Automated conversational agents for post-intervention follow-up: a systematic review.

BACKGROUND: Advances in natural language processing and other machine learning techniques have led to the development of automated agents (chatbots) that mimic human conversation. These systems have mainly been used in commercial settings, and within medicine, for symptom checking and psychotherapy. The aim of this systematic review was to determine the acceptability and implementation success of chatbots in the follow-up of patients who have undergone a physical healthcare intervention. METHODS: A systematic review of MEDLINE, MEDLINE In-process, EMBASE, PsychINFO, CINAHL, CENTRAL and the grey literature using a PRISMA-compliant methodology up to September 2020 was conducted. Abstract screening and data extraction were performed in duplicate. Risk of bias and quality assessments were performed for each study. RESULTS: The search identified 904 studies of which 10 met full inclusion criteria: three randomised control trials, one non-randomised clinical trial and six cohort studies. Chatbots were used for monitoring after the management of cancer, hypertension and asthma, orthopaedic intervention, ureteroscopy and intervention for varicose veins. All chatbots were deployed on mobile devices. A number of metrics were identified and ranged from a 31 per cent chatbot engagement rate to a 97 per cent response rate for system-generated questions. No study examined patient safety. CONCLUSION: A range of chatbot builds and uses was identified. Further investigation of acceptability, efficacy and mechanistic evaluation in outpatient care pathways may lend support to implementation in routine clinical care.

Incomplete surgical excision of keratinocyte skin cancers: a systematic review and meta-analysis.

BACKGROUND: Keratinocyte or nonmelanoma skin cancer (NMSC) is the commonest malignancy worldwide. The usual treatment is surgical excision. Current guidelines underestimate incomplete excision rates. OBJECTIVES: We aimed to determine the risk of incomplete excision of NMSCs through a systematic review and meta-analysis of primary clinical studies. METHODS: A PRISMA-compliant systematic review and meta-analysis was performed using methodology proposed by Cochrane (PROSPERO CRD42019157936). A comprehensive search strategy was applied to MEDLINE, Embase, Scopus, CINAHL, EMCare, Cochrane Library and the grey literature (January 2000-27 November 2019). All studies were included except those on Mohs micrographic surgery, frozen section or biopsies. Abstract screening and data extraction were performed in duplicate. Risk of bias was assessed using a tool for prevalence/incidence studies. The primary outcome was the proportion of incomplete surgical excisions. A random-effects model for pooling of binomial data was used. Differences between proportions were assessed by subgroup meta-analysis and meta-regression, which were presented as risk ratios (RRs). RESULTS: Searching identified 3477 records, with 110 studies included, comprising 53 796 patients with 106 832 basal cell carcinomas (BCCs) and 21 569 squamous cell carcinomas (SCCs). The proportion of incomplete excisions for BCC was 11·0% [95% confidence interval (CI) 9·7-12·4] and for SCC 9·4% (95% CI 7·6-11·4). Proportions of incomplete excisions by specialty were: dermatology, BCCs 6·2% and SCCs 4·7%; plastic surgery, BCCs 9·4% and SCCs 8·2%; general practitioners, BCCs 20·4% and SCCs 18·9%. The risk of incomplete excision for general practitioners was four times that of dermatologists for both BCCs (RR 3·9, 95% CI 2·0-7·3) and SCCs (RR 4·8, 95% CI 1·0-22·8). Studies were heterogeneous (I2  = 98%) and at high risk of bias. CONCLUSIONS: The proportion of incomplete excisions is higher than previously reported. Excisions performed by specialists may lower the risk of incomplete excision.

Meta-analysis of venous anastomosis techniques in free flap reconstruction.

BACKGROUND: Coupler devices and hand-sewn anastomosis techniques are both routinely employed for venous anastomosis in microsurgical free flap transfer. However, uncertainty remains about whether those two techniques are different in terms of risk of venous thrombosis. The aim of this review was to evaluate the quality of the evidence and quantify the difference in venous thrombosis rates in both techniques. METHOD: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses compliant systematic review and meta-analysis were performed according to a previously published protocol. MEDLINE and Embase databases were searched from inception to 1 October 2018. Clinical studies using coupler devices for venous anastomoses in free tissue transfer were included. The primary outcome was post-operative venous thrombosis risk. Surgical anastomosis time was a secondary outcome. The risk of bias was assessed with the ROBINS-I or NIH tool and recommendations were made using the GRADE criteria. RESULTS: A total of 10,851 patients across 32 observational retrospective studies were included, with data available for 12,769 free flaps in breast, head and neck, limb and other reconstructions. Direct comparison meta-analysis of 7 studies showed a reduced post-operative thrombosis risk for venous coupler, although this was an imprecise estimate (RR 0.68 [95% CI 0.39-1.19]). The risk of bias was consistently high across all studies. CONCLUSION: Venous couplers may reduce the risk of venous thrombosis, but further randomised trial data are needed to improve the accuracy of this estimate. Further research should also assess size-mismatch between donor and recipient vessel, and the influence of coupler size on outcomes (PROSPERO registration ID: CRD42018110111).

Rhinological interventions for obstructive sleep apnoea - a systematic review and descriptive meta-analysis.

OBJECTIVES: Obstructive sleep apnoea is a common chronic sleep disorder characterised by collapse of the upper airway during sleep. The nasal airway forms a significant part of the upper airway and any obstruction is thought to have an impact on obstructive sleep apnoea. A systematic review was performed to determine the role of rhinological surgical interventions in the management of obstructive sleep apnoea. METHODS: A systematic review of current literature was undertaken; studies were included if they involved comparison of a non-surgical and/or non-rhinological surgical intervention with a rhinological surgical intervention for treatment of obstructive sleep apnoea. RESULTS: Sixteen studies met the selection criteria. The pooled data suggest that there are reductions in the apnoea/hypopnea index and respiratory disturbance index following nasal surgery. However, the current body of studies is too heterogeneous for statistically significant meta-analysis to be conducted. CONCLUSION: Nasal surgery may have limited benefit for a subset of patients based on current evidence.

Systematic review of fibrin glue in burn wound reconstruction.

BACKGROUND: In the reconstruction of burns using split-skin grafts (SSGs), fibrin glue can be used to improve graft take and reduce haematoma formation, although the efficacy and cost-effectiveness are unknown. This systematic review evaluated outcomes of fibrin glue compared with conventional SSG attachment techniques. Outcomes of interest included SSG take, haematoma formation, patient satisfaction and cost-effectiveness. METHODS: This PROSPERO-registered review was performed in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and PRISMA statement. Embase, PubMed, Cochrane and ClinicalTrial.gov databases were searched systematically. Observational and experimental studies comparing fibrin glue with other methods of SSG attachment in burn wounds were included. Risk of bias was assessed using the Cochrane risk-of-bias and Risk of Bias In Non-Randomized Studies - of Intervention tools. The quality of the evidence was assessed using the GRADE tool. RESULTS: Two RCTs and four observational studies were included. Graft take at day 5 was not significantly different between groups (3 studies, 183 individuals). Fibrin glue significantly reduced the risk of postoperative haematoma in two studies and reduced patient-reported pain in two studies, with suggested cost savings in four studies. All studies were at risk of methodological bias and the quality of the evidence was universally very low. CONCLUSION: As the evidence is sparse, the quality very low and the risk of bias significant both within and across studies, it is not possible to make any recommendations regarding the use of fibrin glue in burn wounds.

Surgical intervention for chronic migraine headache: A systematic review.

AIMS: Migraine is a global phenomenon, affecting more than 10% of the world's population. It is characterized by unilateral headache that may be accompanied by vomiting, nausea, photophobia and phonophobia. Some patients with chronic migraine respond to extra-cranial botulinum toxin type A injection, although the benefits observed are temporary. The rationale for surgical trigger site deactivation is to achieve lasting symptomatic improvement or permanent relief from migraine. METHODS: We performed a PRISMA-compliant systematic review of clinical studies evaluating surgical intervention for migraine by searching Ovid MEDLINE and EMBASE databases from inception to June 2017. Studies were independently screened by two authors. Data were extracted on study characteristics, migraine outcomes, adverse events and recurrence. The quality of evidence was assessed using the GRADE approach. The review protocol was prospectively registered on the PROSPERO database (CRD42017068577). RESULTS: The search strategy identified 789 articles; of them, 18 studies (4 RCTs and 14 case series) were eligible for analysis. Surgical interventions were heterogeneous and variably involved peripheral nerve decompression by myectomy or foraminotomy, nerve excision, artery resection and/or nasal surgery. All studies reported significant reductions in migraine intensity, frequency, duration and composite headache scores following surgery. Study heterogeneity precluded formal meta-analysis. Where reported, adverse event rates varied markedly between studies. The quality of included studies was consistently low or very low. CONCLUSION: There is insufficient evidence to support the effectiveness of any specific surgical intervention for chronic migraine, especially with regard to permanent relief; however, all included studies report improvements in key outcomes following migraine surgery. A definitive, well-powered RCT with objective surgical and patient-reported outcome measures and robust adverse event reporting is required.

A 24-month cost and outcome analysis comparing traditional fronto-orbital advancment and remodeling with endoscopic strip craniectomy and molding helmet in the management of unicoronal craniosynostosis: A retrospective bi-institutional review.

INTRODUCTION: Endoscopic strip craniectomy with helmeting (ESCH) has been shown to be a safe and efficacious alternative to fronto-orbital remodeling (FOR) for selected children with craniosynostosis. In addition to clinical factors, there may be economic benefits from the use of ESCH instead of FOR. METHODS: A retrospective review of 23 patients with nonsyndromic unicoronal craniosynostosis (UCS) treated with FOR was carried out at Great Ormond Street Hospital (GOSH) for Children in London, UK. Secondary data were used for the ESCH cohort from a paper published by Jimenez and Barone (2013). Data were collected on surgical time, transfusion rates, length of hospital stay, adverse event rates, reintervention rates, and overall costs. Costs were categorized and then assigned to the appropriate data sets. RESULTS: The mean age of patients undergoing FOR (vs. ESCH) was 17.4 mo (vs. 3.1 mo) with a mean surgical time of 234 min (vs. 55 min), mean transfusion volume of 221.6 mL (vs. 80.0 mL), mean transfusion rate of 14/23 (vs. 2/115), and a total immediate overnight stay of 3.13 days (vs. 97% next-day discharge). The FOR group had a higher adverse event rate (5/23 vs. 4/115, p=<0.005) and a higher number requiring extraocular muscle surgery (4/23 vs. 7/109, p=0.16). There was a substantial difference in overall costs between the two groups. Total variance cost for the FOR group was £7436.5 vs. £4951.35, representing a cost difference of £2485.15 over the 24-month study period. CONCLUSION: ESCH, in comparison to FOR, appears as a more economical method in the management of USC patients, as well as having clinical benefits including reduced adverse event rate and improved ophthalmic outcomes.

A systematic review and meta-analysis of adverse outcomes following non-buried versus buried Kirschner wires for paediatric lateral condyle elbow fractures.

PURPOSE: Fractures of the lateral condyle of the humerus in children are a common injury. If displaced or unstable they may require surgical reduction and fixation with Kirschner wires (K-wires). K-wires are placed using either an open or closed technique. The decision to bury or leave the ends extending through the skin is surgeon-dependent and based on factors including post-operative infection risk, bony union and ease of wire removal. METHODS: We performed a systematic review and meta-analysis of non-buried versus buried K-wires for lateral condyle elbow fractures in children in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. A comprehensive search strategy included Medline, Embase and CINAHL via NICE Evidence from database inception to June 2017. Two authors independently reviewed, included or excluded articles, extracted data and assessed for quality with the ROBINS-I tool. We performed direct comparison meta-analysis for all adverse events, post-operative infection and failure of bony union. RESULTS: Three studies were analysed comprising of 434 participants. There was a significantly reduced relative risk of adverse events in the non-buried group, equating to approximately 45% reduced risk (RR 0.55, 95% confidence interval 0.34 to 0.88). There were no significant differences in risk of post-operative infection or failure of bony union. All three cost-analyses in the included studies observed savings with non-buried K-wires. CONCLUSION: Non-buried K-wires for lateral condyle elbow fractures convey a lower risk of adverse events and may be more cost-effective compared with buried K-wires. Non-buried K-wires do not appear to increase the risk of infection or failure of bony union. These findings are limited by a high risk of bias due to inherent methodological flaws in the design of included studies.

Does the site of anastomosis for esophagectomy affect long-term quality of life?

Long-term survival after esophagectomy is improving, and hence, quality of life (QOL) of these patients has become a priority. There has been extensive debate regarding the optimal site of surgical anastomosis (cervical or intrathoracic). We aimed to evaluate the impact of anastomotic site on long-term QOL postesophagectomy. Quality of life questionnaires (European Organisation for Research and Treatment of Cancer [EORTC] C-30 and OG-25) were sent to patients surviving over 3 years following esophagectomy. The data were analyzed by site of esophagogastric anastomosis: intrathoracic or cervical. EORTC C-30 data were compared against the reference population data. Of the patients, 62 responded (82%) with a median time postsurgery of 6.1 years (range 3-12 years). Patient demographics were comparable. There was no significant difference between cervical or intrathoracic anastomosis groups for functional or symptom scores, focusing on dysphagia (cervical = 8.8 vs. intrathoracic = 17.6, P = 0.24), odynophagia (cervical = 13.4 vs. intrathoracic = 16.1, P = 0.68) and swallowing problems (cervical = 8.1 vs. intrathoracic = 13.4, P = 0.32). There was no difference in overall health score between groups (cervical = 70.5 vs. intrathoracic = 71.6, P = 0.46). Overall general health score was comparable with the reference population (esophagectomy group P = 70.9 ± 22.1 vs. reference population = 71.2 ± 22.4, P = 0.93). There is no difference in long-term QOL after esophagectomy between patients with a cervical or intrathoracic anastomosis. Scores compare favorably with EORTC reference data. Survival after esophagectomy is associated with recovery of QOL in the long term, regardless of site of anastomosis and despite worse gastrointestinal-related symptoms.

Regenerative medicine in otorhinolaryngology.

BACKGROUND: Tissue engineering using biocompatible scaffolds, with or without cells, can permit surgeons to restore structure and function following tissue resection or in cases of congenital abnormality. Tracheal regeneration has emerged as a spearhead application of these technologies, whilst regenerative therapies are now being developed to treat most other diseases within otolaryngology. METHODS AND RESULTS: A systematic review of the literature was performed using Ovid Medline and Ovid Embase, from database inception to 15 November 2014. A total of 561 papers matched the search criteria, with 76 fulfilling inclusion criteria. Articles were predominantly pre-clinical animal studies, reflecting the current status of research in this field. Several key human research articles were identified and discussed. CONCLUSION: The main issues facing research in regenerative surgery are translation of animal model work into human models, increasing stem cell availability so it can be used to further research, and development of better facilities to enable implementation of these advances.