Ricardo J. Bello

Comprehensive Observations of Resident Evolution: A Novel Method for Assessing Procedure-Based Residency Training

Background: Assessment of surgical skills in the operating room remains a challenge. Increasing documentation requirements of the Accreditation Council for Graduate Medical Education are necessitating mechanisms to document trainee competence without hindering operative turnover. The authors created a comprehensive electronic resource to facilitate plastic surgery training program compliance with changes mandated by Next Accreditation System Milestones and the ACGME. Methods: In 2013, the authors implemented the Comprehensive Observations of Resident Evolution, or CORE, a Web-based tool to assess plastic surgery residents. It comprises a rapid electronic assessment of resident operating room performance completed after each surgery; a data dashboard displaying graphical summaries of resident progress by case, Milestone, or current procedural terminology code; and an electronic Milestones tracker (MileMarker), which enables ongoing trainee assessments. Results: From January through October of 2014, 24 residents completed nearly 1300 Operative Entrustability Assessments. Thirty-eight percent of residents reported more immediate feedback regarding operative performance. The assessment demonstrates construct validity, which distinguishes novice residents from experienced residents. Individual case data identify resident-specific operative strengths and weaknesses. Using assessment data, the first two Clinical Competency Committee reviews were 81 percent and 87 percent shorter than Milestones pilot test site reports (average, 11.5 and 8 minutes versus 60 minutes per resident, respectively). Conclusions: Comprehensive Observations of Resident Evolution is capable of capturing operative performance data on all operating room cases by primary current procedural terminology code. It increases immediate attending/trainee feedback and assessment transparency, enables trainee self-monitoring, and informs end-of-rotation reviews, programwide assessments, and tailoring of training to address specific needs. It is a valuable resource for tracking resident progress in real-time while maintaining compliance with evolving ACGME requirements.

Systematic Review of the Surgical Treatment of Extremity Lymphedema

Background Although conservative management of lymphedema remains the first‐line approach, surgery is effective in select patients. The purpose of this study was to review the literature and develop a treatment algorithm based on the highest quality lymphedema research. Methods A systematic literature review was performed to examine the surgical treatments for lymphedema. Studies were categorized into five groups describing excision, liposuction, lymphovenous anastomosis (LVA), vascularized lymph node transfer (VLNT), and combined/multiple approaches. Studies were scored for methodological quality using the methodological index for nonrandomized studies (MINORS) scoring system. Results A total of 69 articles met inclusion criteria and were assigned MINORS scores with a maximum score of 16 or 24 for noncomparative or comparative studies, respectively. The average MINORS scores using noncomparative criteria were 12.1 for excision, 13.2 for liposuction, 12.6 for LVA, 13.1 for VLNT, and 13.5 for combined/multiple approaches. Loss to follow‐up was the most common cause of low scores. Thirty‐nine studies scoring > 12/16 or > 19/24 were considered high quality. In studies measuring excess volume reduction, the mean reduction was 96.6% (95% confidence interval [CI]: 86.2–107%) for liposuction, 33.1% (95% CI: 14.4–51.9%) for LVA, and 26.4% (95% CI: − 7.98 to 60.8%) for VLNT. Included excision articles did not report excess volume reduction. Conclusion Although the overall quality of lymphedema literature is fair, the MINORS scoring system is an effective method to isolate high‐quality studies. These studies were used to develop an evidence‐based algorithm to guide clinical practice. Further studies with a particular focus on patient follow‐up will improve the validity of lymphedema surgery research.

The Therapeutic Efficacy of Botulinum Toxin in Treating Scleroderma-Associated Raynaud's Phenomenon: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial

To assess the therapeutic efficacy of local injections of botulinum toxin type A (Btx‐A) in improving blood flow to the hands of patients with Raynauds phenomenon (RP) secondary to scleroderma.

Efficacy of Monitoring Devices in Support of Prevention of Pressure Injuries: Systematic Review and Meta-analysis.

GENERAL PURPOSE:To present a systematic review of the literature assessing the efficacy of monitoring devices for reducing the risk of developing pressure injuries. TARGET AUDIENCE:This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES:After participating in this educational activity, the participant should be better able to:1. Explain the methodology of the literature review and its results.2. Discuss the scope of the problem and the implications of the research. ABSTRACTOBJECTIVE: To assess the efficacy of monitoring devices for reducing the risk of developing pressure injuries (PIs).DATA SOURCES: The authors systematically reviewed the literature by searching PubMed/MEDLINE and CINAHL databases through January 2016.STUDY SELECTION: Articles included clinical trials and cohort studies that tested monitoring devices, evaluating PI risk factors on patients in acute and skilled nursing settings. The articles were scored using the Methodological Index for Non-randomized Studies.DATA EXTRACTION: Using a standardized extraction form, the authors extracted patient inclusion/exclusion criteria, care setting, key baseline, description of monitoring device and methodology, number of patients included in each group, description of any standard of care, follow-up period, and outcomes.DATA SYNTHESIS: Of the identified 1866 publications, 9 met the inclusion criteria. The high-quality studies averaged Methodological Index for Non-randomized Studies scores of 19.4 for clinical trials and 12.2 for observational studies. These studies evaluated monitoring devices that measured interface pressure, subdermal tissue stress, motion, and moisture. Most studies found a statistically significant decrease in PIs; 2 studies were eligible for meta-analysis, demonstrating that use of monitoring devices was associated with an 88% reduction in the risk of developing PIs (Mantel-Haenszel risk ratio, 0.12; 95% confidence interval, 0.04–0.41; I2 = 0%).CONCLUSIONS: Pressure injury monitoring devices are associated with a strong reduction in the risk of developing PIs. These devices provide clinicians and patients with critical information to implement prevention guidelines. Randomized controlled trials would help assess which technologies are most effective at reducing the risk of developing PIs.

The Effect of Resident Involvement on Postoperative Short-Term Surgical Outcomes in Immediate Breast Reconstruction: A National Surgical Quality Improvement Program Study of 24,005 Patients

Background: The association between resident involvement and surgical morbidity in immediate breast reconstruction is not fully elucidated, and prior studies have had conflicting results. The authors studied whether resident involvement in immediate breast reconstruction is associated with the most important short-term outcomes: increased 30-day surgical morbidity, readmission and reoperation rates, operative time, and length of stay. Methods: Patients undergoing immediate breast reconstruction were identified in the 2005 to 2012 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files. The authors used simple and multivariable regression to assess surgical complications and secondary outcomes, stratifying by training level and reconstruction type. Results: A total of 24,191 patients underwent immediate breast reconstruction; 17,840 had resident involvement. Thirty-day surgical morbidity was observed in 5.25 percent (95 percent CI, 4.92 to 5.58 percent) of cases with resident involvement and 5.12 percent (95 percent CI, 4.59 to 5.58 percent) of cases without, with no evidence of association between resident involvement and 30-day morbidity (adjusted OR, 0.97; 95 percent CI, 0.85 to 1.11; p = 0.652). Resident involvement was not associated with an increase in complications in implant-based or mixed types of reconstruction, and was associated with lower odds of complications in autologous reconstructions (OR, 0.70; 95 percent CI, 0.53 to 0.91; p = 0.008). It was associated with longer operative times (an average of 24 additional minutes for implant-based and 54 additional minutes for autologous reconstructions; p < 0.001); this was balanced by a shorter length-of-stay for patients undergoing implant-based reconstruction (adjusted OR, 0.88; 95 percent CI, 0.79 to 0.96; p = 0.010). Conclusion: In immediate breast reconstruction patients, resident involvement was not associated with increased postoperative surgical morbidity or complications, although operative time was significantly increased with resident involvement across all levels of training. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

CORE: A Novel Method for Assessing Procedure-Based Residency Training.

BACKGROUNDnAssessing operative skills in the OR remains challenging. Increasing ACGME documentation requirements are necessitating mechanisms capable of documenting trainee competence without hindering operative turnover. Therefore, we created a comprehensive electronic resource facilitating plastic surgery training program compliance with Next Accreditation System Milestones and ACGME-mandated changes.nnnMETHODSnIn 2013 we implemented the Comprehensive Observations of Resident Evolution (CORE), a web-based tool to assess plastic surgery residents. CORE comprises a rapid electronic assessment of resident OR performance completed after each surgery; a data dashboard displaying graphical summaries of resident progress by case, Milestone, or CPT code; and an electronic Milestones tracker (MileMarker©) enabling ongoing trainee assessments.nnnRESULTSnFrom January-October 31, 2014, nearly 1,300 Operative Entrustability Assessments (OEAs) were completed by 24 residents. Thirty-eight percent of residents reported more immediate feedback regarding operative performance. The OEA demonstrates construct validity, distinguishing novice from experienced residents. Individual case data identifies resident-specific operative strengths and weaknesses. Using OEA data, our first two Clinical Competency Committee reviews were 81% and 87% shorter than Milestones pilot test site reports (avg: 11.5 and 8 min. vs. 60 min. per resident, respectively).nnnCONCLUSIONSnCORE is capable of capturing operative performance data on all OR cases by primary CPT code. It increases immediate attending/trainee feedback and assessment transparency, enables trainee self-monitoring, and informs end-of-rotation reviews, program-wide assessments, and tailoring of training to address specific needs. These features make CORE a valuable resource through which programs and trainees can track resident progress in real-time while maintaining compliance with evolving ACGME requirements.

Pressure ulcer prevalence and perceptions on prevention: A hospital-wide survey of health professionals

OBJECTIVEnHospital-acquired pressure ulcers (HAPUs) remain a problem despite numerous prevention initiatives. To understand why, it is necessary to know health professionals perceptions regarding the importance of prevention, and the usability of current initiatives. We hypothesised that positive perceptions of existing initiatives would not be correlated with low HAPU prevalence, and that health professionals would perceive the initiatives to have a low usability.nnnMETHODnA two-part, online survey was developed and distributed electronically to nurses, in-training physicians and attending physicians, across all inpatient and perioperative departments of an academic hospital. Part one of the survey was the Agency for Healthcare Research and Quality (AHRQ) Staff Attitude Scale on beliefs regarding PU prevention; part two was additional questions on the usability of existing preventative initiatives. The results of the survey were compared with quarterly HAPU prevalence data by hospital unit.nnnRESULTSnIn total, 839 health professionals completed the survey (579 nurses, 131 residents, 119 attending physicians). The mean score for the AHRQ survey was 42.5 (≥40 denoting positive perceptions). There was a moderate correlation between AHRQ scores and prevalence of HAPUs (r=-0.60, p=0.402). For usability, repositioning was felt to be the most effective intervention (mean: 4.54, standard deviation (SD): 0.64), while educational posters were felt to be the least effective (mean: 3.31, SD: 0.99). Respondents generally rated satisfaction much lower, with no single initiative significantly better than the others (range: 3.21-3.79). Perceived effectiveness and satisfaction were all positively correlated.nnnCONCLUSIONnHigh HAPU prevalence, despite position perceptions, suggests that prevention methods are not as effective as thought, or they are not being used as widely as they should. Further research should take advantage of positive attitudes by prospectively investigating the usability of novel interventions.

Understanding Surgical Resident and Fellow Perspectives on Their Operative Performance Feedback Needs: A Qualitative Study

OBJECTIVEnOperative performance feedback is essential for surgical training. We aimed to understand surgical trainees views on their operative performance feedback needs and to characterize feedback to elucidate factors affecting its value from the resident perspective.nnnDESIGNnUsing a qualitative research approach, 2 research fellows conducted semistructured, one-on-one interviews with surgical trainees. We analyzed recurring themes generated during interviews related to feedback characteristics, as well as the extent to which performance rating tools can help meet trainees operative feedback needs.nnnSETTINGnDepartments or divisions of general or plastic surgery at 9 US academic institutions.nnnPARTICIPANTSnSurgical residents and clinical fellows in general or plastic surgery.nnnRESULTSnWe conducted 30 interviews with 9 junior residents, 14 senior residents, and 7 clinical fellows. Eighteen (60%) participants were in plastic and 12 (40%) were in general surgery. Twenty-four participants (80%) reported feedback as very or extremely important during surgical training. All trainees stated that verbal, face-to-face feedback is the most valuable, especially if occurring during (92%) or immediately after (65%) cases. Of those trainees using performance rating tools (74%), most (57%) expressed positive views about them but wanted the tools to complement and not replace verbal feedback in surgical education. Trainees value feedback more if received within 1 week or the case.nnnCONCLUSIONSnVerbal, face-to-face feedback is very or extremely important to surgical trainees. Residents and fellows prefer to receive feedback during or immediately after a case and continue to value feedback if received within 1 week of the event. Performance rating tools can be useful for providing formative feedback and documentation but should not replace verbal, face-to-face feedback. Considering trainee views on feedback may help reduce perceived gaps in feedback demand-versus-supply in surgical training, which may be essential to overcoming current challenges in surgical education.

Breast reconstruction and risk of arm lymphedema development: A meta-analysis

BACKGROUNDnLymphedema remains a significant complication following breast cancer surgery when there is axillary lymph node intervention. Previous systematic reviews have identified risk factors for breast cancer-related lymphedema, including increased BMI, number of lymph nodes dissected and radiotherapy. However, they have not examined the effect of breast reconstruction on lymphedema occurrence. In this systematic review and meta-analysis, we sought to evaluate the association between breast reconstruction (BR) and lymphedema.nnnMETHODSnWe searched PubMed (1966-2016), Embase (1966-2016), Scopus (2004-2016) and Google Scholar (2004-2016) for studies involving breast reconstruction and upper-extremity lymphedema or breast cancer-related lymphedema. Our primary outcome was lymphedema occurrence. We performed a meta-analysis using random effects due to heterogeneity of the studies.nnnRESULTSnOur search strategy identified 934 articles. After screening, 19 studies were included in our meta-analysis evaluating outcomes based on number of patients (7501) or number of breasts surgically treated (2063). Breast reconstruction was significantly associated with lower odds of lymphedema (pu2009<u20090.001) compared to mastectomy only or breast-conserving surgery. Lymphedema rates were not statistically significantly different between patients undergoing implant-based or autologous BR.nnnCONCLUSIONSnBreast reconstruction is associated with lower rates of lymphedema compared to mastectomy only or breast conserving surgery patients. Although the study does not prove causation, we hypothesize that this association is likely due to multiple factors, including a self-selecting population and mechanisms through which BR may contribute to primary or secondary prevention of lymphedema. Further prospective studies are needed to clarify this beneficial relationship between breast reconstruction and reduced lymphedema risk.

The Ethics of Hand Transplantation: A Systematic Review

PURPOSEnWe conducted a systematic review to document ethical concerns regarding human upper extremity (UE) allotransplantation and how these concerns have changed over time.nnnMETHODSnWe performed a systematic review of 5 databases to find manuscripts addressing ethical concerns related to UE allotransplantation. Inclusion criteria were papers that were on the topic of UE allotransplantation, and related ethical concerns, written in English. We extracted and categorized ethical themes under the 4 principles of bioethics: Autonomy, Beneficence, Nonmaleficence, and Justice. We assessed theme frequency by publication year using Joinpoint regression, analyzing temporal trends, and estimating annual percent change.nnnRESULTSnWe identified 474 citations; 49 articles were included in the final analysis. Publication years were 1998 to 2015 (mean, 3 publications/y; range, 0-7 publications/y). Nonmaleficence was mostxa0often addressed (46 of 49 papers; 94%) followed by autonomy (36 of 49; 74%), beneficence (35 of 49; 71%), and justice (31 of 49; 63%). Of the 14 most common themes, only Need for Morexa0Research/Data (nonmaleficence) demonstrated a significant increase from 1998 toxa02002.nnnCONCLUSIONSnUpper extremity transplantation is an appealing reconstructive option for patients and physicians. Its life-enhancing (vs life-saving) nature and requirement for long-term immunosuppression have generated much ethical debate. Availability of human data has influenced ethical concerns over time. Our results indicate that discussion of ethical issues in the literature increased following publication of UE transplants and outcomes as well as after meetings of national societies and policy decisions by regulatory agencies.nnnCLINICAL RELEVANCEnBecause UE transplantation is not a life-saving procedure, much ethical debate has accompanied its evolution. It is important for UE surgeons considering referring patients for evaluation to be aware of this discussion to fully educate patients and help them make informed treatment decisions.