The role of platelet-rich plasma in androgenetic alopecia: A systematic review

BACKGROUND

Androgenetic alopecia (AGA), also referred to as male or female pattern hair loss, is the commonest cause of chronic hair loss and affects up to 80% of men by the age of 70. Despite a high prevalence, there are few approved therapies, which show minimal efficacy.

OBJECTIVES

This systematic review aims to evaluate the efficacy of platelet-rich plasma (PrP) in the treatment of AGA in male patients.

METHODS

MEDLINE, EMBASE, Cochrane (CENTRAL), CINAHL, clinicaltrials.gov, Google Scholar and the Science Citation Index database were searched to identify eligible studies. All randomized controlled trials (RCTs) and prospective cohort studies related to PrP use in AGA were included. Primary outcomes included changes in hair density and hair count. Methodological quality was assessed using bias assessment tools.

RESULTS

Eight RCTs and one cohort study were included in the review with a total of 291 participants. Six studies reported a statistically significant increase in hair density in the PrP group versus the control. Five studies reported a statistically significant increase in hair count with PrP. Seven studies showed moderate risk and two showed low risk of bias.

CONCLUSION

In a methodologically robust review on the effectiveness of PrP on male AGA, PrP demonstrated some potential to be used therapeutically. However, the low quality of evidence, moderate risk of bias, and high heterogeneity of included studies limit inferences and call for more robust designs to investigate this further.

High-Intensity Focused Electromagnetic (HIFEM) Energy With and Without Radiofrequency for Noninvasive Body Contouring: A Systematic Review

BACKGROUND

Emsculpt Neo (EmSculpt NEO Device, BTL Industries, Inc.) is a FDA-cleared noninvasive body contouring treatment for increasing muscle tone and/or reducing fat. The device uses high-intensity electromagnetic energy to stimulate muscle contractions and to build muscle mass (Emsculpt) or a combination of electromagnetic energy with radiofrequency (Emsculpt NEO) to produce a synergistic effect of building muscle mass and reducing fat. In this study, we conduct a high-quality systematic review to evaluate outcomes for Emsculpt and Emsculpt NEO treatments for noninvasive body contouring.

METHODS

An electronic search was performed of the PubMed, MEDLINE, Embase, and Web of Science databases using the key terms "High intensity focused electromagnetic therapy; HIFEM; Emsculpt; Emsculpt NEO; BTL Industries." The search included all articles published in English through January 2023. Inclusion criteria included articles noninvasive body contouring and reporting at least one outcome of interest (clinical or patient-reported outcomes). Methodological quality and risk of bias were assessed using the GRADE criteria. Articles involving applications other than for body contouring, animal studies, and review articles were excluded.

RESULTS

Of the 159 articles identified in the initial search strategy, 51 met relevance based on abstract screening. Fifteen clinical studies were identified, including Emsculpt (n=11) and Emsculpt NEO (n=2). The typical protocol involved four treatments given over a 2-4-week period (range 3-8 treatments) with increase to 100% intensity setting and 1-6-month follow-ups. No complications were reported. Abdominal measurements were obtained using imaging were reported in eight studies. Treated areas included the buttocks (n=4), thighs (n=3), arms or calves (n=1), and abdomen (n=11). For abdominal contouring, mean reductions of fat thickness were 5.5 mm, muscle thickness of 2 mm, and rectus diastasis improvement of 3.0 mm. No studies reported weight change before and after treatment. All studies with patient-reported outcomes report high patient satisfaction. Two studies report marginal or no benefit of treatment. Certain studies failed to report comorbidities or demographic characteristics other than age and sex, which precludes analysis of specific subgroups that may benefit from treatment. Furthermore, certain studies failed to address how missing data or the final study population was analyzed.

CONCLUSION

This systematic review reports on currently published evidence regarding the efficacy and safety of Emsculpt and Emsculpt NEO for body contouring. High-quality level data reporting with patient-reported outcomes will optimize shared decision-making and informed consent.

LEVEL OF EVIDENCE II

Therapeutic study. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Application of a Microsuction Background Device for Microanastomosis in a Rat Femoral Vessel Model

SUMMARY

Microvascular anastomoses can be challenging to perform when edematous fluids and blood continuously flood and compromise the field of view. Intermittent irrigation and suctioning disturb workflow, require an assistant, and can increase risk of arterial thrombosis from vessels being drawn into suction drains. The authors developed and patented a novel three-dimensionally printed background device with microfluidic capabilities to provide autonomous, continuous irrigation and suction to optimize operator autonomy and efficiency. The authors tested this in a rat femoral vessel model. Twelve end-to-end anastomoses were performed by two senior microsurgeons [six conventional, six suction-assisted background (SAB)] in a rat femoral artery model. The primary outcome was time taken to complete the anastomosis. Secondary outcomes included the validated Structured Assessment of Microsurgery Skills (SAMS) score and the total number of "wiping" events to obtain field clarity. Each procedure was recorded, and videos were independently rated by two blinded experts using the SAMS score. Time taken to complete the anastomosis was greater in the conventional group compared with the SAB group (741.7 ± 203.1 seconds versus 584 ± 155.9 seconds; P = 0.007). The median SAMS score was lower in the conventional group compared with the SAB group (32.3 ± 1.4 versus 38.3 ± 1.5; P = 0.001). The median number of wiping events was significantly greater in the conventional group compared with the SAB group (13 ± 2.2 versus 1.7 ± 1.2; P < 0.001). The authors show that a novel microfluidic background device allows continuous irrigation and suctioning without the need for an assistant, optimizing the efficiency of the microvascular anastomosis.

CLINICAL RELEVANCE STATEMENT

The authors have designed a novel, patented, three-dimensionally printed microsurgical background device that provides continuous irrigation and suction, reduces operative time, and provides better vessel clarity during a microsurgical anastomosis compared to standard background.

The Use of Hyaluronic Acid in Non-surgical Rhinoplasty: A Systematic Review of Complications, Clinical, and Patient-Reported Outcomes

INTRODUCTION

In cosmetic practices, non-surgical rhinoplasty using filler injections has become increasingly common. Nevertheless, the outcome and overall complications have not been studied as a systematic review in the literature. This study provides a high-quality systematic review of studies reporting clinical and patient-reported outcomes following non-surgical rhinoplasty with hyaluronic acid (HA) to further guide practitioners.

METHODS

This systematic review was conducted in accordance with PRISMA guidelines and was registered in PROSPERO. The search was conducted using MEDLINE, EMBASE, and Cochrane. The literature retrieval was conducted by three independent reviewers, and the remaining articles were screened by two independent reviewers. The quality of included articles was assessed using the MINORS and methodological quality and synthesis of case series and case reports tools.

RESULTS

A total of 874 publications were found based on the search criteria. A total of 3928 patients were reviewed for this systematic review from 23 full-text articles. For non-surgical rhinoplasty, Juvéderm ultra was the most commonly used HA filler. The nasal tip was most commonly injected (13 studies), followed by the columella (12 studies). Nasal hump deformities are the most common reason for non-surgical rhinoplasty. All studies showed high patient satisfaction. Among all patients reviewed, eight developed major complications.

CONCLUSION

Non-surgical rhinoplasty performed with HA has minimal side effects and a short recovery period. Furthermore, non-surgical rhinoplasty with HA results in high satisfaction. To strengthen the presently available evidence, further well-designed RCTs are needed.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266.

Sural communicating nerve for application as a vascularized nerve graft: A microneurovascular anatomic study in cadavers

INTRODUCTION

Sural nerve harvest causes paraesthesia to the lateral heel of the foot, which can debilitate those with already compromised proprioception. To circumvent this, we investigated an alternative donor nerve, branch of the lateral sural nerve complex called the sural communicating nerve (SCoNe), for its harvest and use as a vascularized nerve graft, in cadaver.

METHODS

The SCoNe was visualized by dissection in 15 legs from 8 human cadavers and the relationship of the SCoNe to the overall sural nerve complex was documented. The surface markings, dimensions, and the micro-neurovascular anatomy in the super-microsurgery range (up to 0.30 mm) of the SCoNe was recorded and analyzed.

RESULTS

SCoNe graft surface marking was confined within a triangle drawn between the fibular head laterally, the popliteal vertical midline medially and the tip of the lateral malleolus inferiorly. The proximal end of the SCoNe was situated at a mean intersection distance of 5 cm from both the fibular head and popliteal midline respectively. The mean length of the SCoNe was 226 ± 43 mm with a mean proximal diameter of 0.82 mm and mean distal diameter of 0.93 mm. In 53% of the cadavers, an arterial input was present in the proximal third of the SCoNe and veins were predominantly (87%) present in the distal third. In 46% and 20% of the 15 legs respectively, there was a nutrient artery and vein perfusing the SCoNe in its central segment. The external mean diameter of this artery was 0.60 ± 0.30 mm, while the vein was slightly larger with a mean diameter of 0.90 ± 0.50 mm.

DISCUSSION

SCoNe graft may preserve lateral heel sensation, compared to sural nerve harvest, pending clinical studies. It may have wide applications as a vascularized nerve graft, including being ideal as a vascularized cross-facial nerve graft because its nerve diameter is similar to the distal facial nerve branches. The accompanying artery is a good anastomotic match to the superior labial artery.

A Systematic Review of the Efficacy and Safety of Tranexamic Acid in Facelift Surgery

Tranexamic acid (TXA) has become widely utilized in different specialities including facelift surgery. The aim of this review was to robustly evaluate the quality of available evidence on the efficacy and safety of TXA use in facelift surgery. We searched the MEDLINE (National Institutes of Health, Bethesda, MD), Embase (Elsevier, Amsterdam, the Netherlands), CINAHL (EBSCO Information Services, Ipswich, MA), Cochrane Central Register of Controlled Trials (CENTRAL; Wiley, Hoboken, NJ), Google Scholar (Alphabet Inc. Mountain View, CA), Science Citation Index (Clarivate, London, UK), and Latin American and Caribbean Center on Health Sciences Information (LILACS; São Paulo, Brazil) databases for randomized controlled trials (RCTs) and observational studies. Primary outcomes were blood loss, postoperative hematoma, ecchymosis, and swelling, in addition to technical considerations and complications. We assessed review quality with the AMSTAR 2 tool, study quality with Grading of Recommendations, Assessment, Development, and Evaluations approach (GRADE) tool, and the risk of bias with Cochrane's RoB 2.0 tool for RCTs and ROBINS-I for nonrandomized studies. Of the 368 articles, a total of 3 studies including 150 patients met the inclusion criteria. The RCT reported a significant reduction in postoperative serosanguineous collections in the TXA group (P < .01), and in surgeon-rated postoperative ecchymosis and bruising. The prospective cohort study reported reduced drainage output in first 24 hours in the TXA group (P < .01). The retrospective cohort study reported lower intraoperative blood loss, mean postoperative day 1 drain output, percentage of drain removal on postoperative day 1, and number of days to drain removal in the TXA group (all P < .01). The quality of studies was moderate, and this review was the highest rated compared to previous reviews, as per the AMSTAR 2 tool. Based on limited literature, TXA improves clinical outcomes regardless of the route of administration. Topical TXA is an emerging route, expediting drain removal and reducing blood loss. Future Level I high-quality studies are required.

Comparing the Efficacy and Safety of Combination Triamcinolone Acetonide and 5-Fluorouracil versus Monotherapy Triamcinolone Acetonide or 5-Fluorouracil in the Treatment of Hypertrophic Scars and Keloids: A Systematic Review and Meta-Analysis

BACKGROUND

Keloids and hypertrophic scars cause physical and psychosocial problems. Combination 5-fluorouracil (5-FU) with triamcinolone acetonide (TAC) may enhance the treatment of pathological scars, although the evidence base is limited.

OBJECTIVES

We aimed to evaluate the efficacy and complication rates of combination intralesional TAC and 5-FU in comparison to monotherapy intralesional TAC or 5-FU for the treatment of keloids and hypertrophic scars.

METHODS

EMBASE, MEDLINE and CENTRAL were searched by two independent reviewers. The primary outcome was treatment efficacy (51% to 100% improvement). Study quality and risk of bias were assessed using Cochrane's risk of bias tool, respectively.

RESULTS

Of 277 articles screened, 13 studies were included comprising 12 randomised control trials (RCT) and 1 non-randomised study. There were six and nine studies comparing combination intralesional therapy versus monotherapy 5-FU and monotherapy TAC, respectively. The combined group demonstrated superior objective treatment efficacy compared to the monotherapy TAC group (OR 3.45, 95% C.I: [2.22-5.35], I 2=0%, P<0.00001) and monotherapy 5-FU group (OR 4.17, 95% C.I: [2.21-7.87], I 2=0%, P<0.0001). Telangiectasia was less frequent in combination therapy (OR 0.24, 95% CI: [0.11-0.52], I 2=0%, P=0.0003) compared to monotherapy TAC.

CONCLUSIONS

Combined intralesional TAC and 5-FU administration demonstrated superior treatment efficacy outcomes compared to monotherapy TAC or 5-FU. Patient-reported outcome measures, lacking here, should be incorporated in the design of future research to justify clinical recommendations.

A Cross-Sectional Study on Inequity and Unmet Needs in Conducting Systematic Reviews (SRMA) and Meta-Analysis Among Medical Students and Junior Doctors

Background

Systematic reviews and meta-analyses allow a transparent, rigorous, and replicable analysis to summarize the results of multiple related studies and are considered top of the evidence-based medicine study hierarchy. The COVID-19 pandemic has shed light on the unmet educational needs of students worldwide, notably those from underprivileged backgrounds. This cross-sectional study aimed to ascertain students' and junior doctors' attitudes on their current knowledge, confidence and preparedness of appraising and conducting systematic reviews and meta-analysis internationally.

Methods

A free online webinar was held in May 2021 by the senior author and a pre-event questionnaire was distributed. Responses collected were used for analysis anonymously to ascertain students' knowledge, experience, and confidence in preparing a systematic review and meta-analysis using a 1-5 Likert scale using IBM SPSS 26.0. Associations were examined using Chi-square and crosstabs analysis.

Results

Out of 2004 responses from 104 countries included in the analysis, the majority of delegates were from lower middle-income countries and were not familiar with the PRISMA checklist (59.2% and 81.1% respectively of the total number of participants). The majority had never attended any formal training (83%) and felt their medical institute gave them minimal advice (72.5%) in preparing systematic reviews. Among those who had attended formal training, the proportion was significantly higher in those belonging to high and upper middle-income countries combined (20.3%) than lower and lower-middle-income countries combined (15%).

Conclusion

This study highlights gaps that need addressing to enhance the knowledge of medical students and junior doctors performing systematic reviews and meta-analyses. Clear disparities are found in country income and the level of education. Future large-scale studies are needed to understand the rationale of working on online research projects and the opportunities available to medical students and junior doctors that may lead to medical curriculum changes.

Smile Outcomes When Using Masseteric Nerve-based Nerve Transfers versus Direct Muscle Neurotization in Facial Palsy Patients

When dealing with a weak smile, nerve transfer is a viable strategy. We evaluated outcomes of masseteric nerve to facial nerve transfers and compared them with direct muscle neurotization (DMN).

Methods

In a retrospective cohort study of 20 patients (n = 20), we compared nerve transfer versus DMN over a 6-year period (2016-2021). Outcomes were measured using the validated Sunnybrook score, Ackerman Smile Index, and Terzis scores. Statistical analysis was performed using the Wilcoxon sign rank and Mann-Whitney U tests.

Results

Comparing pre- versus postoperative scores after nerve transfers, there was a significant improvement in median overall Sunnybrook score (24 versus 47, P = 0.043), lip elevation (1 versus 2, P = 0.046), open mouth smile (1 versus 3, P = 0.003), and Terzis scores (1 versus 3, P = 0.005), with no difference in resting symmetry (-15 versus -5; P = 0.496). Compared with DMN, there was no difference in median Terzis score improvement from preoperative to postoperative state (2 versus 1, P = 0.838), median smile improvement (2 versus 2, P = 0.838), resting symmetry (10 versus 5, P = 0.144) or overall Sunnybrook score (23 versus 21, P = 1.000). Lip elevation improvement was in favor of nerve transfers (1 versus 0, P = 0.047).

Conclusions

This is the first study evaluating nerve transfer neurotization of smile-mimetic muscles and comparing the outcomes with DMN, with masseteric nerve as donor. Nerve transfer leads to improved facial mimetic function, smile excursion and open mouth smiles, as does DMN, with improvement in lip elevation in favor of nerve transfer. Nerve transfer was preferred for more severe smile weakness.

MicroSUCI: A Microsurgical Background That Incorporates Suction Under Continuous Irrigation

The microsurgical anastomosis is integral to the success of autologous-free tissue transfer. Successful performance of this procedure relies strongly on operator dexterity, which can be made more challenging when blood and edematous fluids obscure the field of view. Workflow is impeded by intermittent irrigation and suctioning, necessitating presence of an assistant, with risk of arterial thrombosis, from vessels being drawn into suction drains. To negate these current disadvantages and minimize the barrier of entry to microvascular operations, we designed, manufactured, and patented a novel three-dimensional printed microsurgical background device with microfluidic capabilities that allow continuous suction and irrigation as well as provide platforms that enable multiangle retraction to facilitate operator autonomy. This was validated in an ex vivo model, with the device found to be superior to the current standard. We believe that this will have major applicability to the improvement of microsurgeon.

Efficacy and Complications of External and Internal Pediatric Blepharoptosis Repair Techniques: A Systematic Review

PURPOSE

To review and evaluate the efficacy and complication rates of external and internal blepharoptosis repair techniques in pediatric patients.

METHODS

The systematic review protocol was published on PROSPERO (CRD42020197343). Embase, MEDLINE, CENTRAL, and ClinicalTrials.gov were searched without date limitations. Two independent reviewers evaluated the articles for inclusion. Study quality and risk of bias were assessed using GRADE and Cochrane's ROBINS-I tool, respectively.

RESULTS

Of 2,228 articles screened, 23 studies involving 730 patients were included. There were 20 case series and 3 retrospective cohort studies, but no randomized controlled studies. Overall study quality was low with serious risk of bias according to the GRADE and ROBINS-I criteria, respectively. External levator resection was the most studied procedure, evaluated in 18 studies. Seven studies investigated internal approaches including the Fasanella-Servat procedure. There was no standardized evaluation of surgical efficacy. Reoperation rates were 16.6% (range 3.6-50.9%) for external levator resection compared with 22.2% (range 0.0-25.8%) for internal approaches. The commonest postoperative complications were not sight-threatening. The most consistently reported complication was undercorrection, occurring at rates of 8.4% (range 2.4-16.7%) and 15.3% (range 2.7-75.0%) for external levator resection and internal approaches, respectively. There were no consistently applied, validated patient-reported outcomes or cosmetic outcomes.

CONCLUSIONS

External and internal approaches have been successfully employed in pediatric blepharoptosis repair. However, noncomparative designs and risk-of-bias limit existing studies. Thus, prospectively designed studies with standardized outcome measures are required to minimize reporting bias, facilitate evidence synthesis, and support clinical decision making.

The 100 Most-Cited Articles in Liposuction: A Bibliometric Analysis

BACKGROUND

Liposuction is one of the most common cosmetic surgical procedures performed worldwide. Despite previous citation analyses in plastic surgery, the most-cited works in liposuction have not yet been qualitatively or quantitatively appraised. We hypothesized that use of validated outcome measures and levels of evidence would be low among these articles. Thus, we performed a bibliometric analysis aiming to comprehensively review the most-cited liposuction literature, evaluating characteristics and quality of the top 100 articles.

METHODS

The 100 most-cited articles in liposuction were identified on Web of Science, across all available journals and years (1950-2020). Study details, including the citation count, main subject, and outcome measures, were extracted from each article by 2 independent reviewers. The level of evidence of each study was also assessed.

RESULTS

The 100 most-cited articles in liposuction were cited by a total of 4809 articles. Citations per article ranged from 602 to 45 (mean, 92). Most articles were level of evidence 4 (n = 33) or 5 (n = 35), representative of the large number of case series, expert-opinion articles, and narrative reviews. Ten articles achieved level of evidence 3, 22 articles achieved level of evidence 2, and none reached level 1. The main subject was operative technique in 63 articles, followed by outcomes in 32 articles. Five articles assessed the metabolic effects of liposuction. Only 1 article used a validated objective cosmetic outcome measure, and none used validated patient-reported outcome measures.

CONCLUSIONS

This analysis provides an overview of the top cited liposuction literature. Overall, level of evidence was low, and no articles achieved the highest level of evidence. Improving the quality of literature requires prioritization of better-designed studies and incorporation of validated outcome measures, which will increase patient satisfaction and ensure provision of excellent, reproducible clinical care.

Evaluating the Usefulness and Acceptability of a Revision-Purposed 'Specialties' Webinar for Educating UK-Based Fifth and Final Year Medical Students During the COVID-19 Pandemic: Is This the Future of Medical Education?

BACKGROUND

To assess whether an online course is a useful method of learning for medical students revising for specialty examinations in the context of social distancing restrictions during the COVID-19 pandemic.

METHODS

A free, one-day webinar was offered to fifth and final year medical students with an examination-based approach. Teaching was delivered by trainees in Psychiatry, Obstetrics and Gynaecology and Paediatrics (the 'specialties'). An online, questionnaire-based cross-sectional study was conducted to assess usefulness and acceptability of the webinar by enrolled students, who were invited to complete the research questionnaire. Student responses pertaining to knowledge, confidence and interest, pre- and post-webinar, were collected and analysed.

RESULTS

A total of 247 students attended the webinar, with a 98.4% response rate to the questionnaire. Ninety-one percent of students agreed that webinars offer flexibility and convenience. About 55.1% felt that the pandemic had impacted their ability to learn new information. About 92.7% felt that the webinar was useful. Matched data showed an increase in participants' knowledge (p = <0.001) and confidence (p < 0.001).

CONCLUSION

Online learning provides a useful, accessible and safe method of providing medical education in the context of the global pandemic. Webinars adopting a lecture-based, examination-style approach improved students' perceived confidence and knowledge.

Changing Student Perception of an Online Integrated Structured Clinical Examination During the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has created a hiatus in in-person clinical assessments due to safety and logistical concerns. We aimed to evaluate student perception and utility of an online Integrated Structured Clinical Examinations (ISCEs) during the pandemic.

METHODS

Final-year medical students from a single institution were offered an online mock ISCE through a student-to-student ("near-peer") teaching-programme. A questionnaire-based cross-sectional study was conducted pre- and post-online mock ISCE.

RESULTS

Sixty-four students completed the study. Pre- and post-data showed an increase in confidence (p<0.0001), less worry regarding the online format (p<0.0001) and less anxiety about excelling in ISCEs (p<0.001). Students felt that having done the mock, an online format would more positively affect their overall performance (p=0.007).

CONCLUSION

This study demonstrates a positive change in student perception and confidence in online ISCEs. Online ISCEs are thus feasible, though sole reliance on this format may provide an incomplete assessment of student's overall clinical competency.

Prospective assessment of a critical appraisal teaching programme on medical students' confidence and performance in appraising medical literature

BACKGROUND

Previous research has demonstrated that medical students have insufficient knowledge of critical appraisal, a fundamental aspect of evidence-based medicine. We aimed to enhance medical students' critical appraisal skills using an innovative mixed-methods programme.

METHODS

We designed a 2-day, mixed-methods, national teaching programme, including an interactive lecture and workshop, quiz and viva-style examination. Course efficacy was assessed using pre- and post-course confidence questionnaires and a quiz adapted from the validated Berlin Questionnaire. Data were analysed primarily using Wilcoxon Signed Ranks test.

RESULTS

Fifty-nine participants from 17 medical schools completed the programme. Pre- and post-course scores demonstrated significant improvement in confidence (median score 5 vs 8; p < 0.001) and quiz performance (median score 9 vs 13; p < 0.001).

CONCLUSION

Our study demonstrates the efficacy of a novel mixed-methods programme in teaching medical students about critical appraisal. Implementation of our approach within the undergraduate curriculum should enhance the uptake of these fundamental skills.

Virtual Interview, Real Anxiety: Prospective Evaluation of a Focused Teaching Programme on Confidence Levels Among Medical Students Applying for Academic Clinical Posts

BACKGROUND

In 2020, final year medical students applying for the United Kingdom's competitive academic training posts face an additional challenge because interviews are conducted online rather than in-person. We assessed how this new format influences anxiety and the impact of a targeted course on candidates' confidence levels.

METHODS

A mixed-methods national teaching programme including online bespoke mock interviews was delivered to prospective Academic Foundation Programme applicants. Pre- and post-interview questionnaires assessed anxiety levels subjectively and using a Measure of Anxiety in Selection Interviews (MASI) scores.

RESULTS

Individuals self-reported greater confidence, experience and preference for interviews delivered in-person as compared to online interviews. Post-course, there was an increase in self-reported confidence specific to online interviews (p = 0.009) and lower MASI scores in three of five domains, indicating reduced anxiety (social anxiety: p = 0.004, performance anxiety: p <0.001, behavioral anxiety: p = 0.003).

CONCLUSION

A structured course can increase confidence and reduce anxiety for online academic medicine interviews.

Machine Learning Demonstrates High Accuracy for Disease Diagnosis and Prognosis in Plastic Surgery

INTRODUCTION

Machine learning (ML) is a set of models and methods that can detect patterns in vast amounts of data and use this information to perform various kinds of decision-making under uncertain conditions. This review explores the current role of this technology in plastic surgery by outlining the applications in clinical practice, diagnostic and prognostic accuracies, and proposed future direction for clinical applications and research.

METHODS

EMBASE, MEDLINE, CENTRAL and ClinicalTrials.gov were searched from 1990 to 2020. Any clinical studies (including case reports) which present the diagnostic and prognostic accuracies of machine learning models in the clinical setting of plastic surgery were included. Data collected were clinical indication, model utilised, reported accuracies, and comparison with clinical evaluation.

RESULTS

The database identified 1181 articles, of which 51 articles were included in this review. The clinical utility of these algorithms was to assist clinicians in diagnosis prediction (n=22), outcome prediction (n=21) and pre-operative planning (n=8). The mean accuracy is 88.80%, 86.11% and 80.28% respectively. The most commonly used models were neural networks (n=31), support vector machines (n=13), decision trees/random forests (n=10) and logistic regression (n=9).

CONCLUSIONS

ML has demonstrated high accuracies in diagnosis and prognostication of burn patients, congenital or acquired facial deformities, and in cosmetic surgery. There are no studies comparing ML to clinician's performance. Future research can be enhanced using larger datasets or utilising data augmentation, employing novel deep learning models, and applying these to other subspecialties of plastic surgery.

592 Surgical Management of Open Tibia Fractures at A Major Trauma Centre: A Review of Cases Over A One-Year Period

Introduction

The BOAST/BAPRAS updated the open fracture guidelines in December 2017 to replace BOAST 4 Open fracture guidelines; the changes gave clearer recommendations for timing of surgery and recommendations for reducing infection rates.

Method

Our work retrospectively evaluates the surgical management of open tibia fractures at a Major Trauma Centre (MTC), over a one-year period in light of key standards (13,14 and 15 of the standards for open fractures).

Results

The vast majority of cases (93%) had definitive internal stabilization only when immediate soft tissue coverage was achievable. 90% of cases were not managed as ‘clean cases’ following the initial debridement. 50% of cases underwent definitive closure within 72 hours. The reasons for definitive closure beyond 72hours were: patients medically unwell (20%), multiple wound debridement’s (33%) and no medical or surgical reason was clearly stated (47%).

Conclusions

The implementation of a ‘clean surgery’ protocol following surgical debridement is essential in diminishing risk of recontamination and infection. Hence, this must be the gold standard and should be clearly documented in operation notes. The extent of availability of a joint Orthoplastic theatre list provides a key limiting step in definitive bony fixation and soft tissue coverage of open tibia fractures.

594 Optimising Hand Trauma Care at a Major Trauma Centre (MTC) During the COVID-19 Pandemic

Introduction

This study evaluates the management of hand injuries during COVID-19 following the prompt implementation of the BOA guidelines; reconfiguration of hand services and implementation of the ‘one-stop’ model.

Method

285 cases OVER A 1-MONTH PERIOD were RETROSPECTIVELY reviewed to evaluate the effectiveness of managing patients using the ‘one-stop’ model and the new Urgent Treatment Centre (UTC).

Results

277 patients were included in the study. During Covid-19, operative cases fell by 62%. 86.3% (239/277) of cases were managed in the UTC; 54.4% (130/239) required conservative management and 45.6% (109/239) required minor procedures (in UTC). REMOVABLE SPLINT USE was optimized through design of ‘softcasts’ for non-operative management of distal radius fractures. A patient education video: ‘softcast removal at home’ was created and in cases requiring sutures, 95.1% (39/41) were absorbable, thereby avoiding COVID-19 exposure for follow-up. Only 50.5% (140/277) of patients had formal follow-up arranged and patient information follow-up cards were developed.

Conclusions

The one-stop model prevents delay in definitive treatment, allows effective initial treatment, and minimizes the need for face-to-face follow up. In light of a possible second wave of COVID-19 cases, this new model should be considered for implementation by all hand’s units for the foreseeable future.

593 The Utility of Routine Operative Swab Culture in Uncomplicated Peri-Anal Abscesses

Introduction

Despite perianal abscess being a common presentation, certain aspects of its management remain controversial, especially the routine use of intra-operative swab cultures.

Method

A retrospective review of patients that underwent incision and drainage procedures for a perianal abscess over a six-month period was undertaken.

Results

Over 6 months, 50 patients were identified. The male to female ratio was 3:1 and median ASA score was 1. Only 6/50 patients presented with recurrent abscess and 1 patient had history of inflammatory bowel disease. On the basis of operative findings, 39 patients (78%) had uncomplicated abscess (not associated with cellulitis, sinus or fistula); swab cultures were performed in 26 (67%) of these patients. All patients were discharged on the same day; microbiology reports did not impact the treatment and no patients were followed up in clinic post-operatively or presented with recurrence. The number of unnecessary microbiology swabs undertaken in this cohort equates to approximately 52 unnecessary swabs a year. The cost of one swab is £10.10p, which means £520 could potentially be saved annually.

Conclusions

Routine intra-operative swab cultures do not impact management decisions, add to unnecessary costs and therefore should not be undertaken in uncomplicated or first presentation of peri-anal abscesses.

Workplace factors associated with mental health of healthcare workers during the COVID-19 pandemic: an international cross-sectional study

BACKGROUND

The association of workplace factors on mental health of healthcare workers (HCWs) during the COVID-19 pandemic needs to be urgently established. This will enable governments and policy-makers to make evidence-based decisions. This international study reports the association between workplace factors and the mental health of HCWs during the pandemic.

METHODS

An international, cross-sectional study was conducted in 41 countries. The primary outcome was depressive symptoms, derived from the validated Patient Health Questionnaire-2 (PHQ-2). Multivariable logistic regression identified factors associated with mental health outcomes. Inter-country differences were also evaluated.

RESULTS

A total of 2527 responses were received, from 41 countries, including China (n = 1213; 48.0%), UK (n = 891; 35.3%), and USA (n = 252; 10.0%). Of all participants, 1343 (57.1%) were aged 26 to 40 years, and 2021 (80.0%) were female; 874 (34.6%) were doctors, and 1367 (54.1%) were nurses. Factors associated with an increased likelihood of depressive symptoms were: working in the UK (OR = 3.63; CI = [2.90-4.54]; p < 0.001) and USA (OR = 4.10; CI = [3.03-5.54]), p < 0.001); being female (OR = 1.74; CI = [1.42-2.13]; p < 0.001); being a nurse (OR = 1.64; CI = [1.34-2.01]; p < 0.001); and caring for a COVID-19 positive patient who subsequently died (OR = 1.20; CI = [1.01-1.43]; p = 0.040). Workplace factors associated with depressive symptoms were: redeployment to Intensive Care Unit (ICU) (OR = 1.67; CI = [1.14-2.46]; p = 0.009); redeployment with perceived unsatisfactory training (OR = 1.67; CI = [1.32-2.11]; p < 0.001); not being issued with appropriate personal protective equipment (PPE) (OR = 2.49; CI = [2.03-3.04]; p < 0.001); perceived poor workplace support within area/specialty (OR = 2.49; CI = [2.03-3.04]; p < 0.001); and perceived poor mental health support (OR = 1.63; CI = [1.38-1.92]; p < 0.001).

CONCLUSION

This is the first international study, demonstrating that workplace factors, including PPE availability, staff training pre-redeployment, and provision of mental health support, are significantly associated with mental health during COVID-19. Governments, policy-makers and other stakeholders need to ensure provision of these to safeguard HCWs' mental health, for future waves and other pandemics.

The effect of smoking on COVID-19 severity: A systematic review and meta-analysis

Various comorbidities represent risk factors for severe coronavirus disease 2019 (COVID‐19). The impact of smoking on COVID‐19 severity has been previously reported in several meta‐analyses limited by small sample sizes and poor methodology. We aimed to rigorously and definitively quantify the effects of smoking on COVID‐19 severity. MEDLINE, Embase, CENTRAL, and Web of Science were searched between 1 December 2019 and 2 June 2020. Studies reporting smoking status of hospitalized patients with different severities of disease and/or at least one clinical endpoint of interest (disease progression, intensive care unit admission, need for mechanical ventilation, and mortality) were included. Data were pooled using a random‐effects model. This study was registered on PROSPERO: CRD42020180920. We analyzed 47 eligible studies reporting on 32 849 hospitalized COVID‐19 patients, with 8417 (25.6%) reporting a smoking history, comprising 1501 current smokers, 5676 former smokers, and 1240 unspecified smokers. Current smokers had an increased risk of severe COVID‐19 (risk ratios [RR]: 1.80; 95% confidence interval [CI]: 1.14‐2.85; P = .012), and severe or critical COVID‐19 (RR: 1.98; CI: 1.16‐3.38; P = .012). Patients with a smoking history had a significantly increased risk of severe COVID‐19 (RR: 1.31; CI: 1.12‐1.54; P = .001), severe or critical COVID‐19 (RR: 1.35; CI: 1.19‐1.53; P < .0001), in‐hospital mortality (RR: 1.26; CI: 1.20‐1.32; P < .0001), disease progression (RR: 2.18; CI: 1.06‐4.49; P = .035), and need for mechanical ventilation (RR: 1.20; CI: 1.01‐1.42; P = .043). Patients with any smoking history are vulnerable to severe COVID‐19 and worse in‐hospital outcomes. In the absence of current targeted therapies, preventative, and supportive strategies to reduce morbidity and mortality in current and former smokers are crucial.

The first high‐quality systematic review and meta‐analysis assessing the impact of smoking on COVID‐19 severity.

To date, the largest meta‐analysis among peer‐reviewed literature assessing the impact of smoking on COVID‐19 severity, including 32,849 hospitalised patients with COVID‐19.

Patients who were current smokers had an increased risk of severe COVID‐19 and severe or critical COVID‐19.

Patients with a smoking history had an increased risk of severe COVID‐19, severe or critical COVID‐19, in‐hospital mortality, disease progression and need for mechanical ventilation.

Case report: Neoadjuvant systemic therapy for melanoma

We report a case of rapidly enlarging metastatic melanoma in 45-year-old White male following primary resection of thin melanoma five years ago. Location and large size of the lesion possessed significant risk of complications from surgery, therefore provided a challenge in treatment options. Neoadjuvant targeted chemotherapy was commenced and resulted in a significant reduction in size of the lesion, which allowed subsequent safe surgical resection with no residual disease on histopathology results. This case provides a good example of successful utilization of neoadjuvant systemic therapy in advanced metastatic melanoma.

Modern Plastic Surgical Practice: Technical Competence Alone Is Not Enough

Annually, an estimated 234 million major surgical operations occur worldwide, with concomitant seven million complications and one million deaths. It is now well established that technical competence is necessary, but not sufficient for modern surgical practice and outcomes. Breakdown in non-technical skills has been attributed as a key root cause for near misses and patient harm in the operating room. This article discusses the multi-faceted skills-set that is necessary for the modern surgeon to succeed and for optimal patient outcomes. This includes technical skills, non-technical skills, with a focus on key CanMEDS framework domains, including leadership, communication, evidence-based surgery and mentorship.

Immediate and delayed autologous abdominal microvascular flap breast reconstruction in patients receiving adjuvant, neoadjuvant or no radiotherapy: a meta-analysis of clinical and quality-of-life outcomes

BACKGROUND

Effects of postmastectomy radiotherapy (PMRT) on autologous breast reconstruction (BRR) are controversial regarding surgical complications, cosmetic appearance and quality of life (QOL). This systematic review evaluated these outcomes after abdominal free flap reconstruction in patients undergoing postoperative adjuvant radiotherapy (PMRT), preoperative radiotherapy (neoadjuvant radiotherapy) and no radiotherapy, aiming to establish evidence-based optimal timings for radiotherapy and BRR to guide contemporary management.

METHODS

The study was registered on PROSPERO (CRD42017077945). Embase, MEDLINE, Google Scholar, CENTRAL, Science Citation Index and ClinicalTrials.gov were searched (January 2000 to August 2018). Study quality and risk of bias were assessed using GRADE and Cochrane's ROBINS-I respectively.

RESULTS

Some 12 studies were identified, involving 1756 patients (350 PMRT, 683 no radiotherapy and 723 neoadjuvant radiotherapy), with a mean follow-up of 27·1 (range 12·0-54·0) months for those having PMRT, 16·8 (1·0-50·3) months for neoadjuvant radiotherapy, and 18·3 (1·0-48·7) months for no radiotherapy. Three prospective and nine retrospective cohorts were included. There were no randomized studies. Five comparative radiotherapy studies evaluated PMRT and four assessed neoadjuvant radiotherapy. Studies were of low quality, with moderate to serious risk of bias. Severe complications were similar between the groups: PMRT versus no radiotherapy (92 versus 141 patients respectively; odds ratio (OR) 2·35, 95 per cent c.i. 0·63 to 8·81, P = 0·200); neoadjuvant radiotherapy versus no radiotherapy (180 versus 392 patients; OR 1·24, 0·76 to 2·04, P = 0·390); and combined PMRT plus neoadjuvant radiotherapy versus no radiotherapy (272 versus 453 patients; OR 1·38, 0·83 to 2·32, P = 0·220). QOL and cosmetic studies used inconsistent methodologies.

CONCLUSION

Evidence is conflicting and study quality was poor, limiting recommendations for the timing of autologous BRR and radiotherapy. The impact of PMRT and neoadjuvant radiotherapy appeared to be similar.

The applications of machine learning in plastic and reconstructive surgery: protocol of a systematic review

BACKGROUND

Machine learning, a subset of artificial intelligence, is a set of models and methods that can automatically detect patterns in vast amounts of data, extract information and use it to perform various kinds of decision-making under uncertain conditions. This can assist surgeons in clinical decision-making by identifying patient cohorts that will benefit from surgery prior to treatment. The aim of this review is to evaluate the applications of machine learning in plastic and reconstructive surgery.

METHODS

A literature review will be undertaken of EMBASE, MEDLINE and CENTRAL (1990 up to September 2019) to identify studies relevant for the review. Studies in which machine learning has been employed in the clinical setting of plastic surgery will be included. Primary outcomes will be the evaluation of the accuracy of machine learning models in predicting a clinical diagnosis and post-surgical outcomes. Secondary outcomes will include a cost analysis of those models. This protocol has been prepared using the Preferred Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines.

DISCUSSION

This will be the first systematic review in available literature that summarises the published work on the applications of machine learning in plastic surgery. Our findings will provide the basis of future research in developing artificial intelligence interventions in the specialty.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019140924.

The impact of mobile technology on teamwork and communication in hospitals: a systematic review

OBJECTIVES

Effective communication is critical to the safe delivery of care but is characterized by outdated technologies. Mobile technology has the potential to transform communication and teamwork but the evidence is currently uncertain. The objective of this systematic review was to summarize the quality and breadth of evidence for the impact of mobile technologies on communication and teamwork in hospitals.

MATERIALS AND METHODS

Electronic databases (MEDLINE, PsycINFO, EMBASE, CINAHL Plus, HMIC, Cochrane Library, and National Institute of Health Research Health Technology Assessment) were searched for English language publications reporting communication- or teamwork-related outcomes from mobile technologies in the hospital setting between 2007 and 2017.

RESULTS

We identified 38 publications originating from 30 studies. Only 11% were of high quality and none met best practice guidelines for mobile-technology-based trials. The studies reported a heterogenous range of quantitative, qualitative, and mixed-methods outcomes. There is a lack of high-quality evidence, but nonetheless mobile technology can lead to improvements in workflow, strengthen the quality and efficiency of communication, and enhance accessibility and interteam relationships.

DISCUSSION

This review describes the potential benefits that mobile technology can deliver and that mobile technology is ubiquitous among healthcare professionals. Crucially, it highlights the paucity of high-quality evidence for its effectiveness and identifies common barriers to widespread uptake. Limitations include the limited number of participants and a wide variability in methods and reported outcomes.

CONCLUSION

Evidence suggests that mobile technology has the potential to significantly improve communication and teamwork in hospital provided key organizational, technological, and security challenges are tackled and better evidence delivered.

The evidence-base for the management of flexor tendon injuries of the hand: Review

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There is no consensus on the optimal flexor tendon repair technique at each anatomical flexor zone.

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There is paucity of high quality evidence.

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Heterogenous study designs limit inter-study comparisons.

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Patient reported outcome measures are crucial but there is a perennial need for robust disease-specific tools to be utilised.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Implementation of a checklist to enhance operation note quality at a UK burns centre

INTRODUCTION

Operation notes are fundamental for clinical, academic and medico-legal purposes. Good Surgical Practice (2014) provides guidelines to assist note completion but the literature suggests poor adherence to these. The aim of this study was to evaluate and improve operation note quality at a UK burns centre through implementation of a burns surgery-specific checklist.

METHODS

A 22-component burns surgery-specific checklist, modified from Good Surgical Practice (2014), was designed and implemented. The quality of 80 operation notes (40 pre and 40 post-implementation) was assessed against this checklist. Fisher's exact and Mann-Whitney U statistical tests were used to evaluate pre and post-intervention note quality.

RESULTS

Before checklist implementation, only 6/22 components (27.3%) were recorded on every note. 4/22 components (18.2%) were not recorded on any, including microbiology specimen and clinical photography, which are particularly important in burns. After implementation, 16/22 (72.7%) were recorded on every note, with a statistically significant improvement in all other components (p≤0.01), except venous thromboembolism prophylaxis (p=0.10). The median percentage score of components recorded improved from 78.2 to 100% (p<0.01).

CONCLUSION

To our knowledge, this is the first study in available literature to show that a burns surgery-specific checklist can significantly improve burns operation note quality. This presents a simple and cheap method to improve note quality and may enhance post-operative intra/inter-team communication and patient care. At our unit, we have now developed an electronic checklist format with mandatory field completion to facilitate total compliance.

Selective non-operative management for penetrating extremity trauma: A paradigm shift in management?

BACKGROUND

Selective non-operative management (SNOM) has been proposed as a safe and adequate strategy for penetrating extremity trauma (PET) management. This may reduce unwarranted surgical exploration and enhance cost-effectiveness. Our experience at a UK major trauma centre advocates SNOM-PET as a viable and safe strategy for selected patients. A PET management algorithm is proposed.

METHODS

A retrospective review was undertaken for isolated PET from October 2015 to October 2016. Examination findings were recorded as positive if neurovascular or tendon deficits were elicited. Surgical exploration was recorded as positive if neurovascular or tendon injuries were found. Diagnostic statistics were employed for upper limb (UL) and lower limb (LL) examinations.

RESULTS

One hundred sixty patients [112 UL and 48 LL PET injuries] were included. Fifty-six out of 112 (50%) patients with UL PET had no examination findings. Twenty-three out of 56 (41%) patients had negative surgical explorations and 33 of 56 (59%) patients had positive surgical explorations. Thirty-four out of 48 patients with LL PET had no examination findings. All 34 patients had negative surgical explorations. The sensitivity (0.61 vs 1.00, p = 0.005), specificity (0.82 vs 0.97, p = 0.043) and negative predictive value (NPV; 0.41 vs 1.00, p < 0.001) were lower for UL PET than for LL PET examinations. There were no statistically significant differences in sensitivity, specificity as well as NPV and positive predictive value between plastic surgery residents and emergency medicine residents for UL and LL examinations.

CONCLUSION

This is the first UK evaluation of SNOM-PET. It may be safely utilised for LL PET. UL PET should be surgically explored. SNOM-PET may avoid unwarranted surgical exploration, associated complications and cost.