Secondary Reconstruction of Panfacial Fractures With Virtual Reality Surgical Planning Using Both Pre and Postreconstruction Scans.

Late secondary reconstruction is sometimes required in patients with suboptimal primary panfacial fracture repair. At this stage, it can be difficult to discern original facial architecture due to malunion and bony remodeling. By utilizing the original postinjury CT scan to complete fracture reduction in the virtual reality (VR) planning environment, the surgeon may attempt to recreate an "ideal" facial bony anatomy for patients. This technique was completed in 2 patients presenting with facial deformity secondary to malunited panfacial fracture. Each had a cone-beam CT (CBCT) scan taken at presentation and the initial postinjury CT scans were obtained. Fracture reductions were completed in VR to recreate the preinjury anatomy. The resulting model was overlaid with current anatomy to create surgical aids. The first patient, a 23-year-old man, presented with malunion of all bones of the midface. Cutting guides were designed for the Lefort 1 segment, left zygomaticomaxillary complex (ZMC), and naso-orbito-ethmoid (NOE) osteotomies. The second patient, a 30-year-old woman, had bilateral ZMC and subcondylar fractures, midface retrusion, and malunion of parasymphyseal fracture. A 2-stage procedure was planned, including an initial Lefort I and bilateral sagittal split osteotomy with midline wedge excision. To address malar projection, a second surgery was planned using custom MEDPOR midface implants for the NOE and zygomatic regions. Both patients were discharged home, and all surgical goals and esthetic objectives were achieved.

Outcomes of Cancer Patients with COVID-19: The Virginia Commonwealth University Experience.

PURPOSE: The cancer population is significantly impacted by coronavirus disease 2019 (COVID-19) due to inherent risks of infection imposed by malignancy and therapeutic agents. Evaluating risk factors in this group will lead to improved guidelines for the treatment of malignancy in the setting of a COVID-19 pandemic. PATIENTS AND METHODS: This retrospective study reviewed 295 inpatient cancer patients positive for COVID-19 between February 2020 and December 2021 to determine specific risk factors of mortality and associated complications. Various patient characteristics were collected to evaluate outcomes in patient death, oxygen requirement, ventilatory support, and increased length of stay. RESULTS: 31 (10.5%) of 295 patients died due to COVID-19. Of those that died, the majority had hematologic cancer (48.4%). There was no difference in the odds of death among the cancer groups. Those vaccinated had a reduced risk of death (OR 0.04, CI 0-0.23). Patients with lung cancer (OR 3.69, CI 1.13-12.31), obesity (OR 3.27, CI 1.18-9.27), CHF (OR 2.68, CI 1.07-6.89) were more likely to require ventilation. Those treated with hormonal therapy had higher odds of having a prolonged admission (OR 5.04, CI 1.17-2.53). Otherwise, cancer therapy had no significant difference in any outcome. CONCLUSION: The mortality rate of cancer patients was 10.5%, lower than in other studies. Vaccinations had mortality benefits, but no effect on hypoxia, ventilator use, or LOS. Delaying cancer therapy during peak infection is likely not necessary based on the results of this study. With improved knowledge in the risks of infection and the utility of personalized precautions, both providers and patients can better prepare for another potential wave of COVID-19.

Cervical and postural strategies for maintaining horizontal gaze in asymptomatic adults.

PURPOSE: To investigate the different cervical strategies for maintaining horizontal gaze in asymptomatic subjects. METHODS: One hundred and forty-four asymptomatic adults filled the SF-36 quality of life questionnaire and underwent full-body biplanar radiographs. Chin brow vertical angle (CBVA) and postural and cervical parameters were measured. Subjects were grouped according to cervical spine curvature (C2-C7 angle): kyphotic (< - 5°), straight [- 5°, 5°], lordotic (> 5°). Demographics, SF-36 component scores and CBVA were compared between groups. All other parameters were compared between groups, while controlling for confounding factors (ANCOVA). A correlation test was conducted between all cervical parameters. RESULTS: 32% of subjects had kyphotic (- 12° ± 7°), 27% straight (0° ± 3°) and 41% lordotic (12° ± 7°) cervical spines. While demographic and SF-36 data did not differ between groups, CBVA differed between lordotic and kyphotic groups (2° vs. 6.5°, p = 0.002). Sagittal vertical axis (SVA) and thoracic kyphosis (TK) were lower in the kyphotic group (SVA: K = - 26 ± 20 mm vs. L = - 2 ± 21 mm, p < 0.001; TK: K = 40° ± 6° vs. L = 51° ± 8°, p < 0.001). C2 slope (K = 29° ± 6° vs. L = 18° ± 6°, p < 0.001), C0-C2 (K = 42° ± 8° vs. L = 30° ± 8°, p < 0.001) and C1-C2 (K = 33° ± 6° vs. L = 28° ± 6°, p = 0.004) were higher in the kyphotic group. Significant correlations were found between almost all cervical parameters and C2-C7 angle. CONCLUSIONS: Subjects with cervical kyphosis presented with more posterior global alignment and lower TK than subjects with lordosis. In order to maintain horizontal gaze, subjects with cervical kyphosis presented with a more lordotic upper cervical spine than subjects with cervical lordosis. Subjects with straight cervical curvature presented with an intermediate sagittal alignment. These slides can be retrieved under Electronic Supplementary Material.

Normscan: open-source Python software to create average models from CT scans.

PURPOSE: Age-matched average 3D models facilitate both surgical planning and intraoperative guidance of cranial birth defects such as craniosynostosis. We aimed to develop an algorithm that accepts any number of CT scans as input and generates highly accurate, average models with minimal user input that are ready for 3D printing and clinical use. METHODS: Using a compiled database of 'normal' pediatric computed tomography (CT) scans, we report Normscan, an open-source platform built in Python that allows users to generate normative models of CT scans through user-defined landmarks. We use the basion, nasion, and left and right porions as anatomical landmarks for initial correspondence and then register the models using the iterative closest points algorithm before downstream averaging. RESULTS: Normscan is fast and easy to use via our user interface and also creates highly accurate average models of any number of input models. Additionally, it is highly repeatable, with coefficients of variance for the surface area and volume of the average model being less than 3% across ten independent trials. Average models can then be 3D printed and/or visualized in augmented reality. CONCLUSIONS: Normscan provides an end-to-end pipeline for the creation of average models of skulls. These models can be used for the generation of databases of specific demographic anatomical models as well as for intraoperative guidance and surgical planning. While Normscan was designed for craniosynostosis repair, due to the modular nature of the algorithm, Normscan has many applications in other areas of surgical planning and research.

Prompt engineering to increase GPT3.5's performance on the Plastic Surgery In-Service Exams.

This study assesses ChatGPT's (GPT-3.5) performance on the 2021 ASPS Plastic Surgery In-Service Examination using prompt modifications and Retrieval Augmented Generation (RAG). ChatGPT was instructed to act as a "resident," "attending," or "medical student," and RAG utilized a curated vector database for context. Results showed no significant improvement, with the "resident" prompt yielding the highest accuracy at 54%, and RAG failing to enhance performance, with accuracy remaining at 54.3%. Despite appropriate reasoning when correct, ChatGPT's overall performance fell in the 10th percentile, indicating the need for fine-tuning and more sophisticated approaches to improve AI's utility in complex medical tasks.

PI3k Inhibitors in NHL and CLL: An Unfulfilled Promise.

Phosphatidylinositol 3-kinases (PI3Ks) are a family of intracellular signal transducer enzymes that can attach a phosphate group to the 3'-hydroxyl of the inositol moiety of membrane-embedded phosphatidylinositol (PI). PI3Ks have been shown to play important roles in cell proliferation, growth, survival, motility, and metabolism. Nonetheless, the PI3K pathway has also shown to be overactivated in several tumors, particularly B-cell malignancies. In recent years, the PI3K signaling pathway has become the major focus of substantial drug discovery and development efforts. Selective (PI3K) inhibitors have been approved for the treatment of chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL), and indolent non-Hodgkin lymphomas (iNHL), such as follicular lymphoma and marginal-zone lymphoma. Four selective PI3K inhibitors have received accelerated FDA approvals for the treatment of patients with relapsed/refractory (R/R) CLL and/or iNHL based mainly on single-arm Phase II studies: Idelalisib (PI3K-δ inhibitor), copanlisib (dual PI3K-α and PI3K-δ inhibitor), duvelisib (dual PI3K-γ and PI3K-δ inhibitor), and umbralisib (dual PI3Kδ and CK1ε inhibitor). Conversely, recent interim results of randomized control trials (RCTs) involving some of these agents, showed a worrisome trend of decrease in overall survival (OS), and an increase in fatal and severe adverse effects, in comparison with patients in the control arms. Consequently, the class of PI3K inhibitors came under scrutiny, with an FDA expert panel voting on April 21, 2022, recommending that future FDA approvals of PI3K inhibitors be supported by randomized data, rather than single-arm data only, and further discontinuing the use of almost all the PI3K inhibitors in hematologic malignancies. As we believe further research is needed to help potentialize PI3K inhibitors by improving their safety profiles, this mini-review aims at revisiting the clinical successes, the failures, and the promising aspect of this class of drugs, while presenting possible ways that could benefit its successful development.

Are the sagittal cervical radiographic modifiers of the Ames-ISSG classification specific to adult cervical deformity?

OBJECTIVEThe Ames-International Spine Study Group (ISSG) classification has recently been proposed as a tool for adult cervical deformity evaluation. This classification includes three radiographic cervical sagittal modifiers that have not been evaluated in asymptomatic adults. The aim of this study was to determine whether the sagittal radiographic modifiers described in the Ames-ISSG cervical classification are encountered in asymptomatic adults without alteration of health-related quality of life (HRQOL).METHODSThe authors conducted a cross-sectional study of subjects with an age ≥ 18 years and no cervical or back-related complaints or history of orthopedic surgery. All subjects underwent full-body biplanar radiographs with the measurement of cervical, segmental, and global alignment and completed the SF-36 HRQOL questionnaire. Subjects were classified according to the sagittal radiographic modifiers (chin-brow vertical angle [CBVA], mismatch between T1 slope and cervical lordosis [TS-CL], and C2-7 sagittal vertical axis [cSVA]) of the Ames-ISSG classification for cervical deformity, which also includes a qualitative descriptor of cervical deformity, the modified Japanese Orthopaedic Association (mJOA) myelopathy score, and the Scoliosis Research Society (SRS)-Schwab classification for spinal deformity assessment. Characteristics of the subjects classified by the different modifier grades were compared.RESULTSOne hundred forty-one asymptomatic subjects (ages 18-59 years, 71 females) were enrolled in the study. Twenty-seven (19.1%) and 61 (43.3%) subjects were classified as grade 1 in terms of the TS-CL and CBVA modifiers, respectively. Ninety-eight (69.5%) and 4 (2.8%) were grade 2 for these same respective modifiers. One hundred thirty-six (96.5%) subjects had at least one modifier at grade 1 or 2. There was a significant relationship between patient age and grades of TS-CL (p < 0.001, Cramer's V [CV] = 0.32) and CBVA (p = 0.04, CV = 0.22) modifiers. The HRQOL, global alignment, and segmental alignment parameters were similar among the subjects with different modifier grades (p > 0.05).CONCLUSIONSThe CBVA and TS-CL radiographic modifiers of the Ames-ISSG classification do not seem to be specific to subjects with cervical deformities and can occur in asymptomatic subjects without alteration in HRQOL.