Application of the Pareto principle to identify and address drug-therapy safety issues

Ethical Incorporation of Artificial Intelligence into Neurosurgery: A Generative Pretrained Transformer Chatbot-Based, Human-Modified Approach

INTRODUCTION

Artificial intelligence (AI) has become increasingly used in neurosurgery. Generative pretrained transformers (GPTs) have been of particular interest. However, ethical concerns regarding the incorporation of AI into the field remain underexplored. We delineate key ethical considerations using a novel GPT-based, human-modified approach, synthesize the most common considerations, and present an ethical framework for the involvement of AI in neurosurgery.

METHODS

GPT-4, ChatGPT, Bing Chat/Copilot, You, Perplexity.ai, and Google Bard were queried with the prompt "How can artificial intelligence be ethically incorporated into neurosurgery?". Then, a layered GPT-based thematic analysis was performed. The authors synthesized the results into considerations for the ethical incorporation of AI into neurosurgery. Separate Pareto analyses with 20% threshold and 10% threshold were conducted to determine salient themes. The authors refined these salient themes.

RESULTS

Twelve key ethical considerations focusing on stakeholders, clinical implementation, and governance were identified. Refinement of the Pareto analysis of the top 20% most salient themes in the aggregated GPT outputs yielded 10 key considerations. Additionally, from the top 10% most salient themes, 5 considerations were retrieved. An ethical framework for the use of AI in neurosurgery was developed.

CONCLUSIONS

It is critical to address the ethical considerations associated with the use of AI in neurosurgery. The framework described in this manuscript may facilitate the integration of AI into neurosurgery, benefitting both patients and neurosurgeons alike. We urge neurosurgeons to use AI only for validated purposes and caution against automatic adoption of its outputs without neurosurgeon interpretation.

Unintentional injury deaths associated with sport and recreation in Québec, Canada, 2006-2019

OBJECTIVES

This study examined trends in the frequencies and rates of deaths associated with unintentional injuries in sport and recreation in Québec, Canada, for the period January 2006-December 2019.

METHODS

In this descriptive retrospective study, data were extracted from the database of the Bureau du coroner du Québec. Incidence rates were calculated using participation data from the Étude des blessures subies au cours de la pratique d'activités récréatives et sportives au Québec (ÉBARS) and Canadian census population data. Poisson regression was used to investigate changes in death rates over the 14-year period by estimating incidence rate ratios.

RESULTS

There were 1937 unintentional injury deaths and the population-based death rate was 1.72 per 100 000 person-years. The participation-based rate was 1.40 per 100 000 participant-years, considering the 24 matching activities in both ÉBARS' editions. Using both population-based and participation-based denominators, separate analyses consistently showed declining death rates in non-motorised navigation and cycling. Deaths related to all-terrain vehicles, snowmobiles, swimming, cycling, motorised navigation and non-motorised navigation activities accounted for 80.2% of all deaths. Drowning was documented as a cause of death in 39.3% of all fatalities. Males represented 86.8% of all deaths, with males aged 18-24 years and 65 and over having the highest rates.

CONCLUSION

The death rates of unintentional injury deaths associated with non-motorised navigation and cycling declined, from January 2006 to December 2019. The characteristics and mechanisms of drowning deaths and fatalities that occurred in activities associated with higher death frequencies and rates need to be further investigated.

Development in Prescriptions of Contraindicated and Potentially Harmful QT Interval-Prolonging Drugs in a Large Geriatric Inpatient Cohort From 2011 to 2021

Regulatory authorities put major emphasis on QT (interval)-prolonging properties of new molecular entities. Product information/Summaries of Product Characteristics (SmPCs) of multiple drugs contain warnings or contraindications regarding QT prolongation, e.g., on coadministration of QT-prolonging drugs (QT drugs). To characterize the development of the QT drug burden, we performed a trend analysis of prescriptions and co-prescriptions of QT drugs in a large geriatric inpatient cohort. The German SmPCs (status of 2014 and of 2021) and the year-wise listings in the CredibleMeds^® database from 2011 to 2021 were used as sources. There were 402,631 geriatric cases included. The group of QT drugs according to SmPCs in 2014, which must not be combined with other QT drugs, was less frequently involved in contraindicated co-prescriptions in 2021 compared with 2015 (3.0% (2.5-3.7%) of cases with at least one of those drugs in 2021 vs. 4.0% (3.5-4.5%) in 2015), with citalopram, escitalopram, and amiodarone involved in nearly 90% of the co-prescriptions. The number of CredibleMeds-QT-drugs per patient increased from 0.4 (SD=1.1) in 2011 to 1.8 (SD=3.9) in 2021. The percentage of contraindicated co-prescriptions of drugs with known risk for torsade de pointes according to CredibleMeds^® listings at the beginning of the respective years increased from 1.7% in 2011 to 6.1% in 2021. Considering the regularly updated CredibleMeds^® QT drugs list, the contraindicated co-prescriptions of QT drugs markedly increased in the last decade. If prescribers considered only the few most frequently (co-) prescribed QT drugs, then most of the medication errors regarding QT drugs could be prevented.

Systematic Review of Risk Factors Assessed in Predictive Scoring Tools for Drug-Related Problems in Inpatients

Drug-related problems (DRP, defined as adverse drug events/reactions and medication errors) are a common threat for patient safety. With the aim to aid improved allocation of specialist resources and to improve detection and prevention of DRP, numerous predictive scoring tools have been proposed. The external validation and evidence for the transferability of these tools still faces limitations. However, the proposed scoring tools include partly overlapping sets of similar factors, which may allow a new approach to estimate the external usability and validity of individual risk factors. Therefore, we conducted this systematic review and analysis. We identified 14 key studies that assessed 844 candidate risk factors for inclusion into predictive scoring tools. After consolidation to account for overlapping terminology and variable definitions, we assessed each risk factor in the number of studies it was assessed, and, if it was found to be a significant predictor of DRP, whether it was included in a final scoring tool. The latter included intake of ≥ 8 drugs, drugs of the Anatomical Therapeutic Chemical (ATC) class N, ≥1 comorbidity, an estimated glomerular filtration rate (eGFR) <30 mL/min and age ≥60 years. The methodological approach and the individual risk factors presented in this review may provide a new starting point for improved risk assessment.

The CredibleMeds® list: Usage of QT interval prolonging drugs in Germany and discordances with prescribing information

AIMS

A substantial number of Summaries of Product Characteristics (SmPCs)/Prescribing Information (PI) have warnings or contraindications on QT interval prolongation. The goal of this work was to quantify usage of QT interval prolonging drugs according to the CredibleMeds^® database of the German outpatient drug prescription market and to evaluate discrepancies between German SmPCs/US PI and CredibleMeds^® .

METHODS

Drugs listed on CredibleMeds^® with known, possible or conditional risk for torsade de pointes were evaluated from 2000 to 2020. The German drug prescription report was used as source for defined daily dose- (DDD-) based prescriptions of the German outpatient drug prescription market of the public health insurance system. German SmPCs and US PI of 253 CredibleMeds^® -listed drugs were evaluated for contents regarding QT interval prolongation.

RESULTS

Of the drugs currently listed on CredibleMeds^® , 59.7% (95% confidence interval [CI] 53.5-65.5%) were listed after 2012. Due to newly listed drugs, the proportion of DDDs of CredibleMeds^® drugs among all prescriptions increased from 4.6% in 2013 to 21.1% in 2019. DDD-based usage of the CredibleMeds^® drugs already listed in 2013 was similar in 2019. Among the drugs with known QT risk according to CredibleMeds^® , 7.5% (95% CI 2.6-19.9%) of German SmPCs and 21.1% (95% CI 11.1-36.3%) of US PI had no mention of QT issues whatsoever.

CONCLUSION

A significant proportion of all drugs prescribed in the outpatient sector is associated with QT risks according to CredibleMeds^® . SmPCs and PI should systematically be evaluated for concordance with the widely used CredibleMeds^® database to increase medication safety.

Performance of HIV detection in Zhejiang province in China: The Pareto principle at work

Background

Timely detection of HIV infection is critical for curbing the AIDS epidemic, and building an extensive and effective HIV laboratory network is of great importance. Therefore, improving quality management of the laboratory network and optimizing detection strategies are desirable research issues.

Methods

We assessed the applicability of the Pareto principle to HIV detection performance. We conducted a retrospective review of basic information and numbers of screening tests among an HIV laboratory network (1,452 laboratories) in Zhejiang province in 2014 and statistically analyzed HIV testing data for different population categories.

Results

Approximately, 80% of the cumulative HIV screening tests and positive screening tests originated from 17.3% (251/1,452) and 11.7% (170/1,452) of the laboratories in the whole province, respectively, and similar patterns were observed at the prefectural level. We found that the top five population screening categories (25%, 5/20) had the highest contribution (approximately 80%) to not only the number of screening tests (77.2%) but also the numbers of positive (76.4%) and confirmed positive tests (81.5%).

Conclusions

The Pareto principle provides a method for identifying noteworthy laboratories to deliver prior quality supervision and developing highly efficient screening strategies that best suit local needs.

Health and Disease Are Dynamic Complex-Adaptive States Implications for Practice and Research

Interoception, the ability to convey one's overall physiological state, allows people to describe their health along an experiential continuum, from excellent, very good, good, fair to poor. Each health state reflects a distinct pattern of one's overall function. This assay provides a new frame of understanding health and disease as complex-adaptive system states of the person as-a-whole. It firstly describes how complex patterns can emerge from simple equations. It then discusses how clinical medicine in certain domains has started to explore the pattern characteristics resulting in the heterogeneity of disease, and how this better understanding has improved patient management. The experiential state of health can be surprising to the observer-some are in good health with disabling disease, others are in poor health without the evidence of any. The main part of the assay describes the underlying complexity principles that contribute to health, and synthesizes available evidence from various research perspectives to support the philosophic/theoretical proposition of the complex-adaptive nature of health. It shows how health states arise from complex-adaptive system dynamics amongst the variables of a hierarchically layered system comprising the domains of a person's macro-level external environment to his nano-level biological blueprint. The final part suggests that the frame of health as a dynamic complex-adaptive state defines a new paradigm, and outlines ways of translating these expanded understandings to clinical practice, future research, and health system design.

Risk assessment of postoperative pneumonia among children undergoing otolaryngologic surgery: Derivation and validation of a preoperative risk profiling

BACKGROUND

Postoperative pneumonia is a serious complication because it may be associated with morbidity, mortality and substantially increased cost of surgical care. Risk of postoperative pneumonia varies across surgical specialties, although its incidence and risk factors in pediatric otolaryngology have not been comprehensively elucidated.

OBJECTIVE

To identify factors associated with postoperative pneumonia and determine whether a subset of children with a disproportionate risk of pneumonia can be identified.

METHODS

Using the National Surgical Quality Improvement- Pediatric (NSQIP-P) database, we first selected children (N = 17,776; age under 18 years) who underwent inpatient pediatric otolaryngology procedures between 2012 and 2017. Using a random subset of 80% of the study population (derivation cohort), we next developed a multivariable logistic regression model to identify independent risk factors for postoperative pneumonia. We then divided children into risk groups and evaluated whether the Pareto principle applied to distribution of postoperative pneumonia across the risk groups.

RESULTS

Among the 12,443 children in the derivation cohort, 177 (1.4%) developed postoperative pneumonia. A multivariable risk model identified patients who developed postoperative pneumonia with good accuracy in both the derivation and validation cohorts. Stratification of patients into five mutually exclusive risk groups showed that 71% of postoperative pneumonia occurred in the highest risk group representing 20% the study cohort. Children who developed postoperative pneumonia were 18 times more likely to require an extended hospital length of stay (OR: 18.6; 95%CI: 12.3-28.2), and 7 times more likely to die compared to children without pneumonia (OR: 7.40, 95%CI: 3.53-15.48).

CONCLUSIONS

We identified key preoperative risk factors for postoperative pneumonia in children undergoing otolaryngology surgery. A small proportion (20%) of high-risk patients accounted for a large proportion (71%) of postoperative pneumonia indicating an underlying Pareto distribution and underscoring the need for targeted interventions for this "vital few". Postoperative pneumonia in pediatric otolaryngology surgical inpatients was associated with longer hospital stay and a higher risk of mortality.

CLINICAL TRIAL NUMBER AND REGISTRY

Not applicable.

Reasons for failure to perform interventional pain procedures in cancer patients: an analysis of pain clinic consultations

Background

Interventional pain procedures (IPPs) may be necessary for some cancer patients when conservative treatment fails. However, many IPPs are often delayed or cancelled for cancer patients who are referred to the pain clinic.

Methods

We retrospectively analyzed the reasons for such cancellations to identify clinically avoidable causes of the delay in IPP.

Results

We enrolled 350 cancer patients who were referred to our pain clinic for an IPP between March 2016 and February 2018. There were 213 (60.9%) cases that were cancelled, among which 115 (54%) cases were potentially avoidable and 98 (46%) were unavoidable. The most common reasons for cancellation were patient-derived factors, which accounted for 85 (39.9%) cases. Patient refusal was a common reason for cancellation, with 33 (15.5%) cases attributed to this cause. The primary avoidable causes of cancellation were a recommendation that the patient continue with their current pharmacological pain treatment, conflict with another planned treatment, and pain characteristics that were not suitable for an IPP. Together, these accounted for 76.5% of all avoidable cancellations.

Conclusions

Comprehensive and accurate pain assessments before IPP may result in more favorable outcomes for the efficient use of medical resource and effective pain relief in cancer patients.

Ultrasound features and the diagnostic strategy of subhepatic appendicitis

Background

This study aimed to compare the differences of ultrasound findings between subhepatic appendicitis and appendicitis at a normal position, then discuss the diagnostic strategies and improve the accuracy of diagnosis.

Methods

A retrospective analysis was performed in our hospital. One thousand five hundred ninety-one patients with appendicitis were diagnosed from January 2014 to January 2018. Eighteen patients with subhepatic appendicitis and 25 patients with appendicitis with regular positions were selected randomly as the control group. The difference in ultrasound features between the two groups was studied. Comparisons between the two groups showed statistically significant differences in the frequencies of the fishbone sign, enlarged appendix, appendicoliths, and hyperechoic omental cap (P<0.05).

Results

Statistical significance was not observed with the difference in the frequency of whether there was lymphadenectasis (P>0.05) in the abdominal cavity between the two groups. The Pareto chart was drawn to look for the main factors associated. The results of interpretation on the critical points of diagnosis for subhepatic appendicitis: (I) the fishbone sign of a dilated ileum in the right lower abdomen; and (II) the fishbone sign of a dilated ileum in the right lower abdomen + presence of an enlarged appendix in the right upper abdomen.

Conclusions

An abnormally dilated ileum in the right lower abdomen – the fishbone sign, is a vital sign leading to the diagnosis of subhepatic appendicitis. The fishbone sign of a dilated ileum in the right lower abdomen + whether there is a vermiform structure is an important diagnostic indicator for subhepatic appendicitis.

A Quantitative Comparison Approach for Methylphenidate Drug Regimens in Attention-Deficit/Hyperactivity Disorder Treatment

OBJECTIVE

Different methylphenidate (MPH) formulations, immediate release (IR) or extended release (ER), have been developed to treat Attention-Deficit/Hyperactivity Disorder (ADHD). A better use of these formulations, with a proper choice of their timing, dosage, and combination, can help to attain optimal therapeutic effect while maintaining a good quality of life. In this study, we aim at presenting a quantitative comparison approach to help identify drug regimens that provide best therapeutic performances and respect patients' specific needs.

METHODS

Using pharmacokinetic (PK) models of various MPH formulations constructed with data in hand and a formerly developed performance metric for MPH regimens, we proposed a statistical integral strategy for regimen comparison, which comprises a sequential, a relative, and a probability-over-threshold method. The first is hierarchical in nature and sequentially compares the regimen performance, the total daily dose, and the administration frequency. The second compares two regimens by quantifying their similarity. The third computes the probability of an incremental regimen performance over a specified threshold. The first two comparison approaches are used for naive patients, whereas the third one is for patients under treatment.

RESULTS

PK models of one compartment effectively describe both the IR and ER data. Applied to three frequent MPH clinical situations, the three-methods strategy is able to distinguish the regimens proposed for each. A combined regimen of IR and ER taken at the same time performs better than a single ER dose.

CONCLUSION

The proposed statistical strategy is able to differentiate ADHD regimens in various clinically relevant situations, and adapt the use of MPH drugs to a patient's daily routine. Since it does not compare fixed doses and formulations but rather any MPH regimen, our approach generalizes the current context of bioequivalence study and provides an accessible computational tool for objectively selecting MPH regimens.

Data Requirements for the Correct Identification of Medication Errors and Adverse Drug Events in Patients Presenting at an Emergency Department

BACKGROUND

Adverse drug events (ADE) involving or not involving medication errors (ME) are common, but frequently remain undetected as such. Presently, the majority of available clinical decision support systems (CDSS) relies mostly on coded medication data for the generation of drug alerts. It was the aim of our study to identify the key types of data required for the adequate detection and classification of adverse drug events (ADE) and medication errors (ME) in patients presenting at an emergency department (ED).

METHODS

As part of a prospective study, ADE and ME were identified in 1510 patients presenting at the ED of an university teaching hospital by an interdisciplinary panel of specialists in emergency medicine, clinical pharmacology and pharmacy. For each ADE and ME the required different clinical data sources (i.e. information items such as acute clinical symptoms, underlying diseases, laboratory values or ECG) for the detection and correct classification were evaluated.

RESULTS

Of all 739 ADE identified 387 (52.4%), 298 (40.3%), 54 (7.3%), respectively, required one, two, or three, more information items to be detected and correctly classified. Only 68 (10.2%) of the ME were simple drug-drug interactions that could be identified based on medication data alone while 381 (57.5%), 181 (27.3%) and 33 (5.0%) of the ME required one, two or three additional information items, respectively, for detection and clinical classification.

CONCLUSIONS

Only 10% of all ME observed in emergency patients could be identified on the basis of medication data alone. Focusing electronic decisions support on more easily available drug data alone may lead to an under-detection of clinically relevant ADE and ME.

Co-Prescription of QT-Interval Prolonging Drugs: An Analysis in a Large Cohort of Geriatric Patients

BACKGROUND

Drug-induced QT-interval prolongation is associated with occurrence of potentially fatal Torsades de Pointes arrhythmias (TdP). So far, data regarding the overall burden of QT-interval prolonging drugs (QT-drugs) in geriatric patients are limited.

OBJECTIVE

This study was performed to assess the individual burden of QT-interval prolonging drugs (QT-drugs) in geriatric polymedicated patients and to identify the most frequent and risky combinations of QT-drugs.

METHODS

In the discharge medication of geriatric patients between July 2009 and June 2013 from the Geriatrics in Bavaria-Database (GiB-DAT) (co)-prescriptions of QT-drugs were investigated. QT-drugs were classified according to a publicly available reference site (CredibleMeds®) as ALL-QT-drugs (associated with any QT-risk) or High-risk-QT-drugs (corresponding to QT-drugs with known risk of Torsades de Pointes according to CredibleMeds®) and in addition as SmPC-high-risk-QT-drugs (according to the German prescribing information (SmPC) contraindicated co-prescription with other QT-drugs).

RESULTS

Of a cohort of 130,434 geriatric patients (mean age 81 years, 67% women), prescribed a median of 8 drugs, 76,594 patients (58.7%) received at least one ALL-QT-drug. Co-prescriptions of two or more ALL-QT-drugs were observed in 28,768 (22.1%) patients. Particularly risky co-prescriptions of High-risk-QT-drugs or SmPC-high-risk-QT-drugs with at least on further QT-drug occurred in 55.9% (N = 12,633) and 54.2% (N = 12,429) of these patients, respectively. Consideration of SmPCs (SmPC-high-risk-QT-drugs) allowed the identification of an additional 15% (N = 3,999) patients taking a risky combination that was not covered by the commonly used CredibleMeds® classification. Only 20 drug-drug combinations accounted for more than 90% of these potentially most dangerous co-prescriptions.

CONCLUSION

In a geriatric study population co-prescriptions of two and more QT-drugs were common. A considerable proportion of QT-drugs with higher risk only could be detected by using more than one classification-system. Local adaption of international classifications can improve identification of patients at risk.

Pharmacist-Led Medication Reviews to Identify and Collaboratively Resolve Drug-Related Problems in Psychiatry - A Controlled, Clinical Trial

Aim of the study

This prospective, controlled trial aimed to assess the effect of pharmacist-led medication reviews on the medication safety of psychiatric inpatients by the resolution of Drug-Related Problems (DRP). Both the therapy appropriateness measured with the Medication Appropriateness Index (MAI) and the number of unsolved DRP per patient were chosen as primary outcome measures.

Methods

Depending on their time of admission, 269 psychiatric patients that were admitted to a psychiatric university hospital were allocated in control (09/2012-03/2013) or intervention group (05/2013-12/2013). In both groups, DRP were identified by comprehensive medication reviews by clinical pharmacists at admission, during the hospital stay, and at discharge. In the intervention group, recommendations for identified DRP were compiled by the pharmacists and discussed with the therapeutic team. In the control group, recommendations were not provided except for serious or life threatening DRP. As a primary outcome measure, the changes in therapy appropriateness from admission to discharge as well as from admission to three months after discharge (follow-up) assessed with the MAI were compared between both groups. The second primary outcome was the number of unsolved DRP per patient after completing the study protocol. The DRP type, the relevance and the potential of drugs to cause DRP were also evaluated.

Results

The intervention led to a reduced MAI score by 1.4 points per patient (95% confidence interval [CI]: 0.8–2.0) at discharge and 1.3 points (95% CI: 0.7–1.9) at follow-up compared with controls. The number of unsolved DRP in the intervention group was 1.8 (95% CI: 1.5–2.1) less than in control.

Conclusion

The pharmaceutical medication reviews with interdisciplinary discussion of identified DRP appears to be a worthy strategy to improve medication safety in psychiatry as reflected by less unsolved DRP per patient and an enhanced appropriateness of therapy. The promising results of this trial likely warrant further research that evaluates direct clinical outcomes and health-related costs.

Trial Registration

Deutsches Register Klinischer Studien (DRKS), DRKS00006358