Journal of Graduate Medical Education, Aug 1, 2021
Background Previous studies have shown men and women attending physicians rate or provide operati... more Background Previous studies have shown men and women attending physicians rate or provide operating room (OR) autonomy differently to men and women residents, with men attendings providing higher ratings and more OR autonomy to men residents. Particularly with the advent of competency-based training in plastic surgery, differential advancement of trainees influenced by gender bias could have detrimental effects on resident advancement and time to graduation. Objective We determined if plastic surgery residents are assessed differently according to gender. Methods Three institutions' Operative Entrustability Assessment (OEA) data were abstracted from inception through November 2018 from MileMarker, a web-based program that stores trainee operative skill assessments of CPT-coded procedures. Ratings are based on a 5-point scale. Linear regression with postgraduate year adjustment was applied to all completed OEAs to compare men and women attendings' assessments of men and women residents. We included 8377 OEAs completed on 64 unique residents (25% women) by 51 unique attendings (29% women): men attendings completed 83% (n ¼ 6972; 5859 assessments of men residents; 1113 of women residents) and women attendings completed 17% (n ¼ 1405; 1025 assessments of men residents; 380 of women residents). Adjusted analysis showed men attendings rated women residents lower than men residents (P , .001); scores by women attendings demonstrated no significant difference (P ¼ .067). Conclusions Our dataset including 4.5 years of data from 3 training programs showed men attendings scored women plastic surgery residents lower than their men counterparts.
Purpose: Rheumatoid arthritis (RA) is a destructive inflammatory disease that commonly involves j... more Purpose: Rheumatoid arthritis (RA) is a destructive inflammatory disease that commonly involves joints of the hand and wrist. Different recommendations exist for continuing or discontinuing immunosuppressant medications during the perioperative time period. The purpose of our study was to determine if continuing steroids, non-biologic DMARDs, and/or biologic DMARDs were associated with an increased risk of postoperative complications. Methods: We performed a single-centered, retrospective review of a consecutive cohort of RA patients who had elective hand surgery by a single surgeon. Patients were included if they had a documented diagnosis of seropositive RA by a rheumatologist, and had elective hand surgery and/or disease-related surgical procedure involving the upper extremity from January 2008 to August 2018. We stratified patients into different groups for comparison by classes of immunosuppressant medications for managing RA. These classes included corticosteroids, non-biological DMARDs, biologic DMARDs, and/or no medications. Groups were then compared for the incidence of postoperative complications. Results: Eighty-eight consecutive patients had elective hand and/or upper extremity surgeries for RA. Mean patient age at the time of surgery (±SD) was 55±13 years (range: 24 to 74 years). Of these 88 patients, eight (9%) overall complications occurred. Complications were wound healing failures, (n=5, 6%), tendon rupture, (n=1, 1%), hematoma, (n=1, 1%), and surgical site infection, (n=1, 1%). Perioperative medications included steroids (n=31), nonbiologic DMARDs (n=68), and biologic DMARDs (n=5). There were no significant findings between patients on perioperative corticosteroids, nonbiologic DMARDs, and/or biologic DMARDs and the incidence of complications. Mean follow-up was 69±65 weeks (range: 8 to 296 weeks). Conclusions: Patients with RA who continued corticosteroids, non-biologic DMARDs, and/or biologic DMARDS within one dosing interval of their usual dose were not associated with a higher risk for postoperative complications compared to patients discontinuing these medications perioperatively, following elective hand surgery.
INTRODUCTION: TME is associated with decreased local recurrence and improved disease-free surviva... more INTRODUCTION: TME is associated with decreased local recurrence and improved disease-free survival after rectal cancer (RC) resection. The extent to which TME has been adopted in the US is unknown. We sought to assess trends in TME performance and grading in Michigan hospitals.
Introduction: Patient-reported outcomes are important for burn injury research and clinical pract... more Introduction: Patient-reported outcomes are important for burn injury research and clinical practice. The NIHfunded Patient Reported Outcomes Measurement System (PROMIS)-25 profile has been validated for use in diverse populations of children with many conditions, though not among children living with burn injuries. The purpose of this study was to examine the reliability and validity of PROMIS-25 scores in children living with burn injury. Methods: Data were provided by children who were participating in a multi-center longitudinal study of outcomes after burn injury. The PROMIS-25 Profile, which includes 4 items for each domain of physical function mobility, anxiety, depression, fatigue, peer relationships, and pain interference, was evaluated for reliability and validity. Floor and ceiling effects, unidimensionality, internal consistency, and reliability were examined. Correlations with other measures (Post-Traumatic Growth Inventory-Child (PTGI-C), Child PTSD Symptom Scale (CPSS) and Burn Outcome Questionnaire Body Image Scale (BOQBI)) were calculated to assess concurrent validity. Results: 256 children living with burn injury who sustained a moderate to severe injury provided responses on PROMIS-25 domains 6 months-10 years post burn. Participants' age ranged from 8-18 years at time of assessment; mean years since injury was 4.3 (SD 4.1). All PROMIS-25 domains showed high internal consistency (Cronbach's α=0.90-0.95). Substantial portions of the sample reported no symptoms (anxiety [58.2%], depressive symptoms [54.6%], fatigue [50.8%], pain [60.1%]). There was a large ceiling effect on peer relationships (46.8%) and physical function mobility (57.5%). One-factor confirmatory factor analyses supported unidimensionality for all domains (all CFI >0.98). Reliability was credible for group mean comparisons ( >0.8) across at least some trait levels for all domains except fatigue and anxiety which had low reliability (< 0.8) across the entire trait range. The magnitude and direction of correlations were as anticipated (0.32 for peer relationships and body image; 0.51 for depressive symptoms and PTSD) with the exception of weak negative correlations between PTGI-C and the anxiety and depression domains. The results provide some evidence of reliability and validity of PROMIS-25 scores among children living with burn injury. Reliability of all domains was low to moderate and would likely be improved, and ceiling effects reduced, by administering the PROMIS-37, which includes 6 items per domain.
Journal of The American College of Surgeons, Oct 1, 2017
polytrauma criteria, have been reviewed. One hundred and twenty eight patients were excluded from... more polytrauma criteria, have been reviewed. One hundred and twenty eight patients were excluded from statistical analysis (incomplete folder, missed values of ISS or imagistic findings, unmentioned maneuvers in ICU or omitted autopsy protocol) and finally from 362 patients remained we retained 47 deaths (13% of patients included). RESULTS: Twelve patients (3.3% admissions) had recognized errors in care that contributed to their death. Important errors patterns included: delayed control of abdominal and intra-thoracic hemorrhage or inadequate recognition (6.3%), failure to secure or protect airway (4.2%), inappropriate management of unstable patients in 8.5% of deaths (long operative procedures, unstable patients sent to CT or to interhospital transfer), missed or delayed diagnoses (4.2%), and inadequate DVT prophylaxis (2.1%). By the internal processing classification of causes, 25% were input errors, 41.7% were intentions errors and 33.3% were execution errors. By phase of trauma management, 16.6% of errors occurred in the ED, 25% during the secondary survey and initial diagnostic, 33.3% during surgery, 16.6% during transport to CT or interhospital transfer, and 8.3% in the ICU stay. CONCLUSIONS: This study combines contemporary understanding of error causation, classification and proposes their remediation with a specific process and protocols.
Plastic and reconstructive surgery. Global open, Sep 1, 2017
patient population, IM centers are an underutilized adjunct in the care of our patients. Further ... more patient population, IM centers are an underutilized adjunct in the care of our patients. Further study into specific IM services that may benefit our patients would be helpful in increasing IM utilization in our field.
The Senate Finance Committee (Committee) has jurisdiction over the Medicare and Medicaid programs... more The Senate Finance Committee (Committee) has jurisdiction over the Medicare and Medicaid programs and as part of its oversight of these programs has conducted numerous inquiries over the years to improve patient safety and transparency. 1 In December 2015, Committee staff became aware of a surgical practice-referred to by hospitals as "concurrent", "overlapping", or "simultaneous" surgeries-from a Boston Globe article. 2 Previously, the practice was not widely understood beyond the medical field. Regardless of the specific terminology used, the practice involves a surgeon scheduling and conducting operations on two different patients during the same period of time. Alarmed by the allegations of patient harm, surgeon misconduct, and inappropriate billing highlighted in that article, the Committee launched an initial inquiry to better understand the practice and the frequency with which it occurs. In early 2016, the Committee sent a letter to 20 teaching hospitals querying them about the practice in their institutions. This letter generated strong interest from hospitals, individual physicians, patient advocates, and others who reached out to the Committee to share their experiences, insights, and knowledge about these issues. Additionally, Committee staff examined guidance issued by the Centers for Medicare & Medicaid Services (CMS), within the Department of Health and Human Services (HHS), and the American College of Surgeons (ACS), policies and other information provided to the Committee by hospitals and others in response to our letter, and other information gathered from stakeholders. This report is a summary of the Committee's staff's findings to date and an overview of key issues and areas of Congressional concern. The Boston Globe article provided an in-depth review of concurrent surgeries being practiced at certain hospitals operating in the Boston area, alleging that the practice may have resulted in several instances of measurable patient harm, including deaths. Specifically, the article described operations in which surgeons divided their attentions between two operating rooms over several hours, failed to return to the operation when residents or fellows needed assistance, or failed to arrive on-time for surgeries, leaving residents or fellows to perform surgeries unsupervised or resulting in patients under anesthesia for prolonged periods. The article also noted that patients were not informed their surgeries would run concurrently with another, calling into question hospitals' patient consent processes. A number of patient advocates also raised concerns to the Committee that the primary motivation for a surgeon to conduct concurrent surgeries was financial, enriching surgeons at the expense of patient care. Advocates of concurrent surgeries argue that this longstanding practice enables timelier access to highskilled, in-demand surgeons by freeing up their time to perform more specialized operations, helps train medical professionals by pairing senior doctors with residents or fellows, and improves the utilization of operating facilities. Additionally, some hospital officials said that their internal analyses found no differences in complication rates between concurrent and other surgeries. Indeed, the American Hospital Association reported to Committee staff that they are aware of only one study that presents research on 1 See, for example, Senate Finance Committee.
Journal of The American College of Surgeons, Oct 1, 2017
INTRODUCTION: TME is associated with decreased local recurrence and improved disease-free surviva... more INTRODUCTION: TME is associated with decreased local recurrence and improved disease-free survival after rectal cancer (RC) resection. The extent to which TME has been adopted in the US is unknown. We sought to assess trends in TME performance and grading in Michigan hospitals.
Plastic and reconstructive surgery. Global open, May 1, 2019
rhinoplasty. Demographics, perioperative characteristics, and postoperative complications were co... more rhinoplasty. Demographics, perioperative characteristics, and postoperative complications were compared between cohorts. Two-hundred-and-sixty-two and 255 subjects underwent breast, abdominal-based, and face/eye aesthetic procedures in the resident and attending clinics, respectively. Subjects presenting to the resident clinic tended to be younger (43.4 vs. 51.4, p<0.001), less obese (26.2 vs. 27.4, p=0.02), lower median income ($65,000 vs. $75,000, p<0.001), and healthier with lower rates of diabetes (4.2% vs. 12.6%, p<0.001), COPD (0.4% vs. 3.1%, p=0.02), PVD (2.3% vs. 6.7%, p=0.02), hypertension (13.4% vs. 31.2%, p<0.001), and history of cancer (3.8% vs. 19.2%, p<0.001). Mean length of procedure significantly differed between resident and attending cohorts at 210 and 152 minutes, respectively (p<0.001). Postoperative complications were similar between cohorts (p=0.48). Reoperation (p<0.03) and readmission (p<0.02) rates were greater in the attending cohorts. The resident aesthetic clinic provides increases independence and decision-making, while maintaining patient safety in commonly performed breast, abdominal, face/eye procedures. Patients operated on in the resident clinic tended to be younger and healthier, highlighting the importance of careful patient selection to maximize both autonomy and safety.
Background: A model that predicts a patient’s risk of developing chronic, burn-related nerve pain... more Background: A model that predicts a patient’s risk of developing chronic, burn-related nerve pain may guide medical and/or surgical management. This study determined anatomy-specific variables and constructed a mathematical model to predict a patient’s risk of developing burn-related nerve pain. Methods: A retrospective analysis was conducted from 1862 adults admitted to a burn center from 2014 to 2019. One hundred thirteen patients developed burn-related nerve pain. Comparisons were made using 11 anatomy-specific locations between patients with and without burn-related nerve pain. The modified Delphi technique was used to select 14 potential risk variables. Multivariate regression techniques, Brier scores, area under the curve, Hosmer-Lemeshow goodness-of-fit, and stratified K-fold cross-validation was used for model development. Chronic pain was defined as pain lasting 6 or more months after release from the Burn Center. Results: Prevalence rates of burn-related nerve pain were similar in the development (6.1 percent) and validation (5.4 percent) cohorts [Brier score = 0.15; stratified K-fold cross-validation (K = 10): area under the curve, 0.75; 95 percent CI, 0.68 to 0.81; Hosmer-Lemeshow goodness-of-fit, p = 0.73; n = 10 groups]. Eight variables were included in the final equation. Burn-related nerve pain risk score = −6.3 + 0.02 (age) + 1.77 (tobacco use) + 1.04 (substance abuse) + 0.67 (alcohol abuse) + 0.84 (upper arm burn) + 1.28 (thigh burn) + 0.21 (number of burn operations) + 0.01 (hospital length-of-stay). Burn-related nerve pain predicted probability = 1 − 1/[1 + exp(burn-related nerve pain risk score)] for 6-month burn-related nerve pain risk score. As the number of risk factors increased, the probability of pain increased. Conclusions: Risk factors were identified for developing burn-related nerve pain at 11 anatomical locations. This model accurately predicts a patient’s risk of developing burn-related nerve pain at 6 months. Age, tobacco use, substance abuse, alcohol abuse, upper arm burns, thigh burns, the number of burn operations, and hospital length of stay represented the strongest predictors. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.
Purpose Chronic neuropathic pain (CNP) after burn injury to the hand/upper extremity is relativel... more Purpose Chronic neuropathic pain (CNP) after burn injury to the hand/upper extremity is relatively common, but not well described in the literature. This study characterizes patients with CNP after hand/upper extremity burns to help guide risk stratification and treatment strategies. We hypothesize that multiple risk factors contribute to the development of CNP and refractory responses to treatment. Methods Patients older than 15 years admitted to the burn center after hand/upper extremity burns, from January 1, 2014, through January 1, 2019, were included. Chronic neuropathic pain was defined as self-described pain for longer than 6 months after burn injury, not including pain due to preexisting illness/medications. Two analyses were undertaken: (1) determining risk factors for developing CNP among patients with hand/upper extremity burns, and (2) determining risk factors for developing refractory pain (ie, nonresponsive to treatment) among hand/upper extremity burn patients with CNP. Of the 914 patients who met the inclusion criteria, 55 (6%) developed CNP after hand/ upper extremity burns. Twenty-nine of these patients (53%) had refractory CNP. Significant risk factors for developing CNP after hand/upper extremity burns included history of substance abuse and tobacco use. Among CNP patients, significant risk factors for developing refractory pain included symptoms of burning sensations. In all CNP patients, gabapentin and ascorbic acid were associated with significant decreases in pain scores on follow-up. Conclusions Substance abuse and tobacco use may contribute to the development of CNP after hand/upper extremity burns. Those who developed refractory CNP were more likely to use the pain descriptor, burning sensations. Pharmacological pain management with gabapentin or pregabalin and ascorbic acid may provide the most relief of CNP symptoms.
Background: Anecdotally, faculty report that independent residents’ operative skills differ from ... more Background: Anecdotally, faculty report that independent residents’ operative skills differ from those of their integrated peers. This study compared operative competency between integrated (postgraduate years 4 to 6) and independent plastic surgery residents. Methods: The authors compared independent (postgraduate years 1 to 3) and integrated (postgraduate years 4 to 6) plastic surgery residents at their institution using operative performance data from the Operative Entrustability Assessment, a validated five-point assessment tool that provides residents with real-time feedback about their operative performance, documenting performance at the point of care. Independent postgraduate year 1, 2, and 3 residents were categorized as postgraduate year 4, 5, and 6 residents, respectively, for comparison. The authors analyzed attending physician (evaluator) Operative Entrustability Assessment scores over time using the independent t test. Results: From July 1, 2013, to June 30, 2018, Oper...
T he Plastic Surgery In-Service Training Examination (PSITE) is administered annually by the Amer... more T he Plastic Surgery In-Service Training Examination (PSITE) is administered annually by the American Society of Plastic Surgeons (ASPS). 1 As of 2016, the exam comprises 5 sections: Comprehensive, Hand and Lower Extremity, Craniomaxillofacial (CMF), Breast and Cosmetic, and Core Surgical Principles. The goal of the PSITE is to give "Surgeons and Residents a comprehensive review of the core curriculum of plastic surgery." 2 Whereas the PSITE is administered to more than 600 residents each year, the greater proportion of test-takers are practicing plastic surgeons who can earn up to 37.5 continuing medical education (CME) credits. 4 Due to the diverse examinee population, the ASPS In-Service Training Examination (ISE) Committee seeks to balance the goals of graduate and CME in preparing the PSITE. Recently, several studies have looked at the content of various sections of the PSITE. Recently, several studies have looked at the content of various sections of the PSITE where the authors found an emphasis on decision-making over direct recall. They also sought to provide a guide for resident training and preparation for the PSITE by identifying frequently tested topics. One aspect of the PSITE that has not been previously studied is the frequency of rare diseases tested on the examination. With the goal of broadly reviewing the core curriculum in plastic surgery, we hypothesize that rare diseases should appear with relatively low frequency on the PSITE, reflecting the incidence of these diseases in a plastic surgeon's daily practice. This study sought to determine the representation of rare diseases on the PSITE.
The association between resident involvement and surgical morbidity in immediate breast reconstru... more The association between resident involvement and surgical morbidity in immediate breast reconstruction is not fully elucidated, and prior studies have had conflicting results. The authors studied whether resident involvement in immediate breast reconstruction is associated with the most important short-term outcomes: increased 30-day surgical morbidity, readmission and reoperation rates, operative time, and length of stay. Patients undergoing immediate breast reconstruction were identified in the 2005 to 2012 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files. The authors used simple and multivariable regression to assess surgical complications and secondary outcomes, stratifying by training level and reconstruction type. A total of 24,191 patients underwent immediate breast reconstruction; 17,840 had resident involvement. Thirty-day surgical morbidity was observed in 5.25 percent (95 percent CI, 4.92 to 5.58 percent) of cases with ...
Introduction The wrist represents a complex anatomic region in the upper extremity and a highly f... more Introduction The wrist represents a complex anatomic region in the upper extremity and a highly functional and intricate structural joint. Perilunate injuries have classically been described as involving a greater or lesser arc as described by Mayfield and imply a specific pattern of force transmission. The greater and lesser arc classifications do not include descriptions of when non-scaphoid carpal fractures occur as part of a perilunate injury. Methods/Results We present three cases of complex and rare perilunate fracture dislocation patterns and discuss the surgical management as a treatment model for these complex wrist injuries: the trans-scaphoid, trans-capitate perilunate dislocation, the trans-scapholunate ligament, trans-capitate dislocation, and the trans-scaphoid, transtriquetral perilunate dislocation. Discussion Although there is a low incidence of injury to non-scaphoid carpal bones, it is beneficial to understand the approach to the perilunate reduction and scaphoid fixation through a combined volar and dorsal approach, which will also allow for the reduction and fixation of more rare and complex carpal fractures.
Introduction: Extensor pollicis longus (EPL) tendon rupture is a well-described phenomenon in pat... more Introduction: Extensor pollicis longus (EPL) tendon rupture is a well-described phenomenon in patients with rheumatoid arthritis. Mechanisms of EPL tendon rupture in the nonrheumatoid population have also been described and include traumatic rupture, repetitive motion strain, and steroid injection into the tendon. Methods: The operative records for patients undergoing extensor pollicis longus reconstruction by the senior author were reviewed. Patients with a history of trauma to the wrist or inflammatory arthropathy were excluded. Results: We identified 3 patients who presented with spontaneous EPL tendon rupture. These patients reported no risk factors (as listed earlier) or inciting event. All 3 patients had some exposure to local steroids but this exposure was not at the site of subsequent tendon rupture. All patients were operatively repaired and went on to full recovery of EPL function. Discussion: In patients with sudden loss of extension of the thumb interphalangeal joint, a thorough history of steroid exposure including local steroid exposure remote to the affected EPL tendon may be relevant.
Journal of Graduate Medical Education, Aug 1, 2021
Background Previous studies have shown men and women attending physicians rate or provide operati... more Background Previous studies have shown men and women attending physicians rate or provide operating room (OR) autonomy differently to men and women residents, with men attendings providing higher ratings and more OR autonomy to men residents. Particularly with the advent of competency-based training in plastic surgery, differential advancement of trainees influenced by gender bias could have detrimental effects on resident advancement and time to graduation. Objective We determined if plastic surgery residents are assessed differently according to gender. Methods Three institutions' Operative Entrustability Assessment (OEA) data were abstracted from inception through November 2018 from MileMarker, a web-based program that stores trainee operative skill assessments of CPT-coded procedures. Ratings are based on a 5-point scale. Linear regression with postgraduate year adjustment was applied to all completed OEAs to compare men and women attendings' assessments of men and women residents. We included 8377 OEAs completed on 64 unique residents (25% women) by 51 unique attendings (29% women): men attendings completed 83% (n ¼ 6972; 5859 assessments of men residents; 1113 of women residents) and women attendings completed 17% (n ¼ 1405; 1025 assessments of men residents; 380 of women residents). Adjusted analysis showed men attendings rated women residents lower than men residents (P , .001); scores by women attendings demonstrated no significant difference (P ¼ .067). Conclusions Our dataset including 4.5 years of data from 3 training programs showed men attendings scored women plastic surgery residents lower than their men counterparts.
Purpose: Rheumatoid arthritis (RA) is a destructive inflammatory disease that commonly involves j... more Purpose: Rheumatoid arthritis (RA) is a destructive inflammatory disease that commonly involves joints of the hand and wrist. Different recommendations exist for continuing or discontinuing immunosuppressant medications during the perioperative time period. The purpose of our study was to determine if continuing steroids, non-biologic DMARDs, and/or biologic DMARDs were associated with an increased risk of postoperative complications. Methods: We performed a single-centered, retrospective review of a consecutive cohort of RA patients who had elective hand surgery by a single surgeon. Patients were included if they had a documented diagnosis of seropositive RA by a rheumatologist, and had elective hand surgery and/or disease-related surgical procedure involving the upper extremity from January 2008 to August 2018. We stratified patients into different groups for comparison by classes of immunosuppressant medications for managing RA. These classes included corticosteroids, non-biological DMARDs, biologic DMARDs, and/or no medications. Groups were then compared for the incidence of postoperative complications. Results: Eighty-eight consecutive patients had elective hand and/or upper extremity surgeries for RA. Mean patient age at the time of surgery (±SD) was 55±13 years (range: 24 to 74 years). Of these 88 patients, eight (9%) overall complications occurred. Complications were wound healing failures, (n=5, 6%), tendon rupture, (n=1, 1%), hematoma, (n=1, 1%), and surgical site infection, (n=1, 1%). Perioperative medications included steroids (n=31), nonbiologic DMARDs (n=68), and biologic DMARDs (n=5). There were no significant findings between patients on perioperative corticosteroids, nonbiologic DMARDs, and/or biologic DMARDs and the incidence of complications. Mean follow-up was 69±65 weeks (range: 8 to 296 weeks). Conclusions: Patients with RA who continued corticosteroids, non-biologic DMARDs, and/or biologic DMARDS within one dosing interval of their usual dose were not associated with a higher risk for postoperative complications compared to patients discontinuing these medications perioperatively, following elective hand surgery.
INTRODUCTION: TME is associated with decreased local recurrence and improved disease-free surviva... more INTRODUCTION: TME is associated with decreased local recurrence and improved disease-free survival after rectal cancer (RC) resection. The extent to which TME has been adopted in the US is unknown. We sought to assess trends in TME performance and grading in Michigan hospitals.
Introduction: Patient-reported outcomes are important for burn injury research and clinical pract... more Introduction: Patient-reported outcomes are important for burn injury research and clinical practice. The NIHfunded Patient Reported Outcomes Measurement System (PROMIS)-25 profile has been validated for use in diverse populations of children with many conditions, though not among children living with burn injuries. The purpose of this study was to examine the reliability and validity of PROMIS-25 scores in children living with burn injury. Methods: Data were provided by children who were participating in a multi-center longitudinal study of outcomes after burn injury. The PROMIS-25 Profile, which includes 4 items for each domain of physical function mobility, anxiety, depression, fatigue, peer relationships, and pain interference, was evaluated for reliability and validity. Floor and ceiling effects, unidimensionality, internal consistency, and reliability were examined. Correlations with other measures (Post-Traumatic Growth Inventory-Child (PTGI-C), Child PTSD Symptom Scale (CPSS) and Burn Outcome Questionnaire Body Image Scale (BOQBI)) were calculated to assess concurrent validity. Results: 256 children living with burn injury who sustained a moderate to severe injury provided responses on PROMIS-25 domains 6 months-10 years post burn. Participants' age ranged from 8-18 years at time of assessment; mean years since injury was 4.3 (SD 4.1). All PROMIS-25 domains showed high internal consistency (Cronbach's α=0.90-0.95). Substantial portions of the sample reported no symptoms (anxiety [58.2%], depressive symptoms [54.6%], fatigue [50.8%], pain [60.1%]). There was a large ceiling effect on peer relationships (46.8%) and physical function mobility (57.5%). One-factor confirmatory factor analyses supported unidimensionality for all domains (all CFI >0.98). Reliability was credible for group mean comparisons ( >0.8) across at least some trait levels for all domains except fatigue and anxiety which had low reliability (< 0.8) across the entire trait range. The magnitude and direction of correlations were as anticipated (0.32 for peer relationships and body image; 0.51 for depressive symptoms and PTSD) with the exception of weak negative correlations between PTGI-C and the anxiety and depression domains. The results provide some evidence of reliability and validity of PROMIS-25 scores among children living with burn injury. Reliability of all domains was low to moderate and would likely be improved, and ceiling effects reduced, by administering the PROMIS-37, which includes 6 items per domain.
Journal of The American College of Surgeons, Oct 1, 2017
polytrauma criteria, have been reviewed. One hundred and twenty eight patients were excluded from... more polytrauma criteria, have been reviewed. One hundred and twenty eight patients were excluded from statistical analysis (incomplete folder, missed values of ISS or imagistic findings, unmentioned maneuvers in ICU or omitted autopsy protocol) and finally from 362 patients remained we retained 47 deaths (13% of patients included). RESULTS: Twelve patients (3.3% admissions) had recognized errors in care that contributed to their death. Important errors patterns included: delayed control of abdominal and intra-thoracic hemorrhage or inadequate recognition (6.3%), failure to secure or protect airway (4.2%), inappropriate management of unstable patients in 8.5% of deaths (long operative procedures, unstable patients sent to CT or to interhospital transfer), missed or delayed diagnoses (4.2%), and inadequate DVT prophylaxis (2.1%). By the internal processing classification of causes, 25% were input errors, 41.7% were intentions errors and 33.3% were execution errors. By phase of trauma management, 16.6% of errors occurred in the ED, 25% during the secondary survey and initial diagnostic, 33.3% during surgery, 16.6% during transport to CT or interhospital transfer, and 8.3% in the ICU stay. CONCLUSIONS: This study combines contemporary understanding of error causation, classification and proposes their remediation with a specific process and protocols.
Plastic and reconstructive surgery. Global open, Sep 1, 2017
patient population, IM centers are an underutilized adjunct in the care of our patients. Further ... more patient population, IM centers are an underutilized adjunct in the care of our patients. Further study into specific IM services that may benefit our patients would be helpful in increasing IM utilization in our field.
The Senate Finance Committee (Committee) has jurisdiction over the Medicare and Medicaid programs... more The Senate Finance Committee (Committee) has jurisdiction over the Medicare and Medicaid programs and as part of its oversight of these programs has conducted numerous inquiries over the years to improve patient safety and transparency. 1 In December 2015, Committee staff became aware of a surgical practice-referred to by hospitals as "concurrent", "overlapping", or "simultaneous" surgeries-from a Boston Globe article. 2 Previously, the practice was not widely understood beyond the medical field. Regardless of the specific terminology used, the practice involves a surgeon scheduling and conducting operations on two different patients during the same period of time. Alarmed by the allegations of patient harm, surgeon misconduct, and inappropriate billing highlighted in that article, the Committee launched an initial inquiry to better understand the practice and the frequency with which it occurs. In early 2016, the Committee sent a letter to 20 teaching hospitals querying them about the practice in their institutions. This letter generated strong interest from hospitals, individual physicians, patient advocates, and others who reached out to the Committee to share their experiences, insights, and knowledge about these issues. Additionally, Committee staff examined guidance issued by the Centers for Medicare & Medicaid Services (CMS), within the Department of Health and Human Services (HHS), and the American College of Surgeons (ACS), policies and other information provided to the Committee by hospitals and others in response to our letter, and other information gathered from stakeholders. This report is a summary of the Committee's staff's findings to date and an overview of key issues and areas of Congressional concern. The Boston Globe article provided an in-depth review of concurrent surgeries being practiced at certain hospitals operating in the Boston area, alleging that the practice may have resulted in several instances of measurable patient harm, including deaths. Specifically, the article described operations in which surgeons divided their attentions between two operating rooms over several hours, failed to return to the operation when residents or fellows needed assistance, or failed to arrive on-time for surgeries, leaving residents or fellows to perform surgeries unsupervised or resulting in patients under anesthesia for prolonged periods. The article also noted that patients were not informed their surgeries would run concurrently with another, calling into question hospitals' patient consent processes. A number of patient advocates also raised concerns to the Committee that the primary motivation for a surgeon to conduct concurrent surgeries was financial, enriching surgeons at the expense of patient care. Advocates of concurrent surgeries argue that this longstanding practice enables timelier access to highskilled, in-demand surgeons by freeing up their time to perform more specialized operations, helps train medical professionals by pairing senior doctors with residents or fellows, and improves the utilization of operating facilities. Additionally, some hospital officials said that their internal analyses found no differences in complication rates between concurrent and other surgeries. Indeed, the American Hospital Association reported to Committee staff that they are aware of only one study that presents research on 1 See, for example, Senate Finance Committee.
Journal of The American College of Surgeons, Oct 1, 2017
INTRODUCTION: TME is associated with decreased local recurrence and improved disease-free surviva... more INTRODUCTION: TME is associated with decreased local recurrence and improved disease-free survival after rectal cancer (RC) resection. The extent to which TME has been adopted in the US is unknown. We sought to assess trends in TME performance and grading in Michigan hospitals.
Plastic and reconstructive surgery. Global open, May 1, 2019
rhinoplasty. Demographics, perioperative characteristics, and postoperative complications were co... more rhinoplasty. Demographics, perioperative characteristics, and postoperative complications were compared between cohorts. Two-hundred-and-sixty-two and 255 subjects underwent breast, abdominal-based, and face/eye aesthetic procedures in the resident and attending clinics, respectively. Subjects presenting to the resident clinic tended to be younger (43.4 vs. 51.4, p<0.001), less obese (26.2 vs. 27.4, p=0.02), lower median income ($65,000 vs. $75,000, p<0.001), and healthier with lower rates of diabetes (4.2% vs. 12.6%, p<0.001), COPD (0.4% vs. 3.1%, p=0.02), PVD (2.3% vs. 6.7%, p=0.02), hypertension (13.4% vs. 31.2%, p<0.001), and history of cancer (3.8% vs. 19.2%, p<0.001). Mean length of procedure significantly differed between resident and attending cohorts at 210 and 152 minutes, respectively (p<0.001). Postoperative complications were similar between cohorts (p=0.48). Reoperation (p<0.03) and readmission (p<0.02) rates were greater in the attending cohorts. The resident aesthetic clinic provides increases independence and decision-making, while maintaining patient safety in commonly performed breast, abdominal, face/eye procedures. Patients operated on in the resident clinic tended to be younger and healthier, highlighting the importance of careful patient selection to maximize both autonomy and safety.
Background: A model that predicts a patient’s risk of developing chronic, burn-related nerve pain... more Background: A model that predicts a patient’s risk of developing chronic, burn-related nerve pain may guide medical and/or surgical management. This study determined anatomy-specific variables and constructed a mathematical model to predict a patient’s risk of developing burn-related nerve pain. Methods: A retrospective analysis was conducted from 1862 adults admitted to a burn center from 2014 to 2019. One hundred thirteen patients developed burn-related nerve pain. Comparisons were made using 11 anatomy-specific locations between patients with and without burn-related nerve pain. The modified Delphi technique was used to select 14 potential risk variables. Multivariate regression techniques, Brier scores, area under the curve, Hosmer-Lemeshow goodness-of-fit, and stratified K-fold cross-validation was used for model development. Chronic pain was defined as pain lasting 6 or more months after release from the Burn Center. Results: Prevalence rates of burn-related nerve pain were similar in the development (6.1 percent) and validation (5.4 percent) cohorts [Brier score = 0.15; stratified K-fold cross-validation (K = 10): area under the curve, 0.75; 95 percent CI, 0.68 to 0.81; Hosmer-Lemeshow goodness-of-fit, p = 0.73; n = 10 groups]. Eight variables were included in the final equation. Burn-related nerve pain risk score = −6.3 + 0.02 (age) + 1.77 (tobacco use) + 1.04 (substance abuse) + 0.67 (alcohol abuse) + 0.84 (upper arm burn) + 1.28 (thigh burn) + 0.21 (number of burn operations) + 0.01 (hospital length-of-stay). Burn-related nerve pain predicted probability = 1 − 1/[1 + exp(burn-related nerve pain risk score)] for 6-month burn-related nerve pain risk score. As the number of risk factors increased, the probability of pain increased. Conclusions: Risk factors were identified for developing burn-related nerve pain at 11 anatomical locations. This model accurately predicts a patient’s risk of developing burn-related nerve pain at 6 months. Age, tobacco use, substance abuse, alcohol abuse, upper arm burns, thigh burns, the number of burn operations, and hospital length of stay represented the strongest predictors. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.
Purpose Chronic neuropathic pain (CNP) after burn injury to the hand/upper extremity is relativel... more Purpose Chronic neuropathic pain (CNP) after burn injury to the hand/upper extremity is relatively common, but not well described in the literature. This study characterizes patients with CNP after hand/upper extremity burns to help guide risk stratification and treatment strategies. We hypothesize that multiple risk factors contribute to the development of CNP and refractory responses to treatment. Methods Patients older than 15 years admitted to the burn center after hand/upper extremity burns, from January 1, 2014, through January 1, 2019, were included. Chronic neuropathic pain was defined as self-described pain for longer than 6 months after burn injury, not including pain due to preexisting illness/medications. Two analyses were undertaken: (1) determining risk factors for developing CNP among patients with hand/upper extremity burns, and (2) determining risk factors for developing refractory pain (ie, nonresponsive to treatment) among hand/upper extremity burn patients with CNP. Of the 914 patients who met the inclusion criteria, 55 (6%) developed CNP after hand/ upper extremity burns. Twenty-nine of these patients (53%) had refractory CNP. Significant risk factors for developing CNP after hand/upper extremity burns included history of substance abuse and tobacco use. Among CNP patients, significant risk factors for developing refractory pain included symptoms of burning sensations. In all CNP patients, gabapentin and ascorbic acid were associated with significant decreases in pain scores on follow-up. Conclusions Substance abuse and tobacco use may contribute to the development of CNP after hand/upper extremity burns. Those who developed refractory CNP were more likely to use the pain descriptor, burning sensations. Pharmacological pain management with gabapentin or pregabalin and ascorbic acid may provide the most relief of CNP symptoms.
Background: Anecdotally, faculty report that independent residents’ operative skills differ from ... more Background: Anecdotally, faculty report that independent residents’ operative skills differ from those of their integrated peers. This study compared operative competency between integrated (postgraduate years 4 to 6) and independent plastic surgery residents. Methods: The authors compared independent (postgraduate years 1 to 3) and integrated (postgraduate years 4 to 6) plastic surgery residents at their institution using operative performance data from the Operative Entrustability Assessment, a validated five-point assessment tool that provides residents with real-time feedback about their operative performance, documenting performance at the point of care. Independent postgraduate year 1, 2, and 3 residents were categorized as postgraduate year 4, 5, and 6 residents, respectively, for comparison. The authors analyzed attending physician (evaluator) Operative Entrustability Assessment scores over time using the independent t test. Results: From July 1, 2013, to June 30, 2018, Oper...
T he Plastic Surgery In-Service Training Examination (PSITE) is administered annually by the Amer... more T he Plastic Surgery In-Service Training Examination (PSITE) is administered annually by the American Society of Plastic Surgeons (ASPS). 1 As of 2016, the exam comprises 5 sections: Comprehensive, Hand and Lower Extremity, Craniomaxillofacial (CMF), Breast and Cosmetic, and Core Surgical Principles. The goal of the PSITE is to give "Surgeons and Residents a comprehensive review of the core curriculum of plastic surgery." 2 Whereas the PSITE is administered to more than 600 residents each year, the greater proportion of test-takers are practicing plastic surgeons who can earn up to 37.5 continuing medical education (CME) credits. 4 Due to the diverse examinee population, the ASPS In-Service Training Examination (ISE) Committee seeks to balance the goals of graduate and CME in preparing the PSITE. Recently, several studies have looked at the content of various sections of the PSITE. Recently, several studies have looked at the content of various sections of the PSITE where the authors found an emphasis on decision-making over direct recall. They also sought to provide a guide for resident training and preparation for the PSITE by identifying frequently tested topics. One aspect of the PSITE that has not been previously studied is the frequency of rare diseases tested on the examination. With the goal of broadly reviewing the core curriculum in plastic surgery, we hypothesize that rare diseases should appear with relatively low frequency on the PSITE, reflecting the incidence of these diseases in a plastic surgeon's daily practice. This study sought to determine the representation of rare diseases on the PSITE.
The association between resident involvement and surgical morbidity in immediate breast reconstru... more The association between resident involvement and surgical morbidity in immediate breast reconstruction is not fully elucidated, and prior studies have had conflicting results. The authors studied whether resident involvement in immediate breast reconstruction is associated with the most important short-term outcomes: increased 30-day surgical morbidity, readmission and reoperation rates, operative time, and length of stay. Patients undergoing immediate breast reconstruction were identified in the 2005 to 2012 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files. The authors used simple and multivariable regression to assess surgical complications and secondary outcomes, stratifying by training level and reconstruction type. A total of 24,191 patients underwent immediate breast reconstruction; 17,840 had resident involvement. Thirty-day surgical morbidity was observed in 5.25 percent (95 percent CI, 4.92 to 5.58 percent) of cases with ...
Introduction The wrist represents a complex anatomic region in the upper extremity and a highly f... more Introduction The wrist represents a complex anatomic region in the upper extremity and a highly functional and intricate structural joint. Perilunate injuries have classically been described as involving a greater or lesser arc as described by Mayfield and imply a specific pattern of force transmission. The greater and lesser arc classifications do not include descriptions of when non-scaphoid carpal fractures occur as part of a perilunate injury. Methods/Results We present three cases of complex and rare perilunate fracture dislocation patterns and discuss the surgical management as a treatment model for these complex wrist injuries: the trans-scaphoid, trans-capitate perilunate dislocation, the trans-scapholunate ligament, trans-capitate dislocation, and the trans-scaphoid, transtriquetral perilunate dislocation. Discussion Although there is a low incidence of injury to non-scaphoid carpal bones, it is beneficial to understand the approach to the perilunate reduction and scaphoid fixation through a combined volar and dorsal approach, which will also allow for the reduction and fixation of more rare and complex carpal fractures.
Introduction: Extensor pollicis longus (EPL) tendon rupture is a well-described phenomenon in pat... more Introduction: Extensor pollicis longus (EPL) tendon rupture is a well-described phenomenon in patients with rheumatoid arthritis. Mechanisms of EPL tendon rupture in the nonrheumatoid population have also been described and include traumatic rupture, repetitive motion strain, and steroid injection into the tendon. Methods: The operative records for patients undergoing extensor pollicis longus reconstruction by the senior author were reviewed. Patients with a history of trauma to the wrist or inflammatory arthropathy were excluded. Results: We identified 3 patients who presented with spontaneous EPL tendon rupture. These patients reported no risk factors (as listed earlier) or inciting event. All 3 patients had some exposure to local steroids but this exposure was not at the site of subsequent tendon rupture. All patients were operatively repaired and went on to full recovery of EPL function. Discussion: In patients with sudden loss of extension of the thumb interphalangeal joint, a thorough history of steroid exposure including local steroid exposure remote to the affected EPL tendon may be relevant.
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Papers by Scott Lifchez