Perceptions and Earliest Experiences of Medical Students and Faculty With ChatGPT in Medical Education: Qualitative Study

BACKGROUND

With the rapid development of artificial intelligence technologies, there is a growing interest in the potential use of artificial intelligence-based tools like ChatGPT in medical education. However, there is limited research on the initial perceptions and experiences of faculty and students with ChatGPT, particularly in Saudi Arabia.

OBJECTIVE

This study aimed to explore the earliest knowledge, perceived benefits, concerns, and limitations of using ChatGPT in medical education among faculty and students at a leading Saudi Arabian university.

METHODS

A qualitative exploratory study was conducted in April 2023, involving focused meetings with medical faculty and students with varying levels of ChatGPT experience. A thematic analysis was used to identify key themes and subthemes emerging from the discussions.

RESULTS

Participants demonstrated good knowledge of ChatGPT and its functions. The main themes were perceptions of ChatGPT use, potential benefits, and concerns about ChatGPT in research and medical education. The perceived benefits included collecting and summarizing information and saving time and effort. However, concerns and limitations centered around the potential lack of critical thinking in the information provided, the ambiguity of references, limitations of access, trust in the output of ChatGPT, and ethical concerns.

CONCLUSIONS

This study provides valuable insights into the perceptions and experiences of medical faculty and students regarding the use of newly introduced large language models like ChatGPT in medical education. While the benefits of ChatGPT were recognized, participants also expressed concerns and limitations requiring further studies for effective integration into medical education, exploring the impact of ChatGPT on learning outcomes, student and faculty satisfaction, and the development of critical thinking skills.

Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline

CLINICAL QUESTION

What is the comparative effectiveness and safety of commonly used interventional procedures (such as spinal injections and ablation procedures) for chronic axial and radicular spine pain that is not associated with cancer or inflammatory arthropathy?

CURRENT PRACTICE

Chronic spine pain is a common, potentially disabling complaint, for which clinicians often administer interventional procedures. However, clinical practice guidelines provide inconsistent recommendations for their use.

RECOMMENDATIONS

For people living with chronic axial spine pain (≥3 months), the guideline panel issued strong recommendations against: joint radiofrequency ablation with or without joint targeted injection of local anaesthetic plus steroid; epidural injection of local anaesthetic, steroids, or their combination; joint-targeted injection of local anaesthetic, steroids, or their combination; and intramuscular injection of local anaesthetic with or without steroids. For people living with chronic radicular spine pain (≥3 months), the guideline panel issued strong recommendations against: dorsal root ganglion radiofrequency with or without epidural injection of local anaesthetic or local anaesthetic plus steroids; and epidural injection of local anaesthetic, steroids, or their combination.

HOW THIS GUIDELINE WAS CREATED

An international guideline development panel including four people living with chronic spine pain, 10 clinicians with experience managing chronic spine pain, and eight methodologists, produced these recommendations in adherence with standards for trustworthy guidelines using the GRADE approach. The MAGIC Evidence Ecosystem Foundation provided methodological support. The guideline panel applied an individual patient perspective when formulating recommendations.

THE EVIDENCE

These recommendations are informed by a linked systematic review and network meta-analysis of randomised trials and a systematic review of observational studies, summarising the current body of evidence for benefits and harms of common interventional procedures for axial and radicular, chronic, non-cancer spine pain. Specifically, injection of local anaesthetic, steroids, or their combination into the cervical or lumbar facet joint or sacroiliac joint; epidural injections of local anaesthetic, steroids, or their combination; radiofrequency of dorsal root ganglion; radiofrequency denervation of cervical or lumbar facet joints or the sacroiliac joint; and paravertebral intramuscular injections of local anaesthetic, steroids, or their combination.

UNDERSTANDING THE RECOMMENDATIONS

These recommendations apply to people living with chronic spine pain (≥3 months duration) that is not associated with cancer or inflammatory arthropathy and do not apply to the management of acute spine pain. Further research is warranted and may alter recommendations in the future: in particular, whether there are differences in treatment effects based on subtypes of chronic spine pain, establishing the effectiveness of interventional procedures currently supported by low or very low certainty evidence, and effects on poorly reported patient-important outcomes (such as opioid use, return to work, and sleep quality).

Managing low-back pain in rural Uganda: a qualitative study exploring the perspectives and practices of frontline health workers regarding LBP management in primary care

BACKGROUND AND AIMS

Low-back pain (LBP) is the main cause of years lived with disabilities (YLDs) worldwide and the second cause of YLDs in Uganda. In 2019, it was responsible for 7.4% of global YLDs and 5% of YLDs in Uganda. LBP takes a significant toll on people's quality of life and disproportionately affects lower socioeconomic classes, elders, and women. In rural Uganda, LBP is managed in health centres by clinical officers and nurses with limited resources. This study aims to understand the perspectives and practices of these health workers.

METHOD

A qualitative design using semi-structured focus-group discussions was employed. Purposive sampling allowed us to identify relevant participants based on their roles as healthcare professionals working in primary care context in rural South-West Uganda. Data was analysed using thematic analysis.

FINDINGS

LBP is a common and persistent complaint among patients presenting to rural health centres in Uganda. Manual labour and female specific health conditions were deemed to be common causes. There was a strong reliance on medication prescription, coupled with X-ray diagnosis, with little emphasis on education or exercise. Finally, findings highlighted major barriers for patients within the referral system to hospital care or rehabilitation.

DISCUSSION

Education and training of frontline clinicians in terms of appropriate prescribing and rehabilitation for LBP is crucial. Evidence-based rehabilitation interventions need to be developed and adapted so that they can be delivered within the time and resource constraints of the health workforce, ensuring that they are acceptable and effective to patients in the context of rural Uganda.

Profoundly Delayed Emergence due to Pulmonary Embolism

Pulmonary embolism is a rare, but serious, potential perioperative complication and crisis. We present a case of a 12-year-old female undergoing distal femoral and proximal tibial osteotomies with internal fixations who experienced acute onset hypercapnia, tachycardia, and prolonged minimal responsiveness following deflation of the tourniquet and cessation of inhaled sevoflurane. CT-chest demonstrated bilateral partially occlusive filling defects of the pulmonary vasculature. We concluded that the patient experienced a pulmonary embolism resulting in V/Q mismatch, retained sevoflurane, and ultimately delayed emergence.

Objective Pain Assessment Using Deep Learning Through EEG-Based Brain-Computer Interfaces

Objective pain measurements are essential in clinical settings for determining effective treatment strategies. This study aims to utilize brain-computer interface technology for reliable pain classification and detection. We developed an electroencephalography-based pain detection system comprising two main components: (1) pain/no-pain detection and (2) pain severity classification across three levels: low, moderate, and high. Deep learning models, including convolutional neural networks and recurrent neural networks, were employed to classify the wavelet features extracted through time-frequency domain analysis. Furthermore, we compared the performance of our system against conventional machine learning models, such as support vector machines and random forest classifiers. Our deep learning approach outperformed the baseline models, achieving accuracies of 91.84% for pain/no-pain detection and 87.94% for pain severity classification, respectively.

The role of Prolyl 3-Hydroxylase 1 (P3H1) in tumor development and prognosis: a pan-cancer analysis with validation in colonic adenocarcinoma

BACKGROUND

Cancer is a multifaceted disease characterized by unregulated cell proliferation, evasion of apoptosis, and metastasis. Recent studies have highlighted the importance of extracellular matrix remodeling and post-translational modifications in tumorigenesis. Prolyl 3-hydroxylase 1 (P3H1), an enzyme involved in collagen hydroxylation, has gained attention for its role in cancer progression.

METHODS

This study investigates P3H1 expression, prognostic value, and functional relevance across multiple human cancers using a combination of bioinformatic and experimental approaches.

RESULTS

Using The Cancer Genome Atlas (TCGA) data from TIMER2.0 and UALCAN databases, we observed a significant upregulation of P3H1 mRNA and protein in various cancers. Prognostic analysis using GEPIA2 and KM plotter revealed that high P3H1 expression correlates with poorer overall survival in colon adenocarcinoma (COAD), kidney renal clear cell carcinoma (KIRC), and liver hepatocellular carcinoma (LIHC). Further, genetic and promoter methylation analyses showed low mutation frequencies and reduced methylation of P3H1 in specific cancer types. Functional and pathway enrichment analyses indicated that P3H1 is involved in collagen formation, endoplasmic reticulum activity, and pathways such as ECM-receptor interaction and PI3K-Akt signaling. Validation by enzyme linked immunosorbent assay in COAD patient serum samples demonstrated significantly elevated P3H1 levels compared to healthy controls, with an AUC approaching 1.0 by receiver operating characteristic (ROC) curve analysis. This suggests its potential as a diagnostic biomarker. Additionally, functional experiments were conducted in COAD cells to assess P3H1's role in tumorigenesis. Knockdown of P3H1 in HCT116 cells resulted in a significant reduction in cell proliferation, colony formation, and migratory abilities of these cells.

CONCLUSION

These findings emphasize P3H1's relevance in COAD, KIRC, and LIHC pathogenesis and possible utility in clinical diagnosis.

Diagnosis and Management of Orthopaedic Conditions Associated With Hereditary Sensory Autonomic Neuropathies

Hereditary sensory and autonomic neuropathies (HSANs) encompass a diverse group of inherited neuropathies characterized by notable sensory and autonomic involvement that affects musculoskeletal structures and systemic function. There are 8 recognized types of HSAN. The orthopaedic manifestations of HSAN are complex and diverse, including spinal deformity, Charcot arthropathy, osteomyelitis, fractures, osteonecrosis, osteoporosis, and skeletal deformities. The sensory neuropathy with involvement of small nerve fibers can lead to unnoticed burns, fractures, and joint trauma. Spinal involvement includes progressive scoliosis/kyphosis and acute neurologic compromise. Diagnosis is dependent on clinical suspicion and confirmed with genetic analysis. Treatment is focused on the eradication of infection, stabilization of fractures, and prevention of joint instability in the spine and extremities. This review focuses on the orthopaedic manifestations to aid healthcare professionals in the recognition and treatment of these conditions.

Evaluation of the Performance of Three Large Language Models in Clinical Decision Support: A Comparative Study Based on Actual Cases

BACKGROUND

Generative large language models (LLMs) are increasingly integrated into the medical field. However, their actual efficacy in clinical decision-making remains partially unexplored. This study aimed to assess the performance of the three LLMs, ChatGPT-4, Gemini, and Med-Go, in the domain of professional medicine when confronted with actual clinical cases.

METHODS

This study involved 134 clinical cases spanning nine medical disciplines. Each LLM was required to provide suggestions for diagnosis, diagnostic criteria, differential diagnosis, examination and treatment for every case. Responses were scored by two experts using a predefined rubric.

RESULTS

In overall performance among the models, Med-Go achieved the highest median score (37.5, IQR 31.9-41.5), while Gemini recorded the lowest (33.0, IQR 25.5-36.6), showing significant statistical difference among the three LLMs (p < 0.001). Analysis revealed that responses related to differential diagnosis were the weakest, while those pertaining to treatment recommendations were the strongest. Med-Go displayed notable performance advantages in gastroenterology, nephrology, and neurology.

CONCLUSIONS

The findings show that all three LLMs achieved over 60% of the maximum possible score, indicating their potential applicability in clinical practice. However, inaccuracies that could lead to adverse decisions underscore the need for caution in their application. Med-Go's superior performance highlights the benefits of incorporating specialized medical knowledge into LLMs training. It is anticipated that further development and refinement of medical LLMs will enhance their precision and safety in clinical use.

Chronic Pain in Italy: Turning Numbers Into Actionable Solutions

Chronic pain (CP) is a condition that looms over the global social and health scenarios. After many years without having national data, an extensive overview of this disorder in Italy has been published in the first Rapporto Censis Grünenthal (Censis Grünenthal Pain Report). It confirms that 19.8% of the Italian adult population suffers from moderate or severe CP, and the vast majority of patients (86.2%) are not aware of the existence of pain management (PM) centers. Starting with the Rapporto Censis Grünenthal data analysis by the representatives of three Italian pain scientific societies, several unmet needs were highlighted for which affordable, innovative, and technological strategies were proposed. These solutions focused on interventions in three strategic areas: (1) information, education, and awareness about CP among patients and physicians; (2) organization of pain center networks to adequately cover the national territory, promoting a multimodal-interdisciplinary approach; and (3) use of currently available novel technologies to foster access to treatment. For this purpose, the authors suggested feasible solutions, such as promoting public educational campaigns to raise awareness of the existence of pain centers and the right to receive a proper PM, as indicated in Italy by the pioneering law 38/2010. Regarding organizational gaps, the authors highlighted the possibility of drawing on international models to improve pain centers with completely dedicated staff and community-based pain services while supporting the development of specialized procedural PM standards. Concerning technologies, investments in telehealth and digital tools would improve access to therapies throughout the territory, enabling efficient clinical assessment and helping deliver the most suitable treatments. Overall, greater awareness of the impact of CP and a better allocation of resources are needed to improve patient quality of life, thereby reducing costs for the healthcare system.

Models of Integrated Acute Care for Older Adult Inpatients That Incorporate Integrative Health: An Integrative Review

Background

The use of integrated acute care for older adult inpatients is a growing field, especially the use of integrative health-care practices for managing complex, chronic, age-related health conditions. Scientific evidence suggests that these practices should be incorporated into older adult inpatients' daily care.

Aim

Conduct an integrative review of studies on integrated acute-care models for older adult inpatients that incorporate integrative health services.

Methods

We searched Medline Ovid ALL, Embase.com, CINAHL, APA PsycINFO Ovid, Web of Science Core Collection, ProQuest Dissertations & Theses A&I, Cochrane Library, and CAMBase bibliographic databases for studies, published between 1990 and 2023, on integrated acute-care models for older adult inpatients that incorporated integrative health services. The search associated the domains of acute care, geriatrics, internal medicine, rehabilitation, hospitalization, geriatric psychiatry, integrated/integrative care, care models, practices and coordination, interprofessionalism and multidisciplinarity, collaborative practices, and complementary therapies. The review was completed in June 2024.

Results

We retained 32 studies conducted in North America, Europe, Australia, and Asia, including 46,899 older adult inpatients, 39 physicians, 148 nurses, 695 allied health-care professionals, and 358 informal caregivers. Three integrated acute care models were identified: the Acute Care for Elders model, the Integrated General Hospital model, and the Transitional Care model. Three integrated acute psychogeriatric-care models were identified: the Admiral Nursing model, the Lewy body dementia Admiral nursing service model, and the Care for Acute Mentally Infirm Elders model. A single, hybrid, Integrated, People-Centred Health Services model for acute and community health care was identified. We found the Scaling Integrated Care in Context model for measuring integrated care development within health-care systems.

Conclusion

Few studies have investigated integrated acute-care models incorporating integrative health services for older adult inpatients. Existing acute-care models including integrative medicine should be explored further, and new, more inclusive models should be developed.

Evaluating ChatGPT-4's performance on oral and maxillofacial queries: Chain of Thought and standard method

Objectives

Oral and maxillofacial diseases affect approximately 3.5 billion people worldwide. With the continuous advancement of Artificial Intelligence technologies, particularly the application of generative pre-trained transformers like ChatGPT-4, there is potential to enhance public awareness of the prevention and early detection of these diseases. This study evaluated the performance of ChatGPT-4 in addressing oral and maxillofacial disease questions using standard approaches and the Chain of Thought (CoT) method, aiming to gain a deeper understanding of its capabilities, potential, and limitations.

Materials and methods

Three experts, drawing from their extensive experience and the most common questions in clinical settings, selected 130 open-ended questions and 1,805 multiple-choice questions from the national dental licensing examination. These questions encompass 12 areas of oral and maxillofacial surgery, including Prosthodontics, Pediatric Dentistry, Maxillofacial Tumors and Salivary Gland Diseases, and maxillofacial Infections.

Results

Using CoT approach, ChatGPT-4 exhibited marked enhancements in accuracy, structure, completeness, professionalism, and overall impression for open-ended questions, revealing statistically significant differences compared to its performance on general oral and maxillofacial inquiries. In the realm of multiple-choice questions, the application of CoT method boosted ChatGPT-4's accuracy across all major subjects, achieving an overall accuracy increase of 3.1%.

Conclusions

When employing ChatGPT-4 to address questions in oral and maxillofacial surgery, incorporating CoT as a querying method can enhance its performance and help the public improve their understanding and awareness of such issues. However, it is not advisable to consider it a substitute for doctors.

The Potential of Hydrogel Preparations Containing Plant Materials in Supporting the Treatment of Vaginal and Vulvar Infections-Current State of Knowledge

Vaginal hydrogels are a modern alternative to solid (tablets, globules) and other semi-solid forms of medication (ointments, creams) in the control of pathogenic microorganisms in diseases of the female reproductive tract. This review aims to summarize the current state of knowledge regarding the efficacy of hydrogels containing plant materials in the treatment of vaginal and vulvar infections. New therapies are essential to address the growing antimicrobial resistance crisis. Google Scholar, Web of Science, Cochrane, and Medline (PubMed) databases were searched. Twenty-five studies were included in the review, including basic, pre-clinical, and clinical studies. The results obtained confirmed the therapeutic potential of plant raw materials embedded in the polymer matrix of hydrogels. However, due to the small number of clinical trials conducted, further research in this area is needed.

Performance of artificial intelligence on Turkish dental specialization exam: can ChatGPT-4.0 and gemini advanced achieve comparable results to humans?

BACKGROUND

AI-powered chatbots have spread to various fields including dental education and clinical assistance to treatment planning. The aim of this study is to assess and compare leading AI-powered chatbot performances in dental specialization exam (DUS) administered in Turkey and compare it with the best performer of that year.

METHODS

DUS questions for 2020 and 2021 were directed to ChatGPT-4.0 and Gemini Advanced individually. DUS questions were manually entered into AI-powered chatbot in their original form, in Turkish. The results obtained were compared with each other and the year's best performers. Candidates who score at least 45 points on this centralized exam are deemed to have passed and are eligible to select their preferred department and institution. The data was statistically analyzed using Pearson's chi-squared test (p < 0.05).

RESULTS

ChatGPT-4.0 received 83.3% correct response rate on the 2020 exam, while Gemini Advanced received 65% correct response rate. On the 2021 exam, ChatGPT-4.0 received 80.5% correct response rate, whereas Gemini Advanced received 60.2% correct response rate. ChatGPT-4.0 outperformed Gemini Advanced in both exams (p < 0.05). AI-powered chatbots performed worse in overall score (for 2020: ChatGPT-4.0, 65,5 and Gemini Advanced, 50.1; for 2021: ChatGPT-4.0, 65,6 and Gemini Advanced, 48.6) when compared to overall scores of the best performer of that year (68.5 points for year 2020 and 72.3 points for year 2021). This poor performance also includes the basic sciences and clinical sciences sections (p < 0.001). Additionally, periodontology was the clinical specialty in which both AI-powered chatbots achieved the best results, the lowest performance was determined in the endodontics and orthodontics.

CONCLUSION

AI-powered chatbots, namely ChatGPT-4.0 and Gemini Advanced, passed the DUS by exceeding the threshold score of 45. However, they still lagged behind the top performers of that year, particularly in basic sciences, clinical sciences, and overall score. Additionally, they exhibited lower performance in some clinical specialties such as endodontics and orthodontics.

Appropriateness and Consistency of an Online Artificial Intelligence System's Response to Common Questions Regarding Cervical Fusion

STUDY DESIGN

Prospective survey study.

OBJECTIVE

To address a gap that exists concerning ChatGPT's ability to respond to various types of questions regarding cervical surgery.

SUMMARY OF BACKGROUND DATA

Artificial Intelligence (AI) and machine learning have been creating great change in the landscape of scientific research. Chat Generative Pre-trained Transformer(ChatGPT), an online AI language model, has emerged as a powerful tool in clinical medicine and surgery. Previous studies have demonstrated appropriate and reliable responses from ChatGPT concerning patient questions regarding total joint arthroplasty, distal radius fractures, and lumbar laminectomy. However, there is a gap that exists in examining how accurate and reliable ChatGPT responses are to common questions related to cervical surgery.

MATERIALS AND METHODS

Twenty questions regarding cervical surgery were presented to the online ChatGPT-3.5 web application 3 separate times, creating 60 responses. Responses were then analyzed by 3 fellowship-trained spine surgeons across 2 institutions using a modified Global Quality Scale (1-5 rating) to evaluate accuracy and utility. Descriptive statistics were reported based on responses, and intraclass correlation coefficients were then calculated to assess the consistency of response quality.

RESULTS

Out of all questions proposed to the AI platform, the average score was 3.17 (95% CI, 2.92, 3.42), with 66.7% of responses being recorded to be of at least "moderate" quality by 1 reviewer. Nine (45%) questions yielded responses that were graded at least "moderate" quality by all 3 reviewers. The test-retest reliability was poor with the intraclass correlation coefficient (ICC) calculated as 0.0941 (-0.222, 0.135).

CONCLUSION

This study demonstrated that ChatGPT can answer common patient questions concerning cervical surgery with moderate quality during the majority of responses. Further research within AI is necessary to increase response.

A Descriptive Study Nursing Students' Knowledge and Attitudes Pediatric Pain: Where Are We Now?

Pain management is an ethical responsibility of all professional nurses. Pain is a common symptom experienced in clients across the lifespan.

PURPOSE

The purpose of this study was to examine nursing students' knowledge and attitudes regarding pediatric pain management.

DESIGN

A retrospective descriptive design.

METHODS

Use of the Pediatric Nurses Knowledge and Attitudes Survey Regarding Pain Management (PNKAS Shriners Version 2002). The sample comprised of scores from 320 students enrolled in a pediatric course at a private school of nursing in the Northeastern United States.

RESULTS

Findings identified that the rate of correct answers ranged from 21.95% to 97.56%. Results showed a low level of student nurses' knowledge and attitudes regarding pediatric pain management.

CONCLUSIONS

The results highlight that regardless of the curricular changes that have been made, students continue to struggle with pediatric pain management with emphasis on pain management pharmacology.

CLINICAL IMPLICATIONS

Pediatric pain education needs to be improved in the undergraduate educational curricula. It is important for nursing schools to consider the possibility of integrating pain education in a systematic manner to better prepare students.

The cathartic dream: Using a large language model to study a new type of functional dream in healthy and clinical populations

According to some theories of emotion regulation, dreams could modify negative emotions and ultimately reduce their intensity. We introduce here the idea of cathartic dream, a specific and separate type of emotional dream, which is characterized by a dynamic plot with emotional twists, and where negative emotions are expressed and ultimately decreased. This process would reflect psychological relief (catharsis according to the Aristotelian definition) and fulfil an emotion regulation function. We developed and validated a tool using a large language model to emotionally categorize the different dreams from dream diaries. Based on this tool, we were able to detect the prevalence of cathartic dreams in datasets of both healthy participants and patients with nightmares. Additionally, we observed the increase of cathartic dreams during 2 weeks of imagery rehearsal therapy and targeted memory reactivation during rapid eye movement sleep. We also demonstrate how the increase of cathartic dreams correlates significantly with the decrease of depression scores in patients with nightmares under therapy, thus supporting their likely functional role in well-being and their distinct nature among other emotional dreams.

Artificial Intelligence in Biomedical Engineering and Its Influence on Healthcare Structure: Current and Future Prospects

Artificial intelligence (AI) is a growing area of computer science that combines technologies with data science to develop intelligent, highly computation-able systems. Its ability to automatically analyze and query huge sets of data has rendered it essential to many fields such as healthcare. This article introduces you to artificial intelligence, how it works, and what its central role in biomedical engineering is. It brings to light new developments in medical science, why it is being applied in biomedicine, key problems in computer vision and AI, medical applications, diagnostics, and live health monitoring. This paper starts with an introduction to artificial intelligence and its major subfields before moving into how AI is revolutionizing healthcare technology. There is a lot of emphasis on how it will transform biomedical engineering through the use of AI-based devices like biosensors. Not only can these machines detect abnormalities in a patient's physiology, but they also allow for chronic health tracking. Further, this review also provides an overview of the trends of AI-enabled healthcare technologies and concludes that the adoption of artificial intelligence in healthcare will be very high. The most promising are in diagnostics, with highly accurate, non-invasive diagnostics such as advanced imaging and vocal biomarker analyzers leading medicine into the future.

Polyphenol-Based Prevention and Treatment of Cancer Through Epigenetic and Combinatorial Mechanisms

Polyphenols have been shown to be utilized as an effective treatment for cancer by acting as a DNMT or HDAC inhibitor, reducing inflammatory processes, and causing cell cycle arrest. While there have been many studies demonstrating the anti-cancerous potential of individual polyphenols, there are limited studies on the combinatorial effects of polyphenols. This review focuses on how combinations of different polyphenols can be used as a chemotherapeutic treatment option for patients. Specifically, we examine the combinatorial effects of three commonly used polyphenols: curcumin, resveratrol, and epigallocatechin gallate. These combinations have been shown to induce apoptosis, prevent colony formation and migration, increase tumor suppression, reduce cell viability and angiogenesis, and create several epigenetic modifications. In addition, these anti-cancerous effects were synergistic and additive. Thus, these findings suggest that using different combinations of polyphenols at the appropriate concentrations can be used as a better and more efficacious treatment against cancer as compared to using polyphenols individually.

Hydromorphone reduced the incidence of emergence agitation after adenotonsillectomy in children with obstructive sleep apnea: A randomized, double-blind study

Purpose

Emergence agitation (EA) after (adeno)tonsillectomy (AT) surgery impairs recovery in children. Adequate analgesia plays a crucial role in reducing EA incidence. This study investigated whether hydromorphone infusion (30 μg/kg) during anesthesia induction could reduce EA following AT surgery for obstructive sleep apnea in children.

Patients and methods

A total of 186 ASA I-III children aged 3-7 years undergoing AT surgery were enrolled in a blinded randomized trial comparing hydromorphone (30 μg/kg) to fentanyl (4 μg/kg). The primary outcome was EA incidence within 30 min post-extubation. Secondary outcomes included pediatric anesthesia emergence delirium (PAED), face, legs, activity, crying, consolability (FLACC), Ramsay sedation scores, extubation time, rescue analgesia incidence, and adverse events.

Results

The incidence of EA was significantly lower in the hydromorphone group [48.4% (45/93) vs 64.5% (60/93); absolute difference: 16.1%; 95% CI: 18.9-29.5%; P = 0.027]. Hydromorphone improved PAED, FLACC, and Ramsay scores and reduced moderate-to-severe pain and rescue analgesia. No postoperative complications occurred in either group.

Conclusion

Hydromorphone at 30 μg/kg effectively reduces the incidence of EA within 30 min post-extubation in children after AT surgery compared to fentanyl. It shows superior analgesia and has a low incidence of adverse effects.

Platycodon grandiflorum-derived extracellular vesicles suppress triple-negative breast cancer growth by reversing the immunosuppressive tumor microenvironment and modulating the gut microbiota

Despite the approval of several artificial nanotherapeutics for the treatment of triple-negative breast cancer (TNBC), significant challenges, including unsatisfactory therapeutic outcomes, severe side effects, and the high cost of large-scale production, still restrict their long-term application. In contrast, plant-derived extracellular vesicles (PEVs) exhibit promising potential in cancer therapy due to their negligible systemic toxicity, high bioavailability and cost- effectiveness. In this study, we developed an alternative strategy to inhibit TNBC via Platycodon grandiflorum (PG)-derived extracellular vesicles (PGEVs). The PGEVs were isolated by ultracentrifugation and sucrose gradient centrifugation method and contained adequate functional components such as proteins, lipids, RNAs and active molecules. PGEVs exhibited remarkable stability, tolerating acidic digestion and undergoing minimal changes in simulated gastrointestinal fluid. They were efficiently taken up by tumor cells and induced increased production of reactive oxygen species (ROS), leading to tumor cell proliferation inhibition and apoptosis, particularly in the TNBC cell line 4T1. Additionally, PGEVs facilitated the polarization of tumor-associated macrophages (TAMs) toward M1 phenotype and increased the secretion of pro-inflammatory cytokines. Further in vivo investigations revealed that PGEVs efficiently accumulated in 4T1 tumors and exerted significant therapeutic effects through boosting systemic anti-tumor immune responses and modulating the gut microbiota whether administered orally or intravenously (i.v.). In conclusion, these findings highlight PGEVs as a promising natural, biocompatible and efficient nanotherapeutic candidate for treating TNBC.

Consciousness Research Through Pain

Background/Objectives: Consciousness is a complex and elusive phenomenon encompassing self-awareness, sensory perception, emotions, and cognition. Despite significant advances in neuroscience, understanding the neural mechanisms underlying consciousness remains challenging. Pain, as a subjective and multifaceted experience, offers a unique lens for exploring consciousness by integrating sensory inputs with emotional and cognitive dimensions. This study examines the relationship between consciousness and pain, highlighting the potential of pain as a model for understanding the interplay between subjective experience and neural activity. Methods: Literature review. Results: Key theories of consciousness, such as the Global Workspace Theory and the Integrated Information Theory, provide diverse frameworks for interpreting the emergence of consciousness. Similarly, pain research emphasizes the role of subjective interpretation and emotional context in shaping sensory experiences, reflecting broader challenges in consciousness studies. The limitations of current methodologies, particularly the difficulty of objectively measuring subjective phenomena, like pain and consciousness, are also addressed. This highlights the importance of neural correlates, with a particular focus on brain regions, such as the anterior cingulate cortex and the insula, which bridge sensory and emotional experiences. By analyzing the shared attributes of pain and consciousness, this study underscores the potential for pain to serve as a measurable proxy in consciousness research. Conclusions: Ultimately, it contributes to unraveling the neural and philosophical underpinnings of consciousness, offering implications for mental health treatment and advancements in artificial intelligence. This study fills a critical gap by leveraging pain as a measurable and reproducible model for exploring the neural and subjective mechanisms of consciousness. By combining theoretical frameworks with empirical evidence, it offers novel insights into how consciousness emerges from neural processes.

GRP78 in Glioma Progression and Therapy: Implications for Targeted Approaches

Glioma is the most common primary malignant brain tumor, accounting for the majority of brain cancer-related deaths. Considering the limited efficacy of conventional therapies, novel molecular targeted therapies have been developed to improve outcomes and minimize toxicity. Glucose-regulated protein 78 (GRP78), a molecular chaperone primarily localized in the endoplasmic reticulum (ER), has received increasing attention for its role in glioma progression and resistance to conventional therapies. Overexpressed in gliomas, GRP78 supports tumor growth, survival, and therapeutic resistance by maintaining cellular homeostasis and regulating multiple signaling pathways. Its aberrant expression correlates with higher tumor grades and poorer patient prognosis. Beyond its intracellular functions, GRP78's presence on the cell surface and its role in the tumor microenvironment underscore its potential as a therapeutic target. Recent studies have explored innovative strategies to target GRP78, including small molecule inhibitors, monoclonal antibodies, and chimeric antigen receptor (CAR) T cell therapy, showing significant potential in glioma treatment. This review explores the biological characteristics of GRP78, its role in glioma pathophysiology, and the potential of GRP78-targeted therapy as a novel strategy to overcome treatment resistance and improve clinical outcomes. GRP78-targeted therapy, either alone or in combination with conventional treatments, could be a novel and attractive strategy for future glioma treatment.

Advancements in clinical research and emerging therapies for triple-negative breast cancer treatment

Triple-negative breast cancer (TNBC), defined by the lack of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor 2 (HER2) expression, is acknowledged as the most aggressive form of breast cancer (BC), comprising 15%-20% of all primary cases. Despite the prevalence of TNBC, effective and well-tolerated targeted therapies remain limited, with chemotherapy continuing to be the mainstay of treatment. However, the horizon is brightened by recent advancements in immunotherapy and antibody-drug conjugates (ADCs), which have garnered the U.S. Food and Drug Administration (FDA) approval for various stages of TNBC. Poly (ADP-ribose) polymerase inhibitors (PARPi), particularly for TNBC with BRCA mutations, present a promising avenue, albeit with the challenge of resistance that must be addressed. The success of phosphoinositide-3 kinase (PI3K) pathway inhibitors in hormone receptor (HR)-positive BC suggests potential applicability in TNBC, spurring optimism within the research community. This review endeavors to offer a comprehensive synthesis of both established and cutting-edge targeted therapies for TNBC. We delve into the specifics of PARPi, androgen receptor (AR) inhibitors, Cancer stem cells (CSCs), PI3K/Protein Kinase B (AKT)/mammalian target of rapamycin (mTOR), the transforming growth factor-beta (TGF-β), Ntoch, Wnt/β-catenin, hedgehog (Hh) pathway inhibitors, Epigenetic target-mediated drug delivery, ADCs, immune checkpoint inhibitors (ICIs)and novel immunotherapeutic solutions, contextualizing TNBC within current treatment paradigms. By elucidating the mechanisms of these drugs and their prospective clinical applications, we aim to shed light on the challenges and underscore the beacon of hope that translational research and innovative therapies represent for the oncology field.

Intravenously Administered Nonsteroidal Anti-Inflammatory Drugs in Clinical Practice: A Narrative Review

Intravenously administered nonsteroidal anti-inflammatory drugs (NSAIDs) constitute a crucial component of multimodal analgesia strategies in surgical settings. This narrative review aims to provide an up-to-date evaluation of the efficacy, safety, and clinical use of intravenous (IV) NSAIDs for perioperative pain management in adults and children. The NSAIDs and selective COX-2 inhibitors (coxibs) approved in Europe for the short-term symptomatic treatment of acute, moderate perioperative pain via IV infusion in adults and/or children have been influenced by US and global guidelines and practice: the drugs primarily reviewed here are ibuprofen, ketorolac, ketoprofen, naproxen, paracetamol, and acetylsalicylic acid. Furthermore, intravenous ibuprofen is authorized for the short-term symptomatic treatment of fever. In contrast to intravenous ketoprofen, intravenous ibuprofen is authorized for administration to children over 6 years of age or weighing more than 20 kg. Overall, IV ibuprofen had a more favorable profile with regard to peri- and postoperative opioid sparing and pain relief. Oral ibuprofen and IV ibuprofen have similar levels of efficacy, although IV ibuprofen has a shorter onset of action and is required in patients who are unable to take oral medications. The frequency of significant adverse events appears to be similar for ibuprofen and paracetamol. Systematic reviews and meta-analyses report that intravenous NSAIDs reduce postoperative opioid consumption by approximately 20-60%, improving pain management with fewer opioid-related side effects. In indications in infants, the choice of medication is limited, and the oral route is not always feasible; IV formulations of ibuprofen are preferred in this setting. Topics for further research should include head-to-head trials of IV NSAIDs.

Cigarette Smoke Contributes to the Progression of MASLD: From the Molecular Mechanisms to Therapy

Cigarette smoke (CS), an intricate blend comprising over 4000 compounds, induces abnormal cellular reactions that harm multiple tissues. Non-alcoholic fatty liver disease (NAFLD) is a prevalent chronic liver disease (CLD), encompassing non-alcoholic fatty liver (NAFL), non-alcoholic steatohepatitis (NASH), cirrhosis, and hepatocellular carcinoma (HCC). Recently, the term NAFLD has been changed to metabolic dysfunction-associated steatotic liver disease (MASLD), and NASH has been renamed metabolic dysfunction-associated steatohepatitis (MASH). A multitude of experiments have confirmed the association between CS and the incidence and progression of MASLD. However, the specific signaling pathways involved need to be updated with new scientific discoveries. CS exposure can disrupt lipid metabolism, induce inflammation and apoptosis, and stimulate liver fibrosis through multiple signaling pathways that promote the progression of MASLD. Currently, there is no officially approved efficacious pharmaceutical intervention in clinical practice. Therefore, lifestyle modifications have emerged as the primary therapeutic approach for managing MASLD. Smoking cessation and the application of a series of natural ingredients have been shown to ameliorate pathological changes in the liver induced by CS, potentially serving as an effective approach to decelerating MASLD development. This article aims to elucidate the specific signaling pathways through which smoking promotes MASLD, while summarizing the reversal factors identified in recent studies, thereby offering novel insights for future research on and the treatment of MASLD.

The impact of PD-L1 polymorphisms on the efficacy of immune checkpoint inhibitors depends on the tumor proportion score: a retrospective study

PURPOSE

This study aims to clarify the relationship between rs2282055, a single-nucleotide polymorphism (SNP) in programmed death-ligand 1 (PD-L1), and TPS. Polcaro et al. (2024) showed that rs822336, a SNP in PD-L1, predicts the effect of immune checkpoint inhibitors (ICIs). However, the study did not show a relationship between rs822336 and the tumor proportion score (TPS), which is currently used as a primary marker. Therefore, we examined this relationship.

METHOD

Patients treated with immune checkpoint inhibitor monotherapy for non-small cell lung cancer at Kyoto University Hospital until January 2023, with TPS data and biological specimens available for SNP measurement, were eligible for this study. Genomic DNA was extracted from peripheral blood leukocytes. We used rs2282055, which is in linkage disequilibrium with rs822336, instead of rs822336, because of its distribution in the Asian patient population. We retrospectively extracted data on age, sex, smoking history, driver mutations, TPS, progression-free survival (PFS), and best response to ICI from medical records.

RESULT

The rs2282055 T/T genotype was associated with significantly better PFS in the TPS-negative population than in the other genotypes. In contrast, no differences were observed in TPS-positive patients.

CONCLUSION

The rs2282055 genotype may help in selecting cases from the TPS-negative patient population that may benefit from ICI therapy.

Sentinel Node Biopsy in Laryngeal Cancer: A Systematic Review and Meta-Analysis

Background: Sentinel lymph node (SLN) biopsy offers a minimally invasive approach to staging lymph node involvement in laryngeal squamous cell carcinoma (SCC). Despite its adoption in other cancers, its accuracy in laryngeal SCC remains under investigation. This systematic review and meta-analysis evaluates the diagnostic performance of SLN mapping in laryngeal cancer. Methods: A systematic search of MEDLINE, Scopus, and Google Scholar was conducted using the keywords "(larynx OR laryngeal) AND sentinel", with no date or language restrictions. Studies reporting SLN detection rates and/or sensitivity in laryngeal SCC were included. A random-effects model was applied for data pooling, and subgroup analyses were performed based on tumor location (supraglottic versus transglottic) and mapping material (radiotracer versus blue dye). Publication bias was assessed using funnel plots and statistical methods. Results: Nineteen studies, encompassing 366 patients, were analyzed. The overall pooled SLN detection rate was 90.8% (95% CI: 86-94.1), and sensitivity was 88% (95% CI: 81-94). Supraglottic tumors demonstrated superior outcomes (detection rate: 93.7%, sensitivity: 96%) compared to transglottic tumors (detection rate: 84.7%, sensitivity: 71%). Radiotracers significantly outperformed blue dye, with detection rates of 90.8% versus 81.5% and sensitivities of 88% versus 77%. Conclusions: SLN mapping is a reliable technique for staging laryngeal SCC, particularly for supraglottic tumors, where high detection rates and sensitivity were observed. Radiotracers offer superior performance compared to blue dye, underscoring their clinical value. These findings support the feasibility and accuracy of SLN biopsy in laryngeal cancer, while emphasizing the importance of tumor location and mapping material.

Addressing Note Bloat: Solutions for Effective Clinical Documentation

Clinical documentation in the United States has grown longer and more difficult to read, a phenomenon described as "note bloat." This issue is especially pronounced in emergency medicine, where high diagnostic uncertainty and brief evaluations demand focused, efficient chart review to inform decision-making. Note bloat arises from multiple factors: efforts to enhance billing, mitigate malpractice risk, and leverage electronic health record tools that improve speed and completeness. We discuss best practices based on available evidence and expert opinion to improve note clarity and concision. Recent E/M coding reforms aim to streamline documentation by prioritizing medical decision-making over details of historical and physical examination, though implementation varies. New technologies such as generative artificial intelligence present opportunities and challenges for documentation practices. Addressing note bloat will require ongoing effort from clinical leadership, electronic health record vendors, and professional organizations.

PPARα-mediated lipid metabolism reprogramming supports anti-EGFR therapy resistance in head and neck squamous cell carcinoma

Anti-epidermal growth factor receptor (EGFR) therapy (cetuximab) shows a limited clinical benefit for patients with locally advanced or recurrent/metastatic head and neck squamous cell carcinoma (HNSCC), due to the frequent occurrence of secondary resistance mechanisms. Here we report that cetuximab-resistant HNSCC cells display a peroxisome proliferator-activated receptor alpha (PPARα)-mediated lipid metabolism reprogramming, with increased fatty acid uptake and oxidation capacities, while glycolysis is not modified. This metabolic shift makes cetuximab-resistant HNSCC cells particularly sensitive to a pharmacological inhibition of either carnitine palmitoyltransferase 1A (CPT1A) or PPARα in 3D spheroids and tumor xenografts in mice. Importantly, the PPARα-related gene signature, in human clinical datasets, correlates with lower response to anti-EGFR therapy and poor survival in HNSCC patients, thereby validating its clinical relevance. This study points out lipid metabolism rewiring as a non-genetic resistance-causing mechanism in HNSCC that may be therapeutically targeted to overcome acquired resistance to anti-EGFR therapy.

Effect of Tranexamic Acid in Reducing Seroma Formation and Drain Output After Modified Radical Mastectomy: A Double Blind Randomized Control Trial

Seroma and high drain output is common complication after modified radical mastectomy (MRM). MRM leaves behind a negative space which fills up with fluid from cut lymphatics and tissue leading to seroma. Tranexamic acid decreases clot degradation thereby plugging the vessels leading to decreased seroma. This study is to determine if tranexamic acid reduces the incidence of seroma formation, drain output, and wound-related complications in post-operative cases of MRM. We conducted a prospective, double blinded, parallel arm, randomized control trial of 160 women with breast cancer undergoing MRM to study the effect of tranexamic in reducing seroma and drain output. Patients were recruited from a period of 2021-2022. Tranexamic acid was given 15 mg/kg IV at the time of administration of anaesthesia and 500 mg twice a day for 5 days with the control group receiving a placebo. The cases were followed up for a period of one month. Drain output, clinical seroma formation, and wound-related complications were recorded. There was a significant reduction in the drain output compared to the patients receiving a placebo (590 ml vs 725 ml: p = 0.001). The number of patients developing a clinically detectable seroma was also reduced (16.3% vs 31.3%: p = 0.025). Tranexamic acid also led to reduction in wound infection (6.3% vs 23.8%: p = 0.002). Wound dehiscence and flap necrosis was also lower in the tranexamic acid group, but it was not statistically significant. Our results show that tranexamic acid reduces seroma formation, facilitates early drain removal, and reduces the wound infection in patients undergoing MRM.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-024-02050-5.

Comprehensiveness of Large Language Models in Patient Queries on Gingival and Endodontic Health

AIM

Given the increasing interest in using large language models (LLMs) for self-diagnosis, this study aimed to evaluate the comprehensiveness of two prominent LLMs, ChatGPT-3.5 and ChatGPT-4, in addressing common queries related to gingival and endodontic health across different language contexts and query types.

METHODS

We assembled a set of 33 common real-life questions related to gingival and endodontic healthcare, including 17 common-sense questions and 16 expert questions. Each question was presented to the LLMs in both English and Chinese. Three specialists were invited to evaluate the comprehensiveness of the responses on a five-point Likert scale, where a higher score indicated greater quality responses.

RESULTS

LLMs performed significantly better in English, with an average score of 4.53, compared to 3.95 in Chinese (Mann-Whitney U test, P < .05). Responses to common sense questions received higher scores than those to expert questions, with averages of 4.46 and 4.02 (Mann-Whitney U test, P < .05). Among the LLMs, ChatGPT-4 consistently outperformed ChatGPT-3.5, achieving average scores of 4.45 and 4.03 (Mann-Whitney U test, P < .05).

CONCLUSIONS

ChatGPT-4 provides more comprehensive responses than ChatGPT-3.5 for queries related to gingival and endodontic health. Both LLMs perform better in English and on common sense questions. However, the performance discrepancies across different language contexts and the presence of inaccurate responses suggest that further evaluation and understanding of their limitations are crucial to avoid potential misunderstandings.

CLINICAL RELEVANCE

This study revealed the performance differences of ChatGPT-3.5 and ChatGPT-4 in handling gingival and endodontic health issues across different language contexts, providing insights into the comprehensiveness and limitations of LLMs in addressing common oral healthcare queries.

Optimizing neuromuscular block monitoring and reversal: A large-scale quality improvement initiative in a diverse healthcare setting

BACKGROUND

Residual neuromuscular block (NMB) after anesthesia poses significant risk to patients, which can be reduced by adhering to evidence-based practices for the dosing, monitoring, and reversal of NMB. Incorporation of best practices into routine clinical care remains uneven across providers and institutions, prompting the need for effective implementation strategies.

METHODS

An interdisciplinary quality improvement initiative aimed to optimize NMB reversal practices across a large multi-campus urban medical center. Using the Institute for Healthcare Improvement (IHI) framework, interventions were designed to increase Train-of-Four (TOF) monitoring and promote evidence-based and cost-effective use of the NMB reversal agents. Process and outcome measures were tracked through Plan-Do-Study-Act (PDSA) cycles. Qualitative interviews provided insights into clinician perspectives.

RESULTS

The study encompassed 35,198 surgical cases utilizing NMB agents. The interventions led to a sustained increase in TOF monitoring from 42 % to 83 %. Significant increases were also observed in TOF ratio documentation and utilization of sugammadex. Postoperative respiratory complication rates decreased by 41 % (RR 0.59, 95 % CI 0.32-0.96) over the course of the initiative. The most pronounced increases in TOF monitoring were associated with financial incentives for the achievement of department-wide target monitoring rate.

CONCLUSION

This initiative demonstrates successful large-scale integration of quantitative TOF monitoring and evidence based NMB management across a diverse medical center, while highlighting important barriers in implementation. These findings contribute to the broader discussion on translating evidence into practice, offering insights for improving patient care and safety through tailored implementation strategies.

Clinical and genetic drivers of oligo-metastatic disease in colon cancer

BACKGROUND

Oligo-metastatic disease (OMD) in colon cancer patients exhibits distinct clinical behavior compared to poly-metastatic disease (PMD), with a more responsive and indolent course. This study aims to identify clinical and biological factors uniquely associated with oligo-metastatic behavior.

METHODS

Metastatic colon cancer patients from an academic center underwent genetic characterization. OMD was defined as ≤3 lesions per organ, each with a total diameter <70 mm and none exceeding 25 mm. Tumor DNA sequencing by NGS utilized the TruSight Oncology 500 kit. Overall survival (OS) was determined from metastasis diagnosis until death using Kaplan-Meier analysis. Multivariate Cox regression examined prognostic links between clinicopathological and genetic factors. Associations with metastatic patterns were evaluated using Chi-square.

RESULTS

The analysis involved 104 patients (44 with OMD, 60 with PMD). OMD was more prevalent in males (P = 0.0299) and with single organ involvement (P = 0.0226). Multivariate analysis adjusted for age (>70 vs. <70 years), gender (male vs. female), tumor side (right vs. left), metastatic involvement (more than one site vs. one site), response to first-line therapy (disease control vs. no disease control), and RAS/BRAF variants (wild-type vs. mutated) identified OMD vs. PMD as the strongest independent predictor of survival (HR: 0.14; 95 % CI: 0.06-0.33; P<0.0001). OMD patients exhibited distinct molecular characteristics, including lower frequencies of BRAF p.V600E (P=0.0315) and KRAS mutations (P=0.0456), as well as a higher frequency of high tumor mutational burden (P=0.0127). Additionally, by integrating data from public datasets and our case study, we hypothesize that some gene alterations (i.e.: BRAF, SMAD4, RAF1, and mTOR) may prevent OMD occurrence.

CONCLUSION

OMD, characterized by male predominance, single-site involvement, and distinct molecular features in colon cancer, suggests the need for tailored management strategies.

The Future of Artificial Intelligence Using Images and Clinical Assessment for Difficult Airway Management

Artificial intelligence (AI) algorithms, particularly deep learning, are automatic and sophisticated methods that recognize complex patterns in imaging data providing high qualitative assessments. Several machine-learning and deep-learning models using imaging techniques have been recently developed and validated to predict difficult airways. Despite advances in AI modeling. In this review article, we describe the advantages of using AI models. We explore how these methods could impact clinical practice. Finally, we discuss predictive modeling for difficult laryngoscopy using machine-learning and the future approach with intelligent intubation devices.

Residual neuromuscular block in the postanaesthesia care unit: a single-centre prospective observational study and systematic review

BACKGROUND

Concerns regarding residual neuromuscular block (RNMB) have persisted since the introduction of neuromuscular blocking agents, with reported incidences in the 21st century up to 50%. Advances in neuromuscular transmission (NMT) monitoring and the introduction of sugammadex have addressed this issue, but the impact of these developments remains unclear.

METHODS

This prospective observational study evaluated RNMB in 500 surgical patients in a large Dutch teaching hospital with readily available quantitative NMT monitoring and reversal agents. The anaesthetic technique and intraoperative NMT monitoring were independently chosen by the attending anaesthesiologist. Acceleromyography was performed upon arrival in the PACU for patients who received nondepolarising neuromuscular blocking agents. RNMB was defined as a train-of-four ratio (TOFR) <0.9. A systematic review was conducted to analyse trends in RNMB in contemporary practice.

RESULTS

Out of 500 patients, 11 (2.2%) had a TOFR <0.9. Intraoperative NMT monitoring was performed in 77.6% of patients, and sugammadex was administered to 38% of patients. No patient received neostigmine. The only difference was an automatically recorded TOFR ≥0.9 at the end of surgery in 61.1% in the non-RNMB group compared with 18.2% in the RNMB group (P=0.009). Our systematic review identified incidences ranging from 3.5% to 53.3% since 2000, with a decreasing trend in Europe and North America.

CONCLUSIONS

The incidence of residual neuromuscular block in the PACU was 2.2%. This suggests significant improvement in the prevention of residual neuromuscular block and stresses the importance of rigorous neuromuscular transmission monitoring and adequate use of reversal agents.

The Analgesic Effect of a Transdermal Lappaconitine Patch Combined With Ibuprofen Suspension for Children After Adenoidectomy and Tonsillectomy: A Randomized Clinical Trial

PURPOSE

To study the analgesic effects and side effects of a transdermal lappaconitine (TLA) patch, ibuprofen suspension (IS), and TLA combined with IS (TLACIS) after adenoidectomy and tonsillectomy.

DESIGN

Prospective, randomized clinical trial.

METHODS

The patients were randomized into three groups defined by different analgesic drug regimens: the TLA group, the IS group, and the TLACIS group. Pain scores at 2, 12, and 24 hours after surgery and adverse-event reports within the first postoperative week were collected.

RESULTS

Ultimately, this study included 102 cases in the TLA group, 101 cases in the IS group, and 101 cases in the TLACIS group. At 2 hours after surgery, the pain scores of the TLA and the TLACIS groups were both significantly lower than that of the IS group (all P < .05). At 12 and 24 hours after surgery, the pain score of the TLACIS group was significantly lower than those of the TLA and IS groups (all P < .05); furthermore, the pain score of the IS group was significantly lower than that of the TLA group (P < .05). Within 1 week after the operation, there was no significant difference in the incidence of adverse events.

CONCLUSIONS

The addition of a TLA patch can speed the onset of analgesia. In terms of analgesic effects, IS alone is more advantageous than TLA alone, while the combination of TLA and IS has the best analgesic effect. No significant differences were found in the incidence of adverse events among the three regimens.

Nutritional aspects in neuroendocrine neoplasms. bridging the gap between dietary interventions and cancer care strategies: a scoping review

PURPOSE

Neuroendocrine neoplasms (NENs) represent heterogeneous tumors arising from neuroendocrine cells in different organs. Despite growing interest in the nutritional aspects of NEN management, research in this area is limited. Aim of this review is to summarize the current state of knowledge, highlight research gaps, and underscore the significance of nutrition in the comprehensive care of NEN patients.

METHODS

We conducted an extensive bibliographic search focusing on studies (including retrospective and prospective studies, systematic reviews, case series, and guidelines) exploring the relationship between nutritional assessments, dietary interventions, micronutrient deficiencies, and their impact on NEN outcomes.

RESULTS

Significant gaps exist in current research, particularly in understanding the specific nutritional needs of NEN patients and how tailored nutritional interventions can improve clinical outcomes. Evidence suggests that a high-fat Western diet may promote the growth of NEN, while a Mediterranean diet may help lower insulin levels and strengthen the immune system, potentially preventing tumor development. The ketogenic diet and intermittent fasting may also have positive impacts. Addressing common micronutrient deficiencies, such as vitamin D and niacin, is crucial to mitigate disease progression. There's a crucial need for future studies to include a comprehensive nutritional assessment incorporating patient-reported outcomes, to fully capture the impact of nutritional strategies.

CONCLUSION

Nutritional management, an important but under-researched facet of NEN treatment, significantly improves patients' quality of life and survival. Integrating nutrition into personalized cancer care is essential, highlighting the role of nutritional strategies in optimizing patient outcomes.

Palmitoylethanolamide supplementation for human health: A state-of-the-art systematic review of Randomized Controlled Trials in patient populations

Interest in preventative dietary interventions for human health has increasingly focused on the endocannabinoid (eCB)-like compound palmitoylethanolamide (PEA), a bioactive lipid mediator with anti-inflammatory, analgesic, and neuroprotective properties. This Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020-compliant systematic review aimed at collecting and comprehensively discussing all available data from Randomized Controlled Trials (RCTs) evaluating the efficacy and tolerability of PEA supplementation across human illnesses in patient populations. Overall, 48 eligible outputs from 47 RCTs were extracted, covering neuropsychiatric (n = 15), neurological (n = 17), somatic (n = 13), and visceral (n = 11) disturbances, as well as PEA effects on blood/plasma or other tissue biomarkers (n = 10). The strongest evidence emerged from RCTs exploring PEA impact on pain management and measures of general wellbeing, especially in its ultramicronized/micronized or cold-water dispersible formulations, showing good tolerability compared to controls. Also, alongside symptom improvement, PEA demonstrated to modulate biomarkers early altered in the initial phases of an illness or contributing to its progression, suggesting a disease-modifying potential. This systematic review provided a comprehensive overview of the therapeutic potential of PEA across RCTs, highlighting its versatility either as monotherapy or add-on treatment for various clinical conditions.

EGFR, TP53, and CUL3 Triple Mutation in Non-Small Cell Lung Cancer and its Potentially Poor Prognosis: A Case Report and Database Analysis

Concurrent mutations in tumor protein p53 (TP53) or Kelch-like ECH-associated protein 1-nuclear factor erythroid 2-related factor 2-pathway components are linked to poor outcomes in epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer (NSCLC), but the impact of triple mutations remains unclear. We report a case of EGFR-, TP53-, and Cullin 3 (CUL3)-mutant NSCLC in a 43-year-old woman with widespread metastases at diagnosis, including those in the contralateral lung, distant lymph nodes, pericardium, liver, bones, left adrenal gland, and brain. She received osimertinib as first-line therapy, but pericardial effusion and liver metastases progressed rapidly over 3 months, and she was switched to carboplatin and pemetrexed. By the eighth cycle of pemetrexed, the bone metastases had progressed, resulting in disseminated intravascular coagulation (DIC) due to bone marrow carcinomatosis. The patient received third-line therapy with albumin-bound paclitaxel and fourth-line therapy with docetaxel, but further treatment was suspended owing to DIC progression. She passed away 23 months after the initiation of osimertinib. Public database analysis revealed that the EGFR/TP53/CUL3 triple mutation accounts for 0.4% of EGFR-mutant NSCLC cases, yielding significantly shorter survival than EGFR mutations alone and likely shorter than EGFR/TP53 double mutations. Gaining a deeper understanding of the clinical significance of coexisting genetic mutations in patients with EGFR-mutant NSCLC will be crucial to develop future therapies.

Artificial intelligence in obstetric anaesthesiology - the future of patient care?

The use of artificial intelligence (AI) in obstetric anaesthesiology shows great potential in enhancing our practice and delivery of care. In this narrative review, we summarise the current applications of AI in four key areas of obstetric anaesthesiology (perioperative care, neuraxial procedures, labour analgesia and obstetric critical care), where AI has been employed to varying degrees for decision support, event prediction, risk stratification and procedural assistance. We also identify gaps in current practice and propose areas for further research. While promising, AI cannot replace the expertise and clinical judgement of a trained obstetric anaesthesiologist. It should, instead, be viewed as a valuable tool to facilitate and support our practice.

Artificial intelligence in the era of planetary health: insights on its application for the climate change-mental health nexus in the Philippines

This review explores the transformative potential of Artificial Intelligence (AI) in the light of evolving threats to planetary health, particularly the dangers posed by the climate crisis and its emerging mental health impacts, in the context of a climate-vulnerable country such as the Philippines. This paper describes the country's mental health system, outlines the chronic systemic challenges that it faces, and discusses the intensifying and widening impacts of climate change on mental health. Integrated mental healthcare must be part of the climate adaptation response, particularly for vulnerable populations. AI holds promise for mental healthcare in the Philippines, and be a tool that can potentially aid in addressing the shortage of mental health professionals, improve service accessibility, and provide direct services in climate-affected communities. However, the incorporation of AI into mental healthcare also presents significant challenges, such as potentially worsening the existing mental health inequities due to unequal access to resources and technologies, data privacy concerns, and potential AI algorithm biases. It is crucial to approach AI integration with ethical consideration and responsible implementation to harness its benefits, mitigate potential risks, and ensure inclusivity in mental healthcare delivery, especially in the era of a warming planet.

Endoscopic Epidurolysis for the Management of Chronic Spinal Pain: A Delphi-Based Italian Experts Consensus

INTRODUCTION

Endoscopic epidurolysis (EE) is a minimally invasive procedure used to manage chronic spinal pain, particularly in cases unresponsive to traditional treatments. Despite its growing recognition, the literature lacks comprehensive guidelines on its optimal use. This study utilized a modified Delphi approach to gather expert consensus on best practices for EE in the Italian pain therapy network.

METHODS

The study's scientific board conducted an extensive literature review to define key investigation topics, including clinical indications, preoperative assessments, and technical aspects of EE. A semi-structured questionnaire was developed and administered to a panel of experts. A two-round Delphi process was implemented, with consensus defined as at least 70% agreement on a 7-point Likert scale (agree or strongly agree). Statements that did not reach consensus in the first round were rephrased and resubmitted in the second round.

RESULTS

Twenty-six clinicians participated in the study, with a 100% response rate in both rounds. In the first round, consensus was achieved for 9 out of 19 statements. In the second round, 8 out of 10 rephrased statements reached the consensus threshold. Key areas of agreement included the clinical indications for EE, the importance of preoperative imaging and anesthetic assessments, and the use of specific techniques and tools for EE. However, consensus was not reached on the use of EE for disc herniation with radicular pain and the safety of interlaminar access compared to sacral hiatus access.

CONCLUSION

The study highlights the need for standardized protocols in EE to ensure consistent and effective treatment of chronic spinal pain. The consensus reached by the expert panel provides a framework for best practices, which can guide clinical decision-making and improve patient outcomes. Further research is necessary to validate these findings and address areas where consensus was not achieved.

Prevalence of burnout syndrome in European and North American anesthesiologists: A systematic review and meta-analysis

AIMS

The prevalence of burnout syndrome dimensions in anesthesiologists show notable international differences. In this study, mean prevalences of European and North American anesthesiologists are compared.

METHODS

Quantitative systematic review (meta-analysis) following the PRISMA and MOOSE criteria. Only studies made with the Maslach Burnout Inventory that includes a Human Services Survey (MBI-HSS) were included. The quality of the studies was evaluated with a modified Newcastle-Ottawa scale, which was used in the meta-regression analyzes together with the Healthcare Access and Quality Index (HAQI) and Gross National Income (GNI) indicators for each country. Publication bias due to small size studies was evaluated with the Egger test.

RESULTS

The means of Emotional Exhaustion and Depersonalization were lower in anesthesiologists from Western Europe than in those from Eastern Europe and North America, but the differences were only statistically significant in the Emotional Exhaustion dimension. Meta-regression results were not statistically significant in any of the burnout dimensions for any of the three moderating variables. The test for publication bias was not statistically significant in any of the three dimensions.

CONCLUSIONS

Based on the results of the meta-analysis and the information from the included studies, social and organizational factors are the most important etiological factors that explain the differences in prevalence. Some of them are related specifically to Eastern Europe and other factors are more relevant in North America. These differences are discussed in this paper.

Improving quantitative neuromuscular monitoring: an education initiative on stimulating electrode placement

Quantitative neuromuscular monitoring reduces the incidence of residual neuromuscular block, but broad acceptance of monitoring has been elusive despite recommendations for quantitative monitoring for decades. Acceptance of quantitative monitoring may, in part, be related to the quality of the data from monitoring systems. This evaluation explored proper stimulating electrode positioning for electromyographic (EMG) monitoring, the impact of an educational intervention on electrode positioning and anesthesia provider (anesthesiologist, resident, anesthetist) confidence in the monitoring data from the device. In a single-center, observations of EMG electrode placement by anesthesia technicians, in 55 adult elective surgery patients were made by an independent observer. Separately, the anesthesia provider satisfaction with EMG derived data was recorded after reversal of neuromuscular block. An educational intervention then occurred on proper electrode positioning, including prior observations of electrode positioning, and prior anesthesia provider satisfaction with the EMG derived data. After the intervention, stimulating electrode position was observed with an additional 60 patients and anesthesia provider satisfaction with the data was again ascertained. The educational intervention significantly increased the proportion of ideal ulnar nerve groove electrode positioning from 74.5% to 95% (P < 0.003) and ideal wrist crease positioning (distal electrode within 2 cm of crease) from 61.8% to 96.7% (P < 0.001). Anesthesia provider confidence with EMG derived information during anesthesia delivery, increased from 67 to 90% after the education (P = 0.005). There was a significant relationship between correct stimulating electrode placement and anesthesia provider confidence in the EMG derived data on neuromuscular block status. An educational intervention to improve EMG electrode positioning proved meaningful. It increased anesthesia provider confidence in the EMG derived data during anesthesia case management.

Portable multi-parametric microscopy for noninvasive metabolic and vascular imaging of orthotopic tongue cancer models in vivo

Significance

Precise imaging of tumor metabolism with its vascular microenvironment becomes emerging critical for cancer research because increasing evidence shows that the key attribute that allows a tumor to survive therapies is metabolic and vascular reprogramming. However, there are surprisingly few imaging techniques available to provide a systems-level view of tumor metabolism and vasculature in vivo on small animals for cancer discoveries.

Aim

We aim to develop a new multi-parametric microscope that can faithfully recapitulate in vivo metabolic and vascular changes with a wide field of view and microscope-level resolution to advance cancer-related investigations. To maximize the ease and accessibility of obtaining in vivo tissue metabolism and vasculature measurements, we aim to develop our new metabolic imaging tool with minimal cost and size, allowing one to easily quantify tissue metabolic and vascular endpoints together in vivo, advancing many critical biomedical inquiries.

Approach

We have combined fluorescence microscopy and dark-field microscopy in a re-emission geometry into one portable microscope to image the key metabolic and vascular endpoints on the same tissue site. The portable microscope was first characterized by tissue-mimicking phantoms. Then the multi-parametric system was demonstrated on small animals to image glucose uptake (using 2-NBDG) and mitochondrial membrane potential (using TMRE) along with vascular parameters (oxygen saturation and hemoglobin contents) of orthotopic tongue tumors in vivo.

Results

Our phantom studies demonstrated the capability of the portable microscope for effective measurements of several key vascular and metabolic parameters with a comparable accuracy compared with our former reported benchtop spectroscopy and imaging systems. Our in vivo animal studies revealed increased glucose uptake and mitochondrial membrane potential along with reduced vascular oxygenation in tongue tumors compared with normal tongue tissues. The spatial analysis of metabolic and vascular images showed a more heterogeneous metabolic and oxygenation profile in tongue tumors compared with normal tongue tissues.

Conclusions

Our in vivo animal studies demonstrated the capability of our portable multi-parametric microscope for imaging the key metabolic and vascular parameters at the same tissue site with about one hour delay using an orthotopic tongue tumor model in vivo. Our study showed the potential of a portable functional microscope to noninvasively evaluate tumor biology using orthotopic tongue cancer models for future head and neck cancer research.

Evaluating the Feasibility of ChatGPT-4 as a Knowledge Resource in Bariatric Surgery: A Preliminary Assessment

This study evaluates the feasibility of ChatGPT-4 as a knowledge resource in bariatric surgery. Using a problem set of 30 questions covering key aspects of bariatric care, responses were reviewed by three bariatric surgery experts. ChatGPT-4 achieved strong performance, with 50% of responses scoring the highest possible rating for alignment with clinical guidelines. However, limitations were noted, including outdated criteria, lack of specificity, and occasional poor response structuring. The study highlights the potential of ChatGPT-4 as a supplementary tool for patient education and healthcare provider support, as well as its broader public health applications, such as obesity prevention and healthy lifestyle education. Despite its promise, challenges such as handling complex clinical cases, reliance on up-to-date evidence, and ethical concerns like privacy and misinformation must be addressed. Future research should refine the model's applications and explore its integration into clinical practice and public health strategies.

Systemic anti-cancer therapy and anaesthesia: a narrative review

INTRODUCTION

Cancer research has revolutionised the treatment, quality of life and life expectancy of people living with cancer. Systemic anti-cancer treatments have expanded to involve not only cytotoxic drugs, but targeted drugs and immunotherapy. Although highly effective in many patients, these drugs can cause serious and sometimes life-threatening adverse reactions. As part of their treatment, many patients living with cancer will be offered both systemic anti-cancer therapy and surgery, and many patients will undergo recurrent episodes of both with the aims of cure, palliation or prolongation of life expectancy. It is important for anaesthetists to understand the effects of systemic anti-cancer therapy on their patients.

METHODS

An electronic literature search using was conducted in May 2024 for peer-reviewed articles in English. An initial search of the terms 'anaesthesia' and 'chemotherapy' revealed that existing review literature was tailored towards the neoadjuvant setting and prompted this review to include the complications of targeted therapies, emergency care and intra-operative administration of systemic anti-cancer therapy to reflect this evolving field. A narrative approach was taken to discuss common regimens and their complications.

RESULTS

The review encompasses a wide range of sub-topics including pharmacology; physiology; peri-operative medicine; specialist surgery; adverse events; and safety. Data from multicentre trials that form the basis of current treatment regimens and practice were prioritised during the selection process. Smaller studies, case series and case reports were included to illustrate the rarer but clinically significant adverse effects of specific therapies.

CONCLUSIONS

It is important for anaesthetists to have a comprehensive understanding of the effects of systemic anti-cancer therapies, including cytotoxic and immunotherapies. There are many potential toxicities and complications associated with these treatments, particularly in the context of emergency surgery and the administration of cytotoxic drugs within the operating theatre environment.

Transcutaneous carbon dioxide monitoring in children undergoing rigid bronchoscopy: a prospective blinded observational study

PURPOSE

Anesthetic management during rigid bronchoscopy in children can be challenging, and continuous end-tidal carbon dioxide (EtCO2) monitoring is often unachievable. Transcutaneous carbon dioxide (TcCO2) monitoring is strongly correlated with the partial pressure of carbon dioxide (PaCO2) and EtCO2. We aimed to investigate the incidence of hypercapnia in children undergoing rigid bronchoscopy.

METHODS

We enrolled patients aged < 18 yr scheduled for rigid bronchoscopy in a prospective observational study. We recorded TcCO2 values from anesthesia induction to the postanesthesia care unit (PACU) stay. We ended monitoring when TcCO2 reached values ≤ 50 mm Hg. The operating room (OR) team was blinded to the TcCO2. The outcome of primary interest was the incidence of hypercapnia (TcCO2 > 50 mm Hg) in the OR. Other outcomes were the incidences of hypercapnia in the PACU and severe hypercapnia (TcCO2 > 90 mm Hg), factors possibly related to hypercapnia (patient, surgery, or anesthesia factors), and the incidence of perioperative adverse events.

RESULTS

A total of 30 patients were enrolled. The median [interquartile range (IQR)] age was 3.5 [1.5-8.0] yr. The incidence of hypercapnia was 100% in the OR and 60% in the PACU. Five cases (17%) presented with severe hypercapnia in the OR. The highest median [IQR] TcCO2 was 69 [61-79] mm Hg. The most common adverse event was oxygen desaturation (57%, 17/30). Patients with severe hypercapnia had long stays in the PACU.

CONCLUSION

Hypercapnia was a frequent event in children undergoing rigid bronchoscopy and severe hypercapnia was associated with a long PACU stay. Further studies are needed to assess the utility of TcCO2 monitoring in guiding ventilatory interventions during these cases.

The Selective WEE1 Inhibitor Azenosertib Shows Synergistic Antitumor Activity with KRASG12C Inhibitors in Preclinical Models

SIGNIFICANCE

Resistance to KRASG12C inhibitors is a growing clinical concern. The synergistic interaction observed between azenosertib and multiple KRASG12C inhibitors could result in deeper and more durable responses.