ChatGPT's adherence to otolaryngology clinical practice guidelines.

OBJECTIVES: Large language models, including ChatGPT, has the potential to transform the way we approach medical knowledge, yet accuracy in clinical topics is critical. Here we assessed ChatGPT's performance in adhering to the American Academy of Otolaryngology-Head and Neck Surgery guidelines. METHODS: We presented ChatGPT with 24 clinical otolaryngology questions based on the guidelines of the American Academy of Otolaryngology. This was done three times (N = 72) to test the model's consistency. Two otolaryngologists evaluated the responses for accuracy and relevance to the guidelines. Cohen's Kappa was used to measure evaluator agreement, and Cronbach's alpha assessed the consistency of ChatGPT's responses. RESULTS: The study revealed mixed results; 59.7% (43/72) of ChatGPT's responses were highly accurate, while only 2.8% (2/72) directly contradicted the guidelines. The model showed 100% accuracy in Head and Neck, but lower accuracy in Rhinology and Otology/Neurotology (66%), Laryngology (50%), and Pediatrics (8%). The model's responses were consistent in 17/24 (70.8%), with a Cronbach's alpha value of 0.87, indicating a reasonable consistency across tests. CONCLUSIONS: Using a guideline-based set of structured questions, ChatGPT demonstrates consistency but variable accuracy in otolaryngology. Its lower performance in some areas, especially Pediatrics, suggests that further rigorous evaluation is needed before considering real-world clinical use.

Tele-medicine controlled hospital at home is associated with better outcomes than hospital stay.

BACKGROUND: Hospital-at-home (HAH) is increasingly becoming an alternative for in-hospital stay in selected clinical scenarios. Nevertheless, there is still a question whether HAH could be a viable option for acutely ill patients, otherwise hospitalized in departments of general-internal medicine. METHODS: This was a retrospective matched study, conducted at a telemedicine controlled HAH department, being part of a tertiary medical center. The objective was to compare clinical outcomes of acutely ill patients (both COVID-19 and non-COVID) admitted to either in-hospital or HAH. Non-COVID patients had one of three acute infectious diseases: urinary tract infections (UTI, either lower or upper), pneumonia, or cellulitis. RESULTS: The analysis involved 159 HAH patients (64 COVID-19 and 95 non-COVID) who were compared to a matched sample of in-hospital patients (192 COVID-19 and 285 non-COVID). The median length-of-hospital stay (LOS) was 2 days shorter in the HAH for both COVID-19 patients (95% CI: 1-3; p = 0.008) and non-COVID patients (95% CI; 1-3; p < 0.001). The readmission rates within 30 days were not significantly different for both COVID-19 patients (Odds Ratio (OR) = 1; 95% CI: 0.49-2.04; p = 1) and non-COVID patients (OR = 0.7; 95% CI; 0.39-1.28; p = 0.25). The differences remained insignificant within one year. The risk of death within 30 days was significantly lower in the HAH group for COVID-19 patients (OR = 0.34; 95% CI: 0.11-0.86; p = 0.018) and non-COVID patients (OR = 0.38; 95% CI: 0.14-0.9; p = 0.019). For one year survival period, the differences were significant for COVID-19 patients (OR = 0.5; 95% CI: 0.31-0.9; p = 0.044) and insignificant for non-COVID patients (OR = 0.63; 95% CI: 0.4-1; p = 0.052). CONCLUSIONS: Care for acutely ill patients in the setting of telemedicine-based hospital at home has the potential to reduce hospitalization length without increasing readmission risk and to reduce both 30 days and one-year mortality rates.

Advancing the future of equitable access to health care: recommendations from international health care leaders.

Disparities in access to health care are persistent and contribute to poor health outcomes for many populations around the world. Barriers to access are often similar across countries, despite differences in how health systems are structured. Health care leaders can work to address these barriers through bold, evidence-based actions. The Future of Health (FOH), an international community of senior health leaders, collaborated with the Duke-Margolis Institute for Health Policy to identify priority organizational and policy actions needed to improve equitable access to health care through a consensus-building exercise, a targeted literature review, and an expert discussion group. This paper describes four key action areas for health care leaders that FOH members identified as critical to enabling the future of equitable access to health care: ensuring prioritization of and accountability for equitable access to care; establishing comprehensive, organization-wide strategies to address barriers to access; clearly defining and incentivizing improvement on key measures related to reducing disparities in access; and establishing cross-sector partnerships to improve equitable access.

Machine learning in cardiac stress test interpretation: a systematic review.

Coronary artery disease (CAD) is a leading health challenge worldwide. Exercise stress testing is a foundational non-invasive diagnostic tool. Nonetheless, its variable accuracy prompts the exploration of more reliable methods. Recent advancements in machine learning (ML), including deep learning and natural language processing, have shown potential in refining the interpretation of stress testing data. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review of ML applications in stress electrocardiogram (ECG) and stress echocardiography for CAD prognosis. Medical Literature Analysis and Retrieval System Online, Web of Science, and the Cochrane Library were used as databases. We analysed the ML models, outcomes, and performance metrics. Overall, seven relevant studies were identified. Machine-learning applications in stress ECGs resulted in sensitivity and specificity improvements. Some models achieved rates of above 96% in both metrics and reduced false positives by up to 21%. In stress echocardiography, ML models demonstrated an increase in diagnostic precision. Some models achieved specificity and sensitivity rates of up to 92.7 and 84.4%, respectively. Natural language processing applications enabled the categorization of stress echocardiography reports, with accuracy rates nearing 98%. Limitations include a small, retrospective study pool and the exclusion of nuclear stress testing, due to its well-documented status. This review indicates the potential of artificial intelligence applications in refining CAD stress testing assessment. Further development for real-world use is warranted.

Home Versus Hospital Rehabilitation of Older Adults Following Hip Fracture Yields Similar Patient-Reported Outcome Measures.

The increase in hip fractures (HF) due to aging of the population and the rise in attractiveness of services provided at home following the COVID-19 pandemic, emphasize the need to compare outcomes of home versus hospital HF rehabilitation. To date, studies comparing the 2 services have focused primarily on clinical outcomes rather than patient-reported outcomes (PROs). This longitudinal observational study evaluated PROs of older adults with HF in the 2 settings. The SF36 questionnaire was used to measure PROs 3 times after surgery. The first PRO was retrospective and reflected pre-fracture health status. Descriptive statistics and mixed-effect logistic regression were used. Of 86 patients participating in the study, 41 had home rehabilitation and 45 had hospital rehabilitation. In both groups, the mental and physical scores plummeted 2 weeks after the HF, compared to pre-fracture status. The difference in improvement from pre-fracture status to recovery in both groups, were not significantly (P < .05) different, except for the pain domain. PROs of home versus hospital rehabilitation were similar, suggesting that rehabilitation at home can be as effective as hospital rehabilitation for suitable patients. This knowledge can improve quality of care in an aging global population.

Sink-traps are a major source for carbapenemase-producing Enterobacteriaceae transmission.

OBJECTIVE: We studied the extent of carbapenemase-producing Enterobacteriaceae (CPE) sink contamination and transmission to patients in a nonoutbreak setting. METHODS: During 2017-2019, 592 patient-room sinks were sampled in 34 departments. Patient weekly rectal swab CPE surveillance was universally performed. Repeated sink sampling was conducted in 9 departments. Isolates from patients and sinks were characterized using pulsed-field gel electrophoresis (PFGE), and pairs of high resemblance were sequenced by Oxford Nanopore and Illumina. Hybrid assembly was used to fully assemble plasmids, which are shared between paired isolates. RESULTS: In total, 144 (24%) of 592 CPE-contaminated sinks were detected in 25 of 34 departments. Repeated sampling (n = 7,123) revealed that 52%-100% were contaminated at least once during the sampling period. Persistent contamination for >1 year by a dominant strain was common. During the study period, 318 patients acquired CPE. The most common species were Klebsiella pneumoniae, Escherichia coli, and Enterobacter spp. In 127 (40%) patients, a contaminated sink was the suspected source of CPE acquisition. For 20 cases with an identical sink-patient strain, temporal relation suggested sink-to-patient transmission. Hybrid assembly of specific sink-patient isolates revealed that shared plasmids were structurally identical, and SNP differences between shared pairs, along with signatures for potential recombination events, suggests recent sharing of the plasmids. CONCLUSIONS: CPE-contaminated sinks are an important source of transmission to patients. Although traditionally person-to-person transmission has been considered the main route of CPE transmission, these data suggest a change in paradigm that may influence strategies of preventing CPE dissemination.

Evaluating prompt engineering on GPT-3.5's performance in USMLE-style medical calculations and clinical scenarios generated by GPT-4.

This study was designed to assess how different prompt engineering techniques, specifically direct prompts, Chain of Thought (CoT), and a modified CoT approach, influence the ability of GPT-3.5 to answer clinical and calculation-based medical questions, particularly those styled like the USMLE Step 1 exams. To achieve this, we analyzed the responses of GPT-3.5 to two distinct sets of questions: a batch of 1000 questions generated by GPT-4, and another set comprising 95 real USMLE Step 1 questions. These questions spanned a range of medical calculations and clinical scenarios across various fields and difficulty levels. Our analysis revealed that there were no significant differences in the accuracy of GPT-3.5's responses when using direct prompts, CoT, or modified CoT methods. For instance, in the USMLE sample, the success rates were 61.7% for direct prompts, 62.8% for CoT, and 57.4% for modified CoT, with a p-value of 0.734. Similar trends were observed in the responses to GPT-4 generated questions, both clinical and calculation-based, with p-values above 0.05 indicating no significant difference between the prompt types. The conclusion drawn from this study is that the use of CoT prompt engineering does not significantly alter GPT-3.5's effectiveness in handling medical calculations or clinical scenario questions styled like those in USMLE exams. This finding is crucial as it suggests that performance of ChatGPT remains consistent regardless of whether a CoT technique is used instead of direct prompts. This consistency could be instrumental in simplifying the integration of AI tools like ChatGPT into medical education, enabling healthcare professionals to utilize these tools with ease, without the necessity for complex prompt engineering.

Artificial Intelligence Assessment of Biological Age From Transthoracic Echocardiography: Discrepancies with Chronologic Age Predict Significant Excess Mortality.

BACKGROUND: Age and sex can be estimated using artificial intelligence on the basis of various sources. The aims of this study were to test whether convolutional neural networks could be trained to estimate age and predict sex using standard transthoracic echocardiography and to evaluate the prognostic implications. METHODS: The algorithm was trained on 76,342 patients, validated in 22,825 patients, and tested in 20,960 patients. It was then externally validated using data from a different hospital (n = 556). Finally, a prospective cohort of handheld point-of-care ultrasound devices (n = 319; ClinicalTrials.gov identifier NCT05455541) was used to confirm the findings. A multivariate Cox regression model was used to investigate the association between age estimation and chronologic age with overall survival. RESULTS: The mean absolute error in age estimation was 4.9 years, with a Pearson correlation coefficient of 0.922. The probabilistic value of sex had an overall accuracy of 96.1% and an area under the curve of 0.993. External validation and prospective study cohorts yielded consistent results. Finally, survival analysis demonstrated that age prediction ≥5 years vs chronologic age was associated with an independent 34% increased risk for death during follow-up (P < .001). CONCLUSIONS: Applying artificial intelligence to standard transthoracic echocardiography allows the prediction of sex and the estimation of age. Machine-based estimation is an independent predictor of overall survival and, with further evaluation, can be used for risk stratification and estimation of biological age.

Utilising patient-reported outcomes for goal-directed therapy of hip fracture patients: a sequential controlled trial.

BACKGROUND: Hip fracture patients (HFPs) frequently have multiple underlying conditions, necessitating that agreed-upon goals take these complications into consideration. Communication regarding goals between medical-personnel and patients is not always effective. Patient-reported outcomes (PROs) can outline personal goals and help promote quality health care in HFPs. Few studies have been published on this topic. The study's aim was to outline the process of using PROs for goal-directed therapy among HFPs. METHODS: This sequential controlled trial was conducted among HFPs from two medical centres. The control and the intervention group received integrative rehabilitation. PROs were measured in both groups using the SF36 questionnaire three times postsurgery: 24-48 hours, 2 weeks and 3 months. During the first round of questioning, only the intervention group was asked 'what matters most to you?' during the rehabilitative process. Accordingly, agreed-upon goals that were determined by the SF36's eight topics and were incorporated into the HFP's rehabilitative process. A Likert scale of 1-5, '1' indicating no-achievement and '5' full-achievement, was used to assess the goal achievement 4-6 months post-fracture. RESULTS: 84 HFPs participated in the study: 40 and 44 in the intervention and control group, respectively. In both groups, PROs declined after the HF, then improved somewhat 3 months later, but did not return to prefracture scores. Among the intervention group, 39% reached their specific goals (Likert level 5). Patients who achieved their goals had better PROs in comparison to others. The intervention group indicated PROs helped them articulate their desires and introduced them to new areas of care. CONCLUSIONS: Shifting from asking 'what's the matter?' to 'what matters most to you?' can improve the understanding of HFPs' own priorities, promote quality outcomes and enhance patient-centred care. Using PROs as a guide for goal-directed therapy can create a more inclusive process that includes the patients' most important health determinants and needs.

Qual a contribuição do tilt training (treinamento postural) na prevenção da síncope vasovagal ? / Tilt training: does it have a role in preventing vasovagal syncope? / ¿Cuál es el aporte del tilt training (entrenamiento postural) a la prevención del síncope vasovagal?

Histórico: A síncope vasovagal é um dos quadros clínicos mais comuns em adultos jovens. Estudos anteriores demonstram a eficácia do tilt training (treinamento postural) no tratamento desse transtorno clínico. Realizou-se um estudo prospectivo e randomizado com o objetivo de avaliar a contribuição do tilt training no tratamento de adultos jovens acometidos pela síncope vasovagal. Métodos: Quarenta e seis soldados , 25 dos quais do sexo masculino, média de idade de 19,4 mais ou menos 0,8 anos e diagnóstico clínico de síncope vasovagal pelo tilt teste, foram divididos aleatoriamente em dois grupos: um grupo controle e outro acometido de tilt training diariamente, por três meses. Nos dois grupos, os participantes foram instruídos a aumentar a ingestão de líquidos e sal e evitar situações indutoras de síncope, tais como permanecer em pé por períodos longos. Resultados: A adesão ao programa de treinamento, caracterizada pela realização de 50 por cento ou mais das sessões diárias de tilt training, foi de 91 por cento durante o primeiro mês, caindo para 58 por cento nos três meses. Os que realizaram o treinamento apresentaram uma média (distância interquartilica) e 5,0 episódios de síncope (0,5 a 16,0) durante um ano de acompanhamento, enquanto o grupo controle apresentou média de 2,0 episódios (0 a 6,0, P igual 0,737). Após a randomização não houve diferença significativa no tempo de ocorrência do primeiro episódio entre os dois grupos: média de 1,0 por mês (0,5 a 2,0) no grupo em tratamento...

Background: Vasovagal syncope is one of the most common medical conditions in young adults. Previous trials have shown effectiveness of tilt training in treating this condition. We conducted a prospective, randomized study in order to evaluate the role of tilt-training in young adults with vasovagal syncope. Methods: Forty-six soldiers (mean age 19.4 ± 0.8 years, 25 males), with a clinical diagnosis of vasovagal syncope supported by positive tilt test, were randomized to either three months of daily tilt training (treatment group), or no training (control group). Patients in both groups were instructed to increase fluid and salt intake, and to refrain from syncope-inducing situations, such as prolonged standing. Results: Compliance, defined as performing 50% or more of the tilt training daily sessions, was 91% during the first month, and declined to 58% during three months. Treatment group patients had a median (interquartile range) of 5.0 (0.5–16.0) syncope episodes during one-year follow up, compared to a median of 2.0 (0–6.0) episodes in the control group (P = 0.737). Also, there was no difference in time to first syncope after randomization between groups: a median of 1.0 (0.5–2.0) month in the treatment group, compared to 0.8 (0.5–2.0) month in the control group (P = 0.336). Conclusions: Adding daily three-month tilt training to modifications in lifestyle does not improve treatment results in youngadults with vasovagal syncope. Good compliance is difficult to achieve in a tilt training program.

Historial: El síncope vasovagal es uno de los cuadros clínicos más comunes en adultos jóvenes. Estudios anteriores han demostrado la eficiencia del tilt training (entrenamiento postural) en el tratamiento de ese trastorno clínico. Se llevó a cabo un estudio prospectivo y randomizado con el objetivo de evaluar el aporte del tilt training al tratamiento de adultos jóvenes acometidos por el síncope vasovagal. Métodos: Cuarenta y seis soldados, 25 de ellos del sexo masculino, promedio de edad de 19,4 ± 0,8 años y diagnóstico clínico de síncope vasovagal por el tilt test, fueron divididos aleatoriamente en dos grupos: un grupo control y otro sometido a tilt training diariamente, por tres meses. En ambos grupos, los participantes fueron instruidos a aumentar la ingesta de líquidos y sal y evitar situaciones inductoras del síncope, tales como permanecer en pie por largos períodos. Resultados: La adhesión al programa de entrenamiento, caracterizada por la realización del 50% o más de las sesiones diarias de tilt training, fue del 91% durante el primer mes, bajando al 58% a los tres meses. Quienes llevaron a cabo el entrenamiento presentaron un promedio (distancia intercuartílica) de 5,0 episodios de síncope (0,5 a 16,0) durante un año de acompañamiento, mientras el grupo control presentó un promedio de 2,0 episodios (0 a 6,0; P = 0,737). Tras la randomización, no hubo diferencia significativa en el tiempo de ocurrencia del primer episodio de síncope entre ambos grupos: promedio de 1,0 por mes (0,5 a 2,0) en el grupo en tratamiento y 0,8 (0,5 a 2,0) en el grupo control (P = 0,336). Conclusiones: La realización diaria del tilt training, aliada a los cambios de estilo de vida, no produjo mejora en el resultado del tratamiento de adultos jóvenes con síncope vasovagal. Se verificó asimismo la dificultad de obtener buena adhesión al programa de entrenamiento postural.