Jason Silvestre

Plastic Surgery Residency Websites: A Critical Analysis of Accessibility and Content

BackgroundMedical students applying for plastic surgery residency utilize the Internet to manage their residency applications. Applicants often apply to many programs and rely on advice from colleagues, mentors, and information gathered from plastic surgery residency websites (PSRWs). The purpose of the present study was to evaluate integrated and combined PSRWs with respect to accessibility, resident recruitment, and education. MethodsWebsites from all 63 integrated and combined plastic surgery residencies available to graduating medical students during the 2013 academic year were available for study inclusion. Databases from national bodies for plastic surgery education were analyzed for accessibility of information. PSRWs were evaluated for comprehensiveness in the domains of resident education and recruitment. Residency programs were compared according to program characteristics using the Student t test and ANOVA with Tukey method. ResultsOf the 63 residencies available to graduating medical students, only 57 had combined or integrated program information on their PSRWs (90.5%). In the domain of resident recruitment, evaluators found an average of 5.5 of 15 content items (36.7%). As a whole, 26.3% of PSRWs had academic conference schedules, 17.5% had call schedules, and only 8.8% had operative case listings. For resident education, PSRWs provided an average of 4.6 of 15 content items (30.7%). Only 31.6% of PSRWs had interview schedules, 24.6% had graduate fellowship information, and 5.3% had information on board exam performance. Upon comparison, programs in the Midwest had more online recruitment content than programs in the West (47.1% vs. 24.2%, P < 0.01). Additionally, programs with a larger class of incoming residents (2 vs. 1) had greater online recruitment content (40.0% vs. 26.7%, P < 0.05). Larger programs with 3 integrated spots had more online education content than smaller programs with only 1 integrated spot (40.0% vs. 19.4%, P < 0.01). ConclusionPSRWs are often not readily accessible and do not provide basic information that allow residency applicants to use this recruitment tool effectively. The paucity of online content suggests PSRWs are underutilized as an educational and recruitment tool. These findings have implications for applicants and plastic surgery residency programs, and there may be future opportunity to utilize this tool more effectively.

A 35-year experience with syndromic cleft palate repair: operative outcomes and long-term speech function.

BackgroundAssociated comorbidities can put syndromic patients with cleft palate at risk for poor speech outcomes. Reported rates of velopharyngeal insufficiency (VPI) vary from 8% to 64%, and need for secondary VPI surgery from 23% to 64%, with few studies providing long-term follow-up. The purpose of this study was to describe our institutional long-term experience with syndromic patients undergoing cleft palatoplasty. MethodsA retrospective review was conducted of all patients with syndromic diagnoses undergoing primary Furlow palatoplasty from 1975 to 2011. Outcomes included postoperative oronasal fistula (ONF) and need for secondary VPI surgery. Speech scores for verbal patients 5 years or older were collected via the Pittsburgh scale for speech assessment. Aggregate scores categorized the velopharyngeal mechanism as competent, borderline, or incompetent. Outcomes were analyzed by patient and operative factors. ResultsOne hundred thirty-two patients were included with average age at repair of 20.7 months. Cleft type was 9% submucosal, 16% Veau class I, 50% class II, 12% class III, and 13% class IV. Forty-five syndromes were recorded, most commonly Stickler syndrome (n = 32) and 22q11.2 deletion syndrome [22q11.2DS (n = 19)]. Forty-four patients also had associated Pierre Robin sequence (PRS). The overall ONF rate was 4.5% and was highest in Veau class IV clefts (P = 0.048). Seventy-six patients were included in speech analysis, with an average age at last assessment of 10.4 years. Overall, 60.5% of patients had a competent velopharyngeal mechanism, 23.7% borderline, and 15.8% incompetent mechanism. Fifty percent of 22q11.2DS patients had borderline speech and none had competent speech, compared to 73.3% with Stickler syndrome (P = 0.01) and 71.4% of patients with associated PRS (P = 0.02). Secondary VPI surgery was performed in 11.4% of patients overall. Patients with PRS (13.6%) and with Stickler syndrome (15.6%) had secondary VPI surgery, compared to 31.6% of patients with 22q11.2DS (P = 0.01). ConclusionsThis study demonstrates low rates of postoperative ONF after modified Furlow palatoplasty in syndromic patients. Speech outcomes were comparable to nonsyndromic patients at our institution, but patients with 22q11.2DS consistently had borderline-incompetent speech and a 3-fold higher incidence of secondary VPI surgery.

The Impact of National Institutes of Health Funding on Scholarly Productivity in Academic Plastic Surgery.

Background: The h-index is an objective measure of an investigator’s scholarly impact. The purpose of this investigation was to determine the association between scholarly impact, as measured by the h-index, and the procurement of National Institutes of Health (NIH) grant funding among academic plastic surgeons. Methods: This was a case-control study of NIH-funded plastic surgery faculty identified on the RePORTER database. Non-NIH–funded faculty from the top 10 NIH-funded programs served as a control group. The mean h-index was calculated from Scopus (Elsevier, London, United Kingdom) and compared by funding status, academic rank, and terminal degree(s). The relationship between h-index and career NIH funding was elucidated via Spearman’s correlation coefficient. Results: NIH-funded faculty had higher h-indices than nonNIH–funded faculty (23.9 versus 9.9, p < 0.001), an effect that persisted when controlling for academic rank. Higher rank correlated with higher h-indices and predicted greater NIH funding (p < 0.05). The h-index did not vary by terminal degree (p > 0.05), but investigators with a master’s degree exhibited a trend toward greater NIH funding. Higher h-indices correlated with greater NIH funding (r = 0.481, p < 0.001). Conclusions: A strong relationship exists between scholarly impact and the procurement of NIH funding. Faculty with greater funding had greater scholarly impact, as measured by the h-index, which suggests that this tool may have utility during the NIH grant application process.

Gender Authorship Trends of Plastic Surgery Research in the United States.

BACKGROUND An increasing number of women are entering the medical profession, but plastic surgery remains a male-dominated profession, especially within academia. As academic aspirations and advancement depend largely on research productivity, the authors assessed the number of articles authored by women published in the journal Plastic and Reconstructive Surgery. METHODS Original articles in Plastic and Reconstructive Surgery published during the years 1970, 1980, 1990, 2000, 2004, and 2014 were analyzed. First and senior authors with an M.D. degree and U.S. institutional affiliation were categorized by gender. Authorship trends were compared with those from other specialties. Findings were placed in the context of gender trends among plastic surgery residents in the United States. RESULTS The percentage of female authors in Plastic and Reconstructive Surgery increased from 2.4 percent in 1970 to 13.3 percent in 2014. Over the same time period, the percentage of female plastic surgery residents increased from 2.6 percent to 32.5 percent. By 2014, there were more female first authors (19.1 percent) than senior authors (7.7 percent) (p < 0.001). As a field, plastic surgery had fewer female authors than other medical specialties including pediatrics, obstetrics and gynecology, general surgery, internal medicine, and radiation oncology (p < 0.05). CONCLUSIONS The increase in representation of female authors in plastic surgery is encouraging but lags behind advances in other specialties. Understanding reasons for these trends may help improve gender equity in academic plastic surgery.

Disparities in Aesthetic Procedures Performed by Plastic Surgery Residents

Background: Operative experience in aesthetic surgery is an important issue affecting plastic surgery residents. Objectives: This study addresses the variability of aesthetic surgery experience during plastic surgery residency. Methods: National operative case logs of chief residents in independent/combined and integrated plastic surgery residency programs were analyzed (2011‐2015). Fold differences between the bottom and top 10th percentiles of residents were calculated for each aesthetic procedure category and training model. The number of residents not achieving case minimums was also calculated. Results: Case logs of 818 plastic surgery residents were analyzed. There was marked variability in craniofacial (range, 6.0‐15.0), breast (range, 2.4‐5.9), trunk/extremity (range, 3.0‐16.0), and miscellaneous (range, 2.7‐22.0) procedure categories. In 2015, the bottom 10th percentile of integrated and independent/combined residents did not achieve case minimums for botulinum toxin and dermal fillers. Case minimums were achieved for the other aesthetic procedure categories for all graduating years. Conclusions: Significant variability persists for many aesthetic procedure categories during plastic surgery residency training. Greater efforts may be needed to improve the aesthetic surgery experience of plastic surgery residents.

Utility of screening for obstructive sleep apnea syndrome in children with craniofacial disorders.

Background: Children with craniofacial disorders are at increased risk for obstructive sleep apnea syndrome. Methods for diagnosing obstructive sleep apnea syndrome in this population remain controversial. Sleep studies are the criterion standard but are impractical for all patients. The utility of obstructive sleep apnea syndrome questionnaires such as the Pediatric Sleep Questionnaire is unknown in children with craniofacial disorders. The authors hypothesized that the Pediatric Sleep Questionnaire would be a sensitive tool for detecting obstructive sleep apnea syndrome in children with craniofacial abnormalities. Methods: A retrospective review of consecutive children with diagnosed craniofacial disorders who both completed the Pediatric Sleep Questionnaire and underwent polysomnography was performed. Demographics, Pediatric Sleep Questionnaire score, and polysomnographic data were recorded. Statistical analysis included calculation of sensitivity, specificity, positive predictive value, and negative predictive value for the Pediatric Sleep Questionnaire. Results: Eighty-three children aged 2 to 18 years were included in the study. Of these, 44 (53.0 percent) screened positive on the Pediatric Sleep Questionnaire and 23 (27.7 percent) had polysomnographic evidence of obstructive sleep apnea syndrome, but the sensitivity of the Pediatric Sleep Questionnaire for detecting obstructive sleep apnea syndrome in this sample was only 0.57 and the specificity was 0.48. Positive predictive value and negative predictive value were 0.30 and 0.74, respectively. The correlation between the apnea hypopnea index and Pediatric Sleep Questionnaire score was 0.152 (p = 0.17). Conclusions: A substantial portion of craniofacial patients referred for polysomnography was found to have obstructive sleep apnea syndrome. However, the Pediatric Sleep Questionnaire is not a good screening tool for obstructive sleep apnea syndrome in children with craniofacial conditions. More research is needed to determine which patients with craniofacial disorders should be evaluated for obstructive sleep apnea syndrome by polysomnography or other means. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

The Internet as a communication tool for orthopedic spine fellowships in the United States

BACKGROUND CONTEXT Orthopedic residents seeking additional training in spine surgery commonly use the Internet to manage their fellowship applications. Although studies have assessed the accessibility and content of Web sites in other medical specialties, none have looked at orthopedic spine fellowship Web sites (SFWs). PURPOSE The purpose of this study was to evaluate the accessibility of information from commonly used databases and assess the content of SFWs. STUDY DESIGN This was a Web site accessibility and content evaluation study. METHODS A comprehensive list of available orthopedic spine fellowship programs was compiled by accessing program lists from the SF Match, North American Spine Society, Fellowship and Residency Electronic Interactive Database (FREIDA), and Orthopaedicsone.com (Ortho1). These databases were assessed for accessibility of information including viable links to SFWs and responsive program contacts. A Google search was used to identify SFWs not readily available on these national databases. SFWs were evaluated based on online education and recruitment content. RESULTS Evaluators found 45 SFWs of 63 active programs (71%). Available SFWs were often not readily accessible from national program lists, and no program afforded a direct link to their SFW from SF Match. Approximately half of all programs responded via e-mail. Although many programs described surgical experience (91%) and research requirements (87%) during the fellowship, less than half mentioned didactic instruction (46%), journal clubs (41%), and national meetings or courses attended (28%). Evaluators found an average 45% of fellow recruitment content. Comparison of SFWs by program characteristics revealed three significant differences. Programs with greater than one fellowship position had greater online education content than programs with a single fellow (p=.022). Spine fellowships affiliated with an orthopedic residency program maintained greater education (p=.006) and recruitment (p=.046) content on their SFWs. CONCLUSIONS Most orthopedic spine surgery programs underuse the Internet for fellow education and recruitment. The inaccessibility of information and paucity of content on SFWs allow for future opportunity to optimize these resources.

Clostridium difficile colitis in patients undergoing lumbar spine surgery.

Study Design. Retrospective database analysis. Objective. To investigate incidence, comorbidities, and impact on health care resources of Clostridium difficile infection after lumbar spine surgery. Summary of Background Data. C. difficile colitis is reportedly increasing in hospitalized patients and can have a negative impact on patient outcomes. No data exist on estimates of C. difficile infection rates and its consequences on patient outcomes and health care resources among patients undergoing lumbar spine surgery. Methods. The Nationwide Inpatient Sample was examined from 2002 to 2011. Patients were included for study based on International Classification of Diseases, Ninth Revision, Clinical Modification, procedural codes for lumbar spine surgery for degenerative diagnoses. Baseline patient characteristics were determined and multivariable analyses assessed factors associated with increased incidence of C. difficile and risk of mortality. Results. The incidence of C. difficile infection in patients undergoing lumbar spine surgery is 0.11%. At baseline, patients infected with C. difficile were significantly older (65.4 yr vs. 58.9 yr, P < 0.0001) and more likely to have diabetes with chronic complications, neurological complications, congestive heart failure, pulmonary disorders, coagulopathy, and renal failure. Lumbar fusion (P = 0.0001) and lumbar fusion revision (P = 0.0003) were associated with increased odds of postoperative infection. Small hospital size was associated with decreased odds (odds ratio [OR], 0.5; P < 0.001), whereas urban hospitals were associated with increased odds (OR, 2.14; P < 0.14) of acquiring infection. Uninsured (OR, 1.62; P < 0.0001) and patients with Medicaid (OR, 1.33; P < 0.0001) were associated with higher odds of acquiring postoperative infection. C. difficile increased hospital length of stay by 8 days (P < 0.0001), hospital charges by 2-fold (P < 0.0001), and inpatient mortality to 4% from 0.11% (P < 0.0001). Conclusion. C. difficile infection after lumbar spine surgery carries a 36.4-fold increase in mortality and costs approximately

Analysis of National Institutes of Health Funding to Departments of Urology

10,658,646 per year to manage. These data suggest that great care should be taken to avoid C. difficile colitis in patients undergoing lumbar spine surgery because it is associated with longer hospital stays, greater overall costs, and increased inpatient mortality. Level of Evidence: 3

Near-Infrared Imaging for the Assessment of Anastomotic Patency, Thrombosis, and Reperfusion in Microsurgery: A Pilot Study in a Porcine Model

OBJECTIVE To elucidate the current portfolio of National Institutes of Health (NIH) funding to departments of urology at U.S. medical schools. MATERIALS AND METHODS The NIH Research Portfolio Online Reporting Tools Expenditures and Results was used to generate a comprehensive analysis of NIH research grants awarded to urology departments during 2014. Costs, mechanisms, and institutes were summarized with descriptive statistics. Demographic data were obtained for principal investigators and project abstracts were categorized by research type and area. Fiscal totals were calculated for 2005-2014 and compared with other surgical departments during 2014. RESULTS One hundred one investigators at 36 urology departments received