Evan P. McGlinn

Patient expectations and patient-reported outcomes in surgery: A systematic review

BACKGROUND Recent events in health care reform have brought national attention to integrating patient experiences and expectations into quality metrics. Few studies have comprehensively evaluated the effect of patient expectations on patient-reported outcomes (PROs) after surgery. The purpose of this study is to systematically review the available literature describing the relationship between patient expectations and postoperative PROs. METHODS We performed a search of the literature published before November 1, 2012. Articles were included in the review if (1) primary data were presented, (2) patient expectations regarding a surgical procedure were measured, (3) PROs were measured, and (4) the relationship between patient expectations and PROs was specifically examined. PROs were categorized into 5 subgroups: Satisfaction, quality of life (QOL), disability, mood disorder, and pain. We examined each study to determine the relationship between patient expectations and PROs as well as study quality. RESULTS From the initial literature search yielding 1,708 studies, 60 articles were included. Fulfillment of expectations was associated with improved PROs among 24 studies. Positive expectations were correlated with improved PROs for 28 studies (47%), and poorer PROs for 9 studies (15%). Eighteen studies reported that fulfillment of expectations was correlated with improved patient satisfaction, and 10 studies identified that positive expectations were correlated with improved postoperative. Finally, patients with positive preoperative expectations reported less pain (8 studies) and disability (15 studies) compared with patients with negative preoperative expectations. CONCLUSION Patient expectations are inconsistently correlated with PROs after surgery, and there is no accepted method to capture perioperative expectations. Future efforts to rigorously measure expectations and explore their influence on postoperative outcomes can inform clinicians and policymakers seeking to integrate PROs into measures of surgical quality.

Measuring outcomes and determining long-term disability after revision amputation for treatment of traumatic finger and thumb amputation injuries

Background: Disability ratings after finger amputations are based on anatomical injury according to the American Medical Association’s Guides to the Evaluation of Permanent Impairment. These ratings determine disability and compensation, without considering validated outcomes measures. The authors hypothesize that patient-reported outcomes reflect function and health-related quality of life after traumatic finger amputations, and that Guides scoring does not accurately rate postamputation disability. Methods: Patients were classified by amputation: single finger, thumb, multifinger, or multifinger plus thumb. Eighty-four patients completed functional tests, the Jebsen-Taylor Hand Function Test, and patient-reported outcomes [Brief Michigan Hand Questionnaire (MHQ), Quick Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and the Short Form-36 health-related quality-of-life questionnaire). Patients were given disability scores according to the Guides. Pearson correlations between outcomes metrics were calculated, and linear regression evaluated associations between amputation group, Guides score, and outcomes measures. Results: The Brief MHQ and Quick DASH questionnaires had significant correlation with functional tests, the Jebsen-Taylor test, and the physical component summary of Short Form-36. Only the Brief MHQ correlated with the mental component summary of the Short Form-36 (r = 0.29, p = 0.02). The Guides score only correlated with the Jebsen-Taylor test (r = 0.47, p < 0.001). Regression results indicate that the Brief MHQ, Quick DASH, and Guides score predict Jebsen-Taylor test score; however, amputation group and Guides score do not predict patient-reported outcomes. Conclusions: The American Medical Association Guides score represents anatomical and functional outcomes without addressing mental health and other components of disability. As a result, Guides scoring is inadequate for determining postamputation disability. In evaluating composite amputation outcomes, Brief Michigan Hand Questionnaire outperformed other metrics. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

A Historical Perspective on the Essex-Lopresti Injury

An Essex-Lopresti injury is a fracture of the radial head with concomitant dislocation of the distal radioulnar joint and rupture of the interosseous membrane. Poor outcomes have been associated with this rare injury if the dislocation of the distal radioulnar joint is missed in the acute setting. This injury is named after the British orthopedic surgeon Peter Essex-Lopresti, who made a number of important observations about this injury in 1951. Peter Essex-Lopresti was a promising young surgeon, and his untimely death at the age of 35 brought an early end to a remarkable career. This article investigates the evolution of treatment for this injury and sheds light on the life of the surgeon for whom the injury is named.

A biomechanical and evolutionary perspective on the function of the lumbrical muscle.

The lumbrical muscles of the hand originate from the flexor digitorum profundus tendons and insert onto the lateral band of the extensor tendons. Owing to these movable attachments, the function of this muscle is difficult to visualize. To better determine the function of this muscle, we considered its relative anatomy, biomechanical characteristics, and evolution. With the smallest physiological cross-sectional area in the upper extremity, the lumbrical muscles have weak motor function, which is only 1/10 of the interosseous muscle. Because they are spindle rich, the lumbrical muscles play an important role in the sensory feedback of the distal interphalangeal, proximal interphalangeal, and metacarpophalangeal joints of the fingers. The first 2 lumbrical muscles have lower variation in anatomy and higher density of muscle spindles compared to the ulnar 2 lumbricals. In addition, the index and middle finger lumbrical muscles are innervated by the median nerve, which also innervates the thenar muscles of the thumb. Therefore, it is possible that the first 2 lumbricals are functionally more important than the 2 ulnar lumbricals, specifically for precision pinch movements.

A pause for reflection: incorporating reflection into surgical training.

Reflection is an important learning technique for surgeons during their training and is a valuable tool for life-long learning and maintenance of certification to assure competency. Reflection helps individuals to evaluate their performance in the interest of improving their ability to deal with similar experiences in the future. Additionally, reflection can be helpful for established surgeons to continue to improve upon their performance and hone their craft. This article outlines the theoretical role of reflection in the learning process. We will discuss methods for incorporating reflection into training programs, and review the evidence for implementing reflection in surgical training.

A systematic review of outcomes after revision amputation for treatment of traumatic finger amputation

Background: Revision amputation is often the treatment for traumatic finger amputation injuries. However, patient outcomes are inadequately reported, and their impact is poorly understood. The authors performed a systematic review to evaluate outcomes of revision amputation and amputation wound coverage techniques. Methods: The authors searched all available English literature in the PubMed and Embase databases for articles reporting outcomes of nonreplantation treatments for traumatic finger amputation injuries, including revision amputation, local digital flaps, skin grafting, and conservative treatment. Data extracted were study characteristics, patient demographic data, sensory and functional outcomes, patient-reported outcomes, and complications. Results: A total of 1659 articles were screened, yielding 43 studies for review. Mean static two-point discrimination was 5.0 ± 1.5 mm (n = 23 studies) overall, 6.1 ± 2.4 mm after local flap procedures, and 3.8 ± 0.4 mm after revision amputation. Mean total active motion was 93 ± 8 percent of normal (n = 6 studies) overall. It was 90 ± 9 percent of normal after local flap procedures and 95 percent of normal after revision amputation. Seventy-seven percent of patients reported cold intolerance after revision amputation. Ninety-one percent of patients (217 of 238) reported “satisfactory” or “good/excellent” ratings regardless of treatment. Conclusions: Revision amputation and conservative treatments result in better static two-point discrimination outcomes compared with local flaps. All techniques preserve total active motion, although arc of motion is slightly better with revision amputation. Revision amputation procedures are frequently associated with cold intolerance. Patients report “satisfactory,” “good,” or “excellent” ratings in appearance and quality of life with all nonreplantation techniques.

Mortality trends and the effects of débridement timing in the management of mediastinitis in the United States, 1998 to 2010

Background: The authors examined the relationship between débridement delay and mortality for mediastinitis patients. The authors also assessed mortality trends for mediastinitis patients between 1998 and 2010. Methods: The authors conducted a retrospective cross-sectional study with data from the Nationwide Inpatient Sample, 1998 to 2010. They studied adult patients, 18 years of age or older, who were surgically treated for mediastinitis. They used a logistic regression model adjusted for patient demographic and clinical characteristics to evaluate the association between timing of first operative débridement and in-hospital mortality. Using their logistic model, they calculated the adjusted probability of in-hospital mortality for each year of the study. Results: Results showed that initial débridement after the fourth day of admission increased the odds of in-hospital mortality by 50 percent (odds ratio, 1.5; 95 percent confidence interval, 1.0 to 2.1). In addition, the adjusted probability of in-hospital mortality for an average patient treated for mediastinitis decreased from 10.6 percent in 1998 to 3.1 percent in 2010. Conclusion: There is a survival advantage from timely initial débridement in mediastinitis patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.