Explanatory pragmatism: a context-sensitive framework for explainable medical AI.

Explainable artificial intelligence (XAI) is an emerging, multidisciplinary field of research that seeks to develop methods and tools for making AI systems more explainable or interpretable. XAI researchers increasingly recognise explainability as a context-, audience- and purpose-sensitive phenomenon, rather than a single well-defined property that can be directly measured and optimised. However, since there is currently no overarching definition of explainability, this poses a risk of miscommunication between the many different researchers within this multidisciplinary space. This is the problem we seek to address in this paper. We outline a framework, called Explanatory Pragmatism, which we argue has two attractive features. First, it allows us to conceptualise explainability in explicitly context-, audience- and purpose-relative terms, while retaining a unified underlying definition of explainability. Second, it makes visible any normative disagreements that may underpin conflicting claims about explainability regarding the purposes for which explanations are sought. Third, it allows us to distinguish several dimensions of AI explainability. We illustrate this framework by applying it to a case study involving a machine learning model for predicting whether patients suffering disorders of consciousness were likely to recover consciousness.

Delphi developed syllabus for the medical specialty of sport and exercise medicine: part 2.

Training in the medical specialty of sport and exercise medicine (SEM) is available in many, but not all countries. In 2015, an independent Delphi group, the International Syllabus in Sport and Exercise Medicine Group (ISSEMG), was formed to create a basic syllabus for this medical specialty. The group provided the first part of this syllabus, by identifying 11 domains and a total of 80 general learning areas for the specialty, in December 2017. The next step in this process, and the aim of this paper was to determine the specific learning areas for each of the 80 general learning areas. A group of 26 physicians with a range of primary medical specialty qualifications including, Sport and Exercise Medicine, Family Medicine, Internal Medicine, Cardiology, Rheumatology and Anaesthetics were invited to participate in a multiple round online Delphi study to develop specific learning areas for each of the previously published general learning areas. All invitees have extensive clinical experience in the broader sports medicine field, and in one or more components of sports medicine governance at national and/or international level. SEM, Family Medicine, Internal Medicine, Cardiology, Rheumatology and Anaesthetics were invited to participate in a multiple round online Delphi study to develop specific learning areas for each of the previously published general learning areas. All invitees have extensive clinical experience in the broader sports medicine field, and in one or more components of sports medicine governance at national and/or international level. The hierarchical syllabus developed by the ISSEMG provides a useful resource in the planning, development and delivery of specialist training programmes in the medical specialty of SEM.

Impact of Medications for Opioid Use Disorder on Discharge Against Medical Advice Among People Who Inject Drugs Hospitalized for Infective Endocarditis.

BACKGROUND AND OBJECTIVES: The impact of medications for opioid use disorder (MOUD) on against medical advice (AMA) discharges among people who inject drugs (PWID) hospitalized for endocarditis is unknown. METHODS: A retrospective review of all PWID hospitalized for endocarditis at our institution between 2016 and 2018 (n = 84). RESULTS: PWID engaged with MOUD at admission, compared with those who were not, were less likely to be discharged AMA but this did not reach statistical significance in adjusted analysis (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.033-1.41; P = .11). Among out-of-treatment individuals, newly initiating MOUD did not lead to significantly fewer AMA discharges (OR, 0.98; 95% CI, 0.26-3.7; P = .98). CONCLUSION AND SCIENTIFIC SIGNIFICANCE: PWID hospitalized for endocarditis are at high risk for discharge AMA but more research is needed to understand the impact of MOUD. (Am J Addict 2020;29:155-159).

Psychological Issues.

Psychological distress is common following a burn injury, and many burn survivors have pre-morbid psychiatric illnesses including mood and trauma-related disorders, and substance and alcohol use. This article is intended to be used by all interdisciplinary health care team members to improve the identification and treatment of common psychological concerns experienced by survivors and is organized to follow the general recovery timeline.

The Relationship Between COVID-19 and the Development of Depression: Implications on Mental Health.

Initially, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the virus responsible for coronavirus disease-2019 (COVID-19), was predominantly considered to primarily affect the respiratory system. However, later studies revealed that it also affects brain function through its ability to bind to the angiotensin-converting enzyme type 2 (ACE2) receptors expressed on neural cells. Our study involved a comprehensive review of literature aiming to investigate the relationship between COVID-19 and the development of depression. Our analysis shows a connection between these 2 conditions, as a consequence of the inflammatory response in the nervous system to the COVID-19 virus and the psychophysiological effects of the pandemic. In COVID-19 patients, depression can arise either due to the direct viral infection of the brain or as a result of an indirect immune response triggering neuroinflammation after a cytokine storm. The resulting depression can be treated with non-pharmacological therapies such as psychotherapy, antidepressant medications, or a combination of these treatments depending on the severity of the symptoms.

Giving Feedback.

Effective feedback is critical to medical education in that it promotes learning and ensures that benchmark learning objectives are achieved. Yet the nature of and response to feedback is variable. In this article, the authors provide a comprehensive review of the effective feedback literature. Namely, they discuss the various approaches to feedback, their advantages and disadvantages, as well as barriers to providing effective feedback. Finally, they offer suggestions for steps both the feedback giver and receiver can take to foster a culture of successful feedback in an academic and clinical setting.

Poor yield of Clostridium difficile testing algorithms using glutamate dehydrogenase antigen and C. difficile toxin enzyme immunoassays in a pediatric population with declining prevalence of clostridium difficile strain BI/NAP1/027.

We compared the performance of algorithmic Clostridium difficile infection (CDI) diagnosis with four molecular tests in children. Stool samples in patients 1-18 years old were tested with an algorithm (C. Diff Quik Chek Complete (QCC) reflexed to illumigene C. difficile); AmpliVue C. difficile (ACD); Lyra Direct C. difficile (Lyra); BD MAX C diff (BDM); and Xpert C. difficile (XCD). The gold standard was positivity by two tests. Sensitivity, specificity, positive predictive value, and negative predictive value were 85%, 99%, 93%, 97% for the algorithm; 21%, 99%, 78%, 87% for QCC's toxin component; 94%, 99%, 94%, 99% for ACD; 88%, 99%, 94%, 98% for Lyra; 94%, 100%, 100%, 99% for BDM, and 94%, 99%, 94% and 99% for XCD. 9.6% of samples were ribotype 027. Algorithms may detect CDI with lower sensitivity compared to molecular methods in children. This may be related to low prevalence of NAP-1/ribotype 027.

Management of Autoimmune Status Epilepticus.

Status epilepticus is a neurological emergency with increased morbidity and mortality. Urgent diagnosis and treatment are crucial to prevent irreversible brain damage. In this mini review, we will discuss the recent advances in the diagnosis and treatment of autoimmune status epilepticus (ASE), a rare form of the disorder encountered in the intensive care unit. ASE can be refractory to anticonvulsant therapy and the symptoms include subacute onset of short-term memory loss with rapidly progressive encephalopathy, psychiatric symptoms with unexplained new-onset seizures, imaging findings, CSF pleocytosis, and availability of antibody testing makes an earlier diagnosis of ASE possible. Neuroimmunomodulatory therapies are the mainstay in the treatment of ASE. The goal is to maximize the effectiveness of anticonvulsant agents and find an optimal combination of therapies while undergoing immunomodulatory therapy to reduce morbidity and mortality.

Clinical role of brexpiprazole in depression and schizophrenia.

Brexpiprazole, a serotonin-dopamine activity modulator, is the second D2 partial agonist to come to market and has been approved for the treatment of schizophrenia and as an adjunctive treatment in major depressive disorder. With less intrinsic activity than aripiprazole at the D2 receptor and higher potency at 5-HT2A, 5-HT1A, and α1B receptors, the pharmacological properties of brexpiprazole suggest a more tolerable side effect profile with regard to akathisia, extrapyramidal dysfunction, and sedation. While no head-to-head data are currently available, double-blind placebo-controlled studies show favorable results, with the number needed to treat (NNT) vs placebo of 6-15 for response in acute schizophrenia treatment and 4 for maintenance. NNT is 12 for response and 17-31 for remission vs placebo in major depression. In schizophrenia trials, treatment-emergent adverse effects (TEAEs) and discontinuation rates due to TEAEs were lower in treatment groups vs placebo (7.1%-9.2% vs 14.7%, respectively). Meanwhile, discontinuation rates due to TEAEs in depression studies were higher in treatment groups vs placebo (1.3%-3.5% vs 0-1.4%, respectively) and appeared dose dependent. Rates of akathisia are lower compared to those with aripiprazole and cariprazine, weight gain is more prominent than with aripiprazole, cariprazine, or ziprasidone, and sedation is less than with aripiprazole but more than with cariprazine. Brexpiprazole target dosing is 2-4 mg in schizophrenia and 2 mg in depression augmentation. Dose adjustments should be considered in hepatic or renal dysfunction and/or in poor cytochrome P450 2D6 metabolizers. While brexpiprazole represents an exciting second entry for D2 partial agonists with positive studies thus far, direct head-to-head comparisons will shed more light on the efficacy and side effect profile of brexpiprazole.

Role of Anticonvulsants in the Management of Posttraumatic Epilepsy.

Posttraumatic seizures (PTS) have been recognized as a major complication of traumatic brain injury (TBI). The annual incidence of TBI in the United States is 1.7 million. The role of anticonvulsants in the treatment of posttraumatic epilepsy (PTE) remains uncertain. Based on current studies, however, anticonvulsants have been shown to reduce early PTS occurring within the first 7 days, but little to no benefits have been shown in late PTS occurring after 7 days. In this paper, we provide a mini review of the role of anticonvulsants and current advances in the management of PTE.

Depression in primary care: Strategies for a psychiatry-scarce environment.

More than an algorithm to guide primary care providers through treatment options, integrated care, also called collaborative care, is a validated, systematic, multidisciplinary approach to depression treatment in primary care. Historically, integrated care emerged in response to a mismatch between a growing demand for mental health treatment and scarce mental healthcare resources. Working together, psychiatrists and primary care providers have demonstrated that the principles and tools of chronic disease management improve depression outcomes in primary care. Currently, most antidepressants are prescribed by primary care providers, but with disappointing rates of full, sustained remission. Primary care patients may derive the greatest benefit from existing depression treatment guidelines when they are melded with an approach informed by integrated care principles. This paper will present established guidelines for pharmacologic management of depression as part of a broader framework for depression treatment in the primary care office.