UT Southwestern Medical Center Research Articles

Impact of team performance on the surgical safety checklist on patient outcomes: an operating room black box analysis.

Surgical safety checklists reduce adverse events, but monitoring adherence to checklists is confounded by observation bias. The ORBB platform can monitor checklist compliance and correlate compliance with outcomes. This study aims to evaluate the association between checklist compliance and patient outcomes using the ORBB platform. This is a retrospective analysis of data from the electronic medical record of cases performed in ORBB-equipped operating rooms at a single quaternary referral center. All patients who did not opt out and underwent surgery at UT Southwestern Medical Center in ORBB-equipped rooms from August 2020 to September 2022 were included. The ORBB platform was set-up in five operating rooms and surgical safety checklist compliance was monitored by way of AI-based video review. Overall, 4581 patients were included in this analysis.. Performance on the checklist was associated with lower mortality (OR, 0.96; 95% CI, 0.94-0.98; P < 0.05), and decreased length of stay (estimate [E]: -0.02days; 95% CI, -0.03 to -0.005; P < 0.05). Performance during "timeouts" was associated with mortality (OR, 0.97; 95% CI, 0.94-0.99; P < 0.05). "Debriefings" were independently associated with mortality (OR, 0.98; 95% CI, 0.96-0.99; P < 0.05), length of stay (Estimate, -0.0009days; 95% CI, -0.02 to -0.001; P < 0.05), and ICU admission (OR, 0.99; 95% CI, 0.98-0.99; P < 0.05). Procedures performed by surgical teams who performed better on the surgical safety checklist tended to have better outcomes. This innovative technology could substantially enhance our ability to understand and mitigate threats to patients in real-time.

From Clinic to Kitchen to Electronic Health Record: The Background and Process of Building a Culinary Medicine eConsult Service.

Diet plays a pivotal role in health outcomes, influencing various metabolic pathways and accounting for over 20% of risk-attributable disability adjusted life years (DALYs). However, the limited time during primary care visits often hinders comprehensive guidance on dietary and lifestyle modifications. This paper explores the integration of electronic consultations (eConsults) in Culinary Medicine (CM) as a solution to bridge this gap. CM specialists, with expertise in the intricate connections between food, metabolism, and health outcomes, offer tailored dietary recommendations through asynchronous communication within the electronic health record (EHR) system. The use of CM eConsults enhances physician-patient communication and fosters continuous medical education for requesting clinicians. The benefits extend directly to patients, providing access to evidence-based nutritional information to address comorbidities and improve overall health through patient empowerment. We present a comprehensive guide for CM specialist physicians to incorporate CM eConsults into their practices, covering the historical context of eConsults, their adaptation for CM, billing methods, and insights from the implementation at UT Southwestern Medical Center. This initiative delivers expanded access to patient education on dietary risks and promotes interprofessional collaboration to empower improved health.

Evaluation of ERAS protocol implementation on complex spine surgery complications and length of stay: a Single Institution Study

BACKGROUND CONTEXTWith the goal of improving patient outcomes, the Integrated Spine Center at UT Southwestern Medical Center implemented an enhanced recovery after surgery (ERAS) protocol which includes pre- and post-surgery guidelines. Numerous studies have shown benefit of implementation of ERAS protocols to standardize perioperative care in line with best practices; however, the literature on complication rates, LOS, and readmissions shows mixed results. PURPOSEThe goal of this study was to investigate the impact of the ERAS protocol implementation on complication rates in the perioperative period, as well as hospital and ICU length of stay and hospital re-admission rates. STUDY DESIGN/SETTINGA retrospective cohort study was performed on all patients who underwent spine surgery between September 2016 and September 2021 at a single institution. Patients who met inclusion criteria were divided into non-ERAS and ERAS groups, and comparative statistics were used to evaluate ERAS protocol effectiveness. PATIENT SAMPLEAll patients who underwent spine surgery at UT Southwestern between September 2016 and September 2021 were evaluated for inclusion in the study. The patient sample was further refined to include only complex patient cases which were able to receive the full ERAS protocol (non-emergent admissions). OUTCOME MEASURESPresence of absence of post-operative complications including surgical site infection, AKI, DVT, MI, sepsis, pneumonia, PE, stroke, shock, and other complications were compared between groups, as were hospital and ICU length of stay, and 7, 30, and 90 day readmissions. Self-reported or functional measures were not used in outcome evaluation. METHODSA database of patient and surgery characteristics was built using an EMR query tool with spot checks performed by the authors. Control and treatment groups were matched for gender, age, BMI, ASA score, and surgery type. Total number of complication rates was compared between ERAS and non-ERAS groups, and comparative statistics were used to determine significance. RESULTSSignificant differences between ERAS versus non-ERAS groups were found in rates of UTI (6.8% vs. 3.1%, respectively; p=.031), constipation (20.6% vs. 11.4%, respectively; p=.001), and any complications (31.4% vs. 19.4%, respectively; p<.001). There was no significant difference in the rates of other complications, in length of hospital or ICU stay, or readmissions at 7, 30, and 90 days. CONCLUSIONSImplementation of the ERAS protocol did not decrease complication rates or length of stay, and ERAS patients had significantly higher rates of UTI, constipation, and any complications. There may have been confounding factors due to the impact of COVID-19 on delivery of care, as well as misalignment between ERAS goals and outcome measures.

Characterizing the association of systemic estradiol levels and transcriptional markers of skeletal muscle regeneration in healthy young females

Recent research indicates estradiol's (E2) role in modulating skeletal muscle regeneration. E2 has been observed to enhance myogenic capacity by upregulating myogenic factors and downregulating proteolytic factors[1,2]. The extracellular matrix (ECM) of skeletal muscle also influences regeneration due to its interaction with muscle progenitor cells [5]. Cell and animal studies observed E2's ability to impact on collagen (COL) 1, 3, and 4 production [3,4]. However, limited data from physiologically relevant human models exploring myogenic markers and ECM throughout the menstrual cycle are available. We hypothesize that higher systemic E2 levels will correspond to an increased regenerative gene expression signature. Understanding this relationship is crucial for assessing how E2 levels affect muscle healing in eumenorrheic women and E2’s potential as a therapeutic molecule for enhancing muscle repair. The study included 19 pre-menopausal women aged 18-39 undergoing hip surgery at UT Southwestern (UTSW) Medical Center. This study was approved by the UTSW IRB and conducted in accordance with the Declaration of Helsinki. Blood and muscle biopsies were collected for hormone and gene analysis. Only subjects in the follicular phase (n=12) were included to minimize progesterone's influence. Investigated genes included myogenic factors (MYOD1, MYF5, MYF6, MYOG), proteolytic factors (FOXO3, MuRF1), and COL genes (COL1a1, COL-3a1, COL-4a1, COL-6a1). E2 levels ranged from 26-356 pg/mL, with negligible progesterone levels, consistent with the follicular phase. While no significant relationships were found between myogenic and proteolytic genes, MYF6 exhibited a positive relationship with E2 (p=0.07), while MuRF1 showed a negative one (p=0.09). COL 1, 3, and 6 gene expressions had no significant relationship with E2, but COL 4 exhibited a statistically significant positive relationship (p=0.04) with E2 concentration. Though no statistically significant relationships emerged between myogenic or proteolytic gene expression and E2 levels, there were notable trends toward significance for MYF6 and MuRF1. MYF6, recognized for its role in myogenic differentiation, is implicated in maintaining the satellite cell pool by promoting myokine secretion[6]. In contrast, MuRF1 is a critical component in muscle atrophy[7]. COL4 expression was significantly associated with E2 levels (p=0.4). It is hypothesized that COL4 enhances IGF1-activated myoblast migration, differentiation, and fusion [5]. These findings suggest a potential link between elevated E2 levels and an enhanced regenerative capacity. These findings indicate that higher E2 conditions may create a favorable environment for muscle recovery. Future research should increase sample size and examine protein levels of these factors.

Increasing Diversity in Academic Medicine Via a Strategic Intermural Housestaff Leadership Development Program.

By 2055, the United States will no longer have a single race or ethnic majority. As the nation's demographics change, the field of medicine must also change to meet the needs of diverse patients. In 2013, UT Southwestern Medical Center implemented the Housestaff Emerging Academy of Leaders (HEAL) program, which provides leadership development skills and training to underrepresented in medicine physician residents in preparation for academic medicine careers. Program leaders hypothesized that by providing housestaff with structured mentorship, career coaching, and individualized development plans, HEAL would increase interest in pursuing academic careers and prepare residents for faculty positions. HEAL has since expanded to graduate medical education programs nationwide. From 2013 to 2018, HEAL included housestaff at UT Southwestern and other Texas medical centers, totaling 392 enrollees. In 2019, the program increased to include housestaff from around the country. The first HEAL USA program had 39 housestaff, which increased to 173 in 2019, including 60 faculty from 31 U.S. academic medical centers. The 2019 HEAL USA preassessment survey (32 trainee responses) revealed that 10 (31%) of the housestaff were "extremely interested" in academic medicine, but only 1 (3%) felt "extremely confident" to pursue an academic medicine career. Postassessment responses to these same items (5 trainee responses) were 3 (60%) and 1 (20%), respectively, with 3 (60%) also feeling "extremely prepared" (1 [20%]) or "very prepared" (2 [40%]) to pursue an academic medicine career. Of 70 evaluable participants who attended at least 2 sessions and have graduated from residency, 47 (67%) have attained academic faculty positions, whereas 23 (33%) have pursued positions at nonacademic centers. The next steps for HEAL USA will be continued expansion to additional medical centers and effective delivery of career development and leadership training to encourage participants to pursue academic medical careers.

Predicting Clonal Evolution to Secondary Myeloid Neoplasms in Aplastic Anemia through Machine Learning

Background: One of the major long-term complications in aplastic anemia (AA) is the clonal evolution to secondary myeloid neoplasms (sMNs) such as acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) 1. Hematopoietic stem cell transplantation (HSCT) is largely considered a curative treatment option for AA and is effective at preventing the clonal evolution of sMNs 2. However, patients over 40 years old or those with poor donor options are contraindicated for HSCT due to elevated post-transplant mortality rates 3. When treated with non-transplant strategies, patients with AA have indeed a high risk for acquisition/expansion of somatic myeloid mutations, with some harbingers of future clonal progression to full-blown MDS or AML. Older age, presence of myeloid mutations other than BCOR/L and PIGA at onset, and lack of response to standard immunosuppressive treatment (IST) have been identified as factors predictive for subsequent sMN evolution 4,5,6. If an individual patient's risk of developing a sMN could be assessed through a predictive model that uses information collected at initial AA diagnosis, providers may consider HSCT for traditionally contraindicated patients. However, no such predictive model that could aid in risk assessment currently exists. Methods: In our study, we utilized a large, multi-institutional cohort of patients diagnosed with AA to generate a comprehensive dataset. This dataset contained 76 variables, encompassing relevant clinical and molecular annotations. On this dataset, we trained a machine learning (ML) model to predict patients who would evolve sMNs. Variables with the highest feature impact score (FIS) in predicting clonal evolution to sMN were then chosen to be included in the final ML model, and the algorithm's fitness was calculated using the Leave-One-Out cross-validation method. Variables missing in more than 30% of subjects were imputed using K-Nearest Neighbors (N=20). Of our initial cohort of 455 patients, 213 patients were excluded from the study. 35 patients were excluded because they were treated with HSCT. 39 pediatric cases (defined as &amp;lt;18 years old at the time of diagnosis) were excluded from the study. 91 patients were removed for not receiving specific treatment (IST or HSCT). The remaining 77 patients were excluded due to having a sMN detected at the time of or prior to AA diagnosis, insufficient data, or detection of a germline mutation indicative of an inherited pathophysiology. Our final cohort included a total of 242 acquired AA patients from UT Southwestern Medical Center and Cleveland Clinic. Results: Among our final cohort of 242 patients, 119 (49.2%) were male. The cohort's mean and median ages at AA diagnosis were 53.1 years (SD = 18.9 years) and 58.1 years, respectively. The median follow-up time was 4.04 years. 80 (33.1%) of our patients had a clinically significant PNH clone (defined as &amp;gt;0.001%). 29 patients developed sMNs, with 24 developing MDS and 5 developing AML. Of patients who underwent clonal evolution to sMNs, the median age at the time of AA diagnosis and sMN diagnosis was 63.1 years and 67.2 years, respectively. The median time elapsed from initial AA diagnosis to sMN evolution was 3.78 years. The median time elapsed between initial AA diagnosis and earliest IST administration was 51 days. Chi-squared analysis showed that patients who received ATG treatment were more likely to develop sMNs, with 78.0% of all patients receiving ATG, while 96.6% of patients who developed sMNs had received ATG (p=0.00927). Our ML model achieved a sensitivity of 0.759, a specificity of 0.728, and an AUC of 0.78 using the ten variables with the highest feature impact score (FIS) to predict clonal evolution [Table 1]. All of the variables except for the presence of a PNH clone are positively correlated with sMN evolution. Nine of these variables are supported by existing literature 7,8. The feature with the third highest feature impact score, the time elapsed (days) between diagnosis and IST treatment, has not been established by previous studies and may be an important consideration in establishing optimal AA treatment guidelines. Conclusion: The strategic combination of this ML algorithm with clinical expertise has tremendous potential in improving health outcomes. Identification of patients at high risk for sMN and offering HSCT as a curative option upfront may lead to improved overall survival in AA patients.

Identifying Correlation Among Patient-Reported Outcome Measures: A Study of PROMIS-29, ODI, and VAS in Adult Spinal Deformity Patients

Adult spinal deformity (ASD) is becoming increasingly common in aging populations. Patient-reported outcome measures (PROMs) are self-reported patient surveys administered pre- and postoperatively that provide insight into patient improvement. We aim to compare 3 of the most utilized PROMs: PROMIS-29, Oswestry Disability Index (ODI), and Visual Analogue Scale (VAS), to investigate whether they provide unique and independent assessments of patient outcomes when assessed longitudinally. We retrospectively reviewed a database of ASD at UT Southwestern Medical Center between 2016 and 2021. Adult patients (>18years old) were included if they underwent long-segment (>4 levels) thoracolumbar fusion. PROMIS-29, ODI, and VAS scores were collected preoperatively and at 3-, 6-, 12-, 18-, 24-, 30-, and 36-month follow-ups. Scores were recorded ±1month of the time points. Pearson correlation coefficients for each PROM were then calculated in a pairwise fashion. A total of 163 patients were included in our analysis. ODI and VAS showed significant covariance, with VAS Neck and VAS Back having Pearson coefficients of 0.95 and 0.94, respectively. ODI and PROMIS-29 also showed significant covariance, with Physical Function and ODI showing a Pearson coefficient of 0.95. PROMIS-29 and VAS demonstrated less correlation regarding Pain and Physical Function; however, they showed a significantly high Pearson coefficient when comparing VAS Back with PROMIS-29 Sleep and Pain Intensity (r=0.97 and r=0.96, respectively). All 3 PROMs demonstrated significant correlation over 36months, indicating that simultaneous administration of each during follow-up is redundant. The measure that provided the least unique information was ODI, as both VAS and PROMIS-29 demonstrated similar progression and assessed additional metrics. PROMIS-29 provided the same information as VAS and ODI, with extra facets of patient-reported outcomes, indicating that it may be a more comprehensive measure of longitudinal patient improvement.

Accuracy of incidental visual coronary artery calcium assessment compared with dedicated coronary artery calcium scoring

IntroductionCAC can be detected on routine chest computed tomography (CT) scans and may contribute to CVD risk estimation, but the accuracy of visual CAC scoring may be affected by the specialty of the interpreting radiologist and/or the use of contrast. MethodsThe accuracy of visual CAC estimation on non-gated CT scans was evaluated at UT Southwestern Medical Center (UTSW) and Parkland Health and Hospital System (PHHS). All adults who underwent CAC scanning and a non-gated CT scan within 6 months were identified and the scores from the two CTs were compared overall and stratified by type of reader and whether contrast was used. Visual CAC categories of none, small, moderate, and large were compared to CAC ​= ​0, 1–99, 100–399, and ≥400, respectively. ResultsFrom 2016 to 2021, 934 patients (mean age 60 ​± ​12 ​y, 43% male, 61% White, 34% Black, 24% Hispanic, 54% from PHHS) had both CT scans. Of these, 441 (47%) had no CAC, 278 (30%) small, 147 (16%) moderate, and 66 (7%) large CAC on non-gated CT. Visual CAC estimates were highly correlated with CAC scores (Kendalls tau-b ​= ​0.76, p ​< ​0.0001). Among those with no visual CAC, 76% had CAC ​= ​0 (72% of contrast-enhanced vs 85% of non-contrast scans, 88% of scans interpreted by CT radiologist vs 78% of those interpreted by other radiologist). In those with moderate-to-large visual CAC, 99% had CAC >0 and 88% had CAC ≥100, including 89% of those with contrast, 90% of those without contrast, 80% of those read by a CT radiologist, and 88% of those read by a non-CT radiologist. DiscussionVisual CAC estimates on non-gated CT scans are concordant with Agatston score categories from cardiac CT scans. A lack of visual CAC on non-gated CT scans may not be sufficient to “de-risk” patients, particularly for contrast-enhanced scans and those read by non-CT radiologists. However, the presence of moderate-to-large CAC, including on contrasted scans and regardless of radiologist type, is highly predictive of CAC and may be used to identify high-risk patients for prevention interventions.

Elevated risk of dyspnea in adults with obesity

We investigated whether older adults (OA) with obesity are more likely to have dyspnea compared with OA without obesity, and whether OA with obesity are at a greater risk of having dyspnea compared with middle-aged (MA) and younger adults (YA) with obesity. We obtained de-identified data from the TriNetX UT Southwestern Medical Center database. We identified obesity and dyspnea using ICD-10-CM codes E66 and R06.0, respectively. Patients were separated into three age groups: OA, (65–75 y.o.), MA (45–55 y.o.), and YA (25–35 y.o). Within these groups, those with and without obesity or dyspnea were identified for analysis. The risk of dyspnea was greater in OA (risk ratio: 3.64), MA (risk ratio: 3.52), and YA (risk ratio: 2.76) with obesity compared with age-matched patients without obesity (all p < 0.01). The risk of dyspnea was greater in OA and MA with obesity compared with YA with obesity (both p < 0.001 vs. YA). These findings suggest that clinicians should consider obesity as an independent risk factor for dyspnea.

MRI-Based Deep Learning Method for Classification of IDH Mutation Status.

Isocitrate dehydrogenase (IDH) mutation status has emerged as an important prognostic marker in gliomas. This study sought to develop deep learning networks for non-invasive IDH classification using T2w MR images while comparing their performance to a multi-contrast network. Methods: Multi-contrast brain tumor MRI and genomic data were obtained from The Cancer Imaging Archive (TCIA) and The Erasmus Glioma Database (EGD). Two separate 2D networks were developed using nnU-Net, a T2w-image-only network (T2-net) and a multi-contrast network (MC-net). Each network was separately trained using TCIA (227 subjects) or TCIA + EGD data (683 subjects combined). The networks were trained to classify IDH mutation status and implement single-label tumor segmentation simultaneously. The trained networks were tested on over 1100 held-out datasets including 360 cases from UT Southwestern Medical Center, 136 cases from New York University, 175 cases from the University of Wisconsin-Madison, 456 cases from EGD (for the TCIA-trained network), and 495 cases from the University of California, San Francisco public database. A receiver operating characteristic curve (ROC) was drawn to calculate the AUC value to determine classifier performance. Results: T2-net trained on TCIA and TCIA + EGD datasets achieved an overall accuracy of 85.4% and 87.6% with AUCs of 0.86 and 0.89, respectively. MC-net trained on TCIA and TCIA + EGD datasets achieved an overall accuracy of 91.0% and 92.8% with AUCs of 0.94 and 0.96, respectively. We developed reliable, high-performing deep learning algorithms for IDH classification using both a T2-image-only and a multi-contrast approach. The networks were tested on more than 1100 subjects from diverse databases, making this the largest study on image-based IDH classification to date.

Abstract IA009: Development of HIF2 inhibitors: Bench to bedside and back

Abstract Arguably the most important driver of clear cell renal cell carcinoma (ccRCC), HIF2a was traditionally regarded as undruggable. However, structural analyses at UT Southwestern Medical Center found a vulnerability leading to the identification of small molecule inhibitors, and eventually the development of highly related PT drugs by Peloton Therapeutics (PT2385 and PT2977, also called belzutifan). PT drugs bind to HIF2a and induce a conformational change that triggers its dissociation from HIF1b, thereby inhibiting DNA binding and gene transactivation. PT drugs have shown activity in patients, but resistance develops over time. Resistance mutations have been identified, initially in preclinical models, and subsequently in patients. This has spurred the development of second-generation inhibitors, including siRNA-based therapeutics. Recently, we reported a tumor-directed HIF2a-targeting siRNA drug (siHIF2) developed by Arrowhead Pharmaceuticals that effectively depleted both wild-type and mutant HIF2a. siHIF2 showed activity against ccRCC in preclinical models and in patients. Overall, these studies establish HIF2a as a core dependency and therapeutic target, and set a paradigm for tumor-directed RNA-based therapeutics in cancer. Citation Format: James Brugarolas. Development of HIF2 inhibitors: Bench to bedside and back [abstract]. In: Proceedings of the AACR Special Conference: Advances in Kidney Cancer Research; 2023 Jun 24-27; Austin, Texas. Philadelphia (PA): AACR; Cancer Res 2023;83(16 Suppl):Abstract nr IA009.

Life-threatening hemoptysis in patients with metastatic kidney cancer.

Hemoptysis is a complication of intrathoracic tumors, both primary and metastatic, and the risk may be increased by procedural interventions as well as Stereotactic Ablative Radiation (SAbR). The risk of hemoptysis with SAbR for lung cancer is well characterized, but there is a paucity of data about intrathoracic metastases. Here, we sought to evaluate the incidence of life-threatening/fatal hemoptysis (LTH) in patients with renal cell carcinoma (RCC) chest metastases with a focus on SAbR. We systematically evaluated patients with RCC at UT Southwestern Medical Center (UTSW) Kidney Cancer Program (KCP) from July 2005 to March 2020. We queried Kidney Cancer Explorer (KCE), a data portal with clinical, pathological, and experimental genomic data. Patients were included in the study based on mention of "hemoptysis" in clinical documentation, if they had a previous bronchoscopy, or had undergone SAbR to any site within the chest. Two hundred and thirty four patients met query criteria and their records were individually reviewed. We identified 10 patients who developed LTH. Of these, 4 had LTH as an immediate procedural complication whilst the remaining 6 had prior SAbR to ultra-central (UC; abutting the central bronchial tree) metastases. These 6 patients had a total of 10 lung lesions irradiated (UC, 8; central 1, peripheral 1), with a median total cumulative SAbR dose of 38 Gray (Gy/ lesion) (range: 25-50 Gy). Other risk factors included intrathoracic disease progression (n=4, 67%), concurrent anticoagulant therapy (n=1, 17%) and concurrent systemic therapy (n=4, 67%). Median time to LTH from first SAbR was 26 months (range: 8-61 months). Considering that 130 patients received SAbR to a chest lesion during the study period, the overall incidence of LTH following SAbR was 4.6% (6/130). The patient population that received SAbR (n=130) was at particularly high risk for complications, with 67 (52%) having two or more chest metastaes treated, and 29 (22%) receiving SAbR to three or more lesions. Overall, the risk of LTH following SAbR to a central or UC lesion was 10.5% (6/57). In conclusion, SAbR of RCC metastases located near the central bronchial tree may increase the risk of LTH.

ChatGPT Not Yet Ready for Clinical Practice

Back to table of contents Previous article Next article ViewpointsFull AccessChatGPT Not Yet Ready for Clinical PracticeDarlene King, M.D.Darlene KingSearch for more papers by this author, M.D.Published Online:16 Jun 2023https://doi.org/10.1176/appi.pn.2023.07.7.56AbstractChatGPT is the fastest growing app in the world, surpassing 1 million users five days after launch, according to DemandSage. The website has been visited over 1 billion times in the last month. It can write poetry, essays, summaries, and more. When it comes to technology, we want it to help more than harm, but sometimes new technologies are rapidly adopted, and it isn’t until later that we learn the ramifications. We see this with social media platforms that we now know are addictive and associated with anxiety, depression, and even physical ailments.Psychiatrists are already saying that ChatGPT has the potential to be a valuable tool in psychiatric practice and that students should use it to enhance clinical acumen and increase their skill at integrating technology into patient care. While I agree that ChatGPT is a revolutionary tool with remarkable potential, there are several important concerns to address before utilizing ChatGPT for psychiatric practice.First, let’s consider the sources and quality of information that ChatGPT uses to generate its answers. The large language models underlying ChatGPT are pre-trained with text—16% of the text comes from books and news articles, and 84% comes from webpages. The webpage data include high-quality text such as Wikipedia but also low-quality text like spam mail and Reddit, according to a paper by Wayne Xin Zhao and colleagues published in May in arXiv, a Cornell University publication. Knowing the source of information provides insight into not only the accuracy of the information but also what biases may exist. Bias can originate from data sets and become magnified through the machine learning development pipeline, leading to bias-related harms. For example, false news and racist viewpoints are often shared on Reddit. Another way to think of ChatGPT is as a user interface that packages internet information that existed before 2021. While these sources can be accurate at times, there are more reliable and high-quality resources for students to access. Taking excerpts from a reliable text and asking ChatGPT to summarize it may be a way around this limitation.Second, let’s consider privacy violations. The OpenAI privacy policy states that it collects all conversation history and that data collected trains the algorithm, which users may opt out of. Personal identifiers, commercial information, network activity information, geolocation data, and account login credentials may be disclosed to “affiliates, vendors and service providers, law enforcement, and parties involved in Transactions.” Given this privacy policy, it is ill advised to use ChatGPT to assist with patient documentation or the handling of patient information until safeguards for health care data are in place.Finally, it is difficult to say who is accountable for what and to whom under which circumstances. In computerized systems, “bugs” or accuracy ranges can divert accountability and chalk up an error to just falling within the margin of error. The problem with this is that sometimes the margin of error is a result of human-made decisions along the machine learning pipeline that could be better optimized, blurring accountability, according to a paper by A. Feder Cooper et al. published in arXiv in May. A lack of transparency in chosen models, data sources, and training methods further obscures the picture. Additionally, there is room for influencing decision-making when an algorithm decides which information to present or exclude.Ultimately, while this technology has amazing potential in psychiatry, these mainstream, large language models are not built with adequate sources, privacy protections, or robust enough models to prevent unforeseen harm. Regulation may help increase transparency, accuracy, accountability, and privacy. Striking a balance between innovation and regulation is needed if we want to enjoy this technology and limit the harm. When that day comes, I will sing its praises!An opposing viewpoint to this article is posted here. ■ResourcesChatGPT statistics for 2023“A Survey of Large Language Models”The OpenAI privacy policy“Accountability in an Algorithmic Society: Relationality, Responsibility, and Robustness in Machine Learning”Darlene King, M.D., is an assistant professor in the Department of Psychiatry at UT Southwestern Medical Center, deputy medical information officer at Parkland Health, and the chair of APA’s Committee on Mental Health Information Technology. She graduated from the University of Texas at Austin with a degree in mechanical engineering prior to attending medical school and residency at UT Southwestern. ISSUES NewArchived

SARS-CoV-2 Vaccination IgG Antibody Responses in Patients with Hematologic Malignancies in a Myeloid Enriched Cohort: A Single Center Observation.

Patients diagnosed with hematologic malignancies are at increased risk for severe SARS-CoV-2 infection. We evaluated the serological IgG response following two doses of the SARS-CoV-2 vaccine in patients with hematologic malignancies. Patients treated at UT Southwestern Medical Center with a diagnosis of a myeloid or lymphoid neoplasm were included. SARS-CoV-2 vaccination response was defined as a positive quantifiable spike IgG antibody titer. Sixty patients were included in the study and 60% were diagnosed with a myeloid neoplasm. The majority (85%) of the patients with a myeloid malignancy and 50% of the patients with a lymphoid malignancy mounted a serological response after receiving two doses of the vaccine. Vaccination should be offered irrespective of ongoing treatment or active disease. Findings require validation in a larger cohort of patients.

Immunotherapy-related toxicities: A retrospective analysis of barriers to prompt detection and initiation of treatment in renal cell carcinoma.

e16547 Background: In 2021, there was an estimated 76,000 patients diagnosed with kidney cancer in the United States, and 90% of these patients were diagnosed with renal cell carcinoma (RCC). The current treatment for RCC is the use of immune checkpoint inhibitors (ICIs), which allow the body to naturally fight against cancer cells without impedance. A common side effect of this therapy, however, is immunotherapy-related adverse events (irAE), which are toxicities where the bodies overactive immune system attacks noncancerous organs. When irAEs arise, the patient’s immunotherapy is stopped, and a steroid regiment is begun to dampen the immune system before re-starting immunotherapy. Time is crucial when treating irAEs, and this study is aimed to identify barriers in the onset of steroid treatment and identify interventions that can help providers and patients identify toxicities and begin steroid treatment as soon as possible. Methods: We conducted a retrospective study analyzing adult patients (ages 18-75) being treated for RCC at UT Southwestern Medical Center and Moncrief Cancer Institute (MCI). We specifically looked at patients being treated with ipilimumab, nivolumab, and pembrolizumab. The first portion included a chart review to identify patients and identify barriers to prompt treatment, i.e. fear of worsening hyperglycemia in diabetics, access to healthcare, delay of re-initiating immunotherapy. The second portion of this study will be to identify and test a possible intervention for these patients to ensure timely recognition of toxicities and prompt initiation of steroids. Results: Upon review of 201 patients with RCC stage III/IV, the most common toxicity found was colitis (28.4%), followed by transaminitis (9.0%) and pneumonitis (9.0%). The most common method for identification of toxicities was routine lab work performed before immunotherapy administration (30.4%), check-ins at regularly scheduled appointments (21.7%), and after-hour physician telephone lines (19.6%). Additionally, the average time from irAE identification to steroid administration was 1.45 days. Excluding toxicities found either at office appointments or on routine lab work, the average time to steroids from identification was 3.55 days. Our data collection also demonstrated that routine labs were the most likely factor to identify immunotherapy toxicity in a timely manner. Conclusions: Continuation of current practices can lead to further decreases in time to steroid treatment. This study can be used as a blueprint and expanded to further investigate irAEs in other solid tumors as well as contribute to management of the ever-evolving immunotherapy landscape.

COVID-19 Is No Longer a Public Health Emergency: Implications for Patients and Clinicians

COVID-19 Is No Longer a Public Health Emergency: Implications for Patients and Clinicians

Reasons and predictors for early termination of pediatric polysomnography: one children's hospital's experience.

We sought to identify reasons for early polysomnography termination in pediatric patients. We retrospectively reviewed all studies conducted at the Pediatric Sleep Center at UT Southwestern Medical Center from January 1, 2017, through December 31, 2019, that were terminated before study completion. We investigated reasons for early termination and gathered characteristics such as age, sex, presence of neurocognitive impairment, payor status, seasonal variability, and testing site location. There were 137 patients who terminated their studies before completion, comprising 1.05% of all patients who arrived for their scheduled polysomnographies during that time frame. The 3 main categories of reasons were equipment intolerance (47%), acute illness (33%), and parental refusal (20%). Parental refusal reasons included the patient's becoming combative, a lack of specialized equipment, patient's inability to fall asleep, forgetting the patient's nighttime medications, and the parent's inability to stay the night. Males represented a greater proportion of those who terminated due to intolerance of equipment (75%). Patients who terminated early due to equipment intolerance consisted of more neurologically impaired patients compared with those who terminated due to acute illness (56% vs 24%). Termination due to acute illness occurred more during the wintertime (44%) than in the summer (7%). In those who terminated due to parental refusal, there was a greater proportion of children under 6 years of age (75%). Determining factors that are associated with early polysomnography termination is an important step to help identify at-risk groups and implement strategies to improve study completion. Luong S, Culp M, McCreary M, Wani A, Caraballo M. Reasons and predictors for early termination of pediatric polysomnography: one children's hospital's experience. J Clin Sleep Med. 2023;19(10):1711-1716.

RORγt-Raftlin1 complex regulates the pathogenicity of Th17 cells and intestinal inflammation.

Abstract Th17 cells that produce IL-17 are pathogenic in many human diseases, including inflammatory bowel disease (IBD), but are, paradoxically, essential for maintaining the integrity of the intestinal barrier in a non-inflammatory state. However, the intracellular mechanisms that regulate distinct transcriptional profiles and functional diversity of Th17 cells remain unclear. We have found that Raftlin1, a lipid raft protein, is specifically upregulated in and forms a complex with RORγt via its conserved LLNSL motif in pathogenic Th17 cells. Disruption of the RORγt-Raftlin1 complex in Raftlin1 ΔLLNSLknock-in mice resulted in attenuated pathogenic Th17 cells elicited by Citrobacter rodentium; however, there was no effect on nonpathogenic Th17 cells induced by commensal segmented filamentous bacteria (SFB). Mechanistically, we found that Raftlin1 recruits distinct phospholipids to RORγt and promotes the pathogenicity of Th17 cells. Thus, we have identified a fundamental mechanism that drives the pathogenic function of Th17 cells, which could provide a platform for new therapeutic strategies to dampen Th17-mediated inflammatory diseases. This work was supported by funds from the National Institutes of Health (R01-DK115668, R01-AI155786) and Cancer Prevention Research Institute of Texas (RP190527) and a stimulus grant from the Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center.

Pak2-mediated phosphorylation promotes RORγt ubiquitination and inhibits colonic inflammation

Abstract Dysregulated Interleukin (IL)-17 expression and its downstream signaling is strongly linked to inflammatory bowel diseases (IBD). However, the molecular mechanisms by which the function of RORγt, the transcription factor of IL-17, is regulated remains elusive, which is absolutely necessary to develop advanced strategies to inhibit IL-17-mediated inflammation. By mass spectrometry-based approach, we have identified that Pak2, a Ser/Thr kinase, directly associates with RORγt. Pak2 recognizes a conserved KRLS motif within RORγt and phosphorylated the Serine (S) 316 within this motif. Genetic deletion of Pak2 in Th17 cells resulted in reduced RORγt phosphorylation, increased IL-17 expression and severe colitis upon adoptive transfer to Rag1 −/−mice. Similarly, reconstitution of RORγt-S316A mutant in Rorc −/−Th17 cells resulted in enhanced IL-17 expression and colitis severity. Mechanistically, we demonstrate that Pak2-mediated phosphorylation causes a conformational change resulting in exposure of the ubiquitin ligase Itch interacting PPLY motif and degradation of RORγt. Thus, we have uncovered a novel mechanism by which the activity of RORγt is regulated that can be exploited therapeutically. This work was supported by funds from the National Institutes of Health (R01-DK115668 and R01-AI155786) and Cancer Prevention Research Institute of Texas (RP160577 and RP190527), a translational pilot project grant from the Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center (23001045) to K.V., and R01-DK117001 to K.V. and A.L.T.

Fitness Training-Associated Vertebral Artery Dissection.

1Division of Cerebrovascular Disease, Department of Neurology, ECU Health Medical Center, Greenville, NC 2Division of Cerebrovascular Disease, Department of Neurology, UT Southwestern Medical Center, Dallas, TX Address for correspondence: Nurose Karim, MD, 1910 Stonehenge Drive Apartment 23, Greenville, NC 27858; E-mail: [email protected].