Accuracy of Online Artificial Intelligence Models in Primary Care Settings.

INTRODUCTION: The importance of preventive medicine and primary care in the sphere of public health is expanding, yet a gap exists in the utilization of recommended medical services. As patients increasingly turn to online resources for supplementary advice, the role of artificial intelligence (AI) in providing accurate and reliable information has emerged. The present study aimed to assess ChatGPT-4's and Google Bard's capacity to deliver accurate recommendations in preventive medicine and primary care. METHODS: Fifty-six questions were formulated and presented to ChatGPT-4 in June 2023 and Google Bard in October 2023, and the responses were independently reviewed by two physicians, with each answer being classified as "accurate," "inaccurate," or "accurate with missing information." Disagreements were resolved by a third physician. RESULTS: Initial inter-reviewer agreement on grading was substantial (Cohen's Kappa was 0.76, 95%CI [0.61-0.90] for ChatGPT-4 and 0.89, 95%CI [0.79-0.99] for Bard). After reaching a consensus, 28.6% of ChatGPT-4-generated answers were deemed accurate, 28.6% inaccurate, and 42.8% accurate with missing information. In comparison, 53.6% of Bard-generated answers were deemed accurate, 17.8% inaccurate, and 28.6% accurate with missing information. Responses to CDC and immunization-related questions showed notable inaccuracies (80%) in both models. CONCLUSIONS: ChatGPT-4 and Bard demonstrated potential in offering accurate information in preventive care. It also brought to light the critical need for regular updates, particularly in the rapidly evolving areas of medicine. A significant proportion of the AI models' responses were deemed "accurate with missing information," emphasizing the importance of viewing AI tools as complementary resources when seeking medical information.

ACR Appropriateness Criteria® Abnormal Liver Function Tests.

Liver function tests are commonly obtained in symptomatic and asymptomatic patients. Various overlapping lab patterns can be seen due to derangement of hepatocytes and bile ducts function. Imaging tests are pursued to identify underlying etiology and guide management based on the lab results. Liver function tests may reveal mild, moderate, or severe hepatocellular predominance and can be seen in alcoholic and nonalcoholic liver disease, acute hepatitis, and acute liver injury due to other causes. Cholestatic pattern with elevated alkaline phosphatase with or without elevated γ-glutamyl transpeptidase can be seen with various causes of obstructive biliopathy. Acute or subacute cholestasis with conjugated or unconjugated hyperbilirubinemia can be seen due to prehepatic, intrahepatic, or posthepatic causes. We discuss the initial and complementary imaging modalities to be used in clinical scenarios presenting with abnormal liver function tests. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

A Provider-Based Approach to Address Racial Disparities in Lupus Clinical Trial Participation.

OBJECTIVE: Substantial disparities exist in clinical trial participation, which is problematic in diseases such as lupus that disproportionately affect racial/ethnic minority populations. Our objective was to examine the effectiveness of an online educational course aiming to train medical providers to refer Black and Latino patients to lupus clinical trials (LCTs). METHODS: The American College of Rheumatology's Materials to Increase Minority Involvement in Clinical Trials (MIMICT) study used an online, randomized, 2-group, pretest/posttest design with medical and nursing providers of multiple specialties. We exposed intervention group participants to an education course, while the control group participants received no intervention. Controlling for the effects of participant characteristics, including specialty, and professional experience with lupus, we modeled relationships among exposure to the education course and changes in knowledge, attitudes, self-efficacy, and intentions to refer Black and Latino patients to LCTs. We also examined education course satisfaction. RESULTS: Compared to the control group, the intervention group had significantly higher posttest scores for knowledge, self-efficacy, and intentions to refer Black and Latino patients to LCTs. Both medical and nursing trained intervention group participants had significantly higher mean posttest scores for knowledge and intentions to refer compared to the medical and nursing trained control group participants. Attitude was insignificant in analysis. The online education course, which received a favorable summary score, indicated that satisfaction and intentions to refer were strongly and positively correlated. CONCLUSION: The MIMICT education course is an effective method to educate medical providers about LCTs and to improve their intentions to refer Black and Latino patients.

ACR Appropriateness Criteria® Epigastric Pain.

Epigastric pain can have multiple etiologies including myocardial infarction, pancreatitis, acute aortic syndromes, gastroesophageal reflux disease, esophagitis, peptic ulcer disease, gastritis, duodenal ulcer disease, gastric cancer, and hiatal hernia. This document focuses on the scenarios in which epigastric pain is accompanied by symptoms such as heartburn, regurgitation, dysphagia, nausea, vomiting, and hematemesis, which raise suspicion for gastroesophageal reflux disease, esophagitis, peptic ulcer disease, gastritis, duodenal ulcer disease, gastric cancer, or hiatal hernia. Although endoscopy may be the test of choice for diagnosing these entities, patients may present with nonspecific or overlapping symptoms, necessitating the use of imaging prior to or instead of endoscopy. The utility of fluoroscopic imaging, CT, MRI, and FDG-PET for these indications are discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Associations between stress, anxiety, depression, and emotional intelligence among osteopathic medical students.

Context: Stress, anxiety, and depression affect medical student populations at rates disproportionate to those of general student populations. Emotional intelligence (EI) has been suggested as a protective factor in association with psychological distress. Objective: To explore the relationships between EI and stress, anxiety, and depression among a sample of US osteopathic medical students. Methods: From February to March 2020, a convenience sample of medical students enrolled at an osteopathic medical school in the southeastern region of the United States were invited to complete a voluntary and anonymous 54-item online questionnaire that included sociodemographic items as well as validated and reliable scales assessing perceived stress, anxiety, depression, and EI. Univariate statistics were calculated to describe the participant characteristics and the study variables of interest. Pearson's product-moment correlations were used to examine relationships between EI and study variables. Three multiple regression models were fitted to examine the relationship between EI and stress, anxiety, and depression, adjusting for sociodemographic factors exhibiting significant bivariate relationships with outcome variables. Dichotomous variables were created that were indicative of positive screens for potential depressive disorder or anxiety disorder. Independent-sample t-tests were used to determine the presence of a statistically significant difference in EI scores between positive screeners for depression and anxiety and their respective counterparts; an alpha level of 0.05 was set a priori to indicate statistical significance. Results: In all, 268 medical students participated in this study, for a response rate of approximately 27%. Importantly, EI exhibited significant negative correlations with stress, anxiety, and depression (r=-0.384, p<0.001; r=-0.308, p<0.001; r=-0.286, p<0.001), respectively). Thus, high levels of stress, anxiety, and depression were observed in the sample. Significant relationships remained following covariate adjustment. Established cutoffs for anxiety and depression were used to classify positive and negative screens for these morbidities. Using these classifications, individuals screening positive for potential anxiety and depression exhibited significantly lower levels of EI than their counterparts showing subclinical symptoms (t=5.14, p<0.001 and t=3.58, p<0.001, respectively). Conclusion: Our findings support the notion that higher levels of EI may potentially lead to increased well-being, limit psychological distress, improve patient care, and facilitate an ability to thrive in the medical field. We encourage continued study on the efficacy of EI training through intervention, measurement of EI in both academic and clinical settings as an indicator of those at risk for programmatic dropout or psychological distress, and consideration of EI training as an adjunct to the educational program curriculum.

Proposed Performance-Based Metrics for the Future Funding of Graduate Medical Education: Starting the Conversation.

Graduate medical education (GME) in the United States is financed by contributions from both federal and state entities that total over $15 billion annually. Within institutions, these funds are distributed with limited transparency to achieve ill-defined outcomes. To address this, the Institute of Medicine convened a committee on the governance and financing of GME to recommend finance reform that would promote a physician training system that meets society's current and future needs. The resulting report provided several recommendations regarding the oversight and mechanisms of GME funding, including implementation of performance-based GME payments, but did not provide specific details about the content and development of metrics for these payments. To initiate a national conversation about performance-based GME funding, the authors asked: What should GME be held accountable for in exchange for public funding? In answer to this question, the authors propose 17 potential performance-based metrics for GME funding that could inform future funding decisions. Eight of the metrics are described as exemplars to add context and to help readers obtain a deeper understanding of the inherent complexities of performance-based GME funding. The authors also describe considerations and precautions for metric implementation.

Politics and Graduate Medical Education in Internal Medicine: A Dynamic Landscape.

The promotion of change and growth within medical education is oftentimes the result of a complex mix of societal, cultural and economic forces. Graduate medical education in internal medicine is not immune to these forces. Several entities and organizations can be identified as having a major influence on internal medicine training and graduate medical education as a whole. We have reviewed how this is effectively accomplished through these entities and organizations. The result is a constantly changing and dynamic landscape for internal medicine training.

Strategies for Developing and Recognizing Faculty Working in Quality Improvement and Patient Safety.

Academic clinical departments have the opportunity and responsibility to improve the quality and value of care and patient safety by supporting effective quality improvement activities. The pressure to provide high-value care while further developing academic programs has increased the complexity of decision making and change management in academic health systems. Overcoming these challenges will require faculty engagement and leadership; however, most academic departments do not have a sufficient number of individuals with expertise and experience in quality improvement and patient safety (QI/PS). Accordingly, the authors of this article advocate for a targeted and proactive approach to developing faculty working in QI/PS. They propose a strategy predicated on the identification of QI/PS as a strategic priority for academic departments, the creation of enabling resources in QI/PS, and the expansion of rigorous training programs in change management and in improvement and implementation sciences. Professional organizations, health systems, medical schools, and academic departments should recognize successful QI/PS work with awards and promotions. Individual faculty members should expand their collaborative networks, consider the generalizability and scholarly impact of their efforts when designing QI/PS initiatives, and benchmark the outcomes of their performance. Appointments and promotions committees should work proactively with department and QI/PS leaders to ensure that outstanding achievement in QI/PS is defined and recognized. As with the development of physician-investigators and clinician-educators, departments and health systems need a comprehensive approach to support and recognize the contributions of faculty working in QI/PS to meet the considerable needs and opportunities in health care.

Effect on examination ordering by physician attitude, common knowledge, and practice behavior regarding CT radiation exposure.

PURPOSE: We surveyed ordering physician attitudes, knowledge, and behavior with regard to computed tomography (CT)-related radiation exposure at a large medical center. METHODS: Sixteen questions were sent via electronic survey to 350 physicians. RESULTS AND CONCLUSION: The ability to quickly rule in or rule out conditions effectively strongly influenced the decision to order CT (85%-99%). Fear of litigation influenced CT ordering for those with less experience [odds ratio (OR)=2.3, P<.05]. Residents and primary care physicians were less likely to discuss risks/benefits of CT with patients (P ≤.03) compared to those with >5 years of experience (OR=4.0, P=.04).

The Peyer's patch is a critical immunoregulatory site for mucosal tolerance in experimental autoimmune encephalomylelitis (EAE).

Expression of MCP-1 in the central nervous system (CNS) is associated with various neuroinflammatory diseases, including multiple sclerosis (MS) and experimental autoimmune encephalomyelitis (EAE). In this study, we found that MCP-1 was decreased in the CNS but increased in the gut following oral administration of myelin basic protein (MBP) correlating with protection from EAE. To study the trafficking and the fate of T cells during oral tolerance, MBP-specific TCR transgenic (Tg) CD4(+) T cells were labeled using 5,6-carboxy-succinimidyl-fluorescein-ester (CFSE) and transferred intravenously to syngeneic B10.PL recipients before feeding with either MBP or PBS. We observed that the CFSE-labeled T cells traffic to the peripheral lymphoid tissue and the Peyer's patches (PP). The labeled T cells proliferate in vivo in both the lymph node and the PP 48h after MBP feeding, but the cells are maintained in the PP longer than in the LN. CFSE-labeled cells in the PP have high levels of CD69 and Fas expression which is accompanied by increased apoptosis after MBP feeding. Our observations suggest that oral administration of autoantigen induces an elevation of MCP-1 in the gut, early T cell trafficking and activation in the periphery and the PP, followed by deletion of autoreactive T cells in the PP.

Probiotic administration and the incidence of nosocomial infection in pediatric intensive care: a randomized placebo-controlled trial.

OBJECTIVE: To evaluate the efficacy of probiotics in reducing the rates of nosocomial infection in pediatric intensive care. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: A 16-bed pediatric intensive care unit in a university-affiliated children's hospital. PATIENTS: Sixty-one pediatric patients were enrolled from April 2004 until December 2004. Screening of all patients admitted occurred on a daily basis. Patients were excluded if they had the following: evidence/suspicion of intestinal perforation, evidence/suspicion of mechanical gastrointestinal obstruction, absolute neutrophil count

Regulation of autoreactive T cell function by oral tolerance to self-antigens.

The oral administration of neuroantigens can suppress as well as treat autoimmune disease. Using EAE as a model system, we examined the antigen-presenting cell in oral tolerance. Expansion of dendritic cells (DCs) prior to or after disease is established facilitated oral tolerance. Transfer of oral antigen-loaded DCs resulted in protection from EAE by induction of IL-4 and IL-5 in recipient animals. LPS treatment of donors abrogated the ability of DCs to transfer protection from EAE, emphasizing the importance of the DC activation state. T cells exposed to orally administered antigen were monitored in TCR transgenic mice and found to undergo activation followed by deletion. The thymus plays a critical role in oral tolerance since thymectomized mice could not be tolerized. The thymus is postulated to be a site for deletion of autoreactive T cells or a site for generation of regulatory T cells.

Differences between two strains of myelin basic protein (MBP) TCR transgenic mice: implications for tolerance induction.

Experimental autoimmune encephalomyelitis (EAE) is mediated by CD4+ T cells which preferentially use the Vbeta8.2 TCR in response to myelin basic protein (MBP). Two strains of Tg mice (Valpha2.3/Vbeta8.2 and Valpha4/Vbeta8.2) have T cell receptors that recognize the NAc1-11 immunodominant epitope of MBP. We previously reported that oral administration of MBP protects both Valpha2.3/Vbeta8.2 and Valpha4/Vbeta8.2 mice from EAE; however, tolerance induction differs between strains and is dependent on the timing of oral antigen. Here we analyze the peripheral and gut-associated lymphoid tissue (GALT) environments of the two strains of Tg mice. Tg cells in the Peyer's patch (PP) but not the spleen of Valpha2.3/Vbeta8.2 mice demonstrate increased CD69 and decreased CD45RB relative to Valpha4/Vbeta8.2 mice. High levels of Th1 and Th2 cytokines, proliferative activity and CC chemokines (MCP-1) are observed in the periphery and GALT of Valpha2.3/Vbeta8.2 Tg mice. In contrast, more non-Tg CD4+ cells are seen in the PP of Valpha4/Vbeta8.2 mice. These studies suggest that activated Tg T cells and fewer potential regulatory cells in the PP of Valpha2.3/Vbeta8.2 Tg mice may influence oral tolerance.