A Quantitative Assessment of ChatGPT as a Neurosurgical Triaging Tool.

BACKGROUND AND OBJECTIVES: ChatGPT is a natural language processing chatbot with increasing applicability to the medical workflow. Although ChatGPT has been shown to be capable of passing the American Board of Neurological Surgery board examination, there has never been an evaluation of the chatbot in triaging and diagnosing novel neurosurgical scenarios without defined answer choices. In this study, we assess ChatGPT's capability to determine the emergent nature of neurosurgical scenarios and make diagnoses based on information one would find in a neurosurgical consult. METHODS: Thirty clinical scenarios were given to 3 attendings, 4 residents, 2 physician assistants, and 2 subinterns. Participants were asked to determine if the scenario constituted an urgent neurosurgical consultation and what the most likely diagnosis was. Attending responses provided a consensus to use as the answer key. Generative pretraining transformer (GPT) 3.5 and GPT 4 were given the same questions, and their responses were compared with the other participants. RESULTS: GPT 4 was 100% accurate in both diagnosis and triage of the scenarios. GPT 3.5 had an accuracy of 92.59%, slightly below that of a PGY1 (96.3%), an 88.24% sensitivity, 100% specificity, 100% positive predictive value, and 83.3% negative predicative value in triaging each situation. When making a diagnosis, GPT 3.5 had an accuracy of 92.59%, which was higher than the subinterns and similar to resident responders. CONCLUSION: GPT 4 is able to diagnose and triage neurosurgical scenarios at the level of a senior neurosurgical resident. There has been a clear improvement between GPT 3.5 and 4. It is likely that the recent updates in internet access and directing the functionality of ChatGPT will further improve its utility in neurosurgical triage.

MRI order appropriateness for chronic neck pain: Comparison of ordering practices and treatment outcomes for primary care physicians and specialists.

Chronic neck pain is a common reason for doctor visits in the United States. This diagnosis can be evaluated through patient history, physical examination, and judicious use of radiographs. However, possible inappropriate magnetic resonance imaging (MRI) ordering persists. We hypothesized that no difference in ordering practices, ordering appropriateness, and subsequent intervention would be appreciated regarding physician specialty, location, patient characteristics, and history and physical exam findings. A multisite retrospective review of cervical spine MRI between 2014 and 2018 was performed. A total of 332 patients were included. Statistical analysis was used to assess MRI order appropriateness, detail of history and physical exam findings, and intervention decision-making among different specialties. If significant differences were found, multiple linear regression was performed to evaluate the association of MRI order appropriateness regarding physician specialty, location, patient characteristics and history, and physical exam findings. The significance level for all tests was set at <0.05 Orthopedic surgeons ordered MRIs most appropriately with an average American College of Radiology (ACR) score of 8.4 (p < 0.005). Orthopedic surgeons had more comprehensive physical exams as compared to the remaining specialties. The decision for intervention did not vary by physician specialty or ACR score, except for patients of pain medicine physicians who received pain management (p = 0.000). Orthopedic surgeons utilize MRI most appropriately and have more comprehensive physical exams. These findings suggest a need for increased physician education on what indicates an appropriate MRI order to improve the use of resources and further protect patient risk-benefit profiles. Further research elucidating factors to minimize negative findings in "appropriate" MRIs is indicated. Clinical significance: More detailed physical exams may lead to more appropriately ordered MRIs, subsequently resulting in surgery or procedures being performed when appropriately indicated. This suggests the need for increased physician education on when MRI ordering is appropriate for chronic neck pain to improve the use of resources and further protect patient risk-benefit profiles.

Polymorphous low-grade neuroepithelial tumor of the young with FGFR3-TACC3 fusion mimicking high-grade glioma: case report and series of high-grade correlates.

Background: Polymorphous low-grade neuroepithelial tumor of the young (PLNTY) is a recently described entity that can mimic high-grade glioma (HGG) in histologic and molecular features; however, factors predicting aggressive behavior in these tumors are unclear. Methods: We present an indolent neuroepithelial neoplasm in a 59-year-old female with imaging initially suggestive of HGG, and a series of adult patients with HGG harboring FGFR3-TACC3 fusions are also presented for comparison. Results: Pathology in the case patient revealed low-grade cytomorphology, microcalcifications, unusual neovascularization, and a low proliferation index. The lesion was diffusely CD34+ and harbored an FGFR3-TACC3 fusion and TERT promoter mutation. A diagnosis of PLNTY was therefore favored and the patient was observed with no progression at 15-month follow-up. In patients with HGG with FGFR3-TACC3 fusions, molecular findings included IDH-wildtype status, absence of 1p19q codeletion, CDKN2A loss, TERT promoter mutations and lack of MGMT promoter methylation. These patients demonstrated a median 15-month overall survival and a 6-month progression-free survival. Conclusion: PLNTY is a rare low-grade entity that can display characteristics of HGG, particularly in adults. Presence of FGFR3-TACC3 fusions and other high-grade features should raise concern for a more malignant precursor lesion when a diagnosis of PLNTY is considered.

Endoscopic Third Ventriculostomy Using Penumbra Artemis™ Neuro Evacuation Device: Technical Case Report and Operative Video.

Endoscopic third ventriculostomy (ETV) is an effective cerebrospinal fluid diversion procedure but can be complicated by the presence of a high-riding basilar artery (BA). A 70-year-old female presented with obstructive hydrocephalus caused by melanoma metastatic to the brainstem in the setting of a high-riding BA. ETV was successfully performed using the Penumbra Artemis™ Neuro evacuation device (Artemis; Penumbra Inc, Alameda, CA, USA) to minimize the risk of injury to the BA. This is to our knowledge the first known Artemis-assisted ETV reported in the English literature, which may reduce the risk of BA injury in selected patients. Further characterization of the benefits and limitations of this procedure is needed.

Pituitary metastases: a case series and scoping review.

PURPOSE: To understand the natural history and optimal treatment strategy for pituitary gland metastasis. METHODS: We performed both a retrospective chart review of patients treated at our institution and a scoping review of the topic. RESULTS: The retrospective review identified seven patients with an average age of 59.6 years. Primary histologies included breast cancer (4), melanoma (1), renal cell carcinoma (1), and sarcoma (1). Two patients had anterior pituitary endocrine dysfunction, one of whom was the only patient with visual symptoms. All patients were treated with radiosurgery and two also underwent surgical resection. Overall survival ranged from 6.5 to 117 months. Literature review identified 166 patients from 71 studies. The most common primary cancer was lung (27.7%), followed by breast (18.7%) and renal (14.5%) cancer. 107 presented with endocrine dysfunction, including 41 cases of diabetes insipidus and 55 cases of hypopituitarism. 110 presented with visual compromise. 107 patients received radiotherapy, 96 underwent surgical resection and 44 received systemic chemotherapy/immunotherapy. Surgery was significantly associated with an increased likelihood of vision improvement and a decreased likelihood of endocrine normalization. Radiographic regression predicted visual improvement. Median overall survival was 9.9 months (range: 0.2-96). CONCLUSIONS: This scoping review showed that both radiosurgery and surgical resection have been frequently used to treat pituitary metastases with good response. Vision improvement is more likely to happen following surgical resection, likely at the expense of endocrine dysfunction. Despite treatment and radiographic response, patient survival remains less than a year.

Gastric Outlet Obstruction and Iron Deficiency Anemia Secondary to Gastric Bezoar: A Case Report.

Trichobezoars are an accumulation of undigested hair in the gastrointestinal system. They are a rare finding and are more likely in young females. Diagnosis is largely dependent on history taking and imaging, and treatment involves the removal and psychiatric evaluation.  We describe the case of a 21-year-old female with a history of gastroesophageal reflux disease (GERD) who presented with abdominal pain. Imaging showed a distended stomach with a suspected swallowed foreign substance. The patient subsequently underwent midline laparotomy, gastrotomy, and bezoar extraction. Postoperatively the patient was found to have trichotillomania, trichophagia, anxiety, depression, and symptomatic anemia. Initial management of gastric bezoars includes proper removal, but the additional follow-up needs to include psychiatric evaluation and treatment to prevent reoccurrence. It is also imperative to assess and treat underlying nutritional deficiencies.

The Effect of Derotational Kirschner Wires on Fracture Gap Reduction With Variable-Pitch Headless Screws.

PURPOSE: We evaluated the impact of angled derotational Kirschner wires (K-wires) on fracture gap reduction with variable-pitch headless screws. METHODS: Fully threaded variable-pitch headless screws (20 and 28 mm) were inserted into "normal" bone models of polyurethane blocks. In separate trials, derotational K-wires were inserted at predetermined angles of 0°, 15°, 30°, and 40° and compared with each other, with no K-wire as a control. Fluoroscopic images taken after each screw turn were analyzed. The optimal fracture gap closure, initial screw push-off, and screw back-out gap creation were determined and compared at various derotational K-wire angles. RESULTS: Initial screw push-off due to screw insertion and screw back-out gap creation were not significantly affected by the angle of the derotational K-wire. With a 20-mm screw, only a 40° derotational K-wire led to significantly less gap closure compared with control and with 0°, 15°, and 30° derotational K-wires. It led to an approximately 60% decrease in gap closure compared with no K-wire. With the 28-mm screw, compared with no K-wire, 15° and 30° derotational K-wires led to statistically significant decreases in gap closure (approximately 25%), whereas a 40° derotational K-wire led to an approximately 60% decrease. With the 28-mm screw, the 40° derotational K-wire also led to a statistically significant smaller gap closure when compared with 0°, 15°, and 30° derotational K-wires. CONCLUSIONS: A derotational K-wire placed in parallel to the planned trajectory of a headless compression screw does not affect fracture gap closure. With greater angulation of the derotational K-wire, the fracture gap is still closed, but less tightly. CLINICAL RELEVANCE: Derotational K-wires can help prevent fracture fragment rotation during headless compression screw insertion. At small deviations from parallel (≤30°), fracture gap closure achieved by the screw is minimally affected. At greater angles (ie, 40°), fracture gap closure may be substantially reduced, preventing fracture compression.

Risk Factors for Loss of Reduction After Open Reduction and Internal Fixation of Isolated Olecranon Fractures in Adults.

BACKGROUND: We sought to determine whether any relevant patient, fracture, surgical, or postoperative characteristics are associated with loss of reduction after plate fixation of isolated olecranon fractures in adults. METHODS: Patients who underwent open reduction and internal fixation of an olecranon fracture at our institution over an 11-year period were analyzed. Electronic patient charts and radiographic images were reviewed to gather patient, fracture, surgical, and postoperative data. Statistical analysis to explore the differences between groups was performed. RESULTS: Seven of 96 patients experienced a loss of fracture reduction diagnosed at a median of 19 days after their initial surgery (range: 4-116 days). The radiographic mode of failure of all patients who lost reduction was proximal migration of the proximal fracture fragment with or without implant failure. The group that lost reduction had a significantly smaller proximal fragment (14.2 vs 18.6 mm), a higher incidence of malreduction with a persistent articular step-off greater than 2 mm (6/7 vs 14/89), a greater distance between the most proximal screw and the olecranon tip (19.8 vs 13.5 mm), a higher proportion of constructs with screws placed outside of the primary plate (4/7 vs 14/89), and a higher proportion of patients that were not immobilized postoperatively (3/7 vs 8/89). CONCLUSIONS: Our results suggest anatomical reduction at the articular surface and adequate fixation of the proximal fragment are key factors in maintenance of reduction, with smaller proximal fragments being at higher risk for failure. A period of postoperative immobilization may decrease the risk of loss of reduction.

Written Prescription for Over-the-Counter Nonopioid Pain Medications Does Not Increase the Likelihood of Use after Ambulatory Hand and Upper Extremity Surgery.

Introduction This study looked to determine how providing written prescriptions of nonopioids affected postoperative pain medication usage and pain control. Materials and Methods Patients undergoing hand and upper-extremity surgery ( n = 244) were recruited after the implementation of a postoperative pain control program encouraging nonopioids before opioids. Patients were grouped based on procedure type: bone ( n = 66) or soft tissue ( n = 178). Patients reported postoperative medication consumption and pain control scores. Two-tailed t -tests assuming unequal variance were performed to look for differences in postoperative pain control and medication consumption between those who were and were not given written prescriptions for nonopioids. Results For both soft tissue and bone procedure patients, a written prescription did not significantly affect patients' postoperative pain control or medication consumption. Regardless of receiving a written prescription, patients who underwent soft tissue procedures consumed significantly more daily nonopioids than opioids. Conclusion Receiving written prescriptions for nonopioids may not have a significant effect on postoperative pain control or medication consumption. Patients undergoing soft tissue hand and upper extremity procedures may be more likely to consume more daily nonopioids than opioids postoperatively compared to bone procedure patients regardless of whether they receive a written prescription for nonopioids.

Pubic root fractures are commonly misread as anterior column fractures by radiologists: Single-institution study from a level 1 trauma center.

BACKGROUND: We sought to determine how frequently pubic root fracture is incorrectly identified as anterior column fracture by radiologists and describe differences in characteristics and outcomes between injury patterns. METHODS: We identified 155 patients who sustained pelvic or acetabular fractures at a single, level 1 trauma academic institution. Pelvis computed tomography (CT) scans were evaluated to determine whether patients sustained an anterior column fracture or pubic root fracture. Demographic and clinical factors such as mortality, ambulatory status, type of treatment (nonoperative/surgery), and mechanism of energy were assessed. RESULTS: There were a total of 83 patients in the anterior column group and 72 patients in the pubic root cohort. Eighty-five percent of pubic root fractures were read as anterior column fractures by radiologists. A total of 77.8% of pubic root fractures had posterior ring involvement. Patients with true anterior column acetabular fracture were more likely to need surgery (63.86% vs 41.70%, P = 0.01) and be discharged to skilled nursing or inpatient rehabilitation (59.04% vs 40.27%, P = 0.02) compared to patients with pubic root fracture. CONCLUSION: Pubic root fractures are frequently misread as anterior column fractures in radiology reports. Correctly diagnosing pubic root fractures and differentiating them from anterior column acetabular fractures can have significant impact on patients. LEVEL OF EVIDENCE: III, Therapeutic.

Use of dual mobility components in total hip arthroplasty: Indications and outcomes.

Instability after total hip arthroplasty (THA) can be a problematic complication and remains one of the leading causes of revision surgery in the early post-operative period. Dual mobility (DM) implants decrease dislocation risk after THA but they come with their own set of complications. Selective use of DM implants for THA in high risk groups can confer the advantages of this construct while mitigating the risks. In this paper, we review the current literature to examine the evidence for or against use of DM implants in various clinical scenarios and provide an algorithm for when to consider using DM design construct in THA.

Malignant spinal cord compression.

Malignant spinal cord compression (MSCC) is a potentially devastating consequence of cancer. Early recognition of the signs and symptoms of MSCC can allow diagnosis prior to the development of irreversible complications. Information provision to patients and doctors regarding the risk of MSCC and a streamlined pathway for further investigation are both key to improving the outcome for patients developing this condition. Described in this paper is the development of such a pathway at Aberdeen Royal Infirmary.

Assimilating intraoperative data with brain shift modeling using the adjoint equations.

Biomechanical models of brain deformation are increasingly being used to nonrigidly register preoperative MR (pMR) images of the brain to the surgical scene. These model estimates can potentially be improved by incorporating sparse displacement data available in the operating room (OR), but integrating the intraoperative information with model calculations is a nontrivial problem. We present an inverse method to estimate the unknown boundary and volumetric forces necessary to achieve a least-squares fit between the model and the data that is formulated in terms of the adjoint equations, which are solved directly by the method of representers. The scheme is illustrated in a 2D simulation and in a 2D approximation based on a patient case using actual OR data.

2-Amino-2-thiazoline and its 1:1 organic salt with 2-naphthoxyacetic acid.

The crystal structures of 2-amino-2-thiazoline, C3H6N2S, and 2-amino-2-thiazolinium 2-naphthoxyacetate, C3H7N2S+.C12H9O3-, are reported. The structure of 2-amino-2-thiazoline consists of two unique molecules that construct a convoluted hydrogen-bonded ribbon involving R(2)2(8) graph-set association via both N-H...N and N-H...S interactions. The organic salt structure consists of the two molecules associated via an R(2)2(8) graph-set dimer through N-H...O interactions, with the hydrogen-bonding network propagated via additional N-H...O three-centre interactions from the second 2-amine H atom.

1-(4-chlorophenylsulfanyl)-2-nitro-4-(trifluoromethyl)benzene and 1-(4-chlorophenylsulfanyl)-4-nitro-2-(trifluoromethyl)benzene.

Two chemical isomers of 3-nitrobenzotrifluoride, namely 1-(4-chlorophenylsulfanyl)-2-nitro-4-(trifluoromethyl)benzene, C(13)H(7)ClF(3)NO(2)S, (I), and 1-(4-chlorophenylsulfanyl)-4-nitro-2-(trifluoromethyl)benzene, C(13)H(7)ClF(3)NO(2)S, (II), have been prepared and their crystal structures determined with the specific purpose of forming a cocrystal of the two. The two compounds display a similar conformation, with dihedral angles between the benzene rings of 83.1 (1) and 76.2 (1) degrees, respectively, but (I) packs in P-1 while (II) packs in P2(1)/c, with C-H.O interactions. No cocrystal could be formed, and it is suggested that the C-H.O associations in (II) prevent intermolecular mixing and promote phase separation.