AgentMD: Empowering language agents for risk prediction with large-scale clinical tool learning

ObjectiveTo outline current knowledge regarding workplace-based learning about health promotion in individual patient care.DesignScoping review.Data sourcesPubMed, ERIC, CINAHL and Web of Science from January 2000 to August 2023.Eligibility criteriaWe included...

Despite recent increased clinical trials activity, no regimen has proved able to replace the standard 6-month regimen for drug-sensitive tuberculosis. Understanding the relationship between microbiological markers measured during treatment and long-term clinical outcomes is critical to evaluate their usefulness for decision-making for both individual patient care and for advancing novel regimens into time-consuming and expensive pivotal phase III trials. Using data from the randomized controlled phase III trial REMoxTB, we evaluated sputum-based markers of speed of clearance of bacilli: time to smear negative status; time to culture negative status on LJ or in MGIT; daily rate of change of log10(TTP) to day 56; and smear or culture results at weeks 6, 8 or 12; as individual- and trial-level surrogate endpoints for long-term clinical outcome. Time to culture negative status on LJ or in MGIT, time to smear negative status and daily rate of change in log10(TTP) were each independent predictors of clinical outcome, adjusted for treatment (p <0.001). However, discrimination between low and high risk patients, as measured by the c-statistic, was modest and not much higher than the reference model adjusted for BMI, history of smoking, HIV status, cavitation, gender and MGIT TTP. Culture conversion during treatment for tuberculosis, however measured, has only a limited role in decision-making for advancing regimens into phase III trials or in predicting the outcome of treatment for individual patients. REMoxTB ClinicalTrials.gov number: NCT00864383.

New technologies are constantly being introduced in radiation oncology primarily because they are new and not because they are clearly better than the technologies they are replacing. Often there is a “belief” that the new technology “ought” to be better but many believe that they should be widely adopted in the clinic only after evidence has shown that they are at least as safe and efficacious as existing technologies, which are often less expensive. This is the concern debated in this month's Point/Counterpoint. Arguing for the Proposition is Christopher Njeh, Ph.D. Dr. Njeh obtained his Ph.D. degree in Medical Physics from Sheffield Hallam University, UK, and, after graduation, he worked at the Addenbrooke's Hospital in Cambridge and Queen Elizabeth's Hospital, Birmingham, UK. He then came to the United States as a Visiting Postdoctoral Fellow at the University of California, San Francisco, where he was subsequently appointed as an Assistant Professor of Radiology. He later completed a Medical Physics residency at Johns Hopkins University, Baltimore, and is currently Chief Medical Physicist at Texas Oncology in Tyler, TX, and holds an adjunct faculty position at the University of Texas at Tyler. Dr. Njeh is certified in Therapeutic Radiologic Physics by the ABR. His major research interests include image-guided radiation therapy and accelerated partial breast irradiation. He is author or coauthor of over 50 papers and 10 book chapters and is coeditor of two books. Arguing against the Proposition is Dr. Christian McDonald Langton. Dr. Langton obtained his M.Sc. degree in Medical Physics from the University of Aberdeen and his doctoral degrees from the University of Hull. After working in industry for two years, he returned to academia in the UK and ultimately attained the rank of Professor of Medical Physics at the University of Hull. In 2008, Dr. Langton was appointed Professor of Medical Physics at Queensland University of Technology in Brisbane, Australia, and Director of the Queensland Cancer Physics Collaborative. Dr. Langton's main research interest has been in quantitative bone imaging and characterization, and his work on the science, technology, and clinical utility of ultrasound assessment of cancellous bone and osteoporosis has resulted in over 1800 publication citations. He holds several related patents and there are seven commercial devices currently available adopting his broadband ultrasonic attenuation technique, with over 12 000 systems utilized worldwide. Medical technology encompasses all drugs, devices, and medical and surgical procedures used in medical care as well as the organizational supportive systems within which such care is provided.1 Radiation oncology has recently witnessed an explosion in innovation including but not limited to: proton therapy, CyberKnife, tomotherapy, IGRT, and IMRT. Efficacy, safety, and cost effectiveness, however, remains the focus in the provision of optimal care to patients. While some of these innovations offer unprecedented breakthroughs for some patients, they have the potential to also result in unintended harm if not used appropriately. It is, therefore, essential that adoption of these new technologies be evidence based. Evidence-based medicine can be perceived as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”2 Its practice presupposes the integration of individual clinical expertise with the best available external clinical evidence from systematic collection and synthesis of data, including patients’ values and expectations.3 The gold standard for the attainment of level 1 evidence is usually through randomized controlled trials (RCTs) and meta-analysis of such trials. There are many reported instances in the scientific literature where RCTs refuted evidence from theoretical, observational, physiologic studies or common sense. In the 1890s, Dr. William Halsted, for instance, developed radical mastectomy for breast cancer. His procedure was performed unchallenged for over 80 years. It was, however, not until an RCT was conducted in the late 1980s that it dawned upon the scientific community that radical mastectomy had no advantage over simpler forms of treatment for early-stage breast cancer.4 Another more recent example is vascular brachytherapy that was used to treat in-stent restenosis until an RCT showed that this therapy yielded comparatively inferior outcomes to polymer-based slow-release paclitaxel-eluting stents.5 Opponents of RCTs may be surprised to learn that not all new therapies amount to an improvement compared to the standard of therapy. For example, an analysis of outcome data from 58 RCTs, including a total of 12734 patients, conducted between 1968 and 2002 by the Radiation Therapy Oncology Group, found that, overall, experimental and standard arms were equally successful.6 They also found that treatment-related mortality and morbidity were, on average, higher in the innovative arm. In contemplating these facts, we are reminded of the economist who once said “…man's wants are numerous but his means are limited.” His view is applicable to national health care. Were one to place the cost of new technology into proper context it would be safe to assert that U.S. health care costs have risen faster than the gross domestic product (GDP), often by a substantial margin. While in 1960 approximately 5% of the GDP of the United States was spent on medical care,1 by 2004 it accounted for over 15% and is expected to be as much as 20% of GDP by 2015.7 According to a landmark study by The Kaiser Family Foundation,8 new technology has been identified as one of the causes of this exponential rise in health care cost. I submit, therefore, that new technology needs to fulfill the triple condition of efficacy, safety, and cost-effectiveness so that our limited resources can be put to the most judicious use. Evidence-based medicine is commonly defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”9 These are admirable words, but what do they really mean? Are they a realistic aspiration for adoption of new technologies in radiation oncology? A key factor is the validity of the evidence, so variable in reality that a number of category levels are widely utilized. For example, the U.S. Preventative Services Task Force10 lists three levels of “quality of evidence,” the highest level being “evidence obtained from at least one properly designed randomized controlled trial.” For the laudable randomized clinical trial, there has been a dramatic expansion in the number of publications associated with “radiation oncology” alone. Considering “Web of Science” publications per year using the topic search category of (“RCT” or “randomized clinical trial” or “randomized control trial”) and (“radiation oncology” or “radiotherapy”) yields: 1989 = 2, 1994 = 32, 1999 = 55, 2004 = 107, and 2009 = 228. How do we arrive at a consensus based upon such a wealth of information? Will a comparison be made against an untarnished “gold standard” or with current practice? The latter will inevitably necessitate large cohort numbers in each study arm, often impracticable from a recruitment perspective. Is there potential for a high attrition rate? Will it be difficult to assign and maintain inclusion and exclusion criteria? Will it be difficult to avoid bias? Very few cases are truly “equivalent.” Noting the understandable need to maintain a primary focus on patient welfare, as circumstances potentially change, will it be difficult to maintain a rigid protocol? Will the protocol be readily and reliably transferable multicenter and multinational? How long will it be before the technique could be routinely adopted? Technology developments appear at a fast time rate and may evolve during the course of an RCT such that they are used differently at the end of a trial than at the beginning and might even become outdated before the trial is over. How important are factors such as quality of life and secondary cancer risk? Other criticisms of adopting “evidence-based medicine” include stagnation, bland uniformity, and lowering of standards through deskilling practitioners. Instead of using clinical judgment, they will be encouraged to follow protocols that treat all patients as essentially interchangeable.9 There is also a threat to the adoption of new techniques in radiation oncology through a growing movement of “lack-of-evidence based medicine” that has been used to restrict access to a number of therapies,11 particularly by the UK's National Institute of Clinical Excellence. Perhaps the hottest “new technology in radiation oncology” debate relates to proton verses photon IMRT, with a question raised as to whether large randomized phase III comparative trials should be performed?; that would inherently encompass a significant number of scientific and ethical issues11,12 — I will end with that thought! The sheer volume of information available in the literature is more reason for a unified and systematic approach to synthesize them. Recruitment bias can be avoided by proper randomization.13 EBM makes decision making more thoughtful and more transparent, providing a stronger scientific backbone to medical practice. Not all studies are carried out with the same degree of rigor (quality, quantity, and consistency) hence a need to grade the quality of the research such as required by SORT,14 GRADE,15 or the Center for Evidence Based Medicine. The FDA is not thorough enough in its technology approval process. Recent studies have shown that the FDA premarket approval process is often based on weak studies.16 Ethical dilemmas in RCTs are eliminated by the acknowledgement of the equipoise principle which assumes that the two arms in a study have an equal chance of performing well.17 This principle has been validated by the fact that only 25%–50% of new technology is better than traditional technology.18 Another issue with pursuing RCTs has to do with the vested interests of three players if the RCT proves that the procedure is ineffective: the physician (new technology is accompanied by higher reimbursement), the hospital (need to pay for the equipment), and the manufacturer (need to make a profit).19 In conclusion, obtaining the relevant high quality evidence is a challenging, demanding, time-consuming, and costly pursuit. Nevertheless, it is a rigorous process, which we must demand of new technology so as to remain accountable to our patients. Having carefully considered my opponent's Opening Statement, I am confident that the arguments provided within my own Opening Statement remain valid and wholly intact. There are two primary components of my opposition to the proposition. First, it is impossible in reality to acquire irrefutable evidence as to whether a “new technology” will indeed improve individual patient care. Second, it is impossible to create a single unifying consensus based upon reported data. Allied to this, there has been a dramatic increase in the number of evidence-based medicine derived “clinical guidelines,” so much so that there has been a call for “guidelines for clinical guidelines” within a British Medical Journal Editorial.20 A fundamental question that we must address is whether so-called “evidence-based medicine” serves its purpose of helping clinicians make better decisions for the individual patient; related not only to the primary factors of diagnosis and treatment, but also encompassing prognosis, benefit, risk, and cost. Continuing this somewhat broader perspective, I wish to consider another component of the proposition's title, specifically, what do we really mean by “new technology in radiation oncology”? Are many so-called “new technologies” simply part of a fundamentally evolutionary advancement process? Noting the age-old tenet of “maximally treating the cancer by maximally sparing normal tissue,” are we in danger of being distracted away from aspects of radiation oncology that are of greater importance from an individual patient's perspective? For example, are we in need of true “new technologies” that better target regions of a particular tumor or organ that require, or maybe do not require, “treatment;” and to determine how these relate to both static and temporal anatomy? In summary, while appreciating the ideological paradigm that “the adoption of new technology in radiation oncology should rely on evidence-based medicine,” in reality, this cannot be achieved and we should concentrate on the primary role of helping clinicians make better decisions for the individual patient.

We use changes in tumor measurements to assess response and progression, both in routine care and as the primary objective of clinical trials. However, the variability of computed tomography (CT) -based tumor measurement has not been comprehensively evaluated. In this study, we assess the variability of lung tumor measurement using repeat CT scans performed within 15 minutes of each other and discuss the implications of this variability in a clinical context. Patients with non-small-cell lung cancer and a target lung lesion ≥ 1 cm consented to undergo two CT scans within a period of minutes. Three experienced radiologists measured the diameter of the target lesion on the two scans in a side-by-side fashion, and differences were compared. Fifty-seven percent of changes exceeded 1 mm in magnitude, and 33% of changes exceeded 2 mm. Median increase and decrease in tumor measurements were +4.3% and -4.2%, respectively, and ranged from 23% shrinkage to 31% growth. Measurement changes were within ± 10% for 84% of measurements, whereas 3% met criteria for progression according to Response Evaluation Criteria in Solid Tumors (RECIST; ≥ 20% increase). Smaller lesions had greater variability of percent measurement change (P = .005). Apparent changes in tumor diameter exceeding 1 to 2 mm are common on immediate reimaging. Increases and decreases less than 10% can be a result of the inherent variability of reimaging. Caution should be exercised in interpreting the significance of small changes in lesion size in the care of individual patients and in the interpretation of clinical trial results.

Risk management is a constantly recommended practice by boards of directors and for corporate governance worldwide. This fact stems from the uncertainties encountered daily by private and public organizations, in the face of changes in external and internal environments, through technological innovations, interpersonal relations, economic crises, and governance, among others. Knowing the risks means identifying the threats to which an organization is exposed and perceiving opportunities. Therefore, this study intends to identify and deepen the knowledge about the main risk management methodologies adopted in both private and public environments in Brazil. The study uses a qualitative descriptive process that leads to specific and cumulative results by investigating the general essences of the methods of risk management. The theoretical basis is necessary to support the research under the ForRisco project (“Risk Management in Federal Universities: elaboration of reference model and system implementation”), where the present test was started, for the purpose of launching its own methodology (ForRisco) that focuses on the interests of risk management in public higher educational institutions in Brazil. The project aims to launch a guidebook and software that promote and direct risk management in these institutions. All the investigated methodologies corroborate the promotion and the understanding of a risk management process based on a clear and well-defined structure. Finally, the ForRisco methodology is distinguished for the relationship between public higher educational institutions and risk management processes that are more secure and consistent with the Brazilian public administration.

The ability to assess the accuracy of machine tools is required by both tool builders and users. Builders must have this ability in order to predict the accuracy capability of a machine tool for different part geometry`s, to provide verifiable accuracy information for sales purposes, and to locate error sources for maintenance, troubleshooting, and design enhancement. Users require the same ability in order to make intelligent choices in selecting or procuring machine tools, to predict component manufacturing accuracy, and to perform maintenance and troubleshooting. In both instances, the ability to fully evaluate the accuracy capabilities of a machine tool and the source of its limitations is essential for using the tool to its maximum accuracy and productivity potential. This project was designed to transfer expertise in modern machine tool accuracy testing methods from LLNL to US industry, and to educate users on the use and application of emerging standards for machine tool performance testing.

Objectives: Individualized care has the potential to significantly improve health outcomes in patients with chronic conditions. This study was aimed at evaluating the quality of individualized care and its impact on clinical outcomes in patients with the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) receiving treatment in a resource-limited setting. Materials and Methods: The study was a cross-sectional prospective study carried out in the HIV/AIDS clinic of the University of Uyo Teaching Hospital, Nigeria. Data on the demographic and clinical details of the patients were obtained from patient’s case notes using a suitably designed, pre-piloted data collection instrument. Data on patients’ assessment of the quality of individualized care were obtained using a “Patient Assessment of Quality of Individualized Care for Chronic Illness Scale.” Quantitative data were analyzed using the IBM Statistical Product and Service Solutions version 25.0 computer package. Descriptive statistics was used to summarize data, whereas inferential statistics was used where applicable with statistical significance set at P &lt; 0.05. Results: The overall mean patients’ satisfaction with individualized care score was 3.54 (standard deviation = ±0.86; max. = 5). The majority of the patients (271) had a documented viral load of &lt;50 copies/mL, whereas 27% (109) of the patients had a recently documented CD4 count that was &gt;500 cells/mm3. Bivariate analysis showed that the quality of individualized care was positively correlated with the patients’ CD4 count (r = 0.036; P = 0.657). A negative correlation between the quality of individualized care and the patients’ viral load (r = −0.103; P = 0.177) was also found. Conclusion: Provision of individualized care to patients with HIV/AIDS may improve clinical outcomes. In making therapeutic decisions, clinicians should take into cognizance individual patients’ preferences and needs.

During the last decade, the importance of evidencebased medicine has steadily gained ground. Sackett, in his landmark book published in 1997, defined evidence-based medicine as ‘conscientious, explicit and judicious use of current best evidence in making decisions about care of individual patients’ (Sackett 1997). The evidence may refer to new or existing interventions and to preventive, diagnostic or therapeutic interventions. Sackett suggested five steps on how individual care providers can practice evidence-based medicine: (1) ask clinical questions that you can answer, (2) search for the best evidence, (3) critically appraise the evidence, (4) apply the evidence in care for your patient, and (5) self-evaluation (of the above steps). Although this seems very reasonable, it is probably impossible for individual care providers to search for and critically appraise the evidence. At present, there are more than 2 million new articles published every year.

BackgroundPatient-reported outcomes (PROs) are frequently used for medical decision making, at the levels of both individual patient care and healthcare policy. Evidence increasingly shows that PROs may be influenced by patients’ response shifts (changes in interpretation) and dispositions (stable characteristics).Main textWe identify how response shifts and dispositions may influence medical decisions on both the levels of individual patient care and health policy. We provide examples of these influences and analyse the consequences from the perspectives of ethical principles and theories of just distribution.ConclusionIf influences of response shift and disposition on PROs and consequently medical decision making are not considered, patients may not receive optimal treatment and health insurance packages may include treatments that are not the most effective or cost-effective. We call on healthcare practitioners, researchers, policy makers, health insurers, and other stakeholders to critically reflect on why and how such patient reports are used.

Vitiligo is a common skin disorder causing depigmented macules that can impair a patient's quality of life. Currently, there are no standardized outcome measures to assess the degree of depigmentation. Moreover, there is limited knowledge on the measurement properties of outcome measures in vitiligo. To assess the reliability and responsiveness of the Vitiligo Area Scoring Index (VASI) and the Vitiligo European Task Force assessment (VETFa), two well-described clinician-reported outcomes. We included three vitiligo patient groups. In one group of 31 patients, the interobserver reliability was assessed by three observers. In 27 patients the intraobserver reliability was assessed by two repeated measures by one of the observers. To assess the responsiveness the repigmentation was calculated after 6months of phototherapy in 33 patients and tested against hypotheses. The interobserver reliability was high for VASI [intraclass correlation coefficient (ICC) 0·93] and VETFa depigmentation (ICC 0·88). The intraobserver reliability was high for VASI (ICC 0·93) and VETFa depigmentation (ICC 0·97). The smallest detectable changes (SDCs) were 7·1% and 10·4% for interobserver reliability and 4·7% and 2·9% for intraobserver reliability in VASI and VETFa depigmentation, respectively. All four responsiveness hypotheses formulated a priori were confirmed. VASI and VETFa are reliable and responsive instruments to assess the degree of depigmentation in vitiligo. VASI and VETFa for depigmentation are potential instruments for vitiligo research in the future. However, for use in individual patient care, caution is needed when interpreting score changes in individual patients because of the relatively large SDC.

Big data or population-based information has the potential to reduce uncertainty in medicine by informing clinicians about individual patient care. The objectives of this study were: 1) to explore the feasibility of extracting and displaying population-based information from an actual clinical population's database records, 2) to explore specific design features for improving population display, 3) to explore perceptions of population information displays, and 4) to explore the impact of population information display on cognitive outcomes. We used the Veteran's Affairs (VA) database to identify similar complex patients based on a similar complex patient case. Study outcomes measures were 1) preferences for population information display 2) time looking at the population display, 3) time to read the chart, and 4) appropriateness of plans with pre- and post-presentation of population data. Finally, we redesigned the population information display based on our findings from this study. The qualitative data analysis for preferences of population information display resulted in four themes: 1) trusting the big/population data can be an issue, 2) embedded analytics is necessary to explore patient similarities, 3) need for tools to control the view (overview, zoom and filter), and 4) different presentations of the population display can be beneficial to improve the display. We found that appropriateness of plans was at 60% for both groups (t9=-1.9; p=0.08), and overall time looking at the population information display was 2.3 minutes versus 3.6 minutes with experts processing information faster than non-experts (t8= -2.3, p=0.04). A population database has great potential for reducing complexity and uncertainty in medicine to improve clinical care. The preferences identified for the population information display will guide future health information technology system designers for better and more intuitive display.

What should be the driving force underlying the health care industry in the United States as the twenty-first century approaches? Should it be to maximize the quality of health care and availability of resources for the population or to maximize the return on investment through pricing and service policies? This dichotomy poses what possibly may be the most complex and far-reaching issue ever to confront the American health care system. Thus far, most of the debate on this issue has centered either at the societal (macro) level where questions of access to medical care are addressed, or on the individual patient care (micro) level, involving obligations within the context of the provider-patient relationship. Often overlooked in such discussions has been the institutional, or meso, level ([17], pp. 7—9; [18]). This level concerns the responsibilities of those who manage health care institutions, namely administrators. The classic dilemma arising at this level is the conflict between the traditional charitable healing mission of the health care institution, which is oriented toward benefiting patients without recognizing a limit to resources, and the so-called business ethic, which is geared toward maximizing institutional solvency and, in a growing number of cases, profitability [8].

The progress in information and communication technology, together with the search for the most effective and efficient ways to use the limited resources for health care, are opening new areas for research and development in perinatal care. Information systems and practice oriented by evidence-based medicine are modifying the operation of health services, and the quality of their management is being monitored by the success of their outcomes. As a study case, a Perinatal Information System widely used in Latin America and the Caribbean is discussed in some detail. Future challenges in the compatibility of information systems and databanks, the need for longer follow-up periods and measurement of health-related quality of life as outcomes for perinatal care, and the strategies to integrate all these concepts for the improvement of daily practice are discussed.

Background: The appropriate use of antimicrobials has implications on individual patient care, drug resistance and worldwide public health. Learning to prescribe antimicrobials is therefore an important part of medical education. The aim of this study was to evaluate novice prescribers’ readiness to use antimicrobials, in order to design valid educational activities. Methods: A mixed methods study was carried out amongst final year students at Queen’s University Belfast and foundation year 1 (FY1) doctors working in a Northern Ireland hospital. Data was initially collected using a survey, comprised of quantitative and qualitative elements. This was supplemented by semi-structured interviews. Results: One hundred and fifty-eight students and eighteen doctors participated in the survey. Two students and two doctors were interviewed. Both groups appeared to feel only moderately prepared to prescribe antimicrobials. Agreement with survey statements relating to knowledge and confidence was 61% and 73% for students and FY1 doctors respectively. More focused contextual teaching and practical learning opportunities were felt to be required. Students perceived a long time gap between teaching and clinical exposure. Both groups conveyed the strong influence of the working environment and local prescribing culture. These were sometimes seen as barriers to optimal prescribing. Feedback on prescribing was felt to be useful but lacking. Conclusion: This study suggests that medical students and foundation doctors do not feel adequately prepared to prescribe antimicrobials, which may lead them to be overly influenced by suboptimal prescribing cultures. A number of curriculum development and quality improvement initiatives are suggested as a result.

To identify factors that influence or interfere with referrals by primary care providers (PCPs) to a pharmacist-led telephone-based program to assist patients undergoing opioid tapering. The Support Team Onsite Resource for Management of Pain (STORM) program provides individualized patient care and supports PCPs in managing opioid tapers. Qualitative interviews were conducted with referring PCPs and STORM staff. Interview guides addressed concepts from the RE-AIM framework, focusing on issues affecting referral to the STORM program. An integrated healthcare system (HCS) in the Northwest United States. Thirty-five interviews were conducted with 20 PCPs and 15 STORM staff. Constant comparative analysis was used to identify key themes from interviews. A codebook was developed based on interview data and a qualitative software program was used for coding, iterative review, and content analysis. Representative quotes illustrate identified themes. Use of the STORM opioid tapering program was influenced by PCP, patient, and HCS considerations. Factors motivating use of STORM included lack of PCP time to support chronic pain patients requiring opioid tapering and the perception that STORM is a valued partner in patient care. Impediments to referral included PCP confidence in managing opioid tapering, patient resistance to tapering, forgetting about program availability, and PCP resistance to evolving guidelines regarding opioid tapering goals. PCPs recognized that STORM supported patient safety and reduced clinician burden. Utilization of the program could be improved through ongoing PCP education about the service and consistent co-location of STORM pharmacists within primary care clinics.