American Journal of Medicine最新文献

Background: E-medicine use has surged, and health systems are exploring large language models (LLMs) for message triage. However, it is still unknown whether patient tone alone alters AI-generated clinical or administrative decisions.

Methods: We created 1000 clinician-validated primary-care vignettes (500 clinical, 500 sick-leave) and presented each in eight communication styles. Five agentic LLMs generated structured outputs for triage urgency, sick-leave decisions and other outputs. Differences from the neutral control were assessed using chi-square tests (Cramér's V) and t-tests (Cohen's d), with FDR correction. As external validation, 40 real patient e-messages from a large health network were processed using the same pipeline.

Results: Across 120,000 agent runs, patient tone produced clear and reproducible shifts. Urgent, threatening, and demanding framings increased same-day or urgent care from 14% to 37%-63% (V up to 0.69, P < 0.001). Medication advice shifted modestly toward prescription options (Rx from 5% to 7%-9%, P < 0.001). Emotional tone increased empathy-based responses from 62% to 70%-86% (P < 0.001). In sick-leave tasks, threatening tone reduced approvals (58% to 50%) and granted days (2.60 to 2.36; d = -0.12), while emotional tone slightly increased both. The real-world validation showed the same directional effects. It confirmed that tone influenced model outputs even in authentic messages.

Conclusions: Agentic LLMs treated patient tone as clinical input, altering triage, follow-up, prescribing, and sick-leave decisions despite identical symptoms. These tone-sensitive shifts may introduce hidden biases, affect resource use, and enable misuse in E-medicine workflows.

Background: A portion of patients diagnosed with dementia could instead have cirrhosis and reversible hepatic encephalopathy. Strategies to identify and treat reversible hepatic encephalopathy in patients currently diagnosed with dementia could prevent misdiagnosis and unnecessary healthcare resource use. Our intent was to determine cost-effectiveness of easily available strategies (Fibrosis-4:FIB-4) score, hepatic encephalopathy treatments (lactulose/rifaximin) and hepatology involvement for hepatic encephalopathy diagnosis in dementia patients.

Methods: This study evaluated the cost-effectiveness of screening and treatment strategies for hepatic encephalopathy in patients with dementia, using a decision-analytic model from a societal perspective. A decision tree model compared seven strategies over a 1-year time horizon. Six strategies (FIB-4 + empiric lactulose, FIB-4 + empiric rifaximin, FIB-4 + hepatology consult + lactulose, FIB-4 + hepatology consult + rifaximin, Empiric lactulose for all, empiric rifaximin for all) were compared to status quo.

Results: Five of six intervention strategies showed higher effectiveness at lower cost versus status quo, with savings ranging from $6,160 to $13,236. The most economically efficient strategy was FIB-4 screening followed by hepatology consultation and targeted lactulose therapy, which generated cost savings and a gain in outcomes versus no screening. Sensitivity analyses confirmed robustness of screening strategies, with results most influenced by treatment response, utility values, and cirrhosis prevalence.

Conclusions: The combination of FIB-4 screening, hepatology referral, and lactulose therapy offers the best balance of value and clinical benefit, avoiding unnecessary overtreatment while capturing reversible hepatic encephalopathy. Targeted hepatic encephalopathy screening in dementia is cost-effective, improves diagnostic accuracy, reduces healthcare costs, and offers an opportunity to reverse cognitive impairment in individuals otherwise presumed to have irreversible dementia.

Background: Factor Xa inhibitor-associated major gastrointestinal bleeding is life-threatening and requires rapid anticoagulation reversal. Andexanet alfa, a recombinant factor Xa decoy protein, is approved for reversal but is limited by high cost, restricted availability, and reported thromboembolic risk. Consequently, four-factor prothrombin complex concentrate (4F-PCC) is frequently used in clinical practice, although real-world data remain limited.

Methods: We conducted a single-center retrospective study at Meir Medical Center evaluating patients who received 4F-PCC for reversal of factor Xa inhibitor-associated major gastrointestinal bleeding between August 2016 and May 2025. The primary outcome was 12-hour hemostatic efficacy, assessed using methodology similar to the ANNEXA-4 trial. Safety outcomes included 30-day thromboembolic events and in-hospital mortality.

Results: Of 72 screened patients, 62 were included in the final analysis. Median age was 80 years (interquartile range 76-88), and 33 patients (53.2%) were male. Apixaban was the most commonly used factor Xa inhibitor (74.2%). Hemostatic efficacy was achieved in 72.6% (45/62; 95% CI 60.4-82.1), including excellent responses in 51.6% and good responses in 21.0%. Efficacy was 70.2% in upper gastrointestinal bleeding and 80.0% in lower gastrointestinal bleeding (relative risk 1.14, 95% CI 0.83-1.56; P = 0.53). Thromboembolic events occurred in 4 patients (6.5%; 95% CI 2.5-15.4), and in-hospital mortality occurred in 8 patients (12.9%; 95% CI 6.7-23.4).

Conclusion: Prothrombin complex concentrate achieved 73% hemostatic efficacy in factor Xa inhibitor-associated gastrointestinal bleeding, with low thromboembolic rates and mortality similar to published data, supporting current guideline recommendations for reversal.

Background: Activated charcoal (AC), a known adsorbent in the gastrointestinal tract, has been reported to reduce serum urate (SU) levels. This study aimed to assess the efficacy and safety of AC in managing primary gout.

Methods: This double-blind, double-dummy, randomized controlled trial involved 348 patients, who were randomly assigned to one of four groups: febuxostat 40 mg, febuxostat 20 mg + AC 4.5 g, febuxostat 20 mg + AC 7.2 g, and febuxostat 20 mg. Patients were followed-up every 4 weeks until week 24. The primary endpoint was the proportion of patients achieving SU level < 360 μmol/L.

Results: All 348 enrolled patients were included in analysis. The febuxostat-AC combination regimen didn't demonstrate superior efficacy in controlling SU levels. However, the combination regimen significantly reduced flare rates compared to the febuxostat 20 mg group (≥ 1 and ≥ 3 flares, P < 0.05) and the febuxostat 40 mg group (≥ 1 flare, P < 0.05; ≥ 3 flares, P < 0.01), and it also significantly prolonged the time to first flare. Additionally, the combination regimen resulted in significantly lower low-density lipoprotein cholesterol (LDL-C) levels at week 24. The incidence of adverse events was similar across the groups.

Conclusions: The febuxostat-AC combination regimen didn't enhance urate-lowering effects but significantly reduced gout flare frequency, delayed the onset of first flare, and improved LDL-C levels. These findings underscore the role of AC in comprehensive gout management.

Trial registration: ChiCTR, http://www.chictr.org.cn, ChiCTR2000034138.

From the infectious diseases perspective, the safety of the U.S. blood supply, already high-level, continues to improve via multiple mechanisms, making transfusion-transmitted infections (TTIs) now rare. Blood supply safety in 2026 rests on multiple, interdigitating cornerstones including: (a) updated donor questionnaires and guidances for blood collection centers from the Food and Drug Administration, (b) the long-term commitment and expertise of national organizations (e.g., the American Red Cross and the Association for the Advancement of Blood and Biotherapies), (c) screening of donor blood products using nucleic acid testing (NAT), and (d) retrospective hemovigilance. Recent efforts, reviewed here chronologically, include: (a) testing for babesiosis in endemic states, (b) strategies to control bacterial contamination of platelets (still a TTI problem in 2026), (c) a uniform, non-gender-based individual donor questionnaire with clear-cut donor deferrals to reduce HIV transmission even further, and soon, (d) testing for malaria in appropriately-selected donors, with the potential of eliminating malaria as a TTI in the U.S.