Stephen P. Duquette

Does payer type influence pediatric burn outcomes? A national study using the Healthcare Cost and Utilization Project Kids' Inpatient Database

Pediatric burns are a considerable source of injury in the United States. Socioeconomic status has been demonstrated to influence other disease outcomes. The goal of this study was to analyze national pediatric burn outcomes based on payer type. A retrospective study was designed using the Kids’ Inpatient Database (KID), years 2000 to 2009. Patients 18 years of age and under with Major Diagnostic code number 22 for burn were included. A total of 22,965 patients were identified, estimating 37,856 discharges. Descriptive and bivariate statistics were performed. Multiple regression analysis was used to assess correlation of payer type with complications and length of stay (LOS). The majority of patients were Medicaid (52.3%). Medicaid patients were younger (4.25, P < .05), had a higher rate of being in the first quartile of their zipcode’s income (46.26%, P < .05), and contained a higher proportion of African-Americans (30.01%, P < .05). Overall complication rate was higher among Medicaid patients than private insurance and self-pay patients (6.64 vs 5.51 and 4.35%, respectively, P = .11). Logistic regression analysis of complications showed that Medicaid coverage (P < .001) was associated with complications. The geometric mean LOS among Medicaid patients was 3.7 days compared with private insurance (3.5 days) and self-pay patients (3.1 days). Medicaid patients had longer LOS and more complications. Regression analysis revealed that payer type was a factor in LOS and overall complication rate. Identifying dissimilar outcomes based on patient and injury characteristics is critical in providing information on how to improve those outcomes.

Do Plastic Surgery Programs with Integrated Residencies or Subspecialty Fellowships Have Increased Academic Productivity

Background: The aim of this study was to evaluate the effect of different surgical training pathways on the academic performance of plastic surgical divisions. Methods: Eighty-two academic parameters for 338 plastic surgeons (PS), 1737 general surgeons (GS), and 1689 specialist surgeons (SS) from the top 55 National Institutes of Health (NIH)-funded academic departments of surgery were examined using data gathered from websites, SCOPUS, and NIH Research Portfolio Online Reporting Tools. Results: The median size of a PS division was 7 faculty members. PS faculty had lower median publications (P)/citations (C) (ie, P/C) than GS and SS (PS: 25/328, GS: 35/607, and SS: 40/713, P < 0.05). Publication and citation differences were observed at all ranks: assistant professor (PS: 11/101, GS: 13/169, and SS: 19/249), associate professor (PS: 33/342, GS: 40/691, and SS: 44/780), and professor (PS: 57/968, GS: 97/2451, and SS: 101/2376). PS had a lower percentage of faculty with current/former NIH funding (PS: 13.5%, GS: 22.8%, and SS: 25.1%, P < 0.05). Academic productivity for PS faculty was improved in integrated programs. P/C for PS faculty from divisions with traditional 3-year fellowships was 19/153, integrated 6-year residency was 25/329, and both traditional and 6-year programs were 27/344, P < 0.05. Craniofacial and hand fellowships increased productivity within the integrated residency programs. P/C for programs with a craniofacial fellowship were 32/364 and for those that additionally had a hand fellowship were 45/536. PS faculty at divisions with integrated training programs also had a higher frequency of NIH funding. Conclusions: PS divisions vary in degree of academic productivity. Dramatically improved scholarly output is observed with integrated residency training programs and advanced specialty fellowships.

Does the Organization of Plastic Surgery Units into Independent Departments Affect Academic Productivity

Background: There is an increased push for plastic surgery units in the United States to become independent departments administered autonomously rather than as divisions of a multispecialty surgery department. The purpose of this research was to determine whether there are any quantifiable differences in the academic performance of departments versus divisions. Methods: Using a list of the plastic surgery units affiliated with the American Council of Academic Plastic Surgeons, unit Web sites were queried for departmental status and to obtain a list of affiliated faculty. Academic productivity was then quantified using the SCOPUS database. National Institutes of Health funding was determined through the Research Portfolio Online Reporting Tools database. Results: Plastic surgery departments were comparable to divisions in academic productivity, evidenced by a similar number of publications per faculty (38.9 versus 38.7; p = 0.94), number of citations per faculty (692 versus 761; p = 0.64), H-indices (9.9 versus 9.9; p = 0.99), and National Institutes of Health grants (3.25 versus 2.84; p = 0.80), including RO1 grants (1.33 versus 0.84; p = 0.53). There was a trend for departments to have a more equitable male-to-female ratio (2.8 versus 4.1; p = 0.06), and departments trained a greater number of integrated plastic surgery residents (9.0 versus 5.28; p = 0.03). Conclusion: This study demonstrates that the academic performance of independent plastic surgery departments is generally similar to divisions, but with nuanced distinctions.

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.

An alternative approach to combined autologous breast reconstruction with vascularized lymph node transfer

Dear Sirs, Post-mastectomy upper extremity lymphedema has been reported to occur in 24–49% of breast cancer patients (Becker et al., 2012). Factors such as congenital absence, extent of axillary surgery, radiation therapy, infection, and trauma can cause lymphatic obstruction or destruction, and subsequent lymphedema development. For patients with postmastectomy lymphedema who desire breast reconstruction, simultaneous deep inferior epigastric perforator (DIEP) flap with groin lymph node transfer (LNT) to the axilla has shown promising results (Nguyen, Chang, Suami, Chang, 2015). Because the groin donor site can cause iatrogenic lymphedema (Vignes, Blanchard, Yannoutsos, & Arrault, 2013), we propose an alternative approach of DIEP flap breast reconstruction with gastroepiploic LNT (GELNT) to treat upper extremity lymphedema following mastectomy. Our technique involves dissecting the DIEP flap(s) in the standard fashion with anastomosis to the internal mammary vessels. Once the abdominal flaps are dissected to the level of the xiphoid process, a 7 cm midline epigastric laparotomy incision is then made. Intraoperatively, gastroepiploic lymph nodes are identified using indocyanine green (ICG) lymphangiography. Starting at the scissura gastrica, dissection is carried along the greater curvature of the stomach to isolate the gastroepiploic vessels. The lymph node flap is then placed into the axilla, forearm, or wrist of the affected extremity (Figure 1). Identification of the lymph nodes using ICG permits division of the flap and bilevel vascularized LNT from single donor site and the distal edge of the lymph node flap is based on the left gastroepiploic vessel. We retrospectively studied five patients who underwent this combination procedure. There were no significant differences in patient demographics or comorbidities. All patients underwent preand postoperative volumetric measurements of the affected upper extremity above and below the elbow and above the wrist. Two patients received bi-level GELNT to the affected axilla and wrist, and three patients underwent single-level transfer. Average volumetric reduction rate was 28.72% at 1 month and 66.34% at 3 months postoperatively. There were no donor site postoperative complications. To our knowledge, two prior studies have described combined autologous breast reconstruction with VLNT from the groin to the axilla for treatment of lymphedema following mastectomy (Nguyen et al., 2015; Saaristo et al., 2012). Our approach differs with use of the gastroepiploic lymph nodes, which seem to have decreased the risk of donor site morbidity. Furthermore, our approach allows for lymph node transfer to the elbow and wrist, in addition to the axilla, potentially resulting in larger reductions in lymphedema. We believe our technique to be an excellent alternative to previously described techniques for the treatment of patients with post-mastectomy upper extremity lymphedema who desire breast reconstruction. Further studies, with a larger sample size, are required to validate its true utility and efficacy.

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.