Michael W. Chu

Age at Diagnosis as a Relative Contraindication for Intervention in Facial Nonmelanoma Skin Cancer

Author Affiliations: Center for Colon and Rectal Surgery, Florida Hospital, Orlando (Lee, Monson); Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio (Dietz); Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, New York (Fleming); Department of Surgery, New York University Langone Medical Center, New York (Remzi); Department of Colorectal Surgery, Cleveland Clinic Florida, Weston (Wexner); Division of Research and Optimal Patient Care (Cancer), American College of Surgeons, Chicago, Illinois (Winchester).

Facial Plastic Surgery Patient Resources Exceed National Institute Recommendations

Patient education is essential in enhancing the physician-patient therapeutic alliance, patient satisfaction, and clinical outcomes. The American Medical Association and National Institute of Health recommend that information be written at a 6th-grade reading level, but online resources often exceed patient literacy. The purpose of this study is to assess readability of online material for facial plastics procedures presented on academic plastic surgery and otolaryngology websites.An Internet search was performed of all academic institutions that had both plastic surgery and otolaryngology training programs who offered patient information on facial plastic surgery procedures. National society websites for both plastic surgery and otolaryngology were also analyzed. All procedural information was compiled and readability analyses were performed. A 2-tailed Z-test was used to compare scores, and statistical significance was set at P < 0.05.Sixty-three programs were identified; 42 had educational material. The overall average readability for all information was at a 10th-grade reading level. The national plastic surgery website had a significantly higher word count and number of syllables per word compared to the national otolaryngology website (P < 0.001, P = 0.04).The complexity of written resources represents an obstacle to online patient education and efforts to improve readability could benefit patients seeking medical information online. Current online education materials are a potential hindrance to patient education, satisfaction, and decision making. Healthcare institutions should consider writing new materials with simpler language that would be accessible to patients.Abstract Patient education is essential in enhancing the physician–patient therapeutic alliance, patient satisfaction, and clinical outcomes. The American Medical Association and National Institute of Health recommend that information be written at a 6th-grade reading level, but online resources often exceed patient literacy. The purpose of this study is to assess readability of online material for facial plastics procedures presented on academic plastic surgery and otolaryngology websites. An Internet search was performed of all academic institutions that had both plastic surgery and otolaryngology training programs who offered patient information on facial plastic surgery procedures. National society websites for both plastic surgery and otolaryngology were also analyzed. All procedural information was compiled and readability analyses were performed. A 2-tailed Z-test was used to compare scores, and statistical significance was set at P < 0.05. Sixty-three programs were identified; 42 had educational material. The overall average readability for all information was at a 10th-grade reading level. The national plastic surgery website had a significantly higher word count and number of syllables per word compared to the national otolaryngology website (P < 0.001, P = 0.04). The complexity of written resources represents an obstacle to online patient education and efforts to improve readability could benefit patients seeking medical information online. Current online education materials are a potential hindrance to patient education, satisfaction, and decision making. Healthcare institutions should consider writing new materials with simpler language that would be accessible to patients.

Pyoderma gangrenosum demographics, treatments, and outcomes: an analysis of 2,273 cases

OBJECTIVE Pyoderma gangrenosum is a rare, neutrophil-mediated, auto-inflammatory dermatosis. This condition has clinical features analogous to infectious processes and must be quickly diagnosed to be properly treated. The purpose of this study was to characterise relevant clinical features associated with pyoderma gangrenosum based on a large inpatient cohort. METHOD The National Inpatient Sample (US) was used to identify patients with the diagnosis of pyoderma gangrenosum using ICD-9 diagnosis code 686.01, during the years 2008-2010. Data was collected on demographics, associated diagnoses, treatments and outcomes. Data analysis was performed using SAS 9.3 software. RESULTS A total of 2,273 adult patients were identified with pyoderma gangrenosum. Mean age was 56 years; 66.4% were female; 71.1% were Caucasian. Pyoderma gangrenosum was the primary diagnosis in 22.6% of patients, followed by cellulitis (9.4%), inflammatory bowel disease (IBD) (6.9%), wound/ulcer (5.4%), sepsis (4.7%), and postoperative infection/complication (2.7%). The most common procedures performed were wound debridement (5.3%), skin biopsy (5.1%), esophagogastroduodenoscopy (2%), large bowel biopsy (1.9%), and incision and drainage (1.1%). A total of 74 patients (3.2%) died during hospitalisation. CONCLUSION Pyoderma gangrenosum is a serious skin condition, frequently associated with systemic disease, and often confused with other skin pathergies. Pyoderma gangrenosum should be considered when evaluating patients with ulcers, wounds, and post-operative complications. A high index of suspicion is necessary for early and accurate diagnosis and prompt treatment.

Abstract 20. Tourniquet vs. Epinephrine in Wide-Awake Carpal Tunnel Release

PURPOSE: Carpal tunnel syndrome is a common cause of upper extremity discomfort. Surgical release of the median nerve can be performed under general or local anesthetic, with or without a tourniquet. Wide-awake carpal tunnel release (CTR) (local anesthesia, no sedation) is gaining popularity. Tourniquet discomfort is a reported downside. This study reviews outcomes in wide-awake CTR and compares tourniquet versus no tourniquet use.

Treatment Options for Bilateral Autologous Breast Reconstruction in Patients with Inadequate Donor-Site Volume

More than 250,000 women will be diagnosed with invasive breast cancer in the United States in 2017 alone. A large number of these patients will undergo mastectomy and will be candidates for immediate breast reconstruction. The most common reconstructive options are either implant-based or autologous tissue reconstruction, with the latter having been reported to have higher rates of long-term patient satisfaction, lower cost, and less postoperative pain. A subset of patients, however, may not be ideal candidates for autologous microsurgical reconstruction, for example, due to inadequate abdominal tissues, yet they may desire this reconstructive modality. This is particularly challenging in patients requiring bilateral reconstructions. In this article, the authors discuss the various reconstructive modalities that can be considered in patients who desire bilateral breast reconstruction, are not ideal candidates for autologous reconstruction, yet do not wish to rely solely on implant-based modalities.

Complications and Cost Analysis of Intraoperative Arterial Complications in Head and Neck Free Flap Reconstruction

Background Microvascular anastomotic patency is fundamental to head and neck free flap reconstructive success. The aims of this study were to identify factors associated with intraoperative arterial anastomotic issues and analyze the impact on subsequent complications and cost in head and neck reconstruction. Methods A retrospective review was performed on all head and neck free flap reconstructions from 2005 to 2013. Patients with intraoperative, arterial anastomotic difficulties were compared with patients without. Postoperative outcomes and costs were analyzed to determine factors associated with microvascular arterial complications. A regression analysis was performed to control for confounders. Results Total 438 head and neck free flaps were performed, with 24 (5.5%) having intraoperative arterial complications. Patient groups and flap survival between the two groups were similar. Free flaps with arterial issues had higher rates of unplanned reoperations (p < 0.001), emergent take‐backs (p = 0.034), and major surgical (p = 0.002) and respiratory (p = 0.036) complications. The overall cost of reconstruction was nearly double in patients with arterial issues (p = 0.001). Regression analysis revealed that African American race (OR = 5.5, p < 0.009), use of vasopressors (OR = 6.0, p = 0.024), end‐to‐side venous anastomosis (OR = 4.0, p = 0.009), and use of internal fixation hardware (OR =3.5, p = 0.013) were significantly associated with arterial complications. Conclusion Intraoperative arterial complications may impact complications and overall cost of free flap head and neck reconstruction. Although some factors are nonmodifiable or unavoidable, microsurgeons should nonetheless be aware of the risk association. We recommend optimizing preoperative comorbidities and avoiding use of vasopressors in head and neck free flap cases to the extent possible.

Comparison of Neurologic Trauma and Motorcycle Helmet Use in Drivers vs Passengers

Comparison of Neurologic Trauma and Motorcycle Helmet Use in Drivers vs Passengers Tyler A. Evans, MD, Sarah Sasor, MD, Stephen Duquette, MD, Michael W. Chu, MD, Imtiaz Munshi, MD, MBA, Tahereh Soleimani, MD, MPH, and Sunil S. Tholpady, MD, PhD Indiana University School of Medicine, Indianapolis, Indiana Department of Surgery, R. L. Roudebush VA Medical Center, Indianapolis, Indiana R. L. Roudebush VA Medical Center, Indianapolis, Indiana Corresponding author. Article Information Corresponding Author: Sunil S. Tholpady, MD, PhD, Department of Surgery, R. L. Roudebush VA Medical Center, 705 Riley Hospital Dr, RI 2513, Indianapolis, IN 46202 (stholpad@iupui.edu). Published Online: November 15, 2017. doi:10.1001/jamasurg.2017.3163 Author Contributions: Drs Tholpady and Evans had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Evans, Duquette, Chu, Soleimani, Tholpady. Acquisition, analysis, or interpretation of data: Evans, Sasor, Munshi, Soleimani, Tholpady. Drafting of the manuscript: Evans, Tholpady. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Soleimani, Tholpady. Obtained funding: Tholpady. Administrative, technical, or material support: Evans, Tholpady. Supervision: Chu, Munshi, Tholpady. Conflict of Interest Disclosures: None reported. Meeting Presentation: This study was presented at the 2017 Association of VA Surgeons Annual Meeting, May 7, 2017, Houston, Texas. Received 2017 May 17; Accepted 2017 Jun 25. Copyright 2017 American Medical Association. All Rights Reserved.

Complexity of online gender confirmation resources surpass patient literacy

ABSTRACT Background: Increasing transgender health care coverage has resulted in easier access to gender confirmation surgery. Patients considering surgery consistently access medical information online to improve knowledge regarding surgical options, complications, recovery, and life after transitioning. As a result, national health institutes recommend that patient educational materials be written at a sixth-grade–reading level. The purpose of this study is to assess the complexity of online gender confirmation surgery information. Methods: An Internet search was performed using the key phrase “transgender surgery”. Health care and non–health care websites were evaluated for pertinent articles regarding gender confirmation surgery. Readability analyses were conducted using Flesch-Kincaid Grade Level, Gunning Fog Index, Coleman-Liau Index, Simple Measure of Gobbledygook Index, and Automated Readability Index. A two-tailed z test was used to compare means; significance was set at p ≤ 0.05. Results: A total of 108 articles from 87 websites were analyzed. The average readability for all online gender confirmation-surgery information was at an 11th-grade reading level. Materials written by health care entities were written at a 12th-grade–reading level compared to non–health care articles, which were written at a 10th-grade level (p < 0.001). Male-to-female surgery materials were written at a 12th-grade level, significantly higher than the 11th-grade reading level of female-to-male surgery materials (p = 0.04). Conclusion: Online information regarding gender confirmation surgery is written at a level that is too complex for patients to understand. Informational materials should be written at lower grade levels to improve patient education, informed consent, and outcomes.