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.

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.

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.

Vasovasostomy: A systematic review and meta-analysis comparing macroscopic, microsurgical, and robot-assisted microsurgical techniques

BACKGROUND AND OBJECTIVES

Vasovasostomy is a cost-effective procedure for the reversal of vasectomy. A water-tight adequately blood-supplied mucosal anastomosis is required for better outcomes. This review aimed to compare the outcome of vasovasostomy performed by three different techniques: macroscopic, pure microsurgical, and robot-assisted microsurgical techniques.

METHODS

Scopus, Web of Science, PubMed, Embase, and Cochrane library databases were searched for relevant studies from January 1901 to June 2023. We conducted our quantitative syntheses using the inverse variance method in OpenMeta software. The study's protocol was registered on PROSPERO.

RESULTS

This review involved 95 studies of different designs, with a total sample size of 48,132. The majority of operations were performed bilaterally, and participants were monitored for up to 10 years. The pooled patency rate was the highest following robot-assisted vasovasostomy (94.4%), followed by pure microsurgical vasovasostomy (87.5%), and macroscopic vasovasostomy (83.7%). The pooled pregnancy rate following purely microsurgical vasovasostomy was higher than that of macroscopic vasovasostomy (47.4 vs. 43.7%). Definitive pregnancy rates in robotic vasovasostomy are yet to be determined.

CONCLUSION

Patency outcomes for vasovasostomy were best with robot-assisted microsurgical technique, followed by pure microsurgical technique, and conventional macroscopic technique. Further investigations of robot-assisted microsurgical vasovasostomy outcomes and randomized control trials are required to support this evidence.

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.

The impact of electric scooters in Melbourne: data from a major trauma service

BACKGROUND

The proliferation of electric scooters globally has been associated with an increase in related injuries and consequent economic burden. This study aims to assess the injury patterns and the economic impact associated with electric scooter use in Melbourne, Australia.

METHODS

A retrospective cohort study was conducted using hospital and registry data from January 2022 to January 2023. Data collected included demographic details, alcohol and helmet use, injury type and severity, operative treatment provided, and direct medical costs. The economic impact (in AUD) of the patient's emergency presentation and hospital admission was calculated.

RESULTS

During the study period, 256 electric scooter related injuries were recorded, comprising 247 riders and nine pedestrians. The majority of patients were males (69%) with a median age of 29.5 (15-78). Alcohol use was reported by 34% and helmet use by 33%. Injuries most commonly affected the upper limb (53%) and head (50%), with abrasions (75%) and fractures (48%) being the most common type of injury sustained. The total hospital cost was $1 911 062, and the median cost was $1321.66 per patient (IQR: $479.37-$5096.65).

CONCLUSION

Electric scooter usage, as observed through patient presentations to the Royal Melbourne Hospital, is associated with a considerable number of injuries, primarily among young males, and an ensuing substantial economic burden. The findings underscore the urgent need for improved safety measures to minimize electric scooter-related injuries and their clinical and economic repercussions.

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.

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.

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.

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.

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.

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.

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.

Transforming breast reconstruction: the pioneering role of artificial intelligence in preoperative planning

Autologous breast reconstruction surgery is a vital part of the recovery process for patients with breast cancer. While various reconstructive options exist, the deep inferior epigastric artery perforator (DIEP) flap is often favoured for its ability to closely mimic natural breast tissue. However, the complex vascular anatomy associated with the deep inferior epigastric artery (DIEA) presents challenges for surgeons during DIEP flap execution. Preoperative imaging, such as computed tomography angiography (CTA), is commonly used to understand vascular architecture and aid in selecting appropriate perforators. Conventional reporting of CTA scans is a labour-intensive process that can be challenging and requires specific expertise. The integration of artificial intelligence (AI) and machine learning (ML) algorithms in medical imaging has the potential to address these challenges. AI can enhance CTA through improved data acquisition, image post-processing, and potentially interpretation. By automating the perforator selection process, AI applications can significantly reduce the time spent on preoperative imaging analysis and potentially improve accuracy and reliability. While AI shows promise in optimizing efficiency, accuracy, and reliability in breast reconstruction planning, challenges and ethical considerations need to be addressed. This article explores the challenges, opportunities, and future directions of using AI in the preoperative planning of autologous breast reconstruction.

Comparing the Efficacy of Large Language Models ChatGPT, BARD, and Bing AI in Providing Information on Rhinoplasty: An Observational Study

Background

Large language models (LLMs) are emerging artificial intelligence (AI) technologies refining research and healthcare. However, the impact of these models on presurgical planning and education remains under-explored.

Objectives

This study aims to assess 3 prominent LLMs-Google's AI BARD (Mountain View, CA), Bing AI (Microsoft, Redmond, WA), and ChatGPT-3.5 (Open AI, San Francisco, CA) in providing safe medical information for rhinoplasty.

Methods

Six questions regarding rhinoplasty were prompted to ChatGPT, BARD, and Bing AI. A Likert scale was used to evaluate these responses by a panel of Specialist Plastic and Reconstructive Surgeons with extensive experience in rhinoplasty. To measure reliability, the Flesch Reading Ease Score, the Flesch-Kincaid Grade Level, and the Coleman-Liau Index were used. The modified DISCERN score was chosen as the criterion for assessing suitability and reliability. A t test was performed to calculate the difference between the LLMs, and a double-sided P-value <.05 was considered statistically significant.

Results

In terms of reliability, BARD and ChatGPT demonstrated a significantly (P < .05) greater Flesch Reading Ease Score of 47.47 (±15.32) and 37.68 (±12.96), Flesch-Kincaid Grade Level of 9.7 (±3.12) and 10.15 (±1.84), and a Coleman-Liau Index of 10.83 (±2.14) and 12.17 (±1.17) than Bing AI. In terms of suitability, BARD (46.3 ± 2.8) demonstrated a significantly greater DISCERN score than ChatGPT and Bing AI. In terms of Likert score, ChatGPT and BARD demonstrated similar scores and were greater than Bing AI.

Conclusions

BARD delivered the most succinct and comprehensible information, followed by ChatGPT and Bing AI. Although these models demonstrate potential, challenges regarding their depth and specificity remain. Therefore, future research should aim to augment LLM performance through the integration of specialized databases and expert knowledge, while also refining their algorithms.

Level of Evidence 5

A History of Innovation: Tracing the Evolution of Imaging Modalities for the Preoperative Planning of Microsurgical Breast Reconstruction

Breast reconstruction is an essential component in the multidisciplinary management of breast cancer patients. Over the years, preoperative planning has played a pivotal role in assisting surgeons in planning operative decisions prior to the day of surgery. The evolution of preoperative planning can be traced back to the introduction of modalities such as ultrasound and colour duplex ultrasonography, enabling surgeons to evaluate the donor site's vasculature and thereby plan operations more accurately. However, the limitations of these techniques paved the way for the implementation of modern three-dimensional imaging technologies. With the advancements in 3D imaging, including computed tomography and magnetic resonance imaging, surgeons gained the ability to obtain detailed anatomical information. Moreover, numerous adjuncts have been developed to aid in the planning process. The integration of 3D-printing technologies has made significant contributions, enabling surgeons to create complex haptic models of the underlying anatomy. Direct infrared thermography provides a non-invasive, visual assessment of abdominal wall vascular physiology. Additionally, augmented reality technologies are poised to reshape surgical planning by providing an immersive and interactive environment for surgeons to visualize and manipulate 3D reconstructions. Still, the future of preoperative planning in breast reconstruction holds immense promise. Most recently, artificial intelligence algorithms, utilising machine learning and deep learning techniques, have the potential to automate and enhance preoperative planning processes. This review provides a comprehensive assessment of the history of innovation in preoperative planning for breast reconstruction, while also outlining key future directions, and the impact of artificial intelligence in this field.

Maternal Cigarette Smoking and Congenital Upper and Lower Limb Differences: A Systematic Review and Meta-Analysis

Maternal smoking during pregnancy has been associated with adverse effects on foetal development, including congenital limb anomalies. This systematic review aimed to provide an updated assessment of the association between maternal smoking during pregnancy and the risk of congenital limb anomalies. A systematic search was conducted to identify relevant studies published up to February 2023. Studies reporting on the relationship between maternal smoking during pregnancy and congenital digital anomalies or congenital limb reduction defects were included. Two independent reviewers screened the studies, extracted data, and assessed the quality of the included studies. Meta-analyses were performed to estimate the pooled odds ratios with 95% confidence intervals using fixed and random-effects models. In total, 37 publications comprising 11 cohort and 26 case-control studies were included in the systematic review. The meta-analysis demonstrated a significant increased risk of congenital limb reduction defects (pooled OR: 1.27, 95% CI: 1.18-1.38) in infants born to mothers who smoked during pregnancy. Similarly, a significant relationship was observed for the development of polydactyly/syndactyly/adactyly when considered as a single group (pooled OR: 1.32, 95% CI: 1.25-1.40). Yet, in contrast, no significant association was observed when polydactyly (pooled OR: 1.06, 95% CI: 0.88-1.27) or syndactyly (pooled OR: 0.91, 95% CI: 0.77-1.08) were considered individually. This systematic review provides updated evidence of a significant relationship between maternal smoking during pregnancy and increased risk of congenital limb anomalies. These findings highlight the potential detrimental effects of smoking on foetal limb development and underscore the importance of smoking cessation interventions for pregnant women to mitigate these risks.

Anatomical differences in the abdominal wall between animal species with implications for the transversus abdominis plane block: a systematic review

PURPOSE

With the increased use of simulation-based training using animal models for the education of surgical and anaesthetic techniques, an increased understanding of the anatomy of such models and how they compare to humans is required. The transversus abdominis plane block is a regional anaesthetic technique that requires an understanding of the abdominal wall anatomy along with proficient ultrasound use. The current review aims to compare the anatomy of the abdominal wall across species, particularly focussing on the pertinent differences within the class of mammals, and secondarily, it aims to address the implications of these differences for the use of simulation-based training of the transversus abdominis plane block.

METHODS

To achieve this, the PubMed, Web of Science and Google Scholar databases were searched for relevant literature. Studies pertaining to the musculature, vasculature or innervation of the anterolateral abdominal wall across species were included.

RESULTS

The mammalian abdominal wall differs in its musculature, vasculature or innervation from that of amphibians, birds or reptiles; however, among species of mammals, the structure of the abdominal wall follows a similar framework. Particular differences among mammals include the additional muscular layer of the panniculus carnosus found in most mammals other than humans, the variable arterial origins and dominant vascular supply of the abdominal wall and the number of thoracolumbar nerves innervating the abdominal wall.

CONCLUSION

When using animal models for simulation-based training, the pig is recommended for the transversus abdominis plane block given its closely homologous abdominal wall structure, availability and larger comparative size.

Infections following stingray attacks: A case series and literature review of antimicrobial resistance and treatment

BACKGROUND

Injuries sustained following stingray attacks are at high risk of infection and can progress to serious, debilitating consequences for the patient if not appropriately addressed. Antibiotic treatment of such infections is important to minimise the morbidity experienced by patients. However, antibiotic guidelines relating specific to this patient group are not well established. This study aims to report the experience of a single institution at treating stingray associated wound infections and to review the literature for reported cases. Additionally, we review the microbiological risk in these patients and summarise the literature surrounding antibiotic choice.

METHODS

A retrospective review of all patients presenting with injuries sustained following stingray attacks was conducted at a single institution. Additionally, a comprehensive literature review was conducted to identify cases of infected stingray associated trauma and review the causative micro-organisms and antibiotics used to treat such infections.

RESULTS

22 cases of stingray injuries were identified from a single institution. Of these, eight infections were reported. One case grew a highly resistant Vibrio species. Among the literature, 18 cases of infections were identified many of which led to significant complications for patients. The micro-organisms identified were diverse and there was little consistency among the antibiotic regimens utilised.

CONCLUSION

Based on the antibiotic susceptibilities of causative bacteria along with extrapolation from recommendations and guidelines identified in the literature, ciprofloxacin, doxycycline and trimethoprim-sulfamethoxazole appear to be the most appropriate antibiotics choices for prophylaxis or treatment of localised infection. Antibiotic choices for the empiric treatment of systemic infection requires further research and clarification.

Rationalizing post-operative prophylactic anticoagulation in reconstructive head and neck cancer patients: a review

Microsurgical reconstructive head and neck cancer patients are at high risk of venous thromboembolism. The use of anticoagulation can reduce their risk; however, this also increases their bleeding risk. It is not clear whether the benefits of treatment outweigh the risks, and whether a specific post-operative anticoagulation regime is superior. The aim of this review is to evaluate the evidence pertaining to the risks and benefits of post-operative anticoagulation and to provide a rationale for its use in head and neck cancer patients receiving free flaps. The secondary aim was to determine the optimal post-operative anticoagulation regimen. A search was conducted in the PubMed and EMBASE databases identifying studies reporting venous thromboembolism rates in reconstructive head and neck cancer patients undergoing free flaps. These studies were reviewed for their eligibility. Outcomes measured were rates of venous thromboembolism, bleeding-related and microsurgical complications. A total of 306 studies were found from the search with another seven studies identified from citations of key articles. After assessment, nine studies were included. Venous thromboembolism rates ranged from 0.5% to 7% and the rates of bleeding-related complications ranged from 2.4% up to 29%. Anticoagulation appears to lower the risk of venous thromboembolism in this patient group, but also increases the bleeding risk. Risk stratification using the Caprini risk assessment model can help surgeons make decisions. For patients with cancer, low molecular weight heparin appears to be superior to heparin given twice daily but equal to heparin given three times daily and the bleeding risk of each medication appears similar.