Ziya Gokaslan
· Chair of Neurosurgery, Professor of NeurosurgeryVerifiedBrown University · Microbiology and Immunology
Active 2009–2024
About
Ziya L. Gokaslan is the Chair of Neurosurgery and a Professor of Neurosurgery at Brown University. His educational background includes earning an MD degree from Istanbul University in 1983. As a faculty member at Brown, he is involved in neurosurgical research and education, contributing to the academic and clinical advancements in the field of neurosurgery.
Research topics
- Computer Science
- Political Science
- Psychology
- Medical education
- Law
- Medicine
Selected publications
Using ChatGPT to Facilitate Truly Informed Medical Consent
NEJM AI · 2024 · 78 citations
- Computer Science
- Medical education
- Computer Science
Informed consent is integral to the practice of medicine. Most informed consent documents are written at a reading level that surpasses the reading comprehension level of the average American. Large language models, a type of artificial intelligence (AI) with the ability to summarize and revise content, present a novel opportunity to make the language used in consent forms more accessible to the average American and thus, improve the quality of informed consent. In this study, we present the experience of the largest health care system in the state of Rhode Island in implementing AI to improve the readability of informed consent documents, highlighting one tangible application for emerging AI in the clinical setting.
Neurosurgery · 2023 · 316 citations
- Medicine
- Internal medicine
- Surgery
BACKGROUND AND OBJECTIVES: General large language models (LLMs), such as ChatGPT (GPT-3.5), have demonstrated the capability to pass multiple-choice medical board examinations. However, comparative accuracy of different LLMs and LLM performance on assessments of predominantly higher-order management questions is poorly understood. We aimed to assess the performance of 3 LLMs (GPT-3.5, GPT-4, and Google Bard) on a question bank designed specifically for neurosurgery oral boards examination preparation. METHODS: The 149-question Self-Assessment Neurosurgery Examination Indications Examination was used to query LLM accuracy. Questions were inputted in a single best answer, multiple-choice format. χ 2 , Fisher exact, and univariable logistic regression tests assessed differences in performance by question characteristics. RESULTS: On a question bank with predominantly higher-order questions (85.2%), ChatGPT (GPT-3.5) and GPT-4 answered 62.4% (95% CI: 54.1%-70.1%) and 82.6% (95% CI: 75.2%-88.1%) of questions correctly, respectively. By contrast, Bard scored 44.2% (66/149, 95% CI: 36.2%-52.6%). GPT-3.5 and GPT-4 demonstrated significantly higher scores than Bard (both P < .01), and GPT-4 outperformed GPT-3.5 ( P = .023). Among 6 subspecialties, GPT-4 had significantly higher accuracy in the Spine category relative to GPT-3.5 and in 4 categories relative to Bard (all P < .01). Incorporation of higher-order problem solving was associated with lower question accuracy for GPT-3.5 (odds ratio [OR] = 0.80, P = .042) and Bard (OR = 0.76, P = .014), but not GPT-4 (OR = 0.86, P = .085). GPT-4's performance on imaging-related questions surpassed GPT-3.5's (68.6% vs 47.1%, P = .044) and was comparable with Bard's (68.6% vs 66.7%, P = 1.000). However, GPT-4 demonstrated significantly lower rates of "hallucination" on imaging-related questions than both GPT-3.5 (2.3% vs 57.1%, P < .001) and Bard (2.3% vs 27.3%, P = .002). Lack of question text description for questions predicted significantly higher odds of hallucination for GPT-3.5 (OR = 1.45, P = .012) and Bard (OR = 2.09, P < .001). CONCLUSION: On a question bank of predominantly higher-order management case scenarios for neurosurgery oral boards preparation, GPT-4 achieved a score of 82.6%, outperforming ChatGPT and Google Bard.
Performance of ChatGPT and GPT-4 on Neurosurgery Written Board Examinations
Neurosurgery · 2023 · 202 citations
- Medicine
- Medical physics
- Radiology
BACKGROUND AND OBJECTIVES: Interest surrounding generative large language models (LLMs) has rapidly grown. Although ChatGPT (GPT-3.5), a general LLM, has shown near-passing performance on medical student board examinations, the performance of ChatGPT or its successor GPT-4 on specialized examinations and the factors affecting accuracy remain unclear. This study aims to assess the performance of ChatGPT and GPT-4 on a 500-question mock neurosurgical written board examination. METHODS: The Self-Assessment Neurosurgery Examinations (SANS) American Board of Neurological Surgery Self-Assessment Examination 1 was used to evaluate ChatGPT and GPT-4. Questions were in single best answer, multiple-choice format. χ 2 , Fisher exact, and univariable logistic regression tests were used to assess performance differences in relation to question characteristics. RESULTS: ChatGPT (GPT-3.5) and GPT-4 achieved scores of 73.4% (95% CI: 69.3%-77.2%) and 83.4% (95% CI: 79.8%-86.5%), respectively, relative to the user average of 72.8% (95% CI: 68.6%-76.6%). Both LLMs exceeded last year's passing threshold of 69%. Although scores between ChatGPT and question bank users were equivalent ( P = .963), GPT-4 outperformed both (both P < .001). GPT-4 answered every question answered correctly by ChatGPT and 37.6% (50/133) of remaining incorrect questions correctly. Among 12 question categories, GPT-4 significantly outperformed users in each but performed comparably with ChatGPT in 3 (functional, other general, and spine) and outperformed both users and ChatGPT for tumor questions. Increased word count (odds ratio = 0.89 of answering a question correctly per +10 words) and higher-order problem-solving (odds ratio = 0.40, P = .009) were associated with lower accuracy for ChatGPT, but not for GPT-4 (both P > .005). Multimodal input was not available at the time of this study; hence, on questions with image content, ChatGPT and GPT-4 answered 49.5% and 56.8% of questions correctly based on contextual context clues alone. CONCLUSION: LLMs achieved passing scores on a mock 500-question neurosurgical written board examination, with GPT-4 significantly outperforming ChatGPT.
World Neurosurgery · 2022 · 28 citations
- Medicine
- Surgery
- Internal medicine
North American Spine Society Journal (NASSJ) · 2022 · 30 citations
- Medicine
- Physical therapy
- Surgery
Background: In the context of increased attention afforded to hospital efficiency and improved but safe patient throughput, decreasing unnecessary hospital length of stay (LOS) is imperative. Given that lumbar spine procedures may be among a hospital's most profitable services, identifying patients at risk of increased healthcare resource utilization prior to surgery is a valuable opportunity to develop targeted pre- and peri-operative intervention and quality improvement initiatives. The purpose of the present investigation was to examine patient factors that predict prolonged LOS as well as discharge disposition following elective, posterior, lumbar spine surgery. Methods: We employed a retrospective cohort analysis on 779 consecutive patients treated with lumbar surgery without fusion. Our primary outcome measures were extended LOS (three or more midnights) and discharge disposition. Patient sociodemographic, procedural, and discharge characteristics were adjusted for in our analysis. Sociodemographic variables included Area of Deprivation Index (ADI), a comprehensive metric of socioeconomic status, utilizing income, education, employment, and housing quality based on patient zip code. Multivariable logistic regression and ordinal logistic regression analyses were performed to assess whether covariates were independently predictive of extended LOS and discharge disposition, respectively. Results: 779 patients were studied, with a median age of 66 years (±15) and a median LOS of 1 midnight (range, 1-10 midnights). Patients in the most disadvantaged ADI quintile (adjusted odds ratio, aOR 2.48 95% CI 1.15-5.47), those who underwent a minimally-invasive or tubular retractor surgery (aOR 3.03 95% CI 1.02-8.56), those who had an intra-operative drain placed (aOR 4.46 95% CI 2.53-7.26), who had a cerebrospinal fluid leak (aOR 3.46 95% CI 1.55-7.58), who were discharged anywhere but home (aOR 17.11 95% CI 9.24-33.00), and those who were evaluated by physical therapy (aOR 7.23 95% CI 2.13-45.30) or OT (aOR 2.20 95% CI 1.13-4.22) had a significantly increased chance of an extended LOS. Preoperative opioid use was not associated with an increased LOS following surgery (aOR 1.12 95% CI 0.56-1.46). Extended LOS was not associated with post-discharge emergency department representation or unplanned readmission within 90 days following discharge (p=0.148). Patients who were older (aOR 1.99 95% CI 1.62-2.48), in higher quintiles on ADI (3rd quintile; aOR 1.90 95% CI 1.12-3.23, 4th quintile; aOR 1.79, 95% CI 1.05-3.05, 5th quintile; aOR 2.16 95% CI 1.26-3.75), who had a CSF leak (aOR 2.18 95% CI 1.22-3.86), or who had a longer procedure duration (aOR 1.38 95% CI 1.17-1.62) were more likely to require additional services or be sent to a subacute facility upon discharge. Conclusions: Patient sociodemographics, along with procedural factors, and discharge disposition were all associated with an increased likelihood of prolonged LOS and resource intensive discharges following elective lumbar spine surgery. Several of these factors could be reliably identified pre-operatively and may be amenable to targeted preoperative intervention. Improving discharge disposition planning in the peri-operative period may allow for more efficient use of hospitalization and inpatient and post-acute resources.
World Neurosurgery · 2022 · 26 citations
- Medicine
- Anatomy
- Pathology
BACKGROUND: Patients with hypermobile Ehlers-Danlos syndrome (hEDS), a heritable connective tissue disorder, present frequently with symptoms of tethered cord syndrome (TCS) but without a low-lying conus. Currently, surgical treatment of such cases is controversial. Because connective tissue disorder affects fibrous structures, we hypothesized that a diseased filum terminale (FT) might cause TCS in hEDS, justifying surgical transection for treatment. METHODS: We investigated FT pathology, FT biomechanics, clinical presentation, and outcome following FT excision in 78 radiologically occult hEDS-TCS cases and for comparison in 38 typical TCS cases with low-lying conus and/or fatty FT infiltration but without hEDS. RESULTS: In hEDS-TCS, electron microscopy revealed inherited collagen fibril abnormalities and acquired fibril damage. Biomechanical tension tests revealed elastic properties of the FT in both study groups, but they were impaired in the hEDS TCS. Follow-up examinations at 3 and 12 months after FT excision showed statistically significant improvement of urinary, bowel, and neurologic symptoms in both study groups; intergroup comparison revealed no differences in outcome except more pronounced neurologic improvement in the hEDS-TCS group. CONCLUSIONS: Both morphologic findings and biomechanical tests indicate limited elastic properties of the FT in hEDS, which is no more able to dampen but still transmitting spine movement-related stretch forces. That mechanism exposes the conus medullaris to unphysiologic stretch forces, causing TCS, especially when considering the hypermobile spine in hEDS. This notion is supported by the observed clinical improvement following FT resection in hEDS-TCS cases without a low-lying conus.
Abnormal spinal cord motion at the craniocervical junction in hypermobile Ehlers-Danlos patients
Journal of Neurosurgery Spine · 2021 · 26 citations
- Medicine
- Anatomy
- Surgery
OBJECTIVE: The craniocervical junction (CCJ) is anatomically complex and comprises multiple joints that allow for wide head and neck movements. The thecal sac must adjust to such movements. Accordingly, the thecal sac is not rigidly attached to the bony spinal canal but instead tethered by fibrous suspension ligaments, including myodural bridges (MDBs). The authors hypothesized that pathological spinal cord motion is due to the laxity of such suspension bands in patients with connective tissue disorders, e.g., hypermobile Ehlers-Danlos syndrome (EDS). METHODS: The ultrastructure of MDBs that were intraoperatively harvested from patients with Chiari malformation was investigated with transmission electron microscopy, and 8 patients with EDS were compared with 8 patients without EDS. MRI was used to exclude patients with EDS and craniocervical instability (CCI). Real-time ultrasound was used to compare the spinal cord at C1-2 of 20 patients with EDS with those of 18 healthy control participants. RESULTS: The ultrastructural damage of the collagen fibrils of the MDBs was distinct in patients with EDS, indicating a pathological mechanical laxity. In patients with EDS, ultrasound revealed increased cardiac pulsatory motion and irregular displacement of the spinal cord during head movements. CONCLUSIONS: Laxity of spinal cord suspension ligaments and the associated spinal cord motion disorder are possible pathogenic factors for chronic neck pain and headache in patients with EDS but without radiologically proven CCI.
Neuro-Oncology Advances · 2020 · 16 citations
- Medicine
- Internal medicine
- Oncology
BACKGROUND: Chordomas are the most common primary spinal column malignancy in the United States. The aim of this study was to determine whether chordomas may be detected by evaluating mutations in circulating tumor DNA (ctDNA). METHODS: Thirty-two patients with a biopsy-confirmed diagnosis of chordoma had blood drawn pre-operatively and/or at follow-up appointments. Mutations in the primary tumor were identified by whole exome sequencing and liquid biopsy by ddPCR and/or RACE-Seq was used to detect one or more of these mutations in plasma ctDNA at concurrent or later time points. RESULTS: = .02), and the presence of ctDNA may correlate with response to systemic chemotherapy and/or disease recurrence. CONCLUSIONS: Detection of ctDNA mutations may allow for the detection and monitoring of disease progression for chordomas.
Journal of Neurosurgery Spine · 2020 · 32 citations
- Medicine
- Surgery
OBJECTIVE: Wound breakdown and infection are common postoperative complications following resection of spinal neoplasms. Accordingly, it has become common practice at some centers for plastic surgeons to assist with closure of large posterior defects after spine tumor resection. In this study, the authors tested the hypothesis that plastic surgery closure of complex spinal defects improves wound outcomes following resection of spinal neoplastic disease. METHODS: Electronic medical records of consecutive patients who underwent resection of a spinal neoplasm between June 2015 and January 2019 were retrospectively reviewed. Patients were separated into two subpopulations based on whether the surgical wound was closed by plastic surgery or neurosurgery. Patient demographics, preoperative risk factors, surgical details, and postoperative outcomes were collected in a central database and summarized using descriptive statistics. Outcomes of interest included rates of wound complication, reoperation, and mortality. Known preoperative risk factors for wound complication in spinal oncology were identified based on literature review and grouped categorically. The presence of each category of risk factors was then compared between groups. Univariate and multivariate linear regressions were applied to define associations between individual risk factors and wound complications. RESULTS: One hundred six patients met inclusion criteria, including 60 wounds primarily closed by plastic surgery and 46 by neurosurgery. The plastic surgery population included more patients with systemic metastases (58% vs 37%, p = 0.029), prior radiation (53% vs 17%, p < 0.001), prior chemotherapy (37% vs 15%, p = 0.014), and sacral region tumors (25% vs 7%, p = 0.012), and more patients who underwent procedures requiring larger incisions (7.2 ± 3.6 vs 4.5 ± 2.6 levels, p < 0.001), prolonged operative time (413 ± 161 vs 301 ± 181 minutes, p = 0.001), and greater blood loss (906 ± 1106 vs 283 ± 373 ml, p < 0.001). The average number of risk factor categories present was significantly greater in the plastic surgery group (2.57 vs 1.74, p < 0.001). Despite the higher relative risk, the plastic surgery group did not experience a significantly higher rate of wound complication (28% vs 17%, p = 0.145), reoperation (17% vs 9%, p = 0.234), or all-cause mortality (30% vs 13%, p = 0.076). One patient died from wound-related complications in each group (p = 0.851). Regression analyses identified diabetes, multilevel instrumentation, and BMI as the factors associated with the greatest wound complications. CONCLUSIONS: Involving plastic surgery in the closure of spinal wounds after resection of neoplasms may ameliorate expected increases in wound complications among higher-risk patients.
World Neurosurgery · 2020 · 41 citations
- Medicine
- Radiology
- Surgery
Frequent coauthors
- 200 shared
Y. Raja Rampersaud
University Health Network
- 159 shared
Michael G. Fehlings
University of Toronto
- 144 shared
Charles G. Fisher
Vancouver Spine Surgery Institute
- 137 shared
Neil Manson
Canada East Spine Centre
- 133 shared
Edward Abraham
Canada East Spine Centre
- 131 shared
Christopher S. Bailey
London Health Sciences Centre
- 128 shared
Najmedden Attabib
Canada East Spine Centre
- 127 shared
Joel Finkelstein
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