Clearing the backlog of mildly interesting articles that will never get a full write-up – here’s a quick hit of the most interesting lucky 13!
“Lactated Ringer vs Normal Saline Solution During Sickle Cell Vaso-Occlusive Episodes”
A “target trial emulation” providing observational evidence supporting the superiority of lactated ringers solution over normal saline for the resuscitation of patients being admitted with sickle cell crises. However, only a small fraction of patients actually received LR, and those who did received smaller amounts overall. Frankly, it’s hard to separate these observations from the general concern euvolemic SCD patients are simply receiving far too much fluid during admission.
https://pubmed.ncbi.nlm.nih.gov/39250114/
“Empathy and clarity in GPT-4-Generated Emergency Department Discharge Letters”
The cold, unfeeling computer generates better feels than emergency clinicians. Bland treacle, no doubt, but generic bland treacle will beat the terse output of a distracted human any day. The question now is how to combine the two to create a better human, where suitable.
https://www.medrxiv.org/content/10.1101/2024.10.07.24315034v1
“Mitigating Hallucinations in Large Language Models: A Comparative Study of RAG- enhanced vs. Human-Generated Medical Templates”
Study number n-million demonstrating retrieval-augmented generation – that is to say, using a relatively sophisticated series of prompts to an LLM – improves output and reduces “hallucinations”. In this specific instance, the LLM was effectively mimicking the output of BMJ Best Practice templates.
https://www.medrxiv.org/content/10.1101/2024.09.27.24314506v1
“Towards Democratization of Subspeciality Medical Expertise”
This is one of the AIME demonstration projects, a Google Deepmind output in which an additional layer of “conversational” training has been superimposed upon the underlying model to improve response to consultation-style questions. In this example, the conversational training is tuned to match the response style of genetic cardiology specialists from Stanford University – and the LLM content and style was arguably rated identically to the human specialists.
https://arxiv.org/abs/2410.03741
“The Limits of Clinician Vigilance as an AI Safety Bulwark”
A nice little commentary effectively articulating the elephant in the room: humans are terrible at “vigilance”. The present state of AI/LLM deployment in clinical medicine is replete with omissions and inaccuracies, and it’s not reasonable to simply trust clinicians to catch the mistakes. That said, the five suggested strategies to address vigilance seem … precarious.
https://jamanetwork.com/journals/jama/fullarticle/2816582
“Reviewer Experience Detecting and Judging Human Versus Artificial Intelligence Content: The Stroke Journal Essay Contest”
Who wins an essay competition on controversial topics in stroke and neurology – humans or LLMs? And can reviewers accurately guess which essays are human- versus LLM-generated? The answer, rather distressingly, is that reviewers mostly couldn’t distinguish between author types, and LLM composition quality was arguably higher than human.
https://pubmed.ncbi.nlm.nih.gov/39224979/
“Invasive Treatment Strategy for Older Patients with Myocardial Infarction”
The amusingly named “SENIOR-RITA” trial in which elderly patients with NSTEMI were randomized to an invasive strategy versus a medical management strategy. While this may seem odd to those in the U.S., frailty and baseline life-expectancy are typical considerations for acute care in other countries. In these frail elderly, invasive strategies reduce downstream non-fatal MI, but had no effect on cardiovascular death or the overall composite outcome.
https://pubmed.ncbi.nlm.nih.gov/39225274/
“Thrombolysis After Dabigatran Reversal for Acute Ischemic Stroke: A National Registry-Based Study and Meta-Analysis”
Just another bit from our neurology colleagues patting themselves on the back for doing backflips in order to give everyone thrombolysis. Registry data paired with a garbage-in-garbage-out systematic review and meta-analysis just amplifies the biases prevalent in the underlying practice culture.
https://pubmed.ncbi.nlm.nih.gov/39255429/
“Tenecteplase vs Alteplase for Patients With Acute Ischemic Stroke: The ORIGINAL Randomized Clinical Trial”
This trial makes a claim to be ORIGINAL, but at this point – there’s really no general question remaining whether tenecteplase is a valid alternative to alteplase. It is reasonable to test specific doses in various populations with a goal of minimizing harms, of course.
https://pubmed.ncbi.nlm.nih.gov/39264623/
“Technology-Supported Self-Triage Decision Making: A Mixed-Methods Study”
Can laypersons improve their self-triage decision-making with use of technology? This little preprint tests the Ada Health “symptom checker” app against interaction with a ChatGPT LLM and favors use of the symptom checker. Not hardly rigorous enough to discard the chatbot as a possible tool, but certainly the LLM needs more prompt engineering and/or domain-specific training than just “out of the box”.
https://www.medrxiv.org/content/10.1101/2024.09.12.24313558v1
“Class I Recalls of Cardiovascular Devices Between 2013 and 2022 : A Cross-Sectional Analysis”
A brief report looking at recalled cardiovascular devices is insufficient to make any broad conclusions, but certainly demonstrates the regulatory bar for approval is inadequate. Most did not require pre-market clinical testing, and those that did used surrogate or composite endpoints to support approval.
https://pubmed.ncbi.nlm.nih.gov/39284187/
“Effectiveness of Direct Admission Compared to Admission Through the Emergency Department: A Stepped-Wedge Cluster-Randomized Trial”
A bit of an odd question whether a patient with known requirement for admission needs to stop through the emergency department, or whether the patient can go straight to the ward. Unless a patient requires immediate resuscitation with the resources of an ED, it is very clearly appropriate for a patient to be directly admitted. That said, doing so requires new processes and practices – and this trial demonstrates such processes are feasible and safe (and almost certainly cheaper to avoid ED billing!)
https://pubmed.ncbi.nlm.nih.gov/39301600/
“Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury: The TRAIN Randomized Clinical Trial”
The optimal cut-off is not known, but in this trial, the threshold for transfusion was 9g/dL – and patients randomized to the liberal transfusion strategy did better. An injured brain does not like hypotension and it does not like anemia.
https://pubmed.ncbi.nlm.nih.gov/39382241/