Conservative management of segmental testicular infarction in a patient with sickle cell anemia: A case report.

Vaso-occlusive crisis is a sequela of sickle cell disease that can lead to severe pain and infarction at the location of occlusion. In men, genitourinary complications include priapism, hematuria, and very rarely, testicular infarction. Few cases have been previously reported in the literature, but in all of those cases, partial or complete orchiectomy was performed. We report the first known case of segmental testicular infarct secondary to sickle cell disease treated with medical management without need for surgical intervention.

Prompt matters: evaluation of large language model chatbot responses related to Peyronie's disease.

Introduction: Despite direct access to clinicians through the electronic health record, patients are increasingly turning to the internet for information related to their health, especially with sensitive urologic conditions such as Peyronie's disease (PD). Large language model (LLM) chatbots are a form of artificial intelligence that rely on user prompts to mimic conversation, and they have shown remarkable capabilities. The conversational nature of these chatbots has the potential to answer patient questions related to PD; however, the accuracy, comprehensiveness, and readability of these LLMs related to PD remain unknown. Aims: To assess the quality and readability of information generated from 4 LLMs with searches related to PD; to see if users could improve responses; and to assess the accuracy, completeness, and readability of responses to artificial preoperative patient questions sent through the electronic health record prior to undergoing PD surgery. Methods: The National Institutes of Health's frequently asked questions related to PD were entered into 4 LLMs, unprompted and prompted. The responses were evaluated for overall quality by the previously validated DISCERN questionnaire. Accuracy and completeness of LLM responses to 11 presurgical patient messages were evaluated with previously accepted Likert scales. All evaluations were performed by 3 independent reviewers in October 2023, and all reviews were repeated in April 2024. Descriptive statistics and analysis were performed. Results: Without prompting, the quality of information was moderate across all LLMs but improved to high quality with prompting. LLMs were accurate and complete, with an average score of 5.5 of 6.0 (SD, 0.8) and 2.8 of 3.0 (SD, 0.4), respectively. The average Flesch-Kincaid reading level was grade 12.9 (SD, 2.1). Chatbots were unable to communicate at a grade 8 reading level when prompted, and their citations were appropriate only 42.5% of the time. Conclusion: LLMs may become a valuable tool for patient education for PD, but they currently rely on clinical context and appropriate prompting by humans to be useful. Unfortunately, their prerequisite reading level remains higher than that of the average patient, and their citations cannot be trusted. However, given their increasing uptake and accessibility, patients and physicians should be educated on how to interact with these LLMs to elicit the most appropriate responses. In the future, LLMs may reduce burnout by helping physicians respond to patient messages.

A Student Teaching Assistant Program for Diversity, Equity, Inclusion, and Antiracism Curricular Enhancement.

PROBLEM: In the United States, physician bias is exhibited early in medical training and contributes to systemic inequities within the field of medicine. A lack of diversity, equity, inclusion, and antiracism (DEI-AR) content within medical curricula drives critical gaps in knowledge and deficiencies when preparing medical students to serve patients of diverse backgrounds. At the Mayo Clinic Alix School of Medicine (MCASOM), student-led curricular reviews between 2017 to 2018 and 2020 to 2021 revealed opportunities to improve DEI-AR content within preclinical courses. Course directors expressed concern of limited expertise and time to enact effective changes. APPROACH: The MCASOM DEI-AR teaching assistant (TA) program aims to curate a collaborative partnership between course directors and compensated student TAs to facilitate course enhancements responsive to the prior preclinical course review while centering standardized DEI-AR best practices. OUTCOMES: As of January 2024, the program has engaged 14 TAs and partnered with 24 preclinical courses. Postcourse student evaluation responses were collected from 8 courses for 2021 to 2022 (before enhancements) and 2022 to 2023 (after enhancements). Student satisfaction with DEI-AR content is tracked through postcourse evaluations, with preliminary data demonstrating improvement after DEI-AR curricular integration (improvement of mean preenhancement and postenhancement scores of 3.81 to 4.05; t12 = 1.79, P = .21). Qualitative student comments were sorted into general categories of positive, negative, or neutral, showing a 6.25% median increase in positive perception of DEI. NEXT STEPS: Plans for the MCASOM DEI-AR TA program include application of quality improvement strategies to improve program processes and outcomes. Development of a centralized dashboard that integrates course enhancement progress and ongoing feedback from evaluations is anticipated to facilitate this effort. The program additionally aims to develop partnerships with clinical clerkships, which would allow for a more comprehensive enhancement of the overall medical education experience related to DEI-AR.

NOise Reduction with DIstribution Corrected (NORDIC) PCA improves signal-to-noise in rodent resting-state and optogenetic functional MRI.

NOise Reduction with DIstribution Corrected (NORDIC) principal component analysis (PCA) has been shown to selectively suppress thermal noise and improve temporal signal-to-noise ratio (tSNR) in human functional magnetic resonance imaging (fMRI). However, the feasibility to improve rodent fMRI using NORDIC PCA has not been explored. In this study, we developed a rodent fMRI preprocessing pipeline by incorporating NORDIC and evaluated its performance in a range of rodent fMRI applications from resting-state fMRI to task-evoked fMRI using optogenetics. In resting-state fMRI, we demonstrated a significant increase in tSNR by more than 3 times after NORDIC correction with reduced variance and improved task-free relative cerebrovascular reactivity (rCVR) across cortical depth. In optogenetic fMRI, apart from tSNR increase, more activated voxels and a significant decrease in the variance of activated brain signals were observed after NORDIC correction without apparent change in brain morphology. Taken together, our results signified the values of NORDIC correction for better detection of brain activities in rodent fMRI. Clinical Relevance: NORDIC PCA increases temporal signalto- noise ratio in rodent resting-state and task-evoked functional MRI, which can play an important role in improving the image quality for translational medicine and preclinical research, and for guiding future clinical neuroimaging.

The kappa opioid receptor modulates GABA neuron excitability and synaptic transmission in midbrainprojections from the insular cortex.

As an integrative hub, the insular cortex (IC) translates external cues into interoceptive states that generate complex physiological, affective, and behavioral responses. However, the precise circuit and signaling mechanisms in the IC that modulate these processes are unknown. Here, we describe a midbrain-projecting microcircuit in the medial aspect of the agranular IC that signals through the Gαi/o-coupled kappa opioid receptor (KOR) and its endogenous ligand dynorphin (Dyn). Within this microcircuit, Dyn is robustly expressed in layer 2/3, while KOR is localized to deep layer 5, which sends a long-range projection to the substantia nigra (SN). Using ex vivo electrophysiology, we evaluated the functional impact of KOR signaling in layer 5 of the IC. We found that bath application of dynorphin decreased GABA release and increased glutamate release on IC-SN neurons, but did not alter their excitability. Conversely, dynorphin decreased the excitability of GABA neurons without altering synaptic transmission. Pretreatment with the KOR antagonist nor-BNI blocked the effects of dynorphin in IC-SN neurons and GABA neurons, indicating that the changes in synaptic transmission and excitability were selectively mediated through KOR. Selective inhibition of IC GABA neurons using a KOR-derived DREADD recapitulated these effects. This work provides insight into IC microcircuitry and indicates that Dyn/KOR signaling may act to directly reduce activity of layer 5 GABA neurons. In turn, KOR-driven inhibition of GABA promotes disinhibition of IC-SN neurons, which can modulate downstream circuits. Our findings present a potential mechanism whereby chronic upregulation of IC Dyn/KOR signaling can lead to altered subcortical function and downstream activity.