Pharmacological interventions for early-stage frozen shoulder: a systematic review and network meta-analysis.

OBJECTIVES: To evaluate the efficacy of pharmacological interventions for treating early-stage, pain predominant, adhesive capsulitis, also known as frozen shoulder. METHODS: We performed a systematic review in accordance with PRSIMA guidelines. Searches were conducted on PUBMED, EMBASE and Cochrane Central Register of Controlled Trials on the 24th of February 2022. Outcomes were shoulder pain, shoulder function and range of movement. Synthesis involved both qualitative analysis for all studies and pairwise meta-analyses followed by a network meta-analysis for randomised controlled trials (RCTs). RESULTS: A total of 3,252 articles were found, of which 31 met inclusion criteria, and 22 of these were RCTs. Intraarticular (IA) injection of corticosteroids (8 RCTS, 340 participants) and IA injection of platelet-rich plasma (PRP) (3 RCTs, 177 participants) showed benefit at 12 weeks compared with physical therapy in terms of shoulder pain and function, while oral non-steroidal anti-inflammatories (NSAIDs) (2 RCTs, 44 participants) and IA injection of hyaluronate (2 RCTs, 42 participants) did not show a benefit. Only IA PRP showed benefit over physical therapy for shoulder range of movement. CONCLUSION: These results shows that IA corticosteroids IA PRP injections are beneficial for early-stage frozen shoulder. These findings should be appraised with care considering the risk of bias, heterogeneity, and inconsistency of the included studies. We believe that research focused on early interventions for frozen shoulder could improve patient outcomes and lead to cost-savings derived from avoiding long-term disability. Further well-designed studies comparing with standardised physical therapy or placebo are required to improve evidence to guide management.

Natural language processing to automate a web-based model of care and modernize skin cancer multidisciplinary team meetings.

BACKGROUND: Cancer multidisciplinary team (MDT) meetings are under intense pressure to reform given the rapidly rising incidence of cancer and national mandates for protocolized streaming of cases. The aim of this study was to validate a natural language processing (NLP)-based web platform to automate evidence-based MDT decisions for skin cancer with basal cell carcinoma as a use case. METHODS: A novel and validated NLP information extraction model was used to extract perioperative tumour and surgical factors from histopathology reports. A web application with a bespoke application programming interface used data from this model to provide an automated clinical decision support system, mapped to national guidelines and generating a patient letter to communicate ongoing management. Performance was assessed against retrospectively derived recommendations by two independent and blinded expert clinicians. RESULTS: There were 893 patients (1045 lesions) used to internally validate the model. High accuracy was observed when compared against human predictions, with an overall value of 0.92. Across all classifiers the virtual skin MDT was highly specific (0.96), while sensitivity was lower (0.72). CONCLUSION: This study demonstrates the feasibility of a fully automated, virtual, web-based service model to host the skin MDT with good system performance. This platform could be used to support clinical decision-making during MDTs as 'human in the loop' approach to aid protocolized streaming. Future prospective studies are needed to validate the model in tumour types where guidelines are more complex.

Service implications of the revised 2022 National Institute for Health and Care Excellence (NICE) follow-up guidelines for stage IA-IIC melanoma.

BACKGROUND: The 2022 National Institute for Health and Care Excellence melanoma guideline update made significant changes to follow-up. The aim of this study was to assess the impact these changes will have on a national melanoma cohort over a 5-year follow-up interval. METHODS: Anonymized, individual-level, population-scale, linkable primary and secondary care National Health Service data for an 18-year interval (2000-2018) in Wales, UK were analysed. These data were used to predict the number of patients over a 10-year interval (2020-2030) that would be diagnosed with melanoma. Follow-up schedules for the 2015 and 2022 National Institute for Health and Care Excellence melanoma guidelines were then used to calculate the number of clinician-led appointments, the number of radiological investigations, and the total healthcare cost between 2025 and 2030, corresponding to a 5-year patient follow-up interval, for those with stage IA-IIC melanoma. RESULTS: Between 2025 and 2030 it is predicted that implementation of the 2022 guidelines would lead to 21 122 (range 19 194-23 083) fewer clinician-led appointments for patients with stage IA-IIC melanoma. However, there would be a significant increase in the number of radiological investigations (7812; range 7444-8189). These changes would lead to a €2.74 million (€1.87 million-€3.61 million) reduction in the total cost of follow-up over the interval 2025-2030. CONCLUSION: Melanoma follow-up guideline changes will result in a substantial reduction in the number of clinical follow-up appointments, but a significant additional burden to radiological services. The overall cost of follow-up at a national level will be reduced.

Prevalence and odds of anxiety and depression in cutaneous malignant melanoma: a proportional meta-analysis and regression.

BACKGROUND: The psychological burden of cutaneous malignant melanoma (CM) is all-encompassing, affecting treatment adherence, recurrence and mortality. However, the prevalence and risk factors of anxiety and depression in CM remain unclear. OBJECTIVES: To establish a benchmark pooled prevalence of anxiety and depression in CM, to provide magnitudes of association for clinical, therapeutic and demographic correlates, and to elucidate temporal trends in anxiety and depression from the time of diagnosis. METHODS: This review followed the MOOSE guidelines. MEDLINE, Embase, PsychINFO, Web of Science and the Cochrane Library were queried from database inception to 24 August 2023. Study selection, data extraction and quality assessment were performed by two independent authors, utilizing both the Joanna Briggs Institute (JBI) and National Institutes of Health risk-of-bias tools for the latter. The GRADE approach was used to rate the certainty of evidence. Prevalence rates, 95% confidence intervals (CIs) and prediction intervals (PIs) were derived using a random-effects model and estimating between- and within-study variance. RESULTS: Nine longitudinal and 29 cross-sectional studies were included (7995 patients). Based on the JBI and NIH tools, respectively, quality assessment found 20 and 17 to be at low risk of bias, 12 and 15 to be at moderate risk and 6 and 5 to be at high risk of bias. The prevalence of anxiety [30.6% (95% CI 24.6-37.0; PI 18-47%)] and depression [18.4% (95% CI 13.4-23.9; PI 10-33%)] peaked during treatment, declining to pretreatment levels after 1 year [anxiety: 48% vs. 20% (P = 0.005); depression: 28% vs. 13% (P = 0.03)]. Female sex [odds ratio (OR) 1.8, 95% CI 1.4-2.3; P < 0.001], age < 60 years (OR 1.5, 95% CI 1.2-2.0; P = 0.002) and low educational level (OR 1.5, 95% CI 1.2-2.0; P < 0.001) were likely to result in a large increase in the odds of anxiety. Depression was 12.3% higher in those with stage IV vs. those with stage I CM (P = 0.05). Relative to immune checkpoint inhibition, the rates of depression were 22% (P = 0.002) and 34% (P < 0.001) higher among patients with advanced-stage CM receiving interferon-α and chemotherapy, respectively. A significant reduction in self-reported depression scores was demonstrated over time (P = 0.003). CONCLUSIONS: Notably, anxiety and depression in CM affect women, those younger than 60 years of age and the less educated, with up to 80% higher odds of anxiety in these groups. Anxiety and depression surge during chemotherapy and interferon treatment, especially in advanced CM. Our findings facilitate risk stratification and underscore the need for multidisciplinary vigilance.

Melanoma is a serious type of skin cancer that is becoming more prevalent, particularly in people with lighter skin. The UK-based ReconRegen research group conducted a study to understand the psychological impact of melanoma on people, focusing on anxiety and depression. To do this, a systematic review approach was used to analyse data from existing studies and gather a comprehensive perspective. The study discovered that 30% of people with melanoma are affected by anxiety and 18% by depression, significantly higher than the general population. Key risk factors for anxiety included being female, being younger than 60 years of age and having lower educational attainment. Women are 1.8 times more likely to experience anxiety than men, those under 60 years of age are 1.5 times more likely to experience it and individuals with lower educational levels are also 1.5 times more likely to experience anxiety. Findings showed that anxiety and depression levels peaked during treatment phases, especially in people undergoing chemotherapy and immunotherapy. This highlights the need for targeted mental health support during these treatment periods. The findings advocate for mental health considerations in melanoma care, suggesting regular mental health assessments, particularly for high-risk groups and during intense treatment phases. Highlighting the importance of a holistic treatment approach, the study suggests that future research should include long-term studies to understand the chronic impacts of anxiety and depression. Improved clarity and detail in research reporting are essential for developing effective mental health support for people with melanoma, enhancing overall patient care by addressing both physical and emotional health needs.

The "Flapbot": A Global Perspective on the Validity and Usability of a Flap Monitoring Chatbot.

BACKGROUND: The Flapbot chatbot assists in free-flap monitoring, emphasizing accessibility, user-friendliness, and global reliability. This study assesses Flapbot's worldwide validity and usability and uses qualitative analysis to identify areas for future enhancement. METHODS: Flapbot, built on Google's DialogFlow, was evaluated by international plastic surgeons. Invitations were sent to the International Lower Limb Reconstruction Collaborative (INTELLECT), International Confederation of Plastic Surgery Societies (ICOPLAST), and the International Microsurgery Club. Out of the 42 surgeons who agreed to participate, 21 tested the Flapbot and completed an online survey on its validity and usability. The survey had 13 validity items and 10 usability items. Data analysis involved computing the individual content validity index (I-CVI) and scale-wide content validity index (S-CVI) for validity, and the system usability score (SUS) for usability. Thematic analysis distilled free-text responses to identify key themes. RESULTS: Nine of 13 items had an I-CVI over 0.78, denoting significant relevance. The S-CVI score stood at 0.82, indicating high relevance. The SUS score was 68, representing average usability. Themes highlighted issues with the current model, development suggestions, and surgeons' concerns regarding growing reliance on digital tools in health care. CONCLUSION: Flapbot is a promising digital aid for free-flap monitoring. While it showcases notable validity and usability, improvements in functionality, usability, and accessibility are needed for broader global use.

The epidemiology, healthcare and societal burden of basal cell carcinoma in Wales 2000-2018: a retrospective nationwide analysis.

BACKGROUND: Basal cell carcinoma (BCC) represents the most commonly occurring cancer worldwide within the white population. Reports predict 298 308 cases of BCC in the UK by 2025, at a cost of £265-366 million to the National Health Service (NHS). Despite the morbidity, societal and healthcare pressures brought about by BCC, routinely collected healthcare data and global registration remain limited. OBJECTIVES: To calculate the incidence of BCC in Wales between 2000 and 2018 and to establish the related healthcare utilization and estimated cost of care. METHODS: The Secure Anonymised Information Linkage (SAIL) databank is one of the largest and most robust health and social care data repositories in the UK. Cancer registry data were linked to routinely collected healthcare databases between 2000 and 2018. Pathological data from Swansea Bay University Health Board (SBUHB) were used for internal validation. RESULTS: A total of 61 404 histologically proven BCCs were identified within the SAIL Databank during the study period. The European age-standardized incidence for BCC in 2018 was 224.6 per 100 000 person-years. Based on validated regional data, a 45% greater incidence was noted within SBUHB pathology vs. matched regions within SAIL between 2016 and 2018. A negative association between deprivation and incidence was noted with a higher incidence in the least socially deprived and rural dwellers. Approximately 2% travelled 25-50 miles for dermatological services compared with 37% for plastic surgery. Estimated NHS costs of surgically managed lesions for 2002-2019 equated to £119.2-164.4 million. CONCLUSIONS: Robust epidemiological data that are internationally comparable and representative are scarce for nonmelanoma skin cancer. The rising global incidence coupled with struggling healthcare systems in the post-COVID-19 recovery period serve to intensify the societal and healthcare impact. This study is the first to demonstrate the incidence of BCC in Wales and is one of a small number in the UK using internally validated large cohort datasets. Furthermore, our findings demonstrate one of the highest published incidences within the UK and Europe.

Standardising the management of open extremity fractures: a scoping review of national guidelines.

INTRODUCTION: Open extremity fractures can be life-changing events. Clinical guidelines on the management of these injuries aim to standardise the care of patients by presenting evidence-based recommendations. We performed a scoping systematic review to identify all national clinical practice guidelines published to date. MATERIALS AND METHODS: A PRISMA-compliant scoping systematic review was designed to identify all national or federal guidelines for the management of open fractures, with no limitations for language or publication date. EMBASE and MEDLINE database were searched. Article screening and full-text review was performed in a blinded fashion in parallel by two authors. RESULTS: Following elimination of duplicates, 376 individual publications were identified and reviewed. In total, 12 clinical guidelines were identified, authored by groups in the UK, USA, the Netherlands, Finland, and Malawi. Two of these focused exclusively on antibiotic prophylaxis and one on combat-related injuries, with the remaining nine presented wide-scope recommendations with significant content overlap. DISCUSSION: Clinical practice guidelines serve clinicians in providing evidence-based and cost-effective care. We only identified one open fractures guideline developed in a low- or middle-income country, from Malawi. Even though the development of these guidelines can be time and resource intensive, the benefits may outweigh the costs by standardising the care offered to patients in different healthcare settings. International collaboration may be an alternative for adapting guidelines to match local resources and healthcare systems for use across national borders.

Critical Appraisal of the Quality of Evidence Addressing the Diagnosis, Prognosis, and Management of Peripheral Artery Disease in Patients With Diabetic Foot Ulceration.

AIMS: There is a paucity of robust evidence on prevention and management of diabetic foot ulcers (DFUs) to inform treatment. This study appraises the current quality of the evidence addressing diagnosis, prognosis, and management of peripheral artery disease (PAD) in patients with DFUs using a newly devised 21 point scoring (TOPS) disease specific research appraisal tool published by the International Working Group on the Diabetic Foot (IWGDF) and European Wound Management Association. METHODS: The 2015 IWGDF guidance on diagnosis, prognosis, and management of PAD in patients with DFUs was used to identify studies pertaining to prevention and management. Two reviewers assessed these articles against TOPS, which examines study design, conduct, and outcome reporting. RESULTS: The overall median score was 8 (3-12/21). The median design total score was 2 (0-4/11). The median conduct total score was 2 (1-4/6). The median outcomes total score was 3 (1-4/4). There was improvement with time in overall total (Spearman Rho 0.39, p = .0005), design total (0.35, p = .0023), and outcomes total (0.35, p = .0002), but not conduct total (-0.03, p = .8132) scores. CONCLUSIONS: Although this analysis revealed an improvement over time in the overall calibre of studies, the present quality remains poor on which to inform the diagnosis, management, and prognosis of patients with PAD and diabetic foot ulceration.

Basic Microvascular Anastomosis Simulation Hub Microsurgery Course: An Innovative Competency-Based Approach to Microsurgical Training for Early Year's Plastic Surgery Trainees.

Early year's plastic surgery trainees are faced with a large choice of microsurgery courses to select from. In the context of dwindling study budgets and busy on-call rotas, the pressure to select a high yield course that delivers value for money is of paramount importance.The Basic Microvascular Anastomosis Simulation Hub Microsurgery Course is a GBP £600 (US $790) 5-day 40-hour course based at Barts and The London School of Medicine and Dentistry increasing in popularity among junior trainees to fit this brief.

Course Review: Birmingham and Coventry Hand and Forearm Cadaveric Dissection Course.

Hand surgery constitutes an important part of plastic surgery and orthopedic training curricula. Although the value of simulation-based training is being increasingly recognized, attendance at such courses may be limited owing to cost, availability, and non-learner-centered schedules.The Birmingham and Coventry hand and forearm cadaveric dissection course is a 1-day course with a loose agenda that offers an inexpensive and learner-centered approach toward surgical access, dissection, and soft tissue coverage in the upper limb. This course is held in Coventry, United Kingdom, at a cost of £165 ($220 US dollars). In this review, we provide an evaluation of the course.

Can Large Language Models Generate Outpatient Clinic Letters at First Consultation That Incorporate Complication Profiles From UK and USA Aesthetic Plastic Surgery Associations?

The importance of written communication between clinicians and patients, especially in the wake of the Supreme Court case of Montgomery vs Lanarkshire, has led to a shift toward patient-centric care in the United Kingdom. This study investigates the use of large language models (LLMs) like ChatGPT and Google Bard in enhancing clinic letters with gold-standard complication profiles, aiming to improve patients' understanding and save clinicians' time in aesthetic plastic surgery. The aim of this study is to assess the effectiveness of LLMs in integrating complication profiles from authoritative sources into clinic letters, thus enhancing patient comprehension and clinician efficiency in aesthetic plastic surgery. Seven widely performed aesthetic procedures were chosen, and complication profiles were sourced from the British Association of Aesthetic Plastic Surgeons (BAAPS) and the American Society of Plastic Surgeons (ASPS). We evaluated the proficiency of the ChatGPT4, ChatGPT3.5, and Google Bard in generating clinic letters which incorporated complication profiles from online resources. These letters were assessed for readability using an online tool, targeting a recommended sixth-grade reading level. ChatGPT4 achieved the highest compliance in integrating complication profiles from BAAPS and ASPS websites, with average readability grades between eighth and ninth. ChatGPT3.5 and Google Bard showed lower compliance, particularly when accessing paywalled content like the ASPS Informed Consent Bundle. In conclusion, LLMs, particularly ChatGPT4, show promise in enhancing patient communications in aesthetic plastic surgery by effectively incorporating standard complication profiles into clinic letters. This aids in informed decision making and time saving for clinicians. However, the study underscores the need for improvements in data accessibility, search capabilities, and ethical considerations for optimal LLM integration into healthcare communications. Future enhancements should focus on better interpretation of inaccessible formats and a Human in the Loop approach to combine Artifical Intelligence capabilities with clinician expertise.

Revisiting basal cell carcinoma clinical margins: Leveraging natural language processing and multivariate analysis with updated Royal College of Pathologists histological reporting standards.

INTRODUCTION: Data supporting the current British Association of Dermatologists guidelines for the management of basal cell carcinoma (BCC) are based on historic studies and do not consider the updated Royal College of Pathologists (RCPath) histological reporting standards. The aim of this study was to use natural language processing (NLP)-derived data and undertake a multivariate analysis with updated RCPath standards, providing a contemporary update on the excision margins required to achieve histological clearance in BCC. METHODS: A validated NLP information extraction model was used to perform a rapid multi-centre, pan-specialty, consecutive retrospective analysis of BCCs, managed with surgical excision using a pre-determined clinical margin, over a 17-year period (2004-2021) at Swansea Bay University Health Board. Logistic regression assessed the relationship between the peripheral and deep margins and histological clearance. RESULTS: We ran our NLP algorithm on 34,955 BCCs. Out of the 1447 BCCs that met the inclusion criteria, the peripheral margin clearance was not influenced by the BCC risk level (p = 0.670). A clinical peripheral margin of 6 mm achieved a 95% histological clearance rate (95% confidence interval [CI], 0.93-0.98). Tumour thickness inversely affected deep-margin histological clearance (OR 0.720, 95% CI, 0.525-0.991, p < 0.05). Depth level 2 had a 97% probability of achieving deep-margin histological clearance across all tumour thicknesses. CONCLUSION: Updated RCPath reporting standards minimally impact the peripheral margin histological clearance in BCC. Larger clinical peripheral margins than those indicated by current guidelines may be necessary to achieve excision rates of ≥95%. These findings emphasise the need for continuous reassessment of clinical standards to enhance patient care.

An illustrated anatomical approach to reducing vascular risk during facial soft tissue filler administration - a review.

Vascular complications from soft tissue fillers can have catastrophic consequences for patients. Adverse events are rare, but they are increasing, and their appearance may be the result of intravascular injection. A comprehensive understanding of the 2-dimensional anatomy (distribution) and 3-dimensional anatomy (depth) of the facial vasculature is fundamental for the safe delivery of nonsurgical cosmetic procedures. The purpose of this review is to provide an illustrated approach to examine surgical anatomy specific to the facial vascular system and the anatomical considerations clinicians need to give in specific danger during injectable cosmetic procedures. A grounding in safety and anatomy will help the new injector to mitigate the risk of vascular complications.

Models and materials for teaching auricular framework carving: A systematic review.

INTRODUCTION: The process of carving an auricular framework is technically challenging and unique to the patient. As such, there is a need for a robust and reliable training model for practicing and planning ear reconstruction. The aim of this study is to assess the best models and methods available to practice the carving of an auricular framework. METHODS: A systematic review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines using MEDLINE, Embase, and Cochrane databases. Terms such as "ear", "reconstruction" and "teaching" were searched. RESULTS: A total of 354 articles were identified, and 13 studies met the inclusion criteria. Vegetables, animal tissue, synthetic materials, as well as more advanced methods such as 3D-printed moulds, were analysed. The similarity of these materials to human costal cartilage was investigated to determine the best or most suitable ones for the purpose. The methods used in the studies were also analysed. Due to heterogeneity of the studies, it was not possible to conduct a quantitative analysis. CONCLUSION: This review identifies that for the junior surgeons at the skill acquisition phase of their training in auricular framework carving repetition using firstly a cheap synthetic material would be most useful, followed by animal cartilage or 3D printing using silicone. These materials bear the most resemblance to human costal cartilage, and by repeating the carvings, proficiency will improve. Those surgeons with an established ear reconstruction practise, wishing to undertake immediate pre-operatively simulation could benefit from cross-sectional imaging and 3D printing of a patient's non-affected ear to ensure a good match.

Evaluating remote skin cancer multidisciplinary team meetings in the United Kingdom post-COVID-19.

INTRODUCTION: Prior to the COVID-19 pandemic, there was concern that virtual or remote multidisciplinary teams (MDT) meetings represented a niche concept that was unlikely to replace traditional face-to-face meetings in the management of cancer. However, the sudden shift to virtual meetings during COVID-19 has been one of the most dramatic changes since the inception of the MDT. This study aims to investigate the effectiveness of virtual skin MDTs since the move to virtual meetings. METHODS: A cross-sectional survey was sent to all Specialist Skin Cancer MDTs (SSMDTs) and the British Association of Plastic, Reconstructive, and Aesthetic Surgeons Skin Oncology Special Interest and Advisory Group. RESULTS: There were 68 responses (55.3% response rate) from 36 SSMDTs in the UK. Respondents felt communication, chairing, and decision-making were similar in virtual and in-person MDTs, but the team working was worse in virtual meetings. Recruitment, data security, and patient confidentiality were maintained in virtual MDTs. Most preferred a hybrid format for future MDTs, with the option to attend virtually. Recommendations for improvement included better connectivity, IT support, training, and staff integration. CONCLUSION: The virtual MDT is here to stay. We highlight the strengths and weaknesses of remote virtual skin MDTs. It is key that we look at ways to retain team working to ensure that the collegiate nature of MDT working, and therefore treatment options for patients, are not lost in this transformation in MDT delivery.

Comparative study of ChatGPT and human evaluators on the assessment of medical literature according to recognised reporting standards.

INTRODUCTION: Amid clinicians' challenges in staying updated with medical research, artificial intelligence (AI) tools like the large language model (LLM) ChatGPT could automate appraisal of research quality, saving time and reducing bias. This study compares the proficiency of ChatGPT3 against human evaluation in scoring abstracts to determine its potential as a tool for evidence synthesis. METHODS: We compared ChatGPT's scoring of implant dentistry abstracts with human evaluators using the Consolidated Standards of Reporting Trials for Abstracts reporting standards checklist, yielding an overall compliance score (OCS). Bland-Altman analysis assessed agreement between human and AI-generated OCS percentages. Additional error analysis included mean difference of OCS subscores, Welch's t-test and Pearson's correlation coefficient. RESULTS: Bland-Altman analysis showed a mean difference of 4.92% (95% CI 0.62%, 0.37%) in OCS between human evaluation and ChatGPT. Error analysis displayed small mean differences in most domains, with the highest in 'conclusion' (0.764 (95% CI 0.186, 0.280)) and the lowest in 'blinding' (0.034 (95% CI 0.818, 0.895)). The strongest correlations between were in 'harms' (r=0.32, p<0.001) and 'trial registration' (r=0.34, p=0.002), whereas the weakest were in 'intervention' (r=0.02, p<0.001) and 'objective' (r=0.06, p<0.001). CONCLUSION: LLMs like ChatGPT can help automate appraisal of medical literature, aiding in the identification of accurately reported research. Possible applications of ChatGPT include integration within medical databases for abstract evaluation. Current limitations include the token limit, restricting its usage to abstracts. As AI technology advances, future versions like GPT4 could offer more reliable, comprehensive evaluations, enhancing the identification of high-quality research and potentially improving patient outcomes.