Capacity for large language model chatbots to aid in orthopedic management, research, and patient queries

Large language model (LLM) chatbots possess a remarkable capacity to synthesize complex information into concise, digestible summaries across a wide range of orthopedic subject matter. As LLM chatbots become widely available they will serve as a powerful, accessible resource that patients, clinicians, and researchers may reference to obtain information about orthopedic science and clinical management. Here, we examined the performance of three well-known and easily accessible chatbots-ChatGPT, Bard, and Bing AI-in responding to inquiries relating to clinical management and orthopedic concepts. Although all three chatbots were found to be capable of generating relevant responses, ChatGPT outperformed Bard and BingAI in each category due to its ability to provide accurate and complete responses to orthopedic queries. Despite their promising applications in clinical management, shortcomings observed included incomplete responses, lack of context, and outdated information. Nonetheless, the ability for these LLM chatbots to address these inquires has largely yet to be evaluated and will be critical for understanding the risks and opportunities of LLM chatbots in orthopedics.

Clinical and Radiological Predictors of Slower and Non-Improvement Following Surgical Treatment of L4-5 Degenerative Spondylolisthesis: Preliminary Results

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To identify the predictors of slower and non-improvement following surgical treatment of L4-5 degenerative lumbar spondylolisthesis (DLS).

SUMMARY OF BACKGROUND DATA

There is limited evidence regarding clinical and radiological predictors of slower and non-improvement following surgery for L4-5 DLS.

METHODS

Patients who underwent minimally invasive decompression or fusion for L4-5 DLS and had a minimum of 1-year follow-up were included. Outcome measures were: (1) minimal clinically important difference (MCID), (2) patient acceptable symptom state (PASS), and (3) global rating change (GRC). Clinical variables analyzed for predictors were age, gender, body mass index (BMI), surgery type, comorbidities, anxiety, depression, smoking, osteoporosis, and preoperative patient reported outcome measures (PROMs) (Oswestry Disability Index, ODI; Visual Analog Scale, VAS back and leg; 12-Item Short Form Survey Physical Component Score, SF-12 PCS). Radiological variables analyzed were slip percentage, translational and angular motion, facet diastasis/cyst/orientation, laterolisthesis, disc height, scoliosis, main and fractional curve Cobb angles, and spinopelvic parameters.

RESULTS

233 patients (37% decompression, 63% fusion) were included. At <3 months, high pelvic tilt (PT) (OR 0.92, P 0.02) and depression (OR 0.28, P 0.02) were predictors of MCID non-achievement and GRC non-betterment, respectively. Neither retained significance at >6 months and hence, were identified as predictors of slower improvement. At >6 months, low preoperative VAS leg (OR 1.26, P 0.01) and high facet orientation (OR 0.95, P 0.03) were predictors of MCID non-achievement, high L4-5 slip percentage (OR 0.86, P 0.03) and L5-S1 angular motion (OR 0.78, P 0.01) were predictors of GRC non-betterment, and high preoperative ODI (OR 0.96, P 0.04) was a predictor of PASS non-achievement.

CONCLUSIONS

High PT and depression were predictors of slower improvement and low preoperative leg pain, high disability, high facet orientation, high slip percentage, and L5-S1 angular motion were predictors of non-improvement. However, these are preliminary findings and further studies with homogeneous cohorts are required to establish these findings.

Early Failures After Lumbar Discectomy Surgery: An Analysis of 62 690 Patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine the rate of early failures (readmission or reoperation for new or recurrent pain/neurological symptoms) within 30 days after lumbar discectomy and identify associated risk factors.

METHODS

A retrospective cohort study was conducted of patients undergoing lumbar discectomy in the National Surgical Quality Improvement Program database between 2013 and 2017. Rates of readmission for new or recurrent symptoms or reoperation for revision discectomy or fusion within 30 days postoperatively were measured and correlated with risk factors.

RESULTS

In total 62 690 patients were identified; overall rate of readmission within 30 days was 3.3%, including 1.2% for pain or neurological symptoms. Populations at increased risk of readmission were those with 3 or more levels of treatment (2.0%, odds ratio [OR] 2.8%, P < .01), age >70 years (1.8%, OR 1.6, P < .01), class 3 obesity (1.5%, OR 1.4, P = .04), and female gender (1.4%, OR 1.2, P = .02). The overall rate of reoperation within 30 days was 2.2%, including 1.2% for revision decompression or lumbar fusion surgery. Populations at increased risk of reoperation were revision discectomies (1.4%, OR 1.7, P < .01) and females (1.1%, OR 1.4, P < 0.01). Extraforaminal discectomies were associated with lower rates of readmission (0.7%, OR 0.6, P = 0.02) and reoperation (0.4%, OR 0.4, P = .01).

CONCLUSIONS

Early failures after lumbar discectomy surgery are rare. However, certain subpopulations are associated with increased rates of early failure: obesity, multilevel surgery, females, and revision discectomies.

Periprosthetic Joint Infection in Patients with Inflammatory Joint Disease: Prevention and Diagnosis

PURPOSE OF REVIEW

Periprosthetic joint infection (PJI) is a devastating complication that can occur following total joint arthroplasty (TJA), causing significant morbidity and often requiring revision surgery. This goal of this manuscript is to review the current evidence for the prevention and diagnosis of PJI in patients with inflammatory arthritis.

RECENT FINDINGS

Patients with inflammatory arthritis have a higher risk of PJI after TJA; however, there are several preventive, diagnostic, and therapeutic measures that can be optimized to lower the burden of PJI in this population. This manuscript will review the current evidence and clinical practice recommendations that support specific features of preoperative evaluation, perioperative medication management, and surgical planning in inflammatory arthritis patients undergoing TJA. Evidence and recommendations for the diagnosis of PJI in this patient population will also be reviewed. Despite increased research efforts directed towards PJI, specific approaches directed at the inflammatory arthritis patient population remain surprisingly limited. Optimization strategies such as adequately managing disease-modifying medications, treating preoperative anemia, encouraging smoking cessation, and improving weight management are strongly encouraged before entering the perioperative period. If PJI does occur in the inflammatory arthritis patient, establishing the diagnosis is challenging, since guidelines were created from investigations of PJI in primarily patients without inflammatory arthritis. Future prospective research is required to better guide clinicians in preventing and diagnosing PJI in inflammatory arthritis patients undergoing TJA.

Enhanced TLR2 responses in multiple sclerosis

The roles of the microbiome and innate immunity in the pathogenesis of multiple sclerosis (MS) remain unclear. We have previously documented abnormally low levels of a microbiome‐derived Toll‐like receptor (TLR)2‐stimulating bacterial lipid in the blood of MS patients and postulated that this is indicative of a deficiency in the innate immune regulating function of the microbiome in MS. We postulated further that the resulting enhanced TLR2 responsiveness plays a critical role in the pathogenesis of MS. As proof‐of‐concept, we reported that decreasing systemic TLR2 responsiveness by administering very low‐dose TLR2 ligands attenuated significantly the mouse model of MS, experimental autoimmune encephalomyelitis. Studies of Toll‐like receptor responses in patients with MS have been conflicting. Importantly, most of these investigations have focused on the response to TLR4 ligation and few have characterized TLR2 responses in MS. In the present study, our goal was to characterize TLR2 responses of MS patients using multiple approaches. Studying a total of 26 MS patients and 32 healthy controls, we now document for the first time that a large fraction of MS patients (50%) demonstrate enhanced responsiveness to TLR2 stimulation. Interestingly, the enhanced TLR2 responders include a significant fraction of those with progressive forms of MS, a subset of patients considered unresponsive to adaptive immune system‐targeting therapies. Our results suggest the presence of a pathologically relevant TLR2 related innate immune abnormality in patients with both relapsing–remitting and progressive MS. These findings may have significant implications for understanding the role of innate immunity in the pathogenesis of MS.

Did anything change? Caregivers and schizophrenia after medication changes

This paper reports on a qualitative, critical study into the lives of relatives and partners of people living with enduring effects of schizophrenia. A review of the literature showed that caregivers and relatives of sufferers were seldom asked about their experiences, instead they were subject to blame or criticism regarding their parental or caregiving practices. Caregivers of people with schizophrenia were interviewed in order to reveal their experience of caring for their kin after a medication change to atypical neuroleptics. The interview analysis was compared with mental health professional literature, using a Foucauldian approach to reveal the operation of language and power in the positioning of caregivers. This analysis was then compared to the talk of the caregivers. Similarities and differences in their ways of talking about caring were identified. Caregivers spoke of protracted periods of time before the establishment of a definite diagnosis, ambivalence about medication and 'never giving up'. The paper concludes that life for caregivers is constituted as doubly problematic, experiencing stigma personally and vicariously through their kin.

Design and implementation of an urban/rural Telehealth Network for the Evaluation of Abused Children: implications for global primary care applications

To meet the increasing need for rapid medical evaluation of allegations of child abuse in rural areas and the paucity of trained professionals to provide these evaluations, a model telemedicine network was designed and implemented initially in the State of Florida, USA. The utilization of various types of equipment, transmission modes, and electronic peripherals, will be discussed, as well as utilization of physician extenders for assessment. The expansion of this system for other medical uses will be summarized. Experiences in replication of the model in a southern Alabama rural county will be detailed.

Use of telehealth technology to extend child protection team services

OBJECTIVE

In response to increased referrals to Florida's Child Protection Teams and concern regarding statewide availability of medical expertise in the area of child abuse and neglect, Children's Medical Services of the Florida Department of Health established a telemedicine project to facilitate immediate expert medical evaluations of alleged child abuse or neglect. This article describes a baseline examination of the project, including the technique of concept mapping, to examine how larger systematic factors influence the adaptation of telemedicine technology in child abuse examination settings.

METHODS

This study included interviews of key staff plus the incorporation of concept mapping, which takes qualitative data (individual statements and opinions) and quantifies them (sorts and ranks them by order of group importance).

RESULTS

Findings from interviews revealed that the frequency of use of telehealth services varies across the state as a result of several factors, including space limitations and staff training. Patients, however, seem to be comfortable with the use of the new technology. The concept mapping exercise displayed a progression of issues that are perceived to have an impact on the use of this technology.

CONCLUSIONS

Technology use is affected by unforeseen variables, such as physical space limitations and examination room availability. Family concerns about patient privacy issues were rare and were resolved quickly by the health care practitioner. Although using this equipment is not difficult, the search for user-friendliness should be continued. Staff engagement early in the process likely will result in a greater likelihood of use of the technology.telehealth, telemedicine, child protection, child abuse and neglect, concept mapping.

Re-awakenings? A discourse analysis of the recovery from schizophrenia after medication change

This paper explores the construction of recovery from schizophrenia after medication change through the analysis of people living with schizophrenia. The study is framed by a discourse analysis which assumes that the language used to discuss schizophrenia and its treatment by medication is imbued with the power relations of mental health. The analysis uses research literature, pharmaceutical literature and previous studies of schizophrenia as the discursive background that frames how recovery can be talked about. The discussion highlights how the discourses of medical science construct recovery as a linear event that silences the embodiment of schizophrenia. People with schizophrenia refuse this construction, through finding a 'niche' for themselves. In conclusion, the paper suggests how such analysis opens up for exploration of the silencing of 'insanity', and establishes a beginning dialogue with people who live with the continuing presence of schizophrenia.

A case in point? A parasuicide patient's recollections of being nursed: a discourse analysis

This paper highlights the recollections of being nursed from the perspective of a patient (Gabby) admitted to a general medical ward after attempting suicide. A discourse analysis was used to discuss the way in which Gabby was nursed, enabling identification of the social structure which supports the nurse-patient relationship. This research evolved with the realisation that the point of view of parasuicide patients was primarily absent within nursing literature. Inattention within the literature was later replicated by Gabby's expressions of inadequate interaction between nurses and parasuicide patients.

Identification of a human gastrointestinal tract and immune system receptor for the peptide neuromedin U

Neuromedin U (NmU) is a 25 amino acid peptide prominently expressed in the upper gastrointestinal (GI) tract and central nervous system. It is highly conserved throughout evolution and induces smooth muscle contraction in a variety of species. Our understanding of NmU biology has been limited because the identity of its receptor was unknown. Here we demonstrate that GPR66/FM-3 is specifically stimulated by NmU, causing the mobilization of intracellular calcium. This response was dose-dependent (EC(50) = 10 nM) and specific in that none of over 1000 ligands tested, including other neuromedins (NmB, C, L, K, N), induced a calcium flux in GPR66/FM-3-transfected cells. The GPR66/FM-3 mRNA is prominently expressed in the upper GI tract of humans, as is the mRNA for NmU, consistent with role for this receptor-ligand pair in regulating the function of this organ system. In addition, we show that whereas neuromedin U is expressed by monocytes and dendritic cells, GPR66/FM-3 is expressed by T cells and NK cells. These data suggest a previously unrecognized role for NmU as an immunoregulatory molecule.

GABA(B) receptors function as a heteromeric assembly of the subunits GABA(B)R1 and GABA(B)R2

The principal inhibitory neurotransmitter GABA (gamma-aminobutyric acid) exerts its effects through two ligand-gated channels, GABA(A) and GABA(C) receptors, and a third receptor, GABA(B) , which acts through G proteins to regulate potassium and calcium channels. Cells heterologously expressing the cloned DNA encoding the GABA(B)R1 protein exhibit high-affinity antagonist-binding sites, but they produce little of the functional activity expected from studies of endogenous GABA(B) receptors in the brain. Here we describe a new member of the GABA(B) polypeptide family, GABA(B)R2, that shows sequence homology to GABA(B)R1. Neither GABA(B)R1 nor GABA(B)R2, when expressed individually, activates GIRK-type potassium channels; however, the combination of GABA(B)R1 and GABA(B)R2 confers robust stimulation of channel activity. Both genes are co-expressed in individual neurons, and both proteins co-localize in transfected cells. Moreover, immunoprecipitation experiments indicate that the two polypeptides associate with each other, probably as heterodimers. Several G-protein-coupled receptors (GPCRs) exist as high-molecular-weight species, consistent with the formation of dimers by these receptors, but the relevance of these species for the functioning of GPCRs has not been established. We have now shown that co-expression of two GPCR structures, GABA(B)R1 and GABA(B)R2, belonging to the same subfamily is essential for signal transduction by GABA(B) receptors.

Epidemiology of group C rotavirus infection in Western New York women of childbearing age

Umbilical cord serum samples (380), an average of 10 per month for 3 years (1990 to 1992), were tested by indirect immunofluorescence assay for group C rotavirus immunoglobulin G. Thirty percent were positive, suggesting that approximately one-third of women of childbearing age in western New York have experienced group C rotavirus infection.

Synthesis and hypolipidemic activity of amine-carboxyboranes, and their amides and esters in rodents

A series of amine carboxyboranes including their amides and esters were synthesized and shown to have potent hypolipidemic activity in rodents at 20 mg/kg/day. Ethylamine carboxyborane, di-n-propylamine-carboxyborane, trimethylamine-carbomethoxyborane, n-butylamine carbomethoxyborane, methylamine-N-ethyl carbamoylborane and trimethylamine-N-n-octyl carbamoylborane were the most potent derivatives demonstrating hypocholesterolemic and hypotriglycemic activities in rats orally at 20 mg/kg/day. These derivatives lowered tissue lipids, e.g. cholesterol, in the rat liver, small intestine and aorta. The fecal lipids were elevated. Furthermore, the agents lowered cholesterol and triglycerides in the serum VLDL and LDL fractions but caused elevations in the HDL fraction after 14 days. The agents inhibited hepatic enzymatic activities of rate limiting steps involved in lipid metabolism, e.g. ATP dependent citrate lyase, sn-glycerol-3-phosphate acyltransferase and phosphatidylate phosphohydrolase.

Computed tomography and automated image analysis of prehistoric femora

Non-invasive characterization of limb bone cross-sectional geometry would be useful for biomechanical analyses of skeletal collections. Computed tomography (CT) is potentially the method of choice. Additionally, CT images are suitable for automated analysis. CT is here shown to be both accurate and precise in the analysis of cross-sectional geometry of prehistoric femora. Beam hardening artifacts can be reduced by using a water bath. As the availability of CT for research increases, both bone density and geometry could be determined simultaneously with this method.