Chatbot Performance in Defining and Differentiating Palliative Care, Supportive Care, Hospice Care.

CONTEXT: Artificial intelligence (AI) chatbot platforms are increasingly used by patients as sources of information. However, there is limited data on the performance of these platforms, especially regarding palliative care terms. OBJECTIVES: We evaluated the accuracy, comprehensiveness, reliability, and readability of three AI platforms in defining and differentiating "palliative care," "supportive care," and "hospice care." METHODS: We asked ChatGPT, Microsoft Bing Chat, Google Bard to define and differentiate "palliative care," "supportive care," and "hospice care" and provide three references. Outputs were randomized and assessed by six blinded palliative care physicians using 0-10 scales (10 = best) for accuracy, comprehensiveness, and reliability. Readability was assessed using Flesch Kincaid Grade Level and Flesch Reading Ease scores. RESULTS: The mean (SD) accuracy scores for ChatGPT, Bard, and Bing Chat were 9.1 (1.3), 8.7 (1.5), and 8.2 (1.7), respectively; for comprehensiveness, the scores for the three platforms were 8.7 (1.5), 8.1 (1.9), and 5.6 (2.0), respectively; for reliability, the scores were 6.3 (2.5), 3.2 (3.1), and 7.1 (2.4), respectively. Despite generally high accuracy, we identified some major errors (e.g., Bard stated that supportive care had "the goal of prolonging life or even achieving a cure"). We found several major omissions, particularly with Bing Chat (e.g., no mention of interdisciplinary teams in palliative care or hospice care). References were often unreliable. Readability scores did not meet recommended levels for patient educational materials. CONCLUSION: We identified important concerns regarding the accuracy, comprehensiveness, reliability, and readability of outputs from AI platforms. Further research is needed to improve their performance.

Analyzing cardiovascular treatment guidelines application to women and minority populations.

Despite nearly 30 years of treatment guidelines for cardiovascular diseases and risk factors and a parallel growth in the understanding of cardiovascular disease disparities by sex and race/ethnicity, such disparities persist. The goals of this review are to consider the possible role of three factors: the one-size-fits-all approach of most treatment guidelines, adoption of guideline-recommended treatments in clinical practice, and patient adherence to recommended practice, especially the relationship between adherence and patient perceptions. Guideline authors repeatedly call for more inclusion of women and minorities in the clinical trials that make guidelines possible, but despite challenges, guidelines are largely effective when implemented, as shown by a wealth of post hoc analyses. However, the data also suggest that one-size-fits-all treatment guidelines are not sufficiently generalizable and there is evidence of a distinct lag time between definitive clinical evidence and its widespread implementation. Patient perspectives may also play both a direct and indirect role in adherence to treatments. What emerges from the literature is an important continuing need for increased inclusion of women and minority subgroups in clinical trials to allow analyses that can provide evidence for differential treatments when needed. Increased effort is needed to implement definitive clinical improvements more rapidly. Patient input and feedback may also help inform clinical practice and clinical research with a better understanding of how to enhance patient adherence, but evidence for this is lacking for the groups most affected by disparities.

The influence of shame on posttrauma disorders: have we failed to see the obvious?

BACKGROUND: While fear is known to be the dominant affect associated with posttraumatic stress disorder (PTSD), the presence and possible influence of other emotions is less well explored. Recent changes to diagnostic criteria have added anger, guilt and shame alongside fear as significant emotional states associated with the disorder. This article suggests that shame is a frequent, often poorly recognised sequel to trauma, occurring as a result of the meaning the individual places on the traumatic experience and on subsequent interpersonal and environmental events. METHODS: The article reviews the literature on the socio-interpersonal aspects of the posttraumatic experience with particular emphasis on the emotion of shame as both primary and secondary emotion, in its intrapersonal and interpersonal contexts, and in adaptive and maladaptive forms. RESULTS: The review suggests that posttrauma shame, and maladaptive shame regulation strategies, often manifesting as anger, substance abuse, social withdrawal or depression, may play an important role in the maintenance or exacerbation of the symptoms of PTSD and the development of co-morbidities. CONCLUSION: The recognition of shame and maladaptive shame regulation strategies in PTSD treatment and management is critical. However, because shame is frequently considered a painful and discomforting emotion, it may fail to be addressed in the therapeutic setting by both client and therapist. Examination of potential shame-related changes in self-concept, close interpersonal relationships and social inclusion are recommended for individuals who have experienced a range of traumas to identify and address any underlying unacknowledged shame.

Ramariolides A-D, antimycobacterial butenolides isolated from the mushroom Ramaria cystidiophora.

Four butenolides, ramariolides A-D (1-4), have been isolated from the fruiting bodies of the coral mushroom Ramaria cystidiophora. Their structures were elucidated by analysis of 1D and 2D NMR data and a single-crystal X-ray diffraction analysis of 1, and their absolute configurations were established using Mosher's method. The major metabolite, ramariolide A (1), which contains an unusual spiro oxiranebutenolide moiety, showed in vitro antimicrobial activity against Mycobacterium smegmatis and Mycobacterium tuberculosis.

Outcome study of computer-aided surgical simulation in the treatment of patients with craniomaxillofacial deformities.

PURPOSE: The purpose of this study was to determine whether the surgical outcomes achieved with computer-aided surgical simulation (CASS) are better than those achieved with traditional methods. MATERIALS AND METHODS: Twelve consecutive patients with craniomaxillofacial (CMF) deformities were enrolled. According to the CASS clinical protocol, a 3-dimensional computer composite skull model for each patient was generated and reoriented to the neutral head posture. These models underwent 2 virtual surgeries: 1 was based on CASS (experimental group) and the other was based on traditional methods 1 year later (control group). Once the 2 virtual surgeries were completed, 2 experienced oral and maxillofacial surgeons at 2 different settings evaluated the 2 surgical outcomes. They were blinded to the planning method used on the virtual models and each other's evaluation results. The primary outcome was overall CMF skeletal harmony. The secondary outcomes were individual maxillary, mandibular, and chin harmonies. Statistical analyses were performed. RESULTS: Overall CMF skeletal harmony achieved with CASS was statistically significantly better than that achieved with traditional methods. In addition, the maxillary and mandibular surgical outcomes achieved with CASS were significantly better. Furthermore, although not included in the statistical model, the chin symmetry achieved by CASS tended to be better. A regression model was established between mandibular symmetry and overall CMF skeletal harmony. CONCLUSION: The surgical outcomes achieved with CASS are significantly better than those achieved with traditional planning methods. In addition, CASS enables the surgeon to better correct maxillary yaw deformity, better place proximal/distal segments, and better restore mandibular symmetry. The critical step in achieving better overall CMF skeletal harmony is to restore mandibular symmetry.

Cranio-meta-diaphyseal dysplasia: 25 year follow-up and review of literature.

We report here on a 25-year follow-up of cranio-meta-diaphyseal dysplasia in a 31-year-old Caucasian male, who was reported in the literature at the age of 8 years [Langer et al. (1991); Skeletal Radiol 20:37-41]. He has hyperostotic craniofacial features with protruding lower jaw and midface hypoplasia. He has the typical radiographic features of wide long tubular bones without normal metaphyseal flaring and wide short tubular bones without normal diaphyseal constriction. We describe here his clinical and radiological findings and compare his case with those published in the literature. He is the oldest reported patient with this disorder giving some insight into the natural history of this rare skeletal dysplasia.

A review of case studies evaluating economic incentives to promote occupational safety and health.

OBJECTIVES: In many European countries, external economic incentives are discussed as a policy instrument to promote occupational safety and health (OSH) in enterprises. This narrative case study review aims to support policy-makers in organizations providing such incentives by supplying information about different incentive schemes and their main characteristics such as effectiveness, efficiency, and feasibility. METHODS: The focal point and topic centre network of the European Agency for Safety and Health at Work were used to collect case studies about incentive schemes aimed at supporting the prevention of occupational accidents and diseases in enterprises. Such incentives are rarely described in the scientific literature. To be considered for this review, studies had to focus on external financial benefits that could be provided as part of an insurance-related incentive or a governmental subsidy scheme. RESULTS: In total, 14 cases were included in the review: 6 insurance premium- and 8 subsidy-based schemes. Of these, 13 contained an evaluation of the incentive scheme, of which 7 use quantitative criteria. Three cases provided sufficient data to conduct a cost-benefit analysis. Most qualitative evaluations related to the successful management of the program and the effectiveness of the promoted measures in the workplace. Regarding the latter, quantitative criteria covered accident rates, sick leave, and general improvement in working conditions. The cost-benefit analyses all resulted in a positive payout ratio, ranging from 1.01-4.81 euros return for every 1 euro invested. CONCLUSIONS: Generally, we found economic incentive schemes to be feasible and reasonably effective. However, analysis regarding the efficiency of such schemes is scarce and our evaluation of the cost-benefit analysis had to rely on few cases that, nevertheless, delivered positive results for large samples. Besides this finding, our study also revealed deficits in the quality of evaluations. In order to enable policy-makers to make well-informed decisions about public investments in OSH, better standards for reporting and evaluating incentive schemes are needed.

Anterior vertical osteotomy for mandibular narrowing: assessing short-term outcome.

BACKGROUND: The management of transverse maxillomandibular discrepancies, clinically known as crossbites, is a controversial and rarely discussed topic in both orthodontic and surgical literature. To evaluate the short-term stability of mandibular narrowing after the combination of anterior vertical symphyseal and bilateral sagittal split osteotomies, a prospective cohort study was completed. METHODS: Between December 1996 and June 2006, 40 patients underwent mandibular narrowing for the correction of substantial transverse maxillomandibular discrepancies resulting primarily from relative mandibular widening. Stability assessment was done on 26 patients who returned for the final evaluation. RESULTS: Follow-up periods ranged from 5 to 109 months (mean, 18 mo; N = 26). The stability of mandibular narrowing was evaluated by comparison of preoperative clinical assessment, lower dental impression, posteroanterior cephalogram, and occlusographic analysis with studies completed in the immediate postoperative period and at 6 to 12 months. At the short-term time point, mean mandibular location had relapsed 4.7 degrees in 21 patients. CONCLUSIONS: Although various methods of mandibular narrowing are well described, very little literature has examined its stability. Using an occlusographic analysis based on angular mandibular movement in a large patient cohort, we were able to demonstrate and quantify, for the first time, the relapse. It occurs in 81% of the patients, with a mean of 4.7 degrees.

A novel occlusographic analysis for assessment of mandibular narrowing.

Accurate evaluation of transverse mandibular dimension is a controversial and rarely addressed topic. Although mandibular narrowing via symphyseal osteotomy and bilateral ramus sagittal split was initially described more than 30 years ago, the development of a simple and effective clinical tool to assess the outcome of such procedures remains elusive. Although many quantitative modalities, such as frontal cephalogram, tomography, and interdental distance measurement, are in current use, each possesses significant liabilities. Prompted by a need for improved accuracy, simplicity, and reliability in the clinical setting, we developed and used a novel occlusographic analysis. The Madjidi occlusographic analysis does not rely on the position or tilt of moveable teeth; therefore, orthodontic changes do not influence quantification of mandibular position. Contours and mandibular relationships of interest are seen clearly, radiation is unnecessary, and occlusographic analysis can be quickly reproduced in the clinical setting using widely available materials. Although the evaluation of transverse mandibular dimension after surgical narrowing is frequently more controversial than accurate, the Madjidi occlusographic analysis is a reliably simple solution to an often complex problem.

The Treatment Satisfaction Scale (TSS) is a sensitive measure of treatment effectiveness for both patients and partners: results of a randomized controlled trial with vardenafil.

INTRODUCTION: Erectile dysfunction (ED) treatment studies do not routinely measure "treatment effectiveness," a function of treatment response (based on efficacy and tolerability) and treatment satisfaction (both patient and partner satisfaction). The ED Treatment Satisfaction Scale (TSS) is a brief, comprehensive self-report measure of patient and partner satisfaction. AIM: To measure, for the first time in an ED treatment study, pre- and post-treatment patient and partner satisfaction with the TSS. METHODS: A randomized, double-blind, placebo-controlled, parallel-group, multi-institutional comparison of the efficacy and safety of flexible-dose vardenafil was performed in 229 couples (treated man with ED >6 months and untreated woman partner aged > or =18 years without sexual dysfunction [defined as a total Female Sexual Function Index score >26.55]). MAIN OUTCOME MEASURES: Couples completed the TSS throughout the trial. Couples also completed the modified Sexual Life Quality Questionnaire-Quality of Life domain (mSLQQ-QoL) and men completed the International Index of Erectile Function-erectile function domain (IIEF-EF). Analysis of covariance produced least squares (LS) mean domain scores. Post hoc Pearson correlation coefficients were calculated for patient and partner TSS scores, and for TSS scores with other outcomes. RESULTS: TSS domain scores increased from baseline to last observation carried forward (LOCF) in the vardenafil-treated men and untreated women partners, but exhibited little change for the placebo group (P < 0.0001 vs. placebo). For both patients and partners in the vardenafil group, correlations between TSS domains, the IIEF-EF and the mSLQQ-QoL scores at LOCF were moderate to strong. CONCLUSIONS: The TSS detected that vardenafil was superior to placebo on treatment satisfaction from both patient and partner perspectives. The TSS holds promise for evaluating "treatment effectiveness" by measuring more general treatment satisfaction.

Distraction rate and latency: factors in the outcome of pediatric mandibular distraction.

BACKGROUND: Distraction osteogenesis was initially devised as a way to lengthen the lower extremity. All the basic tenets of the technique were developed based on this use. This includes both the supposed need for a latency period before distraction begins (3 to 5 days) and the ideal rate of distraction (1 mm/day). There is no evidence that these values apply to craniofacial distraction osteogenesis, particularly in children. Indeed, with the markedly improved blood supply in the face when compared with the lower extremity and the use of the technique in children versus adults, one might assume that a shorter latency period and a more rapid rate of distraction are possible. METHODS: This study is a retrospective review of 22 pediatric patients with mandibular hypoplasia undergoing mandibular distraction osteogenesis. All patients were operated on by a team consisting of an oral surgeon and a plastic surgeon. All the distraction devices used were external. All patients had a latency period, before activation, of less than 24 hours and a distraction rate of 2 mm/day. RESULTS: Two patients developed cellulitis at the pin sites, one patient developed premature healing, one patient developed a nonunion that required further surgery. This was the only patient in the series who had distraction of a previous bone graft. No patient undergoing distraction of native mandible developed a nonunion. CONCLUSIONS: Eliminating the latency period and rapidly distracting the mandible in pediatric cases has an acceptably low complication rate. This benefits the patient in terms of an overall reduction in the amount of time that the child needs to remain in the distraction device. The patient spends less time with the distraction device, thus reducing the potential morbidity and increased cost of the treatment. Potential explanations for why this variation in distraction technique is successful include the improved blood supply in the face of children and the failure of external devices to translate all the distracted movements to the bone interface. Some of this force is translated into both bending of the pins and migration of the pins through bone. Although a latency period might be necessary in the distraction of the lower extremities, the application of this concept to the craniofacial skeleton in children is erroneous.

Uncialamycin, a new enediyne antibiotic.

[structure: see text] Laboratory cultures of an undescribed streptomycete obtained from the surface of a British Columbia lichen produce uncialamycin (1), a new enediyne antibiotic. The structure of uncialamycin (1) has been elucidated by analysis of spectroscopic data. Uncialamycin (1) exhibits potent in vitro antibacterial activity against gram-positive and gram-negative human pathogens, including Burkholderia cepacia, a major cause of morbidity and mortality in patients with cystic fibrosis.

Vardenafil in patients with erectile dysfunction: achieving treatment optimization.

This post hoc analysis of data from a multicenter, randomized, double-blind study determined how many attempts were needed to record at least 1 successful penetration and maintenance of erection long enough for successful intercourse in a broad population of men with erectile dysfunction taking vardenafil at 5, 10, or 20 mg or placebo. The cumulative probability of achieving successful penetration and of maintaining an erection increased with the number of attempts for all 3 vardenafil groups. For the first attempt, the probability of achieving successful penetration was higher in all 3 vardenafil groups compared with placebo; 67% in the 5-mg vardenafil group, 77% in the 10-mg vardenafil group, and 74% in the 20-mg vardenafil group compared with 46% for placebo. By the third attempt, the probability of at least 1 success was 82% for 5, 88% for 10, and 85% for 20 mg vardenafil compared with 68% for placebo. The probability of maintaining an erection long enough to complete intercourse at the first attempt was 51% for 5, 69% for 10, and 61% for 20 mg vardenafil compared with 28% for the placebo group. By the third attempt, the probability of maintaining an erection was 66% for 5, 81% for 10, and 77% for 20 mg vardenafil in contrast to 53% for placebo. The results of this analysis indicate that patients without initial treatment success should continue treatment or increase the dose because the cumulative probability of success increases with additional attempts with vardenafil, with a plateau at about the fourth dose.

Penetration and maintenance of erection with vardenafil: a time-from-dosing analysis.

OBJECTIVE: To assess success rates in ability to penetrate (Sexual Encounter Profile question 2 [SEP2]) and maintain erections to completion of intercourse (SEP3) from time of dosing to start of sexual activity in a retrospective analysis of two pivotal trials. METHODS: In two randomized, double-blind studies, men with ED for > 6 months received vardenafil 5 mg, 10 mg, or 20 mg or placebo for 12-26 weeks. Patients were instructed to start sexual activity 1 hour after dosing. In this retrospective pooled analysis, patient diary questions through week 12 were analyzed, providing attempt data was recorded 0-12 hours post-dose. Mean per-patient SEP2 and SEP3 success rates (intent-to-treat population) were calculated by time between dosing and start of sexual activity, from 0-12 hours through week 12. Least-square means and nominal p-values for differences versus placebo were derived by analysis of covariance with terms for baseline, study and treatment. RESULTS: Most attempts at sexual intercourse occurred 30-90 minutes after dosing: 88%-93% of attempts occurred within 120 minutes. SEP2 success rates in patients choosing to attempt sexual activity in each interval from < or = 15 minutes through the 4-8-hour interval were higher with vardenafil compared with placebo, while SEP3 success rates were greater with vardenafil for patients choosing to initiate sexual activity from < or = 15 min through the 8-12-hour interval. The most commonly reported treatment-emergent adverse events in patients receiving vardenafil included headache (11%-22%), flushing (6%-13%), rhinitis (5%-13%), and dyspepsia (2%-7%). CONCLUSION: In this retrospective analysis of two pivotal trials, vardenafil improved success rates compared with placebo in ED patients who attempted intercourse from as early as 15 minutes or less and through 4-8 hours after dosing in ability to penetrate (SEP2) and from as early as 15 minutes or less and through 8-12 hours after dosing in maintenance of erection (SEP3).

Vardenafil provides reliable efficacy over time in men with erectile dysfunction.

OBJECTIVES: To evaluate the reliability of vardenafil efficacy and tolerability within 12 weeks in a broad population of men with erectile dysfunction (ED). METHODS: In a retrospective analysis of two pivotal, Phase III, randomized, double-blind, placebo-controlled trials conducted in 107 centers, 1650 men aged 18 years or older with ED received vardenafil 5 mg, 10 mg, or 20 mg on demand for 12 to 26 weeks. Outcome measures included the first-time and subsequent overall success rate until week 12 for diary entries regarding vaginal penetration (Sexual Encounter Profile [SEP]-2), erection maintenance (SEP-3), satisfaction with erection hardness, and overall satisfaction with the sexual experience. Mean efficacy was calculated for each patient during 12 weeks and then averaged for all patients within each treatment group. RESULTS: At baseline, the intention-to-treat population had moderate ED (International Index of Erectile Function-Erectile Function domain score of 13). For SEP-2 (penetration), the first-attempt and subsequent success rate was 44% and 74% for placebo, 71% and 81% for vardenafil 5 mg, 76% and 86% for vardenafil 10 mg, and 76% and 91% for vardenafil 20 mg, respectively. For SEP-3 (maintenance), first-attempt and subsequent success rate was 25% and 56% for placebo, 51% and 76% for vardenafil 5 mg, 65% and 76% for vardenafil 10 mg, and 59% and 84% for vardenafil 20 mg, respectively. For overall satisfaction with the sexual experience, the first-attempt and subsequent success rate was 19% and 48% for placebo, 48% and 68% for vardenafil 5 mg, 57% and 72% for vardenafil 10 mg, and 56% and 79% for vardenafil 20 mg, respectively. The reliability of vardenafil was similar or slightly greater in sildenafil-naive subjects compared with prior sildenafil responders. The most common adverse events were mild-to-moderate headache, flushing, and rhinitis. CONCLUSIONS: Vardenafil provides reliable efficacy for key erectile function parameters important to patients when continuing oral treatment for ED.

Vertical facial distraction in the treatment of arhinia.

Arhinia is a rare congenital malformation characterized by lack of the formation of external and internal nasal structures. Restricted midfacial growth is secondary to the loss of the midfacial growth centers. Staged reconstruction of the nasal passage and external nose is required. Vertical distraction osteogenesis is a beneficial step in the overall reconstructive program. This provides for additional bone and soft tissue for both improved aesthetic facial proportions and later surgical interventions.

Amniotic band sequence: the use of bone grafting and distraction osteogenesis.

Distraction has proven to be a useful technique in cases of severe bone deficiency in the craniofacial skeleton. This is a report of its use in the treatment of a child affected by amniotic band sequence. This 5 year old Hispanic female presented with transverse deficiences of one lower extremity and both upper extremities. Additionally, she was missing the mandible and overlying soft tissue from ramus to ramus. Although free fibula transfer was a possibility, due to the presence of only one lower extremity, it was elected to utilize the technique of distraction. After preliminary bone grafting to unite these two hemimanibles, the bone graft was distracted bilaterally to create a neomandible. Following consolidation and removal of the distraction devices, the child was markedly improved despite what appeared to be a pathologic fracture in the region of the mandibular angle. Repeat distraction was planned.