Evaluating ChatGPT Responses on Atrial Fibrillation for Patient Education.

Background ChatGPT is a language model that has gained widespread popularity for its fine-tuned conversational abilities. However, a known drawback to the artificial intelligence (AI) chatbot is its tendency to confidently present users with inaccurate information. We evaluated the quality of ChatGPT responses to questions pertaining to atrial fibrillation for patient education. Our analysis included the accuracy and estimated grade level of answers and whether references were provided for the answers. Methodology ChatGPT was prompted four times and 16 frequently asked questions on atrial fibrillation from the American Heart Association were asked. Prompts included Form 1 (no prompt), Form 2 (patient-friendly prompt), Form 3 (physician-level prompt), and Form 4 (prompting for statistics/references). Responses were scored as incorrect, partially correct, or correct with references (perfect). Flesch-Kincaid grade-level unique words and response lengths were recorded for answers. Proportions of the responses at differing scores were compared using the chi-square analysis. The relationship between form and grade level was assessed using the analysis of variance. Results Across all forms, scoring frequencies were one (1.6%) incorrect, five (7.8%) partially correct, 55 (85.9%) correct, and three (4.7%) perfect. Proportions of responses that were at least correct did not differ by form (p = 0.350), but perfect responses did (p = 0.001). Form 2 answers had a lower mean grade level (12.80 ± 3.38) than Forms 1 (14.23 ± 2.34), 3 (16.73 ± 2.65), and 4 (14.85 ± 2.76) (p < 0.05). Across all forms, references were provided in only three (4.7%) answers. Notably, when additionally prompted for sources or references, ChatGPT still only provided sources on three responses out of 16 (18.8%). Conclusions ChatGPT holds significant potential for enhancing patient education through accurate, adaptive responses. Its ability to alter response complexity based on user input, combined with high accuracy rates, supports its use as an informational resource in healthcare settings. Future advancements and continuous monitoring of AI capabilities will be crucial in maximizing the benefits while mitigating the risks associated with AI-driven patient education.

Unlocking Health Literacy: The Ultimate Guide to Hypertension Education From ChatGPT Versus Google Gemini.

Background Google Gemini (Google, Mountain View, CA) represents the latest advances in the realm of artificial intelligence (AI) and has garnered attention due to its capabilities similar to the increasingly popular ChatGPT (OpenAI, San Francisco, CA). Accurate dissemination of information on common conditions such as hypertension is critical for patient comprehension and management. Despite the ubiquity of AI, comparisons between ChatGPT and Gemini remain unexplored. Methods ChatGPT and Gemini were asked 52 questions derived from the American College of Cardiology's (ACC) frequently asked questions on hypertension, following a specified prompt. Prompts included: no prompting (Form 1), patient-friendly prompting (Form 2), physician-level prompting (Form 3), and prompting for statistics/references (Form 4). Responses were scored as incorrect, partially correct, or correct. Flesch-Kincaid (FK) grade level and word count were recorded. Results Across all forms, scoring frequencies were as follows: 23 (5.5%) incorrect, 162 (38.9%) partially correct, and 231 (55.5%) correct. ChatGPT showed higher rates of partially correct answers than Gemini (p = 0.0346). Physician-level prompts resulted in a higher word count across both platforms (p < 0.001). ChatGPT showed a higher FK grade level (p = 0.033) in physician-friendly prompting. Gemini exhibited a significantly higher mean word count (p < 0.001); however, ChatGPT had a higher FK grade level across all forms (p > 0.001). Conclusion To our knowledge, this study is the first to compare cardiology-related responses from ChatGPT and Gemini, two of the most popular AI chatbots. The grade level for most responses was collegiate level, which was above average for the National Institutes of Health (NIH) recommendations, but on par with most online medical information. Both chatbots responded with a high degree of accuracy, with inaccuracies being rare. Therefore, it is reasonable that cardiologists suggest either chatbot as a source of supplementary education.

Pulmonary Embolism in Patients Admitted With Takotsubo Cardiomyopathy: Prevalence and Associated In-Hospital Adverse Events.

Introduction  Takotsubo cardiomyopathy (TCM) is a poorly understood condition typically characterized by abnormal left ventricular wall motion without causative coronary artery disease and typically presents in post-menopausal women after the experience of a physical or emotional stressor. The pathophysiology of TCM is complex and multifactorial, resulting in complications with varied severity; one of the most concerning complications is thromboembolism, specifically, pulmonary embolism (PE), which is understudied in its relation to TCM. The purpose of this study was to characterize and evaluate the real-world prevalence and outcomes of PE in TCM. Methods  Data were derived from the National Inpatient Sample database from January 2016 to December 2019. The primary outcomes assessed were baseline and hospital admission characteristics and comorbidities for patients with TCM with and without PE. Outcomes for TCM patients with PE and predictors of mortality in TCM were also analyzed. Results  PE developed in 788 of 40,120 patients with TCM (1.96%). After multivariate adjustment, PE was found to be independently associated with intracardiac thrombus (adjusted odds ratio (aOR) 2.067; 95% confidence interval (CI): 1.198-3.566; p = 0.009) and right heart catheterization (RHC) (aOR: 1.971; 95% CI: 1.160-3.350; p = 0.012). Mortality in patients with TCM was associated with, among other factors, age in years at admission (aOR: 1.104; 95% CI: 1.010-1.017; p = 0.001), African American race (aOR: 1.191; 95% CI: 1.020-1.391; p = 0.027), Asian or Pacific Islander race (aOR: 1.637; 95% CI: 1.283-2.090; p = 0.001), coagulopathy (aOR: 3.393; 95% CI: 2.889-2.986; p = 0.001), liver disease (aOR: 1.446; 95% CI: 1.147-1.824; p = 0.002), atrial fibrillation (aOR: 1.460; 95% CI: 1.320-1.615; p = 0.001), and pulmonary embolism (aOR: 2.217; 95% CI: 1.781-2.760; p = 0.001). Conclusion  In a large cohort of patients admitted with TCM, we found the prevalence of PE to be 1.96%. PE, along with comorbidities such as coagulopathy and atrial fibrillation, was found to be a significant predictor of mortality in this patient cohort.

Evaluating ChatGPT-3.5 and ChatGPT-4.0 Responses on Hyperlipidemia for Patient Education.

Introduction Hyperlipidemia is prevalent worldwide and affects a significant number of US adults. It significantly contributes to ischemic heart disease and millions of deaths annually. With the increasing use of the internet for health information, tools like ChatGPT (OpenAI, San Francisco, CA, USA) have gained traction. ChatGPT version 4.0, launched in March 2023, offers enhanced features over its predecessor but requires a monthly fee. This study compares the accuracy, comprehensibility, and response length of the free and paid versions of ChatGPT for patient education on hyperlipidemia. Materials and methods ChatGPT versions 3.5 and 4.0 were prompted in three different ways and 25 questions from the Cleveland Clinic's frequently asked questions (FAQs) on hyperlipidemia. Prompts included no prompting (Form 1), patient-friendly prompting (Form 2), and physician-level prompting (Form 3). Responses were categorized as incorrect, partially correct, or correct. Additionally, the grade level and word count from each response were recorded for analysis. Results Overall, scoring frequencies for ChatGPT version 3.5 were: five (6.67%) incorrect, 18 partially correct (24%), and 52 (69.33%) correct. Scoring frequencies for ChatGPT version 4.0 were: one (1.33%) incorrect, 18 (24.00%) partially correct, and 56 (74.67%) correct. Correct answers did not significantly differ between ChatGPT version 3.5 and ChatGPT version 4.0 (p = 0.586). ChatGPT version 3.5 had a significantly higher grade reading level than version 4.0 (p = 0.0002). ChatGPT version 3.5 had a significantly higher word count than version 4.0 (p = 0.0073). Discussion There was no significant difference in accuracy between the free and paid versions of hyperlipidemia FAQs. Both versions provided accurate but sometimes partially complete responses. Version 4.0 offered more concise and readable information, aligning with the readability of most online medical resources despite exceeding the National Institutes of Health's (NIH's) recommended eighth-grade reading level. The paid version demonstrated superior adaptability in tailoring responses based on the input. Conclusion Both versions of ChatGPT provide reliable medical information, with the paid version offering more adaptable and readable responses. Healthcare providers can recommend ChatGPT as a source of patient education, regardless of the version used. Future research should explore diverse question formulations and ChatGPT's handling of incorrect information.

Risk-stratified faecal immunochemical testing (FIT) for urgent colonoscopy in Lynch syndrome during the COVID-19 pandemic.

BACKGROUND: Lynch syndrome is a hereditary cancer disease resulting in an increased risk of colorectal cancer. Herein, findings are reported from an emergency clinical service implemented during the COVID-19 pandemic utilizing faecal immunochemical testing ('FIT') in Lynch syndrome patients to prioritize colonoscopy while endoscopy services were limited. METHODS: An emergency service protocol was designed to improve colonoscopic surveillance access throughout the COVID-19 pandemic in England for people with Lynch syndrome when services were extremely restricted (1 March 2020 to 31 March 2021) and promoted by the English National Health Service. Requests for faecal immunochemical testing from participating centres were sent to the National Health Service Bowel Cancer Screening South of England Hub and a faecal immunochemical testing kit, faecal immunochemical testing instructions, paper-based survey, and pre-paid return envelope were sent to patients. Reports with faecal haemoglobin results were returned electronically for clinical action. Risk stratification for colonoscopy was as follows: faecal haemoglobin less than 10 µg of haemoglobin/g of faeces (µg/g)-scheduled within 6-12 weeks; and faecal haemoglobin greater than or equal to 10 µg/g-triaged via an urgent suspected cancer clinical pathway. Primary outcomes of interest included the identification of highest-risk Lynch syndrome patients and determining the impact of faecal immunochemical testing in risk-stratified colonoscopic surveillance. RESULTS: Fifteen centres participated from June 2020 to March 2021. Uptake was 68.8 per cent amongst 558 patients invited. For 339 eligible participants analysed, 279 (82.3 per cent) had faecal haemoglobin less than 10 µg/g and 60 (17.7 per cent) had faecal haemoglobin greater than or equal to 10 µg/g. In the latter group, the diagnostic accuracy of faecal immunochemical testing was 65.9 per cent and escalation to colonoscopy was facilitated (median 49 versus 122 days, χ2 = 0.0003, P < 0.001). CONCLUSION: Faecal immunochemical testing demonstrated clinical value for Lynch syndrome patients requiring colorectal cancer surveillance during the pandemic in this descriptive report of an emergency COVID-19 response service. Further longitudinal investigation on faecal immunochemical testing efficacy in Lynch syndrome is warranted and will be examined under the 'FIT for Lynch' study (ISRCTN15740250).

Obesity and the Latissimus Dorsi Flap: A Radiologic Study.

Introduction: The increasing prevalence of obesity in patients with breast cancer has prompted a reappraisal of the role of the latissimus dorsi flap (LDF) in breast reconstruction. Although the reliability of this flap in obese patients is well-documented, it is unclear whether sufficient volume can be achieved through a purely autologous reconstruction (eg, extended harvest of the subfascial fat layer). Additionally, the traditional combined autologous and prosthetic approach (LDF + expander/implant) is subject to increased implant-related complication rates related to flap thickness in obese patients. The purpose of this study is to provide data on the thicknesses of the various components of the latissimus flap and discuss the implications for breast reconstruction in patients with increasing body mass index (BMI). Methods: Measurements of back thickness in the usual donor site area of an LDF were obtained in 518 patients undergoing prone computed tomography-guided lung biopsies. Thicknesses of the soft tissue overall and of individual layers (e.g., muscle, subfascial fat) were obtained. Patient, demographics including age, gender, and BMI were obtained. Results: A range of BMI from 15.7 to 65.7 was observed. In females, total back thickness (skin, fat, muscle) ranged from 0.6 to 9.4 cm. Every 1-point increase in BMI resulted in an increase of flap thickness by 1.11 mm (adjusted R2 of 0.682, P < .001) and an increase in the thickness of the subfascial fat layer by 0.513 mm (adjusted R2 of 0.553, P < .001). Mean total thicknesses for each weight category were 1.0, 1.7, 2.4, 3.0, 3.6, and 4.5 cm in underweight, normal weight, overweight, and class I, II, III obese individuals, respectively. The average contribution of the subfascial fat layer to flap thickness was 8.2 mm (32%) overall and 3.4 mm (21%), 6.7 mm (29%), 9.0 mm (30%), 11.1 mm (32%), and 15.6 mm (35%) in normal weight, overweight, class I, II, III obese individuals, respectively. Conclusion: The above findings demonstrate that the thickness of the LDF overall and of the subfascial layer closely correlated with BMI. The contribution of the subfascial layer to overall flap thickness tends to increase as a percentage of overall flap thickness with increasing BMI, which is favourable for extended LDF harvests. Because this layer cannot be separated from overall thickness on examination, these results are useful in estimating the amount of additional volume obtained from an extended latissimus harvest technique.

Introduction: La prévalence croissante d'obésité chez les patientes atteintes du cancer du sein a suscité une réévaluation du rôle du lambeau du grand dorsal (LGD) en reconstruction mammaire. La fiabilité de ce lambeau est bien établie en cas d'obésité, mais on ne sait pas si le volume suffit pour effectuer une reconstruction purement autologue (p. ex., prélèvement élargi de la couche adipeuse sous-aponévrotique). De plus, en cas d'obésité, la combinaison habituelle de l'approche autologue et prothétique (LGD+expanseur et implant) est liée à un taux de complications plus élevé lié aux implants à cause de l'épaisseur du lambeau. La présente étude visait à obtenir des données sur l'épaisseur des diverses parties du grand dorsal et à traiter des conséquences de la reconstruction mammaire chez les patientes ayant un IMC plus élevé. Méthodologie: Les chercheurs ont mesuré l'épaisseur du dos au siège habituel de prélèvement du LGD chez 518 patientes dans le cadre d'une biopsie pulmonaire orientée par tomodensitométrie en position couchée. Ils ont mesuré l'épaisseur globale du dos et l'épaisseur de chaque couche dans cette région. Ils ont également obtenu les données démographiques des patientes, y compris l'âge, le genre et l'IMC. Résultats: Les chercheurs ont observé une fourchette d'IMC de 15,7 à 65,7. Chez les femmes, l'épaisseur totale du dos (peau, adiposité, muscle) variait entre 0,6 et 9,4 cm. Chaque point ajouté à l'IMC est associé à une augmentation de l'épaisseur du lambeau de 1,11 mm (rapport de cote rajusté [RCR] de 0,682, p<0,001) et à une augmentation de l'épaisseur de la couche adipeuse sous-aponévrotique de 0,513 mm (RCR de 0,553, p<0,001). L'épaisseur totale moyenne pour chaque catégorie de poids correspondait à 1,0, 1,7, 2,4, 3,0, 3,6 et 4, cm chez les patientes en insuffisance pondérale, de poids normal, en surpoids et obèses de classe I, II et III, respectivement. L'apport moyen de la couche adipeuse sous-aponévrotique à l'épaisseur du lambeau était de 8,2 mm (32 %) globalement et de 3,4 mm (21 %), 6,7 mm (29 %), 9,0 mm (30 %), 11,1 (32 %) et 15,6 mm (35 %) chez les patientes de poids normal, en surpoids et obèses de classe I, II, III, respectivement. Conclusion: Les résultats précédents démontrent que l'épaisseur globale du LGD et de la couche sous-aponévrotique est étroitement liée à l'IMC. L'apport de la couche sous-aponévrotique a tendance à être proportionnel à l'IMC en pourcentage de l'épaisseur globale du lambeau, ce qui est favorable à un prélèvement étendu du LGD. Puisque cette couche ne peut pas être séparée de l'épaisseur globale à l'examen, ces résultats sont utiles pour évaluer le volume supplémentaire obtenu à partir de la technique de prélèvement élargi du grand droit.

Does Smoking Status Influence Health-Related Quality of Life Outcome Measures in Patients Undergoing ACDF?

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: Whereas smoking has been shown to affect the fusion rates for patients undergoing an anterior cervical discectomy and fusion (ACDF), the relationship between smoking and health-related quality of life outcome measurements after an ACDF is less clear. The purpose of this study was to evaluate whether smoking negatively affects patient outcomes after an ACDF for cervical degenerative pathology. METHODS: Patients with tumor, trauma, infection, and previous cervical spine surgery and those with less than a year of follow-up were excluded. Smoking status was assessed by self-reported smoking history. Patient outcomes, including Neck Disability Index, Short Form 12 Mental Component Score, Short Form 12 Physical Component Score (PCS-12), Visual Analogue Scale (VAS) arm pain, VAS neck pain, and pseudarthrosis rates were evaluated. Outcomes were compared between smoking groups using multiple linear and logistic regression, controlling for age, sex, and body mass index (BMI), among other factors. A P value <.05 was considered significant. RESULTS: A total of 264 patients were included, with a mean follow-up of 19.8 months, age of 53.1 years, and BMI of 29.6 kg/m2. There were 43 current, 69 former, and 152 nonsmokers in the cohort. At baseline, nonsmokers had higher PCS-12 scores than current smokers (P = .010), lower VAS neck pain than current (P = .035) and former (P = .014) smokers, as well as lower VAS arm pain than former smokers (P = .006). Postoperatively, nonsmokers had higher PCS-12 scores than both current (P = .030) and former smokers (P = .035). Smoking status was not a significant predictor of change in patient outcome in multivariate analysis. CONCLUSIONS: Whereas nonsmokers had higher function and lower pain than former or current smokers preoperatively, smoking status overall was not found to be an independent predictor of outcome scores after ACDF. This supports the notion that smoking status alone should not deter patients from undergoing ACDF for cervical degenerative pathology.

Impact of the COVID-19 pandemic on UK endoscopic activity and cancer detection: a National Endoscopy Database Analysis.

OBJECTIVE: The COVID-19 pandemic has had a major global impact on endoscopic services. This reduced capacity, along with public reluctance to undergo endoscopy during the pandemic, might result in excess mortality from delayed cancer diagnosis. Using the UK's National Endoscopy Database (NED), we performed the first national analysis of the impact of the pandemic on endoscopy services and endoscopic cancer diagnosis. DESIGN: We developed a NED COVID-19 module incorporating procedure-level data on all endoscopic procedures. Three periods were designated: pre-COVID (6 January 2020 to 15 March), transition (16-22 March) and COVID-impacted (23 March-31 May). National, regional and procedure-specific analyses were performed. The average weekly number of cancers, proportion of missing cancers and cancer detection rates were calculated. RESULTS: A weekly average of 35 478 endoscopy procedures were performed in the pre-COVID period. Activity in the COVID-impacted period reduced to 12% of pre-COVID levels; at its low point, activity was only 5%, recovering to 20% of pre-COVID activity by study end. Although more selective vetting significantly increased the per-procedure cancer detection rate (pre-COVID 1.91%; COVID-impacted 6.61%; p<0.001), the weekly number of cancers detected decreased by 58%. The proportion of missing cancers ranged from 19% (pancreatobiliary) to 72% (colorectal). CONCLUSION: This national analysis demonstrates the remarkable impact that the pandemic has had on endoscopic services, which has resulted in a substantial and concerning reduction in cancer detection. Major, urgent efforts are required to restore endoscopy capacity to prevent an impending cancer healthcare crisis.

A 21-Year-Old Man With a Cough.

CASE PRESENTATION: A 21-year-old male African American college student from Southern California, with no significant medical history, was visiting family in southwestern Texas when he presented to the hospital with 1 week history of cough, shortness of breath, lower back pain, and a 10-pound weight loss.

BowelScope: Accuracy of Detection Using Endocuff Optimisation of Mucosal Abnormalities (the B-ADENOMA Study): a multicentre, randomised controlled flexible sigmoidoscopy trial.

OBJECTIVES: Adenoma detection rate (ADR) is an important quality marker at lower GI endoscopy. Higher ADRs are associated with lower postcolonoscopy colorectal cancer rates. The English flexible sigmoidoscopy (FS) screening programme (BowelScope), offers a one-off FS to individuals aged 55 years. However, variation in ADR exists. Large studies have demonstrated improved ADR using Endocuff Vision (EV) within colonoscopy screening, but there are no studies within FS. We sought to test the effect of EV on ADR in a national FS screening population. DESIGN: BowelScope: Accuracy of Detection Using ENdocuff Optimisation of Mucosal Abnormalities was a multicentre, randomised controlled trial involving 16 English BowelScope screening centres. Individuals were randomised to Endocuff Vision-assisted BowelScope (EAB) or Standard BowelScope (SB). ADR, polyp detection rate (PDR), mean adenomas per procedure (MAP), polyp characteristics and location, participant experience, procedural time and adverse events were measured. Comparison of ADR within the trial with national BowelScope ADR was also undertaken. RESULTS: 3222 participants were randomised (53% male) to receive EAB (n=1610) or SB (n=1612). Baseline demographics were comparable between arms. ADR in the EAB arm was 13.3% and that in the SB arm was 12.2% (p=0.353). No statistically significant differences were found in PDR, MAP, polyp characteristics or location, participant experience, complications or procedural characteristics. ADR in the SB control arm was 3.1% higher than the national ADR. CONCLUSION: EV did not improve BowelScope ADR when compared with SB. ADR in both arms was higher than the national ADR. Where detection rates are already high, EV is unable to improve detection further. TRIAL REGISTRATION NUMBERS: NCT03072472, ISRCTN30005319 and CPMS ID 33224.

Cost-effectiveness Applications of Patient-reported Outcome Measures (PROMs) in Spine Surgery.

Because of the rising health care costs in the United States, there has been a focus on value-based care and improving the cost-effectiveness of surgical procedures. Patient-reported outcome measures (PROMs) can not only give physicians and health care providers immediate feedback on the well-being of the patients but also be used to assess health and determine outcomes for surgical research purposes. Recently, PROMs have become a prominent tool to assess the cost-effectiveness of spine surgery by calculating the improvement in quality-adjusted life years (QALY). The cost of a procedure per QALY gained is an essential metric to determine cost-effectiveness in universal health care systems. Common patient-reported outcome questionnaires to calculate QALY include the EuroQol-5 dimensions, the SF-36, and the SF-12. On the basis of the health-related quality of life outcomes, the cost-effectiveness of various spine surgeries can be determined, such as cervical fusions, lumbar fusions, microdiscectomies. As the United States attempts to reduce costs and emphasize value-based care, PROMs may serve a critical role in spine surgery moving forward. In addition, PROM-driven QALYs may be used to analyze novel spine surgical techniques for value-based improvements.

Statistics for the Practicing Spine Surgeon: Fundamental Measurements.

There are vast numbers of evidenced-based clinical trials produced each year, making it increasingly difficult to stay up to date with new treatments and protocols designed to provide the most optimal patient care. A physician's ability to combine existing knowledge with new data is limited by a basic understanding of the background statistics used in these studies. Our goal is to not only define the basic statistics commonly used in clinical trials but to also ensure that practitioners are able to have a working understanding of these statistical measurements to effectively make the most informed and efficacious decisions regarding patient management. On the basis of the recent growth of empirical spine literature, it is becoming more important for spine surgeons to have the basic statistical background necessary to efficiently interpret new data, which may affect clinical decision making regarding patient care.

Statistics for the Practicing Spine Surgeon: Supplementary Data Analysis Measurements.

With the rapid rise of clinical spine surgery literature in the last few decades, there is a greater need for practicing spine surgeons to confidently analyze and critique published literature within the field. The conclusions drawn from published studies are often integrated into a physician's clinical decision-making. A strong knowledge in the fundamental statistical measurements used most frequently in spine surgery literature can enhance the ability to properly interpret the meaning of a study's results. However, medical education often lacks the incorporation of clinically relevant statistical analysis. The purpose of this review is to provide an overview of some of the most commonly used statistical measurements in spine surgery, specifically intraclass correlation coefficient, diagnostic testing analyses, Kaplan-Meier curves, hazard ratios, distribution, and variance.

Wearable Technology in Spine Surgery.

Although patient-reported outcome measures (PROMs) provide valuable insight into the effectiveness of spine surgery, there still remain limitations on measuring outcomes in this manner. Among other deficiencies, PROMs do not always correlate with more objective measures of surgery success. Wearable technology, such as pedometers, tri-axis accelerometer, or wearable cameras, may allow physicians to track patient progress following spine surgery more objectively. Recently, there has been an emphasis on using wearable devices to measure physical activity and limb and spine function. Wearable devices could play an important role as a supplement to PROMs, although they might have to be substantiated through adequate controlled studies to identify normative data for patients presenting with common spine disorders. This review will detail the current state of wearable technology applications in spine surgery and its direction as its utilization expands.

Optimal Inframammary Fold Incision Length Based on Implant Volume for Breast Enlargement: A Cadaveric Study.

Purpose: Breast augmentation is the most commonly performed aesthetic operation in the Unites States annually. With the increasing popularity of gel implants, optimal incisional length for specific implant volumes becomes a factor to consider. Our study is the first, to date, to measure optimal incisional length for increasing Mentor smooth, round, moderate plus silicone implant volumes. Method: Three cadaver breasts were dissected in our anatomy laboratory. After dissection of a subpectoral pocket via an inframammary fold incision, time of implant insertion was measured for increasing volumes with the use of increasing incisional site lengths. Results: Values for increased incisions are as follows: 2.5-cm incision facilitated 100-cm3 implant (average time [AvgT] 76 seconds); 3-cm incision 100-cm3 implant (AvgT 32 seconds), 200 cm3 (AvgT 84.33 seconds); 3.5-cm incision 100-cm3 implant (AvgT 13.00 seconds), 200 cm3 (AvgT 22.00 seconds), 300 cm3 (AvgT 33.67 seconds); 4-cm incision 100-cm3 implant (AvgT 5.67 seconds), 200 cm3 (AvgT 11.33 seconds), 300 cm3 (AvgT 21.33 seconds), 400 cm3 (AvgT 26 seconds); 4.5-cm incision 100-cm3 implant (AvgT 5 seconds), 200 cm3 (AvgT 15.17 seconds), 300 cm3 (AvgT 19.67 seconds), 400 cm3 (AvgT 26 seconds), 500 cm3 (AvgT 39.67 seconds), 600 cm3 (AvgT 59.33 seconds), 700 cm3 (AvgT 78.67 seconds); 5-cm incision 100-cm3 implant (AvgT 1 second), 200 cm3 (AvgT 3.67 seconds), 300 cm3 (AvgT 8 seconds), 400 cm3 (AvgT 13 seconds), 500 cm3 (AvgT 19.33 seconds), 600 cm3 (AvgT 23.33 seconds), 700 cm3 (AvgT 28 seconds), 800 cm3 (AvgT 33 seconds). Conclusion: Based on our results, the optimal incision size for increasing Mentor smooth, round, moderate plus volumes is as follows: 2.5 cm for 100-cm3 implant, 3 cm for 200-cm3 implant, 3.5 cm for 300-cm3 implant, 4 cm for 400-cm3 implant, 4.5 cm for 500- to 700-cm3 implant, and 5 cm for 800-cm3 implant. This guideline can be used to provide the most aesthetic results without tissue compromise.

Earplug Umbilicoplasty: A Simple Method to Prevent Umbilical Stenosis in a Tummy Tuck.

Objective: An aesthetically pleasing umbilicus is a vital component of patient satisfaction following an abdominoplasty. An umbilicus that is moderate to small is desired to achieve the best aesthetic result, but a small umbilicus has potential for stenosis. This article presents a method for umbilical stenting that creates a modest umbilicus, while preventing stenosis. Methods: All patients underwent abdominoplasty with an umbilical reconstruction using an inverted U-flap method between 2015 and 2017. An earplug was placed into the umbilicus at 2 weeks postoperatively for a total of 4 to 6 week. Patients were evaluated subjectively on the aesthetic outcome. Results: Twenty-one female patients were evaluated 6 weeks postsurgery. In all cases, both the patient and the surgeon were 100% satisfied with the final size. Umbilical size ranged from 1.8 to 2.2 cm. Conclusions: Use of an earplug for umbilical stenting is a simple and reproducible method to create an aesthetically pleasing umbilicus and avoid stenosis.

Improved adenoma detection with Endocuff Vision: the ADENOMA randomised controlled trial.

OBJECTIVE: Low adenoma detection rates (ADR) are linked to increased postcolonoscopy colorectal cancer rates and reduced cancer survival. Devices to enhance mucosal visualisation such as Endocuff Vision (EV) may improve ADR. This multicentre randomised controlled trial compared ADR between EV-assisted colonoscopy (EAC) and standard colonoscopy (SC). DESIGN: Patients referred because of symptoms, surveillance or following a positive faecal occult blood test (FOBt) as part of the Bowel Cancer Screening Programme were recruited from seven hospitals. ADR, mean adenomas per procedure, size and location of adenomas, sessile serrated polyps, EV removal rate, caecal intubation rate, procedural time, patient experience, effect of EV on workload and adverse events were measured. RESULTS: 1772 patients (57% male, mean age 62 years) were recruited over 16 months with 45% recruited through screening. EAC increased ADR globally from 36.2% to 40.9% (P=0.02). The increase was driven by a 10.8% increase in FOBt-positive screening patients (50.9% SC vs 61.7% EAC, P<0.001). EV patients had higher detection of mean adenomas per procedure, sessile serrated polyps, left-sided, diminutive, small adenomas and cancers (cancer 4.1% vs 2.3%, P=0.02). EV removal rate was 4.1%. Median intubation was a minute quicker with EAC (P=0.001), with no difference in caecal intubation rate or withdrawal time. EAC was well tolerated but caused a minor increase in discomfort on anal intubation in patients undergoing colonoscopy with no or minimal sedation. There were no significant EV adverse events. CONCLUSION: EV significantly improved ADR in bowel cancer screening patients and should be used to improve colonoscopic detection. TRIAL REGISTRATION NUMBER: NCT02552017, Results; ISRCTN11821044, Results.

Combined Autologous and Prosthetic Breast Reconstruction: Defining the Upper Limits of Safe Expansion in Obesity.

BACKGROUND: Combined latissimus dorsi and prosthetic reconstruction is a useful reconstructive option in patients with a history of breast radiation who are not good candidates for abdominally based autologous reconstruction. One difficulty, particularly in obese patients, is that the thickness of the flap can impair port localization, increasing the risk of inadvertent puncture during expansion. The authors sought to investigate the upper limits of tissue thickness at which tissue expansion can be reliably performed. METHODS: A cadaveric study was designed in which 2 blinded observers attempted to localize the port of a Mentor CPX-4 expander under tissue 1, 2, 3, 4, 5, and 6 cm thick. Thirty attempts were made per tissue thickness. RESULTS: For tissue thicknesses of 1 to 4 cm, the success rate was 100% (k = 1). At 5 cm, the success rate decreased to 86.6% (k = 1); at 6 cm, 43.3% (k = 0.85). Point biserial correlation revealed a negative correlation between tissue thickness and accuracy at a thicknesses of greater than 4 cm (r = -0.55, P < 0.00001). Converting tissue thickness to a dichotomous variable based on the results (thickness, <4 and >4 cm), Fisher exact test revealed a statistically significant difference between these 2 populations (P < 0.00001). CONCLUSIONS: In obese patients with a skin pinch of greater than 8 cm or a flap thickness of greater than 4 cm, steps should be taken to minimize the risk of inadvertent puncture of the expander during postoperative expansion. This can include foregoing tissue expander placement in favor of an implant, port localization with ultrasound guidance, or the use of remote port expanders. These findings are relevant not only in breast reconstruction with latissimus flaps and implants but also in any setting where autologous and prosthetic reconstructions are combined.