Sarah E. Sasor

The Cost of Intraoperative Plastic Surgery Education

PURPOSE Within the surgical community, it is commonly accepted that the length and cost of a surgical case increase when a resident physician participates. Many accountable care organizations, however, believe the opposite, that is, resident assistance enhances efficiency and diminishes operative time. The purpose of this study is to determine the opportunity cost to the attending surgeon for intraoperative teaching during index plastic surgery cases. METHODS A single senior surgeons experience over a 7-year period was evaluated retrospectively for Current Procedural Terminology codes 40700 (repair of primary, unilateral cleft lip) and 42200 (palatoplasty). Variables collected include operative time, the presence or absence of a physician learner, and postgraduate year level. Statistical analysis was performed with the Kruskal-Wallis test using the S+ programming language. A cost analysis was performed to quantify the effect of longer operative times in terms of relative value units (RVUs) lost. RESULTS During the study period, a total of 45 patients had primary, unilateral cleft lip repair; 70 patients had cleft palate repair. Of those cases, 39 (87%) cleft lip repairs and 60 (86%) cleft palate repairs were performed with a resident or fellow present. There was a statistically significant difference in the amount of time required to perform either surgery with a physician learner than without, with operative times being 60% (p = 0.020) longer for cleft lip repair and 65% (p = 0.0016) longer for cleft palate repair. The results were further stratified based on level of training, with craniofacial fellows and plastic surgery residents (independent and integrated) compared separately. Cases where a craniofacial fellow was present required the longest operative times: 103% (p = 0.0012) longer for cleft lip repairs and 104% (p < 0.0001) longer for cleft palate repairs when compared with the senior surgeon operating alone. Using the 2011 physician work RVUs for these surgeries and the 2011 Medicare conversion factor for RVUs to dollars, the opportunity cost is over

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

275 per case per trainee for any physician learner. When craniofacial fellows are analyzed separately, over

Omental Vascularized Lymph Node Flap: A Radiographic Analysis

440 is invested in intraoperative teaching per case per fellow. CONCLUSIONS Resident involvement in the operating room is crucial to the education of independent surgeons. This involvement, however, comes at a significant opportunity cost to the attending surgeon. As an incentive to retain academic surgeons and uphold a quality academic environment in the OR, compensation should be offered for intraoperative teaching.

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

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.

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

Background Vascularized lymph node transfer is an increasingly popular option for the treatment of lymphedema. The omental donor site is advantageous for its copious soft tissue, well‐defined collateral circulation, and large number of available nodes, without the risk of iatrogenic lymphedema. The purpose of this study is to define the anatomy of the omental flap in the context of vascularized lymph node harvest. Methods Consecutive abdominal computed tomography angiography (CTA) images performed at a single institution over a 1‐year period were reviewed. Right gastroepiploic artery (RGEA) length, artery caliber, lymph node size, and lymph node location in relation to the artery were recorded. A two‐tailed Z ‐test was used to compare means. A Gaussian Mixture Model confirmed by normalized entropy criterion was used to calculate three‐dimensional lymph node cluster locations along the RGEA. Results In total, 156 CTA images met inclusion criteria. The RGEA caliber at its origin was significantly larger in males compared with females (p < 0.001). An average of 3.1 (1.7) lymph nodes were present per patient. There was no significant gender difference in the number of lymph nodes identified. Average lymph node size was significantly larger in males (4.9 [1.9] × 3.3 [0.6] mm in males vs. 4.5 [1.5] × 3.1 [0.5] mm in females; p < 0.001). Three distinct anatomical variations of the RGEA course were noted, each with a distinct lymph node clustering pattern. Total lymph node number and size did not differ among anatomical subgroups. Conclusion The omentum is a reliable lymph node donor site with consistent anatomy. This study serves as an aid in preoperative planning for vascularized lymph node transfer using the omental flap.

Complexity of online gender confirmation resources surpass patient literacy

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.

Pediatric pyoderma gangrenosum: is it just big wounds on little adults?

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.

Scholarly activity in academic plastic surgery: the gender difference

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.