Sherise Epstein

Prevalence of Work-Related Musculoskeletal Disorders Among Surgeons and Interventionalists: A Systematic Review and Meta-analysis

Importance Physicians in procedural specialties are at high risk for work-related musculoskeletal disorders (MSDs). This has been called “an impending epidemic” in the context of the looming workforce shortage; however, prevalence estimates vary by study. Objectives To estimate the prevalence of work-related MSDs among at-risk physicians and to evaluate the scope of preventive efforts. Data Sources and Study Selection Systematic search in MEDLINE (Ovid), Embase (Elsevier), Web of Science, PubMed (National Center for Biotechnology Information), and 2 clinical trial registries, without language restriction, for studies reporting on the prevalence and prevention of work-related MSDs among at-risk physicians published until December 2016. The Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines for meta-analyses and systematic reviews of observational studies were used. At-risk physicians were defined as surgeons and medical interventionalists. Studies reporting on specific disorders or pain assessed with validated instruments were included. Data Extraction and Synthesis Study characteristics; disease prevalence for the neck, shoulder, back, and upper extremity; and measures of resulting disability were recorded. Study estimates were pooled using random-effects meta-analytic models. Main Outcomes and Measures Career prevalence of injuries and 12-month prevalence of pain. Results Among 21 articles (5828 physicians [mean age, 46.0 years; 78.5% male; 12.8 years in practice; 14.4 hours performing procedures per week]) included in this systematic review and meta-analysis, pooled crude prevalence estimates of the most common work-related MSDs were degenerative cervical spine disease in 17% (457 of 2406 physicians) (95% CI, 12%-25%), rotator cuff pathology in 18% (300 of 1513 physicians) (95% CI, 13%-25%), degenerative lumbar spine disease in 19% (544 of 2449 physicians) (95% CI, 5%-16%), and carpal tunnel syndrome in 9% (256 of 2449 physicians) (95% CI, 5%-16%). From 1997 to 2015, the prevalence of degenerative cervical spine disease and degenerative lumbar spine disease increased by 18.3% and 27%, respectively. Pooled prevalence estimates for pain ranged from 35% to 60% and differed by assessment instrument. Of those with a work-related MSD, 12% (277 of 2319 physicians) (95% CI, 7%-18%) required a leave of absence, practice restriction or modification, or early retirement. Heterogeneity was considerable for all crude analyses (mean I2 = 93.5%) but was lower for sensitivity analyses (mean I2 = 72.3%). Interventions focused on products and behaviors. Twelve at-risk specialties described a gross lack of awareness and an unmet need for ergonomics education. Conclusions and Relevance Prevalence estimates of work-related MSDs among at-risk physicians appear to be high. Further research is needed to develop and validate an evidence-based applied ergonomics program aimed at preventing these disorders in this population.

Literacy analysis of National Comprehensive Cancer Network patient guidelines for the most common malignancies in the United States

Cancer information is of critical interest to the public. The National Comprehensive Cancer Network (NCCN) offers a series of comprehensive patient guidelines on the management of the most common cancer diagnoses. This study was aimed at assessing the health literacy demands of NCCN patient guidelines for the most common malignancies in the United States.

Work-Related Musculoskeletal Disorders among Plastic Surgeons: A Systematic Review

Background To date, no review has been conducted on the growing body of literature describing various work‐related musculoskeletal disorders (MSDs), ergonomic hazards, and potential interventions relevant to plastic surgeons. This systematic review sought to (1) define the scope of coverage of this important issue in the peer‐reviewed literature; (2) critically assess the evidence; and (3) provide recommendations for future directions. Methods We conducted a literature search of MEDLINE, Embase, Web of Science, and PubMed from the inception of each database until 2016. All articles reporting on work‐related MSDs or ergonomics among plastic surgeons were reviewed, summarized, and assessed for trends. Results Sixteen articles met our inclusion criteria including five expert opinions, four cross‐sectional studies and case reports/series, one review, and six experimental studies. Four articles presented evidence on disease burden. The most commonly described work‐related MSD was cervical spine disease, for which one study reported a career prevalence of 24.7% (point prevalence in the general population: 0.1‐0.4%); three studies reported 64 cases of surgeon work‐related MSD resulting in surgical intervention, decreased productivity, or involuntary early retirement. Eight studies described interventions, most of which aimed to improve the ergonomics of microsurgery. Conclusion This review found low‐level evidence of plastic surgeons’ vulnerability to a work‐related MSD at times severe enough to end careers. Further investigation is needed to clearly define this important problem in plastic surgery. Specifically, future directions should include more methodologically rigorous epidemiologic studies evaluating disease burden.

Conventional Versus Hypofractionated Radiation Therapy for Localized Prostate Cancer: A Meta-analysis of Randomized Noninferiority Trials

CONTEXT Whether hypofractionated radiation therapy (RT) compared with conventionally fractionated RT provides comparable or possibly improved cancer control without increased toxicity in localized prostate cancer (PC) remains unknown. OBJECTIVE Realizing from the CHHiP trial that outcomes are highly sensitive to the dose fractionation schedule and number of treatments, we conducted a systematic review and meta-analysis selecting only the randomized noninferiority trials, because the randomized arms closely approximated one another in terms of the dose fractionation schedule, and compared cancer control and toxicity of hypofractionated RT with conventionally fractionated RT for localized PC. EVIDENCE ACQUISITION Randomized noninferiority trials evaluating hypofractionated (2.4-4Gy daily fractions for 15-30 treatments) versus conventionally fractionated RT (1.8-2Gy daily fractions for 40-45 treatments) in men with localized PC were selected. Studies that were not noninferiority trials, used extreme hypofractionation, or treated metastatic disease were excluded. Three studies were retained for analysis. Data were pooled using a random-effects model to determine hazard ratio (HR) and risk ratio (RR). Heterogeneity was assessed via chi-square test, I2 statistics, and metaregression. The primary outcome was disease-free survival (DFS), defined as death from any cause or biochemical, local, regional, or distant progression. EVIDENCE SYNTHESIS Of the 5484 men, 3553 (64.8%) had intermediate-risk PC. Hypofractionated RT as compared with conventionally fractionated RT was associated with significantly improved DFS (HR 0.869; 95% confidence interval [CI], 0.757, 0.998; p=0.047), whereas overall survival was not (HR 0.84; 95% CI, 0.66, 1.07; p=0.16). Acute grade 2 or higher gastrointestinal toxicity was significantly increased with hypofractionation (RR 1.42; 95% CI 1.15, 1.77; p=0.002); however, this did not translate into late grade 2 or higher gastrointestinal toxicity. An increase in late grade 2 or higher genitourinary complications was observed (RR 1.18; 95% CI 0.98, 1.43; p=0.08). CONCLUSIONS Hypofractionated RT as compared with conventionally fractionated RT could improve DFS in men with intermediate-risk PC and, therefore, would be reasonable to consider in men who do not have risk factors for late genitourinary complications. PATIENT SUMMARY Treatment with a shorter course of radiation, using higher doses per treatment over fewer days, may be the preferred approach in appropriately selected patients with localized prostate cancer.

Fireworks Legislation and the Incidence of Severe Fireworks-Related Injuries in Washington State

Census data, and municipal coding provided by the State Fire Marshal data sources, we collected incidence data about patients with fireworks-related injuries admitted to Washington state’s only level 1 trauma center from 2005 to 2015. Primary Investigator: Sherise Epstein, MD, MPH (PGY1/R1) Study Team: Todd W. Lyons, MD MPH; Rahel Hintza; Brinkley K. Sandvall, MD; Ali Rowhani-Rahbar, MD, MPH, PhD; Monica S. Vavilala, MD; Kari A. Keys, MD

Racial disparities in postmastectomy breast reconstruction: National trends in utilization from 2005 to 2014: Breast Reconstruction Racial Disparities

Evidence of racial disparities in the receipt of postmastectomy breast reconstruction is well documented. The objective of this study was to describe trends in racial disparities overall and by reconstructive technique.

Abstract: Implant-Based Breast Reconstruction and the Timing of Adjuvant Radiotherapy

CONCLUSIONS: These data show biosynthetic P4HB mesh to be a safe alternative to ADM in expander-based breast reconstruction, with trends toward decreased rates of infection and need for device removal using P4HB mesh. There was also a trend toward decreased infection rates in P4HB patients that were not radiated. Although our results are limited to a small series of initial patients, P4HB porous mesh may be a promising novel technique to decrease complications inherent to use of ADM.