Easing the Burden on Caregivers- Applications of Artificial Intelligence for Physicians and Caregivers of Children with Cleft Lip and Palate.

OBJECTIVE: Many caregivers of children with cleft lip and palate experience a high level of anxiety throughout their child's medical and surgical care. We aim to evaluate artificial intelligence (AI) as a tool to mitigate these feelings and can aid clinicians in the development of robust pediatric educational materials for caregivers and families. DESIGN: Thirteen of the most common postoperative questions following cleft lip and/or palate repair were developed by an expert panel of senior Pediatric Plastic Surgeons and were posed to ChatGPT. Professional answers from the expert panel were provided and compared to responses from ChatGPT. A literature review was also conducted to generate a new support model for caregivers with children undergoing a surgical procedure. SETTING: Department of Pediatric Plastic Surgery at a metropolitan Children's Hospital. PARTICIPANTS: Senior Pediatric Plastic Surgeons at a metropolitan Children's Hospital. INTERVENTIONS: None. MAIN OUTCOME MEASURE: The primary outcome was to determine the ability of ChatGPT to respond to common postoperative questions and to develop a model for AI assistance in family-centered perioperative care. RESULTS: ChatGPT had a postoperative question response accuracy rate of 69% when compared with subject matter expert responses, with its greatest errors being information errors. An extensive literature search revealed that AI can assist in multiple traditional perioperative strategies to reduce caregivers and patient anxiety. CONCLUSIONS: Artificial Intelligence can help to reduce the burden of generating patient education materials as well as support caregivers in multiple aspects and perioperative care.

Geographic Differences in Patient Demographics and Performance of Gender-Affirming Surgery From 2016 to 2019.

BACKGROUND: Although legislation prohibiting gender identity discrimination in health insurance has shown some improvement in insurance coverage for gender-affirming surgery (GAS), recent bills criminalizing GAS providers in the South and Midwest regions pose threats to patient care. OBJECTIVES: To investigate the influence of US census region on patient demographics and GAS rates in the ambulatory surgery setting. METHODS: Individuals with gender dysphoria who underwent GAS in the ambulatory setting from 2016 to 2019 were identified in the Nationwide Ambulatory Surgery Sample (NASS) with billing codes. Demographic and clinical characteristics were analyzed and stratified by US census region. RESULTS: The data set included a weighted estimate of 33,174 encounters with 72.8% (95% CI, 69.1-76.2) for chest reconstruction; 24.1% (95% CI, 20.9-27.5) for surgery on the genitals and reproductive organs; and 6.0% (95% CI, 4.6-7.8) for facial surgery. Overall, the rates of GAS increased by 187%, from 4320 encounters in 2016 to 12,396 encounters in 2019. In the Midwest, GAS increased by 257% compared to 203% in the Northeast, 218% in the South, and 154% in the West. Compared to patients in the West, those in other regions had higher odds of anxiety and depression (odds ratio, 1.57; 95% CI, 1.09-2.26; P < .05) and were more likely to have lower incomes than other ambulatory surgery patients in the region (P < .001). CONCLUSIONS: Between 2016 and 2019, there was substantial growth of GAS in the Midwest, South, and Northeast. Regional differences in insurance coverage, socioeconomic status, availability of facial surgery, and comorbidities were observed.

Risk factors and outcomes of cutaneous melanoma in women less than 50 years of age.

BACKGROUND: Melanoma is the fifth most common cancer in the United States, with recent reports indicating increasing incidence among young women. OBJECTIVE: This study sought to investigate histopathology, staging, risk factors, and outcomes of cutaneous melanoma in women younger than 50 years. METHODS: All female patients aged up to 49 years with biopsy-proven diagnosis of melanoma between 1988 and 2012 were included. Patients with a follow-up of less than 2 years were excluded. RESULTS: A total of 462 patients were identified, with mean age of 34.7 years. Invasive melanoma was less common in women 19 years of age or younger (P < .0008). Positive sentinel node status (P < .008), recurrence rates, metastatic disease (P < .001), and death rates (P < .008) were higher for women ages 40 to 49 years. The 41 patients with a pregnancy-associated melanoma had a significantly worse prognosis in comparison with a control group of nonpregnant patients, with a 9-fold increase in recurrence (P < .001), 7-fold increase in metastasis (P = .03) and 5-fold increase in mortality (P = .06). LIMITATIONS: This was a retrospective study. CONCLUSION: The increasing incidence of melanoma for women younger than 50 years suggests that regular skin checks and self-examinations are warranted. In addition, in women given the diagnosis of melanoma during or within 1 year after childbirth, regular follow-up and monitoring for recurrence are recommended.

The reconstructive challenges and approach to patients with excoriation disorder.

Many mental and emotional disorders have some variations of physical manifestations that are often the first definitive sign of disease. One such disorder is excoriation (skin-picking) disorder, also known as dermatillomania, acne excoriée, neurotic excoriation, or psychogenic excoriation. First identified in the dermatologic literature in 1920, excoriation disorder involves repetitive scratching behavior that sometimes accompanies pruritus and is often associated with depression, anxiety, and obsessive-compulsive disorder. In the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the Diagnostic and Statistical Manual of Mental Disorders fifth edition, excoriation or skin-picking disorder is listed as a stand-alone disorder associated with obsessive-compulsive disorder. In certain patients, the skin lesions are shallow and have adherent crusts that can be mistaken for acne. These lesions, once healed, may appear white and partially atrophic. Because these patients often initially present to dermatologists or plastic surgeons for their skin conditions rather than to psychiatric professionals, it is important to recognize the salient diagnostic features and to acknowledge the importance of a multidisciplinary approach to patient care and management. We present a case of a 51-year-old woman with excoriation disorder who required medical management by dermatology, neurosurgery, psychiatry, and plastic surgery for a definitive surgical treatment.

National patterns in the use of International Statistical Classification of Diseases and Health Related Problems, tenth revision Z codes in ambulatory surgery from 2016 to 2019.

BACKGROUND: In the tenth revision of the International Statistical Classification of Disease and Health Related Problems (ICD-10), Z codes were added to improve documentation and understanding of health-related social needs. We estimated national Z code use in the ambulatory surgery setting from 2016 to 2019. METHODS: Using the Nationwide Ambulatory Surgery Sample (NASS), we identified encounters for ambulatory surgery with an ICD-10 code between Z55.0 and Z65.9. Data were stratified by Z code domains from the Centers for Medicare and Medicaid Services (CMS). RESULTS: This analysis of 41,827 ambulatory surgery encounters with documented Z codes found that the most documented determinants of health related to multiparity or unwanted pregnancy, homelessness, and incarceration. There was a 16.1% increase in the use of Z codes from 2016 to 2019. CONCLUSION: Rates of Z code use in the ambulatory surgery setting are increasing with current documentation serving as a specific but not sensitive measure of socioeconomic need.

Surviving an Extensive Burn Injury Using Advanced Skin Replacement Technologies.

There have been significant improvements in the technology available for treating extensive burns in the past decade. This case presents two unique, skin replacement technologies that were used to treat an 86% surface area flame burn in a pediatric patient. A temporary dermal replacement, known as "Novosorb™ Biodegradable Temporizing Matrix" was first used to stabilize the burn injury and remained in place for approximately 3 months. Given the large burn size and lack of available donor skin for grafting, a permanent skin replacement product known as "Self-Assembled Skin Substitute (SASS)" was then utilized to cover the burns. SASS is a novel technology that was developed to replace skin as an autologous skin graft and is currently available in Canada through a clinical trial for major burns. Ultimately, the concurrent use of these two technologies allowed for the unprecedented survival of a child following an extensive and life-threatening burn injury.

To Admit or Not to Admit: That is the Cleft Lip Question. Confirming the Safety of Outpatient Cleft Lip Repair.

BACKGROUND: There is no accepted protocol for inpatient versus ambulatory cleft lip surgery. The aim of this study was to review the safety of outpatient repair and develop guidelines. METHODS: A retrospective review of patients younger than 2 years undergoing primary cleft lip repair from 2008 to 2015 at six centers was performed. Patients were divided into two groups: predominantly ambulatory (discharged or admitted for specific concerns) and inpatient (admitted due to surgeon's preference). The impact of independent variables on admission, emergency department visits, and readmission within 1 month of discharge was analyzed. RESULTS: Of 546 patients, 68.1 percent were boys, 4.4 percent had syndromes, and 23.6 percent had comorbidities. One hundred forty-two patients were admitted postoperatively. Forty-nine admissions were attributable to the surgeon's preference. After excluding this subset, our ambulatory surgery rate was 81 percent. There was no difference in emergency department visits (3 percent versus 2.2 percent; p = 0.6) or readmissions (0 percent versus 1.45 percent; p = 0.5) between groups. None of the ambulatory surgery patients were readmitted within 36 hours, for a successful ambulatory surgery rate of 100 percent. Female sex; surgical time; prematurity and/or postconceptional age younger than 52 weeks; and cardiac, respiratory, central nervous system, gastrointestinal, genitourinary, and other congenital comorbidities had significant impact on admission rates in the predominantly ambulatory group (p < 0.05). Respiratory comorbidities and syndromes were risk factors for readmission if patients presented to the emergency department (p < 0.05). CONCLUSIONS: Ambulatory cleft lip repair can be performed safely in most patients with no difference in emergency department visits or readmission. Patients with comorbidities should be admitted for observation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Liposomal Bupivacaine in Implant-Based Breast Reconstruction.

PURPOSE: This study evaluates the role of liposomal bupivacaine in implant-based breast reconstruction. METHODS: A prospective, randomized, single-blind trial of liposomal bupivacaine in implant-based breast reconstruction was performed. Patients in the control arm were treated with 20 mL 0.25% bupivacaine with epinephrine 1:200,000 to each breast pocket. Patients in the experimental arm were treated with 10 mL 1.3% liposomal bupivacaine delivered to each breast pocket. Pain scores were recorded over the course of patients' hospital stay. Consumption of pain medications, benzodiazepines, and anti-emetics was monitored. Length of stay and other direct cost data were collected. RESULTS: Twenty-four patients were enrolled, with 12 women randomized to each arm. Average postoperative pain scores were 3.66 for patients in the control arm and 3.68 for patients in the experimental arm. Opioid consumption was 1.43 morphine equivalent dosing/h for patients in the control arm and 0.76 morphine equivalent dosing/h for patients in the experimental arm (P = 0.017). Diazepam consumption was 0.348 mg/h for patients in the control arm and 0.176 mg/h for patients in the experimental arm (P = 0.011). Average length of hospital stay was 46.7 hours for patients in the control arm and 29.8 hours for patients in the experimental arm (P = 0.035). Average hospital charges were $18,632 for patients in the control arm and $10,828 for patients in the experimental arm (P = 0.039). CONCLUSIONS: Liposomal bupivacaine reduces opioid and benzodiazepine consumption, length of stay, and hospital charges. These data support a role for liposomal bupivacaine in implant-based breast reconstruction.

Microcirculatory effect of topical vapocoolants.

BACKGROUND: Vapocoolant sprays are commonly used to minimize pain following minor interventions such as venipuncture, shave biopsy or needle insertion. Although these sprays have been widely used in clinical practice, little is known about their effect on microcirculation or cutaneous blood flow. OBJECTIVE: To evaluate the real-time effect of a topical vapocoolant using a well-established, rat cremaster muscle microcirculatory model, allowing direct measurement of changes in vessel diameter, capillary density and leukocyte behaviour. METHODS: Fifty rats were divided into a control and four experimental groups: group 1: 4 s spray with vapocoolant at 18 cm distance; group 2: 10 s spray at 18 cm distance; group 3: 4 s spray at 8 cm distance; and group 4: 10 s spray at 8 cm distance. Vessel diameters, capillary density and leukocyte behaviour were monitored for 1 h thereafter. Muscle was harvested for immunohistochemistry analysis of proangiogenic markers (vascular endothelial growth factor and von Willebrand factor), leukocyte behaviour markers (E-selectin, vascular cell adhesion molecule, intercellular adhesion molecule), pimonidazole-hypoxia staining and ApopTag (Millipore, USA) staining for apoptosis. Gene expression for inflammatory markers (interleukin [IL]-1ß, IL-2, IL-4, IL-6, IL-10, tumour necrosis factor-alpha and interferon-gamma) was evaluated using polymerase chain reaction and myeloperoxidase assay for inflammation was performed. RESULTS: The use of refrigerant spray decreased vessel diameter and capillary density initially, although none of these decreases were statistically significant. Polymerase chain reaction showed no significant changes. The myeloperoxidase assay showed statistically significant increase in myeloperoxidase activity in groups 2, 3 and 4. Immunohistochemistry was negative for angiogenic and proinflammatory markers. CONCLUSIONS: The lack of statistically significant changes in vessel diameter and inflammatory markers corroborated the safety on microcirculation.

HISTORIQUE: Les pulvérisateurs à froid sont couramment utilisés pour réduire la douleur après des interventions mineures comme les ponctions veineuses, les biopsies par rasage ou l'insertion d'aiguilles. Même si ces vaporisateurs sont largement utilisés en pratique clinique, on ne sait pas grand-chose de leur effet sur la microcirculation ou la circulation cutanée. OBJECTIF: Évaluer l'effet en temps réel d'un pulvérisateur à froid topique au moyen d'un modèle microcirculatoire bien établi du muscle crémaster de rats, afin de mesurer directement les modifications au diamètre, à la densité capillaire et au comportement leucocytaire des vaisseaux. MÉTHODOLOGIE: Les chercheurs ont réparti 50 rats en un groupe témoin et quatre groupes expérimentaux (groupe 1 : pulvérisation à froid de quatre secondes à une distance de 18 cm; groupe 2 : pulvérisation à froid de dix secondes à une distance de 18 cm; groupe 3 : pulvérisation à froid de quatre secondes à une distance de 8 cm; groupe 4 : pulvérisation à froid de dix secondes à une distance de 8 cm). Ils ont ensuite surveillé le diamètre, la densité capillaire et le comportement leucocytaire des vaisseaux pendant une heure. Ils ont prélevé le muscle pour effectuer une analyse immunohistochimique des marqueurs proangiogéniques (facteur de croissance de l'endothélium vasculaire et facteur de von Willebrand), des marqueurs de comportement leucocytaire (E-sélectine, molécule d'adhésion des cellules vasculaires, molécule d'adhésion intercellulaire), du pimonidazole, marqueur d'hypoxie, et de la trousse ApopTag (Millipore, États-Unis) pour déceler l'apoptose. Ils ont évalué l'expression génique des marqueurs inflammatoires (interleukine [IL]-1ß, IL-2, IL-4, IL-6, IL-10, facteur de nécrose tumorale alpha et interféron gamma) au moyen de la réaction en chaîne de la polymérase et du dosage de myéloperoxydase pour déterminer l'inflammation. RÉSULTATS: Au départ, l'utilisation d'un pulvérisateur à froid a réduit le diamètre et la densité capillaire des vaisseaux, mais pas de manière statistiquement significative. La réaction en chaîne de la polymérase n'a pas changé de manière significative. Le dosage de myéloperoxydase a révélé une augmentation statistiquement significative de l'activité de la myéloperoxydase dans les groupes 2, 3 et 4. L'immunohistochimie était négative aux marqueurs angiogéniques et pro-inflammatoires. CONCLUSIONS: L'absence de changements statistiquement significatifs du diamètre des vaisseaux et des marqueurs inflammatoires en ont corroboré l'innocuité sur la microcirculation.