President Biden was deemed to be "healthy" and "vigorous" in his latest physical conducted Thursday but medical experts pointed out his doctor didn't mention the president's mental status.

Speaking with Fox News Digital after examining the results of the exam, Dr. Janette Nesheiwat, a family and emergency medical professional and Fox News contributor, questioned how Biden performed on his "mini mental status exam."

"This physical exam is more significant for what it leaves out than what it actually tells us."

— Dr. Marc Siegel

"How did he do on that? What was his score? I would like to know," she said. "Physical mental emotional health are all as equally important.

‘WHITE’ FEDERAL WORKERS WOULD NO LONGER INCLUDE MIDDLE EASTERN, NORTH AFRICAN HERITAGE UNDER NEW BIDEN PLAN

"The job of the presidency is a very demanding stressful job," she added. "We must ensure our leader is physically mentally and emotionally capable, especially when it comes to, decisions, regarding life and death and the overall health, safety, and well-being of our nation."

Since taking office, Biden has faced questions about his age and mental capacity. Republican presidential candidate Nikki Haley took aim at the president Wednesday, saying that politicians over age 75 should have to take a mental cognitive test before assuming office. 

"Biden will be our oldest sitting president," said Nesheiwat. "We need a president who is sharp, shrewd, who has the cognitive stamina and the mental acumen to lead our great country."

Fox News contributor Dr. Marc Siegel asked Tucker Carlson on "Tucker Carlson Tonight" Thursday how Biden's doctors arrived at those results without a complete battery of testing.

'THE FIVE': WHITE HOUSE EXPLODES OVER QUESTIONS ABOUT BIDEN'S DOCTOR

Dr. Siegel highlighted Biden's "stiff gait" saying "it is sometimes a sign of cognitive problems." The explanation for the stiff gait in the president's physical was attributed to "peripheral neuropathy, meaning loss of sensation in his feet," however, Biden's doctors "don't know where that's coming from," according to Dr. Siegel. "They're basing that on a physical examination of multiple doctors but no MRI, I don't see anywhere in there about an MRI."

"This physical exam is more significant for what it leaves out than what it actually tells us," Dr. Siegel said. 

White House Dr. Kevin O'Conner assessed Biden and concluded he was a healthy, vigorous 80-year-old male who is fit to successfully execute the duties of the presidency.

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He noted that a lesion discovered on his chest was removed and that he still experiences stiff gait and symptoms of gastroesophageal reflux, primarily having to clear his throat more often, mostly after meals.

"His physical results are of no surprise to me and is typical of an 80-year-old," Nesheiwat said. 

High-stakes examinations are an integral part of medical education. To practice in the United States (U.S.), students must pass the U.S. Medical Licensing Examinations (USMLE). With the transition of USMLE Step 1 to pass/fail scoring on January 26, 2022, a worldwide debate regarding how residency program directors will view the Step 2 Clinical Knowledge (CK) exam emerged. Here, the authors explore the role of formal, informal, and hidden curricula related to USMLE, with broader implications for high-stakes examinations. Six focus groups of fourth-year students who recently took Step 2 CK and a supplemental curricular content analysis were conducted to explore students’ decision-making and emotions regarding the exam, including how the formal, informal, and hidden curricula influence their perspectives. Participants highlighted how informal and hidden curricula drive the belief that high-stakes examinations are the single most important factor in medical school. Prior experience with Step 1 drives behaviors and attitudes when preparing for Step 2 CK. Pressures from these examinations have unintended consequences on burnout, professional identity, specialty choice, and interpersonal interactions. Both interpersonal interactions within medical education as well as subconscious, unintended messaging can influence medical student approaches to and perspectives about high-stakes examinations. Within the context of U.S. medical training, with the transition to a new era of a pass/fail Step 1 examination, careful consideration to prevent shifting the current “Step 1 mania” to a “Step 2 CK mania” is warranted. More broadly, medical educators must examine the unintended yet potentially damaging pressures institutions generate in their medical trainees in relation to high-stakes examinations.
Copyright: © 2023 Geraghty et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

In a latest study published in PLOS Digital Health, researchers evaluated the performance of an artificial intelligence (AI) model named ChatGPT to perform clinical reasoning on the United States Medical Licensing exam (USMLE).

The USMLE comprises three standardized exams, clearing which help students get medical licensure in the US.

Background

There have been advancements in artificial intelligence (AI) and deep learning in the past decade. These technologies have become applicable across several industries, from manufacturing and finance to consumer goods. However, their applications in clinical care, especially healthcare information technology (IT) systems, remain limited. Accordingly, AI has found relatively few applications in widespread clinical care.

One of the main reasons for this is the shortage of domain-specific training data. Large general domain models are now enabling image-based AI in clinical imaging. It has led to the development of Inception-V3, a top medical imaging model that spans domains from ophthalmology and pathology to dermatology.

In the last few weeks, ChatGPT, an OpenAI-developed general Large Language Model (LLM) (not domain specific), garnered attention due to its exceptional potential to perform a suite of natural language tasks. It uses a novel AI algorithm that predicts a given word sequence based on the context of the words written prior to it.

Thus, it could generate plausible word sequences based on the natural human language without being trained on humongous text data. People who have used ChatGPT find it capable of deductive reasoning and developing a chain of thought.

Regarding the choice of the USMLE as a substrate for ChatGPT testing, the researchers found it linguistically and conceptually rich. The test contained multifaceted clinical data (e.g., physical examination and laboratory test results) used to generate ambiguous medical scenarios with differential diagnoses.

About the study

In the present study, researchers first encoded USMLE exam items as open-ended questions with variable lead-in prompts, then as multiple-choice single-answer questions with no forced justification (MC-NJ). Finally, they encoded them as multiple-choice single-answer questions with a forced justification of positive and negative selections (MC-J). In this way, they assessed ChatGPT accuracy for all three USMLE steps, steps 1, 2CK, and 3.

Next, two physician reviewers independently arbitrated the concordance of ChatGPT across all questions and input formats. Further, they assessed its potential to enhance medical education-related human learning. Two physician reviewers also examined AI-generated explanation content for novelty, nonobviousness, and validity from the perspective of medical students.

Furthermore, the researchers assessed the prevalence of insight within AI-generated explanations to quantify the density of insight (DOI). The high frequency and moderate DOI (>0.6) indicated that it might be possible for a medical student to achieve some knowledge from the AI output, especially when answering incorrectly. DOI indicated the uniqueness, novelty, nonobviousness, and validity of insights provided for more than three out of five answer choices.

Results

ChatGPT performed at over 50% accuracy across all three USMLE examinations, exceeding the 60% USMLE pass threshold in some analyses. It is an extraordinary feat because no other prior models reached this benchmark; merely months prior, they performed at 36.7% accuracy. Chat GPT iteration GPT3 achieved 46% accuracy with no prompting or training, suggesting that further model tuning could fetch more precise results. AI performance will likely continue to advance as LLM models mature.

In addition, ChatGPT performed better than PubMedGPT, a similar LLM trained exclusively in biomedical literature (accuracies ~60% vs. 50.3%). It seems that ChatGPT, trained on general non-domain-specific content, had its advantages as exposure to more clinical content, e.g., patient-facing disease primers are far more conclusive and consistent.

Another reason why the performance of ChatGPT was more impressive is that prior models most likely had ingested many of the inputs while training, while it had not. Note that the researchers tested ChatGPT against more contemporary USMLE exams that became publicly available in the year 2022 only). However, they had trained other domain-specific language models, e.g., PubMedGPT and BioBERT, on the MedQA-USMLE dataset, publically available since 2009.

Intriguingly, the accuracy of ChatGPT was inclined to increase sequentially, being lowest for Step 1 and highest for Step 3, reflecting the perception of real-world human users, who also find Step 1 subject matter difficult. This particular finding exposes AI's vulnerability to becoming connected to human ability.

Furthermore, the researchers noted that missing information drove inaccuracy observed in ChatGPT responses which fetched poorer insights and indecision in the AI. Yet, it did not show an inclination towards the incorrect answer choice. In this regard, they could try to Boost ChatGPT performance by merging it with other models trained on abundant and highly validated resources in the clinical domain (e.g., UpToDate).

In ~90% of outputs, ChatGPT-generated responses also offered significant insight, valuable to medical students. It showed the partial ability to extract nonobvious and novel concepts that might provide qualitative gains for human medical education. As a substitute for the metric of usefulness in the human learning process, ChatGPT responses were also highly concordant. Thus, these outputs could help students understand the language, logic, and course of relationships encompassed within the explanation text.

Conclusions

The study provided new and surprising evidence that ChatGPT could perform several intricate tasks relevant to handling complex medical and clinical information. Although the study findings provide a preliminary protocol for arbitrating AI-generated responses concerning insight, concordance, accuracy, and the advent of AI in medical education would require an open science research infrastructure. It would help standardize experimental methods and describe and quantify human-AI interactions.

Soon AIs could become pervasive in clinical practice, with varied applications in nearly all medical disciplines, e.g., clinical decision support and patient communication. The remarkable performance of ChatGPT also inspired clinicians to experiment with it.

At AnsibleHealth, a chronic pulmonary disease clinic, they are using ChatGPT to assist with challenging tasks, such as simplifying radiology reports to facilitate patient comprehension. More importantly, they use ChatGPT for brainstorming when facing diagnostically difficult cases.

The demand for new examination formats continues to increase. Thus, future studies should explore whether AI could help offload the human effort of taking medical tests (e.g., USMLE) by helping with the question-explanation process or, if feasible, writing the whole autonomously.

PrepLadder, one of India’s leading online learning platforms, today announced that 156 Learners have qualified for the Foreign Medical Graduates Examination (FMGE) January 2023 session. The examination is a bi-annual screening test for medical graduates who procured their degree from outside India to be eligible to practice medicine in India.

The results announced by the National Board of Examinations saw all the qualifying PrepLadder Learners score over 200 marks in the exam.  Further, 07 Learners scored above 235, and 28 Learners secured more than 220 marks, a commendable score in the highly challenging and competitive exam. FMG exam requires all individuals to score at least 150 out of 300 to qualify.

Among PrepLadder’s top scorers are Dr. Faizan Gulzar Das (250 marks) from Srinagar, Dr. Arshlan Ahmad (240 marks) from Gorakhpur, Dr. Tafheem Iftikhar (239 marks) from Srinagar, Dr. Sasim (238 marks) from Hyderabad, Dr. Md Javed Akhtar (237 marks) from Kolkata.

Key highlights of the PrepLadder’s FMG January 2023 exam result:

• 07 Learners have scored over 235 marks
• 28 Learners have scored over 220 marks
• 156 Learners have secured over 200 marks

The outstanding result of PrepLadder’s Learners is a testament to the effectiveness of the platform's study content and approach to learning. The successful Learners will now be able to obtain the registration certificate from the National Medical Commission (NMC) or State Medical Council (SMC) to practice Medicine in the country.

Prior to the announcement of the FMG exam result, PrepLadder also announced that there were a staggering 94.4% direct repeats from their study content in this year’s FMG exam. This further demonstrates the platform's commitment to providing the most up-to-date, effective and relevant study content to its Learners.

PrepLadder offers a simplified learning experience through engaging video lectures and study content for Medical PG aspirants. In January 2023, PrepLadder announced Dream Team Next comprising top faculty members across different medical specialisations who will curate new learning experiences for aspirants. Dream Team Next will also feature a specialized faculty for the FMG exam. Through this, PrepLadder aims to stimulate a next-gen learning experience for postgraduate medical aspirants in compliance with the latest exam pattern.

• ChatGPT is a chatbot launched by OpenAI that uses generative artificial intelligence to create its own content.

• The bot has been used to generate essays and write exams, often passing, but making mistakes, too.

• Insider rounded up a list of the assignments, quizzes, and tests ChatGPT has passed.

Wharton MBA exam

Wharton professor Christian Terwiesch recently tested the technology with questions from his final exam in operations management— which was once a required class for all MBA students — and published his findings.

Terwiesch concluded that the bot did an "amazing job" answering basic operations questions based on case studies, which are focused examinations of a person, group, or company, and a common way business schools teach students.

In other instances though, ChatGPT made simple mistakes in calculations that Terwiesch thought only required 6th-grade-level math. Terwiesch also noted that the bot had issues with more complex questions that required an understanding of how multiple inputs and outputs worked together.

Ultimately, Terwiesch said the bot would receive an B or B- on the exam.

US medical licensing exam

Researchers put ChatGPT through the United States Medical Licensing exam — a three part exam that aspiring doctors take between medical school and residency — and reported their findings in a paper published in December 2022.

The paper's abstract noted that ChatGPT "performed at or near the passing threshold for all three exams without any specialized training or reinforcement. Additionally, ChatGPT demonstrated a high level of concordance and insight in its explanations."

Ultimately, the results show that large language models — which ChatGPT has been trained on— may have "the potential" to assist with medical education and even clinical decision making, the abstract noted.

The research is still under peer review, Insider noted based on a report from Axios.

Essays

It didn't take long after ChatGPT was released for students to start using it for essays and educators to start worrying about plagiarism.

Story continues

In December, Bloomberg podcaster Matthew S. Schwartz tweeted that the "take home essay is dead." He noted that he had fed a law school essay prompt into ChatGPT and it had "responded *instantly* with a solid response."

In another instance, a philosophy professor at Furman University caught a student turning in an AI-generated essay upon noticing it had "well-written misinformation," Insider reported. 

"Word by word it was a well-written essay," the professor told Insider. As he took a more careful look however, he noticed that the student made a claim about the philosopher David Hume that "made no sense" and was "just flatly wrong" Insider reported. 

In an interview in January, Sam Altman— CEO of OpenAI which makes ChatGPT — said that while the company will devise ways to help schools detect plagiarism, he can't guarantee full detection.

Microbiology quiz

Science journalist and executive editor of Big Think, Alex Berezow, tested ChatGPT with a 10-question microbiology quiz that he devised. 

Berezow, who also holds a Ph.D in microbiology, noted that the questions would be appropriate for a final exam for college level students. ChatGPT "blew it away," Berezow wrote.

In one example, Berezow asked:

"An emergency room patient presents with a terrible headache and stiff neck. The doctor orders a spinal tap to collect cerebrospinal fluid. A Gram stain of the CSF reveals the presence of Gram negative diplococci. What is the diagnosis?"

To which ChatGPT correctly responded:

Based on the information you provided, the Gram stain of the cerebrospinal fluid (CSF) shows the presence of Gram-negative diplococci, which are bacteria that are typically oval-shaped and occur in pairs. This finding is consistent with the diagnosis of meningitis.

In another instance he asked:

"In five words or less, what is the point of Koch's postulates?"

To which ChatGPT said: 

Establish causality between microbe and disease.

Taking out the word "and" Berezow said ChatGPT "Nailed it."

Law School Exams

ChatGPT recently passed exams in four law school courses at the University of Minnesota, based on a recently published paper written by four law school professors at the school.

In total, the bot answered over 95 multiple choice questions and 12 essay questions that were blindly graded by the professors. Ultimately, the professors gave ChatGPT a "low but passing grade in all four courses" approximately equivalent to a C+.

Still the authors pointed out several implications for what this might mean for lawyers and law education. In one section they wrote:

"Although ChatGPT would have been a mediocre law student, its performance was sufficient to successfully earn a JD degree from a highly selective law school, assuming its work remained constant throughout law school (and ignoring other graduation requirements that involve different skills). In an era where remote exam administration has become the norm, this could hypothetically result in a struggling law student using ChatGPT to earn a JD that does not reflect her abilities or readiness to practice law."

Stanford Medical School clinical reasoning final

ChatGPT passed a Stanford Medical School final in clinical reasoning. According to a YouTube video uploaded by Eric Strong — a clinical associate professor at Stanford — ChatGPT passed a clinical reasoning exam with an overall score of 72%.

In the video, Strong described clinical reasoning in five parts. It includes analyzing a patient's symptoms and physical findings, hypothesizing possible diagnoses, selecting appropriate tests, interpreting test results, and recommending treatment options.

He said, "it's a complex, multi-faceted science of its own, one that is very patient-focused, and something that everything every practicing doctor does on a routine basis."

Strong noted in the video that the clinical reasoning exam is normally given to first-year medical students who need a score of 70% to pass.

Read the original article on Business Insider

Dr. Marc Siegel, Fox News Contributor and Professor Of Medicine at NYU Langone Medical Center, gave his diagnosis for prominent lawmakers who have shown signs of cognitive or physical health issues while serving in office, sounding the alarm on the need for "more transparency" for the American people.

"I believe the voters of the states involved have a right to know whether their senator is fit for the job and able to serve," Siegel said. "While technology can help [Sen. John] Fetterman and teleprompters can help Biden this isn't enough. Are they up to the job? We need more transparency and info. The lives of others are on the line based on the important decisions they have to make."

"The majority of the American public (even Democrats) feel he is too old to run, but the issue isn't age, it's the question of fitness," Seigel said of Biden, who often raises eyebrows over misspoken words (he has dealt with a stutter since he was a child) and times when he appears confused.

The president underwent his annual physical exam Thursday that cleared him as fit to serve, but the report failed to mention any results from neurological tests. 

BIDEN HEALTH EVALUATION MISSING MENTAL STATUS EXAM: MEDICAL EXPERT

"Biden, the issue is that his stiff legged gait and frequent cognitive errors could be a tip off to a brain problem such as dementia or normal pressure hydrocephalus, but the workup would be an MRI or brain imaging study and neuropsych testing including a cognitive exam such as the Montreal cognitive test. The mini-mental status exam that was mentioned is very limited and wouldn't add much," Siegel told Fox News Digital. 

DOCTORS REACT AFTER FETTERMAN CHECKS INTO HOSPITAL FOR CLINICAL DEPRESSION

"It is very noteworthy that [Biden's physician Dr. Kevin] O'Connor ascribed the stiff gait to arthritis of the spine and peripheral neuropathy and mentioned physical examination to rule out serious neurological disorders such as MS and stroke, but made no mention of MRI of the brain or neurocognitive tests. These are significant omissions in the report esp given the frequency and severity of his so-called gaffs," Siegel added.

Fetterman was admitted into a Washington, D.C. hospital twice in a week, checking himself in on Thursday to be treated for "clinical depression."

"We should feel compassion and as a physician I am glad he is coming forward and can be a role model for others, but at the same time clinical depression requiring hospitalization is severe and according to a Cochrane review especially difficult to treat after stroke requiring combinations of medicine and therapy," Siegel said of Fetterman, who suffered a stroke in May 2022 while on the campaign trail.

Siegel also speculated that the depression could be a side effect of last year's stroke. "According to a 2016 study in STROKE 1/3 people after stroke are reported to have depression, but the number is likely far greater," he said.

Sen. Dianne Feinstein, D-Calif., who announced that she will not be seeking re-election in 2024, did not realize she resigned when asked by a reporter about the announcement on Tuesday.

"Feinstein too appears to be well past the point where she can function effectively," Siegel wrote.

The Democrat, who is 89 years old, also reportedly left the Senate floor not knowing if she voted for anything.

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Sen. Bob Casey, D-Pa., also recently had a "successful" prostate cancer surgery, and Siegel believes he will be in good enough health to serve after his recovery.

"Casey is undergoing surgery for prostate cancer which will likely cure him, and he will be able to resume work shortly in a matter of days or weeks," he stated.

Hyderabad: One month ahead of NEET PG 2023, several medical aspirants across the country are urging the Ministry of Health and Family Welfare (MoHFW) to postpone NEET PG 2023 for six to eight weeks. Organisations like FAIMA (Federation of All India Medical Association) and UDFA (United Doctors' Front Association) are in support of the medical students and have reached out to the Health Ministry to convey the same.

The National Board of Examinations (NBE) has announced that the NEET PG exam will be conducted on March 5, 2023, and the results would be out by March 31, 2023. The cut-off date for completing the mandatory medical internship has been extended to August 11, 2023. However, as the counselling for the NEET PG exam will be conducted post the internship, there will be a huge gap between the NEET PG exam and the counselling date. Medical experts and counsellors point out that this time would help candidates prepare better for their exams.

Dr Mandaviya further added that the decision to not postpone NEET PG 2023 has been taken to streamline the process to avoid further delay in the exam and counselling process caused due to COVID-19.

Experts’ view on the situation

Speaking to ETHealthworld Dr Sharad Kumar Agarwal, National President, Indian Medical Association said, “It is mental harassment for students preparing for the NEET PG exam. The exam should be followed by counselling. Not counselling post the exam or postponing the counselling for several months, then what is the point of taking the exam right now? Let us give time to the students. On one side we say there is a shortage of specialist doctors and another side we are not supporting them. IMA has also requested the ministry to call us for the discussion so we can clear the queries.”

Supporting Dr Agarwal’s statements, Dr Aviral Mathur, President, Federation of Resident Doctors Association (FORDA) said, "We are happy with the ministry’s decision to include the interns by extending dates. The internship completion date for the final year MBBS students is August 11, 2023, and the exam date of the NEET PG exam is March 5, 2023. There will be a gap of six months between the exam and the counselling date. So, If the NEET PG exam will be postponed to a later date, then this time will be helpful for medical aspirants to prepare well for the exam.”

Students plight

With rumours abounding of a possible postponement, students claim to be suffering from anxiety and stress regarding the lack of clarity on the exam date.

Aditya Jha, NEET PG aspirant commented, “Other than sitting idle, we cannot do anything in the time gap between the exam and counselling date. On top of that, the ongoing rumours about the NEET PG postponement are resulting in stress and anxiety at this already stressful time of preparing for the impending exam. The ministry should understand the dilemma of the students. Postponing the NEET PG exam for six to eight weeks will be extremely beneficial, but the decision should come as early as possible to alleviate us of this unnecessary stress.”

Another aspirant Rahul Patil, who is working hard for his second attempt at the NEET PG exam commented, “Next year, the exam will be changed to the NExT PG exam and the pattern will change, this is our last chance to qualify for this exam. So, we want extra time because we had only four-five months from the last examination and the last counselling. The last counselling was completed in January this year, It was a very short time for us to prepare for all the subjects of a five-year course which include almost 1821 subjects, it’s really difficult, and we need extra time to excel in this exam.”

As the ongoing uncertainty about the postponement of NEET PG is creating nervousness amongst the students, Dr Agarwal advised, “Medical aspirants should focus on their studies. They should forget about the exam when it will happen. Because there is no point in wasting their time on agitation. We at IMA are pursuing the ministry and I am 100 per cent sure that the ministry will take appropriate action and decisions in favour of the students. But the students should not waste their time. They should focus on their studies.”

Demands for postponement of the NEET PG exam has become a trend in the last few years. When analysed comprehensively, it can be seen that post-COVID, with the disruption of the academic cycle, similar demands for rescheduling NEET PG have been made in 2019, 2020, 2021,2022. Thus the postponement of the NEET PG exam is suspenseful even though NBE has confirmed March 5, 2023, for the NEET PG exam.

The MarketWatch News Department was not involved in the creation of this content.

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The NEET is a pre-medical entrance test for admissions in undergraduate medical courses such as MBBS and BDS and also for post-graduate courses in government and private medical colleges

Representative Image. Pic/iStock

The Tamil Nadu government has moved the Supreme Court challenging the validity of the National Eligibility cum Entrance Examination (NEET) for admissions in medical courses in colleges across the nation, alleging that the single window common test is violative of the principle of federalism.

The NEET is a pre-medical entrance test for admissions in undergraduate medical courses such as MBBS and BDS and also for post-graduate courses in government and private medical colleges.

In a lawsuit, filed under Article 131 of the Constitution, the state government has alleged that the principle of federalism, which is part of the basic structure of the Constitution, is being violated by examinations like NEET as it takes away the autonomy of states to make decisions regarding education.

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The plea, filed through lawyer Amit Anand Tiwari, said the validity of NEET was upheld in 2020 by the apex court on grounds that it was required to curb the evil of unfair practises such as granting admission based on paying capacity of candidates, charging capitation fee, large-scale malpractices, exploitation of students, profiteering, and commercialisation.

However, such grounds are not applicable in the case of admissions to government seats and the reasoning of the judgment is applicable only to private college seats, it said, adding the verdict upholding the NEET does not bind a state in so far as admissions to government seats are concerned.

The suit seeks a decree declaring that Sections 14 of the National Medical Commission Act, 2019, the National Commission for Indian System of Medicine Act, 2020 and the National Commission of Homeopathy Act, 2020, Regulations 9 and 9A of the Post-Graduate Medical Education Regulations, 2000, Regulations I(2), I(5) and II of the BDS Course Regulations, 2007 respectively are violative of Article 14 of the Constitution, violate federalism and therefore void”. 

This story has been sourced from a third party syndicated feed, agencies. Mid-day accepts no responsibility or liability for its dependability, trustworthiness, reliability and data of the text. Mid-day management/mid-day.com reserves the sole right to alter, delete or remove (without notice) the content in its absolute discretion for any reason whatsoever.