Translating ethical and quality principles for the effective, safe and fair development, deployment and use of artificial intelligence technologies in healthcare

OBJECTIVE

The complexity and rapid pace of development of algorithmic technologies pose challenges for their regulation and oversight in healthcare settings. We sought to improve our institution's approach to evaluation and governance of algorithmic technologies used in clinical care and operations by creating an Implementation Guide that standardizes evaluation criteria so that local oversight is performed in an objective fashion.

MATERIALS AND METHODS

Building on a framework that applies key ethical and quality principles (clinical value and safety, fairness and equity, usability and adoption, transparency and accountability, and regulatory compliance), we created concrete guidelines for evaluating algorithmic technologies at our institution.

RESULTS

An Implementation Guide articulates evaluation criteria used during review of algorithmic technologies and details what evidence supports the implementation of ethical and quality principles for trustworthy health AI. Application of the processes described in the Implementation Guide can lead to algorithms that are safer as well as more effective, fair, and equitable upon implementation, as illustrated through 4 examples of technologies at different phases of the algorithmic lifecycle that underwent evaluation at our academic medical center.

DISCUSSION

By providing clear descriptions/definitions of evaluation criteria and embedding them within standardized processes, we streamlined oversight processes and educated communities using and developing algorithmic technologies within our institution.

CONCLUSIONS

We developed a scalable, adaptable framework for translating principles into evaluation criteria and specific requirements that support trustworthy implementation of algorithmic technologies in patient care and healthcare operations.

Unhealthy behaviours for self-management of HIV-related peripheral neuropathy

The prevalence of peripheral neuropathy is frequent in HIV disease and is often associated with antiretroviral therapy. Unhealthy behaviours, particularly substance-use behaviours, are utilized by many HIV-positive individuals to manage neuropathic symptoms. As part of a larger study on self-care for symptoms in HIV disease, this study analyzed the prevalence and characteristics of unhealthy behaviours to self-manage peripheral neuropathy in HIV disease. Sociodemographic and disease-related correlates and unhealthy behaviours were examined in a convenience sample of 1,217 respondents who were recruited from data collection sites in several US cities, Puerto Rico, Colombia, and Taiwan. Results of the study indicated that respondents with peripheral neuropathy (n=450) identified a variety of unhealthy self-care behaviours including injection drug use, oral drug use, smoking cigarettes and alcohol ingestion. Specific unhealthy behaviours that participants reported to alleviate peripheral neuropathy included use of marijuana (n=67), smoking cigarettes (n=139), drinking alcohol (n=81) and street drugs (n=30). A subset of those individuals (n=160), who identified high levels of neuropathy (greater than five on a scale of 1-10), indicated significantly higher use of amphetamines and injection drug use in addition to alcohol use and cigarette smoking. For participants from Norway, substance use (using alcohol: 56%) was one of the most frequent self-management strategies. Implications for clinical practice include assessment and education of persons with HIV for self-care management of the complex symptom of peripheral neuropathy.

Symptom management and self-care for peripheral neuropathy in HIV/AIDS

Peripheral neuropathy is the most common neurological complication in HIV and is often associated with antiretroviral therapy. As part of a larger study on self-care for symptoms in HIV disease, this study analyzed the prevalence and characteristics of peripheral neuropathy in HIV disease, sociodemographic and disease-related correlates and self-care strategies. A convenience sample of 1,217 respondents was recruited from data collection sites in several US cities, Puerto Rico, Colombia and Taiwan. Results of the study indicated that respondents with peripheral neuropathy (n=450) identified 20 self-care behaviors including complementary therapies, use of medications, exercise and rest and/or elevation of extremities. Ratings of frequency and effectiveness were also included. An activities checklist summarized into five categories of self-care behaviors including activities/thoughts, exercise, medications, complementary therapies and substance was used to determine self-care behaviors. Taking a hot bath was the most frequent strategy used by those with peripheral neuropathy (n=292) and received the highest overall rating of effectiveness of any self-management strategies included in this study at 8.1 (scale 1-10). Other self-care strategies to manage this symptom included: staying off the feet (n=258), rubbing the feet with cream (n=177), elevating the feet (n=236), walking (n=262), prescribed anti-epileptic agent (n=80), prescribed analgesics (n=84), over-the-counter medications (n=123), vitamin B (n=122), calcium supplements (n=72), magnesium (n=48), massage (n=156), acupuncture (n=43), reflexology (n=23) and meditation (n=80). Several behaviors that are often deemed unhealthy were included among the strategies reported to alleviate peripheral neuropathy including use of marijuana (n=67), cigarette smoking (n=139), drinking alcohol (n=81) and street drugs (n=30).

Silent infarction as a risk factor for overt stroke in children with sickle cell anemia: a report from the Cooperative Study of Sickle Cell Disease

OBJECTIVE

To determine whether children with homozygous sickle cell anemia (SCD) who have silent infarcts on magnetic resonance imaging (MRI) of the brain are at increased risk for overt stroke.

METHODS

We selected patients with homozygous SCD who (1) enrolled in the Cooperative Study of Sickle Cell Disease (CSSCD) before age 6 months, (2) had at least 1 study-mandated brain MRI at age 6 years or older, and (3) had no overt stroke before a first MRI. MRI results and clinical and laboratory parameters were tested as predictors of stroke.

RESULTS

Among 248 eligible patients, mean age at first MRI was 8.3 +/- 1.9 years, and mean follow-up after baseline MRI was 5.2 +/- 2.2 years. Five (8.1%) of 62 patients with silent infarct had strokes compared with 1 (0.5%) of 186 patients without prior silent infarct; incidence per 100 patient-years of follow-up was increased 14-fold (1.45 per 100 patient-years vs 0.11 per 100 patient-years, P =.006). Of several clinical and laboratory parameters examined, silent infarct was the strongest independent predictor of stroke (hazard ratio = 7.2, P =.027).

CONCLUSIONS

Silent infarct identified at age 6 years or older is associated with increased stroke risk.

Multicenter comparison of magnetic resonance imaging and transcranial Doppler ultrasonography in the evaluation of the central nervous system in children with sickle cell disease

PURPOSE

To compare the results of standardized magnetic resonance imaging (MRI) of the brain and transcranial Doppler (TCD) ultrasonography of cerebral arteries in school-aged children with sickle cell disease to determine the correlation between these two different neurodiagnostic tests.

PATIENTS AND METHODS

Data were analyzed from 78 children with sickle cell disease (mean age 11 yrs) who participated in both the Cooperative Study of Sickle Cell Disease (CSSCD) and the Stroke Prevention Trial in Sickle Cell Anemia (STOP). Patients who had experienced an overt stroke were excluded. MRI findings were classified as normal or "silent infarct." Results of TCD were classified as normal, conditional, or abnormal, based on the time-averaged maximum mean flow velocity in the proximal middle cerebral and distal internal carotid arteries.

RESULTS

Of 61 patients who had a normal MRI examination, 11 (18%) had either conditional (5 patients) or abnormal (6 patients) TCD results. Among 17 patients in whom silent infarction was seen on MRI, only 5 (29%) had a conditional (1 patient) or abnormal (4 patients) TCD velocity. Thus, discordant results were seen in 23 patients: 12 in which the TCD result was normal and the MRI abnormal; 11 in which the TCD velocity was elevated and the MRI normal.

CONCLUSIONS

Abnormal TCD and MRI examinations reveal different aspects of the pathophysiology of central nervous system (CNS) injury in sickle cell disease and are often discordant. Although TCD abnormality is predictive of overt stroke, the lack of concordance between TCD and MRI findings suggests a need to develop more sensitive and specific indicators of early CNS pathology, such as neuropsychometric testing and positron-emission tomography (PET) scans, and to obtain more information about microvascular pathologic processes that may affect CNS function.

Silent cerebral infarcts in sickle cell anemia: a risk factor analysis. The Cooperative Study of Sickle Cell Disease

BACKGROUND

Silent infarcts have been reported in 17% of young patients with sickle cell disease and are associated with impaired performance on standardized psychometric tests. Risk factors for the development of these lesions have not been identified.

METHODS

Investigators in the Cooperative Study of Sickle Cell Disease performed a brain magnetic resonance imaging scan on sickle cell anemia patients age 5.9 years and older who had been followed according to the protocols of the Cooperative Study since birth. Individuals with a known history of cerebrovascular accident were excluded from this analysis. Patients with and without silent infarctions were compared with regard to clinical and laboratory parameters.

RESULTS

The study sample included 42 patients (18.3%) with silent infarcts. Patients who had silent infarcts were significantly more likely to have a clinical history of seizure and a lower painful event rate. Lower hemoglobin level, increased leukocyte count, elevated pocked red blood cell count, and SEN betaS globin gene haplotype were associated also with the presence of silent infarcts. There was no relationship between silent infarcts and platelet count, fetal hemoglobin level, reticulocyte percentage, serum aspartate aminotransferase level, total bilirubin concentration, blood pressure, growth parameters, or presence of alpha-thalassemia. A multivariate model for silent infarction identified the following as risk factors: low pain event rate, history of seizure, leukocyte count >/=11.8 x 10(9)/L, and the SEN betaS globin gene haplotype.

CONCLUSIONS

Patients with risk factors for silent infarcts should be evaluated for cerebrovascular disease. If evidence of infarction is found, consideration must be given to therapeutic intervention. At present, the appropriate treatment has not been determined.

The era of managed care: the struggle of cost containment and compassionate, effective care of persons with HIV/AIDS

Managed care is an increasingly widespread way of delivering health care that combines medical care provider systems (doctors, nurses, clinics, hospitals) with the payor system (health insurance). This article gives a historical overview of managed health care, discusses managed HIV care, and managed care reform.

HIV education: a challenge to adult learning theory and practice

While there are enormous bodies of literature that separately address adult learning theory and HIV disease education, there is a scarcity of literature that examines the way adult learning theory and education about HIV disease intersect. The author's focus is on successful, creative methods of combining these bodies of information in order to provide continuing education for health professionals. A review of the literature combined with the reported experience of AIDS Education and Training Centers (AETCs) from across the country identify useful strategies for successful HIV education.

Gastrointestinal manifestations of HIV/AIDS

HIV-infected patients are faced with a number of infections that affect every organ system. The gastrointestinal system is highly vulnerable to the many pathogens that are capable of invading the immunocompromised patient, thus creating some of the most frustrating problems for both the patient and the clinician. This article reviews the potential problems in the HIV-infected patient specific to the GI tract and discusses the current therapies available for these problems.

Feminism and regulation collide: the Food and Drug Administration's approval of the cervical cap

In May 1988, the Prentif Cavity Rim cervical cap, a barrier method of contraception, was approved by the Food and Drug Administration (FDA) for contraceptive purposes in the United States. This paper describes some of the events leading to the approval of the cervical cap as a contraceptive. Of major interest is the unprecedented involvement of the feminist health movement in clinic-based research, policy making, and distribution of the cervical cap. The recall of the Vimule cervical cap, the use of lay health workers in fitting an experimental device, and the feminist providers' response to the FDA's regulation of the cervical cap are detailed.

Perianal Bowen's disease and associated malignancies. Results of a survey

In 1959, Graham and Helwig reported that 80 percent of patients with Bowen's disease developed associated cutaneous or internal malignancies. Subsequent to the publication of this report, extensive and invasive workup of patients with Bowen's disease became the standard of practice. The authors' personal experience with perianal Bowen's disease suggested a substantially lower correlation between that disease and associated malignancies. Therefore a survey was initiated by contacting active members of the American Society of Colon and Rectal Surgeons to investigate further. Analysis of 106 cases demonstrated a lower incidence of associated malignancies (4.7 percent) subsequent to diagnosis of perianal Bowen's disease. The data further indicated, however, that these patients are at risk to develop recurrent Bowen's disease (9.4 percent) and invasive carcinoma (5.7 percent). It is concluded that an extensive and invasive workup of patients with perianal Bowen's disease is not indicated and that the patient's greatest risk is development of recurrent or invasive disease.

Soft tissue changes associated with advancement genioplasty performed concomitantly with superior repositioning of the maxilla

A retrospective study of the osseous and soft tissue changes of the chins of ten patients treated for vertical maxillary excess by Le Fort I osteotomy and advancement genioplasty was undertaken. The patients were characterized by excessive lower anterior facial height, obtuse or normal nasolabial angles, prominent maxillary incisors, lip incompetence, everted lower lips, anterior open bites, lack of chin prominence, and excessive chin height. A change in the proportion of osseous to soft tissue of 1.0 to 0.87 was obtained by advancement genioplasty and concomitant superior repositioning of the maxilla by Le Fort I osteotomy.

Surgical treatment of an arteriovenous malformation of the mandible in a child. A case report

Arteriovenous malformations of the mandible are rare and potentially life threatening lesions. They are very unusual in young individuals. A case is reported in which a form of surgical treatment is advocated that permits preservation of the continuity of the mandible and the dentition with little potential for life threatening bleeding.

The versatility of genioplasty using a broad pedicle

The biologic and clinical foundation for using a broad soft-tissue pedicle genioplasty technique is described. This technique is versatile and stable and produces more predictable soft-tissue changes than previously reported methods of altering chin contour with alloplastic implants. The broad pedicle genioplasty technique has clear advantages over other techniques for procedures such as secondary genioplasty using local anesthesia, concomitant genioplasty and anterior subapical osteotomy, simultaneous genioplasty and submental lipectomy, and segmentalization of the chin to facilitate narrowing or widening.

Penicillin-induced anaphylaxis in a patient under hypotensive anesthesia

Elective use of penicillin during hypotensive anesthesia for orthognathic surgery induced a nearly fatal anaphylactic reaction. The first symptom of anaphylaxis was increased inspiratory resistance to mechanical ventilation, followed by severe hypotension. The therapeutic management of anaphylaxis is discussed. Patients susceptible to reactions from the administration of B-lactam antibiotics can be identified through skin tests. Patients reactive to such antibiotics should be treated with alternate antibiotics or they should be desensitized prior to receiving penicillin.

Fibrolipoma of the cheek in a child

Fibrolipomas in the oral cavity are infrequent neoplasms. Their occurrence in children is even more unusual. A case of this tumor involving the check in a child is reported, and the histogenesis discussed. These lesions represent a variant of lipoma and derive their name from their relative amounts of adipose and fibrous tissue. Knowledge of fatty tumors in this region is important to all surgeons who operate in and about the oral cavity.

The relation between nasorespiratory function and dentofacial morphology: a review

It is commonly assumed that nasorespiratory function can exert a dramatic effect upon the development of the dentofacial complex. Specifically, it has been stated that chronic nasal obstruction leads to mouth breathing, which causes altered tongue and mandibular positions. If this occurs during a period of active growth, the outcome is development of the "adenoid facies" (dentofacial morphology). Such patients characteristically manifest a vertically long lower third facial height, narrow alar bases, lip incompetence, a long and narrow maxillary arch, and a greater than normal mandibular plane angle. These dentofacial traits have repeatedly been attributed to restricted nasorespiratory function. It is generally believed that environmental factors can exert subtle or dramatic effects upon dentofacial morphology, depending upon their magnitude, duration, and time of occurrence. The purpose of this article is to present a critical review of the literature concerning the effect of one such environmental factor, nasal airway function, upon dentofacial morphogenesis. This review will critically examine the most frequently cited papers reporting a relationship between nasorespiratory function and dentofacial morphology. In summary, this critical review fails to support a consistent relationship between obstructed nasorespiratory function and the adenoid facies or long-face syndrome. Additional objective evaluations of this relation are encouraged.

Comparison of Silastic and Proplast implants in the temporomandibular joint after condylectomy for osteoarthritis

This study was undertaken to compare the long-term stability of Silastic and proplast when used as alloplastic implants following high condylectomy. Twelve patients with osteoarthritis of the temporomandibular joint (TMJ) were treated either unilaterally or bilaterally. The follow-up period ranged from one to four years. In all ten TMJs that received Silastic implants and in ten that received Proplast implants, there were no discernible differences relative to comfort, masticatory function, or TMJ mobility. Although Silastic and Proplast had similar functional characteristics, Proplast implants had better long-term stability than the Silastic implants.

Current concepts in the surgical treatment of patients with myasthenia gravis

Patients undergoing surgical treatment often have concurrent diseases. An in-depth understanding of such diseases permits the dentist to initiate treatment with minimal risk to the patient. Myasthenia gravis (MG) is one such disease; it is characterized by various degrees of muscle weakness and fatigue. Many of the physical signs and symptoms affect the oral and facial musculature. A review of the symptoms, etiology, and treatment of myasthenia gravis, with special reference to the patient undergoing surgical treatment, is presented.

Infection following intraoral surgical correction of dentofacial deformities: a review of 140 consecutive cases

Prophylactic antibiotics are often administered during orthognathic surgery to prevent infection. A total of 140 consecutive patients who underwent "clean" intraoral maxillary and mandibular orthognathic surgery and received antibiotics in the preoperative period are reviewed with respect to postoperative infection. In four patients, infections developed, two of which were related to alloplastic implants. The microorganisms cultured from the infections were species not normally found in oral infections. One patient had an antibiotic-induced anaphylactic reaction. The theory and applicability of antibiotic prophylaxis for intraoral orthognathic surgery are discussed.

Hemifacial microsomia: an anesthetic airway problem

Hemifacial microsomia is a rare congenitally acquired dentofacial deformity characterized by unilateral hypoplasia of the hard and soft tissues of the face and cranium. Associated anomalies of the vertebrae and hypopharynx cause perioperative airway management to be difficult. The case of a patient with severe heimfacial microsomia, cervical spine fusion, and temporomandibular joint ankylosis is presented, with special emphasis on anesthetic airway management. A device to aid fiberoptic nasolaryngoscopy when difficult endotracheal intubations are encountered is described.

Induced hypotension for orthognathic surgery

Achieving satisfactory hemostasis during orthognathic surgery may be difficult because of the extensive vascularity of facial structures. Hypotensive anesthetic techniques provide clear operative fields by altering regional tissue perfusion through the use of systemic vasodilators, ganglionic blocking agents, and positioning of the patient. Thorough monitoring during surgery, careful selection of patients, and close communication between the surgeon and anesthesiologist permit safe anesthesia, can decrease operating time, and usually obviate the need for transfusions.

Low rectovaginal fistulas. Approach and treatment

Experience with thirty-two patients with a low rectovaginal fistula with or without attendant sphincter damage is reported. The technic used is advancement of the anterior rectal wall with excision of the infected anal glandular tissue and repair of muscle tissue when indicated. Anorectal infection and childbirth injuries were the common causes. An acceptable recurrence rate was achieved. Colostomy was not used in this series.