Malignant upgrade rate and associated clinicopathologic predictors for concordant intraductal papilloma without atypia: A systematic review and meta-analysis.

Previously reported upgrade rates for benign breast intraductal papilloma (IDP) are widely variable. However, many previous studies have failed to consider radiologic-pathologic discordance of lesions. This review aims to synthesize malignant upgrade data for benign, concordant IDP at surgical excision. Thirteen studies were included in our meta-analysis. The pooled estimate for percentage underestimation of carcinoma was 1.4% (95% CI: 0.8%-2.0%). We conclude that these lesions can be safely managed by active surveillance.

Rate of Benign and Malignant Secondary Tumors Associated With Nevus Sebaceous: A Systematic Review and Meta-Analysis.

BACKGROUND: Nevus sebaceous (NS) is a rare congenital skin lesion affecting approximately 0.3% of all newborns. Although benign, NS lesions can harbor malignant secondary tumors. The published rate of development of these malignant tumors varies. This meta-analysis aimed to identify the rate of malignant and benign secondary neoplasms occurring in NS. METHODS: A literature search was conducted using PubMed, Embase, and Web of Science from inception to April 2023. Eligible studies reported incidence or risk of secondary neoplasms in patients with NS. Two independent reviewers screened studies, extracted data, and assessed the quality of included studies. The primary outcome was the pooled incidence of secondary neoplasms. Studies with sample sizes greater than 50 patients were eligible for meta-analysis using the random-effects model. RESULTS: Twenty-eight studies were identified, 22 of which were eligible for meta-analysis. The overall rate of secondary neoplasms was 12.8% (95% confidence interval [Cl], 9.2%-17.6%). The rates of development of malignant and benign tumors were 2.4% (95% CI, 1.4%-4.1%) and 10.3% (95% CI, 7.5%-13.9%), respectively. The rate of development of basal cell carcinoma was 1.7% (95% CI, 0.9%-3.2%), whereas the rate of the development of syringocystadenoma papilliferum was 3.6% (95% CI, 2.5%-5.3%) and that if trichoblastoma was 2.6% (95% CI, 1.7%-3.8%). CONCLUSIONS: Although the rate of development of malignant tumors within a primary NS lesion is low, it is not negligible. Prophylactic early excision remains a viable approach to prevent secondary malignant neoplasms, address cosmetic and functional complications, and preempt the need for complex reconstruction in the future. We propose that resection of NS lesions in childhood remains a reasonable first-line option in the appropriate patient keeping in mind that it may leave an undesirable scar.

Anomalous anatomic variation of an absent deep inferior epigastric artery: implications for autologous breast reconstruction.

Autologous breast reconstruction using abdominally based perforator flaps has become increasingly popular following mastectomy for breast cancer. Of these, the deep inferior epigastric artery perforator (DIEP) flap represents one of the most popular techniques. However, surgeons must remain cognizant of anatomic variations in the abdominal wall vasculature that could complicate or preclude planned DIEP flaps. In this case, a 64-year-old female with a history of prior tubal ligations and caesarean sections underwent preoperative computed tomographic angiography (CTA) for planned autologous breast reconstruction with a DIEP flap. CTA revealed complete absence of the left deep inferior epigastric artery, with a sizeable left abdominal wall perforator visualized receiving retrograde flow from a crossing midline branch originating from the contralateral right deep inferior epigastric system. This vessel traversed the midline in a superficial plane in the subcutaneous tissue. Despite this aberrant anatomy, the surgical team successfully raised a unilateral DIEP flap based on the right pedicle. This case represents a unique anatomical variation of the abdominal wall and emphasises the importance of preoperative imaging when planning abdominally based free flaps.

The anatomy of the superficial inferior epigastric artery: Cautious optimism and rightful reluctance for the championing of a minimally morbid abdominal flap.

The superficial inferior epigastric artery (SIEA) flap has gained interest due to its potential as an abdominal breast reconstruction flap that incurs minimal donor site morbidity. Historical descriptions of its anatomy however paint the artery as small in calibre, with a restrictive angiosome and a high agenesis rate. This review examines the most contemporary anatomical data of the SIEA across clinical, cadaver and radiological modalities and balances the promise of encouraging anatomical data against the clinical practicalities of consistently and safely raising an SIEA flap.

The Use of Medicinal Leeching in Breast Surgery: A Systematic Review.

Background: The medicinal leech has been used in plastic surgery to resolve venous congestion that can threaten the viability of tissue transfer. Within the context of breast surgery, venous congestion is a pertinent consideration for reconstructive and non-reconstructive breast surgery such as mammoplasty and mastopexy. However, leeching is closely associated with complications such as infection, pain, and anaemia. This is the first systematic review that examines the methodology, efficacy, and post therapeutic outcome data across all existing studies on medicinal leeching in breast surgery. Methods: A systematic search of PubMed and Embase databases from their inception to November 2023 was conducted. Inclusion criteria included studies reporting on the use of leeches to resolve venous congestion in any breast surgery. The JBI Critical Appraisal Checklist for Case Series tool was used for bias analysis. Descriptive statistics were undertaken in Microsoft Excel. Results: A total of 18 studies with a combined sample size of 28 were examined, including 4 case series and 14 case reports. Patients mostly underwent reconstructive breast surgery (75%). The median number of leeches used was two, with a median number of three leeching sessions per day and 3 days of leeching. Medicinal leeching successfully prevented the loss of 75% of all tissue transfers. The complication rate was high at 81.14% and mainly included infection and anaemia. Conclusions: Medicinal leeching is an effective method to relieve venous congestion in breast surgery but must be judiciously used within the clinical context of the patient to maximise efficacy and mitigate harm from complications.

Therapeutic challenges in small cell carcinoma of the larynx.

Primary small cell neuroendocrine carcinoma (SCNC) of the larynx is a rare subtype of laryngeal cancer, accounting for less than 1% of all laryngeal tumours. It most commonly affects smokers in their fifth to sixth decade of life and is characterised by a high incidence of advanced disease at presentation and an aggressive clinical course. Here we present a case of SCNC of the larynx, presenting initially with dysphonia, and an associated literature review collating current knowledge regarding therapeutic approaches. After review of 260 cases in the literature we determined a disease-specific survival of 33.1%. Combined chemoradiotherapy is currently the recommended first-line treatment option.

Evaluating Artificial Intelligence's Role in Teaching the Reporting and Interpretation of Computed Tomographic Angiography for Preoperative Planning of the Deep Inferior Epigastric Artery Perforator Flap.

Background: Artificial intelligence (AI) has the potential to transform preoperative planning for breast reconstruction by enhancing the efficiency, accuracy, and reliability of radiology reporting through automatic interpretation and perforator identification. Large language models (LLMs) have recently advanced significantly in medicine. This study aimed to evaluate the proficiency of contemporary LLMs in interpreting computed tomography angiography (CTA) scans for deep inferior epigastric perforator (DIEP) flap preoperative planning. Methods: Four prominent LLMs, ChatGPT-4, BARD, Perplexity, and BingAI, answered six questions on CTA scan reporting. A panel of expert plastic surgeons with extensive experience in breast reconstruction assessed the responses using a Likert scale. In contrast, the responses' readability was evaluated using the Flesch Reading Ease score, the Flesch-Kincaid Grade level, and the Coleman-Liau Index. The DISCERN score was utilized to determine the responses' suitability. Statistical significance was identified through a t-test, and P-values < 0.05 were considered significant. Results: BingAI provided the most accurate and useful responses to prompts, followed by Perplexity, ChatGPT, and then BARD. BingAI had the greatest Flesh Reading Ease (34.7±5.5) and DISCERN (60.5±3.9) scores. Perplexity had higher Flesch-Kincaid Grade level (20.5±2.7) and Coleman-Liau Index (17.8±1.6) scores than other LLMs. Conclusion: LLMs exhibit limitations in their capabilities of reporting CTA for preoperative planning of breast reconstruction, yet the rapid advancements in technology hint at a promising future. AI stands poised to enhance the education of CTA reporting and aid preoperative planning. In the future, AI technology could provide automatic CTA interpretation, enhancing the efficiency, accuracy, and reliability of CTA reports.

Primary pulmonary enteric adenocarcinoma presenting as a solitary skull mass.

Pulmonary enteric adenocarcinoma (PEAC) is a rare, aggressive variant of lung adenocarcinoma with early metastatic potential. We present the case of a male smoker in his 50s who presented with right-sided numbness, pain and headache. Imaging revealed a destructive skull base mass invading the right sphenoid sinus. Histopathology was consistent with PEAC. The diagnosis was metastatic PEAC with a distant spread to the skull and represents the first case reported in the literature. We present an associated literature review of the clinical presentation, histological features and management of PEAC with skull metastasis. Metastasis should be considered when evaluating any persistent cranial lesion. Diagnosis requires thorough clinical, radiological and pathological assessment. Treatment involves surgical resection, chemoradiation and targeted therapy. Prognosis directly correlates with clinical stage at presentation. This case highlights the importance of careful evaluation of skull lesions, even in patients without known primary malignancy. Early diagnosis and multimodal therapy may improve outcomes.

Corticosteroid injection versus immobilisation for the treatment of De Quervain's tenosynovitis: A systematic review and meta-analysis.

OBJECTIVE: De Quervain's tenosynovitis causes pain and impairment of thumb function. Conservative treatments comprise corticosteroid injection and immobilization, and it is unclear which offers greater efficacy. Previous reviews were limited by the small number of included studies; thus an updated review and meta-analysis is warranted. METHODS: A systematic review of the PubMed, Embase, and Web of Science databases was conducted. Randomized control trials comparing corticosteroid injection to immobilization were included. Two authors screened articles, extracted data, and assessed the risk of bias of included studies. Meta-analyses using the random-effects model were conducted, calculating pooled relative risks and mean differences with 95% confidence intervals. RESULTS: 16 studies comprising 1206 patients were included. Corticosteroid injection showed greater treatment success than immobilization (relative risk: 1.61; 95% confidence interval: 1.21-2.15). Combining treatments demonstrated greater efficacy than immobilization (relative risk: 2.15; 95% confidence interval: 1.77-2.62) or injection alone (relative risk: 1.23; 95% confidence interval: 1.12-1.34). Pain and disability scores were lower with injection than immobilization and with combined treatment than with either alone. CONCLUSION: Corticosteroid injection is more effective than immobilization for De Quervain's tenosynovitis, and combining the two treatments provides additional benefit. We recommend corticosteroid injection in first line treatment and immobilization as adjuvant therapy. Further research is required regarding optimal corticosteroid and local anesthetic formulations.

Comparison of large language models in management advice for melanoma: Google's AI BARD, BingAI and ChatGPT.

Large language models (LLMs) are emerging artificial intelligence (AI) technology refining research and healthcare. Their use in medicine has seen numerous recent applications. One area where LLMs have shown particular promise is in the provision of medical information and guidance to practitioners. This study aims to assess three prominent LLMs-Google's AI BARD, BingAI and ChatGPT-4 in providing management advice for melanoma by comparing their responses to current clinical guidelines and existing literature. Five questions on melanoma pathology were prompted to three LLMs. A panel of three experienced Board-certified plastic surgeons evaluated the responses for reliability using reliability matrix (Flesch Reading Ease Score, the Flesch-Kincaid Grade Level and the Coleman-Liau Index), suitability (modified DISCERN score) and comparing them to existing guidelines. t-Test was performed to calculate differences in mean readability and reliability scores between LLMs and p value <0.05 was considered statistically significant. The mean readability scores across three LLMs were same. ChatGPT exhibited superiority with a Flesch Reading Ease Score of 35.42 (±21.02), Flesch-Kincaid Grade Level of 11.98 (±4.49) and Coleman-Liau Index of 12.00 (±5.10), however all of these were insignificant (p > 0.05). Suitability-wise using DISCERN score, ChatGPT 58 (±6.44) significantly (p = 0.04) outperformed BARD 36.2 (±34.06) and was insignificant to BingAI's 49.8 (±22.28). This study demonstrates that ChatGPT marginally outperforms BARD and BingAI in providing reliable, evidence-based clinical advice, but they still face limitations in depth and specificity. Future research should improve LLM performance by integrating specialized databases and expert knowledge to support patient-centred care.

Impact of nutrition on skin wound healing and aesthetic outcomes: A comprehensive narrative review.

Background: While current wound treatment strategies often focus on antimicrobials and topical agents, the role of nutrition in wound healing and aesthetic outcomes is crucial but frequently overlooked. This review assesses the impact of specific nutrients and preoperative nutritional status on surgical outcomes. Methods: A comprehensive search was conducted in PubMed, Scopus, Web of Science, and the Cochrane Library, from the inception of the study to October 2023. The study focused on the influence of macronutrients and micronutrients on aesthetic outcomes, the optimization of preoperative nutritional status, and the association between nutritional status and postoperative complications. Inclusion criteria were English language peer-reviewed articles, systematic reviews, meta-analyses, and clinical trials related to the impact of nutrition on skin wound healing and aesthetic outcomes. Exclusion criteria included non-English publications, non-peer-reviewed articles, opinion pieces, and animal studies. Results: Omega-3 fatty acids and specific amino acids were linked to enhanced wound-healing and immune function. Vitamins A, B, and C and zinc positively influenced healing stages, while vitamin E showed variable results. Polyphenolic compounds showed anti-inflammatory effects beneficial for recovery. Malnutrition was associated with increased postoperative complications and infections, whereas preoperative nutritional support correlated with reduced hospital stays and complications. Conclusion: Personalized nutritional plans are essential in surgical care, particularly for enhanced recovery after surgery protocols. Despite the demonstrated benefits of certain nutrients, gaps in research, particularly regarding elements such as iron, necessitate further studies. Nutritional assessments and interventions are vital for optimal preoperative care, underscoring the need for more comprehensive guidelines and research in nutritional management for surgical patients.

Cryptogenic pyogenic liver abscess caused by Fusobacterium necrophorum in an immunocompetent patient.

Pyogenic liver abscesses are potentially fatal conditions that require prompt treatment with drainage and appropriate antimicrobial therapy. Fusobacterium necrophorum is a gram-negative rod that is found in the oral cavity, gastrointestinal tract and female genital tract. It is an extremely rare cause of liver abscess, particularly in the absence of risk factors or exposures. We describe an unusual case of a cryptogenic F. necrophorum hepatic abscess without a clear source despite extensive investigation in a young, immunocompetent patient without known risk factors or exposures for such an infection.

Lymphoedema surgery in Australia: a narrative review.

Background and Objective: Lymphoedema is a chronic condition that affects millions of people worldwide. It is often caused by the damage or removal of lymph nodes during cancer treatment. One of the most effective management options for lymphoedema is surgery, which can reduce swelling and potentially improve lymphatic drainage. Throughout history, Australia has been at the forefront of research and development in this field. In this review, we aim to examine the contributions of Australian research to lymphoedema surgery. Methods: We conducted a search in the PubMed and Embase databases to identify Australian research relating to lymphoedema surgery from inception to the present day. Studies that met the inclusion criteria were reviewed and analysed, and the results were presented. Key Content and Findings: After reviewing the literature, it was apparent that the field of lymphoedema surgery owes much to the contributions of Australian research. Early work from famous Australian surgeons such as Bernard O'Brien and Geoffrey Ian Taylor laid the bedrock for modern surgical techniques. Furthermore, more recently, Australia has seen a resurgence of clinical research contributing to the international evidence for lymphoedema surgery. Conclusions: Australia has made significant contributions to the field of lymphoedema surgery, particularly in the development of modern microsurgical techniques such as lymphovenous anastomosis or vascularised lymph node transfer. These contributions have led to improved patient outcomes and quality of life. Going forward, Australia will hopefully continue to be a leader in research and innovation in this field.