1
|
Zolkefli Y. When Healthcare Professionals Disagree: Finding the Right Balance. Malays J Med Sci 2024; 31:223-227. [PMID: 39247114 PMCID: PMC11376999 DOI: 10.21315/mjms2024.31.4.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/24/2024] [Indexed: 09/10/2024] Open
Abstract
Healthcare disagreements are common, but recognising the causes is essential to reaching a moral consensus. The article describes the challenges associated with resolving the disagreements. Therefore, a systematic and timely team-based discussion, ethics consultation with ethicists and the hospital ethics committee, active participation of all members' discussions, and scheduled debriefings are pragmatic ways to find balance when healthcare professionals disagree. Teams need these attempts to build consensus and make moral decisions. It also fosters harmony, prioritises patient and team interests and, most importantly, keeps the team intact.
Collapse
Affiliation(s)
- Yusrita Zolkefli
- PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam, Brunei Darussalam
- School of Health in Social Science, The University of Edinburgh, Edinburgh, United Kingdom
| |
Collapse
|
2
|
Kim P, Seo B, De Silva H. Concordance of clinician, Chat-GPT4, and ORAD diagnoses against histopathology in Odontogenic Keratocysts and tumours: a 15-Year New Zealand retrospective study. Oral Maxillofac Surg 2024:10.1007/s10006-024-01284-5. [PMID: 39060850 DOI: 10.1007/s10006-024-01284-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 07/19/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND This research aimed to investigate the concordance between clinical impressions and histopathologic diagnoses made by clinicians and artificial intelligence tools for odontogenic keratocyst (OKC) and Odontogenic tumours (OT) in a New Zealand population from 2008 to 2023. METHODS Histopathological records from the Oral Pathology Centre, University of Otago (2008-2023) were examined to identify OKCs and OT. Specimen referral details, histopathologic reports, and clinician differential diagnoses, as well as those provided by ORAD and Chat-GPT4, were documented. Data were analyzed using SPSS, and concordance between provisional and histopathologic diagnoses was ascertained. RESULTS Of the 34,225 biopsies, 302 and 321 samples were identified as OTs and OKCs. Concordance rates were 43.2% for clinicians, 45.6% for ORAD, and 41.4% for Chat-GPT4. Corresponding Kappa value against histological diagnosis were 0.23, 0.13 and 0.14. Surgeons achieved a higher concordance rate (47.7%) compared to non-surgeons (29.82%). Odds ratio of having concordant diagnosis using Chat-GPT4 and ORAD were between 1.4 and 2.8 (p < 0.05). ROC-AUC and PR-AUC were similar between the groups (Clinician 0.62/0.42, ORAD 0.58/0.28, Char-GPT4 0.63/0.37) for ameloblastoma and for OKC (Clinician 0.64/0.78, ORAD 0.66/0.77, Char-GPT4 0.60/0.71). CONCLUSION Clinicians with surgical training achieved higher concordance rate when it comes to OT and OKC. Chat-GPT4 and Bayesian approach (ORAD) have shown potential in enhancing diagnostic capabilities.
Collapse
Affiliation(s)
- Paul Kim
- Oral and Maxillofacial Surgery Registrar, Dunedin Hospital, Dunedin, New Zealand.
| | - Benedict Seo
- Department of Oral Diagnostic and Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - Harsha De Silva
- Department of Oral Diagnostic and Surgical Sciences, University of Otago, Dunedin, New Zealand
| |
Collapse
|
3
|
Huang AP, Holloway RG. Navigating Neurologic Illness: Skills in Neuropalliative Care for Persons Hospitalized with Neurologic Disease. Semin Neurol 2024. [PMID: 39053504 DOI: 10.1055/s-0044-1788723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Persons hospitalized for neurologic illness face multidimensional care needs. They can benefit from a palliative care approach that focuses on quality of life for persons with serious illness. We describe neurology provider "skills" to help meet these palliative needs: assessing the patient as a whole; facilitating conversations with patients to connect prognosis to care preferences; navigating neurologic illness to prepare patients and care partners for the future; providing high-quality end-of-life care to promote peace in death; and addressing disparities in care delivery.
Collapse
Affiliation(s)
- Andrew P Huang
- Department of Neurology, University of Rochester, Rochester, New York
| | - Robert G Holloway
- Department of Neurology, University of Rochester, Rochester, New York
| |
Collapse
|
4
|
Padovani P, Roy A, Guerra A, Cadeau O, Ly M, Vasile CM, Pass RH, Baruteau AE. Cognitive biases in pediatric cardiac care. Front Cardiovasc Med 2024; 11:1423680. [PMID: 39027004 PMCID: PMC11254769 DOI: 10.3389/fcvm.2024.1423680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 06/21/2024] [Indexed: 07/20/2024] Open
Abstract
Medical practitioners are entrusted with the pivotal task of making optimal decisions in healthcare delivery. Despite rigorous training, our confidence in reasoning can fail when faced with pressures, uncertainties, urgencies, difficulties, and occasional errors. Day-to-day decisions rely on swift, intuitive cognitive processes known as heuristic or type 1 decision-making, which, while efficient in most scenarios, harbor inherent vulnerabilities leading to systematic errors. Cognitive biases receive limited explicit discussion during our training as junior doctors in the domain of paediatric cardiology. As pediatric cardiologists, we frequently confront emergencies necessitating rapid decision-making, while contending with the pressures of stress, fatigue, an earnest interest in "doing the right thing" and the impact of parental involvement. This article aims to describe cognitive biases in pediatric cardiology, highlighting their influence on therapeutic interventions for congenital heart disease. Whether future pediatric cardiologists or experienced professionals, understanding and actively combating cognitive biases are essential components of our ongoing medical education. Furthermore, it is our responsibility to thoroughly examine our own practices in our unwavering commitment to providing high-quality care.
Collapse
Affiliation(s)
- Paul Padovani
- CHU Nantes, Department of Pediatric Cardiology and Pediatric Cardiac Surgery, FHU PRECICARE, Nantes Université, Nantes, France
- CHU Nantes, INSERM, CIC FEA 1413, Nantes Université, Nantes, France
| | - Arnaud Roy
- LPPL, SFR Confluences, Nantes Université, Université d’Angers, Angers, France
- CHU Nantes, Centre Référent des Troubles d’Apprentissage, Nantes Université, Nantes, France
| | - Amanda Guerra
- LPPL, SFR Confluences, Nantes Université, Université d’Angers, Angers, France
| | - Olivier Cadeau
- LPPL, SFR Confluences, Nantes Université, Université d’Angers, Angers, France
| | - Mohamed Ly
- CHU Nantes, Department of Pediatric Cardiology and Pediatric Cardiac Surgery, FHU PRECICARE, Nantes Université, Nantes, France
| | - Corina M. Vasile
- Pediatrics Department at Filantropia Municipal Hospital of Craiova, Craiova, Romania
| | - Robert H. Pass
- Department of Pediatric Cardiology, Mount Sinai Kravis Children’s Hospital, New York, NY, United States
| | - Alban-Elouen Baruteau
- CHU Nantes, Department of Pediatric Cardiology and Pediatric Cardiac Surgery, FHU PRECICARE, Nantes Université, Nantes, France
- CHU Nantes, INSERM, CIC FEA 1413, Nantes Université, Nantes, France
- CHU Nantes, CNRS, INSERM, l’institut du Thorax, Nantes Université, Nantes, France
- INRAE, UMR 1280, PhAN, Nantes Université, Nantes, France
| |
Collapse
|
5
|
Kirby RP, Kim S, Abdurrahman LM, Kietzman A, Doan J, Hernandez D. Distant Multilevel Spinal Metastasis Secondary to Hypopharyngeal Squamous Cell Carcinoma. Cureus 2024; 16:e64715. [PMID: 39156392 PMCID: PMC11328829 DOI: 10.7759/cureus.64715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2024] [Indexed: 08/20/2024] Open
Abstract
Head and neck squamous cell carcinomas account for most head and neck malignancies. While multi-modality treatment may be offered for locally advanced cancer, distant metastasis still occurs in a significant number of patients. This paper aims to present a rare case of a patient who developed bony metastases in the cervical spine from a primary hypopharyngeal malignancy status post-laryngopharyngectomy. We report a case of a male patient presenting with acute-on-chronic hypercapnic and hypoxic respiratory failure with two months of dysphagia and weight loss. On arrival, a barium swallow revealed mucosal irregularity of the upper thoracic esophagus as well as narrowing and stenosis. A direct laryngoscopy with biopsy revealed squamous cell carcinoma of the hypopharynx. CT neck and chest were obtained for staging. He underwent a total laryngopharyngectomy, bilateral neck dissections, and a free flap. His final staging was pT4aN2c cM0. Three months post-admission, during inpatient radiation therapy, the patient reported midline neck pain with focal bone tenderness, and an MRI was obtained of his cervical and thoracic spine with a report concerning spinal metastasis.A subsequent bone biopsy showed findings consistent with osseous metastasis from a primary hypopharyngeal squamous cell carcinoma. After multidisciplinary goals of care discussions, the patient ultimately decided to be discharged to inpatient hospice. This report highlights a rare case of hypopharyngeal carcinoma metastasis to the cervical spine. Despite its rarity and poor prognosis, such a metastasis should be considered in the differential diagnosis of patients with a history of hypopharyngeal squamous cell carcinoma and localizing symptoms.
Collapse
Affiliation(s)
- R Parker Kirby
- Otolaryngology - Head and Neck Surgery, Baylor College of Medicine, Houston, USA
| | - Sarah Kim
- Otolaryngology - Head and Neck Surgery, Baylor College of Medicine, Houston, USA
| | - Lama M Abdurrahman
- Otolaryngology - Head and Neck Surgery, Baylor College of Medicine, Houston, USA
| | - Alexander Kietzman
- Otolaryngology - Head and Neck Surgery, Baylor College of Medicine, Houston, USA
| | - James Doan
- Pathology, Baylor College of Medicine, Houston, USA
| | - David Hernandez
- Otolaryngology - Head and Neck Surgery, Baylor College of Medicine, Houston, USA
| |
Collapse
|
6
|
Carson RA, Lyles JL. Cognitive Bias in an Infant with Constipation. J Pediatr 2024; 270:113996. [PMID: 38432294 DOI: 10.1016/j.jpeds.2024.113996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Rebecca A Carson
- Clinical Assistant Professor, Conway School of Nursing, The Catholic University of America, Washington, DC
| | - John L Lyles
- Assistant Professor of Pediatrics, Division of Gastroenterology/Hepatology/Nutrition, Duke University School of Medicine, Durham, NC.
| |
Collapse
|
7
|
Serpa A, Bailey M, Shehabi Y, Hodgson CL, Bellomo R. Alternative approaches to analyzing ventilator-free days, mortality and duration of ventilation in critical care research. CRITICAL CARE SCIENCE 2024; 36:e20240246en. [PMID: 38808905 PMCID: PMC11098075 DOI: 10.62675/2965-2774.20240246-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/05/2024] [Indexed: 05/30/2024]
Abstract
OBJECTIVE To discuss the strengths and limitations of ventilator-free days and to provide a comprehensive discussion of the different analytic methods for analyzing and interpreting this outcome. METHODS Using simulations, the power of different analytical methods was assessed, namely: quantile (median) regression, cumulative logistic regression, generalized pairwise comparison, conditional approach and truncated approach. Overall, 3,000 simulations of a two-arm trial with n = 300 per arm were computed using a two-sided alternative hypothesis and a type I error rate of α = 0.05. RESULTS When considering power, median regression did not perform well in studies where the treatment effect was mainly driven by mortality. Median regression performed better in situations with a weak effect on mortality but a strong effect on duration, duration only, and moderate mortality and duration. Cumulative logistic regression was found to produce similar power to the Wilcoxon rank-sum test across all scenarios, being the best strategy for the scenarios of moderate mortality and duration, weak mortality and strong duration, and duration only. CONCLUSION In this study, we describe the relative power of new methods for analyzing ventilator-free days in critical care research. Our data provide validation and guidance for the use of the cumulative logistic model, median regression, generalized pairwise comparisons, and the conditional and truncated approach in specific scenarios.
Collapse
Affiliation(s)
- Ary Serpa
- Monash UniversitySchool of Public Health and Preventive MedicineAustralian and New Zealand Intensive Care Research CentreMelbourneVictoriaAustraliaAustralian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University - Melbourne, Victoria, Australia.
- Hospital Israelita Albert EinsteinDepartment of Critical Care MedicineSão PauloSPBrazilDepartment of Critical Care Medicine, Hospital Israelita Albert Einstein - São Paulo (SP), Brazil.
| | - Michael Bailey
- Monash UniversitySchool of Public Health and Preventive MedicineAustralian and New Zealand Intensive Care Research CentreMelbourneVictoriaAustraliaAustralian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University - Melbourne, Victoria, Australia.
| | - Yahya Shehabi
- Monash UniversityMonash Health School of Clinical SciencesMelbourneVictoriaAustraliaMonash Health School of Clinical Sciences, Monash University - Melbourne, Victoria, Australia.
| | - Carol L Hodgson
- Monash UniversitySchool of Public Health and Preventive MedicineAustralian and New Zealand Intensive Care Research CentreMelbourneVictoriaAustraliaAustralian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University - Melbourne, Victoria, Australia.
| | - Rinaldo Bellomo
- Austin HospitalDepartment of Intensive CareHeidelberg VICAustraliaDepartment of Intensive Care, Austin Hospital - Heidelberg VIC, Australia.
| |
Collapse
|
8
|
Sullivan TM, Sippel GJ, Gestrich-Thompson WV, Jensen AR, Burd RS. Survival bias in pediatric hemorrhagic shock: Are we misrepresenting the data? J Trauma Acute Care Surg 2024; 96:785-792. [PMID: 37752639 DOI: 10.1097/ta.0000000000004119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND Studies of hemorrhage following pediatric injury often use the occurrence of transfusion as a surrogate definition for the clinical need for a transfusion. Using this approach, patients who are bleeding but die before receiving a transfusion are misclassified as not needing a transfusion. In this study, we aimed to evaluate the potential for this survival bias and to estimate its presence among a retrospective observational cohort of children and adolescents who died from injury. METHODS We obtained patient, injury, and resuscitation characteristics from the 2017 to 2020 Trauma Quality Improvement Program database of children and adolescents (younger than 18 years) who arrived with or without signs of life and died. We performed univariate analysis and a multivariable logistic regression to analyze the association between the time to death and the occurrence of transfusion within 4 hours after hospital arrival controlling for initial vital signs, injury type, body regions injured, and scene versus transfer status. RESULTS We included 6,063 children who died from either a blunt or penetrating injury. We observed that children who died within 15 minutes had lower odds of receiving a transfusion (odds ratio, 0.1; 95% confidence interval, 0.1-0.2) compared with those who survived longer. We estimated that survival bias that occurs when using transfusion administration alone to define hemorrhagic shock may occur in up to 11% of all children who died following a blunt or penetrating injury but less than 1% of all children managed as trauma activations. CONCLUSION Using the occurrence of transfusion alone may underestimate the number of children who die from uncontrolled hemorrhage early after injury. Additional variables than just transfusion administration are needed to more accurately identify the presence of hemorrhagic shock among injured children and adolescents. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
Collapse
MESH Headings
- Humans
- Shock, Hemorrhagic/therapy
- Shock, Hemorrhagic/mortality
- Shock, Hemorrhagic/etiology
- Shock, Hemorrhagic/diagnosis
- Child
- Female
- Male
- Retrospective Studies
- Adolescent
- Blood Transfusion/statistics & numerical data
- Child, Preschool
- Infant
- Bias
- Wounds, Penetrating/mortality
- Wounds, Penetrating/therapy
- Wounds, Penetrating/complications
- Wounds, Penetrating/diagnosis
- Wounds, Nonpenetrating/mortality
- Wounds, Nonpenetrating/therapy
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/complications
- Resuscitation/methods
- Resuscitation/statistics & numerical data
Collapse
Affiliation(s)
- Travis M Sullivan
- From the Division of Trauma and Burn Surgery (T.M.S., G.J.S., W.V.G.-T., R.S.B.), Children's National Hospital, Washington, DC; Department of Surgery (A.R.J.), University of California San Francisco; and Division of Pediatric Surgery (A.R.J.), UCSF Benioff Children's Hospitals, San Francisco, CA
| | | | | | | | | |
Collapse
|
9
|
Tejani AS, Ng YS, Xi Y, Rayan JC. Understanding and Mitigating Bias in Imaging Artificial Intelligence. Radiographics 2024; 44:e230067. [PMID: 38635456 DOI: 10.1148/rg.230067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Artificial intelligence (AI) algorithms are prone to bias at multiple stages of model development, with potential for exacerbating health disparities. However, bias in imaging AI is a complex topic that encompasses multiple coexisting definitions. Bias may refer to unequal preference to a person or group owing to preexisting attitudes or beliefs, either intentional or unintentional. However, cognitive bias refers to systematic deviation from objective judgment due to reliance on heuristics, and statistical bias refers to differences between true and expected values, commonly manifesting as systematic error in model prediction (ie, a model with output unrepresentative of real-world conditions). Clinical decisions informed by biased models may lead to patient harm due to action on inaccurate AI results or exacerbate health inequities due to differing performance among patient populations. However, while inequitable bias can harm patients in this context, a mindful approach leveraging equitable bias can address underrepresentation of minority groups or rare diseases. Radiologists should also be aware of bias after AI deployment such as automation bias, or a tendency to agree with automated decisions despite contrary evidence. Understanding common sources of imaging AI bias and the consequences of using biased models can guide preventive measures to mitigate its impact. Accordingly, the authors focus on sources of bias at stages along the imaging machine learning life cycle, attempting to simplify potentially intimidating technical terminology for general radiologists using AI tools in practice or collaborating with data scientists and engineers for AI tool development. The authors review definitions of bias in AI, describe common sources of bias, and present recommendations to guide quality control measures to mitigate the impact of bias in imaging AI. Understanding the terms featured in this article will enable a proactive approach to identifying and mitigating bias in imaging AI. Published under a CC BY 4.0 license. Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Rouzrokh and Erickson in this issue.
Collapse
Affiliation(s)
- Ali S Tejani
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - Yee Seng Ng
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - Yin Xi
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - Jesse C Rayan
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| |
Collapse
|
10
|
Garudadri CS. Metacognition and Medicine. Indian J Ophthalmol 2024; 72:461-463. [PMID: 38546464 PMCID: PMC11149521 DOI: 10.4103/ijo.ijo_419_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Affiliation(s)
- Chandra S Garudadri
- VST Centre for Glaucoma Care, L. V. Prasad Eye Institute, Hyderabad, Telangana, India E-mail:
| |
Collapse
|
11
|
Tort Saadé PJ, White AA. Sports Medicine Patient Experience: Implicit Bias Mitigation and Communication Strategies. Clin Sports Med 2024; 43:279-291. [PMID: 38383110 DOI: 10.1016/j.csm.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Unconscious bias, also known as implicit bias, is the principal contributor to the perpetuation of discrimination and is a robust determinant of people's decision-making. Unconscious bias occurs despite conscious nonprejudiced intentions and interferes with the actions of the reflective and conscious side. Education and self-awareness about implicit bias and its potentially harmful effects on judgment and behavior may lead individuals to pursue corrective action and follow implicit bias mitigation communication strategies. Team physicians must follow existing communication strategies and guidelines to mitigate unconscious bias and begin an evolution toward nonbiased judgment and decision-making to improve athlete care.
Collapse
Affiliation(s)
- Pedro J Tort Saadé
- Surgery Department, Doctors' Center Hospital San Juan, San Juan, Puerto Rico; Universidad Central del Caribe School of Medicine, Bayamon, Puerto Rico.
| | - Augustus A White
- Ellen and Melvin Gordon Distinguished Professor Emeritus of Medical Education and Professor Emeritus of Orthopedic Surgery at Harvard Medical School, Boston, MA, USA
| |
Collapse
|
12
|
Gray M, Samala R, Liu Q, Skiles D, Xu J, Tong W, Wu L. Measurement and Mitigation of Bias in Artificial Intelligence: A Narrative Literature Review for Regulatory Science. Clin Pharmacol Ther 2024; 115:687-697. [PMID: 38018360 DOI: 10.1002/cpt.3117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/21/2023] [Indexed: 11/30/2023]
Abstract
Artificial intelligence (AI) is increasingly being used in decision making across various industries, including the public health arena. Bias in any decision-making process can significantly skew outcomes, and AI systems have been shown to exhibit biases at times. The potential for AI systems to perpetuate and even amplify biases is a growing concern. Bias, as used in this paper, refers to the tendency toward a particular characteristic or behavior, and thus, a biased AI system is one that shows biased associations entities. In this literature review, we examine the current state of research on AI bias, including its sources, as well as the methods for measuring, benchmarking, and mitigating it. We also examine the biases and methods of mitigation specifically relevant to the healthcare field and offer a perspective on bias measurement and mitigation in regulatory science decision making.
Collapse
Affiliation(s)
- Magnus Gray
- Division of Bioinformatics & Biostatistics, National Center for Toxicological Research, US Food and Drug Administration, Jefferson, Arkansas, USA
| | - Ravi Samala
- Division of Imaging, Diagnostics, and Software Reliability, Office of Science and Engineering Laboratories, US Food and Drug Administration Center for Devices and Radiological Health, Silver Spring, Maryland, USA
| | - Qi Liu
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Denny Skiles
- Office of Management, National Center for Toxicological Research, US Food and Drug Administration, Jefferson, Arkansas, USA
| | - Joshua Xu
- Division of Bioinformatics & Biostatistics, National Center for Toxicological Research, US Food and Drug Administration, Jefferson, Arkansas, USA
| | - Weida Tong
- Division of Bioinformatics & Biostatistics, National Center for Toxicological Research, US Food and Drug Administration, Jefferson, Arkansas, USA
| | - Leihong Wu
- Division of Bioinformatics & Biostatistics, National Center for Toxicological Research, US Food and Drug Administration, Jefferson, Arkansas, USA
| |
Collapse
|
13
|
Vrudhula A, Kwan AC, Ouyang D, Cheng S. Machine Learning and Bias in Medical Imaging: Opportunities and Challenges. Circ Cardiovasc Imaging 2024; 17:e015495. [PMID: 38377237 PMCID: PMC10883605 DOI: 10.1161/circimaging.123.015495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Bias in health care has been well documented and results in disparate and worsened outcomes for at-risk groups. Medical imaging plays a critical role in facilitating patient diagnoses but involves multiple sources of bias including factors related to access to imaging modalities, acquisition of images, and assessment (ie, interpretation) of imaging data. Machine learning (ML) applied to diagnostic imaging has demonstrated the potential to improve the quality of imaging-based diagnosis and the precision of measuring imaging-based traits. Algorithms can leverage subtle information not visible to the human eye to detect underdiagnosed conditions or derive new disease phenotypes by linking imaging features with clinical outcomes, all while mitigating cognitive bias in interpretation. Importantly, however, the application of ML to diagnostic imaging has the potential to either reduce or propagate bias. Understanding the potential gain as well as the potential risks requires an understanding of how and what ML models learn. Common risks of propagating bias can arise from unbalanced training, suboptimal architecture design or selection, and uneven application of models. Notwithstanding these risks, ML may yet be applied to improve gain from imaging across all 3A's (access, acquisition, and assessment) for all patients. In this review, we present a framework for understanding the balance of opportunities and challenges for minimizing bias in medical imaging, how ML may improve current approaches to imaging, and what specific design considerations should be made as part of efforts to maximize the quality of health care for all.
Collapse
Affiliation(s)
- Amey Vrudhula
- Icahn School of Medicine at Mount Sinai, New York
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center
| | - Alan C Kwan
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center
| | - David Ouyang
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Medical Center
| | - Susan Cheng
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center
| |
Collapse
|
14
|
Weaver ML, Drudi LM, Adams AM, Faria I, Feldman HA, Gudmundsdottir H, Marmor H, Miles MVP, Ochoa B, Ruff SM, Sundland R, Tonelli C, Altieri MS, Cannada LK, Dewan K, Etkin Y, Marmor R, Plichta JK, Reyna C, Tatebe LC, Hicks CW. Implementation of a novel peer review academy by Surgery and the Association of Women Surgeons. Surgery 2024; 175:323-330. [PMID: 37953152 PMCID: PMC10842028 DOI: 10.1016/j.surg.2023.09.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/28/2023] [Accepted: 09/26/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND A novel Peer Review Academy was developed as a collaborative effort between the Association of Women Surgeons and the journal Surgery to provide formal training in peer review. We aimed to describe the outcomes of this initiative using a mixed methods approach. METHODS We developed a year-long curriculum with monthly online didactic sessions. Women surgical trainee mentees were paired 1:1 with rotating women surgical faculty mentors for 3 formal peer review opportunities. We analyzed pre-course and post-course surveys to evaluate mentee perceptions of the academy and assessed changes in mentee review quality over time with blinded scoring of unedited reviews. Semi-structured interviews were conducted upon course completion. RESULTS Ten women surgical faculty mentors and 10 women surgical trainees from across the United States and Canada successfully completed the Peer Review Academy. There were improvements in the mentees' confidence for all domains of peer review evaluated, including overall confidence in peer review, study novelty, study design, analytic approach, and review formatting (all, P ≤ .02). The mean score of peer review quality increased over time (59.2 ± 10.8 vs 76.5 ± 9.4; P = .02). In semi-structured interviews, important elements were emphasized across the Innovation, Implementation Process, and Individuals Domains, including the values of (1) a comprehensive approach to formal peer review education; (2) mentoring relationships between women faculty and resident surgeons; and (3) increasing diversity in the scientific peer review process. CONCLUSION Our novel Peer Review Academy was feasible on a national scale, resulting in significant qualitative and quantitative improvements in women surgical trainee skillsets, and has the potential to grow and diversify the existing peer review pool.
Collapse
Affiliation(s)
- M Libby Weaver
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Laura M Drudi
- Division of Vascular Surgery, Centre Hospitalier de L'Universite de Montreal, Montreal, QC, Canada
| | - Alexandra M Adams
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX
| | - Isabella Faria
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA
| | - Hope A Feldman
- Department of General Surgery, Geisinger Medical Center, Danville, PA
| | | | - Hannah Marmor
- Department of Surgery, State University of New York Upstate Medical University, Syracuse, NY
| | - M Victoria P Miles
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Brielle Ochoa
- Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Samantha M Ruff
- Division of Surgical Oncology, The Ohio State University, Columbus, OH
| | | | - Celsa Tonelli
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Maria S Altieri
- Department of Surgery, University of Pennsylvania, Pennsylvania Hospital, Philadelphia, PA
| | - Lisa K Cannada
- Novant Health Fracture Clinic, University of North Carolina-Charlotte School of Medicine, Charlotte, NC
| | - Karuna Dewan
- Department of Otolaryngology, Head and Neck Surgery, Louisiana State University, New Orleans, LA
| | - Yana Etkin
- Division of Vascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Rebecca Marmor
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Chantal Reyna
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Leah C Tatebe
- Department of Surgery, Northwestern University, Chicago, IL
| | - Caitlin W Hicks
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| |
Collapse
|
15
|
Cherin N, Patel S, Jukic M. Delayed amyotrophic lateral sclerosis diagnosis with subtle cardiac manifestations: Was anchoring bias contributory? Clin Case Rep 2024; 12:e8544. [PMID: 38385052 PMCID: PMC10879635 DOI: 10.1002/ccr3.8544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/10/2024] [Accepted: 01/19/2024] [Indexed: 02/23/2024] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a rare, progressive neurodegenerative disease affecting both upper and lower motor neurons. Throughout medical training, it is taught that the most recognizable clinical presentation involves both motor and bulbar changes. Given the complexity of the diagnosis however, it is no surprise that there is significant multisystem involvement secondary to the autonomic dysfunction associated with the disease. The clinical cognitive biases that exist due to prior educational training and patient provided chief complaint can mislead clinicians and prevent a holistic, inclusive approach toward each patient encounter. This can delay diagnosis and increase unnecessary healthcare spending. In a disease with such a poor prognosis, this effect can be catastrophic, resulting in unacceptable medical, functional, and psychosocial outcomes. As clinicians, it is imperative to acknowledge these cognitive biases through introspection, which can improve clinical outcomes and ultimately patient quality of life for those facing this devastating disease. We report a case of a 55-year-old female who presented with a chief complaint of palpitations and minimal slurred speech on multiple encounters, subsequently leading to a focused cardiovascular workup. It was not until after several hospital encounters that a thorough functional and neuromuscular exam was performed, which ultimately helped to broaden the differential and lead to the diagnosis of ALS. Unfortunately, due to this delayed diagnosis, the patient's functionality was beyond repair. Given the underlying cognitive biases that are present in all clinicians, we hypothesize this patient's sex, presenting symptom, and primary chief complaint misled clinicians to perform limited history and physical examinations, therefore, leading to a narrowed differential. If diagnosed in a timely fashion, vital services such as rehabilitation could have provided this patient with the necessary medical, functional, and psychosocial support to face this devastating disease.
Collapse
Affiliation(s)
- Neyha Cherin
- Department of Physical Medicine and RehabilitationPenn State Health Milton S. Hershey Medical CenterHersheyPennsylvaniaUSA
| | - Shivani Patel
- Department of Physical Medicine and RehabilitationPenn State Health Milton S. Hershey Medical CenterHersheyPennsylvaniaUSA
| | - Michelle Jukic
- Department of Physical Medicine and RehabilitationPenn State Health Milton S. Hershey Medical CenterHersheyPennsylvaniaUSA
| |
Collapse
|
16
|
Pott H, J LeBlanc J, S ElSherif M, Hatchette TF, McNeil SA, Andrew MK. Clinical features and outcomes of influenza and RSV coinfections: a report from Canadian immunization research network serious outcomes surveillance network. BMC Infect Dis 2024; 24:147. [PMID: 38291361 PMCID: PMC10826021 DOI: 10.1186/s12879-024-09033-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/18/2024] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Influenza and RSV coinfections are not commonly seen but are concerning as they can lead to serious illness and adverse clinical outcomes among vulnerable populations. Here we describe the clinical features and outcomes of influenza and RSV coinfections in hospitalized adults. METHODS A cohort study was performed with pooled active surveillance in hospitalized adults ≥ 50 years from the Serious Outcomes Surveillance Network of the Canadian Immunization Research Network (CIRN SOS) during the 2012/13, 2013/14, and 2014/15 influenza seasons. Descriptive statistics summarized the characteristics of influenza/RSV coinfections. Kaplan-Meier estimated the probability of survival over the first 30 days of hospitalization. RESULTS Over three influenza seasons, we identified 33 cases of RSV and influenza coinfection, accounting for 2.39 cases per 1,000 hospitalizations of patients with acute respiratory illnesses. Adults aged 50 + years commonly reported cough (81.8%), shortness of breath (66.7%), sputum production (45.5%), weakness (33.3%), fever (27.3%), and nasal congestion (24.2%) as constitutional and lower respiratory tract infection symptoms. The mortality rate was substantial (12.1%), and age, comorbidity burden, and frailty were associated with a higher risk for adverse clinical outcomes. CONCLUSIONS Older adults are at higher risk for complications from influenza and RSV coinfections, especially those over 65 with a high comorbidity burden and frailty.
Collapse
Affiliation(s)
- Henrique Pott
- Canadian Center for Vaccinology, Dalhousie University, Halifax, Canada.
- Department of Medicine, Universidade Federal de São Carlos, Rod. Washington Luis, km 235. São Carlos, São Carlos, 13656-905, Brazil.
| | - Jason J LeBlanc
- Canadian Center for Vaccinology, Dalhousie University, Halifax, Canada
- Department of Pathology, Dalhousie University, Halifax, Canada
- Division of Microbiology, Department of Pathology and Laboratory Medicine, Nova Scotia Health, Halifax, Canada
| | - May S ElSherif
- Canadian Center for Vaccinology, Dalhousie University, Halifax, Canada
- Department of Microbiology and Immunology, Dalhousie University, Halifax, Canada
| | - Todd F Hatchette
- Canadian Center for Vaccinology, Dalhousie University, Halifax, Canada
- Department of Pathology, Dalhousie University, Halifax, Canada
- Division of Microbiology, Department of Pathology and Laboratory Medicine, Nova Scotia Health, Halifax, Canada
| | - Shelly A McNeil
- Canadian Center for Vaccinology, Dalhousie University, Halifax, Canada
- Department of Medicine (Infectious Diseases), Dalhousie University, Halifax, Canada
| | - Melissa K Andrew
- Canadian Center for Vaccinology, Dalhousie University, Halifax, Canada
- Department of Medicine (Geriatrics), Dalhousie University, Halifax, Canada
| |
Collapse
|
17
|
Ott DE. Limitations in Medical Research: Recognition, Influence, and Warning. JSLS 2024; 28:e2023.00049. [PMID: 38405216 PMCID: PMC10882193 DOI: 10.4293/jsls.2023.00049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Abstract
Background As the number of limitations increases in a medical research article, their consequences multiply and the validity of findings decreases. How often do limitations occur in a medical article? What are the implications of limitation interaction? How often are the conclusions hedged in their explanation? Objective To identify the number, type, and frequency of limitations and words used to describe conclusion(s) in medical research articles. Methods Search, analysis, and evaluation of open access research articles from 2021 and 2022 from the Journal of the Society of Laparoscopic and Robotic Surgery and 2022 Surgical Endoscopy for type(s) of limitation(s) admitted to by author(s) and the number of times they occurred. Limitations not admitted to were found, obvious, and not claimed. An automated text analysis was performed for hedging words in conclusion statements. A limitation index score is proposed to gauge the validity of statements and conclusions as the number of limitations increases. Results A total of 298 articles were reviewed and analyzed, finding 1,764 limitations. Four articles had no limitations. The average was between 3.7% and 6.9% per article. Hedging, weasel words and words of estimative probability description was found in 95.6% of the conclusions. Conclusions Limitations and their number matter. The greater the number of limitations and ramifications of their effects, the more outcomes and conclusions are affected. Wording ambiguity using hedging or weasel words shows that limitations affect the uncertainty of claims. The limitation index scoring method shows the diminished validity of finding(s) and conclusion(s).
Collapse
|
18
|
Greenblatt AS, Beniczky S, Nascimento FA. Pitfalls in scalp EEG: Current obstacles and future directions. Epilepsy Behav 2023; 149:109500. [PMID: 37931388 DOI: 10.1016/j.yebeh.2023.109500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 10/15/2023] [Accepted: 10/17/2023] [Indexed: 11/08/2023]
Abstract
Although electroencephalography (EEG) serves a critical role in the evaluation and management of seizure disorders, it is commonly misinterpreted, resulting in avoidable medical, social, and financial burdens to patients and health care systems. Overinterpretation of sharply contoured transient waveforms as being representative of interictal epileptiform abnormalities lies at the core of this problem. However, the magnitude of these errors is amplified by the high prevalence of paroxysmal events exhibited in clinical practice that compel investigation with EEG. Neurology training programs, which vary considerably both in the degree of exposure to EEG and the composition of EEG didactics, have not effectively addressed this widespread issue. Implementation of competency-based curricula in lieu of traditional educational approaches may enhance proficiency in EEG interpretation amongst general neurologists in the absence of formal subspecialty training. Efforts in this regard have led to the development of a systematic, high-fidelity approach to the interpretation of epileptiform discharges that is readily employable across medical centers. Additionally, machine learning techniques hold promise for accelerating accurate and reliable EEG interpretation, particularly in settings where subspecialty interpretive EEG services are not readily available. This review highlights common diagnostic errors in EEG interpretation, limitations in current educational paradigms, and initiatives aimed at resolving these challenges.
Collapse
Affiliation(s)
- Adam S Greenblatt
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sándor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Center, Dianalund and Aarhus University Hospital, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Fábio A Nascimento
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.
| |
Collapse
|
19
|
AbdelMassih AF, Gomaa FEZM, AbuGhosh RZ, Shebl N, Enab SE, ElBanna MA, Ali N. How the COVID-19 Pandemic Contributed to Diagnostic Bias. Cureus 2023; 15:e48282. [PMID: 38058327 PMCID: PMC10697045 DOI: 10.7759/cureus.48282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2023] [Indexed: 12/08/2023] Open
Abstract
Diagnosis bias in the medical field is a recognized entity that can contribute to misdiagnoses and incorrect management. It remains a constant challenge that must be recognized and addressed. Several factors play a role in the formation of preconceptions which influence the physicians' decision-making process. The aim of this paper is to present a case that was misdiagnosed and mistakenly managed due to diagnosis bias during the coronavirus disease 2019 (COVID-19) pandemic. We also suggest two ways to reduce the risk of diagnosis bias. Multi-inflammatory syndrome of children (MIS-C) was described during the COVID-19 pandemic. The rise in the incidence of MIS-C masked the diagnosis of other diseases that present in a similar fashion. In this paper, we describe the case of a seven-year-old girl, who presented in 2020, with acute onset respiratory distress. Her chest images were suggestive of COVID-19 pneumonitis which prompted the physicians to complete the MIS-C workup by performing an echocardiogram. A large aneurysm of the left main artery was seen which led to a preliminary diagnosis of MIS-C. A repeat echocardiography, 48 hours after the initiation of MIS-C treatment, was suggestive of a large coronary fistula complicated by infective endocarditis and multiple septic pulmonary emboli. It can be inferred that the misdiagnosis occurred as a result of availability and premature-closure biases. Efforts to decrease such biases include group decision-making and using checklists during the assessment of a patient.
Collapse
Affiliation(s)
| | | | | | | | - Salah E Enab
- Critical Care, Sheikh Khalifa Medical City, Abu Dhabi, ARE
| | | | - Noha Ali
- Pediatric Cardiology, Cairo University, Cairo, EGY
| |
Collapse
|
20
|
Edje L, Casillas C, O'Toole JK. Strategies to Counteract Impact of Harmful Bias in Selection of Medical Residents. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:S75-S85. [PMID: 37099404 DOI: 10.1097/acm.0000000000005258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Human biases impact medical care in ways that perpetuate health disparities. Research has demonstrated that biases negatively affect patient outcomes and stifle diversity across the physician workforce, further compounding health disparities by worsening patient-physician concordance. Taken as one, the application, interview, recruitment, and selection processes employed by residency programs has been one of the critical junctures where bias has exacerbated inequities among future physicians. In this article, the authors define diversity and bias, review the history of bias in residency programs' processes for selecting residents, explore the impact of this history on workforce demographics, and discuss ways to optimize and work toward equity in the practices used by residency programs to select residents.
Collapse
Affiliation(s)
- Louito Edje
- L. Edje is associate dean of graduate medical education, designated institutional official, and professor of medical education and family and community medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: https://orcid.org/0000-0002-9125-7180
| | - Carlos Casillas
- C. Casillas is a fellow in pediatric hospital medicine, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: https://orcid.org/0000-0001-5789-0620
| | - Jennifer K O'Toole
- J.K. O'Toole is program director, internal medicine-pediatrics residency program and professor of pediatrics and internal medicine, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: https://orcid.org/0000-0002-6277-1113
| |
Collapse
|
21
|
Alverdy JC. Biologically inspired gastrointestinal stapler design: "Getting to Zero" complications. Am J Surg 2023; 226:48-52. [PMID: 36775790 PMCID: PMC10293041 DOI: 10.1016/j.amjsurg.2023.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 01/15/2023] [Accepted: 01/31/2023] [Indexed: 02/04/2023]
Abstract
As next generation stapling devices enter the marketplace with robotic adaptations, tri-staple technology, preloaded reinforcement materials, etc., in this perspective piece we assert that a "refresh" in our understanding of the mechanisms of action of these devices is needed. While much attention has been paid to explain the mechanical features of one device versus another, it seems that little to no attention is being paid to understand how an intestinal anastomosis responds biologically to the variations in their use and design. Here we will review various aspects of gastrointestinal stapling in the context of emerging technology in the field and expose the gaps in knowledge that exist regarding the effect of gastrointestinal stapling on the biology of healing.
Collapse
Affiliation(s)
- John C Alverdy
- University of Chicago, 5841 S Maryland MC 6090, Chicago, Illinois, 60637, USA.
| |
Collapse
|
22
|
Sullivan TM, Sippel GJ, Matison EA, Gestrich-Thompson WV, DeWitt PE, Carlisle MA, Oluigbo D, Oluigbo C, Bennett TD, Burd RS. Development and validation of a Bayesian network predicting neurosurgical intervention after injury in children and adolescents. J Trauma Acute Care Surg 2023; 94:839-846. [PMID: 36917100 PMCID: PMC10205657 DOI: 10.1097/ta.0000000000003935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
BACKGROUND Timely surgical decompression improves functional outcomes and survival among children with traumatic brain injury and increased intracranial pressure. Previous scoring systems for identifying the need for surgical decompression after traumatic brain injury in children and adults have had several barriers to use. These barriers include the inability to generate a score with missing data, a requirement for radiographic imaging that may not be immediately available, and limited accuracy. To address these limitations, we developed a Bayesian network to predict the probability of neurosurgical intervention among injured children and adolescents (aged 1-18 years) using physical examination findings and injury characteristics observable at hospital arrival. METHODS We obtained patient, injury, transportation, resuscitation, and procedure characteristics from the 2017 to 2019 Trauma Quality Improvement Project database. We trained and validated a Bayesian network to predict the probability of a neurosurgical intervention, defined as undergoing a craniotomy, craniectomy, or intracranial pressure monitor placement. We evaluated model performance using the area under the receiver operating characteristic and calibration curves. We evaluated the percentage of contribution of each input for predicting neurosurgical intervention using relative mutual information (RMI). RESULTS The final model included four predictor variables, including the Glasgow Coma Scale score (RMI, 31.9%), pupillary response (RMI, 11.6%), mechanism of injury (RMI, 5.8%), and presence of prehospital cardiopulmonary resuscitation (RMI, 0.8%). The model achieved an area under the receiver operating characteristic curve of 0.90 (95% confidence interval [CI], 0.89-0.91) and had a calibration slope of 0.77 (95% CI, 0.29-1.26) with a y intercept of 0.05 (95% CI, -0.14 to 0.25). CONCLUSION We developed a Bayesian network that predicts neurosurgical intervention for all injured children using four factors immediately available on arrival. Compared with a binary threshold model, this probabilistic model may allow clinicians to stratify management strategies based on risk. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
Collapse
Affiliation(s)
- Travis M. Sullivan
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Genevieve J. Sippel
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Elizabeth A. Matison
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | | | - Peter E. DeWitt
- Departments of Biomedical Informatics and Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | | | | | - Chima Oluigbo
- Department of Neurological Surgery, Children’s National Hospital, Washington, DC
| | - Tellen D. Bennett
- Departments of Biomedical Informatics and Pediatrics, University of Colorado School of Medicine, Aurora, CO
- Children’s Hospital of Colorado, Aurora, CO
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| |
Collapse
|
23
|
Jackson HM, Jones VM, Jayaratne SU, Fokin AA, Masri MM. Diagnostic nightmare: intra-intestinal bleed masks intra-abdominal bleed after colonoscopy. J Surg Case Rep 2023; 2023:rjad049. [PMID: 36846837 PMCID: PMC9946767 DOI: 10.1093/jscr/rjad049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 01/24/2023] [Indexed: 02/25/2023] Open
Abstract
Colonoscopy is a widely used method of screening, diagnosis and intervention. Complications are infrequent and generally present as colonic perforation or colonic hemorrhage. A rare and life-threatening complication of colonoscopy is splenic injury or rupture. We present a case report of an 81-year-old female who was admitted with hemodynamic instability and tachycardia due to gastrointestinal (GI) bleeding and developed hemoperitoneum within 24 hours following colonoscopy. The initial computed tomography (CT) scan was misdiagnosed due to the patient history of GI bleed, and the iatrogenic splenic injury was recognized only during a second CT after continued hemodynamic instability. The patient's initial diagnosis of a GI bleed masked the intraperitoneal bleed and led to a delayed diagnosis of splenic rupture and increased morbidity. This patient required an emergent laparotomy with a total splenectomy with lysis of adhesions.
Collapse
Affiliation(s)
- Hillary M Jackson
- Correspondence address. Department of Graduate Medical Education, General Surgery, Larkin Community Hospital, South Miami, FL 33143, USA. Tel: +1-214-893-1255; Fax: +1-561-495-3410; E-mail:
| | - Victoriann M Jones
- Department of Medical Education, St. George’s University, Great River, NY, USA
| | - Sharani U Jayaratne
- Department of Medical Education, St. George’s University, Great River, NY, USA
| | | | - Mohammad M Masri
- Department of Graduate Medical Education, General Surgery, Larkin Community Hospital, South Miami, FL, USA
| |
Collapse
|
24
|
Weaver ML, Sorber RA, Holscher CM, Cox ML, Henry BV, Brooke BS, Cooper MA. The measurable impact of a diversity, equity, and inclusion editor on diversifying content, authorship, and peer review participation in the Journal of Vascular Surgery. J Vasc Surg 2023; 77:330-337. [PMID: 36368645 DOI: 10.1016/j.jvs.2022.10.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/09/2022] [Accepted: 10/31/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Women and minorities remain under-represented in academic vascular surgery. This under-representation persists in the editorial peer review process which may contribute to publication bias. In 2020, the Journal of Vascular Surgery (JVS) addressed this by diversifying the editorial board and creating a new Editor of Diversity, Equity, and Inclusion (DEI). The impact of a DEI editor on modifying the output of JVS has not yet been examined. We sought to determine the measurable impact of a DEI editor on diversifying perspectives represented in the journal, and on contributing to changes in the presence of DEI subject matter across published journal content. METHODS The authorship and content of published primary research articles, editorials, and special articles in JVS were examined from November 2019 through July 2022. Publications were examined for the year prior to initiation of the DEI Editor (pre), the year following (post), and from September 2021 to July 2022, accounting for the average 47-week time period from submission to publication in JVS (lag). Presence of DEI topics and women authorship were compared using χ2 tests. RESULTS During the period examined, the number of editorials, guidelines, and other special articles dedicated to DEI topics in the vascular surgery workforce or patient population increased from 0 in the year prior to 4 (16.7%) in the 11-month lag period. The number of editorials, guidelines, and other special articles with women as first or senior authors nearly doubled (24% pre, 44.4% lag; P = .31). Invited commentaries and discussions were increasingly written by women as the study period progressed (18.7% pre, 25.9% post, 42.6% lag; P = .007). The number of primary research articles dedicated to DEI topics increased (5.6% pre, 3.3% post, 8.1% lag; P = .007). Primary research articles written on DEI topics were more likely to have women first or senior authors than non-DEI specific primary research articles (68.0% of all DEI vs 37.5% of a random sampling of non-DEI primary research articles; P < .001). The proportion of distinguished peer reviewers increased (from 2.8% in 2020 to 21.9% in 2021; P < .001). CONCLUSIONS The addition of a DEI editor to JVS significantly impacted the diversification of topics, authorship of editorials, special articles, and invited commentaries, as well as peer review participation. Ongoing efforts are needed to diversify subject matter and perspective in the vascular surgery literature and decrease publication bias.
Collapse
Affiliation(s)
- M Libby Weaver
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA.
| | - Rebecca A Sorber
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Courtenay M Holscher
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, MD
| | - Morgan L Cox
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Brandon V Henry
- Division of Vascular Surgery and Endovascular Surgery, Morehouse School of Medicine, Atlanta, GA
| | - Benjamin S Brooke
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Michol A Cooper
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| |
Collapse
|
25
|
Sullivan TM, Gestrich-Thompson WV, Milestone ZP, Burd RS. Time is tissue: Barriers to timely transfusion after pediatric injury. J Trauma Acute Care Surg 2023; 94:S22-S28. [PMID: 35916621 PMCID: PMC9805480 DOI: 10.1097/ta.0000000000003752] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT Strategies to improve outcomes among children and adolescents in hemorrhagic shock have primarily focused on component resuscitation, pharmaceutical coagulation adjuncts, and hemorrhage control techniques. Many of these strategies have been associated with better outcomes in children, but the barriers to their use and the impact of timely use on morbidity and mortality have received little attention. Because transfusion is uncommon in injured children, few studies have identified and described barriers to the processes of using these interventions in bleeding patients, processes that move from the decision to transfuse, to obtaining the necessary blood products and adjuncts, and to delivering them to the patient. In this review, we identify and describe the steps needed to ensure timely blood transfusion and propose practices to minimize barriers in this process. Given the potential impact of time on hemorrhage associated outcomes, ensuring timely intervention may have a similar or greater impact than the interventions themselves.
Collapse
Affiliation(s)
- Travis M. Sullivan
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | | | - Zachary P. Milestone
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| |
Collapse
|
26
|
Jablonska PA, Fong CH, Kruser T, Weiss J, Liu ZA, Takami H, Narita Y, de Moraes FY, Dasgupta A, Ong CK, Yang JCH, Lee JH, Pavlakis N, Kongkham P, Butler M, Shultz DB. Recommended first-line management of brain metastases from melanoma: A multicenter survey of clinical practice. Radiother Oncol 2022; 168:89-94. [PMID: 35121033 DOI: 10.1016/j.radonc.2022.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/23/2022] [Accepted: 01/25/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Radiotherapy (RT) and surgery (Sx) are effective in treating brain metastases. However, immune checkpoint inhibitors (ICI) have shown activity against asymptomatic melanoma brain metastases (MBM). BRAF/MEK inhibitors can be used to treat BRAF V600 mutation positive (BRAF+) MBM. METHOD We conducted an international survey among experts from medical oncology (MO), clinical oncology (CO), radiation oncology (RO), and neurosurgery (NS) about treatment recommendations for patients with asymptomatic BRAF+ or BRAF mutation negative (BRAF-) MBM. Eighteen specific clinical scenarios were presented and a total of 267 responses were collected. Answers were grouped and compared using Fisher's exact test. RESULTS In most MBM scenarios, survey respondents, regardless of specialty, favored RT in addition to systemic therapy. However, for patients with BRAF+ MBM, MO and CO were significantly more likely than RO and NS to recommend BRAF/MEK inhibitors alone, without the addition of RT, including the majority of MO (51%) for patients with 1-3 MBM, all <2cm. Likewise, for BRAF- MBM, MO and CO more commonly recommended single or dual agent ICI only and dual agent ICI therapy alone was the most common recommendation from MO or CO for MBM <2cm. When at least 1 of 3 MBM (BRAF+ or BRAF-) was >2cm, upfront Sx was recommended by all groups with the exception that MO and RO recommended RT for BRAF- MBM. CONCLUSIONS In most clinical settings involving asymptomatic MBM, experts recommended RT in addition to systemic therapy. However, recommendations varied significantly according to specialty, with MO and CO more commonly recommending dual systemic therapy alone for up to 9 BRAF- MBM <2cm.
Collapse
Affiliation(s)
| | - Chin Heng Fong
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
| | | | - Jessica Weiss
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Canada
| | - Zhihui Amy Liu
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Canada
| | - Hirokazu Takami
- Department of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan
| | - Yoshitaka Narita
- Department of Neurosurgery and Neuro-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | | | - Archya Dasgupta
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
| | | | - James C H Yang
- Graduate Institute of Oncology, National Taiwan University, Taipei, Taiwan
| | - Jih Hsiang Lee
- Graduate Institute of Oncology, National Taiwan University, Taipei, Taiwan
| | - Nicholas Pavlakis
- Graduate Institute of Oncology, National Taiwan University, Taipei, Taiwan
| | - Paul Kongkham
- Division of Neurosurgery, Toronto Western Hospital, Canada
| | - Marcus Butler
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - David B Shultz
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.
| |
Collapse
|
27
|
Herbet M, Leonard J, Santangelo MG, Albaret L. Dissimulate or disseminate? A survey on the fate of negative results. LEARNED PUBLISHING 2022. [DOI: 10.1002/leap.1438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Marie‐Emilia Herbet
- Services for researchers, Science Library Université Claude Bernard Lyon 1 Villeurbanne France
| | - Jérémie Leonard
- Services for researchers, Science Library Université Claude Bernard Lyon 1 Villeurbanne France
| | | | - Lucie Albaret
- Services for researchers University Library, Université Grenoble‐Alpes Grenoble France
| |
Collapse
|
28
|
Trevas S, Guerreiro R, Faria C, Santos A. Thinking Outside the Box. Cureus 2022; 14:e20970. [PMID: 35154949 PMCID: PMC8815801 DOI: 10.7759/cureus.20970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2022] [Indexed: 11/18/2022] Open
Abstract
Clinical decision-making process is very complex and influenced by multiple aspects. As diagnosis likelihood assessment is often based on intuitive thinking, data misinterpretation, and diagnostic errors may commonly occur. We present a peculiar clinical case of a 27-year-old obese woman admitted to the emergency department after an inaugural episode of seizures. She had an oncologic disease. She was febrile and hypertensive at first evaluation. The report evolves around the diagnostic assessment, hampered by incongruent anamneses, incorrect data interpretation, and a pinch of clinical obstination, which nearly culminated in two deaths. Then, we discuss the series of biases that have confused the physicians. The only way to escape the intuitive thinking trap is to be humbly aware of our own thinking method’s limitations and to learn about the biases that often lead us into errors. Sometimes, thinking outside the box is the key.
Collapse
|
29
|
Lozada-Martínez ID, Acevedo-Aguilar LM, Mass-Hernández LM, Matta-Rodríguez D, Jiménez-Filigrana JA, Garzón-Gutiérrez KE, Barahona-Botache SA, Vásquez-Castañeda DL, Caicedo-Giraldo SDR, Rahman S. Practical guide for the use of medical evidence in scientific publication: Recommendations for the medical student: Narrative review. Ann Med Surg (Lond) 2021; 71:102932. [PMID: 34659747 PMCID: PMC8503847 DOI: 10.1016/j.amsu.2021.102932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 10/07/2021] [Accepted: 10/07/2021] [Indexed: 11/25/2022] Open
Abstract
Currently, the adaptation of scientific evidence in clinical problem solving is based on the evidence-based medicine method. Medical students and health professionals should have an adequate knowledge of this method and thus provide adequate health care and increasingly provide high quality scientific publications that can be subsequently integrated in different clinical scenarios. Several scales and tools have been proposed as guides to recognize the different levels of quality of the available evidence, their degrees of recommendation and the biases and fallacies that may occur both in the clinical and research areas, with the aim of identifying the best available evidence. However, few students and professionals are aware of them and make proper use of them. Therefore, it is necessary to synthesize these tools in an understandable and practical way.
Collapse
Affiliation(s)
| | | | | | - Duván Matta-Rodríguez
- School of Medicine, Universidad de Ciencias Aplicadas y Ambientales, Bogotá, Colombia
| | | | | | | | | | | | | |
Collapse
|
30
|
Reason for Consult: Still on Oxygen, Discharge Pending, Requesting Thoracentesis. J Bronchology Interv Pulmonol 2021; 28:172-173. [PMID: 34151898 DOI: 10.1097/lbr.0000000000000778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|