Citations

Abstract Background The Middle East is experiencing a rapid increase in inflammatory bowel disease (IBD) likely due to urbanization, dietary changes and environmental factors. The region lacks sufficient data, making it challenging to comprehend the full extent of IBD's impact on healthcare systems. This research aims to investigate IBD trends, disease behaviour, evolution and persistence of advanced therapy (AT) within a predominantly Arab patient population in UAE. Methods This observational study at a tertiary IBD centre in the UAE utilized the local IBD registry (prospective data collection from 2022). Data included disease characteristics, and AT usage. Descriptive statistics, regression models and Kaplan-Meier analysis were employed. Results Of the 859 IBD patients treated from 2012 to 2024, comprehensive data were available for 321 patients under active follow-up of which 64.2% comprised of Crohn’s disease (CD) and 35.8% with ulcerative colitis (UC). A ten-fold rise over a 22-year period in new diagnoses of IBD, particularly CD was observed. Median age at diagnosis was 25 years (IQR 25-42), with CD patients younger (24 years) than UC patients (28 years). Within CD, 20% had stricturing, 17% penetrating and 36% with perianal disease. 85% of CD and 61% of UC patients were exposed to at least one AT; 25% of CD and 18% of UC patients >2 ATs, and 16% of CD and 11% of UC >3 ATs. Infliximab and adalimumab were the main first-line ATs, while ustekinumab and risankizumab used in later AT lines. Ustekinumab and risankizumab, showed higher AT persistence compared to anti-TNFs. In CD, stricturing disease (p<0.05), penetrating disease (p<0.01), longer disease duration (p<0.05), and younger age at diagnosis (p<0.05) were linked to higher exposure to AT lines. In UC, younger age at diagnosis (p=0.001) was associated with increased number of AT exposures. Use of AT significantly changed between 2017–2020 and 2021–2024 (p<0.001). Infliximab, adalimumab and vedolizumab were initially the most prevalent, with ustekinumab, risankizumab, and upadacitinib usage rising substantially by 2022. The time to initiate AT for CD and UC following diagnosis decreased significantly since 2017 by 6.82 and 6.91 months per year, respectively (p<0.001), with a combined median time of 2.46 months (IQR 4.8) for CD for 2023-2024. Conclusion This is the first comprehensive evaluation of IBD in the UAE, highlighting a significant rise in new diagnoses, particularly CD with aggressive phenotypes, reflecting broader regional trends. AT utilization has evolved, with ustekinumab and risankizumab demonstrating better persistence and increasing adoption. These insights into disease patterns will help inform future regional healthcare policies.

Abstract Background There is limited data on the clinical effectiveness of upadacitinib (UPA), an oral selective inhibitor of Janus kinase 1 (JAKi), in patients with perianal Crohn's disease (pCD). The objective of this study was to evaluate the real-world effectiveness of UPA in pCD. Methods This retrospective analysis utilized data on adults (>17 years) who initiated UPA at 45 mg/day for active pCD across 10 centers in the United States and Canada. Standardized data extraction and entry protocols were followed. The primary outcome was clinical response, defined as a ≥3-point reduction in Perianal Disease Activity Index (PDAI) between baseline and follow-up. Secondary outcomes included normalization of CRP (<5 mg/L) or hsCRP (<1 mg/L), clinical remission (PDAI ≤4), and rates of hospitalization, antibiotic use, corticosteroid initiation, and new pCD-related surgeries. Fistula healing on MRI pelvis fistula protocol was defined as an absence of T2-weighted hyperintensity and post-contrast enhancement on T1-weighted images. Predictive analyses used Cox proportional hazards models to evaluate baseline factors influencing time to PDAI remission, including BMI, CRP, albumin, PDAI, pCD disease duration, Montreal location and prior biologic exposure (<2 vs 2+). Results A total of 81 patients were treated with UPA for pCD (median age 35 years and 54.3% male). Most had ileocolonic disease (65.4%), with 54% presenting with complex fistulas. Of these, 92.6% had prior anti-TNF exposure, and 91 (88.9%) had prior exposure to 2+ biologics (Table 1). During a median follow-up of 4 months, clinical response (PDAI) was achieved in 17.3%. Improvement was observed in pain and restriction of activities (27.2%), restriction of sexual activity (13.6%), reduction in number of fistulas (11.1%), degree of induration (11.1%), and discharge (35.8%). Median CRP reduction was 21.05% [IQR: 0.00–74.53], and 21.0% achieved a ≥50% reduction in CRP. MRI healing was limited to 17.7% (6/34). Proctitis decreased from 23.5% at baseline to 7.4% at follow-up. During follow-up, hospitalizations occurred in 9.9%, 14.8% required antibiotics, 8.6% underwent examination under anesthesia in 8.6%, seton placement in 6.2%, and abscess drainage in 6.2%. Patients with ileocolonic disease showed the highest remission (54%) and response (15%) rates, while MRI healing was limited across all Montreal locations (7.4%). Lower baseline CRP (p < 0.05) and PDAI scores (p < 0.01) predicted shorter time to remission. Number of prior biologic exposures (p =0.2) and Montreal location (p = 0.7) were not predictive of time to PDAI remission (Figure 1). Conclusion UPA in a real-world cohort is effective in the management of treatment-refractory pCD. Randomized trials are needed to confirm these observations.

Introduction: Dynamic vertebral artery insufficiency is a rare vascular phenomenon characterized by insufficient flow of the posterior cerebral circulation induced by dynamic motion of the head. Prior case reports have been limited to vertebral artery occlusion by cervical osteophytes or other structural impingements. Case Report: In this case report, we discuss the unusual case of a 61-year-old female with a history of vertigo, diplopia, nystagmus, and left subclavian stenosis admitted to the hospital for syncope elicited by a left head turn and left shoulder raise. Transcranial Doppler (TCD) ultrasound and angiography showed evidence of dynamic vertebrobasilar insufficiency elicited by a left-head turn. Percutaneous stenting of the left subclavian artery led to the resumption of normal vessel flow as assessed by TCD and the resolution of the patient’s symptoms. Conclusions: This case highlights an unusual cause of dynamic vertebrobasilar insufficiency induced by head turn and/or left shoulder raise due to subclavian stenosis, diagnosed by TCD and angiography, and successfully treated with subclavian artery stenting.

Importance Eligibility criteria for randomized clinical trials (RCTs) are designed to select clinically relevant patient populations. However, not all eligibility criteria are strongly justified, potentially excluding marginalized groups, and limiting the generalizability of trial findings. Objective To summarize and evaluate the justification of exclusion criteria in published RCTs in critical care medicine. Evidence Review A systematic sampling review of parallel-group RCTs published in the top 5 general internal medicine journals by impact factor ( The Lancet, New England Journal of Medicine, Journal of the American Medical Association, British Medical Journal, and Annals of Internal Medicine ) between January 1, 2018, and February 23, 2023, was conducted. RCTs enrolling adults in intensive care units (ICUs) and RCTs enrolling critically ill patients who required life-sustaining interventions typically initiated in the ICU were included. All study exclusion criteria were categorized as either poorly justified, potentially justified, or strongly justified, adapting previously established criteria, independently and in duplicate. Findings In total, 225 studies were identified, 75 of which were included. The median (IQR) number of exclusion criteria per trial was 19 (14-24), with 1455 total exclusion criteria. Common exclusion criteria were related to the risk of adverse reaction to interventions (302 criteria [20.8%]), followed by inability to obtain consent (120 criteria [8.2%]), and treatment limitation decisions (97 criteria [6.7%]). Most exclusion criteria were either strongly justified (1080 criteria [74.2%]) or potentially justified (297 criteria [20.4%]), whereas 5.4% (78 criteria) were poorly justified. Of the 78 poorly justified exclusion criteria, the most common were pregnancy (19 criteria [24.4%]), communication barriers (11 criteria [14.1%]), lactation (10 criteria [12.8%]), and lack of health insurance (10 criteria [12.8%]). Overall, 45 of 75 studies (60.0%) had at least 1 poorly justified exclusion criteria. Conclusions and Relevance Most exclusion criteria in critical care medicine RCTs were strongly justifiable. Across poorly justified criteria, the most common exclusions were pregnant or lactating persons, those with communication barriers, and individuals without health insurance. This highlights the need to carefully consider exclusion criteria when designing trials to minimize the inappropriate exclusion of participants and enhance generalizability.

AbstractEUS-guided gallbladder drainage (EUS-GBD) using lumen apposing metal stents (LAMS) has excellent technical and short-term clinical success for acute cholecystitis (AC). The goals of this study were to determine the long-term clinical outcomes and adverse events (AEs) of EUS-GBD with LAMS.A multicenter, retrospective study was conducted at 18 US tertiary care institutions. Inclusion criteria: any AC patient with attempted EUS-GBD with LAMS and minimum 30-day post-procedure follow-up. Long-term clinical success was defined as absence of recurrent acute cholecystitis (RAC) > 30 days and long-term AE was defined as occurring > 30 days from the index procedure.A total of 109 patients were included. Technical success was achieved in 108 of 109 (99.1%) and initial clinical success in 106 of 109 (97.2%). Long-term clinical success was achieved in 98 of 109 (89.9%) over a median follow-up of 140 days (range 30–1188). On multivariable analysis (MVA), acalculous cholecystitis (odds ratio [OR] 15.93, 95% confidence interval [CI] 1.22–208.52, P = 0.04) and the occurrence of a LAMS-specific AE (OR 63.60, 95% CI 5.08–799.29, P <0.01) were associated with RAC. AEs occurred in 38 of 109 patients (34.9%) at any time, and in 10 of 109 (9.17%) > 30 days from the index procedure. Most long-term AEs (7 of 109; 6.42%) were LAMS-specific. No technical or clinical factors were associated with occurrence of AEs. LAMS were removed in 24 of 109 patients (22%). There was no difference in RAC or AEs whether LAMS was removed or not.EUS-GBD with LAMS has a high rate of long-term clinical success and modest AE rates in patients with AC and is a reasonable destination therapy for high-risk surgical candidates.

Abstract Objective Data extraction from the published literature is the most laborious step in conducting living systematic reviews (LSRs). We aim to build a generalizable, automated data extraction workflow leveraging large language models (LLMs) that mimics the real-world 2-reviewer process. Materials and Methods A dataset of 10 trials (22 publications) from a published LSR was used, focusing on 23 variables related to trial, population, and outcomes data. The dataset was split into prompt development (n = 5) and held-out test sets (n = 17). GPT-4-turbo and Claude-3-Opus were used for data extraction. Responses from the 2 LLMs were considered concordant if they were the same for a given variable. The discordant responses from each LLM were provided to the other LLM for cross-critique. Accuracy, ie, the total number of correct responses divided by the total number of responses, was computed to assess performance. Results In the prompt development set, 110 (96%) responses were concordant, achieving an accuracy of 0.99 against the gold standard. In the test set, 342 (87%) responses were concordant. The accuracy of the concordant responses was 0.94. The accuracy of the discordant responses was 0.41 for GPT-4-turbo and 0.50 for Claude-3-Opus. Of the 49 discordant responses, 25 (51%) became concordant after cross-critique, increasing accuracy to 0.76. Discussion Concordant responses by the LLMs are likely to be accurate. In instances of discordant responses, cross-critique can further increase the accuracy. Conclusion Large language models, when simulated in a collaborative, 2-reviewer workflow, can extract data with reasonable performance, enabling truly “living” systematic reviews.

Education-level or socioeconomic background of patients may dictate their ability to understand medical jargon. Inability to understand primary findings from a radiology report may lead to unnecessary anxiety among patients or missed follow up. We aim to meet this challenge by developing a patient-sensitive summarization model for radiology reports. We selected computed tomography (CT) exams of chest as a use-case and collected 7,000 studies from Mayo Clinic. Summarization model was built on top of the T5 large language model (LLM) as our experiments indicated that its text-to-text transfer architecture was suited for abstractive text summarization, resulting in a model with 0.77B trainable parameters. Noisy ground truth for model training was collected by prompting LLaMA-13B model. We recruited experts (board-certified radiologists) and laymen to manually evaluate model-generated summaries generated by model. Our model rarely missed information as marked by majority opinion of radiologists. Laymen indicated 63% improvement in their understanding by reading model-generated layman summaries. Comparison with zero-shot performance of ChatGPT indicated that the proposed model reduced the rate of hallucination by half and rate of missing important information by fivefold. The proposed model can generate reliable summaries for radiology reports understandable by patients with vastly different levels of medical knowledge.

Abstract Aims We aimed to perform a retrospective cohort study using the Centers for Disease Control and Prevention’s (CDC’s) Wide-Ranging Online Data for Epidemiologic Research (WONDER) database to analyse the trends in cardiovascular disease (CVD)–related mortality in patients with myeloproliferative neoplasms (MPNs) from 1999 to 2020. Methods and results We analysed the death certificate data from the CDC WONDER database from 1999 to 2020 for CVD with co-morbid myeloproliferative disorders in the US population. Age-adjusted mortality rates (AAMRs) and 95% confidence intervals (CIs) were computed per 1 million population by standardizing crude mortality rates to the 2000 US census population. To assess annual national mortality trends, we employed the Joinpoint regression model, calculating the annual per cent change in AAMR and corresponding 95% CIs. A total of 15 269 deaths related to CVD occurred in patients with co-morbid MPNs from 1999 to 2020. Overall, there was a decreasing trend in CVD-related AAMRs throughout these years. Males contributed to 51% of total deaths, and their AAMR was persistently higher than women throughout the study. Non-Hispanic (NH) Whites had the highest overall AAMR, followed by NH Blacks, NH American Indians or Alaska Natives, Hispanics or Latinos, and NH Asian or Pacific Islanders. Conclusion Our findings indicate a significant decline with notable gender, racial/ethnic, and regional differences in CVD-related mortality among patients with MPN over the past two decades. We emphasize the importance of a collaborative approach between oncologists and cardiologists in managing these patients, highlighting the potential benefits of integrating cardio-oncology services to enhance patient outcomes.