David A. Daar

Abstract: Predictors of Adverse Outcomes in the Management of Mandibular Fractures

SSI, and operative complications (including osteomyelitis, nonunion, malocclusion, and hardware infections). PostAbx complications included Clostridium Difficile colitis, urinary tract infections, pulmonary infections, nervous system infections, blood stream infections and multidrug resistance identified on re-admission. Difference between groups were analyzed by running ANOVA test for continuous variables and Pearson Chi-squared test for categorical variables.

The Latino Physician Shortage: How the Affordable Care Act Increases the Value of Latino Spanish-Speaking Physicians and What Efforts Can Increase Their Supply

The United States Latino population is growing at a rapid pace and is set to reach nearly 30% by 2050. The demand for culturally and linguistically competent health care is increasing in lockstep with this growth; however, the supply of doctors with skills and experience suited for this care is lagging. In particular, there is a major shortage of Latino Spanish-speaking physicians, and the gap between demand and supply is widening. The implementation of the Affordable Care Act (ACA) has increased the capacity of the US healthcare system to care for the growing Latino Spanish-speaking population, through health insurance exchanges, increased funding for safety net institutions, and efforts to improve efficiency and coordination of care, particularly with Accountable Care Organizations and the Hospital Readmissions Reduction Program. With these policies in mind, the authors discuss how the value of Latino Spanish-speaking physicians to the healthcare system has increased under the environment of the ACA. In addition, the authors highlight key efforts to increase the supply of this physician population, including the implementation of the Deferred Action for Childhood Arrivals Act, premedical pipeline programs, and academic medicine and medical school education initiatives to increase Latino representation among physicians.

Readability of online materials for Dupuytren's contracture

Study Design: Descriptive. Background: Dupuytrens contracture is a common disorder involving fibrosis of the palmar fascia. As patients are increasingly using online materials to gather health care information, it is imperative to assess the readability and appropriateness of this content. The recommended grade level for patient educational materials is seventh to eighth grade according to the National Institutes of Health. This study aims to assess the readability and content of online patient resources for Dupuytrens contracture. Purpose of the Study: Evaluate readability of online patient education materials for Dupuytrens contracture. Methods: The largest public search engine, Google, was queried using the term “Dupuytrens contracture surgery” on February 26, 2016. Location filters were disabled, and sponsored results were excluded to avoid any inadvertent search bias. The 10 most popular Web sites were identified, and all relevant patient‐directed information within 1 click from the original site was downloaded and saved as plain text. Readability was analyzed using 6 established analyses (Readable.io, Added Bytes, Ltd, UK). Results: Analysis of 10 Web sites demonstrates an average grade level of at least 11th grade (Flesch‐Kincaid grade level, 10.2; Gunning‐Fog grade level, 13.1; Coleman‐Liau grade level, 14.4; Simple Measure of Gobbledygook grade level, 10.0; automated readability grade level, 9.7; and average grade level, 11.5). Overall Flesch‐Kincaid reading ease index was 46.4, which is difficult. No single article was at the recommended reading level. Conclusions: Online materials available for treatment of Dupuytrens contracture are above recommended reading levels and do not include a comprehensive explanation of treatment options, which may negatively impact decision making in patients seeking treatment for this condition. Surgeons and hand therapists alike should be cognizant of available online patient materials and make efforts to develop and provide more appropriate materials. Level of Evidence: V.

The Bagautdinov dressing method: negative pressure wound therapy in a patient with an allergy to acrylate adhesive

Current embodiments of negative pressure wound therapy (NPWT) create a hermetically sealed chamber at the surface of the body using polyurethane foam connected to a vacuum pump, which is then covered by a flexible adhesive drape. Commercially available NPWT systems routinely use flexible polyethylene films that have a sticky side, coated with the same acrylate adhesives used in other medical devices such as ECG leads and grounding pads. Severe reactions to the acrylate adhesives in these other devices, although uncommon, have been reported. We describe the case of a 63‐year‐old woman with an intractable leg ulcer resulting from external‐beam radiotherapy (XRT). Treatment with a standard commercial NPWT system induced severe inflammation of the skin in direct contact with drape adhesive. We successfully administered prolonged, outpatient NPWT to the patient using an alternative method (first described by Bagautdinov in 1986), using plain polyethylene film and petrolatum. The necessary hermetic seal is achieved by smearing the skin with petrolatum before applying the polyethylene film and activating the vacuum pump. The Bagautdinov method is a practical solution to the problem of adapting NPWT to patients with contact sensitivity or skin tears related to the adhesive compounds in the flexible drapes. Its use of a circumferential elastic wrap to maintain constant pressure on the seal probably limits the Bagautdinov technique to the extremities.

Abstract: Readability of Online Materials for Dupuytren’s Contracture

results: Four hundred thirty-three patients were included, of whom 88 had infections (20.3%). Twenty-three patients had superficial infections, fifty-four had deep infections, and 11 developed both. Infection was more common among patients undergoing implant reconstruction (OR 2.65, 1.50– 4.70). Seventy-one implant reconstruction patients (25.2% of all implant-based reconstruction) developed an infection versus 17 autologous reconstruction patients (11.3% of all autologous reconstructions). On univariate analysis, patients who developed infections had more co-morbidities (1.2 ± 1.2 versus 0.92 ± 1.3, p=0.042). They were more likely to be Caucasian (OR 1.69, 1.05–2.71), to be current smokers (OR 2.50, 1.20–5.19), to have undergone implant reconstruction (OR 2.65, 1.50–4.70), to have received radiation (OR 1.76, 1.09–2.85) or to have received chemotherapy (OR 1.62, 1.00–261). Patients with infections were also more likely to have had a dehiscence (OR 2.27, 1.35–3.81), seroma (OR 1.99, 1.11–3.55), or implant exposure (OR 9.79, 3.61– 26.60). Factors found to be significant on univariate analysis were entered together into a multivariate regression. Results showed that implant exposure increased odds of infection by 165% (p=0.003), implant-based reconstruction increased them by 90.6% (p=0.004), and dehiscence increased these odds by 65.1% (p=0.034). Patients with infections were more likely to decline further reconstructive procedures (OR 2.10, 1.21–3.64) and require more procedures overall (5.08 ± 2.35 versus 3.74 ± 1.75, p<0.0001), largely driven by more implant exchanges (1.89 ± 1.74 versus 1.29 ± 1.13, p=0.017). Infected patients were not any less likely to finish their reconstructions, as indicated by nipple reconstruction or tattooing (OR 0.90, 0.58–1.49).

Abstract P2-13-06: Acellular dermal allograft fenestrations decrease outpatient expander fills and increase direct to implant incidence in implant-based immediate breast reconstruction

Introduction: The innovation of fenestrated allograft (acellular dermal matrix, ADM) has improved patient outcomes in two-stage tissue expander/implant breast reconstruction. This technical alteration utilizes optimal fenestration overlap and has enhanced the efficiency of the reconstructive experience. We present a follow-up study of one- and two-stage breast reconstruction with a more refined, standardized method of surgeon-designed fenestration of ADM. Methods: We conducted a retrospective review of 52 patients (91 breasts) having undergone one- and two-stage breast reconstruction using fenestrated ADM at our institution from 2013 to 2014. Results: Mean intra-operative fill volume (IOFV) measured 402cc (SD=118cc), and IOFV as a percent of tissue expander size averaged 79.1% (SD=16.7%). Ten breasts were expanded to 100% and completed reconstruction in one stage with implant placement. IOFV as a percentage of total fill volume at completion of expansion averaged 73.6% (SD=16.6%). Two-stage reconstruction patients underwent 1.8 post-operative expansions on average (range 0-4) and averaged 81.2cc (SD=29.3cc) per in-office expansion. Days to full expansion averaged 45.1 days, while days to exchange averaged 137.8 days (Table 1). Mean days to exchange between our first 24 breasts to complete reconstruction vs. our last 23 breasts to complete reconstruction differed significantly, with 205 ± 43.8 days vs. 137.7 ± 138.1 days, respectively (p=0.03). The major complication rate requiring re-operation within 30 days post-operatively was 11.0%. Four breasts experienced partial mastectomy flap necrosis requiring re-operation with implant salvage (4.4%). Six breasts (6.6%) underwent explantation due to: infection (three), flap necrosis (two), and patient preference (one) (Table 2). Conclusion: Our fenestrated technique is demonstrated to increase intra-operative fill volume, decrease number of post-operative expansions and time to full expansion, and improve expansion rate with subjectively less pain. We believe our patients benefited from improved cosmetic outcomes with better shape, maintenance of breast footprint, and enhanced comfort due to the decreased number of intra-office fills and increased intra-operative expansion. Citation Format: Daar DA, Bourgeois JM, Mowlds DS, Wirth GA, Paydar KZ. Acellular dermal allograft fenestrations decrease outpatient expander fills and increase direct to implant incidence in implant-based immediate breast reconstruction. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-13-06.