Non-Breast Implantable Medical Devices and Associated Malignancies: A Systematic Review.

Innovation in healthcare has led to the development of numerous implantable medical devices (IMDs). However, advances in our knowledge of breast implant-associated malignancies have raised questions about the prevalence, etiology and management of malignancies associated with non-breast IMDs. The objective of this study was to examine the prevalence and characteristics of malignancies associated with non-breast IMDs. An expert medical librarian developed the search strategy for this review. Databases included MEDLINE (National Library of Medicine, Bethesda, MD; date range of search: 1946 to June 21, 2023), EMBASE (Elsevier, Amsterdam, the Netherlands; date range of search: 1946 to June 21, 2023), and Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Library, Wiley, Hoboken, NJ; date range of search: 1946 to June 21, 2023). In addition, grey literature sources were searched and relevant references from systematic reviews and meta-analyses were included. The PRISMA guideline was used to guide the review. Risk of bias was evaluated using the JBI Critical Appraisal tools. A total of 12,230 articles were reviewed with a total of 77 meeting inclusion criteria. Risk of bias was highest with case reports (moderate, average of 65.1% with range of 37.5 to 100%) and low for the remaining study types. In total, 616 cases of IMD-associated malignancies were identified. Malignancies associated with IMDs were reported in the head/neck (543, 88.1%), lower extremity (57, 9.6%), thorax (9, 1.4%), abdomen (3, 0.5%), and genitourinary system (2, 0.3%). The most common malignancy type in the lower extremity was sarcoma, in the head and neck was squamous cell carcinoma, and in the thorax was lymphoma. This study is the first comprehensive systematic review of its kind. Overall, the oncologic risk of IMDs is low. The discussion of malignancy is an important part to the overall consent process and malignancy should be considered with any new signs or symptoms in the anatomic area of an implant. More data is needed to better understand how primary malignancies occur around IMDs and how to reduce this risk.

Reconstruction of Large Defects Using Extended Temporomandibular Joint Patient-Matched Prostheses.

PURPOSE: Custom temporomandibular joint (TMJ) prostheses are useful in reconstructing large defects following TMJ resection. The purpose of this study is to evaluate the feasibility of extended-temporomandibular joint replacement (e-TJR) for reconstructing these defects. METHODS: This is a single-group retrospective cohort study that enrolled patients having received an e-TJR between January 2004 and November 2019 at the University of Toronto. The primary outcome variable was a change in maximal interincisal opening (MIO) following reconstruction with an e-TJR, while the secondary outcome variables were changes in pain and quality of life following surgery. The investigators also documented the frequency and types of postoperative complications. Multivariate linear regressions were conducted and were considered significant at P < .05. RESULTS: The sample was composed of 17 patients (10 unilateral and 7 bilateral joint replacements). The mean age of those included was 44.0 years (standard deviation [SD] = 18.6), and 11 (65%) were female. The median follow-up time was 32 months. Starting at a baseline mean MIO of 28.8 mm (SD = 15.4), the mean MIO increased slightly to 35.2 mm (SD = 7.1) after e-TJR (P = .10). Similarly, mean pain scores decreased from 4.0 (SD = 4.0) to 1.0 (SD = 1.3), and mean quality of life scores improved from 0.50 (SD = 0.29) to 0.86 (SD = 0.10) following surgery (P = .007 and P = .001, respectively). No mechanical failures or catastrophic infections were observed. CONCLUSIONS: This initial study supports the e-TJR for the reconstruction of large TMJ and maxillofacial defects. Further high-quality studies are required to confirm these findings.

Clearing the surgical backlog caused by COVID-19 in Ontario: a time series modelling study.

BACKGROUND: To mitigate the effects of coronavirus disease 2019 (COVID-19), jurisdictions worldwide ramped down nonemergent surgeries, creating a global surgical backlog. We sought to estimate the size of the nonemergent surgical backlog during COVID-19 in Ontario, Canada, and the time and resources required to clear the backlog. METHODS: We used 6 Ontario or Canadian population administrative sources to obtain data covering part or all of the period between Jan. 1, 2017, and June 13, 2020, on historical volumes and operating room throughput distributions by surgery type and region, and lengths of stay in ward and intensive care unit (ICU) beds. We used time series forecasting, queuing models and probabilistic sensitivity analysis to estimate the size of the backlog and clearance time for a +10% (+1 day per week at 50% capacity) surge scenario. RESULTS: Between Mar. 15 and June 13, 2020, the estimated backlog in Ontario was 148 364 surgeries (95% prediction interval 124 508-174 589), an average weekly increase of 11 413 surgeries. Estimated backlog clearance time is 84 weeks (95% confidence interval [CI] 46-145), with an estimated weekly throughput of 717 patients (95% CI 326-1367) requiring 719 operating room hours (95% CI 431-1038), 265 ward beds (95% CI 87-678) and 9 ICU beds (95% CI 4-20) per week. INTERPRETATION: The magnitude of the surgical backlog from COVID-19 raises serious implications for the recovery phase in Ontario. Our framework for modelling surgical backlog recovery can be adapted to other jurisdictions, using local data to assist with planning.

Reprise du retard en chirurgie causé par la COVID-19 en Ontario : étude de modélisation de séries chronologiques.

CONTEXTE: Pour limiter la propagation de la maladie à coronavirus 2019 (COVID-19), de nombreux pays ont décidé de réduire le nombre d'interventions chirurgicales non urgentes, ce qui a créé des retards en chirurgie partout dans le monde. Notre objectif était d'évaluer l'ampleur du retard pour ce type d'interventions en Ontario, au Canada, ainsi que le temps et les ressources nécessaires pour y remédier. MÉTHODES: Nous avons consulté 6 bases de données administratives décrivant la population ontarienne et canadienne pour dégager la distribution du volume chirurgical et de la cadence des salles d'opération pour chaque type d'interventions et chaque région, et connaître la durée d'occupation d'un lit d'hôpital et d'un lit de soins intensifs. Les données utilisées concernent l'ensemble ou une partie de la période du 1er janvier 2017 au 13 juin 2020. Nous avons estimé l'ampleur du retard accumulé et prédit le temps nécessaire pour le reprendre dans un scénario avec capacité d'appoint de + 10 % (ajout d'un jour à 50 % de la capacité par semaine) à l'aide de modèles de séries chronologiques, de modèles de files d'attente et d'une analyse de sensibilité probabiliste. RÉSULTATS: Entre le 15 mars et le 13 juin 2020, le retard en chirurgie à l'échelle de l'Ontario s'est accru de 148 364 opérations (intervalle de prévision à 95 % 124 508­174 589) au total, et en moyenne de 11 413 opérations par semaine. Pour reprendre le retard accumulé, il faudra environ 84 semaines (intervalle de confiance [IC] à 95 % 46­145) et une cadence hebdomadaire de 717 patients (IC à 95 % 326­1367), qui elle demande 719 heures passées au bloc opératoire (IC à 95 % 431­1038), 265 lits d'hôpital (IC à 95 % 87­678) et 9 lits de soins intensifs (IC à 95 % 4­20) par semaine. INTERPRÉTATION: L'ampleur du retard en chirurgie dû à la COVID-19 laisse entrevoir de graves conséquences pour la phase de reprise en Ontario. Le cadre qui nous a servi à modéliser la reprise du retard peut être adapté ailleurs, avec des données locales, pour faciliter la planification.

ChatGPT-3.5 and Bing Chat in ophthalmology: an updated evaluation of performance, readability, and informative sources.

BACKGROUND/OBJECTIVES: Experimental investigation. Bing Chat (Microsoft) integration with ChatGPT-4 (OpenAI) integration has conferred the capability of accessing online data past 2021. We investigate its performance against ChatGPT-3.5 on a multiple-choice question ophthalmology exam. SUBJECTS/METHODS: In August 2023, ChatGPT-3.5 and Bing Chat were evaluated against 913 questions derived from the Academy's Basic and Clinical Science Collection collection. For each response, the sub-topic, performance, Simple Measure of Gobbledygook readability score (measuring years of required education to understand a given passage), and cited resources were collected. The primary outcomes were the comparative scores between models, and qualitatively, the resources referenced by Bing Chat. Secondary outcomes included performance stratified by response readability, question type (explicit or situational), and BCSC sub-topic. RESULTS: Across 913 questions, ChatGPT-3.5 scored 59.69% [95% CI 56.45,62.94] while Bing Chat scored 73.60% [95% CI 70.69,76.52]. Both models performed significantly better in explicit than clinical reasoning questions. Both models performed best on general medicine questions than ophthalmology subsections. Bing Chat referenced 927 online entities and provided at-least one citation to 836 of the 913 questions. The use of more reliable (peer-reviewed) sources was associated with higher likelihood of correct response. The most-cited resources were eyewiki.aao.org, aao.org, wikipedia.org, and ncbi.nlm.nih.gov. Bing Chat showed significantly better readability than ChatGPT-3.5, averaging a reading level of grade 11.4 [95% CI 7.14, 15.7] versus 12.4 [95% CI 8.77, 16.1], respectively (p-value < 0.0001, ρ = 0.25). CONCLUSIONS: The online access, improved readability, and citation feature of Bing Chat confers additional utility for ophthalmology learners. We recommend critical appraisal of cited sources during response interpretation.

Aesthetic Refinements in Male Chest Lifting.

The authors describe aesthetic refinements to the approach for male chest lifting in male patients with grade 3 gynecomastia and/or significant chest skin excess. An inferior pedicle is used to transpose the nipple-areolar complex allowing preservation of pigment and sensation, liposuction and direct excision are used to reduce volume and excess skin, and the resulting curvilinear scar along the inferior and lateral border of the chest provide a more masculine appearance. Early experience with this technique has shown it to be safe and effective. Perioperative management and the detailed steps of the procedure are outlined.

Refining the thoracic surgical oncology regionalization standards for esophageal surgery in Ontario, Canada: Moving from good to better.

BACKGROUND: The consolidation of surgical practices has been suggested to improve patient outcomes for complex surgeries. In 2005, Ontario Health-Cancer Care Ontario released the Thoracic Surgical Oncology Standards to facilitate the regionalization process at thoracic centers in Ontario, Canada. This work describes the quality-improvement process involved in updating the minimum surgical volume and supporting requirement recommendations for thoracic centers to further optimize patient care for esophageal cancer. METHODS: We conducted a literature review to identify and synthesize evidence informing the volume-outcome relationship related to esophagectomy. The results of this review and esophageal cancer surgery common indicators (reoperation rate, unplanned visit rate, 30-day and 90-day mortality) from Ontario's Surgical Quality Indicator Report were presented and reviewed by a Thoracic Esophageal Standards Expert Panel and Surgical Oncology Program Leads at Ontario Health-Cancer Care Ontario. Hospital outliers were identified, and a subgroup analysis was conducted to determine the most appropriate minimum surgical volume threshold based on 30- and 90-day mortality rates data from the last 3 fiscal years. RESULTS: Based on the finding that a significant decrease in mortality occurred at 12 to 15 esophagectomies per year, the Thoracic Esophageal Standards Expert Panel reached a consensus that thoracic centers should perform a minimum of 15 esophagectomies per year. The panel also recommended that any center performing esophagectomies have at least 3 thoracic surgeons to ensure continuity in clinical care. CONCLUSIONS: We have described the process involved in updating the provincial minimum volume threshold and the appropriate support services for esophageal cancer surgery in Ontario.

A Canadian Experience With Off-the-Shelf, Aseptically Processed, Costal Cartilage Segment Allografts in Complex Rhinoplasty.

Background: Complex primary and secondary rhinoplasties usually necessitate grafting materials when native nasal cartilage is inadequate for reconstruction. Fresh frozen, aseptically processed, and nonterminally sterilized costal cartilage segment allografts (CCSAs) are a novel grafting material for such cases that avoid donor-site morbidity, improve operating efficiency, and mitigate the postoperative risks. Objectives: To report the early experience using fresh frozen, aseptically processed, and nonterminally sterilized CCSAs used in complex primary and secondary rhinoplasties, in Canada. Methods: We retrospectively reviewed 21 patients (17 female and 4 male patients) who underwent a primary or secondary rhinoplasty surgery using CCSAs from June 2019 to April 2022. Results: The mean age was 39 years (range, 27-58 years), and the mean body mass index was 23.7 kg/m2 (range, 24-40 kg/m2). Of the 21 procedures, 11 were primary (52.4%) and 10 were secondary (47.6%) rhinoplasties. The mean operative time was 185 min (range, 85-330 min), with a mean follow-up time of 15.0 months (range, 2.0-37.8 months). At follow-up, 19 patients (90.5%) reported being "very satisfied" with their aesthetic results, and only 2 (9.5%) underwent revision surgery. No serious complications were reported, and only 1 case showed evidence of graft resorption. Conclusions: Based on early experience, this CCSA avoids donor-site morbidity and reduces operative time while maintaining a low complication rate, providing a viable alternative to the use of autologous costal cartilage when indicated in complex primary or secondary rhinoplasties with inadequate native nasal cartilage.

Restructuring Skin Cancer Care in Ontario: A Provincial Plan.

There is a global rise in skin cancer incidence, resulting in an increase in patient care needs and healthcare costs. To optimize health care planning, costs, and patient care, Ontario Health developed a provincial skin cancer plan to streamline the quality of care. We conducted a systematic review and a grey literature search to evaluate the definitions and management of skin cancer within other jurisdictions, as well as a provincial survey of skin cancer care practices, to identify care gaps. The systematic review did not identify any published comprehensive skin cancer management plans. The grey literature search revealed skin cancer plans in isolated regions of the United Kingdom (U.K.), National Institute for Health and Care Excellence (NICE) guidelines for skin cancer quality indicators and regional skin cancer biopsy clinics, and wait time guidelines in Australia and the U.K. With the input of the Ontario Cancer Advisory Committee (CAC), unique definitions for complex and non-complex skin cancers and the appropriate cancer services were created. A provincial survey of skin cancer care yielded 44 responses and demonstrated gaps in biopsy access. A skin cancer pathway map was created and a recommendation was made for regional skin cancer biopsy clinics. We have created unique definitions for complex and non-complex skin cancer and a skin cancer pathways map, which will allow for the implementation of both process and performance metrics to address identified gaps in care.