Exploring Generative Artificial Intelligence-Assisted Medical Education: Assessing Case-Based Learning for Medical Students.

The recent public release of generative artificial intelligence (GenAI) has brought fresh excitement by making access to GenAI for medical education easier than ever before. It is now incumbent upon both students and faculty to determine the optimal role of GenAI within the medical school curriculum. Given the promise and limitations of GenAI, this study aims to assess the current capabilities of a GenAI (Chat Generative Pre-trained Transformer, ChatGPT), specifically within the framework of a pre-clerkship case-based active learning curriculum. The role of GenAI is explored by evaluating its performance in generating educational materials, creating medical assessment questions, answering medical queries, and engaging in clinical reasoning by prompting it to respond to a problem-based learning scenario. Our results demonstrated that GenAI addressed epidemiology, diagnosis, and treatment questions well. However, there were still instances where it failed to provide comprehensive answers. Responses from GenAI might offer essential information, hint at the need for further inquiry, or sometimes omit critical details. GenAI struggled with generating information on complex topics, raising a significant concern when using it as a 'search engine' for medical student queries. This creates uncertainty for students regarding potentially missed critical information. With the increasing integration of GenAI into medical education, it is imperative for faculty to become well-versed in both its advantages and limitations. This awareness will enable them to educate students on using GenAI effectively in medical education.

Traumatic Brain Injury, Electrolyte Levels, and Associated Outcomes: A Systematic Review.

INTRODUCTION: Although it has been established that electrolyte abnormalities are a consequence of traumatic brain injury (TBI), the degree to which electrolyte imbalances impact patient outcomes has not been fully established. We aim to determine the impact of sodium, potassium, calcium, and magnesium abnormalities on outcomes in patients with TBI. METHODS: Four databases were searched for studies related to the impact of electrolyte abnormalities on outcomes for TBI patients. Outcomes of interest were rates of mortality, Glasgow Outcome Scale (GOS), and intensive care unit length of stay (ICU-LOS). The search included studies published up to July 21, 2022. Articles were then screened and included if they met inclusion and exclusion criteria. RESULTS: In total, fourteen studies met inclusion and exclusion criteria for analysis in this systematic review. In patients with TBI, an increased mortality rate was associated with hypernatremia, hypokalemia, and hypocalcemia in the majority of studies. Both hyponatremia and hypomagnesemia were associated with worse GOS at 6 months. Whereas, both hyponatremia and hypernatremia were associated with increased ICU-LOS. There was no evidence to suggest other electrolyte imbalances were associated with either GOS or ICU-LOS. CONCLUSIONS: Hyponatremia and hypomagnesemia were associated with worse GOS. Hypernatremia was associated with increased mortality and ICU-LOS. Hypokalemia and hypocalcemia were associated with increased mortality. Given these findings, future practice guidelines should consider the effects of electrolytes' abnormalities on outcomes in TBI patients prior to establishing management strategies.

Outcomes of Transfusion With Whole Blood, Component Therapy, or Both in Adult Civilian Trauma Patients: A Systematic Review and Meta-Analysis.

INTRODUCTION: This systematic review and meta-analysis was conducted to compare outcomes, including transfusion volume, complications, intensive care unit length of stay, and mortality for adult civilian trauma patients transfused with whole blood (WB), components (COMP), or both (WB + COMP). METHODS: A systematic review and meta-analysis were conducted using studies that evaluated outcomes of transfusion of WB, COMP, or WB + COMP for adult civilian trauma patients. A search of PubMed, Embase, and Cochrane from database inception to March 3, 2022 was conducted. The search resulted in 18,400 initial articles with 16 studies remaining after the removal of duplicates and screening for inclusion and exclusion criteria. RESULTS: This study identified an increased risk of 24-h mortality with COMP versus WB + COMP (relative risk: 1.40 [1.10, 1.78]) and increased transfusion volumes of red blood cells with COMP versus WB at 6 and 24 h, respectively (-2.26 [-3.82, -0.70]; -1.94 [-3.22, -0.65] units). There were no differences in the calculated rates of infections or intensive care unit length of stay between WB and COMP, respectively (relative risks: 1.35 [0.53, 3.46]; -0.91 [-2.64, 0.83]). CONCLUSIONS: Transfusion with WB + COMP is associated with lower 24-h mortality versus COMP and transfusion with WB is associated with a lower volume of red blood cells transfused at both 6 and 24 h. Based on these findings, greater utilization of whole blood in civilian adult trauma resuscitation may lead to improved mortality and reduced transfusion requirements.

Comparing Outcomes of Appendectomy Versus Non-operative Antibiotic Therapy for Acute Appendicitis: A Systematic Review and Meta-Analysis of Randomized Clinical Trials.

BACKGROUND: Acute appendicitis is one of the most common etiologies of an acute abdomen in the emergency department and first-line standard surgical care for the condition has recently been reconsidered. We aim to evaluate the effectiveness and outcomes of surgical intervention versus non-operative antibiotic therapy in the treatment of acute appendicitis in adult and pediatric patients. METHODS: A literature search was conducted using PubMed, Google Scholar, and EMBASE. The search included all studies until January 15th, 2022. Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines were followed for abstracting data and assessing data quality and validity. Data were independently extracted by the authors of the study. Meta-analysis was performed and Cohen's Q test for heterogeneous effects was performed to determine if fixed or random-effects models were appropriate for use. RESULTS: Twelve randomized controlled trials investigating a total of 3703 acute appendicitis patients met inclusion criteria and were included in the meta-analysis. In the systematic review, eleven RCTs demonstrated that appendectomy had improved effectiveness compared to non-operative antibiotic management. The meta-analysis demonstrated that patients undergoing appendectomy had significantly higher treatment effectiveness compared with antibiotics-only treatment (98.4% vs. 73.3%, P < .0001). The meta-analysis did demonstrate a significant .54-day reduction in hospital length of stay for the appendectomy group compared to the non-operative antibiotic therapy group. CONCLUSIONS: Surgical intervention is associated with increased effectiveness of treatment and reduced in-hospital length of stay among patients with acute appendicitis. Guidelines established by institutions and surgical organizations should indicate appendectomy as the standard and superior treatment option for patients presenting with acute appendicitis.

Standardized Medical Coding Curriculum in Surgical Graduate Medical Education.

INTRODUCTION: Despite the increasing importance of coding and billing in healthcare as a whole and calls from the Accreditation Council for Graduate Medical Education (ACGME) to emphasize systems-based practice, many surgical training programs have not prioritized coding and billing within their curricula. We aim to evaluate the performance of surgical residents and early career surgeons in coding and billing and to appraise interventions to improve coding and billing abilities within this group. METHODS: A literature search from conception to March 15th, 2022 utilizing PubMed, Google Scholar, and EMBASE was conducted to search for studies that evaluate surgical resident coding practices and interventions to improve practice management and financial competency. RESULTS: Discrepancies in coding and billing ability are prominent between residents, surgeons, and professional coders. One study demonstrated coding accuracy of 76.5% for professional coders, 62.1% for surgical attendings, and 54.1% for surgical residents, whereas another study reported a 52.82% coding accuracy and residents. Resident performance in coding and billing was inferior to their more experienced surgical attending counterparts and professional coders. Surgical residents and fellows demonstrated significantly improved knowledge and confidence in coding following the administration of either individual or longitudinal educational interventions. CONCLUSION: Coding and billing discrepancies among students, residents, and surgeons persist due to a lack of formalized training. Integration of standardized and mandated medical coding curricula and interventions within residency programs has great potential to improve surgical coding practices and should be a mandatory component of graduate medical education.

Palliative Care in the Trauma and Surgical Critical Care Settings: A Narrative Review.

BACKGROUND: We aimed to conduct a narrative review of available literature to understand the use of palliative care in the trauma and surgical critical care setting. METHODS: PubMed, EMBASE, and Google Scholar databases were searched for studies investigating the use of palliative care in the trauma and surgical critical care setting. The search included all studies published through January 9th, 2022. The risk of bias of included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist tools. Outcomes were summarized in tables and synthesized qualitatively. RESULTS: A total of 22 studies were included in this review. Key elements of successful palliative care include communication, shared decision-making, family involvement, pain control, establishing a patient's prognosis, and end-of-life management. Approaches to implementation based upon these key elements include best-case/worst-case scenarios, consultation trigger systems, and integrated institutional palliative care programs. Palliative care may reduce hospital length of stay, improve symptom management, and increase patient satisfaction, but the impact on mortality is unclear. CONCLUSION: The core elements of palliative care have been identified and palliative care has been shown to improve outcomes in trauma and surgical critical care. However, the approaches for implementation still require development. The underutilization of palliative care for trauma patients reveals the need for refining criteria for use of palliative care and improvement in the education of surgical critical care teams to provide primary palliative care services.

Comprehensive Assessment of Burnout Among Surgical Trainees and Practicing Surgeons: A Systematic Review.

OBJECTIVE: Surgeon burnout has received increasing attention due to evidence of high prevalence across specialties. We aimed to (1) systematically characterize existing definitions of burnout, (2) evaluate tools to measure burnout, and (3) determine risk factors of surgical burnout. DESIGN: PubMed, Google Scholar, and Embase databases were searched to identify burnout rates and tools used to measure the quality of life (QoL) published from January 2000-December 2021. PARTICIPANTS: Surgical Trainees and Practicing Surgeons. RESULTS: We identified 39 studies that defined surgical burnout, with 9 separate tools used to measure QoL. Surgeon burnout rates were found to be highest among general surgery trainees (20%-95%). Burnout among general surgery attendings ranged from 25% to 44%. Those most likely to experience burnout were younger and female. High rates of surgeon burnout were reported among all surgical specialties; however, these rates were lower than those of general surgeons. CONCLUSION: Definitions of burnout vary throughout the surgical literature, but are consistently characterized by emotional exhaustion, depersonalization, and lack of personal accomplishment. The most utilized tool to measure surgical burnout has been the Maslach Burnout Inventory. Across specialties, there are high rates of burnout in both surgical trainees and attendings, indicating that this is a systemic issue within the field of surgery. Given the wide-scale nature of the problem, it is recommended that institutions provide support to surgical trainees and attending surgeons and that individual surgeons take steps toward mitigating burnout.

Gender Distribution of First and Senior Authorship Across Most Cited Studies Within the Top Ten Surgical Journals From 2015-2020: Cementing Women Academic Surgery Representation.

INTRODUCTION: The aim of this study is to investigate the gender distribution of first and senior authors in the most highly cited original research studies published in the top 10 surgical journals from 2015 to 2020 to identify disparities and changes over time. METHODS: A retrospective study analyzing the gender distribution of first and senior authors in the top 10 most cited studies from the top 10 surgical journals from 2015 to 2020. The genders of the first and senior authors of each study were assessed using National Provider Identifier (NPI) numbers or pronouns from institutional biographies or news articles. RESULTS: The genders of 1200 first and senior authors from 600 original research studies were assessed. First author gender distribution consisted of 71.8% men, 22.3% women, 0% non-binary, and 5.8% unknown. Senior author gender distribution was 82.3% men, 14.3% women, 0% non-binary, and 3.3% unknown. Studies published by first authors who are women received more citations than those published by first authors that are men in 2015 (169.1 versus 112.9, P = 0.002) and 2016 (144.2 versus 101.5, P = 0.011). There was an increase in first authorship among men from 2015 to 2020 (P = 0.035). CONCLUSIONS: Men represent a significantly higher proportion of both first and senior authorships in top surgical research and the gap has widened from 2015 to 2020. However, studies written by women first authors received significantly more citations than those written by men.

Evaluation of Citation Inaccuracies in Surgical Literature by Journal Type, Study Design, and Level of Evidence: Towards Safeguarding the Peer-Review Process.

BACKGROUND: Accurate citation practices are key to furthering knowledge in an efficient and valid manner. The aim of this study is to investigate the prevalence of citation inaccuracies in original research from the top-ranked surgical journals and to evaluate the impact level of evidence has on citation inaccuracy. METHODS: A retrospective study evaluating the citation accuracy of the top 10 ranked surgical journals using the SJCR indicators. For each year between 2015 and 2020, the top 10 cited studies were selected, totaling 60 studies from each journal. From each individual study, 10 citations were randomly selected and evaluated for accuracy. Categories of inaccuracy included fact not found, study not found, contradictory conclusion, citation of a citation, and inaccurate population. RESULTS: A total of 5973 citations were evaluated for accuracy. Of all the citations analyzed, 15.2% of them had an inaccuracy. There was no statistically significant difference in citations inaccuracy rates among the years studied (P = .38) or study level of evidence (P = .21). Annals of Surgery, Plastic and Reconstructive Surgery and Annals of Surgical Oncology had significantly more citation inaccuracies than other journals evaluated (P < .05). JAMA Surgery, The Journal of Endovascular Therapy and The Journal of Thoracic and Cardiovascular Surgery had significantly fewer citation inaccuracies. CONCLUSIONS: Although 84.8% of citations from 2015-2020 were determined to be accurate, citation inaccuracies continue to be prevalent throughout highly-ranked surgical literature. There were no significant differences identified in citation inaccuracy rates between the years evaluated or based on study level of evidence.

GLP-1 and Insulin Recruit Muscle Microvasculature and Dilate Conduit Artery Individually But Not Additively in Healthy Humans.

CONTEXT: Glucagon-like peptide-1 (GLP-1) and insulin increase muscle microvascular perfusion, thereby increasing tissue endothelial surface area and nutrient delivery. OBJECTIVE: To examine whether GLP-1 and insulin act additively on skeletal and cardiac microvasculature and conduit artery. DESIGN: Healthy adults underwent three study protocols in random order. SETTING: Clinical Research Unit at the University of Virginia. METHODS: Overnight-fasted participants received an intravenous infusion of GLP-1 (1.2 pmol/kg/min) or normal saline for 150 minutes with or without a 2-hour euglycemic insulin clamp (1 mU/kg/min) superimposed from 30 minutes onward. Skeletal and cardiac muscle microvascular blood volume (MBV), flow velocity, and flow; brachial artery diameter, flow velocity, and blood flow; and pulse wave velocity (PWV) were measured. RESULTS: GLP-1 significantly increased skeletal and cardiac muscle MBV and microvascular blood flow (MBF) after 30 minutes; these remained elevated at 150 minutes. Insulin also increased skeletal and cardiac muscle MBV and MBF. Addition of insulin to GLP-1 did not further increase skeletal and cardiac muscle MBV and MBF. GLP-1 and insulin increased brachial artery diameter and blood flow, but this effect was not additive. Neither GLP-1, insulin, nor GLP-1 and insulin altered PWV. Combined GLP-1 and insulin infusion did not result in higher whole-body glucose disposal. CONCLUSION: GLP-1 and insulin at physiological concentrations acutely increase skeletal and cardiac muscle microvascular perfusion and dilate conduit artery in healthy adults; these effects are not additive. Thus, GLP-1 and insulin may regulate skeletal and cardiac muscle endothelial surface area and nutrient delivery under physiological conditions.

Denitrogenative hydrofluorination of aromatic aldehyde hydrazones using (difluoroiodo)toluene.

An operationally simple conversion of aromatic aldehyde hydrazones to monofluoromethylated arenes is reported. The hypervalent iodine reagent TolIF2 serves as an oxidant, converting the hydrazone to the corresponding diazo compounds. The by-product of the oxidation process, HF, is consumed in situ by a denitrogenative hydrofluorination reaction of the diazo group.

GLP-1 at physiological concentrations recruits skeletal and cardiac muscle microvasculature in healthy humans.

Muscle microvascular surface area determines substrate and hormonal exchanges between plasma and muscle interstitium. GLP-1 (glucagon-like peptide-1) regulates glucose-dependent insulin secretion and has numerous extrapancreatic effects, including a salutary vascular action. To examine whether GLP-1 recruits skeletal and cardiac muscle microvasculature in healthy humans, 26 overnight-fasted healthy adults received a systemic infusion of GLP-1 (1.2 pmol/kg of body mass per min) for 150 min. Skeletal and cardiac muscle MBV (microvascular blood volume), MFV (microvascular flow velocity) and MBF (microvascular blood flow) were determined at baseline and after 30 and 150 min. Brachial artery diameter and mean flow velocity were measured and total blood flow was calculated before and at the end of the GLP-1 infusion. GLP-1 infusion raised plasma GLP-1 concentrations to the postprandial levels and suppressed plasma glucagon concentrations with a transient increase in plasma insulin concentrations. Skeletal and cardiac muscle MBV and MBF increased significantly at both 30 and 150 min (P<0.05). MFV did not change in skeletal muscle, but decreased slightly in cardiac muscle. GLP-1 infusion significantly increased brachial artery diameter (P<0.005) and flow velocity (P=0.05) at 150 min, resulting in a significant increase in total brachial artery blood flow (P<0.005). We conclude that acute GLP-1 infusion significantly recruits skeletal and cardiac muscle microvasculature in addition to relaxing the conduit artery in healthy humans. This could contribute to increased tissue oxygen, nutrient and insulin delivery and exchange and therefore better prandial glycaemic control and tissue function in humans.

Candesartan acutely recruits skeletal and cardiac muscle microvasculature in healthy humans.

CONTEXT: Angiotensin II type 1 receptor (AT(1)R) tone restricts muscle microvascular blood volume (MBV) and decreases muscle insulin delivery and glucose use. OBJECTIVE: The objective of the study was to examine whether acute AT(1)R blockade alters microvascular perfusion in skeletal and cardiac muscle in humans. SETTING: The study was conducted at the General Clinical Research Center at the University of Virginia. METHODS: Eight overnight-fasted healthy young adults were studied thrice in random order. In study 1, each subject received candesartan (32 mg) orally at time 0. In study 2, each subject received placebo at time 0 and a 1 mU/min · kg euglycemic insulin clamp from time 240 to 360 min. In study 3, each subject received candesartan (32 mg) orally at time 0 and insulin infusion from 240 to 360 min. Forearm skeletal and cardiac muscle MBV, microvascular flow velocity, and microvascular blood flow (MBF) were determined at baseline and at 240 and 360 min. RESULTS: Candesartan treatment acutely recruited microvasculature in both skeletal and cardiac muscle by significantly increasing MBV (P < 0.03 and P = 0.02, respectively) and MBF (P < 0.03 for both) without altering microvascular flow velocity. Insulin infusion significantly increased cardiac MBV (P = 0.02) and MBF (P < 0.02). Superimposing insulin infusion 4 h after candesartan ingestion did not further recruit microvasculature. Insulin-mediated whole-body glucose disposal did not differ with or without candesartan pretreatment. CONCLUSIONS: Acute AT(1)R blockade with candesartan recruits skeletal as well as cardiac muscle microvasculature in healthy humans without altering insulin-mediated whole-body glucose disposal. This may contribute to the observed improvement in the cardiovascular outcomes in patients receiving prolonged treatment with AT(1)R blockers.