral Arteriotomy in Vascular Intervention

Vascular intervention via the femoral artery can cause vascular access complications and complications from closure of the arteriotomic incision site such as bleeding, thrombotic complications and vascular trauma. These types of complications occur in about 2% to 10% of the cases. After removal of the catheter, hemostasis is traditionally achieved by manual compression as a standard method. Many vascular closure devices have been developed in an attempt to improve the patient's comfort and to decrease the time to ambulation. Yet the safety and effectiveness of these vascular closure devices as compared to that of manual compression remains unclear. Herein we report on a case of femoral arterial occlusion due to vascular closure devices and the operative management.

A Case of Cyclosporine-Induced Type I Renal Tubular Acidosis after Kidney Transplantation / 대한신장학회지

Cyclosporine is an immunosuppressive agent that plays an important therapeutic role for organ transplantation. However, complications due to type 1 renal tubular acidosis, albeit rare, have been reported. We experienced a case of severe metabolic acidosis associated with cyclosporine administration after renal transplantation. A 54-year old man was hospitalized for seizure, confusion and weakness. He demonstrated severe metabolic acidosis and hypokalemia. Continuous renal replacement therapy was started and sodium bicarbonate was administered to correct the acidosis and the dosage of cyclosporine was reduced. Thereafter, the cyclosporine level in whole blood decreased gradually, and the metabolic acidosis improved.

Laparoscopic Resection of an Asymptomatic Intra-Abdominal Lymphangioma / 대한내시경복강경외과학회지

An intra-abdominal cystic lymphangioma is a benign neoplasm that rarely occurs within the abdominal cavity. Intra-abdominal cystic lymphangioma is treated by a resection performed through a radical procedure. We report a case of a 37-year-old woman who had an asymptomatic mesenteric cyst that was discovered incidentally during a routine physical check-up. Treatment was completed without complications using a laparoscope.

Analysis of the Potential Deceased Donors in the Neurosurgical Intensive Care Units of Korea / 대한이식학회지

BACKGROUND: The shortage of donor organs is the main problem that needs to be solved in Korea as well as in other countries. To expand the donor pool, we retrospectively reviewed the brain-dead patients who expired without organ donation in the neurosurgical intensive care units (NICU) and evaluated the potential deceased donors (PDDs). METHODS: Between January 2008 and December 2008, PDDs who expired without organ donation in the NICU were recruited from 52 secondary or tertiary referral hospitals in Korea. The data of a total 2,288 PDD cases were collected from the questionnaire. Of these, 1,980 cases were eligible for analysis. RESULTS: There were 1,166 males (58.9%) and 793 females (40.1%) with a mean age of 57.6+/-18.0 years (21.2% in the 5th decade; 21.0% in the 6th decade). The most common cause of death of PDDs was cerebrovascular accident (n=1,034; 52.2%). Glasgow Coma scale was 3 in 23.1% and 4 in 12.1% of the PDDs. Craniotomy was performed in 996 patients (50.3%). Sepsis developed in 276 patients (14.0%) among the total PPDs. Diagnostic procedure for assessment of brain death was performed in 194 patients (9.8%). The seroprevalence of HBsAg and HCVAb was 1.7% and 0.6%, respectively. The mean AST/ALT level on admission and after brain death were 80.9+/-344.9/49.0+/-162.19 and 308.6+/-1,485.2/142.5+/-596.27 IU/L, respectively. Uriney protein level was normal in 1,221 patients (61.7%) after brain death. Of the 1980 PDDs, 19 patients (1%) donated their organs for transplantation. CONCLUSION: Only a small percentage (1%) of PDDs in the NICU donated their organs in Korea. We suggest that continuous and active donor action is needed to increase organ donation from the potential deceased donors.

A useful approach to identify novel small-molecule inhibitors of Wnt-dependent transcription.

The Wnt signaling pathway is frequently deregulated in cancer due to mutations in genes encoding APC, beta-catenin, and axin. To identify small-molecule inhibitors of Wnt signaling as potential therapeutics, a diverse chemical library was screened using a transcription factor reporter cell line in which the activity of the pathway was induced at the level of Disheveled protein. A series of deconvolution studies was used to focus on three compound series that selectively killed cancer cell lines with constitutive Wnt signaling. Activities of the compounds included the ability to induce degradation of beta-catenin that had been stabilized by a glycogen synthase kinase-3 (GSK-3) inhibitor. This screen illustrates a practical approach to identify small-molecule inhibitors of Wnt signaling that can seed the development of agents suitable to treat patients with Wnt-dependent tumors.

Laparoscopic vs Transumbilical Single-Port Laparoscopic Appendectomy; Results of Prospective Randomized Trial

PURPOSE: Conventional three-port laparoscopic appendectomy (LA) is more commonly performed than transumbilical single port laparoscopic appendectomy (TUSPLA). In this report, we performed a prospective randomized study comparing the outcomes of LA and TUSPLA. METHODS: Between April 14, 2009 and June 10, 2009, 40 patients who required laparoscopic appendectomies were randomly selected to receive either a TUSPLA or a LA. None of these patients had perforation or abscess. Twenty of the patients received a LA and the other 20 received a TUSPLA. The clinical outcomes and visual analog pain scores (VAS) were compared between the groups. RESULTS: The TUSPLA procedures were performed successfully in every indicated patient. Clinical outcomes were similar in both study groups. The TUSPLA group showed a significantly higher VAS score 24 hours postoperatively than the LA group. CONCLUSION: Compared with LA, TUSPLA was technically feasible and safe in patients with non-complicated appendicitis. However, the patients in the TUSPLA group reported more postoperative pain than those in the LA group.

Expression of E-cadherin, Heat Shock Protein 47, Transforming Growth Factor beta1 and C4d in Chronic Allograft Nephropathy / 대한이식학회지

BACKGROUND: Chronic allograft nephropathy (CAN), which causes graft failure, is related to tubular atrophy and interstitial fibrosis. E-cadherin is a well-known epithelial marker and heat shock protein (HSP)-47 is a collagen-specific molecular chaperone that regulates collagen synthesis. Transforming growth factor (TGF)-beta1, a profibrotic cytokine, downregulates E-cadherin and induces expression of mesenchymal markers in an in vitro model. C4d expression is considered a poor prognostic marker for graft survival. This study evaluated the relationship between the expression of E-cadherin, HSP47, TGF-beta1, and C4d with the prognosis for CAN. METHODS: Between March 1991 and August 2007, we performed renal allograft biopsies on 42 recipients with deteriorating renal function. CAN was diagnosed according to the chronic allograft damage index (Banff classification). Renal allograft biopsies were examined for the expression of E-cadherin, HSP47, TGF-beta1, or C4d by immunohistochemistry. The HSP47, TGF-beta1, and E-cadherin staining was scored semiquantitatively by analyzing ten different fields of cortical interstitium and tubules. Biopsies with endothelial C4d staining in peri-tubular capillaries (> or =25%) were designated as C4d-positive. RESULTS: Of 42 recipients, 17 (40.5%) were in the graft survival group (GS) and 25 (59.5%) were in the graft failure group (GF). E-cadherin expression in tubular cells of the GS was much higher than that of the GF (94.1% vs 52%, P=0.04). HSP47 expression in tubular cells and interstitium in the GF was much higher than that in the GS (84% vs 35.3%, P=0.001). TGF-beta1 expression in tubular cells and interstitium in the GF was much higher than that in the GS (72% vs 23.5%, P=0.02). CONCLUSIONS: E-cadherin, HSP47, and TGF-beta1 expression was strongly correlated with the CAN prognosis.

Early activation of FGF and nodal pathways mediates cardiac specification independently of Wnt/beta-catenin signaling.

BACKGROUND: Cardiac induction, the first step in heart development in vertebrate embryos, is thought to be initiated by anterior endoderm during gastrulation, but what the signals are and how they act is unknown. Several signaling pathways, including FGF, Nodal, BMP and Wnt have been implicated in cardiac specification, in both gain- and loss-of-function experiments. However, as these pathways regulate germ layer formation and patterning, their specific roles in cardiac induction have been difficult to define. METHODOLOGY/PRINCIPAL FINDINGS: To investigate the mechanisms of cardiac induction directly we devised an assay based on conjugates of anterior endoderm from early gastrula stage Xenopus embryos as the inducing tissue and pluripotent ectodermal explants as the responding tissue. We show that the anterior endoderm produces a specific signal, as skeletal muscle is not induced. Cardiac inducing signal needs up to two hours of interaction with the responding tissue to produce an effect. While we found that the BMP pathway was not necessary, our results demonstrate that the FGF and Nodal pathways are essential for cardiogenesis. They were required only during the first hour of cardiogenesis, while sustained activation of ERK was required for at least four hours. Our results also show that transient early activation of the Wnt/beta-catenin pathway has no effect on cardiogenesis, while later activation of the pathway antagonizes cardiac differentiation. CONCLUSIONS/SIGNIFICANCE: We have described an assay for investigating the mechanisms of cardiac induction by anterior endoderm. The assay was used to provide evidence for a direct, early and transient requirement of FGF and Nodal pathways. In addition, we demonstrate that Wnt/beta-catenin pathway plays no direct role in vertebrate cardiac specification, but needs to be suppressed just prior to differentiation.

Decision Factors on Mycophenolic Acid Dose after Renal Transplantation / 대한이식학회지

BACKGROUND: Triple immunosuppressant therapy including anti-metabolites is the representative immunosuppressive therapy after renal transplantation. This study is to evaluate the factors that influence Mycophenolate sodium (MPS, Myfortic, Novartis, Basel, Switzerland) dosage patterns in renal transplantation patients who take MPS as an inosine monophosphate dehydrogenase (IMPDH) among antimetabolites. METHODS: From May 2007 to April 2008, 16 clinical departments of 14 transplantation centers in Korea retrospectively performed a survey on 650 renal transplantation recipients taking MPS. This survey collected personal information, clinical factors related to transplantation and immunosuppressive therapy. RESULTS: The mean age of the patients was 43.0+/-12.0 (7~75) and the study included 364 males (56.0%) and 286 females (44.0%). The average follow up period after renal transplantation was 49.5+/-53.4 (1~307) months. There were 366 (56.3%) living related cases, 145 (22.3%) living non-related cases and 139 (21.4%) deceased donor cases. Cyclosporine was the most common calcineurin inhibitor (CNI) used in combination therapy with MPS (476 cases, 73.2%) followed by tacrolimus (169 cases, 26.0%). The mean daily dose of MPS was 909.7+/-336.3 (180~1,620)mg and the mean daily dose per kg was 15.3+/-5.9 (2.65~32.73)mg/kg. The daily dose showed significant positive correlation with patient body weight but the daily dose per kg showed negative correlation. The daily dose of MPS was significantly higher in the combination therapy with cyclosporine than that with tacrolimus. The daily dose and the dose per kg decreased with increment of recipient age and post-transplant period. CONCLUSIONS: Our study concluded that MPS dosages correlated with the combined type of CNI, post-transplant period and age.

The Minimal Invasive Approach for Early Gastric Cancer with Abdominal Aortic Aneurysm

Around two-thirds of all abdominal aortic aneurysms (AAA) are incidentally discovered. Open surgical repair of these aneurysms is considered the standard, traditional method of treatment. This report details the minimal invasive approach for a patient who presented with early gastric cancer and an AAA, and the patient underwent endovascular repair of the aneurysm prior to laparoscopic assisted distal gastrectomy. Esophagogastroduodenoscopy identified a malignant ulcer in the antrum and preoperative abdominal computer-tomography incidentally revealed a large AAA. The abdominal aortic aneurysm was the infra-renal type and the estimated size was 65 mm. Compared to open surgical intervention, the treatment of abdominal aortic aneurysm via endovascular aneurysm repair (EVAR) shortens the period of recovery. Also, intra-abdominal adhesion is avoided so that minimal invasive surgical intervention through the laparoscopic approach is possible for treating malignancy. EVAR is the recommended treatment for asymptomatic abdominal aortic aneurysm when this is associated with intra-abdominal malignancy.

A Case of Kaposi's Sarcoma Improved by Sirolimus Treatment in the Kidney Transplant Recipient / 대한신장학회지

The incidence of Kaposi's sarcoma (KS) increases in kidney transplant recipients who had the immunosuppressive therapy. The usual treatment of KS is to reduce the dosage of immunosuppressive agents, with chemotherapy and/or radiotherapy. Several studies have recently demonstrated that the conversion to proliferation signal inhibitors (PSIs) from calcineurin inhibitors (CNI) leads to the remission of some post-transplant tumors such as KS. PSIs were well tolerated with stable renal function and no episode of acute rejection was reported. On the basis of these findings, we report a case of Kaposi's sarcoma in the kidney transplant patient, who had multiple lymphadenopathy and hepatic involvement without skin lesions. This patient responded well to the change of the immunosuppressive treatment from cyclosporine to sirolimus, one of PSIs.

Comparison of New Onset Diabetes according to the Time of Onset in Kidney Transplant Recipients / 대한이식학회지

BACKGROUND: New onset diabetes is a common complication after kidney transplantation. However, the clinical course of post-transplant diabetes mellitus (PTDM) remains unclear. The aim of the present study is to analyze the natural courses and risk factors of PTDM according to the time of onset. METHODS: A total of 216 consecutive kidney transplant recipients were enrolled and patient medical records were investigated retrospectively. PTDM was defined as glucose > or =126mg without previous diabetic history. Patients were classified according to the onset (12 months): early PTDM (E-PTDM) and late PTDM (L-PTDM). RESULTS: PTDM was observed in 34 (17.4%) patients. The number of E-PTDM and L-PTDM patients was 17 and 17. Compared with normoglycemic patients, the PTDM group was older and showed higher pre-transplant HbA1c level. The use of tacrolimus was associated with the development of E-PTDM (OR=4.87, 1.71~13.8 in 95% CI) but not L-PTDM (OR=0.34, 0.04~2.70 in 95% CI) CONCLUSIONS: The development of E-PTDM and L-PTDM may have different risk factors. It will be important to choose different therapeutic strategy according to the onset of PTDM.