ChatGPT-4 Surpasses Residents: A Study of Artificial Intelligence Competency in Plastic Surgery In-service Examinations and Its Advancements from ChatGPT-3.5.

Background: ChatGPT, launched in 2022 and updated to Generative Pre-trained Transformer 4 (GPT-4) in 2023, is a large language model trained on extensive data, including medical information. This study compares ChatGPT's performance on Plastic Surgery In-Service Examinations with medical residents nationally as well as its earlier version, ChatGPT-3.5. Methods: This study reviewed 1500 questions from the Plastic Surgery In-service Examinations from 2018 to 2023. After excluding image-based, unscored, and inconclusive questions, 1292 were analyzed. The question stem and each multiple-choice answer was inputted verbatim into ChatGPT-4. Results: ChatGPT-4 correctly answered 961 (74.4%) of the included questions. Best performance by section was in core surgical principles (79.1% correct) and lowest in craniomaxillofacial (69.1%). ChatGPT-4 ranked between the 61st and 97th percentiles compared with all residents. Comparatively, ChatGPT-4 significantly outperformed ChatGPT-3.5 in 2018-2022 examinations (P < 0.001). Although ChatGPT-3.5 averaged 55.5% correctness, ChatGPT-4 averaged 74%, a mean difference of 18.54%. In 2021, ChatGPT-3.5 ranked in the 23rd percentile of all residents, whereas ChatGPT-4 ranked in the 97th percentile. ChatGPT-4 outperformed 80.7% of residents on average and scored above the 97th percentile among first-year residents. Its performance was comparable with sixth-year integrated residents, ranking in the 55.7th percentile, on average. These results show significant improvements in ChatGPT-4's application of medical knowledge within six months of ChatGPT-3.5's release. Conclusion: This study reveals ChatGPT-4's rapid developments, advancing from a first-year medical resident's level to surpassing independent residents and matching a sixth-year resident's proficiency.

Interleukin-15 is a hair follicle immune privilege guardian.

The autoimmunity-promoting cytokine, Interleukin-15 (IL-15), is often claimed to be a key pathogenic cytokine in alopecia areata (AA). Yet, rhIL-15 promotes human hair follicle (HF) growth ex vivo. We have asked whether the expression of IL-15 and its receptor (IL-15R) isoforms is altered in human AA and how IL-15 impacts on human HF immune privilege (HF-IP) in the presence/absence of interferon-γ (IFNγ), the well-documented key AA-pathogenic cytokine, as well as on hair regrowth after experimental AA induction in vivo. Quantitative immunohistomorphometry showed the number of perifollicular IL-15+ T cells in AA skin biopsies to be significantly increased compared to healthy control skin, while IL-15, IL-15Rα, and IL-15Rγ protein expression within the hair bulb were significantly down-regulated in AA HFs. In organ-cultured human scalp HFs, rhIL-15 significantly reduced hair bulb expression of MICA, the key "danger" signal in AA pathogenesis, and increased production of the HF-IP guardian, α-MSH. Crucially, ex vivo, rhIL-15 prevented IFNγ-induced HF-IP collapse, restored a collapsed HF-IP by IL-15Rα-dependent signaling (as documented by IL-15Rα-silencing), and protected AA-preventive immunoinhibitory iNKT10 cells from IFNγ-induced apoptosis. rhIL-15 even promoted hair regrowth after experimental AA induction in human scalp skin xenotransplants on SCID/beige mice in vivo. Our data introduce IL-15 as a novel, functionally important HF-IP guardian whose signaling is constitutively defective in scalp HFs of AA patients. Our data suggest that selective stimulation of intrafollicular IL-15Rα signaling could become a novel therapeutic approach in AA management, while blocking it pharmacologically may hinder both HF-IP restoration and hair re-growth and may thus make HFs more vulnerable to AA relapse.

mTORC1 activity negatively regulates human hair follicle growth and pigmentation.

Dysregulation of the activity of the mechanistic target of rapamycin complex 1 (mTORC1) is commonly linked to aging, cancer, and genetic disorders such as tuberous sclerosis (TS), a rare neurodevelopmental multisystemic disease characterized by benign tumors, seizures, and intellectual disability. Although patches of white hair on the scalp (poliosis) are considered as early signs of TS, the underlying molecular mechanisms and potential involvement of mTORC1 in hair depigmentation remain unclear. Here, we have used healthy, organ-cultured human scalp hair follicles (HFs) to interrogate the role of mTORC1 in a prototypic human (mini-)organ. Gray/white HFs exhibit high mTORC1 activity, while mTORC1 inhibition by rapamycin stimulated HF growth and pigmentation, even in gray/white HFs that still contained some surviving melanocytes. Mechanistically, this occurred via increased intrafollicular production of the melanotropic hormone, α-MSH. In contrast, knockdown of intrafollicular TSC2, a negative regulator of mTORC1, significantly reduced HF pigmentation. Our findings introduce mTORC1 activity as an important negative regulator of human HF growth and pigmentation and suggest that pharmacological mTORC1 inhibition could become a novel strategy in the management of hair loss and depigmentation disorders.

Seroma tardio em reconstruções mamárias e mamoplastias com implante de silicone: relato de caso e revisão da literatura / Late seroma in breast reconstructions and mammoplasty with silicone implants: a case report and literature review

A ocorrência de seroma como complicação tardia por implante de silicone mamário é de grande interesse, dadas as implicações estéticas, como assimetria, e a possível associação com infecções ou até mesmo malignidades. Acredita-se que esta complicação seja exclusiva de próteses texturizadas. Os autores fazem síntese da literatura a partir de pesquisa de dados em publicações disponíveis em MEDLINE com o termo "late breast seroma" em busca de maior esclarecimento da patologia. A etiologia é desconhecida na maioria dos casos. Nota-se que o tratamento definitivo de escolha é cirúrgico, sendo que grande parte dos autores recomenda a avaliação bacteriológica e citológica do seroma, preferencialmente guiado por ultrassonografia. O tratamento deve ser individualizado, de acordo com a clínica apresentada, antecipando a possibilidade de recorrência do evento e a sequela final, oferecendo, assim, o melhor tratamento à paciente.

The occurrence of seroma as a late complication of silicone breast implant is of great interest, given the aesthetic implications such as asymmetry and the possible association with infections or even malignancies. This complication is believed to be exclusive of textured prostheses. The present authors reviewed the literature by conducting a search of data in publications available in Medline by using the search term "late breast seroma" in order to clarify the pathological features of seroma. The etiology is unknown in most cases. The definitive treatment of choice is surgery, and most authors recommend bacteriological and cytological evaluations for seroma, preferably guided by ultrasonography. To provide patients with the best treatment, the treatment should be individualized according to clinical presentation, anticipating the possibility of recurrence and final sequelae.

Abordagem de hidrocistomas palpebrais écrinos por incisão de blefaroplastia inferior / Excision of eyelid eccrine hidrocystomas via lower blepharoplasty incision

INTRODUÇÃO: O hidrocistoma palpebral écrino corresponde a lesão cística rara, usualmente de pequenas dimensões, não ultrapassando o diâmetro de 10 mm. Sua abordagem usualmente é por excisão simples e biópsia. É alto o índice de recidiva local. MÉTODOS: Paciente com múltiplos hidrocistomas bilaterais, vários maiores que 10 mm. Sob anestesia local, foi realizada incisão infraciliar tradicionalmente usada para blefaroplastia inferior e retirada dos hidrocistomas com cápsula íntegra. RESULTADOS: Paciente com excelentes resultados estéticos e sem recidivas até o presente momento, mais de seis meses após o procedimento. CONCLUSÃO: A incisão infraciliar de blefaroplastia inferior é uma técnica promissora para exérese de hidrocistomas maiores que 10 mm. Mais estudos devem ser realizados para confirmação do bom resultado estético-funcional desta técnica.

INTRODUCTION: Eccrine eyelid hidrocystoma is a rare cystic lesion, usually small and not exceeding 10 mm in diameter. Its treatment is usually by simple excision and biopsy. The rate of local recurrence is high. METHODS: A patient presented with multiple bilateral hidrocystomas, several larger than 10 mm. Under local anesthesia, an infraciliary incision traditionally used for lower blepharoplasty was performed, and hidrocystomas with intact capsules were withdrawn. RESULTS: The patient had excellent esthetic results, with no recurrence for more than six months after the procedure. CONCLUSION: The infraciliary lower blepharoplasty incision is a promising technique for excising hidrocystomas larger than 10 mm. More studies should be conducted to confirm the good esthetic and functional outcomes of this technique.

Associação de retalho mucoso e retalho cutâneo local na reconstrução de perda de substância em região da bochecha / Mucosal and local skin flap reconstruction for loss of substance in the cheek region

A face representa uma estrutura importante nos seres humanos, devido a ser a parte mais visível do corpo e conter elementos delicados e complexos, que são essenciais em termos de beleza e funcionalidade. As reconstruções faciais, em áreas de grandes perdas de substâncias, permanecem como um desafio para os cirurgiões. Apresentam várias opções de reparo, todas com suas vantagens e desvantagens. Mostramos o caso de um paciente apresentando perda de substância de espessura total em região de bochecha, que foi submetido à associação de retalho mucoso e retalho cutâneo local, apresentando bom resultado e preservação funcional.

The face is an important structure, because it is the most visible part of the body and contains delicate and complex elements that are essential for aesthetics and functionality. Facial reconstruction of areas with substantial substance loss remains a surgical challenge. There are several repair options, with corresponding advantages and disadvantages. We present a case of a patient with substance loss of the total thickness of the cheek region who received mucosal and local skin flap surgery, with good results and functional preservation.

Predição de pré-eclâmpsia: realidade atual e as direções futuras / Prediction of pre-eclampsia: the current reality and future directions

A pré-eclâmpsia (PE) é a principal causa de morbimortalidade materno-fetal, acometendo de 5 a 7% das gestantes no mundo. Apesar de exaustivamente estudada, ainda não existe tratamento satisfatório, além da interrupção da gestação nos casos mais graves. Além da divisão clássica da doença entre leve e grave, os estudos mais recentes sugerem uma nova classificação, subdividindo a PE em precoce (com aparecimento dos sintomas antes de 34 semanas de gestação) e tardia (sintomas após 34 semanas de gestação). As etapas fisiopatológicas diferem de tal forma entre esses dois grupos que alguns autores chegam a propor que se trata de entidades patológicas distintas. O objetivo deste estudo foi realizar uma revisão bibliográfica dos métodos de predição de PE atualmente pesquisados, dando ênfase a exames que podem ser realizados ainda no primeiro trimestre de gestação e àqueles que melhor identificam a paciente com risco aumentado de desenvolver PE precoce, devido ao pior prognóstico materno-fetal dessa condição.

Pre-eclampsia (PE) is the main cause of maternal and fetal morbidity and mortality, reaching 5 to 7% of pregnant women in the world. Although it has been broadly studied, there is still no satisfactory treatment other than the interruption of pregnancy in the most serious cases. In addition to the classical division of the disease in mild and severe, more recent studies suggest a new classification, subdividing the PE in early (with the appearance of symptoms before 34 weeks of gestation) and late (symptoms showing after 34 weeks of gestation). Physiopathology events differ so between these groups that some authors propose that those pathological entities are distinct. The goal of this study was to perform a bibliographic review of methods for predicting PE currently in research, emphasizing the exams that can be performed even in the first trimester of pregnancy and those that best recognize the patient with increased risk of developing PE early due to the worse prognosis of this condition.

Miocardiopatia periparto / Peripartum cardiomyopathy

A miocardiopatia periparto (MCPP) é doença rara, reconhecida como entidade distinta das cardiomiopatias preexistentes, de ocorrência em mulheres previamente saudáveis, durante o período periparto. É pouco conhecida em relação a sua etiologia, risco e prognóstico. As manifestações clínicas mais comuns são as da insuficiência cardíaca sistólica. Sua terapia farmacológica convencional inclui diuréticos, digoxina, inibidores da enzima conversora de angiotensina, bloqueadores dos receptores de angiotensina e bloqueadores beta-adrenérgicos. Os pacientes refratários à terapia farmacológica convencional requerem o suporte circulatório mecânico e o transplante cardíaco. Não existe consenso sobre os riscos de futuras gravidezes em pacientes com MCPP prévia.

Peripartum cardiomyopathy (PPCM) is a rare disease, recognized as a distinct entity from preexisting cardiomyopathy. It occurs in previously healthy woman, during the peripartum period. PPCM is still a little known disease concerning its etiology, risk and prognosis. The most common clinical manifestations are those of systolic heart dysfunction. The objective of the study is to review the scientific literature about the several aspects of PPCM. A total of 19 publications were evaluated. The conventional therapy for congestive heart failure includes diuretics, digoxin, angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB) and beta-adrenergic blockers. For those patients who are resistant to all conventional pharmacological therapy, the viable options are cardiac transplant and mechanical circulation support. There is no consensus about the recommendations on risk of future pregnancies in these patients. Results demonstrate the need for more studies to the understanding of this disease etiology, epidemiology and prognosis.

Miocardiopatia periparto: aspectos relevantes / Peripartum cardiomyopathy: relevant aspects

A miocardiopatia periparto constitui entidade clínica rara, caracterizada por dilatação cardíaca e manifestações de insuficiência cardíaca grave, capaz de evoluir de forma fatal. Ocorre nos meses finais da gestação ou precocemente no puerpério. Sua etiologia e epidemiologia ainda são pouco conhecidas. Há grande discrepância nos prognósticos observados em relatos de caso, variando desde recuperação completa da função ventricular até fatalidade. Neste artigo é relatada a apresentação da doença de forma típica. O objetivo é enfatizar sua importância para que seja instituída precocemente sua terapêutica, evitando assim sua progressão para formas graves.

Peripartum cardiomyopathy (PPCM) is a rare clinical condition characterized by cardiac dilation and signs of severe heart failure and can be fatal. Its main characteristic is to affect women in the final months of pregnancy or early puerperium. Although the high morbidity and mortality, its etiology and epidemiology are poorly known. However, the outcome reports differ widely from complete recovery to death. The article reports a case to illustrate a typical manifestation of the disease. Our objective is to emphasize the importance of the theme not only to cardiologists but also to obstetricians, as the early therapy is the most important way to prevent the progression to severe conditions. Therefore the diagnosis of PPCM requires a lot of care and attention, and preventive counseling after PPCM is important due the increased risk for recurrence in a subsequent pregnancy.