Is AI the future of evaluation in medical education?? AI vs. human evaluation in objective structured clinical examination

BACKGROUND

Objective Structured Clinical Examinations (OSCEs) are widely used in medical education to assess students' clinical and professional skills. Recent advancements in artificial intelligence (AI) offer opportunities to complement human evaluations. This study aims to explore the consistency between human and AI evaluators in assessing medical students' clinical skills during OSCE.

METHODS

This cross-sectional study was conducted at a state university in Turkey, focusing on pre-clinical medical students (Years 1, 2, and 3). Four clinical skills-intramuscular injection, square knot tying, basic life support, and urinary catheterization-were evaluated during OSCE at the end of the 2023-2024 academic year. Video recordings of the students' performances were assessed by five evaluators: a real-time human assessor, two video-based expert human assessors, and two AI-based systems (ChatGPT-4o and Gemini Flash 1.5). The evaluations were based on standardized checklists validated by the university. Data were collected from 196 students, with sample sizes ranging from 43 to 58 for each skill. Consistency among evaluators was analyzed using statistical methods.

RESULTS

AI models consistently assigned higher scores than human evaluators across all skills. For intramuscular injection, the mean total score given by AI was 28.23, while human evaluators averaged 25.25. For knot tying, AI scores averaged 16.07 versus 10.44 for humans. In basic life support, AI scores were 17.05 versus 16.48 for humans. For urinary catheterization, mean scores were similar (AI: 26.68; humans: 27.02), but showed considerable variance in individual criteria. Inter-rater consistency was higher for visually observable steps, while auditory tasks led to greater discrepancies between AI and human evaluators.

CONCLUSIONS

AI shows promise as a supplemental tool for OSCE evaluation, especially for visually based clinical skills. However, its reliability varies depending on the perceptual demands of the skill being assessed. The higher and more uniform scores given by AI suggest potential for standardization, yet refinement is needed for accurate assessment of skills requiring verbal communication or auditory cues.

Assessing ChatGPT 4.0's Capabilities in the United Kingdom Medical Licensing Examination (UKMLA): A Robust Categorical Analysis

Advances in the various applications of artificial intelligence will have important implications for medical training and practice. The advances in ChatGPT-4 alongside the introduction of the medical licensing assessment (MLA) provide an opportunity to compare GPT-4's medical competence against the expected level of a United Kingdom junior doctor and discuss its potential in clinical practice. Using 191 freely available questions in MLA style, we assessed GPT-4's accuracy with and without offering multiple-choice options. We compared single and multi-step questions, which targeted different points in the clinical process, from diagnosis to management. A chi-squared test was used to assess statistical significance. GPT-4 scored 86.3% and 89.6% in papers one-and-two respectively. Without the multiple-choice options, GPT's performance was 61.5% and 74.7% in papers one-and-two respectively. There was no significant difference between single and multistep questions, but GPT-4 answered 'management' questions significantly worse than 'diagnosis' questions with no multiple-choice options (p = 0.015). GPT-4's accuracy across categories and question structures suggest that LLMs are competently able to process clinical scenarios but remain incapable of understanding these clinical scenarios. Large-Language-Models incorporated into practice alongside a trained practitioner may balance risk and benefit as the necessary robust testing on evolving tools is conducted.

Sclerosing Angiomatoid Nodular Transformation of the Laparoscopically Resected Spleen: Case Reports and Review of the Literature

INTRODUCTION

Most splenic tumors are benign; however, it is essential to differentiate them from malignant tumors, such as malignant lymphoma and metastatic tumors. Sclerosing angiomatoid nodular transformation (SANT) is a relatively rare benign tumor that has been reported recently. Splenectomy is performed in most cases of SANT because of the challenges associated with a definitive diagnosis. However, in some cases, SANT can be diagnosed through endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), and these cases are subsequently followed up. In this report, we present 2 cases of splenic SANT that underwent laparoscopic resection. In Case 1, atypical imaging findings required EUS-FNA for further evaluation. Case 2 exhibited typical imaging findings of SANT, and therefore, EUS-FNA was not performed.

CASE PRESENTATION

Case 1: A 47-year-old female was found to have a 26 mm tumor in the spleen on abdominal ultrasonography during follow-up for gallbladder polyps. Abdominal computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography-CT were performed. EUS-FNA was performed because of the high surgical risk associated with pulmonary hypertension and because hemangioendothelioma, an intermediate malignancy, was suspected. Subsequently, laparoscopic splenectomy was performed, and SANT was diagnosed. Case 2: A 46-year-old female had an incidental detection of a tumor in the spleen on CT. SANT was suspected based on CT and MRI findings. Malignancy could not be completely ruled out owing to the gradual growth of the mass; therefore, the patient was referred to our hospital for surgery. Laparoscopic splenectomy was performed, and SANT was subsequently diagnosed.

CONCLUSION

SANT is a benign tumor that is difficult to diagnose; however, in some cases, it can be diagnosed using EUS-FNA. We report 2 cases of SANT of the spleen that underwent laparoscopic resection. In cases where the diagnosis is confirmed through imaging or histological examination, disease management with follow-up and without surgery is a possible alternative.

MRI-based prediction of the need for wide resection margins in patients with single hepatocellular carcinoma

OBJECTIVES

To develop an MRI-based score that enables individualized predictions of the survival benefit of wide over narrow resection margins.

MATERIALS AND METHODS

This single-center retrospective study (December 2011 to May 2022) included consecutive patients who underwent curative-intent resection for single Barcelona Clinic Liver Cancer (BCLC) 0/A HCC and preoperative contrast-enhanced MRI. In patients with narrow resection margins, preoperative demographic, laboratory, and MRI variables independently associated with early recurrence-free survival (RFS) were identified using Cox regression analyses, which were employed to develop a predictive score (named "MARGIN"). Survival outcomes were compared between wide and narrow resection margins in a propensity-score matched cohort for the score-stratified low- and high-risk groups, respectively.

RESULTS

Four hundred nineteen patients (median age, 54 years; 361 men) were included, 282 (67.3%) undergoing narrow resection margins. In patients with narrow resection margins, age, alpha-fetoprotein (AFP) > 400 ng/mL, protein induced by vitamin K absence or antagonist-II (PIVKA-II) > 200 mAU/mL, radiological involvement of liver capsule, and infiltrative appearance were associated with early RFS (p values, 0.002-0.04) and formed the MARGIN score with a testing dataset C-index of 0.75 (95% CI: 0.65-0.84). In the matched cohort, wide resection margin was associated with improved early RFS rate for the high-risk group (MARGIN score ≥ - 1.3; 71.1% vs 41.0%; p = 0.02), but not for the low-risk group (MARGIN score < - 1.3; 79.7% vs 76.1%; p = 0.36).

CONCLUSION

In patients with single BCLC 0/A HCC, the MARGIN score may serve as promising decision-making to indicate the need for wide resection margins.

CLINICAL RELEVANCE STATEMENT

The MARGIN score has the potential to identify patients who would benefit more from wide resection margins than narrow resection margins, improving the postoperative survival of patients with single BCLC 0/A hepatocellular carcinoma (HCC).

KEY POINTS

Age, AFP, PIVKA-II, radiological involvement of liver capsule, and infiltrative appearance were associated with early RFS and formed the MARGIN score. The MARGIN score achieved a testing dataset C-index of 0.75. Wide resection margins were associated with improved early RFS for the high-risk group, but not for the low-risk group.

Immune Checkpoint Inhibitors and Liver Transplantation: Case Report and Review of the Literature

As immunotherapy is becoming more inevitable in everyday oncology, we are witnessing a higher number of patients who are on immunosuppressive medication but are also candidates for immune checkpoint inhibitors (ICIs) treatment. There have been few case reports and several small retrospective studies investigating the use of ICIs in liver transplant recipients mainly with hepatocellular carcinoma and skin cancer, but there is no report regarding the use of atezolizumab for the treatment of metastatic breast cancer in liver transplant recipients. We are presenting a metastatic breast cancer female patient undergoing both immunosuppressive treatment after liver transplantation due to cryptogenic liver failure and anti-programmed death ligand 1 (PDL1) medication-atezolizumab whose liver enzymes and tacrolimus level we have monitored intensively through 18 months and is still ongoing. Our patient has not presented with any signs of acute graft rejection and has a regression on follow-up imaging despite the treatment combination.

Impact of Artificial Intelligence on Gastroenterology Trainee Education

Artificial intelligence (AI) is transforming gastroenterology, particularly in endoscopy, which has a direct impact on trainees and their education. AI can serve as a valuable resource, providing real-time feedback and aiding in tasks like polyp detection and lesion differentiation, which are challenging for trainees. However, its implementation raises concerns about cognitive overload, overreliance, and even access disparities, which could affect training outcomes. Beyond endoscopy, AI shows promise in clinical management and interpreting diagnostic studies such as motility testing. Thoughtful adoption of AI can optimize training and prepare future trainees for the modern healthcare landscape.

Multimodal Assessment in Clinical Simulations: A Guide for Moving Towards Precision Education

Technological advances and cutting-edge data analytics approaches give new prospects for using multimodal assessments in simulation-based medical education. These multimodal approaches consider the interaction of data obtained from multiple sources and can enhance our ability to assess the educational efficacy of simulations and optimize learning experiences for each individual learner. However, several challenges could jeopardize the successful implementation of this approach. We present a practical guide for integrating multimodal assessment in clinical simulation-based education, offering educators and researchers a systematic checklist to consider before undertaking these multimodal assessment initiatives.

Sclerosing angiomatoid nodular transformation (SANT), a rare splenic tumor with increasing incidence

SANT (sclerosing angiomatoid nodular transformation) tumor is a rare splenic tumor of unknown etiology and vascular lineage, first described in 2004. Most cases are asymptomatic, although cases of anemia or abdominal pain in association with growth have been described. Spontaneous ruptures have not been described. Radiologically it presents a radial pattern with centripetal filling in dynamic MRI, being a characteristic feature, but not pathognomonic. It may present hypermetabolism in PET-CT. Its incidence is increasing since its description as an independent clinical and histopathological entity, especially in the oncological patients follow-up. Due to its radiological resemblance to metastatic lesions and its growth despite being a vascular lesion, splenectomy is indicated following the principles of oncologic surgery until a definitive diagnosis is made. It presents a benign behavior, requiring neither treatment nor specific subsequent surveillance. Two diagnosed cases of SANT are presented, as well as a review of the clinical, radiological and histopathological characteristics of this little-known splenic lesion.

Suppressing, stimulating and/or inhibiting: The evolving management of HCC patient after liver transplantation

Liver transplantation (LT) is a curative strategy for hepatocellular carcinoma (HCC), but the risk of HCC recurrence remains a challenging problem. In patients with HCC recurrence after LT (HCC-R_LT), the locoregional and surgical approaches are complex, and the guidelines do not report evidence-based strategies for the management of immunosuppression. In recent years, immunotherapy has become an effective option for patients with advanced HCC in pre-transplant settings. However, due to the risk of potentially fatal allograft rejection, the use of immunotherapy is avoided in post-transplant settings. Combining immunosuppressants with immunotherapy in transplant patients is also challenging due to the complex tumor microenvironment and immunoreactivity. The fear of acute liver rejection and the lack of predictive factors hinder the successful clinical application of immunotherapy for post-liver transplantation HCC recurrence. This review aims to comprehensively summarize the risk of HCC-R_LT, the available evidence for the efficacy of immunotherapy in patients with HCC-R_LT, and the clinical issues regarding the innovative management of this patient population.

A scoping review of nonmedical barriers to living donor liver transplant

This study aims to identify and categorize nonmedical barriers encountered by recipients, donors, and health care providers in the context of living donor liver transplantation (LDLT). Liver transplantation is vital for individuals with liver failure, yet high mortality rates on the transplant waitlist persist. LDLT was introduced to address deceased donor organ shortages; however, its adoption varies widely across regions, prompting the need to explore barriers hindering its implementation. The scoping review employed inclusion and exclusion criteria to identify studies focusing on nonmedical barriers to LDLT in both adult and pediatric populations. Qualitative, quantitative, and mixed-method studies were considered, covering the period from January 2005 to February 2023. The review's search strategy was conducted in the Ovid MEDLINE and Ovid EMBASE databases. Studies meeting the criteria were assessed for their characteristics and findings, which were synthesized into recipient, donor, and provider-level barriers. Among 2394 initially screened articles, 17 studies were eligible for inclusion. Recipient-level barriers encompassed systemic disparities in access, limited social support, immigration status, and inadequate awareness of LDLT. Donor-level barriers involved surgery-related risks, recovery time concerns, financial burdens, and religious beliefs. Provider-level barriers highlighted institutional support inadequacies and specialized surgeon shortages. The scoping review underscores nonmedical barriers to LDLT across recipient, donor, and provider levels. These barriers include socioeconomic disparities, information gaps, and inadequate institutional support. The findings underscore the need for comprehensive national efforts to raise awareness about LDLT and provide essential financial support.

Laparoscopic Appendectomy for Perforated Appendicitis Caused by a Fish Bone: A Case Report

Foreign body ingestion is relatively common, with most objects passing through the gastrointestinal tract without complications. However, some foreign bodies can cause gastrointestinal perforation, leading to severe complications. Fish bone-induced gastrointestinal perforation is relatively common in regions with high fish consumption, but appendiceal perforation remains extremely rare and diagnostically challenging. We report a case of a 76-year-old male patient who presented with worsening lower abdominal pain. Computed tomography (CT) revealed a swollen appendix (16 mm) with a high-density area and surrounding fat stranding, confirming acute appendicitis caused by appendicolith. Emergency laparoscopic appendectomy revealed a markedly swollen appendix with a central perforation. A 10-mm wedge-shaped fish bone was identified within the appendiceal lumen, confirming fish bone-induced perforated appendicitis. Histopathological examination confirmed severe inflammation with focal necrosis. Postoperative multiplanar reconstruction (MPR) images revealed a wedge-shaped hyperdense linear structure within the appendix, which was identified as a fish bone. Fish bone-induced perforated appendicitis is a rare but important differential diagnosis in regions with high fish consumption. A detailed dietary history and careful review of MPR images on CT are essential for accurate preoperative diagnosis. Early recognition and laparoscopic surgical intervention can prevent severe complications and improve patient outcomes.

Impact of artificial intelligence on the academic performance and test anxiety of pharmacy students in objective structured clinical examination: a randomized controlled trial

BACKGROUND

The rapid advancement of generative artificial intelligence (AI) in recent years has led to its increased application across various fields including education. One area where AI can significantly impact is clinical education, particularly in the preparation and execution of objective structured clinical examinations (OSCEs).

AIM

This study aimed to evaluate the impact of AI-generated study material and feedback on the academic performance and level of anxiety of pharmacy students in formative OSCE.

METHOD

This was a 4-week (June-July 2024) randomized controlled study. Students of 6th semester PharmD program were randomized into either an intervention or control group. The intervention group received intervention which comprised a comprehensive training session on how to use AI tools (ChatGPT, Gemini and Perplexity) for generating study materials with personalized feedback, in addition to usual OSCE instructions. The control group only received the usual OSCE instructions. In addition, all students completed the test anxiety inventory (TAI) questionnaire before the OSCE.

RESULTS

Eighty-eight (40 male, 48 female) out of 92 (96%) students attended the OSCE and completed the TAI questionnaire. Each group had 44 (50%) students. The mean OSCE mark was 13.26 (± 5.05) out of 30. No significant difference was found between the intervention [12.98 (± 5.15)] and control [13.54 (± 5.00)] groups regarding mean OSCE marks (p = 0.550). Similarly, no significant difference was found between the groups regarding the total TAI score (p = 0.917).

CONCLUSION

While the use of AI tools did not improve the academic performance of students or reduce test-related anxiety, they did not negatively impact these outcomes either. Future research should investigate the long-term effects of AI-based interventions on educational outcomes.

Sequential living donor liver transplantation after liver resection optimizes outcomes for patients with high-risk hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality. While liver transplantation (LT) provides the best long-term survival, it is constrained by organ scarcity and strict criteria. Liver resection (LR) is often the initial treatment for patients with solitary tumors and preserved liver function. The high recurrence rates associated with LR has prompted the exploration of sequential living donor liver transplantation (seqLDLT) after LR as a strategy for HCC patients with high-risk of recurrence.

METHODS

We analyzed data from 27 adult patients who underwent seqLDLT after LR for HCC at Kaohsiung Chang Gung Memorial Hospital (KCGMH) between June 1994 and December 2023. Patients were selected based on high-risk histopathological features post-LR or as part of downstaging strategy. Outcomes measured included overall survival (OS) and disease-free survival (DFS).

RESULTS

Among 765 HCC patients who underwent LDLT, 204 received LR before LDLT, and 27 underwent seqLDLT. Five patients (19%) underwent living donor liver transplantation (LDLT) following LR as a downstaging strategy while the rest received seqLDLT as a preemptive strategy. The median age was 53.5 years with 85% males. Chronic hepatitis B was the predominant underlying disease (74%). The 1-, 3-, and 5-year OS and DFS rates were 100%, 96.0%, 96.0% and 100%, 96.2%, 96.2%, respectively, with two patients experiencing HCC recurrence. One patient died from HCC recurrence. High-risk histopathological features included microvascular invasion (52%), satellite nodules (15%), multiple tumors (26%), tumors > 5 cm (19%), and a total tumor diameter > 10 cm (7%).

CONCLUSIONS

SeqLDLT offers a promising, tailored approach for managing HCC with adverse histopathologic features. Combining seqLDLT, downstaging strategies, and multidisciplinary treatments can achieve satisfactory OS and DFS in carefully selected patients, highlighting the need for refined criteria to identify the best candidates.

Artificial intelligence and pain medicine education: Benefits and pitfalls for the medical trainee

OBJECTIVES

Artificial intelligence (AI) represents an exciting and evolving technology that is increasingly being utilized across pain medicine. Large language models (LLMs) are one type of AI that has become particularly popular. Currently, there is a paucity of literature analyzing the impact that AI may have on trainee education. As such, we sought to assess the benefits and pitfalls that AI may have on pain medicine trainee education. Given the rapidly increasing popularity of LLMs, we particularly assessed how these LLMs may promote and hinder trainee education through a pilot quality improvement project.

MATERIALS AND METHODS

A comprehensive search of the existing literature regarding AI within medicine was performed to identify its potential benefits and pitfalls within pain medicine. The pilot project was approved by UPMC Quality Improvement Review Committee (#4547). Three of the most commonly utilized LLMs at the initiation of this pilot study - ChatGPT Plus, Google Bard, and Bing AI - were asked a series of multiple choice questions to evaluate their ability to assist in learner education within pain medicine.

RESULTS

Potential benefits of AI within pain medicine trainee education include ease of use, imaging interpretation, procedural/surgical skills training, learner assessment, personalized learning experiences, ability to summarize vast amounts of knowledge, and preparation for the future of pain medicine. Potential pitfalls include discrepancies between AI devices and associated cost-differences, correlating radiographic findings to clinical significance, interpersonal/communication skills, educational disparities, bias/plagiarism/cheating concerns, lack of incorporation of private domain literature, and absence of training specifically for pain medicine education. Regarding the quality improvement project, ChatGPT Plus answered the highest percentage of all questions correctly (16/17). Lowest correctness scores by LLMs were in answering first-order questions, with Google Bard and Bing AI answering 4/9 and 3/9 first-order questions correctly, respectively. Qualitative evaluation of these LLM-provided explanations in answering second- and third-order questions revealed some reasoning inconsistencies (e.g., providing flawed information in selecting the correct answer).

CONCLUSIONS

AI represents a continually evolving and promising modality to assist trainees pursuing a career in pain medicine. Still, limitations currently exist that may hinder their independent use in this setting. Future research exploring how AI may overcome these challenges is thus required. Until then, AI should be utilized as supplementary tool within pain medicine trainee education and with caution.

Perspectives on enhancing clinical informatics education in the artificial intelligence era

Objectives

This paper aims to analyze clinical informatic (CI) - a subfield of biomedical and health informatics (BHI) - programs to identify challenges and provide solutions for CI education. Using an online clinical decision support system (CDSS) course as a case study, we demonstrate how these challenges can be addressed. In addition, we discuss the potential impact of generative artificial intelligence (AI), along with the opportunities and risks it presents for CI education.

Methods

This is a perspective paper. The viewpoint analysis is based on a review of formal academic and training programs offered by the American Medical Informatics Association (AMIA) Academic Forum members, Accreditation Council for Graduate Medical Education (ACGME)-accredited CI programs, current literature, and experiences and insights of the authors, who are all CI or BHI educators. An online CDSS course serves as a case study.

Results

We identified the following challenges in CI education: the absence of consensus on CI curriculum content, the diversity of student backgrounds, issues with timely and accurate evaluation of both teaching and learning, insufficient long-term mentoring, and the impact of new AI technologies like generative AI. We used an online CDSS course as an example to demonstrate the solutions in course design, textbook selection, teaching methods, and class project development. These solutions include developing standardized course content for the CI curriculum, incorporating group projects to accommodate diverse student backgrounds, implementing multi-level evaluations, providing ongoing mentoring and support, and cautiously integrating generative AI technologies.

Conclusions

This paper identifies challenges in CI education, shares practical solutions, and discusses the potential impact of generative AI, a double-edged sword for teaching and learning. It provides a foundation and practical reference for CI education, situating it within the broader context of BHI, its foundational discipline. We aim to achieve safer and better healthcare through CI education and practice.

Artificial intelligence, ChatGPT, and dental education: Implications for reflective assignments and qualitative research

INTRODUCTION

Reflections enable students to gain additional value from a given experience. The use of Chat Generative Pre-training Transformer (ChatGPT, OpenAI Incorporated) has gained momentum, but its impact on dental education is understudied.

OBJECTIVES

To assess whether or not university instructors can differentiate reflections generated by ChatGPT from those generated by students, and to assess whether or not the content of a thematic analysis generated by ChatGPT differs from that generated by qualitative researchers on the same reflections.

METHODS

Hardcopies of 20 reflections (10 generated by undergraduate dental students and 10 generated by ChatGPT) were distributed to three instructors who had at least 5 years of teaching experience. Instructors were asked to assign either 'ChatGPT' or 'student' to each reflection. Ten of these reflections (five generated by undergraduate dental students and five generated by ChatGPT) were randomly selected and distributed to two qualitative researchers who were asked to perform a brief thematic analysis with codes and themes. The same ten reflections were also thematically analyzed by ChatGPT.

RESULTS

The three instructors correctly determined whether the reflections were student or ChatGPT generated 85% of the time. Most disagreements (40%) happened with the reflections generated by ChatGPT, as the instructors thought to be generated by students. The thematic analyses did not differ substantially when comparing the codes and themes produced by the two researchers with those generated by ChatGPT.

CONCLUSIONS

Instructors could differentiate between reflections generated by ChatGPT or by students most of the time. The overall content of a thematic analysis generated by the artificial intelligence program ChatGPT did not differ from that generated by qualitative researchers. Overall, the promising applications of ChatGPT will likely generate a paradigm shift in (dental) health education, research, and practice.

Sclerosing angiomatoid nodular transformation (SANT) of the spleen: a case report

SANT is a rare, non-lymphoid, benign entity, originating from the red pulp of the spleen. It is characterized by the presence of vascular nodules surrounded by a stroma of collagen fibers. It was introduced as a distinct disease entity by Martel et al in 2004, after the histopathological examination of 25 cases. Symptoms are unspecific, and in most cases, it is incidentally diagnosed, mostly in patients who undergo imaging for other underlying conditions. Moreover, radiological findings are usually inconclusive, and a definite diagnosis is established through histopathological examination. We herein report the case of a 76-year-old female diagnosed with stage I rectal cancer who was subsequently diagnosed with a splenic lesion after a Computed Tomography (CT) scan that was performed for follow-up purposes. Different imaging modalities were employed for further assessment; however, findings were inconclusive and the possibility of metastatic disease could not be excluded. The patient was referred for splenectomy and the diagnosis of SANT was established through histopathological examination.

Clinicopathological analysis of sclerosing haemangiomatoid nodular transformation of the spleen: analysis of three cases and a literature review

OBJECTIVE

To examine the clinicopathological features, immunohistochemical profiles, and differential diagnosis of sclerosing angiomatiod nodular transformation (SANT).

METHODS

Three cases of SANT of the spleen, diagnosed between 2014 and 2023 at the Affiliated Hospital of Zunyi Medical University, were analysed. Pathological features were assessed using haematoxylin and eosin staining, followed by immunohistochemistry with the EnVision system. Additionally, a review of relevant literature was conducted.

RESULTS

The study included one male and two female patients aged 40-55 years, with a median age of 47.5 years. All lesions were solitary, with tumour diameters ranging from 4 to 7.4 cm (mean 5.7 cm). Gross examination demonstrated that the masses were well-demarcated from the surrounding splenic tissue, with no evident capsule. The cut surfaces of the masses exhibited irregular, porcelain-white nodules that were tough in consistency, with some areas intermingling with splenic tissue. Microscopic examination revealed round or circular nodules comprising multiple slit-like or sinusoidal capillaries, separated by concentric collagen fibres. The nodules exhibited chronic inflammatory cell infiltration, calcification, haemosiderin deposition, and fibrous connective tissue with hyaline or mucoid changes. Immunohistochemical analysis demonstrated differential expression of markers, including cluster of differentiation (CD) 34, CD31, and CD8, within the sinusoidal nodule areas. Periodic acid-Schiff staining was positive for perinodular collagen deposits, while reticulin staining highlighted nodule profiles and intranodular vessels. None of the patients experienced postoperative recurrence or metastasis, and one patient was on aspirin for thrombocytosis.

CONCLUSION

SANT of the spleen is generally considered a rare, benign lesion with angioma-like characteristics. It exhibits exhibiting distinctive histomorphological features within the red pulp. Understanding the differential diagnosis is crucial to prevent missed or incorrect diagnoses.

Cost management analysis of Objective Structured Clinical Examination (OSCE): guide to the universities of medical sciences

BACKGROUND

The Objective Structured Clinical Examination (OSCE) is a crucial assessment tool for evaluating learners' ability to apply theoretical knowledge in practical clinical situations. It is widely accepted by both students and educators, and the costs associated with conducting OSCE assessments vary depending on the field of study, how it is implemented, staffing needs, standardized patients, and duration of the examination. This study examines the expenses related to administering OSCEs in medical universities.

METHOD

Conducted from June to September 2023; this mixed-method study elucidated the cost intricacies of executing a two-day OSCE with 14 eight-minute stations for 100 nursing students. This process unfolds in two phases: a qualitative segment comprising text reviews and 45-minute in-depth interviews with faculty members and OSCE experts, leading to the development of a validated checklist, followed by a quantitative phase in which the tool was distributed to 25 faculty members and 5 specialists for completion.

RESULT

The examination costs were delineated into three primary components: time, human resources, equipment, consumables, and necessary supplies. In 2023, the total implementation cost of the OSCE for 100 students across 14 clinical stations was $1028.07, with an estimated per-learner cost of $37.50. Human resources incurred the highest expenditure ($1649.37); while supply costs were relatively lower ($1072.17). Educational infrastructure expenses were excluded because the study focused on the Nursing and Midwifery Faculty's Clinical Skills Center.

CONCLUSION

Various factors influence OSCE costs, including national production capabilities of medical supplies, institutional credibility, governance status, examination frequency, student demographics, assessor composition, station count, course content, and examinee volume. The insights derived from this comprehensive examination are significant as entry benchmarks for healthcare systems and higher-level academic evaluations. Understanding OSCE cost dynamics facilitates resource optimization and assessment strategy refinement, thereby improving medical education efficacy.

Intestinal tuberculosis complicated with perforation in an immunocompetent patient: Case report and review of the literature

Introduction

Intestinal tuberculosis (ITB), a rare yet severe manifestation of Mycobacterium tuberculosis infection, poses significant diagnostic and therapeutic challenges due to its nonspecific clinical presentation. Perforation, a life-threatening complication, necessitates prompt surgical intervention and effective antituberculous therapy.

Case presentation

This case study highlights a 41-year-old immunocompetent male who presented with fever, abdominal pain, vomiting, and significant weight loss. A computed tomography scan revealed minimal pneumoperitoneum, intestinal wall thickening, mesenteric fat stranding, lymphadenopathy, and an intra-abdominal abscess. Exploratory laparotomy identified a perforation at the terminal ileum, leading to ileocaecal resection and stoma formation. Histopathological examination confirmed ITB, and a nine-month regimen of antituberculous medication was initiated.

Discussion

ITB, more common in immunocompromised individuals, can also affect immunocompetent patients, often mimicking other gastrointestinal conditions and delaying diagnosis. This case underscores the importance of considering ITB in differential diagnoses for patients with vague gastrointestinal symptoms. Diagnostic confirmation typically requires a combination of clinical, radiological, and microbiological assessments, with histopathology playing a crucial role. Factors such as age and comorbidities can increase the risk of severe complications like perforation. Surgical resection with anastomosis tends to yield better outcomes than direct closure, and comprehensive antituberculous therapy is essential for successful treatment.

Conclusion

The complexity of diagnosing and managing ITB, compounded by its severe complications, necessitates heightened awareness among healthcare providers. Accurate diagnosis, timely surgical intervention, and rigorous antituberculous therapy are vital for improving patient outcomes, especially in high-risk populations or regions with prevalent TB.

Reassessment of palliative surgery in conversion therapy of previously unresectable hepatocellular carcinoma: Two case reports and review of literature

BACKGROUND

Most patients with hepatocellular carcinoma (HCC) have lost the opportunity for direct surgery at the time of diagnosis. Transarterial chemoembolization (TACE) combined with immune checkpoint inhibitors or tyrosine kinase inhibitors (TKI) can partially transform some unresectable HCC and improve the prognosis effectively. However, based on the promising prospects of combined targeted and immunotherapy for the effective treatment of HCC, the positive role of palliative surgery in the conversion treatment of advanced HCC urgently needs further intensive re-assessment.

CASE SUMMARY

In this study, we describe two successful cases of "conversion therapy for unresectable HCC" achieved mainly by palliative surgery combined with TACE plus immunotherapy and TKIs. A 48-year-old patient with newly diagnosed HCC, presenting with a 6-cm mass in the segment VII/VIII of the right liver with multiple intrahepatic metastases, could not undergo one-stage radical surgical resection. He underwent palliative surgery with radiofrequency of metastatic lesions and the palliative resection of the primary mass, and received subsequent TACE treatments twice in the early postoperative period (2 weeks and 6 weeks), in addition to targeted and immune combination therapy with sintilimab injection and oral lenvatinib. No evidence of recurrence was observed during the 11-month follow-up period after surgery. The other patient was a 47-year-old patient with massive HCC (18 cm × 15 cm × 4.5 cm) in the left liver with severe cirrhosis. The left portal branch was occluded and a tumor thrombus formed, and the tumor partly involved the middle hepatic vein. The patient underwent palliative surgery of left hemihepatectomy (including resection of the middle hepatic vein) for HCC, followed by three TACE procedures and oral TKIs 2 weeks after surgery. Six months later, the re-examination via computed tomography revealed no tumour activity in the remaining right liver, while magnetic resonance imaging revealed slight local tumor enhancement in the caudate lobe of the liver considered, TACE was performed once again, and during the next follow-up of 10 months did not reveal new intrahepatic lesions or distant metastases.

CONCLUSION

These cases demonstrate that the addition of palliative surgery to conversion therapy in a selected population with a high tumor burden could benefit patients with initially unresectable HCC.

Minimally invasive removal of a foreign body in the pancreas using digital intelligent technology: a case report

Pancreatitis caused by a fish bone penetrating the posterior wall of the stomach and entering the pancreas is rare. We herein report a case involving a woman in her late 30s with an approximately 1-month history of recurrent upper abdominal pain. Initial evaluation at another hospital failed to identify the cause but raised suspicion of pancreatic cancer. Computed tomography, magnetic resonance imaging, and a detailed consultation led us to suspect that the patient's pain had been caused by inadvertent ingestion of a fish bone. We used three-dimensional visualization technology to determine the location of the fish bone and informed the patient of the lesion and surgical plan through a simulated surgical demonstration. During surgery, we applied augmented reality navigation technology to remove the fish bone by a minimally invasive approach. The patient was discharged on postoperative day 3. She was followed up by telephone 24 hours after discharge. Outpatient follow-up was performed 1 week after discharge and on day 30. The patient recovered well and developed no complications. This case shows that digital medical technology can be applied in patients undergoing surgical removal of a pancreatic foreign body. Such technology assists with preoperative evaluation, patient education, and intraoperative trauma reduction.

Comparative analysis of liver resection in Non-B Non-C and hepatitis virus-associated hepatocellular carcinoma

BACKGROUND

The incidence of non-hepatitis B and non-hepatitis C hepatocellular carcinoma (NBNC-HCC) is increasing in our country. This study assesses the feasibility of employing an identical surgical treatment strategy for resectable NBNC-HCC as that for hepatitis virus-associated HCC (HV-HCC).

METHODS

A retrospective analysis (1993-2023) of 1321 curative liver resections for HCC at a single institution was performed. Propensity score matching ensured a balanced comparison of preoperative clinical factors, including tumor status and background liver condition.

RESULTS

The proportion of NBNC-HCC cases has gradually increased, reaching up to 70 %. After matching, 294 of 473 NBNC-HCC patients and 294 of 848 HV-HCC patients were compared. Operative outcomes, including operation time, blood loss, type of surgical procedure, and morbidity, were comparable. Long-term outcome analysis showed similar recurrence-free survival (HR: 0.86, 95 % CI: 0.70-1.06, P = 0.167) and overall survival (HR: 0.98, 95 % CI: 0.79-1.23, P = 0.865) for NBNC-HCC. Multivariable analysis identified ICGR15 ≥ 15 %, ALBI grade 2 or 3, aspartate aminotransferase ≥40, tumor size > 5 cm, multiple tumors, macrovascular invasion, and microvascular invasion as independent prognostic factors for overall survival, while hepatitis B or C virus status lost significance.

CONCLUSIONS

Despite the increasing incidence of NBNC-HCC, comparable outcomes were achieved between the two groups of matched cohort.

Liver transplantation for acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) occurs in the context of advanced liver disease and is associated with hepatic and extrahepatic organ failure, eventually leading to a major risk of short-term mortality. To date, there are very few effective therapeutic options for ACLF. In many cases, liver transplantation is the only life-saving treatment that has acceptable outcomes in carefully selected recipients. This Review addresses key aspects of the use of liver transplantation for patients with ACLF, providing an in-depth discussion of existing evidence regarding candidate selection, the optimal window for transplantation, potential prioritisation of liver grafts for this indication, and the global management of ACLF to bridge patients to liver transplantation.

Enhancing clinical skills in pediatric trainees: a comparative study of ChatGPT-assisted and traditional teaching methods

BACKGROUND

As artificial intelligence (AI) increasingly integrates into medical education, its specific impact on the development of clinical skills among pediatric trainees needs detailed investigation. Pediatric training presents unique challenges which AI tools like ChatGPT may be well-suited to address.

OBJECTIVE

This study evaluates the effectiveness of ChatGPT-assisted instruction versus traditional teaching methods on pediatric trainees' clinical skills performance.

METHODS

A cohort of pediatric trainees (n = 77) was randomly assigned to two groups; one underwent ChatGPT-assisted training, while the other received conventional instruction over a period of two weeks. Performance was assessed using theoretical knowledge exams and Mini-Clinical Evaluation Exercises (Mini-CEX), with particular attention to professional conduct, clinical judgment, patient communication, and overall clinical skills. Trainees' acceptance and satisfaction with the AI-assisted method were evaluated through a structured survey.

RESULTS

Both groups performed similarly in theoretical exams, indicating no significant difference (p > 0.05). However, the ChatGPT-assisted group showed a statistically significant improvement in Mini-CEX scores (p < 0.05), particularly in patient communication and clinical judgment. The AI-teaching approach received positive feedback from the majority of trainees, highlighting the perceived benefits in interactive learning and skill acquisition.

CONCLUSION

ChatGPT-assisted instruction did not affect theoretical knowledge acquisition but did enhance practical clinical skills among pediatric trainees. The positive reception of the AI-based method suggests that it has the potential to complement and augment traditional training approaches in pediatric education. These promising results warrant further exploration into the broader applications of AI in medical education scenarios.

Longitudinal analysis of liver transplant candidates for hepatocellular carcinoma in a single center

BACKGROUND

Wailitst lost is an critical issue and we investigated the long-term effect of insufficient liver functional reserve at liver transplantation evaluation on waitlist outcomes in patients with hepatocellular carcinoma (HCC).

METHODS

Clinical data of patients with HCC waitlisted for liver transplantation were retrospectively collected from a single hospital cohort during the period from 2014 to 2021. Parameters of liver reserve, including cirrhosis, Child-Pugh grade, and Model for End-Stage Liver Disease (MELD) scores, were analyzed for patient survival, after adjustment for tumor factors.

RESULTS

Of 292 eligible patients, 94.2% had cirrhosis, 55.8% had Child-Pugh grade B or C, and the median MELD score was 13.2. The median follow-up time was 2.2 years, with a dropout rate of 62.7%. Eighty-nine candidates (30.5%) eventually received liver transplant, including 67 from live donors. The estimated 1-year mortality rate reached 40.6% in 203 patients who remained on the waitlist without receiving a transplant, of whom 143 died. Most deaths were attributed to liver failure (37.1%) and cancer death (35.7%). After we adjusted for tumor confounders, including alpha fetoprotein, primary HCC stage, tumor number at evaluation, and sequential cancer treatment before and while waiting, hazard ratios (HRs) for patient survival were 1.69 (95% confidence interval, 1.18-2.41) for cirrhotic stage B or C, 1.07 (1.04-1.10) for MELD scores, and 1.14 (1.04-1.25) for tumor size at transplant evaluation. Transplantation was a protective disease modifier with adjusted HR 0.22 (0.14-0.33).

CONCLUSION

Insufficient liver functional reserve poses more risk than expected to liver transplant waitlist outcomes with HCC.

A scoping review of artificial intelligence in medical education: BEME Guide No. 84

BACKGROUND

Artificial Intelligence (AI) is rapidly transforming healthcare, and there is a critical need for a nuanced understanding of how AI is reshaping teaching, learning, and educational practice in medical education. This review aimed to map the literature regarding AI applications in medical education, core areas of findings, potential candidates for formal systematic review and gaps for future research.

METHODS

This rapid scoping review, conducted over 16 weeks, employed Arksey and O'Malley's framework and adhered to STORIES and BEME guidelines. A systematic and comprehensive search across PubMed/MEDLINE, EMBASE, and MedEdPublish was conducted without date or language restrictions. Publications included in the review spanned undergraduate, graduate, and continuing medical education, encompassing both original studies and perspective pieces. Data were charted by multiple author pairs and synthesized into various thematic maps and charts, ensuring a broad and detailed representation of the current landscape.

RESULTS

The review synthesized 278 publications, with a majority (68%) from North American and European regions. The studies covered diverse AI applications in medical education, such as AI for admissions, teaching, assessment, and clinical reasoning. The review highlighted AI's varied roles, from augmenting traditional educational methods to introducing innovative practices, and underscores the urgent need for ethical guidelines in AI's application in medical education.

CONCLUSION

The current literature has been charted. The findings underscore the need for ongoing research to explore uncharted areas and address potential risks associated with AI use in medical education. This work serves as a foundational resource for educators, policymakers, and researchers in navigating AI's evolving role in medical education. A framework to support future high utility reporting is proposed, the FACETS framework.

Performance of ChatGPT in French language Parcours d'Accès Spécifique Santé test and in OBGYN

OBJECTIVES

To evaluate the performance of ChatGPT in a French medical school entrance examination.

METHODS

A cross-sectional study using a consecutive sample of text-based multiple-choice practice questions for the Parcours d'Accès Spécifique Santé. ChatGPT answered questions in French. We compared performance of ChatGPT in obstetrics and gynecology (OBGYN) and in the whole test.

RESULTS

Overall, 885 questions were evaluated. The mean test score was 34.0% (306; maximal score of 900). The performance of ChatGPT was 33.0% (292 correct answers, 885 questions). The performance of ChatGPT was lower in biostatistics (13.3% ± 19.7%) than in anatomy (34.2% ± 17.9%; P = 0.037) and also lower than in histology and embryology (40.0% ± 18.5%; P = 0.004). The OBGYN part had 290 questions. There was no difference in the test scores and the performance of ChatGPT in OBGYN versus the whole entrance test (P = 0.76 vs P = 0.10, respectively).

CONCLUSIONS

ChatGPT answered one-third of questions correctly in the French test preparation. The performance in OBGYN was similar.

Thermal ablation for hepatic tumors in high-risk locations

Thermal ablative techniques such as radiofrequency and microwave ablation are minimally invasive and cost-effective approaches that are currently being adopted as alternatives to surgical resection for primary and metastatic liver malignancies. However, they are considered to be relatively contraindicated for tumors in high-risk locations due to technical difficulties and a perceived increased risk of perioperative complications. Several techniques, including artificial ascites, non-touch multibipolar ablation, and laparoscopically assisted ablation, can be used to improve the outcomes of ablation for high-risk tumors. This review aims to provide a comprehensive summary of the techniques currently used to improve thermal ablation outcomes for high-risk liver tumors.

Intestinal tuberculosis with small bowel stricture and hemorrhage as the predominant manifestation: Three case reports

BACKGROUND

Intestinal tuberculosis is a chronic disease caused by Mycobacterium tuberculosis that mainly affects the ileum and cecum. Small bowel tuberculosis, characterized by predominant involvement of the small intestine, is an extremely rare condition with highly atypical clinical presentations, making diagnosis even more challenging.

CASE SUMMARY

We report three cases of small intestinal tuberculosis, two of the patients presented primarily with abdominal pain, and one presented with gastrointestinal bleeding. All patients underwent blood tests and imaging examinations. Small bowel endoscopy (SBE) revealed that the main lesions in these patients were intestinal stenosis or gastrointestinal bleeding caused by small intestinal ulcers. One patient ultimately underwent surgical treatment. Following a complex diagnostic process and comprehensive analysis, all patients were confirmed to have small intestinal tuberculosis and received standard antituberculosis treatment, leading to an improvement in their condition.

CONCLUSION

Patients with SBTs present with nonspecific symptoms such as abdominal pain, weight loss, and occasional gastrointestinal bleeding. Accurate diagnosis requires a thorough evaluation of clinical symptoms and various tests to avoid misdiagnosis and complications.

Causes of death and associated factors with death after liver transplantation: a nationwide database study

BACKGROUND/AIMS

This study investigated overall, 1-year, and 5-year mortality rate, the causes of death, and associated factors with death in liver transplantation recipients.

METHODS

A total of 11,590 liver transplant recipients identified from National Health Insurance Service database between 2006 and 2017 were included. Factors associated with all-cause of death were analyzed by Cox proportional regression models. Cumulative mortality rate according to the underlying indication was estimated by Kaplan-Meier method.

RESULTS

The 12-year survival rate for all liver transplant recipients was 68%. In the overall, 1-year, and 5-year mortality of liver transplant recipients, hepatic death was the highest contributing risk, accounting for >65% of the causes of death. Deaths from cirrhosis and liver failure accounted for a high proportion of deaths within 1 year after transplantation, and deaths from malignant tumors such as hepatocellular carcinoma were high among late-stage deaths.

DISCUSSION

Although the most common cause of death from liver transplantation is due to primary disease, there was a difference in the pattern of major causes of death according to the period from transplantation to death. If appropriate medical intervention is performed at each period after transplantation, the survival rate can be improved.

Artificial Intelligence and Objective Structured Clinical Examinations: Using ChatGPT to Revolutionize Clinical Skills Assessment in Medical Education

This article examines the integration of OpenAI's Chat Generative Pre-trained Transformer (ChatGPT) into Objective Structured Clinical Examinations (OSCEs) for medical education. OSCEs, essential in evaluating medical trainees, are time and resource-intensive for educators and medical colleges. ChatGPT emerges as a solution, aiding educators in efficient OSCE preparation, including case development, standardized patient training, assessment methods, and grading rubrics. We explore ChatGPT's role in reducing trainee stress through simulated interactions of realistic practice scenarios and real-time trainee feedback. We also discuss the importance of validating ChatGPT outputs for medical accuracy and address compliance concerns. While highlighting ChatGPT's potential in reducing time and cost burdens for educators, we underscore the need for careful and informed application of Artificial Intelligence in medical education. Through examples, we outline ChatGPT's promising future in augmenting medical training and assessment, balancing technological innovation with educational integrity.

Perforated appendicitis due to fishbone

Appendicitis is a common condition in daily clinical practice. Appendicitis due to foreign bodies is uncommon and may result from obstruction or perforation mechanism. We present a rare case of a 43-year-old male patient who was diagnosed with perforated appendicitis due to a fish bone by imaging studies and confirmed postoperatively. Confirming the fish bone causing the perforation on images is sometimes difficult, requiring the radiologist to actively search and determine the source. In addition to appendectomy, the surgeon also needs to pay attention to removing all foreign objects and treating perforations of surrounding organs.

Validity evidence supporting clinical skills assessment by artificial intelligence compared with trained clinician raters

BACKGROUND

Artificial intelligence (AI) is becoming increasingly used in medical education, but our understanding of the validity of AI-based assessments (AIBA) as compared with traditional clinical expert-based assessments (EBA) is limited. In this study, the authors aimed to compare and contrast the validity evidence for the assessment of a complex clinical skill based on scores generated from an AI and trained clinical experts, respectively.

METHODS

The study was conducted between September 2020 to October 2022. The authors used Kane's validity framework to prioritise and organise their evidence according to the four inferences: scoring, generalisation, extrapolation and implications. The context of the study was chorionic villus sampling performed within the simulated setting. AIBA and EBA were used to evaluate performances of experts, intermediates and novice based on video recordings. The clinical experts used a scoring instrument developed in a previous international consensus study. The AI used convolutional neural networks for capturing features on video recordings, motion tracking and eye movements to arrive at a final composite score.

RESULTS

A total of 45 individuals participated in the study (22 novices, 12 intermediates and 11 experts). The authors demonstrated validity evidence for scoring, generalisation, extrapolation and implications for both EBA and AIBA. The plausibility of assumptions related to scoring, evidence of reproducibility and relation to different training levels was examined. Issues relating to construct underrepresentation, lack of explainability, and threats to robustness were identified as potential weak links in the AIBA validity argument compared with the EBA validity argument.

CONCLUSION

There were weak links in the use of AIBA compared with EBA, mainly in their representation of the underlying construct but also regarding their explainability and ability to transfer to other datasets. However, combining AI and clinical expert-based assessments may offer complementary benefits, which is a promising subject for future research.

Post-transplant malignancy: Focusing on virus-associated etiologies, pathogenesis, evidence-based management algorithms, present status of adoptive immunotherapy and future directions

Modern immunosuppression has led to a decrease in rejection rates and improved survival rates after solid organ transplantation. Increasing the potency of immunosuppression promotes post-transplant viral infections and associated cancers by impairing immune response against viruses and cancer immunoediting. This review reflects the magnitude, etiology and immunological characteristics of various virus-related post-transplant malignancies, emphasizing the need for future research. A multidisciplinary and strategic approach may serve best but overall literature evidence targeting it is sparse. However, the authors attempted to provide a more detailed update of the literature consensus for the prevention, diagnosis, management and surveillance of post-transplant viral infections and associated malignancies, with a focus on the current role of adoptive immunotherapy and the way forward. In order to achieve long-term patient and graft survival as well as superior post-transplant outcomes, collaborative research on holistic care of organ recipients is imperative.

Performance of ChatGPT in Israeli Hebrew OBGYN national residency examinations

PURPOSE

Previous studies of ChatGPT performance in the field of medical examinations have reached contradictory results. Moreover, the performance of ChatGPT in other languages other than English is yet to be explored. We aim to study the performance of ChatGPT in Hebrew OBGYN-'Shlav-Alef' (Phase 1) examination.

METHODS

A performance study was conducted using a consecutive sample of text-based multiple choice questions, originated from authentic Hebrew OBGYN-'Shlav-Alef' examinations in 2021-2022. We constructed 150 multiple choice questions from consecutive text-based-only original questions. We compared the performance of ChatGPT performance to the real-life actual performance of OBGYN residents who completed the tests in 2021-2022. We also compared ChatGTP Hebrew performance vs. previously published English medical tests.

RESULTS

In 2021-2022, 27.8% of OBGYN residents failed the 'Shlav-Alef' examination and the mean score of the residents was 68.4. Overall, 150 authentic questions were evaluated (one examination). ChatGPT correctly answered 58 questions (38.7%) and reached a failed score. The performance of Hebrew ChatGPT was lower when compared to actual performance of residents: 38.7% vs. 68.4%, p < .001. In a comparison to ChatGPT performance in 9,091 English language questions in the field of medicine, the performance of Hebrew ChatGPT was lower (38.7% in Hebrew vs. 60.7% in English, p < .001).

CONCLUSIONS

ChatGPT answered correctly on less than 40% of Hebrew OBGYN resident examination questions. Residents cannot rely on ChatGPT for the preparation of this examination. Efforts should be made to improve ChatGPT performance in other languages besides English.

Linking the choice of the class format and preclass learning experiences sheds light on a step further in blended medical education

BACKGROUND

The core principle of HyFlex ('hybrid' and 'flexible') learning is to maintain learning equity under most circumstances. Within a blended framework in precision medical education, how different preferences of synchronous learning environment influence learning process and outcome is limited. We investigated students' preclass online video learning experiences and their choices toward synchronous class formats.

METHODS

This was a mixed-methods study. During the 2021 academic year, all 5th-year medical students who had viewed online video clips presenting core concepts were asked to complete a survey on their preference for future synchronous class format (face-to-face, online, or HyFlex) and asked to provide reflective comments on their self-learning. Anonymous survey data, online records, and summative assessment scores (short-term learning outcomes) were collected. Kruskal - Wallis or Chi-square tests were used to compare differences between groups, and multiple linear regression was managed to select the factors associated with various choices. The students' comments were coded in a descriptive thematic analysis.

RESULTS

Among 152 medical students, 150 responded to the questionnaires, and 109 provided comments. Medical students spent a median of 32 min online, significantly shorter in the face-to-face group than in the online and HyFlex groups. The online group had a lower preclass video completion rate for certain concepts. The choice was not associated with short-term learning outcomes. Student feedback revealed a higher frequency of multiple themes for each student in the face-to-face and HyFlex groups, and these themes fell into the categories of learning efficiency, focus concentration, and course attractiveness.

CONCLUSIONS

Linking the choice of the class format and learning experiences of preclass online videos sheds light on a step further within a blended framework of precision medical education. Supplement of online interactive elements may help secure learning engagement among students choosing 'online only' class format of HyFlex learning.

Evaluating the performance of ChatGPT-4 on the United Kingdom Medical Licensing Assessment

Introduction

Recent developments in artificial intelligence large language models (LLMs), such as ChatGPT, have allowed for the understanding and generation of human-like text. Studies have found LLMs abilities to perform well in various examinations including law, business and medicine. This study aims to evaluate the performance of ChatGPT in the United Kingdom Medical Licensing Assessment (UKMLA).

Methods

Two publicly available UKMLA papers consisting of 200 single-best-answer (SBA) questions were screened. Nine SBAs were omitted as they contained images that were not suitable for input. Each question was assigned a specialty based on the UKMLA content map published by the General Medical Council. A total of 191 SBAs were inputted in ChatGPT-4 through three attempts over the course of 3 weeks (once per week).

Results

ChatGPT scored 74.9% (143/191), 78.0% (149/191) and 75.6% (145/191) on three attempts, respectively. The average of all three attempts was 76.3% (437/573) with a 95% confidence interval of (74.46% and 78.08%). ChatGPT answered 129 SBAs correctly and 32 SBAs incorrectly on all three attempts. On three attempts, ChatGPT performed well in mental health (8/9 SBAs), cancer (11/14 SBAs) and cardiovascular (10/13 SBAs). On three attempts, ChatGPT did not perform well in clinical haematology (3/7 SBAs), endocrine and metabolic (2/5 SBAs) and gastrointestinal including liver (3/10 SBAs). Regarding to response consistency, ChatGPT provided correct answers consistently in 67.5% (129/191) of SBAs but provided incorrect answers consistently in 12.6% (24/191) and inconsistent response in 19.9% (38/191) of SBAs, respectively.

Discussion and conclusion

This study suggests ChatGPT performs well in the UKMLA. There may be a potential correlation between specialty performance. LLMs ability to correctly answer SBAs suggests that it could be utilised as a supplementary learning tool in medical education with appropriate medical educator supervision.

Immunotherapy and Liver Transplantation: A Narrative Review of Basic and Clinical Data

Immune checkpoint inhibitors (ICIs) have improved the management of patients with intermediate- and advanced-stage HCC, even making some of them potential candidates for liver transplantation. However, acute rejection has been observed after ICI therapy, challenging its safety in transplant settings. We summarize the key basic impact of immune checkpoints on HCC and liver transplantation. We analyze the available case reports and case series on the use of ICI therapy prior to and after liver transplantation. A three-month washout period is desirable between ICI therapy and liver transplantation to reduce the risk of acute rejection. Whenever possible, ICIs should be avoided after liver transplantation, and especially so early after a transplant. Globally, more robust prospective data in the field are required.

Exploring the Potential of Fecal Microbiota Transplantation as a Therapy in Tuberculosis and Inflammatory Bowel Disease

This review explores the potential benefits of fecal microbiota transplantation (FMT) as an adjunct treatment in tuberculosis (TB), drawing parallels from its efficacy in inflammatory bowel disease (IBD). FMT has shown promise in restoring the gut microbial balance and modulating immune responses in IBD patients. Considering the similarities in immunomodulation and dysbiosis between IBD and TB, this review hypothesizes that FMT may offer therapeutic benefits as an adjunct therapy in TB. Methods: We conducted a systematic review of the existing literature on FMT in IBD and TB, highlighting the mechanisms and potential implications of FMT in the therapeutic management of both conditions. The findings contribute to understanding FMT's potential role in TB treatment and underscore the necessity for future research in this direction to fully leverage its clinical applications. Conclusion: The integration of FMT into the comprehensive management of TB could potentially enhance treatment outcomes, reduce drug resistance, and mitigate the side effects of conventional therapies. Future research endeavors should focus on well-designed clinical trials to develop guidelines concerning the safety and short- and long-term benefits of FMT in TB patients, as well as to assess potential risks.

Advanced therapeutics avenues in hepatocellular carcinoma: a novel paradigm

Hepatocellular carcinoma (HCC) is the most frequent type of primary liver cancer, and it poses a significant risk to patients health and longevity due to its high morbidity and fatality rates. Surgical ablation, radiotherapy, chemotherapy, and, most recently, immunotherapy have all been investigated for HCC, but none have yielded the desired outcomes. Several unique nanocarrier drug delivery techniques have been studied for their potential therapeutic implications in the treatment of HCC. Nanoparticle-based imaging could be effective for more accurate HCC diagnosis. Since its inception, nanomedicine has significantly transformed the approach to both the treatment and diagnostics of liver cancer. Nanoparticles (NPs) are being studied as a potential treatment for liver cancer because of their ability to carry small substances, such as treatment with chemotherapy, microRNA, and therapeutic genes. The primary focus of this study is on the most current discoveries and practical uses of nanomedicine-based diagnostic and therapeutic techniques for liver cancer. In this section, we had gone over what we know about metabolic dysfunction in HCC and the treatment options that attempt to fix it by targeting metabolic pathways. Furthermore, we propose a multi-target metabolic strategy as a viable HCC treatment option. Based on the findings given here, the scientists believe that smart nanomaterials have great promise for improving cancer theranostics and opening up new avenues for tumor diagnosis and treatment.

Simultaneous detection of mitochondrial viscosity and peroxynitrite in livers from subjects with drug-induced fatty liver disease using a novel fluorescent probe

Drug-induced fatty liver disease (DIFLD) is a basic clinicopathological example of drug-induced liver injury (DILI). Some drugs can inhibit β-oxidation in hepatocyte mitochondria, leading to steatosis in the liver. Additionally, drug-induced inhibition of β-oxidation and the electron transport chain (ETC) can lead to increased production of reactive oxygen species (ROS) such as peroxynitrite (ONOO^-). Therefore, it is reasonable to suspect that compared to a healthy liver, viscosity and ONOO^- levels are elevated in livers during DIFLD. A novel, smart, dual-response fluorescent probe-Mito-VO-was designed and synthesized for the simultaneous detection of viscosity and ONOO^- content. This probe had a large emission shift of 293 nm and was capable of monitoring the viscosity of, and the ONOO^- content in, cell and animal models alike, either individually or simultaneously. For the first time, Mito-VO was successfully used to demonstrate the elevated viscosity and the amount of ONOO^- in livers from mice with DIFLD.

Longitudinal analysis of transplant candidates with primary sclerosing cholangitis in an Asian liver transplant center

BACKGROUND

Primary sclerosing cholangitis (PSC) is a rare disease in Asia, and few studies have investigated the disease in this ethnicity, particularly in wait-listed patients for liver transplantation (LT). We aimed to investigate the prognostic factors and outcomes of wait-listed patients with PSC in an Asian transplant center.

METHODS

Survival was retrospectively analyzed.

RESULTS

Eighteen (10 male and 8 female) wait-listed patients with PSC, with a median age at diagnosis of 44.5 years, were included. Compared with men, women had significantly higher aspartate aminotransferase to platelet ratio index scores (3.28 vs. 1.13; P  = 0.012) and bilirubin levels (7.68 vs. 4.03 mg/dl; P  = 0.043) and more often presented with decompensating events, including ascites [5 (63%) vs. 1 (10%); P  = 0.043] and splenomegaly [8 (100%) vs. 4 (40%); P  = 0.013]. Compared with the non-LT group, the LT group exhibited a superior survival rate for women ( P  = 0.004) but not for men. In the univariable analysis, significant risk factors associated with overall survival included malignancies with a hazard ratio (95% confidence interval) of 5.53 (1.00-30.51) and esophageal varices (EV) [4.18 (1.05-16.61)], whereas female gender [25.00 (1.49-500.00)], LT [0.09 (0.01-0.80)] and EV [39.03 (2.92-521.96)] were indicated in the multivariable analysis.

CONCLUSIONS

For Asian wait-listed patients with PSC, EV and female gender were the risk factors related to overall survival, and LT was the protective factor. Our experiences suggested that LT brings more benefits in female patients. Strategies are needed to provide equivalent transplant benefits.

Discontinuing Hepatitis Activity Reduced Hepatocellular Carcinoma Recurrence after Primary Curative Therapy

BACKGROUND

Hepatocellular carcinoma (HCC) tends to recur after curative treatment. This study aimed to identify the clinical factors associated with HCC recurrence after initial curative therapy.

METHODS

We retrospectively included patients with early stage HCC Barcelona Clinic Liver Cancer (BCLC) stages 0 and A who received curative surgical resection or local ablation at three different Chang Gung Memorial Hospitals in Taiwan (527 patients from Linkou, 150 patients from Keelung, and 127 patients from Chiayi) from 2000 to 2009. Pretreatment clinical data were subjected to univariate and multivariate logistic analyses to identify the risk factors for HCC recurrence within five years after the primary curative treatment. Recurrence and survival rates were assessed using Kaplan-Meier curves and log-rank tests.

RESULTS

Patients with a history of nucleoside analog or peg-interferon treatment for hepatitis B or hepatitis C infection had lower HCC recurrence rates than did those without such treatment. By contrast, alcohol drinking habits (p = 0.0049, hazard ratio (HR): 1.508, 95%CI: 1.133-2.009), a platelet count of < 14 × 104/μL (p = 0.003, HR: 1.533, 95%CI: 1.155-2.035), and a serum alanine aminotransferase level > 40 U/L (p = 0.0450, HR: 1.305, 95%CI: 1.006-1.694) were independent risk factors for HCC recurrence. The five-year HCC recurrence rates did not differ between patients who received either local radiofrequency ablation or surgical resection at BCLC stages 0 and A.

CONCLUSIONS

Factors contributing to persistent hepatitis activity and advanced fibrosis precipitate tumor recurrence. Active intervention to discontinue liver injury or hepatitis could reduce HCC recurrence.

Clinical informatics training in medical school education curricula: a scoping review

OBJECTIVES

This scoping review evaluates the existing literature on clinical informatics (CI) training in medical schools. It aims to determine the essential components of a CI curriculum in medical schools, identify methods to evaluate the effectiveness of a CI-focused education, and understand its delivery modes.

MATERIALS AND METHODS

This review was informed by the methodological guidance of the Joanna Briggs Institute. Three electronic databases including PubMed, Scopus, and Web of Science were searched for articles discussing CI between January 2010 and December 2021.

RESULTS

Fifty-nine out of 3055 articles were included in our final analysis. Components of CI education include its utilization in clinical practice, ethical implications, key CI-related concepts, and digital health. Evaluation of educational effectiveness entails external evaluation by organizations external to the teaching institute, and internal evaluation from within the teaching institute. Finally, modes of delivery include various pedagogical strategies and teaching CI using a multidisciplinary approach.

DISCUSSION

Given the broad discussion on the required competencies, we propose 4 recommendations in CI delivery. These include situating CI curriculum within specific contexts, developing evidence-based guidelines for a robust CI education, developing validated assessment techniques to evaluate curriculum effectiveness, and equipping educators with relevant CI training.

CONCLUSION

The literature reveals that CI training in the core curricula will complement if not enhance clinical skills, reiterating the need to equip students with relevant CI competencies. Furthermore, future research needs to comprehensively address current gaps in CI training in different contexts, evaluation methodologies, and delivery modes to facilitate structured training.

Conventional and contrast-enhanced ultrasound of scleroring angiomatoid nodular transformation of the spleen

Sclerosing angiomatoid nodular transformation (SANT) is an uncommon non-tumorous disease of the spleen. The low morbidity and non-specific clinical symptoms of SANT might cause a misdiagnosis. The present study reported a case of a 31-year-old female with a SANT of the spleen. Findings on clinical manifestations and examinations, especially on contrast-enhanced ultrasound (CEUS), were carefully analyzed, and relevant literatures have also been reviewed.

Immune checkpoint inhibitors in malignancies after liver transplantation: A systematic review and pooled analysis

BACKGROUND AND AIMS

Treatment of de novo malignancies and recurrent hepatocellular carcinoma with immune checkpoint inhibitors (ICI) in liver transplant recipients (LT) is an attractive strategy that is infrequently pursued because of the lack of strong evidence regarding their safety and efficacy. In this systematic review with pooled analysis, we aimed to assess safety and efficacy of ICI therapy following LT.

METHODS

We performed a systematic search of case reports and series published until January 2022. We included 31 publications reporting a total of 52 patients treated with ICIs after LT and assessed in a pooled analysis the risk of graft rejection and the outcome of ICI therapy.

RESULTS

Acute graft rejection occurred in 15 patients (28.8%) and 7 patients (13.4% of the total cohort) died because of graft loss. Rejection was associated with shorter overall survival (OS) (17.2 months, confidence interval [CI] 12.1-22.2 vs. 3.5 months, CI 1.6-5.4, p < 0.001). Disease control rate was 44.2% (n = 23), and in these patients, OS was longer than in non-responders (26.4 months, CI 20.8-32.0 vs. 3.4 months, CI 2.1-4.7, p < 0.001).

CONCLUSIONS

Observational, off-label experience suggests that treatment with ICI for advanced malignancies in LT recipients might not be discarded a priori. This notwithstanding, ICI treatment in these patients is associated with a substantial risk of graft rejection and mortality. Prospective studies are needed to provide adequate safety and efficacy figures of ICI treatment in this fragile population.

Research progress on short-term prognosis of acute-on-chronic liver failure

INTRODUCTION

Acute-on-chronic liver failure (ACLF) is a clinical syndrome characterized as a severe condition with rapid progression, poor therapeutic response and poor prognosis. Early and timely evaluation of the prognosis is helpful for providing appropriate clinical intervention and prolonging patient survival.

AREAS COVERED

Currently, there are no specific dynamic and comprehensive approaches to assess the prognosis of patients with ACLF. This article reviews the progress in evaluating the short-term prognosis of ACLF to provide future directions for more dynamic prospective large-scale multicenter studies and a basis for individualized and precise treatment for ACLF patients. We searched PubMed and Web of Science with the term 'acute on chronic liver failure' and 'prognosis.' There was no date or language restriction, and our final search was on 26 October 2022.

EXPERT OPINION

ACLF is a dynamic process, and the best prognostic marker is the clinical evolution of organ failure over time. New prognostic markers are developing not only in the fields of genetics and histology but also toward diversification combined with imaging. Determining which patients will benefit from continued advanced life support is a formidable challenge, and accurate short-term prognostic assessments of ACLF are a good approach to addressing this issue.

Immune microenvironment and therapeutic progress of recurrent hepatocellular carcinoma after liver transplantation

HCC is a highly lethal tumor, and orthotopic liver transplantation, as one of the radical treatment methods for HCC, has opened-up a new therapeutic approach for the treatment of primary liver cancer. However, tumor recurrence after liver transplantation is the main reason that affects the long-term survival of recipients. At present, the application of ICIs has brought dawn to patients with refractory HCC. However, because of the special immune tolerance state created by long-term oral immunosuppressants in patients with HCC after liver transplantation, the current focus is how to regulate the immune balance of such patients and simultaneously maximize the anti-tumor effect. This article reviews the relationship between liver cancer and immunity, immune tolerance of liver transplantation, immune microenvironment after liver transplantation for HCC, and the application of immunotherapy in the recurrence of liver transplantation for HCC.

Threshold concepts in health professions education research: a scoping review

Threshold concepts (TCs) are increasingly used in health professions education (HPE) research. TCs are claimed to be conceptual gateways which are often traversed with substantial difficulty. In this paper, we report on a scoping review investigating the following research question: What is the scope and nature of the currently available research on threshold concepts in health professions education literature? We employed Arksey and O'Malley's model for scoping reviews. A search for literature on TCs in HPE research between 2003 and 2020 yielded 999 records of which 59 were included in the review. The data set was subject to quantitative descriptive analysis of article characteristics as well as qualitative thematic analysis of the scope of research on TCs. Among the 59 articles selected for review, there were 30 empirical, 26 conceptual and three reviews. A majority were published in 2015 or later. Almost half of the included articles attempted to identify possible TCs within HPE. Others investigated how TCs can be traversed or suggested how TCs could influence curriculum design. Some critically appraised the framework of TC. Although TCs are increasingly utilised in HPE, the present review identified how researchers came across methodological challenges related to identifying possible TCs and definitional challenges around identifying the essential characteristics of TCs. Before embracing TCs as the next go-to theory for learning in HPE, we acknowledge the need for methodological stringeny and rigour as well as more data to support TCs. Until then, any implementation of TCs in HPE curricula should be done cautiously.