Perspectives of a non-medically and a medically qualified early career anatomy academic on facilitating case-based learning sessions for undergraduate medical students.

Case-based learning (CBL) is a student-centered pedagogy where medical students are given a real-world clinical problem. At St George's University of London (SGUL), anatomy academics can volunteer to facilitate CBL sessions for pre-clinical undergraduate medical students. The major benefits of facilitating CBL sessions from the perspective of a non-medically qualified early career anatomy academic (ECAA) include exposure to clinical cases that help the academic develop an understanding over key clinical cases at the context of clinical anatomy and other disciplines including physiology, pathology, and pharmacology. Furthermore, facilitating CBL sessions assists in the acquisition of basic knowledge over history taking, the conduction of clinical examinations, the investigations performed for the diagnosis of a condition as well as how it is managed. The major benefits of facilitating CBL sessions from the perspective of a medically qualified ECAA include staying in touch with the clinical aspect of medicine and becoming familiar with the country's healthcare system and its professional standards. Perceived benefits shared by both the non-medically and medically qualified ECAA include the opportunity to become familiar with the structure and key elements of the pre-clinical medical curriculum as well as gain experience in facilitating small group teaching sessions. Overall, facilitating CBL sessions can help non-medically and medically qualified ECAAs in different contexts that may help them with their individual career goals, can encourage collaborative discussions between clinical and non-clinical anatomy academics as well as help bridge the gap between the anatomy teaching approaches employed by non-medically qualified and medically qualified anatomy academics.

A Literature Review of the Integration of Ancient Indian Mythology in Clinical Medicine: A Holistic Approach to Health and Healing.

The fusion of mythology and ancient Indian medicine, particularly Ayurveda, is a fascinating synthesis of cultural heritage and scientific endeavor. Ayurveda encompasses a wide range of practices, including pharmacology, anatomy, physiology, surgery, and obstetrics, and integrates the rich tapestry of Hindu mythology, providing a comprehensive understanding of health and disease. The inclusion of mythological figures and narratives in the discourse of ancient Indian medicine offers a unique perspective on the integration of spiritual and empirical knowledge, highlighting the role of mythology in shaping the foundational principles of clinical medicine. The discourse explores the profound impact of Ayurveda and its mythological underpinnings on contemporary clinical practices, underscoring the timeless wisdom embedded in ancient narratives. These stories represent the bedrock of holistic medical practices, emphasizing the parity between mind, body, and spirit that is increasingly validated in modern therapeutic paradigms. The philosophy and methods detailed in the age-old texts of Sushruta and Charaka, coupled with the allegorical tales of Dhanvantari and Bharadwaja, contribute significantly to the foundational principles underpinning today's holistic medical approaches. The enduring legacy of Ayurveda and its mythological narratives continues to influence and inspire a holistic approach to health care, underscoring the indelible connection between ancient wisdom and modern medical practices.

The potential for drug incompatibility and its drivers - A hospital wide retrospective descriptive study.

OBJECTIVE: Drug incompatibility, a significant subset of medication errors, threaten patient safety during the medication administration phase. Despite the undeniably high prevalence of drug incompatibility, it is currently poorly understood because previous studies are focused predominantly on intensive care unit (ICU) settings. To enhance patient safety, it is crucial to expand our understanding of this issue from a comprehensive viewpoint. This study aims to investigate the prevalence and mechanism of drug incompatibility by analysing hospital-wide prescription and administration data. METHODS: This retrospective cross-sectional study, conducted at a tertiary academic hospital, included data extracted from the clinical data warehouse of the study institution on patients admitted between January 1, 2021, and May 31, 2021. Potential contacts in drug pairs (PCs) were identified using the study site clinical workflow. Drug incompatibility for each PC was determined by using a commercial drug incompatibility database, the Trissel's™ 2 Clinical Pharmaceutics Database (Trissel's 2 database). Drivers of drug incompatibility were identified, based on a descriptive analysis, after which, multivariate logistic regression was conducted to assess the risk factors for experiencing one or more drug incompatibilities during admission. RESULTS: Among 30,359 patients (representing 40,061 hospitalisations), 24,270 patients (32,912 hospitalisations) with 764,501 drug prescriptions (1,001,685 IV administrations) were analysed, after checking for eligibility. Based on the rule for determining PCs, 5,813,794 cases of PCs were identified. Among these, 25,108 (0.4 %) cases were incompatible PCs: 391 (1.6 %) PCs occurred during the prescription process and 24,717 (98.4 %) PCs during the administration process. By classifying these results, we identified the following drivers contributing to drug incompatibility: incorrect order factor; incorrect administration factor; and lack of related research. In multivariate analysis, the risk of encountering incompatible PCs was higher for patients who were male, older, with longer lengths of stay, with higher comorbidity, and admitted to medical ICUs. CONCLUSIONS: We comprehensively described the current state of drug incompatibility by analysing hospital-wide drug prescription and administration data. The results showed that drug incompatibility frequently occurs in clinical settings.

A comparison of the diagnostic ability of large language models in challenging clinical cases.

Introduction: The rise of accessible, consumer facing large language models (LLM) provides an opportunity for immediate diagnostic support for clinicians. Objectives: To compare the different performance characteristics of common LLMS utility in solving complex clinical cases and assess the utility of a novel tool to grade LLM output. Methods: Using a newly developed rubric to assess the models' diagnostic utility, we measured to models' ability to answer cases according to accuracy, readability, clinical interpretability, and an assessment of safety. Here we present a comparative analysis of three LLM models-Bing, Chat GPT, and Gemini-across a diverse set of clinical cases as presented in the New England Journal of Medicines case series. Results: Our results suggest that models performed differently when presented with identical clinical information, with Gemini performing best. Our grading tool had low interobserver variability and proved a reliable tool to grade LLM clinical output. Conclusion: This research underscores the variation in model performance in clinical scenarios and highlights the importance of considering diagnostic model performance in diverse clinical scenarios prior to deployment. Furthermore, we provide a new tool to assess LLM output.

Navigating Disease Management: A Comprehensive Review of the De Ritis Ratio in Clinical Medicine.

The De Ritis ratio, defined as the serum aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio, is a widely recognized biochemical marker with significant applications in diagnosing and managing various diseases, particularly liver disorders. This comprehensive review synthesizes current knowledge surrounding the clinical relevance of the De Ritis ratio, examining its historical development, diagnostic utility, and prognostic significance across various medical conditions, including liver diseases, cardiovascular disorders, and muscular pathologies. Through an in-depth analysis of literature spanning several decades, this review highlights the role of the De Ritis ratio not only in differential diagnosis but also as a prognostic indicator for disease progression and patient outcomes. The ratio's ability to distinguish between different types of liver pathology, aid in early disease detection, and its potential use in monitoring treatment response are discussed. Additionally, the review addresses the methodological considerations, such as confounding factors and interpretation challenges, that impact the clinical utility of the De Ritis ratio. Given the evolving landscape of clinical diagnostics and the push toward more personalized medicine, the review concludes with recommendations for further research. These include longitudinal studies to explore the ratio's changes over time, comparative research across diverse populations, and technological integration to enhance diagnostic accuracy and patient care. This review aims to reaffirm the importance of the De Ritis ratio in modern clinical practice and encourages continued exploration into its potential applications and benefits in healthcare.

Person-Centered, Goal-Oriented Care Helped My Patients Improve Their Quality of Life.

When the goal is to help patients improve their quality of life, it makes sense to focus directly on the activities and relationships that are most important to each patient. This can be accomplished most effectively by following a three-step process that includes 1) connecting with the patient around what matters to them, 2) co-creating a goal-oriented plan, and 3) collaborating with patient, family, team members, and consultants to increase the probability of success. Once this approach has been mastered and the necessary systems, processes, and relationships are in place, this should not take more time than a problem-oriented approach, and it will almost certainly be more satisfying for both physician and patient. The impact on population-based quality metrics is uncertain. Though fewer patients may choose to follow standard recommendations, those who do may be more likely to adhere to them.

Picasso's Science and Charity and the evolution of the medical art.

The present article reflects on the evolution of clinical medicine throughout time by commenting on Picasso's painting Science and Charity (1897) through a biomedical lens. The two souls of medicine, namely the cold scientific one and the compassionate one, are examined in their dichotomy and their relationship with today's concepts of cure and well-being.

[Hegemonies, subalternities, and possible counter-hegemonies: The case of traditional medicine of Indigenous peoples in Mexico]. / De hegemonías, subalternidades y posibles contrahegemonías: El caso de la medicina tradicional de los pueblos indígenas de México.

A whole series of processes lead to the decrease in the use of traditional medicine by the indigenous peoples of Mexico, including the reduction in the number of traditional healers and the direct and indirect expansion of biomedicine. This essay addresses the central role these processes play in the relations of hegemony/subalternity that occur in different fields of reality, and especially in the health-illness-care-prevention processes, given that counter-hegemonic processes are not generated, or those that do arise have been ineffective in confronting social hegemony in general and biomedical hegemony in particular.

Toda una serie de procesos conducen a la disminución del uso de la medicina tradicional por los pueblos indígenas de México, incluyendo la reducción del número de curadores tradicionales y la expansión directa e indirecta de la biomedicina. En este ensayo se aborda el papel nuclear que tienen estos procesos en las relaciones de hegemonía/subaltenidad que se dan en los diferentes campos de la realidad y, especialmente, en los procesos de salud-enfermedad-atención-prevención, dado que no se generan procesos contrahegemónicos o, los que surgen, han sido ineficaces para enfrentar la hegemonía social en general y biomédica en particular.

Insights From a Clinically Orientated Workshop on Health Care Cybersecurity and Medical Technology: Observational Study and Thematic Analysis.

BACKGROUND: Health care professionals receive little training on the digital technologies that their patients rely on. Consequently, practitioners may face significant barriers when providing care to patients experiencing digitally mediated harms (eg, medical device failures and cybersecurity exploits). Here, we explore the impact of technological failures in clinical terms. OBJECTIVE: Our study explored the key challenges faced by frontline health care workers during digital events, identified gaps in clinical training and guidance, and proposes a set of recommendations for improving digital clinical practice. METHODS: A qualitative study involving a 1-day workshop of 52 participants, internationally attended, with multistakeholder participation. Participants engaged in table-top exercises and group discussions focused on medical scenarios complicated by technology (eg, malfunctioning ventilators and malicious hacks on health care apps). Extensive notes from 5 scribes were retrospectively analyzed and a thematic analysis was performed to extract and synthesize data. RESULTS: Clinicians reported novel forms of harm related to technology (eg, geofencing in domestic violence and errors related to interconnected fetal monitoring systems) and barriers impeding adverse event reporting (eg, time constraints and postmortem device disposal). Challenges to providing effective patient care included a lack of clinical suspicion of device failures, unfamiliarity with equipment, and an absence of digitally tailored clinical protocols. Participants agreed that cyberattacks should be classified as major incidents, with the repurposing of existing crisis resources. Treatment of patients was determined by the role technology played in clinical management, such that those reliant on potentially compromised laboratory or radiological facilities were prioritized. CONCLUSIONS: Here, we have framed digital events through a clinical lens, described in terms of their end-point impact on the patient. In doing so, we have developed a series of recommendations for ensuring responses to digital events are tailored to clinical needs and center patient care.

Clinical practice enhanced by interdisciplinary theoretical perspectives.

BACKGROUND: Experience-based knowing in general practice includes advanced interpretation of subjective, complex and particular phenomena in a social context. Enabling different metapositions for reflexivity may provide the accountability needed for such knowing to be recognized as evidence-based practice. OBJECTIVE: To demonstrate and discuss the potential of substantive theories to enhance interpretation of complex challenges in clinical knowing in general practice. METHODS: We present a fictional case to demonstrate how interdisciplinary substantive theories, with a relevant and specific match to concrete questions, can situate the clinical interaction at an accountable platform. A female patient with Parkinson's disease consults her GP complaining that the disease is restraining her life and threatening her future. The GP has some new ideas from Bandura's theory of self-efficacy and introduces the patient to strategies for further action. FINDINGS: The case presents an example of how a relevant substantive theory may offer the GP: 1) a sharper focus for achievement: recognising the issues of fear and identity in chronic, progressive illness, 2) a subsequent position for individualized understanding of adequate strategies: encouraging physical and social activity in a well-known context, and 3) an invitation to consider further possibilities: finding ways to alleviate the burden of fear and progressive decline; engaging in joyful living. IMPLICATIONS: General practice knowledge embraces a diversity of sources with different evidence power. The transparency mediated to clinical practice when supported by relevant substantive theories may contribute to recognition of experience-based knowing as evidence-based practice.

Experience-based knowing is an important capacity for interpretation of complex phenomena in general practice, but support for elaboration and analysis of such strategies is limitedInterdisciplinary substantive theories can enable reflexivity and enhance clinical practiceSubstantive theories may offer sharper focus, individualised understanding and recognition of additional possibilitiesA connection to specific theoretical ideas may augment the transparency of experience-based knowing, thus advancing attitudes for evidence-based practice.

Lack of association of impaired upper airway sensation with the presence or absence of obstructive sleep apnoea or chronic rhinosinusitis in World Trade Center responders.

OBJECTIVE: Examine sensory function of the upper airway in four groups of subjects recruited from the World Trade Centre General Responder Cohort (WTCGRC), with/without obstructive sleep apnoea (OSA), and with/without chronic rhinosinusitis (CRS). METHODS: Upper airway sensory function was determined using 2-point discrimination (2-PD) and vibration threshold (VT) in 163 WTCGRC subjects with both OSA and CRS (cases), OSA or CRS alone and without OSA or CRS (controls). Presence of OSA was determined from clinical sleep studies or home sleep testing. Presence of CRS was determined by nasal symptom questionnaire. The relationship between the presence of OSA and CRS and upper airway sensory impairment was assessed using linear regression analysis with each of 2PD and VT sensory threshold values as the dependent variable; OSA, CRS and their interaction were the independent variables. Age, gender and body mass index were covariates in the statistical model. The primary analysis was comparison of OSA+CRS versus controls (no OSA and no CRS) evaluated by linear contrasts. RESULTS: There were no differences in 2-PD or VT in those with OSA+CRS, OSA and CRS alone or controls. However, both 2-PD and VT were significantly higher in the WTCGRC controls compared with values seen in historical controls using the same methodology (median 2-PD 13.0; CI (11.0 to 13.5) vs 10.5; CI (8 to 11); VT: mean±SEM (9.3±0.6 vs 2.2±0.1)). CONCLUSION: While no differences were found in upper airway sensation between cases of OSA and CRS versus controls in the WTGRC population, there was evidence of impaired upper airway sensation in the WTGRC overall.

Resilient Artificial Intelligence in Health: Synthesis and Research Agenda Toward Next-Generation Trustworthy Clinical Decision Support.

Artificial intelligence (AI)-based clinical decision support systems are gaining momentum by relying on a greater volume and variety of secondary use data. However, the uncertainty, variability, and biases in real-world data environments still pose significant challenges to the development of health AI, its routine clinical use, and its regulatory frameworks. Health AI should be resilient against real-world environments throughout its lifecycle, including the training and prediction phases and maintenance during production, and health AI regulations should evolve accordingly. Data quality issues, variability over time or across sites, information uncertainty, human-computer interaction, and fundamental rights assurance are among the most relevant challenges. If health AI is not designed resiliently with regard to these real-world data effects, potentially biased data-driven medical decisions can risk the safety and fundamental rights of millions of people. In this viewpoint, we review the challenges, requirements, and methods for resilient AI in health and provide a research framework to improve the trustworthiness of next-generation AI-based clinical decision support.

Potential medicine waste in the process of outpatients receiving cost-free medicines from medicine pick-up lockers in the North Denmark region.

OBJECTIVES: In the Danish healthcare system, restructuring is an ongoing process to accommodate the rising number of patients and to optimise resource allocation. To ease departmental burdens at hospitals in the North Denmark Region, outpatients are empowered to collect their cost-free medicines from medication pick-up lockers. The lockers function similarly to a package box, thereby enhancing patient freedom. Due to lack of evidence within the published literature regarding cost-free medicines and medicine waste, the aim of our study was to identify the common medications delivered to medicine pick-up lockers and secondly, to evaluate potential medicine waste. METHODS: Data from ApoVision provided insights into medications delivered to medicine pick-up lockers from March to October 2023 in the North Denmark Region. To estimate unused medicines we obtained data on the number of medications returned from medicine pick-up lockers. RESULTS: From 2020 to 2023, the number of patients receiving cost-free medicines at medication pick-up lockers increased. In total, approximately 30 000 packages of medicine were delivered to medicine pick-up lockers from March to October 2023 in the North Denmark Region; 1.7% were returned. Methotrexate, adalimumab, and omalizumab were among the most common deliveries and were also the three most returned from the medicine pick-up lockers. CONCLUSIONS: This study is an initial attempt to investigate potential medicine waste in cost-free medicines dispensed to outpatients via pick-up lockers. Antineoplastic and immunomodulating agents were the most common medicines delivered to medication pick-up lockers in the North Denmark Region from March to October 2023. In this period, approximately 2% of all delivered medicine packages were returned to the hospital pharmacy. Our analysis solely focuses on waste associated with medications left uncollected from medicine pick-up lockers. Addressing the impact of medicine waste in a hospital setting requires a comprehensive approach, thus future studies should also focus on other sites relevant for medication waste as, for example, the patient's household.

Pakikisama: Filipino Patient Perspectives on Health Care Access and Utilization.

PURPOSE: Filipinos have unique social determinants of health, cultural values, and beliefs that contribute to a higher prevalence of cardiovascular comorbidities such as hypertension, diabetes, and dyslipidemia. We aimed to identify Filipino values, practices, and belief systems that influenced health care access and utilization. METHODS: We conducted 1-on-1 semistructured interviews with self-identified Filipino patients. Our qualitative study utilized a constant-comparative approach for data collection, thematic coding, and interpretive analysis. RESULTS: We interviewed 20 Filipinos in a remote rural community to assess structural and social challenges experienced when interacting with the health care system. Our results suggest that Filipinos regard culture and language as pillars of health access. Filipinos trust clinicians who exhibited positive tone and body language as well as relatable and understandable communication. These traits are features of Pakikisama, a Filipino trait/value of "comfortableness and getting along with others." Relatability and intercultural values familiarity increased Filipino trust in a health care clinician. Filipinos may lack understanding about how to navigate the US Health care system, which can dissuade access to care. CONCLUSIONS: For the Filipino community, culture and language are fundamental components of health access. Health care systems have the opportunity to both improve intercultural clinical training and increase representation among clinicians and support staff to improve care delivery and navigation of health services. Participants reported not routinely relying on health care navigators.

Complementary and alternative medicine in HIV care: frequency of consumption, risks and interactions with antiretroviral therapy.

OBJECTIVES: People living with HIV (PLWH) are common users of complementary and alternative medicine (CAM). The main objective of this study was to study the frequency and patterns of CAM natural products use in a large cohort of PLWH and to identify potential drug-drug interactions (DDIs) and the impact on their antiretroviral treatment (ART) adherence and efficacy. METHODS: This was a cross-sectional multicenter survey including 420 PLWH from different Spanish hospitals. Participants completed a face-to-face questionnaire on CAM consumption and different sociodemographic and clinical data were collected. DDIs between CAM and ART were identified and classified according to the Liverpool University Database and patient factors related to CAM consumption were assessed. RESULTS: 420 participants were included (82.6% male, mean age 47 years); 209 patients (49.8%) were taking at least one CAM. The most consumed CAM were green, black and red tea (n=146, 25.4%), ginger (n=26, 4.5%), fish oil (n=25, 4.4%) and cannabis (n=24, 4.2%). An ART based on integrase inhibitors was the only factor independently associated with CAM consumption (OR 1.54, 95% CI 1.04 to 2.26). 50 potential CAM-ART interactions in 43 (20.6%) patients taking CAM were identified, being clinically significant in 80% of the cases. CAM products most frequently involved with a potential significant DDI were supplements containing divalent cations (n=11) and garlic (n=7). No differences in ART efficacy and adherence were observed between patients with and without CAM consumption. CONCLUSIONS: Almost 50% of patients were taking at least one CAM product and its use was associated with an integrase inhibitor based ART. One out of every six patients was at risk of presenting with an interaction between a CAM and their ART, confirming the need to review continuously the use of CAM as part of the medication review process.

An essential component of antimicrobial stewardship during the COVID-19 pandemic in the intensive care unit: de-escalation.

BACKGROUND: The antimicrobial de-escalation strategy (ADE) plays a crucial role in antimicrobial stewardship, reducing the likelihood of bacterial resistance. This study aims to evaluate how often the intensive care unit (ICU) used ADE for empirical treatment during COVID-19. MATERIALS: Adult ICU patients receiving empirical antimicrobial therapy for bacterial infections were retrospectively studied from September 2020 to December 2021. ADE was defined as (1) discontinuation of an antimicrobial in case of empirical combination therapy or (2) replacement of the antimicrobial to narrow the antimicrobial spectrum within the first 3 days of therapy, according to the test results and clinical picture. RESULTS: A total of 99 patients were included in the study. The number of patients who received empirical combined therapy (38.4%) was lower than those who received monotherapy (61.6%). The most preferred monotherapy (45.9%) was piperacillin-tazobactam, while the most preferred in combination treatment (22.7%) was meropenem. Within the first 3 days of admittance to the ICU, 3% of patients underwent ADE for their empirical antimicrobial therapy, 61.6% underwent no change, and 35.4% underwent change other than ADE. Procalcitonin levels were below 2 µg/L on the third day of treatment in 69.7% of the patients. Culture or culture-antibiogram results of 50.5% of the patients were obtained within the first 3 days of empirical therapy. There was no growth in the culture results of 21 patients (21.2%) during their ICU stay. CONCLUSION: In this study, ADE practice was much lower than expected. In order to reduce the significant differences between theory and reality, clinical, laboratory, and organisational conditions must be objectively assessed along with patient characteristics.