Assessing the Utility of ChatGPT Throughout the Entire Clinical Workflow: Development and Usability Study.

BACKGROUND: Large language model (LLM)-based artificial intelligence chatbots direct the power of large training data sets toward successive, related tasks as opposed to single-ask tasks, for which artificial intelligence already achieves impressive performance. The capacity of LLMs to assist in the full scope of iterative clinical reasoning via successive prompting, in effect acting as artificial physicians, has not yet been evaluated. OBJECTIVE: This study aimed to evaluate ChatGPT's capacity for ongoing clinical decision support via its performance on standardized clinical vignettes. METHODS: We inputted all 36 published clinical vignettes from the Merck Sharpe & Dohme (MSD) Clinical Manual into ChatGPT and compared its accuracy on differential diagnoses, diagnostic testing, final diagnosis, and management based on patient age, gender, and case acuity. Accuracy was measured by the proportion of correct responses to the questions posed within the clinical vignettes tested, as calculated by human scorers. We further conducted linear regression to assess the contributing factors toward ChatGPT's performance on clinical tasks. RESULTS: ChatGPT achieved an overall accuracy of 71.7% (95% CI 69.3%-74.1%) across all 36 clinical vignettes. The LLM demonstrated the highest performance in making a final diagnosis with an accuracy of 76.9% (95% CI 67.8%-86.1%) and the lowest performance in generating an initial differential diagnosis with an accuracy of 60.3% (95% CI 54.2%-66.6%). Compared to answering questions about general medical knowledge, ChatGPT demonstrated inferior performance on differential diagnosis (ß=-15.8%; P<.001) and clinical management (ß=-7.4%; P=.02) question types. CONCLUSIONS: ChatGPT achieves impressive accuracy in clinical decision-making, with increasing strength as it gains more clinical information at its disposal. In particular, ChatGPT demonstrates the greatest accuracy in tasks of final diagnosis as compared to initial diagnosis. Limitations include possible model hallucinations and the unclear composition of ChatGPT's training data set.

Minimum 7-Year Follow-Up of Vitamin E-Diffused and Highly Cross-Linked Polyethylene Liners in Total Hip Arthroplasty: Findings From a Prospective, International, Multicenter Study of 977 Patients.

BACKGROUND: Vitamin E-diffused highly cross-linked polyethylene (VEPE) acetabular liners for total hip arthroplasty (THA) have shown favorable results in small cohort studies. However, larger studies are warranted to compare its performance to highly cross-linked polyethylene (XLPE) and demonstrate clinical significance in 10-year arthroplasty outcomes. This study compared acetabular liner wear and patient-reported outcome measures (PROMs) between patients treated with VEPE and XLPE liners in a prospective, international, multicenter study with minimum 7-year follow-up. METHODS: A total of 977 patients (17 centers; 8 countries) were enrolled from 2007 to 2012. The centers were randomly assigned to implants. At 1-year, 3-year, 5-year, and 7-year postoperative visits, radiographs, PROMs, and incidence of revision were collected. Acetabular liner wear was calculated using computer-assisted vector analysis of serial radiographs. General health, disease progression, and treatment satisfaction reported by patients were scored using 5 validated surveys and compared using Mann-Whitney U tests. At 7 years, 75.4% of eligible patients submitted data. RESULTS: The mean acetabular liner wear rate was -0.009 mm/y and 0.024 mm/y for the VEPE and XLPE group, respectively (P = .01). There were no statistically significant differences in PROMs. The overall revision incidence was 1.8% (n = 18). The revision incidence in VEPE and XLPE cohorts were 1.92% (n = 10) versus 1.75% (n = 8), respectively. CONCLUSION: We found that VEPE acetabular liners in total hip arthroplasty led to no significant clinical difference in 7-year outcomes as measured by acetabular liner wear rate, PROMs, and revision rate. While VEPE liners showed less wear, the wear rate for both the VEPE and XLPE liners was below the threshold for osteolysis. Therefore, the difference in liner wear may indicate comparative clinical performance at 7 years, as further indicated by the lack of difference in PROMs and the low revision incidence.

Assessing the Utility of ChatGPT Throughout the Entire Clinical Workflow.

IMPORTANCE: Large language model (LLM) artificial intelligence (AI) chatbots direct the power of large training datasets towards successive, related tasks, as opposed to single-ask tasks, for which AI already achieves impressive performance. The capacity of LLMs to assist in the full scope of iterative clinical reasoning via successive prompting, in effect acting as virtual physicians, has not yet been evaluated. OBJECTIVE: To evaluate ChatGPT's capacity for ongoing clinical decision support via its performance on standardized clinical vignettes. DESIGN: We inputted all 36 published clinical vignettes from the Merck Sharpe & Dohme (MSD) Clinical Manual into ChatGPT and compared accuracy on differential diagnoses, diagnostic testing, final diagnosis, and management based on patient age, gender, and case acuity. SETTING: ChatGPT, a publicly available LLM. PARTICIPANTS: Clinical vignettes featured hypothetical patients with a variety of age and gender identities, and a range of Emergency Severity Indices (ESIs) based on initial clinical presentation. EXPOSURES: MSD Clinical Manual vignettes. MAIN OUTCOMES AND MEASURES: We measured the proportion of correct responses to the questions posed within the clinical vignettes tested. RESULTS: ChatGPT achieved 71.7% (95% CI, 69.3% to 74.1%) accuracy overall across all 36 clinical vignettes. The LLM demonstrated the highest performance in making a final diagnosis with an accuracy of 76.9% (95% CI, 67.8% to 86.1%), and the lowest performance in generating an initial differential diagnosis with an accuracy of 60.3% (95% CI, 54.2% to 66.6%). Compared to answering questions about general medical knowledge, ChatGPT demonstrated inferior performance on differential diagnosis (ß=-15.8%, p<0.001) and clinical management (ß=-7.4%, p=0.02) type questions. CONCLUSIONS AND RELEVANCE: ChatGPT achieves impressive accuracy in clinical decision making, with particular strengths emerging as it has more clinical information at its disposal.

Effects of excessive use of mobile phone technology in India on human health during COVID-19 lockdown.

OBJECTIVE: The global health crisis in the form of COVID-19 has forced people to shift their routine activities into a remote environment with the help of technology. The outbreak of the COVID-19 has caused several organizations to be shut down and forced them to initiate work from home employing technology. Now more than ever, it's important for people and institutions to understand the impact of excessive use of mobile phone technology and electronic gadgets on human health, cognition, and behavior. It is important to understand their perspective and how individuals are coping with this challenge in the wake of the COVID-19 pandemic. The investigation is an effort to answer the research question: whether dependency on technology during lockdown has more effects on human health in comparison to normal times. METHODS: The study included participants from India (n = 122). A questionnaire was framed and the mode of conducting the survey chosen was online to maintain social distancing during the time of the Pandemic. The gathered data was statistically analysed employing RStudio and multiple regression techniques. RESULTS: The statistical analysis confirms that lockdown scenarios have led to an increase in the usage of mobile phone technology which has been confirmed by around 90% of participants. Moreover, 95% of the participants perceive an increased risk of developing certain health problems due to excessive usage of mobile phones and technology. It has been evaluated that participants under the age group 15-30 years are highly affected (45.9%) during lockdown due to excessive dependence on technology. And, amongst different professions, participants involved in online teaching-learning are the most affected (42.6%). CONCLUSION: The findings indicate that dependency on technology during lockdown has more health effects as compared to normal times. So, it is suggested that as more waves of pandemics are being predicted, strategies should be planned to decrease the psychological and physiological effects of the overuse of technology during lockdown due to pandemics. As the lockdown situation unfolds, people and organization functioning styles should be rolled back to the limited dependency on technology.

Cemented vs. cementless fixation in primary total knee arthroplasty: a systematic review and meta-analysis.

Over 100,000 total knee replacements (TKRs) are carried out in the UK annually, with cemented fixation accounting for approximately 95% of all primary TKRs. In Australia, 68.1% of all primary TKRs use cemented fixation, and only 10.9% use cementless fixation. However, there has been a renewed interest in cementless fixation as a result of improvements in implant design and manufacturing technology.This meta-analysis aimed to compare the outcomes of cemented and cementless fixation in primary TKR. Outcome measures included the revision rate and patient-reported functional scores.MEDLINE and EMBASE were searched from the earliest available date to November 2018 for randomized controlled trials of primary TKAs comparing cemented versus cementless fixation outcomes.Six studies met our inclusion criteria and were analysed. A total of 755 knees were included; 356 knees underwent cemented fixation, 399 underwent cementless fixation. They were followed up for an average of 8.4 years (range: 2.0 to 16.6).This study found no significant difference in revision rates and knee function in cemented versus cementless TKR at up to 16.6-year follow-up. Cite this article: EFORT Open Rev 2020;5:793-798. DOI: 10.1302/2058-5241.5.200030.

The outcomes of total knee arthroplasty in morbidly obese patients: a systematic review of the literature.

INTRODUCTION: The increasing prevalence of obesity has led to an increase in total knee arthroplasties (TKAs) being undertaken in patients with a higher body mass index (BMI). TKA in morbidly obese patients can be technically challenging due to numerous anatomical factors and patient co-morbidities. The long-term outcomes in this patient group are unclear. This systematic review aims to compare the long-term revision rates, functional outcomes and complication rates of TKAs in morbidly obese versus non-obese patients. METHODS: A search of PubMed, EMBASE and PubMed Central was conducted to identify studies that reported revision rates in a cohort of morbidly obese patients (BMI ≥ 40 kg/m2) that underwent primary TKA, compared to non-obese patients (BMI ≤ 30 kg/m2). Secondary outcomes included Knee Society Objective Scores (KSOS), Knee Society Functional Scores (KSFS), and complication rates between the two groups. The difference in revision rates was assessed using the Chi-squared test. The Wilcoxon signed-rank test was used to compare pre-operative and post-operative functional scores for each group. KSOS and KSFS for morbidly obese and non-obese patients were compared using the Mann-Whitney test. Statistical significance was defined as p ≤ 0.05. RESULTS: Nine studies were included in this review. There were 624 TKAs in morbidly obese patients and 9,449 TKAs in non-obese patients, average BMI values were 45.0 kg/m2 (range 40-66 kg/m2) and 26.5 kg/m2 (range 11-30 kg/m2) respectively. The average follow-up time was 4.8 years (range 0.5-14.1) and 5.2 years (range 0.5-13.2) respectively, with a revision rate of 7% and 2% (p < 0.001) respectively. All functional scores improved after TKA (p < 0.001). Pre- and post-operative KSOS and KSFS were poorer in morbidly obese patients, however, mean improvement in KSOS was the same in both groups and comparable between groups for KSFS (p = 0.78). Overall complication rates,  including infection, were higher in morbidly obese patients. CONCLUSIONS: This review suggests an increased mid to long-term revision rate following primary TKA in morbidly obese patients, however, these patients have a functional recovery which is comparable to non-obese individuals. There is also an increased risk of perioperative complications, such as superficial wound infection. Morbidly obese patients should be fully informed of these issues prior to undergoing primary TKA.

Total hip arthroplasty outcomes in morbidly obese patients: A systematic review.

The increasing prevalence of obesity has resulted in a marked increase in the number of total hip arthroplasties (THAs) carried out in patients with a high body mass index (BMI).THA in morbidly obese patients is often technically challenging owing to the associated co-morbidities and anatomical factors. Furthermore, the long-term clinical and functional outcomes of the procedure in these patients are not clear.The aim of this systematic review was to compare the long-term failure rate and functional outcomes of THA in morbidly obese versus non-obese patients.A literature search of PubMed, EMBASE and PubMed Central was conducted to identify studies that compared the outcomes of THA in patients defined as morbidly obese (BMI ≥ 35) to a control group (BMI < 30). The primary and secondary outcome measures were rate of revision and functional outcome, respectively, in the long term.Eight studies were included in this review. There were 66,238 THAs in morbidly obese patients and 705,619 THAs in patients with a BMI < 30. The overall revision rate was 7.99% in the morbidly obese patients versus 2.75% in the non-obese controls. The functional outcome was at least comparable to non-obese patients.This review suggests that morbidly obese patients have a slightly increased revision rate following THA. Importantly, these patients have a functional recovery at least comparable to those with a BMI < 30. Morbidly obese patients should be fully informed of these issues prior to undergoing surgery. Cite this article: EFORT Open Rev 2018;3:507-512. DOI: 10.1302/2058-5241.3.180011.

Outcome of total knee arthroplasty in patients with poliomyelitis: A systematic review.

Total knee arthroplasty (TKA) in patients affected by poliomyelitis is technically challenging owing to abnormal anatomical features including articular and metaphyseal angular deformities, external rotation of the tibia, excessive valgus alignment, bone loss, narrowness of the femoral and tibial canals, impaired quadriceps strength, flexion contractures, genu recurvatum and ligamentous laxity. Little information is available regarding the results and complications of TKA in this challenging group of patients.We carried out a systematic review of the literature to determine the functional outcome, complications and revision rates of TKA in patients with poliomyelitis-affected knees. Six studies including 82 knees met the inclusion criteria and were reviewed. The mean patient age was 63 years (45 to 85) and follow-up was 5.5 years (0.5 to 13).All studies reported significant improvement in knee function following TKA. There were six failures requiring revision surgery in 82 cases (7%) occurring at a mean of 6.2 years (0.4 to 12). The reasons for revision surgery were aseptic loosening (17%, n=1), infection (33%, n=2), periprosthetic fracture (17%, n=1) and instability (33%, n=2). Thirty-six knees had a degree of recurvatum pre-operatively (44%), which was in the range of 5° to 30°. Ten of these knees (28%) developed recurrent recurvatum post-operatively.The findings support the use of TKA in patients with poliomyelitis-affected knees. The post-operative functional outcome is similar to other patients; however, the revision rate is higher. Quadriceps muscle power appears to be an important prognostic factor for functional outcome and the use of constrained implant designs is recommended in the presence of less than antigravity quadriceps strength. Cite this article: EFORT Open Rev 2018;3:358-362. DOI: 10.1302/2058-5241.3.170028.

Topical Versus Intravenous Administration of Tranexamic Acid in Primary Total Hip Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Tranexamic acid (TA) is widely used by orthopedic surgeons to decrease blood loss and the need for transfusion following total hip arthroplasty (THA). Although both intravenous and topical applications are described in the literature, there remains no consensus regarding the optimal regimen, dosage and method of delivery of TA during THA. In addition, concerns still exist regarding the risk of thromboembolic events with intravenous administration. The purpose of this meta-analysis was to compare the efficacy and safety of topical versus intravenous administration of TA in THA. A systemic review of the electronic databases PubMed, CENTRAL, EMBASE and Google Scholar was undertaken to identify all randomized controlled trials (RCTs) comparing the topical and intravenous administration of TA during THA, in terms of total blood loss, rate of blood transfusion and incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) post-operatively. A meta-analysis was performed to evaluate and compare the efficacy and safety of both methods of administration. Of 248 potentially relevant papers, three RCTs comprising (482) were eligible for data extraction and meta-analysis. The results showed a slightly higher amount of blood loss [Mean Difference (MD) - 46.37, P=0.12, 95% confidence interval (CI) - 12.54 to 105.29] and rate of transfusion (Risk Ratio 1.30, P=0.39, 95%CI 0.71 to 2.37) postoperatively in the topical TA group, but both did not reach statistical significance. There were 3 cases (1.2%) of DVT/PE in the intravenous group and one case (0.4%) in the topical group. Topical TA is an effective and safe method to reduce blood loss and the rate of transfusion following primary THA. It has comparative effectiveness to IV administration with slightly less post-operative thromboembolic complications. Larger and better-designed RCTs are required to establish the optimum dosage and regimen for topical use.

MicroRNAs in atherosclerosis.

Micro-ribonucleic acids (miRNAs) are a class of endogenous non-coding ribonucleic acids that regulate gene expression. MiRNAs have been shown to act as key regulators in the vascular system, with wide-ranging physio-pathological effects. Atherosclerotic disease is a leading cause of morbidity and mortality worldwide. This review presents current knowledge on miRNAs implicated in atherosclerosis susceptibility, development and progression. They are involved in cell phenotype switching, response to shear stress, cell senescence, adhesion molecule expression, macrophage response to oxidised low-density lipoprotein, Toll-like receptor 4 expression, neointimal lesion formation, plaque angiogenesis and cellular cholesterol homeostasis. Clinically, early work has demonstrated the utility of miRNAs for differentiating patients with arterial disease from controls and predicting future cardiac events; this highlights potential diagnostic and prognostic roles. MiRNA involvement in the crucial stages of atherosclerosis promises new hope in treating arterial disease. However, issues regarding multiple miRNA targets, stability and delivery continue to present challenges.

Azygous collateral thrombosis presenting as ureteric colic.

A 33 year old man presented to Accident and Emergency with haematuria and intermittent left loin pain radiating to the groin. On examination he had evidence of lower limb chronic venous insufficiency. Plain abdominal radiograph was unremarkable however computed tomography (CT) urogram and subsequent CT of thorax/abdomen/pelvis with contrast demonstrated azygous replacement of the inferior vena cava with an enlarged azygous vein and multiple enlarged veins in the abdomen and pelvis. A 5.7 cm by 4.2 cm low density lesion with surrounding inflammatory change was also visualised in the left para-aortic region. Ultrasound and magnetic resonance imaging confirmed this as a thrombosed collateral of the aberrant venous web drainage. Lifelong anti-coagulation was commenced with symptomatic relief.