Comparison of preformed microcuff and preformed uncuffed endotracheal tubes in pediatric cleft palate surgery-A randomized controlled trial.

BACKGROUND AND AIMS: Airway management in children with oral cleft surgery carries unique challenges, concerning the proximity of the surgical site and the tracheal tube. We hypothesized that using a Microcuff oral RAE tube would reduce tube exchange and migration rate. We aimed to compare the performance of Microsoft and uncuffed oral performed tracheal tubes in children undergoing cleft palate surgeries regarding the rate of tracheal tube exchange, endobronchial intubation, and ventilatory parameters. METHODS: One hundred children scheduled for cleft palate surgery were randomized into two groups. In the uncuffed group (n = 50), the tracheal tube was selected using the Modified Coles formula, and in the Microcuff (n = 50) group, the manufacturer's recommendations were followed. Intraoperatively, we compared the primary outcome of tube exchange using the chi-square test. The leak pressure and ventilatory parameters after head extension and mouth gag application were measured in both groups. RESULTS: The tracheal tube exchange rate was significantly lower in the Microcuff group (0/50) than in uncuffed (19/50) preformed tubes (0 vs. 38% respectively; p <.001). The uncuffed and Microcuff tracheal tube were comparable concerning ventilation parameters and leak pressure of finally placed tubes (17.78 ± 3.95 vs. 19.26 ± 3.81 cm H2 O respectively, with a mean difference (95% CI) of -1.48 (-0.01-2.98); p-value =0.059. Cuff pressure did not vary significantly during the initial hour, and the incidence of postoperative airway morbidity between uncuffed and Microcuff tube was comparable, 5/50 (10%) versus 7/50 (14%) with risk ratio (95% CI) of 0.71(0.24-2.1), p value .49. CONCLUSION: Microcuff oral preformed tubes performed better than uncuffed tubes regarding tube exchange during cleft palate surgery.

Preoperative Preparatory Talk (PPT): Developing Operative Expertise of Plastic Surgery Trainees by Three Rounds of Preceptor-Trainee Discussions.

Background Plastic surgery training requires the trainee to assist in surgeries to improve their on-table decision making and hone their surgical skills, but this results in an increased risk of intraoperative complications and increased operative time. It is important to have a training method that orients the trainee toward the surgery to ensure patient safety. Materials and Methods A training method called preoperative preparatory talk (PPT) was devised in which the preceptor orients the trainee toward the planned surgery in three phases. Comparison and statistical analysis of mean operative times of four stages of free flap surgeries after PPT and without PPT were done. Objective Structured Assessment of Technical Skill (OSATS) scores of surgical trainees were also documented for surgeries done with and without PPT and statistical analysis was done for comparing these scores. Results Statistical analysis via unpaired t -test confirmed that after applying PPT, there was a significant decrease in time taken in three out of four stages of free flap surgeries: flap planning and harvesting, recipient site preparation and vessel dissection, and flap division and partial inset. Trainees were found to be better oriented toward the surgery which resulted in a better performance on table that was confirmed by statistical analysis of OSATS score via unpaired t -test. Conclusion PPT ensures better learning for the resident and improves patient safety because of better orientation of the operating team toward the procedure and operating steps. This reduces the operative time of free flap surgeries. We recommend this training method to be incorporated in plastic surgery training programs.

Leveraging Large Language Models (LLM) for the Plastic Surgery Resident Training: Do They Have a Role?

Introduction Large language models (LLMs) are designed for recognizing, summarizing, translating, predicting, and generating text-based content from knowledge gained from extensive data sets. ChatGPT4 (Generative Pre-trained Transformer 4) (OpenAI, San Francisco, California, United States) is a transformer-based LLM model pretrained on public data as well as data obtained from third-party sources using deep learning techniques of fine tuning and reinforcement learning from human feedback to predict the next text. We wanted to explore the role of LLM as a teaching assistant (TA) in plastic surgery. Material and Methods TA roles were first identified in available literature, and based on the roles, a list of suitable tasks was created where LLM could be used to perform the task. Prompts designed to be fed in to the LLM (specifically ChatGPT) to generate appropriate output, were then created and fed to the ChatGPT model. The outputs generated were scored by evaluators and compared for interobserver agreement. Results A final set of eight TA roles were identified where a LLM could be utilized to generate content. These contents were scored for usefulness and accuracy. These were scored independently by the eight study authors in a scoring sheet created for the study. Interobserver agreements for content accuracy, usefulness, and clarity were 100% for content generated for the following: interactive case studies (generation), simulation of preoperative consultations, and generation of ethical considerations. Discussion LLMs in general and ChatGPT (on which this study is based) in specific, can generate answers to questions and prompts based on huge amount of text fed into the model for training the underlying language model. The answers generated have been found to be accurate, readable, and even indistinguishable from human-generated text. This capability of automated content synthesis can be exploited to generate summaries to text, answer short and long answers, and generate case scenarios. We could identify a few such scenarios where the LLM could in general be utilized to play the role of a TA and aid plastic surgery residents in particular. In addition, these models could also be used by students to obtain feedback and gain reflection which itself stimulates critical thinking. Conclusion Incorporating LLMs into the educational arsenal of plastic surgery residency programs can provide a dynamic, interactive, and individualized learning experience for residents and prove to be worthy TAs of future.

Reconstruction of Defects Following Excision of Basal Cell Carcinoma of Face: A Subunit-based Algorithm.

Introduction: Basal cell carcinoma (BCC) is a locally invasive, slowly spreading tumor arising in the basal layer of epidermis and rarely metastasizes. Surgical excision with adequate margins is curative. Reconstruction of post-excisional defects on the face is both essential and challenging. Clinical Cases and Methods: A retrospective review of hospital records for patients operated for BCC of the face excluding the pinna at our institute in the last 3 years was done and a review of the literature was carried out to identify the most common principles governing the optimal reconstruction of post-excisional defects on the face. Literature search was made in Embase, Medline, and Cochrane databases in the last two decades with the filters placed for human and English language studies with the search terms (Facial Basal cell carcinoma) AND reconstruction AND (Humans[Mesh]). Results: Records of 32 patients with facial BCC who underwent excision and reconstruction at our hospital were identified and details were recorded. Our literature search with the terms and filters mentioned above revealed 244 studies with duplicates removed. After further hand-searching, 218 journal articles were identified, reviewed, and a reconstruction algorithm was designed based on the findings. Discussion: Reconstruction of post-BCC excisional defects of the face relies on an adequate understanding of the general principles of reconstruction, subunit principle of facial esthetics, flap anatomy and vascularity as well as operator experience. Complex defects need innovative solutions, multidisciplinary approaches, and newer methods of reconstruction like perforator flaps and newer techniques like supermicrosurgery. Conclusion: Multiple reconstructive options for post-excisional defects of the BCC over the face are available and most defects can be approached in an algorithmic manner. Further well-designed prospective research studies are needed to compare outcomes of different reconstructive options for a given defect and identify the most suitable options.

Auricular Perichondritis of an Unusual Etiology.

Auricular perichondritis leading to perichondral abscess is an unusual complication of periauricular surgery. Early identification of the condition with aggressive and timely management is mandated to prevent permanent damage to the auricle. This article demonstrates the first reported case in literature of auricular perichondritis due to Neisseria flava. We discuss the presentation, diagnosis and management of auricular perichondritis in this patient and review mechanisms by which commensals acquire pathogenicity as seen in this report. An awareness of this unusual etiology and mechanisms of acquiring pathogenic nature by commensals will help guide clinicians in optimizing management of such conditions.

The Impact of "COVID-19" and "Webinar Pandemic" on Plastic Surgery Practice in Teaching Institutes and Resident Training-A Multicentric Perspective.

Introduction The study was carried out to quantify the changes induced by the pandemic in plastic surgery practice and training and to study the impact of the webinars on plastic surgery education from a residents' perspective. Methods In this multicentric study, the number and type of surgeries, cause of injuries, and their regional variation during the coronavirus disease 2019 (COVID-19) period (February-September 2020) were compared with pre-COVID-19 time. An online survey on the impact of webinars was conducted for plastic surgery trainees across the country. Results There was a significant reduction in total number of surgeries ( p = 0.003). The procedures for hand ( p = 0.156), faciomaxillary injuries ( p = 0.25), and replantations ( p = 0.46) were comparable; there was a significant reduction in combined orthopedic-plastic-surgical procedures ( p = 0.009) during the pandemic. There was a significant reduction in road accidents ( p = 0.007) and suicidal injuries ( p = 0.002) and increase in assault ( p = 0.03) and domestic accidents ( p = 0.01) during the COVID-19 period. A usefulness score of >8 was given for the webinars by 68.7% residents. There was no significant difference in perception of utility when correlated with the academic program at their institutes ( p = 0.109); 92% opined webinars should continue in post-COVID times. Conclusion There was a drastic reduction in number of elective and emergency procedures during the COVID-19 time, negatively affecting resident training program. Majority of residents felt that webinars could prove a useful adjunct to training in formal training program in post-COVID-19 scenario.

An Innovative Skin Simulation Model to Augment Competency-based Training in Facial Plastic Surgery.

Introduction Competency-based medical education (CBME) approach in the medical curriculum has been introduced globally with the goal of providing flexibility, accountability, and learner-centeredness among medical learners. Traditional surgical skill training in most places has relied on "see one, do one, teach one model," while simulation model-based training has been shown to improve competencies in surgical trainees. We wanted to assess the usefulness of a hydrophilic barrier adhesive foam wound dressing as a novel skin simulation model for learning biomechanics and practice of cutaneous flaps among plastic surgical resident trainees at our institute. Materials and Methods An absorbent, soft polyurethane foam pad located centrally upon a larger polyurethane membrane, coated with a hydrocolloid adhesive, forming an island dressing, was used as a simulation model for this study. It was obtained from the hospital store either after or nearing their expiry dates of clinical use. Plastic surgery residents in different years of training were invited to participate in a simulation workshop, using this novel model, and give their feedback. Results Seventeen residents in different plastic surgery training levels participated in the workshop and gave their feedback on the skin flap simulation model. The simulation model received extremely high (100%) scores on two parameters, namely, utility for flap and suture practice and high scores (88%-94%) for texture, ability to mark, and improving confidence among trainees. Conclusions Adhesive bilayer polyurethane foam can be used as a novel cutaneous skin flap simulation model for understanding the biomechanics of skin flaps and cutaneous flap practice.

Effects of the COVID-19 Pandemic on the Mental Health of Anesthesiologists: A Cross-Sectional Study.

Introduction: In the COVID-19 pandemic, frontline health-care workers (HCWs) including anesthesiologists have been fatigued due to long working hours in critical care units or operation theaters and necessity to remain available on call at odd hours. In addition, the exposure to numerous diseased and morbid patients throughout the prolonged pandemic period has predisposed them to psychological distress. Materials and Methods: This is a cross-sectional study to evaluate the depression and anxiety among the HCWs during COVID. The demographic and general information of 237 HCWs across India, through an online survey was collected and analyzed. Results: The male: female ratio of the studied population was 53:47. In addition, 50% of the participants were aged <35 years, and 80% of participants were married and living with family and parents. The consultants working in combined (COVID and non-COVID) areas exhibited maximum participation in the survey, with 80% of them involved in aerosol-generating procedures. Of the total, 73.1% of participants exhibited depression, 45.8% of participants exhibited anxiety, 36.2% of participants exhibited stress, and 25.3% of participants exhibited disturbed sleep patterns. Conclusions: Most HCWs on COVID-19 duty exhibited emotional disorders such as anxiety, depression, stress, and insomnia. Addressing risk factors identified in the present study with targeted interventions and psychosocial support will allow health-care workers to cope better.

Cadaveric Bilateral Transhumeral Upper Limb Transplantation: Journey to the Next level.

Organ transplant has, arguably, been the pinnacle of the advancement in medical science so far and vascularized composite allotransplantation has been the most recent addition to it. The scope of vascularized tissue allotransplantation has been widening with each passing day and more and more reports regarding the safety and efficacy of the procedure have been described. Due to the limited available literature on the management of the complications and implications of the hand transplant, the importance of each report on the procedure is paramount. A mid-arm allotransplant is a challenge in terms of expected motor recovery, and many controversies exist over the efficacy of the procedure altogether. Moreover, our case was complicated by a long ischemia time due to logistic reasons. We share our experience of a transhumeral upper limb allotransplantation, the complications associated with it along with the early postoperative results at 10 months follow up.

Cadaveric Bilateral Proximal Forearm Allotransplantation.

Until, sometime ago, microsurgery meant mainly covering a defect or replanting severed parts back to where they belong. Now, restoration of original function and aesthetic consideration is a must in planning reconstructive procedure. Hand transplant combines hand surgery and microsurgery with complex multidisciplinary care.At the anniversary of our first cadaveric bilateral proximal forearm transplantation done in the country's government institute, we would like to share our experience in performing the surgery, outcomes so far, complications, and lessons learned, to contribute to the growing knowledge of vascularized composite allotransplant.

Filarial breast lump.

Lymphatic filariasis is one of the most debilitating and disfiguring scourges among all diseases. This report presents a case of a woman with recurrent breast nodularity after being previously operated for a suspected breast neoplasm. We would like to highlight the issue of similar clinical presentation of a filarial breast lump and other breast lesions leading to inappropriate therapy.

Effectiveness of Fibrin Glue in Adherence of Skin Graft.

BACKGROUND: Graft fixation is important for graft take. Fibrin glue has been proposed as an ideal material, because of its human origin and it provides firm adhesion in seconds or minutes. OBJECTIVE: To evaluate the efficiency of fibrin glue, in increasing the take of skin graft. Assessment includes surgical time taken for graft fixation, haematoma/seroma formation, engraftment and wound closure by day 14. METHODS: The study is an observational prospective study conducted in the Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, from January 2016 to June 2016. Sixteen patients who underwent split skin grafting were assessed during the study period. Fibrin glue was used on the recipient bed before grafting. RESULTS: Better haemostasis and graft adhesion, with a significant reduction of surgical time, were noted. CONCLUSION: The safety profile of fibrin glue was excellent as indicated by the lack of any related serious adverse experiences. These findings demonstrate that it is safe and effective for attachment of skin grafts, with outcomes at least as good as conventional methods.

Antiseptics for burns.

BACKGROUND: Burn wounds cause high levels of morbidity and mortality worldwide. People with burns are particularly vulnerable to infections; over 75% of all burn deaths (after initial resuscitation) result from infection. Antiseptics are topical agents that act to prevent growth of micro-organisms. A wide range are used with the intention of preventing infection and promoting healing of burn wounds. OBJECTIVES: To assess the effects and safety of antiseptics for the treatment of burns in any care setting. SEARCH METHODS: In September 2016 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid MEDLINE (In-Process & Other Non-Indexed Citations), Ovid Embase, and EBSCO CINAHL. We also searched three clinical trials registries and references of included studies and relevant systematic reviews. There were no restrictions based on language, date of publication or study setting. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that enrolled people with any burn wound and assessed the use of a topical treatment with antiseptic properties. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS: We included 56 RCTs with 5807 randomised participants. Almost all trials had poorly reported methodology, meaning that it is unclear whether they were at high risk of bias. In many cases the primary review outcomes, wound healing and infection, were not reported, or were reported incompletely.Most trials enrolled people with recent burns, described as second-degree and less than 40% of total body surface area; most participants were adults. Antiseptic agents assessed were: silver-based, honey, Aloe Vera, iodine-based, chlorhexidine or polyhexanide (biguanides), sodium hypochlorite, merbromin, ethacridine lactate, cerium nitrate and Arnebia euchroma. Most studies compared antiseptic with a topical antibiotic, primarily silver sulfadiazine (SSD); others compared antiseptic with a non-antibacterial treatment or another antiseptic. Most evidence was assessed as low or very low certainty, often because of imprecision resulting from few participants, low event rates, or both, often in single studies. Antiseptics versus topical antibioticsCompared with the topical antibiotic, SSD, there is low certainty evidence that, on average, there is no clear difference in the hazard of healing (chance of healing over time), between silver-based antiseptics and SSD (HR 1.25, 95% CI 0.94 to 1.67; I2 = 0%; 3 studies; 259 participants); silver-based antiseptics may, on average, increase the number of healing events over 21 or 28 days' follow-up (RR 1.17 95% CI 1.00 to 1.37; I2 = 45%; 5 studies; 408 participants) and may, on average, reduce mean time to healing (difference in means -3.33 days; 95% CI -4.96 to -1.70; I2 = 87%; 10 studies; 979 participants).There is moderate certainty evidence that, on average, burns treated with honey are probably more likely to heal over time compared with topical antibiotics (HR 2.45, 95% CI 1.71 to 3.52; I2 = 66%; 5 studies; 140 participants).There is low certainty evidence from single trials that sodium hypochlorite may, on average, slightly reduce mean time to healing compared with SSD (difference in means -2.10 days, 95% CI -3.87 to -0.33, 10 participants (20 burns)) as may merbromin compared with zinc sulfadiazine (difference in means -3.48 days, 95% CI -6.85 to -0.11, 50 relevant participants). Other comparisons with low or very low certainty evidence did not find clear differences between groups.Most comparisons did not report data on infection. Based on the available data we cannot be certain if antiseptic treatments increase or reduce the risk of infection compared with topical antibiotics (very low certainty evidence). Antiseptics versus alternative antisepticsThere may be some reduction in mean time to healing for wounds treated with povidone iodine compared with chlorhexidine (MD -2.21 days, 95% CI 0.34 to 4.08). Other evidence showed no clear differences and is of low or very low certainty. Antiseptics versus non-antibacterial comparatorsWe found high certainty evidence that treating burns with honey, on average, reduced mean times to healing in comparison with non-antibacterial treatments (difference in means -5.3 days, 95% CI -6.30 to -4.34; I2 = 71%; 4 studies; 1156 participants) but this comparison included some unconventional treatments such as amniotic membrane and potato peel. There is moderate certainty evidence that honey probably also increases the likelihood of wounds healing over time compared to unconventional anti-bacterial treatments (HR 2.86, 95% C 1.60 to 5.11; I2 = 50%; 2 studies; 154 participants).There is moderate certainty evidence that, on average, burns treated with nanocrystalline silver dressings probably have a slightly shorter mean time to healing than those treated with Vaseline gauze (difference in means -3.49 days, 95% CI -4.46 to -2.52; I2 = 0%; 2 studies, 204 participants), but low certainty evidence that there may be little or no difference in numbers of healing events at 14 days between burns treated with silver xenograft or paraffin gauze (RR 1.13, 95% CI 0.59 to 2.16 1 study; 32 participants). Other comparisons represented low or very low certainty evidence.It is uncertain whether infection rates in burns treated with either silver-based antiseptics or honey differ compared with non-antimicrobial treatments (very low certainty evidence). There is probably no difference in infection rates between an iodine-based treatment compared with moist exposed burn ointment (moderate certainty evidence). It is also uncertain whether infection rates differ for SSD plus cerium nitrate, compared with SSD alone (low certainty evidence).Mortality was low where reported. Most comparisons provided low certainty evidence that there may be little or no difference between many treatments. There may be fewer deaths in groups treated with cerium nitrate plus SSD compared with SSD alone (RR 0.22, 95% CI 0.05 to 0.99; I2 = 0%, 2 studies, 214 participants) (low certainty evidence). AUTHORS' CONCLUSIONS: It was often uncertain whether antiseptics were associated with any difference in healing, infections, or other outcomes. Where there is moderate or high certainty evidence, decision makers need to consider the applicability of the evidence from the comparison to their patients. Reporting was poor, to the extent that we are not confident that most trials are free from risk of bias.