Jugpal S. Arneja

Qualitative and quantitative outcomes of audience response systems as an educational tool in a plastic surgery residency program.

Background: In-training evaluations in graduate medical education have typically been challenging. Although the majority of standardized examination delivery methods have become computer-based, in-training examinations generally remain pencil-paper–based, if they are performed at all. Audience response systems present a novel way to stimulate and evaluate the resident-learner. The purpose of this study was to assess the outcomes of audience response systems testing as compared with traditional testing in a plastic surgery residency program. Methods: A prospective 1-year pilot study of 10 plastic surgery residents was performed using audience response systems–delivered testing for the first half of the academic year and traditional pencil-paper testing for the second half. Examination content was based on monthly “Core Quest” curriculum conferences. Quantitative outcome measures included comparison of pretest and posttest and cumulative test scores of both formats. Qualitative outcomes from the individual participants were obtained by questionnaire. Results: When using the audience response systems format, pretest and posttest mean scores were 67.5 and 82.5 percent, respectively; using traditional pencil-paper format, scores were 56.5 percent and 79.5 percent. A comparison of the cumulative mean audience response systems score (85.0 percent) and traditional pencil-paper score (75.0 percent) revealed statistically significantly higher scores with audience response systems (p = 0.01). Qualitative outcomes revealed increased conference enthusiasm, greater enjoyment of testing, and no user difficulties with the audience response systems technology. Conclusions: The audience response systems modality of in-training evaluation captures participant interest and reinforces material more effectively than traditional pencil-paper testing does. The advantages include a more interactive learning environment, stimulation of class participation, immediate feedback to residents, and immediate tabulation of results for the educator. Disadvantages include start-up costs and lead-time preparation.

Inpatient silver sulphadiazine versus outpatient nanocrystalline silver models of care for pediatric scald burns: A value analysis.

BACKGROUND/OBJECTIVEnScalds represent the most frequent pediatric burn injury. Inpatient nonsurgical wound management of small or medium-size burns (<20% total body surface area) represents a significant proportion of the cost of care, with nanocrystalline silver (NCS) and silver sulphadiazine (SSD) among the most commonly used dressings. Although several articles have described healing outcomes using these dressings, there are few concurrent economic analyses. To analyze overall health care value (outcomes/cost) in burns not requiring surgery, the authors compared management of scald burns with NCS versus SSD from both a quality perspective and using bottom-up microcosting to determine which dressing option optimizes health care value.nnnMETHODSnA value analysis was performed. Published studies investigating NCS and/or SSD in the treatment of pediatric burns over the past 25 years were analyzed. Healing time, hospital duration and frequency of dressings were chosen as quality metrics. A bottom-up microcosting analysis was performed to estimate costs associated with the two dressing options.nnnRESULTSnOver the 25-year period, 356 studies investigated the use of SSD in burns, while 55 studies evaluated the use of NCS. Mean age and burn size were equivalent. Mean time to healing was 14.9 days for NCS and 17.2 days for SSD. The mean duration of hospital stay was 14.9 days for SSD and 5.9 days for NCS. Dressings were performed twice per week for NCS, and once or twice per day for SSD. The mean total cost per patient to the health care system was estimated to be

Leadership in Canadian Urology: What is the Right Stuff?

61,140 for SSD and

Delayed extensor pollicis longus tendon rupture following nondisplaced distal radius fracture in a child

17,220 for NCS.nnnCONCLUSIONnPublished outcomes of healing time are equivalent or slightly better using NCS over SSD for pediatric scalds. The financial model illustrated a potential significant cost saving with NCS, primarily as a result of an outpatient model of care. Overall health care value is optimized using NCS for pediatric scalds.

Airway Management in Pierre Robin Sequence: The Vancouver Classification

INTRODUCTIONnThere are little data characterizing leadership roles within Canadian Urology. The importance of these positions in urology underscores the need for further investigation to provide insight for recruitment, development, and success.nnnMETHODSnAll Canadian Urology Program Directors and Division/Department Heads were invited to complete an online leadership survey as part of a larger national cohort from 11 other surgical specialties.nnnRESULTSnResponse rate was 62% (13/21), the majority of whom were Caucasian (77%) and male (92%). Only 8% of respondents in urology hold an advanced degree compared with 45% in other specialties. Additional leadership training was done by 54% of the respondents. Residency was completed in Canada by 92%, but 62% completed fellowships abroad. A majority reported no well-defined job description for their role (54%). The top responsibility reported by leaders was mentoring residents (67%), followed by advising staff (62%). Excellence in patient care and teaching were seen as the most important professional characteristics, whereas integrity was the personal quality felt most important. Leaders reported 17% of their income came from their leadership role, equivalent to the time required for position duties (19%). Time management was listed as the greatest challenge faced (54%). Leadership style was reported as democratic by 92%. Leaders in urology most often self-rated their leadership skills lower than leaders from other surgical specialties (7 vs 8/10).nnnCONCLUSIONnPositions of leadership in urology are disproportionately represented by Caucasian males and comparatively few hold relevant advanced degrees. Excellence in the areas of teaching and patient care, and high personal integrity are felt to be the most important characteristics for success. Time management issues are viewed as the greatest challenge. These preliminary data may prove useful for the mentoring, recruitment, and success of future leaders in our specialty.

Management of pediatric penile keloid.

Rupture of the extensor pollicis longus (EPL) tendon is a disabling complication occurring with an estimated frequency of 0.07 to 0.88xa0% following fracture of the distal radius in adults [1, 5, 6, 9]. In this population, most tendon ruptures occurred 4 to 8xa0weeks after trauma [13], affecting people at an average age of 53xa0years [9]. The incidence of EPL tendon rupture is even lower in the pediatric population, and there is limited literature on this subject. The few pediatric case reports have described EPL tendon rupture following either severe injuries requiring intramedullary nailing and open reduction [1, 12, 16] or a markedly displaced fracture [3, 5, 11]. Herein we report a case of delayed EPL tendon rupture in a 15-year-old boy 9xa0weeks following a nondisplaced distal radius fracture.

Early Placement of Ventilation Tubes in Infants with Cleft Lip and Palate: A Systematic Review:

Background: Pierre Robin sequence (PRS) is a triad of micrognathia, glossoptosis, and respiratory distress. There is no standard clinical classification used in the management of neonatal airway in patients with PRS. The goal of our study was to review the presentation and management of patients with PRS and formulate a clinical grading system and treatment algorithm. Methods: A 10-year retrospective review of all neonates diagnosed with PRS was performed after obtaining institutional ethics approval. Patients were identified using our cleft lip and palate program database. Inclusion criteria were 2 of the following 3 clinical features—glossoptosis, retrognathia, or airway obstruction. We collected demographic data, clinical information (coexisting airway morbidity, maxillary-mandibular discrepancy, type of intervention used, complications, and outcomes (feeding, length of stay, and airway status) during the first year of life. Results: Sixty-three patients met our inclusion criteria. Of these, 55 (87%) had cleft palate and 17 (27%) were syndromic. Forty-eight (76%) patients were managed by prone positioning. Of the 15 surgically managed patients, the initial procedure was floor of mouth release in 7, mandibular distraction osteogenesis (MDO) in 4, and tongue-lip adhesion in 4. Five patients with coexisting airway morbidity needed a second surgery; 2 had MDO and 3 tracheostomies (one patient was later decannulated). Seven (47%) of the surgically managed patients required a gastrostomy tube. Conclusion: At present, there is no consensus on neonatal airway management in infants with PRS. From our review of 63 patients with PRS, we hereby propose a simple 4-point classification system and treatment algorithm, based on clinical features.

Are Dog Bites a Problem of Nature or Nurture

Keloids are abnormal scar tissue growths that extend beyond the original area of injury, occasionally occurring post-surgery. Risk factors for keloids include skin trauma, infection, prolonged wound healing and individuals of certain ethnicities. Keloid formation on the penis, however, is a rare occurrence even among circumcised males, and can produce both aesthetic and functional complications. We document the tenth patient in the literature, to our knowledge, to present with a keloid of the penis.

Image guided sclerotherapy for the treatment of venous malformations

Objective Studies have shown that the majority of cleft lip and palate (CLP) children have middle ear fluid present at the time of lip repair (3-4 months). Despite hearing loss, the majority of children do not undergo ventilation tube treatment if required until the time of palate repair (9-12 months). We aimed to examine the effectiveness and potential complications of early ventilation tube placement prior to palatoplasty in infants with cleft lip and palate. Data Sources Medline (1946-2015), Embase (1980-2015), and EBM Reviews (Cochrane Central Register of Controlled). Review Methods Data sources were searched for publications that described the results of early ventilation tube placement in children with CLP prior to cleft palate repair. Two independent reviewers appraised the selected studies. Results Of 226 studies identified, 6 studies met the inclusion criteria. Early ventilation tube insertion in CLP gave similar speech and audiology outcomes to non-CLP children undergoing ventilation tube insertion and better outcomes than those children with CLP having later ventilation tube insertion at or after the time of palate closure. The main reported side effect was otorrhea, being higher for children with CLP having early ventilation tube insertion (67% vs 33%), with a reduction in otorrhea with increasing age. Larger studies with longer-term outcome reporting are required to fully address the study objectives. Conclusion Published data are limited but appear to support early insertion of ventilation tubes in children with CLP to restore middle ear function and maximize audiologic and speech outcomes.

How Well Are We Doing at Teaching Critical Appraisal Skills to Our Residents? A Needs Assessment of Plastic Surgery Journal Club

In the current issue of Plastic Surgery, the authors have given us some insight into the epidemiology and management of dog bite injuries in children. While attempts were made by the authors to correlate dog breed with the incidence of dog bite injuries, the paper continues to highlight the inadequacy of data in the current literature to make an inference on the etiology of such injuries and, specifically, if they’re a problem of nature or nurture.