Clinical use of artificial intelligence requires AI-capable organizations.

Artificial intelligence-based algorithms are being widely implemented in health care, even as evidence is emerging of bias in their design, problems with implementation, and potential harm to patients. To achieve the promise of using of AI-based tools to improve health, healthcare organizations will need to be AI-capable, with internal and external systems functioning in tandem to ensure the safe, ethical, and effective use of AI-based tools. Ideas are starting to emerge about the organizational routines, competencies, resources, and infrastructures that will be required for safe and effective deployment of AI in health care, but there has been little empirical research. Infrastructures that provide legal and regulatory guidance for managers, clinician competencies for the safe and effective use of AI-based tools, and learner-centric resources such as clear AI documentation and local health ecosystem impact reviews can help drive continuous improvement.

Competencies for the Use of Artificial Intelligence-Based Tools by Health Care Professionals.

PURPOSE: The expanded use of clinical tools that incorporate artificial intelligence (AI) methods has generated calls for specific competencies for effective and ethical use. This qualitative study used expert interviews to define AI-related clinical competencies for health care professionals. METHOD: In 2021, a multidisciplinary team interviewed 15 experts in the use of AI-based tools in health care settings about the clinical competencies health care professionals need to work effectively with such tools. Transcripts of the semistructured interviews were coded and thematically analyzed. Draft competency statements were developed and provided to the experts for feedback. The competencies were finalized using a consensus process across the research team. RESULTS: Six competency domain statements and 25 subcompetencies were formulated from the thematic analysis. The competency domain statements are: (1) basic knowledge of AI: explain what AI is and describe its health care applications; (2) social and ethical implications of AI: explain how social, economic, and political systems influence AI-based tools and how these relationships impact justice, equity, and ethics; (3) AI-enhanced clinical encounters: carry out AI-enhanced clinical encounters that integrate diverse sources of information in creating patient-centered care plans; (4) evidence-based evaluation of AI-based tools: evaluate the quality, accuracy, safety, contextual appropriateness, and biases of AI-based tools and their underlying data sets in providing care to patients and populations; (5) workflow analysis for AI-based tools: analyze and adapt to changes in teams, roles, responsibilities, and workflows resulting from implementation of AI-based tools; and (6) practice-based learning and improvement regarding AI-based tools: participate in continuing professional development and practice-based improvement activities related to use of AI tools in health care. CONCLUSIONS: The 6 clinical competencies identified can be used to guide future teaching and learning programs to maximize the potential benefits of AI-based tools and diminish potential harms.

Extra-Axial Cystic Meningioma without Dural Attachment in an Adult: Case Report and Review of Literature.

Intraparenchymal meningiomas, meningiomas without dural attachment, and cystic meningioma are atypical and extremely rare, especially in adults. Only four cases of intraparenchymal cystic meningioma without dural attachment have been reported. A 47-year-old female presented with an altered sensorium. She had a progressive bifrontal headache for 2 months. Computed tomography scan of the brain showed an 8 cm × 6 cm cystic lesion with a solid component in the left frontoparietal region with a midline shift. The solid part of the lesion was enhancing on contrast but the cyst rim was not. Intraoperatively, the cyst was filled with amber-colored fluid, which was drained, and the solid component was completely excised. Histopathological examination of the solid tumor component confirmed cystic meningioma. At 2 years of follow-up, she has no evidence of recurrence. We report the fifth case of this very rare entity and review the literature.

Characterizing Thrombotic Complication Risk Factors Associated With COVID-19 via Heterogeneous Patient Data: Retrospective Observational Study.

BACKGROUND: COVID-19 has been observed to be associated with venous and arterial thrombosis. The inflammatory disease prolongs hospitalization, and preexisting comorbidities can intensity the thrombotic burden in patients with COVID-19. However, venous thromboembolism, arterial thrombosis, and other vascular complications may go unnoticed in critical care settings. Early risk stratification is paramount in the COVID-19 patient population for proactive monitoring of thrombotic complications. OBJECTIVE: The aim of this exploratory research was to characterize thrombotic complication risk factors associated with COVID-19 using information from electronic health record (EHR) and insurance claims databases. The goal is to develop an approach for analysis using real-world data evidence that can be generalized to characterize thrombotic complications and additional conditions in other clinical settings as well, such as pneumonia or acute respiratory distress syndrome in COVID-19 patients or in the intensive care unit. METHODS: We extracted deidentified patient data from the insurance claims database IBM MarketScan, and formulated hypotheses on thrombotic complications in patients with COVID-19 with respect to patient demographic and clinical factors using logistic regression. The hypotheses were then verified with analysis of deidentified patient data from the Research Patient Data Registry (RPDR) Mass General Brigham (MGB) patient EHR database. Data were analyzed according to odds ratios, 95% CIs, and P values. RESULTS: The analysis identified significant predictors (P<.001) for thrombotic complications in 184,831 COVID-19 patients out of the millions of records from IBM MarketScan and the MGB RPDR. With respect to age groups, patients 60 years and older had higher odds (4.866 in MarketScan and 6.357 in RPDR) to have thrombotic complications than those under 60 years old. In terms of gender, men were more likely (odds ratio of 1.245 in MarketScan and 1.693 in RPDR) to have thrombotic complications than women. Among the preexisting comorbidities, patients with heart disease, cerebrovascular diseases, hypertension, and personal history of thrombosis all had significantly higher odds of developing a thrombotic complication. Cancer and obesity were also associated with odds>1. The results from RPDR validated the IBM MarketScan findings, as they were largely consistent and afford mutual enrichment. CONCLUSIONS: The analysis approach adopted in this study can work across heterogeneous databases from diverse organizations and thus facilitates collaboration. Searching through millions of patient records, the analysis helped to identify factors influencing a phenotype. Use of thrombotic complications in COVID-19 patients represents only a case study; however, the same design can be used across other disease areas by extracting corresponding disease-specific patient data from available databases.

Life-threatening perforating brain injury by a rusty iron rod - A case report.

Background: When an object traverses through the cranium leaving behind both an entry and exit wound, it is called perforating brain injury. Perforating open brain injury is rare. A paucity of published literature on such cases and a lack of a standard management protocol pose significant challenges in managing such cases. Case Description: We present a case of a 24-year-old man who worked as a carpenter at the construction site. He slipped while working and fell from a height of 13 feet onto a rusty, vertically placed 3 feet iron rod located on the ground. Iron rod entered his body from the right upper chest, came out from the neck, and again re-entered through the right upper neck medial to the angle of the mandible and finally came out from the posterosuperior surface of the right side of the head. He presented to the emergency department in a conscious state, but his voice was heavy and slow-paced, and he showed signs of lower cranial nerve palsy on the right side. He underwent numerous radiological investigations. The iron rod was removed in the operation theater under strict aseptic precautions. On day 7 after surgery, he developed right lobar pneumonia, and on day 21, he developed an altered sensorium, followed by a loss of consciousness. He did not regain consciousness and, unfortunately, succumbed after 30 days of sustaining the injuries. Conclusion: Perforating open brain injuries are rare, especially in civilian society, and are usually associated with significant morbidity and mortality. Due to a lack of standard guidelines for managing such severe injuries and limited knowledge, many patients with these injuries do not survive. Although each case presents differently, certain management principles must be followed.

An update on hyper-acute management of ischaemic stroke.

This article aims to provide a comprehensive overview of key advances on various aspects of hyper-acute management of acute ischaemic stroke. These include neuroimaging, acute stroke unit care, management of blood pressure, reperfusion therapy including intravenous thrombolysis, mechanical thrombectomy and decompressive hemicraniectomy for malignant stroke syndrome. The challenge ahead is to ensure these evidence-based treatments are now being delivered and implemented to maximise the benefits across the population.

Prevalence and socio-demographic factors of SARS-CoV-2 antibody in multi-ethnic healthcare workers.

INTRODUCTION: Healthcare workers are particularly susceptible to developing COVID-19 owing to close and frequent contact with COVID-19 patients. This cross-sectional study aimed to describe prevalence of SARS-CoV-2 antibodies among healthcare workers within a hospital trust and examine factors associated with increased prevalence of this antibody. METHODS: Data was obtained over a 4-week period in 2020 from a cross-sectional prospective survey of healthcare workers serving a multi-ethnic inner-city population who had immunoglobulin G SARS-CoV-2 antibody test. Anonymised socio-demographic data about staff were cross-referenced with these tests. RESULTS: Of 7,013 staff, 6,212 (89%) undertook the antibody test during this period. Overall detection rate was 26% (1,584/6,212). Univariate analyses revealed no differences in prevalence in terms of gender or age. Compared with white staff members (18%), rates were higher in black (38%) and Asian (27%) members (p<0.001). The rates in general wards (43%) were higher compared with other areas; in emergency medicine and intensive care, prevalence was 23% (p<0.001). Regarding professional groups, prevalence was highest among nursing and allied clinical services (28%), less in doctors (23%) and lower in non-clinical staff (19%). DISCUSSION: This large study has described prevalence of recent exposure to SARS-CoV-2 infection among healthcare workers and determined associations including ethnicity, professional groups and geographical areas within healthcare settings. This information will be useful in future COVID-19 studies examining the role of antibody testing both in general populations and in healthcare settings.

Lesson of the month: Oxycodone-induced leukoencephalopathy: a rare diagnosis.

Oxycodone-induced leukoencephalopathy is a rare diagnosis that should be considered in unconscious patients with appropriate history. We describe a case of a 57-year-old unconscious woman who required intubation and did not respond to naloxone infusion. The unconsciousness was initially thought to be due to hypoxic brain injury. However, a further review of brain imaging showed characteristic features of oxycodone-induced leukoencephalopathy. We describe the pathological and radiological features of this condition, and provide a concise review of the limited literature on this condition. Accurate diagnosis of this condition will be valuable to clinicians and patients in terms of their medium-term and long-term prognosis, and potential for rehabilitation.

A multicentre prospective audit of bedside hydration in hospital.

INTRODUCTION: access to water at the bedside is a cornerstone of patient care. Among bedbound inpatients, water within reach at the bedside is a basic human dignity and one that ought not to be neglected. AIM: the authors sought to identify the extent to which accessible hydration facilities were provided to a bedbound inpatient population. METHODS: a cross-sectional, point-prevalent audit of hospitalised medical inpatients across five centres was conducted. Data were collected between meal times and noted baseline demographics and admission details, adequacy of oral hydration provision at the bedside and, where provision was inadequate, factors associated with this. RESULTS: across a total surveyed patient population of 559 we identified 138 patients who were bedbound. Among these bedbound patients, 6% (n=8) had no water provided at the bedside. However, 7 of these were deemed to be unable to swallow safely. In total, 44 (32%) of the 138 bedbound patients were unable to reach the water at their bedside; 18 of these patients would have been able to drink for themselves had the water been in reach. CONCLUSION: there is significant room for improvement in ensuring patients who are immobile are able to reach drinking apparatus at the bedside. In the five centres surveyed, approximately one in five bedbound patients with no contraindication are unable to reach an essential means of hydration.

Concurrent Spinal Epidural Tubercular and Pyogenic Abscess of Cervical Spine without Bony Involvement.

Spinal epidural abscess (SEA) presents with vertebral body involvement. SEA is mostly pyogenic in developed countries, but in developing countries, tuberculosis is more common cause. Young female presented with fever, neck, and right upper limb pain for 1 month followed by acute onset weakness in the right upper limb. Magnetic resonance imaging study of cervical spine showed contrast-enhancing lesion in C2-C3 epidural region. Surgery-aided by initiation of antibacterial and antitubercular treatment based on culture and histopathological study of pus helped us to get good clinical outcome. One should always keep in mind possibility of tubercular abscess while treating cases of spinal epidural lesions, though it is rare in the absence of osseous involvement. Pyogenic and tubercular abscess can present concurrently and sending pus for culture and sensitivity is must as it plays important role in identifying dual organisms.

Bovine piRNA-like RNAs are associated with both transposable elements and mRNAs.

PIWI proteins and their associated piRNAs have been the focus of intensive research in the past decade; therefore, their participation in the maintenance of genomic integrity during spermatogenesis has been well established. Recent studies have suggested important roles for the PIWI/piRNA system outside of gametogenesis, based on the presence of piRNAs and PIWI proteins in several somatic tissues, cancers, and the early embryo. Here, we investigated the small RNA complement present in bovine gonads, gametes, and embryos through next-generation sequencing. A distinct piRNA population was present in the testis as expected. However, we also found a large population of slightly shorter, 24-27 nt piRNA-like RNA (pilRNAs) in pools of oocytes and zygotes. These oocyte and embryo pilRNAs exhibited many of the canonical characteristics of piRNAs including a 1U bias, the presence of a 'ping-pong' signature, genomic clustering, and transposable element targeting. Some of the major transposons targeted by oocyte and zygote pilRNA were from the LINE RTE and ERV1 classes. We also identified pools of pilRNA potentially derived from, or targeted at, specific mRNA sequences. We compared the frequency of these gene-associated pilRNAs to the fold change in the expression of respective mRNAs from two previously reported transcriptome datasets. We observed significant negative correlations between the number of pilRNAs targeting mRNAs, and their fold change in expression between the 4-8 cell and 8-16 cell stages. Together, these results represent one of the first characterizations of the PIWI/piRNA pathway in the translational bovine model, and in the novel context of embryogenesis.

Changes to postgraduate medical education in the 21st century.

Medicine is a constantly evolving profession, especially with the advent of rapid advances in the scientific base that underpins this vocation. In order to ensure that training in medicine is contemporary with the continuous evolution of the profession, there has been a multitude of changes to postgraduate medical education, particularly in the UK. This article aims to provide an overview of relevant key changes to postgraduate medical education in the UK during the 21st century, including changes to the structure, governance and commissioning of medical education, effects of European Working Time Directive on training, recent recommendations in the Future Hospital Commission report and Shape of training report, and recent requirements for accreditation of medical education trainers. Many of these recommendations will require complex discussions often at organisational levels, hopefully with some realistic and pragmatic solutions for implementation.

Olanzapine and pulmonary embolism, a rare association: a case report.

Venous thromboembolism is a very common pathological process for which there are many well known (and less well-known) predisposing factors. Likewise, olanzapine is a commonly used anti-psychotic medication.We present the case of a young Somali gentleman who developed venous thromboembolic disease after an overdose of olanzapine. The diagnosis was only made 48 hours after admission, due to the non-specific presentation of the pulmonary embolus and the fact that the link between olanzapine and pulmonary embolus was not previously widely described and therefore it did not immediately figure in the differential diagnosis. The patient made a full recovery.There is an increasing body of circumstantial evidence linking olanzapine to pulmonary embolus. Clinicians should bear this possible association in mind when prescribing the drug and when faced with clinical situations where venous thromboembolism (VTE) is a possible diagnosis. VTE has occasionally been described in therapeutic dose olanzapine therapy, but never in the context of an acute overdose. Khat, a recreational drug, has been linked to arterial, but not venous thrombosis.It is hoped that this case report will further encourage research into these associations, which remain to be proven and quantified.In the context of changing population demographics and increasing global migration, a greater awareness of the potential effects of endemic practices and their potential consequences is essential to the modern-day doctor working in a multi-cultural society.

Vanadium in the detection, prevention and treatment of cancer: the in vivo evidence.

Vanadium, a dietary micronutrient, is yet to be established as an essential part of the human diet. Over the past century, several biological effects of vanadium, such as insulin-mimetic action as well as amelioration of hyperlipidemia and hypertension, have been discovered. This transition element is known to influence a battery of enzymatic systems, namely phosphatases, ATPases, peroxidases, ribonucleases, protein kinases and oxidoreductases. Multiple biochemical and molecular actions of vanadium have been implicated in its inhibitory effects on various tumor cells of human origin. Successful in vitro studies over the past few decades have advanced the anticancer research on vanadium into the preclinical stage. Vanadium in several animal cancer models provides protection against all stages of carcinogenesis--initiation, promotion, and progression. This review focuses on the current advances in cancer prevention and treatment as well as early detection by vanadium compounds in preclinical animal models while pointing to possible mechanisms of such diverse beneficial effects. Clinical pharmacokinetic and potential toxicity studies on vanadium are also highlighted in this review. Supporting and challenging evidence as well as future directions of vanadium research exploring the possibility of using this dietary agent for detection, prevention and treatment of human cancers are critically discussed.

Urinary tract infection in hospitalized elderly patients in the United Kingdom: the importance of making an accurate diagnosis in the post broad-spectrum antibiotic era.

The increasing prevalence of Clostridium difficile infection (CDI) has prompted many hospitals in the UK to recommend the use of narrow-spectrum antibiotics targeted at the likely bacteria at the clinical site of infection instead of broad-spectrum antibiotics. An underpinning requirement of such a strategy is the need to make an accurate diagnosis. In elderly patients, diagnosis of urinary tract infection can be challenging due to the frequent presence of respiratory signs and difficulties in the collection of urine specimens. This leads to the use of broad-spectrum antibiotics. Clinicians should attempt to make an accurate diagnosis of respiratory and urinary infections, as this will be crucial in the choice of the appropriate narrow-spectrum antibiotics.

Vertebral artery dissection: not a rare cause of stroke in the young.

We hereby describe a 42-year-old lady who developed vertebral artery dissection following a head injury. The clinical features and management of the condition are discussed.

PF4 ENHANCED assay for the diagnosis of heparin-induced thrombocytopenia in complex medical and surgical patients.

OBJECTIVE: To evaluate the sensitivity and specificity of the PF4 ENHANCED (GTI Diagnostics, Waukesha, WI) enzyme-linked immunosorbent assay for heparin-induced thrombocytopenia using the carbon-14 serotonin-release assay as the reference method. DESIGN: A total of 34 patients were prospectively enrolled with a variety of diagnoses and suspected heparin-induced thrombocytopenia. They were clinically scored and underwent testing with the (14)C-serotonin-release assay. Enzyme-linked immunosorbent assay and (14)C-serotonin-release assay results were also available from 21 medical and surgical patients who had previously been tested. MAIN RESULTS: With the (14)C-serotonin-release assay as the reference method, the sensitivity and specificity of the enzyme-linked immunosorbent assay were 93% and 65%, respectively. There was only one false-negative enzyme-linked immunosorbent assay. The clinical scores were frequently misleading, largely because of difficulty excluding other causes of thrombocytopenia. CONCLUSION: Because of its high sensitivity, we believe the PF4 ENHANCED enzyme-linked immunosorbent assay should be used to identify heparin-induced thrombocytopenia in patients with multiple potential causes of thrombocytopenia, although false-positive results will not be uncommon.

Natural history of cognitive impairment after stroke and factors associated with its recovery.

OBJECTIVES: To describe the natural history of cognitive impairment following stroke over three years; determine factors associated with recovery of post-stroke cognitive impairment and examine the effect of this recovery on stroke outcomes. DESIGN: Observational study. SETTING: Population-based register of first-ever strokes. MEASURES: Mini-Mental State Examination (MMSE) for cognition (cognitive impairment: MMSE<24), Barthel and Frenchay activity indices for disability. METHODS: To describe its natural history, cognition was assessed at three months, 1, 2 and 3 years after stroke in 163 subjects registered in 1995. Recovery of cognitive impairment was examined using a larger cohort registered between 1995 and 1998 (n = 476) and 193 subjects cognitively impaired at three months were reassessed a year post stroke; 34 who had recovered cognitively (MMSE 24-30) were compared with 102 with persistent cognitive impairment in terms of demography, risk factors, initial impairments and stroke subtype. RESULTS: At three months, 1, 2 and 3 years post stroke, the prevalence rates of cognitive impairment were 39%, 35%, 30% and 32% respectively. Multivariable analyses showed that recovery was associated with smoking (OR 3.7; 95% CI 1.2-11.8), compromised by visuospatial neglect (OR 0.27; 95% CI 0.08-0.89), and had a near-significant association with right hemispheric lesion (OR 2.87; 95% CI 0.94-8.78). Cognitive recovery was associated with less institutionalization (p = 0.032) and being less disabled, on Barthel (p = 0.001) and Frenchay Activity Indices (p = 0.028). CONCLUSIONS: Cognitive impairment remains highly prevalent up to three years after first stroke. Recovery from cognitive impairment is associated with smoking and possibly right hemisphere strokes, but compromised by visuospatial neglect. These associations require further clarification.

Cognitive impairment after stroke: clinical determinants and its associations with long-term stroke outcomes.

OBJECTIVES: To identify factors that were associated with cognitive impairment 3 months after stroke, and to examine the associations of cognitive impairment with stroke outcomes up to 4 years after stroke. DESIGN: Observational study. SETTING: Population-based stroke register. PARTICIPANTS: Six hundred forty-five subjects with first-ever stroke, identified from the register. MEASUREMENTS: Subjects were assessed for cognition using the Mini-Mental State Examination (MMSE) 3 months after stroke. Cognitively impaired subjects (MMSE <24, n = 248 (38%)) were compared with cognitively intact subjects (MMSE 24-30, n = 397) in terms of demographic details, stroke risk factors, laterality of stroke, and initial poststroke impairments. Outcome data collected at 1, 3, and 4 years poststroke included disability assessed by the Barthel Index (BI) and the Frenchay Activity Index, case fatality, and institutionalization. RESULTS: Two hundred forty-eight (38%) of 645 subjects were cognitively impaired 3 months after stroke. Using multivariate analyses, cognitive impairment was associated with age of 75 and older (odds ratio (OR) = 2.5, 95% confidence interval (CI) = 1.5-4.2), ethnicity (Caribbean/African (OR = 1.9, 95% CI = 1.2-3.2) and Asian (OR = 3.4, 95% CI = 1.1-10.2), lower socioeconomic class (OR = 2.1, 95% CI = 1.3-3.3), left hemispheric lesion (OR = 1.6, 95% CI = 1.01-2.4), visual field defect (OR = 2.0, 95% CI = 1.2-3.2), and urinary incontinence (OR = 4.8, 95% CI = 3.1-7.3). Using multivariate analyses, cognitive impairment was associated with death or disability (BI <15) at 4 years after stroke (OR = 2.2, 95% CI = 1.1-4.5). In univariate analyses, it was also associated with higher institutionalization 4 years after stroke (P =.001). CONCLUSIONS: Cognitive impairment is common 3 months after stroke and is independently associated with older age, ethnicity, lower social class, left hemispheric stroke, visual field defect, and urinary incontinence. It is associated with poor long-term outcomes, including survival and disability, up to 4 years after stroke. Because physical and cognitive impairments after stroke have independent prognostic implications, measures that evaluate both functions should be used in future studies of stroke outcome and in care of stroke patients.