Margaret E. Gatti

Relationships between beliefs about medications and adherence

PURPOSE The relationships between beliefs about medications, health literacy, and self-reported medication adherence are examined. METHODS Patients from an inner-city hospital pharmacy completed an in-person, interviewer-assisted questionnaire that included the Morisky 8-item Medication Adherence Scale (MMAS-8), the Beliefs About Medicines Questionnaire (BMQ), and the Rapid Estimate of Adult Literacy in Medicine (REALM). Multivariable logistic regression was used to determine predictors of self-reported medication adherence as determined by the MMAS-8. Variables included in the model were summary scores from the BMQ, REALM, and patient or regimen characteristics that were significantly associated with the MMAS-8. RESULTS A majority of the 275 study participants were African-American (86.2%), were women (73.1%), and could read at less than a high school reading level (59.7%). The average age was 53.9 years. Approximately half of the patients (52.7%) reported low medication adherence (MMAS-8 score of >2). Multivariate analyses indicated several factors were associated with low self-reported adherence, including negative beliefs about medications, younger age, low medication self-efficacy, and hyperlipidemia. Health literacy was not independently associated with beliefs or adherence. CONCLUSION Patients who had negative beliefs about medications, who were <65 years of age, or who had low medication self-efficacy reported low medication adherence.

Development and Evaluation of the Adherence to Refills and Medications Scale (ARMS) among Low-Literacy Patients with Chronic Disease

OBJECTIVES Patient literacy affects many aspects of medication use and may influence the measurement of adherence. The aim of the study is to design and evaluate a medication adherence scale suitable for use across levels of patient literacy. METHODS The Adherence to Refills and Medications scale (ARMS) was developed, pilot tested, and administered to 435 patients with coronary heart disease in an inner-city primary care clinic. Psychometric evaluation performed overall and by literacy level, included an assessment of internal consistency, test-retest reliability, and factor analysis. Criterion-related validity was evaluated by comparing scores with Moriskys self-reported measure of adherence, medication refill adherence, and blood pressure measurements. Lexile analysis was performed to assess the reading difficulty of the instrument. RESULTS The final 12-item scale had high internal consistency overall (Cronbachs alpha = 0.814) and among patients with inadequate (alpha = 0.792) or marginal/adequate literacy skills (alpha = 0.828). Factor analysis yielded two subscales, which pertained to taking medications as prescribed and refilling medications on schedule. The ARMS correlated significantly with the Morisky adherence scale (Spearmans rho = -0.651, P < 0.01), and it correlated more strongly with measures of refill adherence than did the Morisky scale. Patients with low ARMS scores (which indicated better adherence) were significantly more likely to have controlled diastolic blood pressure (P < 0.05), and tended to have better systolic blood pressure control. Lexile analysis demonstrated that the instrument had a favorable reading difficulty level below the eight grade. CONCLUSION The ARMS is a valid and reliable medication adherence scale when used in a chronic disease population, with good performance characteristics even among low-literacy patients.

Indications and outcomes following complex abdominal reconstruction with component separation combined with porcine acellular dermal matrix reinforcement.

PurposeComponent separation (CS) is an effective technique for complex abdominal wall reconstruction (AWR). Reinforcement of the repair with mesh can add durability. The purpose of this study was to evaluate the indications and outcomes following CS combined with a porcine acellular dermal matrix (PADM) for reinforcement. MethodsA retrospective review of all patients who underwent complex AWR at the authors’ institution was completed between 2007 and 2010. Patients with complex hernias who underwent CS in conjunction with PADM as an underlay were included. The PADM used in this cohort was Strattice (LifeCell Corporation, Branchburg, NJ). Patient demographics, indications, perioperative details, postoperative care, and long-term outcomes were reviewed. ResultsA total of 78 patients were identified as having PADM implanted for AWR. Of this cohort, 41 patients met the criteria as having a CS to achieve midline closure, with the PADM placed as reinforcement in an underlay manner. These patients were classified as grade II (33; 80.5%), grade III (4; 9.8%), and grade IV (4; 9.8%). Average patient age was 57.6 years (range, 33–80), and average body mass index (BMI) was 35.8 kg/m2 (range, 21.6–52.1). Patient comorbidities included coronary artery disease (19; 46.3%), diabetes mellitus (14; 34.2%), chronic obstructive pulmonary disease (COPD) (6; 14.6%), and chronic steroid use (2; 4.9%). Previous mesh infection occurred in 9 (28.1%). The mean defect diameter was found to be 14.3 cm. Perforator preservation of the subcutaneous flaps was performed in 34 (82.9%) patients. A concomitant panniculectomy was performed in 9 (22%) patients. A staged approach was used in 3 (7.3%) patients. The overall complication rate was 24.4%. Strattice exposure occurred in 5 (12.2%) patients. All patients went on to heal wounds without explantation.No hernia recurrences or symptomatic bulges were observed in the follow-up period of 474 days (range, 194–1017 days). No significant predictors of complications were identified. ConclusionsStrattice is an effective adjunct to AWR when used as reinforcement during CS for a wide variety of indications. Complication rates remain low in complex patients. In addition, Strattice appears to add durability to midline reconstructions with no recurrences during the follow-up period.

Effect of Incision Choice on Outcomes in Primary Breast Augmentation

BACKGROUND Capsular contracture (CC) is the most common complication following primary breast augmentation and one of the most common causes of reoperation. Various studies have suggested certain risk factors, including incision choice. OBJECTIVES The authors investigate a possible association between the three most common breast augmentation incisions (inframammary, periareolar, and transaxillary) and CC. METHODS The authors conducted a retrospective chart review of 197 primary breast augmentation patients treated between 2003 and 2009. Significant CC was determined to have occurred if the patient required reoperation for her CC. Patients were excluded if they underwent an augmentation/mastopexy, had previously undergone breast surgery, or received shaped silicone gel implants. CC rates were analyzed on a per-patient basis with Fishers exact test and on a per-breast basis with the Rao-Scott chi-squared test. RESULTS One hundred eighty-three patients (336 augmented breasts) were included. Average patient age was 36.5 years. Mean follow-up was 392.6 days. Surgical complications included six breasts with CC (1.8%), three with hematoma (0.9%), and one with an infection (0.3%). Transaxillary incisions produced the highest incidence of contracture (6.4%), followed by periareolar (2.4%) and inframammary (0.5%). There was a statistically-significant difference in the incidence of CC among the three incision sites (P=.03). The increased rate seen with transaxillary incisions versus inframammary incisions was also statistically-significant. No significant association between implant fill material and contracture was found (P=.27). CONCLUSIONS The risk of CC is significantly higher with transaxillary incisions than with periareolar or inframammary incisions. LEVEL OF EVIDENCE 4.

A head-to-head comparison of quality of life and aesthetic outcomes following immediate, staged-immediate, and delayed oncoplastic reduction mammaplasty.

Background: Oncoplastic reduction mammaplasty offers patients breast conservation with the added benefit of functional improvement in symptoms related to macromastia. The reduction can be performed in the immediate setting with the lumpectomy, in a staged-immediate fashion after final pathology has been confirmed or in a delayed fashion after completion of both lumpectomy and radiation. This study compared quality of life and aesthetic outcomes for these different cohorts. Methods: A retrospective review was carried out on 16 consecutive patients who had oncoplastic reduction mammaplasty by the senior author (M.Y.N.) between 2003 and 2009. Demographics, oncologic treatment and timing, and reduction techniques were recorded. Patients were asked to complete a questionnaire to assess quality of life and satisfaction. Preoperative and postoperative photographs were evaluated by 15 reviewers. Results: Over a 7-year period, five patients had immediate, six had staged-immediate, and five had delayed reduction mammaplasty. Mean patient age was 52.5 years, and mean body mass index was 31.5. The average timing of reduction was 0, 49, and 734 days for the three groups. Positive margins occurred in two patients, leading to completion mastectomy. In addition, one patient in the staged-immediate group had a recurrence that led to completion mastectomy. Complications occurred in seven (44 percent) of 16 patients. Questionnaire response was 75 percent (12 of 16), showing positive scores in all groups but no statistical significance. Objective aesthetic evaluation also revealed significant improvements within groups comparing various preoperative to postoperative parameters. Importantly, aesthetic scores for the delayed group were consistently lower across all aspects but did not reach significance. Conclusion: Oncoplastic reduction mammaplasty can be safe and effective in carefully selected patients in the immediate, staged-immediate, and delayed settings.

Occupational Injury in Plastic Surgeons

BACKGROUND Little research to date has investigated musculoskeletal injury in the surgical workforce. This study estimates the prevalence and functional impact of work-related injury in plastic surgeons and other surgical specialists. METHODS A validated self-assessment of work-related injury was administered to surgeons at various professional conferences, over the telephone, and via email. Prevalence rates for each injury were tabulated, and a regression analysis was conducted to identify potential associations between demographic risk factors and self-reported injury. RESULTS Of 500 surveys administered, 339 (67.8 percent) were returned. Musculoskeletal symptoms were observed in 81.5 percent of surveyed surgeons. Of 17 injuries of interest, the most prevalent conditions were muscle strain, vision changes, cervical pain, lumbar pain, and shoulder arthritis/bursitis. Carpal tunnel syndrome and epicondylitis were reported by 15.1 and 13.5 percent of respondents, respectively, more than three times general population prevalence rates. Years in practice were associated with carpal tunnel syndrome. Microscope usage of 3 hours or more per week was associated with cervical and thoracic pain. Hand surgeons appeared to be more prone to thumb arthritis than other specialties. CONCLUSIONS Self-reported injury is more prevalent in surgery than in previously described, labor-intensive populations. Sampled surgeons appear younger than the general surgery workforce, and as a result, this study may underestimate the prevalence of occupational injury, particularly carpal tunnel syndrome. This study underscores the need for a formal, multicenter assessment of occupational injury in surgeons.

Management of massive mastectomy skin flap necrosis following autologous breast reconstruction.

BackgroundThe optimal management of severe mastectomy skin flap necrosis continues to remain a challenge. Following autologous reconstruction, small or minor areas of ischemia/tissue necrosis can result in multiple office visits, increased expenses due to dressing supplies and nursing care, and revisional operations. The purpose of this study is to describe outcomes of a common management strategy for surgeons when confronted with a patient with extensive mastectomy skin flap necrosis. MethodsBetween 1997 and 2010, autologous breast reconstructions were performed in 805 women and 1076 breasts. Of these, 12 patients (15 breasts) were identified who met the criteria for massive skin flap loss (>30%). Patient photographs and wound measurements were used to estimate areas of necrosis. All patients were managed initially with local wound care followed by delayed scar excision. ResultsWound closure was ultimately achieved in all patients. Of the patients, 40% were active smokers in the perioperative period. The average patient age was 49.6 (range, 28–59) years with a body mass index of 30.9. The average mastectomy weight was 959.5 g (range, 223–1520). In-office soft-tissue debridement and local wound care was performed until wound closure was complete, which took place at a mean of 120 days (range, 30–300) after initial surgery. The average patient had a mean of 10 office visits before scar revision. There was an average of 1.7 types of dressing changes needed before wound closure. Topical wound therapy included moisturizing gels, wet-to-dry dressing, and antibiotic ointment. Oral antibiotic therapy was used in 60% of patients. Late scar revision was performed in 87% of the patients at an average of 8.9 months (range, 1–14) after initial surgery. After the initial flap surgery, no patient required skin grafting or hospitalization. ConclusionsEarly conservative management followed by late scar revision produced excellent results in patients with massive mastectomy skin flap loss. The outcomes described may help clinicians and patients in the decision-making process when confronted with this difficult problem.

Sports Participation and Alcohol use Among Adolescents: The Impact of Measurement and Other Research Design Elements

INTRODUCTION Sports participation, while offering numerous developmental benefits for adolescents, has been associated with alcohol use in prior research. However, the relationship between sports participation and alcohol use among adolescents remains unclear, particularly how research design elements impact evidence of this relationship. We reviewed the evidence regarding sports participation and alcohol use among adolescents, with a focus on examining the potential impact of research design elements on this evidence. METHODS Studies were assessed for eligibility and coded based on research design elements including: study design, sampling method, sample size, and measures of sports participation and alcohol use. RESULTS Fifty-four studies were assessed for eligibility, 29 of which were included in the review. Nearly two-thirds used a cross-sectional design and a random sampling method, with sample sizes ranging from 178 to 50,168 adolescents (Median = 1,769). Sixteen studies used a categorical measure of sports participation, while 7 applied an index-type measure and 6 employed some other measure of sports participation. Most studies assessed alcohol-related behaviors (n = 18) through categorical measures, while only 6 applied frequency only measures of alcohol use, 1 study applied quantity only measures, and 3 studies used quantity and frequency measures. CONCLUSIONS Sports participation has been defined and measured in various ways, most of which do not differentiate between interscholastic and community-based contexts, confounding this relationship. Stronger measures of both sports participation and alcohol use need to be applied in future studies to advance our understanding of this relationship among youths.

The Association of Mode of Delivery and Common Childhood Illnesses

Participants enrolled in a randomized control trial (RCT) were eligible for this cross-sectional study to determine if children born via cesarean (C)-section had higher rates of common infectious diseases and change in normal daily activities due to illness than children born vaginally. The RCT collected parent-reported health information and mode of delivery was assessed during follow-up calls. Parent-reported rates of infectious sequelae and changes in daily activities were compared between C-section and vaginally delivered children. In total, 72.4% of the 522 children were delivered vaginally. After accounting for age, siblings, breast-feeding as an infant, and clustering within families, C-section delivered children had significantly higher rates of cumulative infectious diseases, lower respiratory tract infections, and cough than vaginally born children. Mode of delivery appears to have some lasting effect on child health 3 to 6 years after birth, specifically respiratory health. Further research is imperative to elucidate the causative effect of mode of delivery on child health.

Factors Associated with Failed Hardware Salvage in High Risk Patients Following Microsurgical Lower Extremity Reconstruction

reSultS: 34 patients were identified, with an average followup of 2.6 years (0.3 – 7.0 years). Fifteen patients had successful salvage; 19 patients required hardware removal, representing a 55.9% failure rate. Comparison of patient demographics revealed similar surgical age, BMI, and co-morbidities between successful versus failed hardware salvage groups. Analysis of wound characteristics revealed significantly longer time to hardware coverage and longer duration of IV antibiotic coverage in failed versus successful hardware salvage patients (38.9 versus 9.3 weeks, p = 0.02; and 6.5 versus 4.1 weeks, p = 0.03, respectively). Initial wound cultures demonstrated a significantly higher positive growth with failed versus successful salvage (100.0% versus 57.1%, p = 0.003); the distribution of microbial flora on initial and final cultures was similar between groups. Initial pathology revealed higher frequency of chronic osteomyelitis in failed versus successful hardware salvage patients (66.7% versus 33.3%, p = 0.08); absence of osteomyelitis and presence of acute osteomyelitis were similar between groups.