The Cases for and against Artificial Intelligence in the Medical School Curriculum

Although artificial intelligence (AI) has immense potential to shape the future of medicine, its place in undergraduate medical education currently is unclear. Numerous arguments exist both for and against including AI in the medical school curriculum. AI likely will affect all medical specialties, perhaps radiology more so than any other. The purpose of this article is to present a balanced perspective on whether AI should be included officially in the medical school curriculum. After presenting the balanced point-counterpoint arguments, the authors provide a compromise. Keywords: Artificial Intelligence, Medical Education, Medical School Curriculum, Medical Students, Radiology, Use of AI in Education © RSNA, 2022.

[Not Available]

Armenia and Azerbaijan fought between September and November 2020 in Nagorno-Karabagh. Several surgical missions were scheduled by Assistance Publique- Hôpitaux de Paris to help care for the warinjured Armenians. These missions included the evaluation of Armenian soldiers suspected of having been injured by phosphorus. Facing, during these missions, such infrequent burns, we were interested in their pathophysiology, care and complications. Repeated up-to-date information is necessary in order to better take care of phosphorus burns. Therefore, we conducted a literature review, using PubMed and the Mesh Terms "phosphorus" and "burns", without setting any date limit. The review acknowledges that phosphorus burns are deep, tend to spread and may be the cause of systemic toxicity including hypocalcaemia, which can lead to heart rate disturbance and even death. In the acute phase, burns should be extensively washed with normal saline or water before a mechanical decontamination. One should not use oily dressings, given the liposolubility of phosphorus. Subsequently, one or many debridements are necessary before starting wound coverage, for which any kind of plastic surgery may be used. Phosphorus burns are infrequent but serious. They mainly occur in warfare and should be known by any caregiver acting in this context.

Novel System of Simulation Models for Aneurysm Clipping Training: Description of Models and Assessment of Face, Content, and Construct Validity

BACKGROUND

Aneurysm clipping simulation models are needed to provide tactile feedback of biological vessels in a nonhazardous but surgically relevant environment.

OBJECTIVE

To describe a novel system of simulation models for aneurysm clipping training and assess its validity.

METHODS

Craniotomy models were fabricated to mimic actual tissues and movement restrictions experienced during actual surgery. Turkey wing vessels were used to create aneurysm models with patient-specific geometry. Three simulation models (middle cerebral artery aneurysm clipping via a pterional approach, anterior cerebral artery aneurysm clipping via an interhemispheric approach, and basilar artery aneurysm clipping via an orbitozygomatic pretemporal approach) were subjected to face, content, and construct validity assessments by experienced neurosurgeons (n = 8) and neurosurgery trainees (n = 8).

RESULTS

Most participants scored the model as replicating actual aneurysm clipping well and scored the difficulty of clipping as being comparable to that of real surgery, confirming face validity. Most participants responded that the model could improve clip-applier-handling skills when working with patients, which confirms content validity. Experienced neurosurgeons performed significantly better than trainees on all 3 models based on subjective (P = .003) and objective (P < .01) ratings and on time to complete the task (P = .04), which confirms construct validity. Simulations were used to discuss clip application strategies and compare them to prototype clinical cases.

CONCLUSION

This novel aneurysm clipping model can be used safely outside the wet laboratory; it has high face, content, and construct validity; and it can be an effective training tool for microneurosurgery training during aneurysm surgery courses.

Artificial Intelligence: Has Its Time Come for Inclusion in Medical School Education? Maybe…Maybe Not

This article was migrated. The article was marked as recommended. Artificial intelligence (AI) has the potential to strongly modify or even transform the landscape of medicine. Judicious utilization of AI can further propel progress in medical research, facilitate precision medicine, and optimize clinical workflow-the applications are limitless. Although technology and AI algorithms are evolving rapidly and have important implications for future physicians, there is a dearth of literature available for medical students and their educators to learn about AI. While scientific journals provide information regarding AI, they often are written for and by scientists, engineers, and physicians who are well-versed in technology. Currently, medical students must navigate the technical jargon and decipher AI literature without any foundational exposure. It is difficult for students to understand the implications of AI if they do not have basic knowledge of AI and its current capabilities. A fear about AI is pervasive amongst medical students. There is virtually no literature that provides a fundamental and easily digestible overview of AI for medical students and educators, while also offering suggestions about how to integrate AI into medical school curricula. Our goal is to address the lack of formal AI instruction by presenting an informative primer with curricular suggestions for each medical school year, from a U.S. perspective, tailored to medical students and their educators. We seek to present a balanced approach, as there are pros and cons about incorporating AI in undergraduate medical education.

Delays in presentation and mortality among Black patients with mechanical thrombectomy after large-vessel stroke at a US hospital

OBJECTIVE

The incidence and severity of stroke are disproportionately greater among Black patients. In this study, the authors sought to examine clinical outcomes among Black versus White patients after mechanical thrombectomy for stroke at a single US institution.

METHODS

All patients who underwent mechanical thrombectomy at a single center from January 1, 2014, through March 31, 2020, were retrospectively analyzed. Patients were grouped based on race, and demographic characteristics, preexisting conditions, clinical presentation, treatment, and stroke outcomes were compared. The association of race with mortality was analyzed in multivariable logistic regression analysis adjusted for potential confounders.

RESULTS

In total, 401 patients (233 males) with a reported race of Black (n = 28) or White (n = 373) underwent mechanical thrombectomy during the study period. Tobacco use was more prevalent among Black patients (43% vs 24%, p = 0.04), but there were no significant differences between the groups with respect to insurance, coronary artery disease, diabetes, illicit drug use, hypertension, or hyperlipidemia. The mean time from stroke onset to hospital presentation was significantly greater among Black patients (604.6 vs 333.4 minutes) (p = 0.007). There were no differences in fluoroscopy time, procedural success (Thrombolysis in Cerebral Infarction grade 2b or 3), hospital length of stay, or prevalence of hemicraniectomy. In multivariable analysis, Black race was strongly associated with higher mortality (32.1% vs 14.5%, p = 0.01). The disparity in mortality rates resolved after adjusting for the average time from stroke onset to presentation (p = 0.14).

CONCLUSIONS

Black race was associated with an increased risk of death after mechanical thrombectomy for stroke. The increased risk may be associated with access-related factors, including delayed presentation to stroke centers.

Visualization of brain microvasculature and blood flow in vivo: Feasibility study using confocal laser endomicroscopy

OBJECTIVE

Qualitative and quantitative analyses of blood flow in normal and pathologic brain and spinal cord microvasculature were performed using confocal laser endomicroscopy (CLE).

METHODS

Blood flow in cortical, dural, and spinal cord microvasculature was assessed in vivo in swine. We assessed microvasculature under normal conditions and after vessel occlusion, brain injury due to cold or surgical trauma, and cardiac arrest. Tumor-associated microvasculature was assessed in vivo and ex vivo in 20 patients with gliomas.

RESULTS

We observed erythrocyte flow in vessels 5-500 µm in diameter. Thrombosis, flow arrest and redistribution, flow velocity changes, agglutination, and cells rolling were assessed in normal and injured brain tissue. Microvasculature in in vivo CLE images of gliomas was classified as normal in 68% and abnormal in 32% of vessels on the basis of morphological appearance. Dural lymphatic channels were discriminated from blood vessels. Microvasculature CLE imaging was possible for up to 30 minutes after a 1 mg/kg intravenous dose of fluorescein.

CONCLUSIONS

CLE imaging allows assessment of cerebral and tumor microvasculature and blood flow alterations with subcellular resolution intraoperative imaging demonstrating precise details of real-time cell movements. Research and clinical scenarios may benefit from this novel intraoperative in vivo microscopic fluorescence imaging modality.

Intraoperative Confocal Laser Endomicroscopy Ex Vivo Examination of Tissue Microstructure During Fluorescence-Guided Brain Tumor Surgery

Background

Noninvasive intraoperative optical biopsy that provides real-time imaging of histoarchitectural (cell resolution) features of brain tumors, especially at the margin of invasive tumors, would be of great value. To assess clinical-grade confocal laser endomicroscopy (CLE) and to prepare for its use intraoperatively in vivo, we performed an assessment of CLE ex vivo imaging in brain lesions.

Methods

Tissue samples from patients who underwent intracranial surgeries with fluorescein sodium (FNa)–based wide-field fluorescence guidance were acquired for immediate intraoperative ex vivo optical biopsies with CLE. Hematoxylin-eosin–stained frozen section analysis of the same specimens served as the gold standard for blinded neuropathology comparison. FNa 2 to 5 mg/kg was administered upon induction of anesthesia, and FNa 5 mg/kg was injected for CLE contrast improvement. Histologic features were identified, and the diagnostic accuracy of CLE was assessed.

Results

Of 77 eligible patients, 47 patients with 122 biopsies were enrolled, including 32 patients with gliomas and 15 patients with other intracranial lesions. The positive predictive value of CLE optical biopsies was 97% for all specimens and 98% for gliomas. The specificity of CLE was 90% for all specimens and 94% for gliomas. The second FNa injection in seven patients, a mean of 2.6 h after the first injection, improved image quality and increased the percentage of accurately diagnosed images from 67% to 93%. Diagnostic CLE features of lesional glioma biopsies and normal brain were identified. Seventeen histologic features were identified.

Conclusions

Results demonstrated high specificity and positive predictive value of ex vivo intraoperative CLE optical biopsies and justify an in vivo intraoperative trial. This new portable, noninvasive intraoperative imaging technique provides diagnostic features to discriminate lesional tissue with high specificity and is feasible for incorporation into the fluorescence-guided surgery workflow, particularly for patients with invasive brain tumors.

AI in the Intensive Care Unit: Up-to-Date Review

AI is the latest technologic trend that likely will have a huge impact in medicine. AI's potential lies in its ability to process large volumes of data and perform complex pattern analyses. The ICU is an area of medicine that is particularly conducive to AI applications. Much AI ICU research currently is focused on improving high volumes of data on high-risk patients and making clinical workflow more efficient. Emerging topics of AI medicine in the ICU include AI sensors, sepsis prediction, AI in the NICU or SICU, and the legal role of AI in medicine. This review will cover the current applications of AI medicine in the ICU, potential pitfalls, and other AI medicine-related topics relevant for the ICU.

Confocal Laser Endomicroscopy Assessment of Pituitary Tumor Microstructure: A Feasibility Study

This is the first study to assess confocal laser endomicroscopy (CLE) use within the transsphenoidal approach and show the feasibility of obtaining digital diagnostic biopsies of pituitary tumor tissue after intravenous fluorescein injection. We confirmed that the CLE probe reaches the tuberculum sellae through the transnasal transsphenoidal corridor in cadaveric heads. Next, we confirmed that CLE provides images with identifiable histological features of pituitary adenoma. Biopsies from nine patients who underwent pituitary adenoma surgery were imaged ex vivo at various times after fluorescein injection and were assessed by a blinded board-certified neuropathologist. With frozen sections used as the standard, pituitary adenoma was diagnosed as “definitively” for 13 and as “favoring” in 3 of 16 specimens. CLE digital biopsies were diagnostic for pituitary adenoma in 10 of 16 specimens. The reasons for nondiagnostic CLE images were biopsy acquisition <1 min or >10 min after fluorescein injection (n = 5) and blood artifacts (n = 1). In conclusion, fluorescein provided sufficient contrast for CLE at a dose of 2 mg/kg, optimally 1–10 min after injection. These results provide a basis for further in vivo studies using CLE in transsphenoidal surgery.

The use of cannabis and perceptions of its effect on fertility among infertility patients

STUDY QUESTION

What is the prevalence of cannabis use and the perceptions of its impact on fertility among infertility patients?

SUMMARY ANSWER

A total of 13% of infertility patients used cannabis within the last year, and current usage is associated with patient perceptions of negative effects of cannabis on fertility and pregnancy.

WHAT IS KNOWN ALREADY

Cannabis use is increasing among the general population and pregnant women, particularly in places where cannabis use is legal despite having known and potential negative effects on fertility and pregnancy.

STUDY DESIGN, SIZE, DURATION

A cross-sectional patient survey study was performed between July 2017 and September 2017. Patients attending a university-affiliated hospital-based fertility clinic (n = 290) were invited to complete a written survey. Inclusion criteria were limited to the ability to read English. There were no exclusion criteria.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Of the 290 patients approached, 270 (93%) agreed to participate. The questions covered demographics, cannabis usage, perceptions of the effect of cannabis on fertility and pregnancy, cessation of use due to infertility and personal history of disclosing cannabis use to healthcare providers (HCP).

MAIN RESULTS AND THE ROLE OF CHANCE

The results showed that 13% of respondents disclosed use of cannabis in the past year (past year users) and 38% had not used cannabis in the past year but had previously used cannabis (>1 year users) while 49% had never used cannabis (never users). Baseline demographics were similar for the three groups, but across four measures of fertility and pregnancy health, past-year users perceived less of a negative effect compared to >1 year users, and never users (P values of 0.02, 0.03, 0.01, <0.001 for questions on pregnancy, offspring health, male fertility and female fertility, respectively). Of past year users, 72% said they had or would disclose use to their HCP, but only 9.4% reported that their HCP had actually instructed them to discontinue use.

LIMITATIONS, REASONS FOR CAUTION

Self-reported patient surveys are subject to reporting bias and may not reflect actual use and perceptions.

WIDER IMPLICATIONS OF THE FINDINGS

This study suggests that cannabis use is common among infertility patients. Given the known negative impacts of cannabis on pregnancy, the authors would have expected informed infertility patients to cease cannabis use as part of their efforts to conceive. As the prevalence of cannabis use in the last year among infertility patients is similar to that in the general Canadian population, it is unclear whether the prevalence of cannabis use in the sample population merely reflects the average usage in society or, after taking into account those who reduced their usage to improve their fertility, is a factor contributing to infertility and thus prompting fertility referral. Given concern about the potential negative impact of cannabis use on fertility, and that only 9% of past year users had been instructed by an HCP to cease cannabis use, HCPs should consider the benefits of counselling about cannabis cessation for patients who are attempting to conceive. Future research should focus on analysing the effects of cannabis use on female fertility and determining whether a reduction in use among patients with infertility can improve conception rates.

STUDY FUNDING/COMPETING INTEREST(S)

Michelle Shin, Clinical Research Associate, is supported by the University of Toronto GREI Fellowship Fund, which is sponsored by unrestricted research grants from EMD Serono, Merck Canada and Ferring Pharmaceuticals. The authors have no potential conflicts of interest to disclose.

Novel small molecules disrupting Hec1/Nek2 interaction ablate tumor progression by triggering Nek2 degradation through a death-trap mechanism

Hec1 (highly expressed in cancer 1) or Nek2 (NIMA-related kinase 2) is often overexpressed in cancers with poor prognosis. Both are critical mitotic regulators, and phosphorylation of Hec1 S165 by Nek2 is required for proper chromosome segregation. Therefore, inactivation of Hec1 and Nek2 by targeting their interaction with small molecules represents an ideal strategy for tackling these types of cancers. Here we showed that new derivatives of INH (inhibitor for Nek2 and Hec1 binding) bind to Hec1 at amino acids 394-408 on W395, L399 and K400 residues, effectively blocking Hec1 phosphorylation on S165 by Nek2, and killing cancer cells at the nanomolar range. Mechanistically, the D-box (destruction-box) region of Nek2 specifically binds to Hec1 at amino acids 408-422, immediately adjacent to the INH binding motif. Subsequent binding of Nek2 to INH-bound Hec1 triggered proteasome-mediated Nek2 degradation, whereas the Hec1 binding defective Nek2 mutant, Nek2 R361L, resisted INH-induced Nek2 degradation. This finding unveils a novel drug-action mechanism where the binding of INHs to Hec1 forms a virtual death-trap to trigger Nek2 degradation and eventually cell death. Furthermore, analysis of the gene expression profiles of breast cancer patient samples revealed that co-elevated expressions of Hec1 and Nek2 correlated with the shortest survival. Treatment of mice with this kind of tumor with INHs significantly suppressed tumor growth without obvious toxicity. Taken together, the new INH derivatives are suitable for translation into clinical application.

Late vitamin K deficiency bleeding leading to a diagnosis of cystic fibrosis: a case report

Vitamin K deficiency bleeding (VKDB) in infants still occurs despite worldwide use of prophylaxis. Clinical manifestations can be dramatic with over 50% of patients presenting with intracranial haemorrhage and a mortality rate of 20% in late vitamin K deficiency bleeding. Special attention should be given to infants with a high risk profile (preterm, breast feeding, cholestasis, malabsorption). A tentative diagnosis can be made observing quick normalisation of some easy-to-perform haemostatic parameters (PT, aPTT) after administration of vitamin K. Nowadays, VKDB can still be the first clinical sign of diseases causing malabsorption of fat-soluble vitamins. In this case report, VKDB led to the diagnosis of cystic fibrosis, the most common fatal autosomal recessive disease among Caucasian people.

Effect of selenium supplementation on thyroid hormone metabolism in an iodine and selenium deficient population

OBJECTIVE

Severe selenium deficiency has been documented in northern Zaïre, already known as one of the most iodine deficient regions in the world and characterized by a predominance of the myxoedematous form of cretinism. This has been attributed to the double deficiency of essential trace elements. A short selenium supplementation programme was conducted in this area to evaluate the effects of a selenium supplementation on thyroid diseases.

DESIGN

Placebo or selenium 50 micrograms as selenomethionine was administered once daily for 2 months. Blood and urine samples were collected before and after supplementation.

PATIENTS

Fifty-two healthy schoolchildren from northern Zaire.

MEASUREMENT

Selenium status, thyroid function and urinary iodide were determined.

RESULTS

After 2 months of selenium supplementation, mean +/- SD serum T4 decreased from 73.1 +/- 45.4 to 48.3 +/- 23.7 nmol/l (P less than 0.001), serum FT4 from 11.8 +/- 6.7 to 8.4 +/- 4.1 pmol/l (P less than 0.01), and serum rT3 from 124 +/- 115 to 90 +/- 72 pmol/l (P less than 0.05), without significant change in serum T3 and serum TSH.

CONCLUSION

Deiodinase type I which has been shown to be a seleno-enzyme could account for the changes in thyroid hormones in our subjects. Our data show that selenium plays a definite role in thyroid hormone metabolism in humans. Selenium could be an important cofactor in the clinical picture of iodine deficiency in Central Africa and could be involved in the aetiology of both forms of cretinism.

Effect of selenium supplementation in hypothyroid subjects of an iodine and selenium deficient area: the possible danger of indiscriminate supplementation of iodine-deficient subjects with selenium

Selenium and seleno dependent glutathione peroxidase (GPX) deficiency has been described in endemias of myxedematous cretinism. In northern Zaire, a selenium supplementation trial has been conducted. Beside correcting the GPX activity, two months of selenium supplementation was shown to modify the serum thyroid hormones parameters in clinically euthyroid subjects and to induce a dramatic fall of the already impaired thyroid function in clinically hypothyroid subjects. These results further support a role of selenium in thyroid hormone metabolism. In an iodine deficient area, this selenium deficiency could lead to opposite clinical consequences: protect the general population and the fetus against iodine deficiency and brain damage; and in turn, favour the degenerative process of the thyroid gland leading to myxoedematous cretinism.