Perioperative gabapentin usage in pediatric patients: A scoping review.

BACKGROUND: There has been a recent focus among anesthesiologists on reducing the use of perioperative opioids in favor of multimodal analgesic regimens. Gabapentin has played an integral role in this evolution of practice. This comprehensive review assesses the current clinical evidence on the efficacy of perioperative gabapentin regarding postoperative pain and opioid requirements among the pediatric surgery population. DATA SOURCES: Pubmed, CINAHL, Embase, Scopus, and Web of Science Review. METHODS: This scoping review of the above databases includes all studies examining the use of gabapentin perioperatively in pediatric patients and its association with postoperative pain intensity and postoperative opioid consumption through July 2021. The inclusion criteria encompassed all studies evaluating gabapentin in the perioperative pediatric population through randomized controlled trials (RCTs) and retrospective studies. Relevant metadata from each study were abstracted and descriptive statistics were used to summarize the results. RESULTS: Fifteen papers met the inclusion criteria for this review, including 11 RCTs and 4 retrospective studies. Sample sizes ranged from 20 to 144 patients. Administered doses varied widely, mainly between 5 and 20 mg/kg. The studies included primarily orthopedic (10) and neck surgery cases (3). Seven papers had gabapentin provided preoperatively only, two postoperative only, and six both pre- and postoperatively. Of the studies assessing postoperative pain, 6/11 studies saw a decrease in postoperative pain in at least one period for the gabapentin group. Of the studies considering opioid requirements, 6/10 reported a reduction, 1/10 an increase, and 3/10 no difference in opioid requirements for the gabapentin groups. Yet, most of these pain and opioid requirement findings were only significant at one to two time points in the study follow-up periods, and the actual decreases had minimal clinical significance. CONCLUSIONS: The current data on perioperative gabapentin in pediatric patients are insufficient to support the routine use of gabapentin in pediatric patients. Additional high-quality RCTs with more standardized protocols for gabapentin administration and outcome measures are necessary to provide more definitive conclusions.

The Medical Student Race to Research: Who Presents More at National Plastic Surgery Conferences?

BACKGROUND: presentations increase research output and facilitate networking for medical students applying to plastic surgery. We aim to determine predictors of increased medical student presentation at national plastic surgery conferences, identifying disparities in access to research opportunities. METHODS: Abstracts presented at the 2 most recent meetings of the American Society of Plastic Surgeons, American Association of Plastic Surgeons, and Plastic Surgery Research Council were extracted from online archives. Presenters without MDs or other professional credentials were classified as medical students. Presenter gender, medical school ranking, plastic surgery division/department, National Institutes of Health funding, number of total and first-author publications, H-index, and research fellowship completion status were recorded. Students with 3 or more (>75th percentile) presentations were compared with those with less by χ2 tests. Univariate and multivariable regressions identified factors associated with 3 or more presentations. RESULTS: Of 1576 abstracts, 549 (34.8%) were presented by 314 students. The gender distribution was 46.5% male and 53.5% female. Most were from the Northeast (36.9%), 35% came from top 20 medical schools, and 85% attended schools with home plastic surgery programs. While 61.8% presented once, 14.6% presented 3 or more times. Those who previously presented, completed research fellowships or had more publications or higher H-indices were likely to present more ( P ≤ 0.007). On multivariable-adjusted analysis, completing research fellowships (odds ratio [OR], 2.34-2.52; P = 0.028-0.045), affiliation with institutions having higher National Institutes of Health funding (OR, 3.47-3.73; P = 0.004-0.006), or having more total number of publications (OR, 3.81; P = 0.018) or first-author publications (OR, 3.84; P = 0.008) was associated with 3 or more presentations. Presenter gender, geographic region, medical school ranking, home program status, and H-indices were not significant predictors on multivariable analysis. CONCLUSIONS: There are several potential inequities in access to research opportunities for medical students, disadvantaging those with less well-funded plastic surgery programs and existing research experience. Improving the equitability of these opportunities is crucial for limiting bias in trainee recruitment and diversifying representation in the field.

Impact of Age on Surgical Outcomes Following Mandible Fracture Repair.

OBJECTIVES: Open repair of mandibular fractures are frequently performed surgical procedures. Increasing rates of such fractures are seen in older adults following falls. This study assesses the impact of older age on early complications following mandible fracture repair. STUDY DESIGN: Retrospective analysis of national registry. METHODS: The 2013-2018 National Surgical Quality Improvement Program database was queried for all cases of open mandible fracture repair and cases were categorized into younger (18-40), middle (41-65), and older (>65) age cohorts. Demographics and comorbidities were compared between the age groups. Rates of surgical, medical, and wound complications within 30-days of surgery were determined. Multivariable logistic analyses were performed to assess the relationship between age and complications. RESULTS: Altogether, 1818 cases were included for analysis, of which 1269 (69.8%) were younger, 459 (25.2%) were middle, and 90 (5.0%) were older age. Increased rates of complications were seen in the older groups, including unplanned reoperation, unplanned readmission, wound disruption, and medical complications (p < 0.01). On unadjusted analysis, the older (>65) age group had an increased odds of experiencing a complication compared to the younger (18-40) group (OR: 4.19, p < 0.001). The older age group continued to have a significantly increased odds of medical complications after multivariable adjustment (adjusted OR: 8.64, p < 0.001). CONCLUSIONS: On this analysis of a national database, advanced age was associated with an increased frequency of early postoperative complications following open mandibular fracture repair. Following multivariable adjustment, advanced age continued to be associated with increased odds of postoperative medical complications within 30 days of surgery. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:287-293, 2023.

Discrepancies in Work Relative Value Unit Assignment Based on Operative Time in Hand Surgery.

BACKGROUND: Work relative value units (wRVUs) are an intricate component of physician reimbursement determination in the United States. This paper assesses whether wRVUs appropriately consider operative time in hand surgery. METHODS: The 50 most common single Current Procedural Terminology code hand surgery cases were queried from the 2013 to 2018 National Surgical Quality Improvement Program database. The average assigned wRVUs and median operative times were calculated for each CPT. Linear regressions were calculated between operative time, wRVUs, and wRVUs per hour. Cases deviating the most from the expected wRVUs based on operative time were identified. RESULTS: In all, 46 800 cases comprising the top 50 most common hand surgery procedures were identified. Among these cases, the median (range) assigned operative time was 62 minutes (18-110), wRVUs were 7.5 (3.5-18.0), and wRVUs per hour was 8.3 (4.9-14.2). There was a positive linear correlation between operative time and wRVUs (R2 = 0.60). Each additional operative hour was associated with an additional 6.3 wRVUs (P < .001). Based on this relationship, the assigned wRVUs for included cases ranged from 59.7% to 172.6% of expected. There was a weak negative relationship between wRVUs per hour and operative time (R2 = 0.25). Cases shorter than 1 hour had more wRVUs per hour than those longer than 1 hour (10.0 vs. 8.1, P = .003). However, this relationship disappeared when considering case turnover. CONCLUSION: This study suggests a moderately strong positive correlation between wRVUs and operative time in hand surgery. Yet, numerous outliers from this trend exist, suggesting some discrepancies in reimbursement.

Research Productivity of Integrated Plastic Surgery Residents: Does Reputation Matter?

INTRODUCTION: It is unknown whether the ranking of plastic surgery residency programs influences resident research output. This study aims to determine whether program reputation and other factors are associated with integrated plastic surgery resident academic productivity. MATERIALS AND METHODS: Programs were divided into four tiers based on Doximity reputation rankings. Residents from 2019 to 2020 were found through program websites and social media accounts. Works published during residency were identified through PubMed and Scopus from July 1 of each resident's intern year to August 10, 2020. Variables included resident demographics and medical school, residency reputation ranking, geographic region, and medical school affiliation. 'High research output' was defined as having ≥75th percentile of publications adjusted by training year. RESULTS: In total, 921 residents in 80 programs were identified. The median (IQR) number of total publications and original articles was 3 (1-6) and 2 (0-4), respectively. On multivariable analysis, residents in top-20 ranked programs (OR = 2.31, 95% CI [1.55; 3.43], P < 0.001) or from programs associated with top-20 medical schools (OR = 1.61, 95% CI [1.08; 2.41], P = 0.020) were more likely to have higher research output. On the other hand, coming from a top-50 in research medical school (OR = 1.80, 95% CI [1.31; 2.47], P < 0.001) or being in a program affiliated with a top-20 medical school (OR = 2.52, 95% CI [1.69; 3.78], P < 0.001) were associated with higher original article output. Gender and geographic location were not associated with higher research output. CONCLUSIONS: Program reputation and affiliated medical school research rankings are associated with research productivity during integrated plastic surgery residency. Applicants with a particular interest in research careers may consider this as they apply to residency.

Relative Value Units and Operative Time in Plastic and Reconstructive Surgery.

BACKGROUND: Work relative value units (wRVUs) are linked to clinical reimbursements and physician compensation in the USA and thus should consider the time of the physician providing care. The primary goal of this study is to assess whether wRVUs appropriately consider operative time in plastic and reconstructive surgery. METHODS: The 2015-2018 National Surgical Quality Improvement Program was queried for the 50 most performed plastic surgery cases with assigned wRVUs and a recorded operative time. Linear regressions were used to assess the relationships between operative time, assigned wRVUs, and wRVUs per hour. The procedures with the highest and lowest assigned wRVUs relative to their operative time were identified. RESULTS: A total of 31,156 cases were included in this analysis. Among the 50 most performed procedures, the median (range) for assigned wRVUs was 10.0 (1.0-42.6), operative time was 61 min (21-441), and wRVUs per hour was 8.7 (2.2-16.2). There was a strong positive linear correlation between assigned wRVUs and median operative time (R2=0.78), with each additional operative hour being associated with an increase of 5.3 wRVUs (p<0.001). The procedures earning the most wRVUs relative to their operative times were breast reconstruction with other techniques and tissue expander placement in breast reconstruction. However, excisional debridements of the muscle/fascia and subcutaneous tissue had the lowest earned wRVUs relative to their operative times. CONCLUSION: Although wRVUs and operative time are correlated in plastic surgery, numerous outliers from this trend exist. This suggests that wRVUs may not be optimally assigned across the range of plastic surgery procedures.

Intraoperative haemodynamics and postoperative intensive care unit admission in older patients with cancer.

PURPOSE: Research on the impact of various intraoperative haemodynamic variables on the incidence of postoperative ICU admission among older patients with cancer is limited. In this study, the relationship between intraoperative haemodynamic status and postoperative intensive care unit admission among older patients with cancer is explored. METHODS: Patients aged ≥75 who underwent elective oncologic surgery lasting ≥120min were analysed. Chi-squared and t-tests were used to assess the associations between intraoperative variables with postoperative intensive care unit admission. Multivariable regressions were used to analyse potential predict risk factors for postoperative intensive care unit admission. RESULTS: Out of 994 patients, 48 (4.8%) were admitted to the intensive care unit within 30 days following surgery. Intensive care unit admission was associated with the presence of ≥4 comorbid conditions, intraoperative blood loss ≥100mL, and intraoperative tachycardia and hypertensive urgency. On multivariable analysis, operation time ≥240min (Odds Ratio [OR] = 2.29, p = 0.01), and each minute spent with intraoperative hypertensive urgency (OR = 1.06, p = 0.01) or tachycardia (OR = 1.01, p = 0.002) were associated with postoperative intensive care unit admission. CONCLUSION: Intraoperative hypertensive urgency and tachycardia were associated with postoperative intensive care unit admission in older patients undergoing cancer surgery.

Survival Predictors of Head and Neck Burkitt's Lymphoma: An Analysis of the SEER Database.

OBJECTIVE: To analyze population-level data for Burkitt's lymphoma of the head and neck. STUDY DESIGN: Retrospective study of a national cancer database. SETTING: Academic medical center. METHODS: The SEER database (Surveillance, Epidemiology, and End Results) identified all patients with primary Burkitt's lymphoma of the head and neck from 1975 to 2015. Demographic, clinicopathologic, and treatment characteristics were analyzed. Multivariable Cox regressions analyzed factors associated with survival while controlling for baseline differences. RESULTS: A total of 920 patients with a mean (SD) age of 37.6 years (25.0) were identified. A majority of patients were White (82.8%) and male (72.3%). The most primary common sites included the lymph nodes (61.3%), pharynx (17.7%), and nasal cavity/paranasal sinuses (5.2%). The majority of patients received chemotherapy (90.5%), while fewer underwent surgery (42.1%) or radiotherapy (12.8%). Choice of treatment differed significantly among patients of different ages, year of diagnosis, primary site, nodal status, and Ann Arbor stage. Overall 10-year survival was 67.8%. On multivariable Cox regression, patients with older age (hazard ratio [HR], 1.05 per year; P < .001) and higher stage at presentation had increased risk of mortality (P < .001). Furthermore, cases diagnosed between 2006 and 2015 (HR, 0.35; P < .001) and 1996 and 2005 (HR, 0.53; P = .001) had lower mortality when compared with those diagnosed between 1975 and 1995. Treatment including surgery and chemotherapy tended to have the best survival (P < .001). CONCLUSION: Burkitt's lymphoma of the head and neck diagnosed in more recent years has had improved survival. Factors significantly associated with survival include age, Ann Arbor stage, and treatment regimen. Treatment including surgery and chemotherapy was associated with the highest survival.

Trends in Female Plastic Surgery Resident Authorship - Signs of Changing Times?

OBJECTIVE: Gender discrepancies exist in academia for leadership positions, advancement opportunities, and research. As of 2019, the ratio of total male-to-female attending plastic and reconstructive surgeons was 4.8:1. However, the ratio of male-to-female residents in integrated plastic surgery programs fell to 1.3:1, indicating rising female representation. With more balanced gender distributions of residents, the authors sought to determine whether this translates to greater equality of opportunities and achievements. Specifically, this study compares the academic productivity of male and female integrated plastic surgery residents. METHODS: A list of integrated plastic surgery residency programs was obtained from the Accreditation Council for Graduate Medical Education website and ranked by reputation using the Doximity Residency Navigator. Integrated plastic surgery residents from 2019 to 2020 were identified via program websites and social media accounts. Works published during residency were identified through PubMed and Scopus from July 1 of each resident's intern year through August 10, 2020. Demographic variables for residents, including training class and medical school, as well as for programs, including geographic region, Doximity ranking, and medical school affiliation, were collected. Medical schools were ranked according to US News by research. Research productivity was assessed through the number of total research articles with authorship position (first, second, or last), the number of articles published in plastic surgery journals with the highest impact factors (Plastic and Reconstructive Surgery and Aesthetic Surgery Journal), and H-indices. Chi-Squared tests and Mann-Whitney U-tests were used to make comparisons between male and female residents (α = 0.05). RESULTS: In total, 931 residents in 81 integrated plastic surgery programs were identified, including 534 (57.4%) male and 397 (42.6%) female residents. There were no differences between male and female residents in terms of training year or program geography. Female residents were more likely to come from a top-50 medical school than males (54.7% vs. 48.1%, p = 0.049). There were no significant differences in gender distribution of residents from top-20 programs or programs affiliated with a top-20 medical school. The median (IQR) number of publications in total, and for each gender, was 3 (1-6). There was no difference in the number of total publications by training year by gender, besides the second-year resident class where male residents had a median (IQR) of 2 (1-4) compared to 1 (0-3) (p = 0.028). Male and female residents did not differ with regards to authorship position or proportion of times publishing in top journals. The distribution of H-indices for male residents was slightly higher than female residents (p = 0.003), but the median (IQR) was the same at 3 (1-5). CONCLUSIONS: Currently, male and female integrated plastic surgery residents have similar levels of academic productivity. This suggests that female representation is slowly increasing along the pipeline in academia, representing a paradigm shift from previous trends of gender inequality in plastic surgery.

Perioperative considerations for cancer patients with obesity: A narrative review.

Cancer in patients with obesity has become increasingly common throughout much of the world. Based on our experiences in a specialized cancer center, we have developed a set of standards and expectations that should streamline the surgical journey for this patient population. These recommendations should inform the perioperative management of oncology patients with obesity and help raise awareness of this critical and under-discussed topic.

Panniculectomy Outcomes by Body Mass Index: an Analysis of 12,732 Cases.

PURPOSE: With an increasing rate of obesity in the USA, bariatric surgery has become widespread, resulting in a greater number of patients seeking panniculectomy. The authors aim to determine the complication profile of panniculectomies by body mass index (BMI). METHODS: The 2012-2018 National Surgical Quality Improvement Program database was queried for all panniculectomy cases. Patients were assigned to a category by their calculated BMI. Rates of complications were compared across BMI ranges. Demographics, comorbidities, and perioperative factors were compared between those with and without complications. Multivariable analyses were performed to analyze the associations between BMI ranges and post-surgical complications. RESULTS: Twelve thousand seven hundred thirty-two cases were analyzed, of which 1759 (13.8%) had at least one postoperative complication. As BMI increased, patients were more likely to experience postoperative complications (p<0.001). Patients experiencing complications were more likely to be male, older, of a higher BMI group, have a higher American Society of Anesthesiologists Personal Status classification, be an inpatient, have various comorbidities, or be undergoing a concurrent procedure. On multivariable analysis, patients who were overweight (OR=1.24, p=0.039), with class 1 (OR=1.72, p<0.001), class 2 (OR=2.10, p<0.001), or class 3 (OR=3.01, p<0.001) obesity were more likely to have a postoperative complication. Wound complications were particularly prevalent in patients who were overweight (OR=1.77, p=0.001) or with class 1 (OR=2.59, p<0.001), class 2 (OR=4.05, p<0.001), or class 3 (p=5.84, p<0.001) obesity compared to non-overweight patients. CONCLUSION: A higher BMI is associated with more postoperative complications, particularly wound healing complications, following panniculectomy in a dose-dependent manner.

Quality, Reliability, and Readability of Online Information on Rhinoplasty.

BACKGROUND: With an ever-growing reliance on technology, patients are increasingly resorting to websites for their medical information. This study evaluates the readability, quality, and reliability of online information available on rhinoplasty provided by academic centers or impartial reference sources and private practice websites. METHODS: A cross-sectional study from July to August 2019 was performed looking at the first 42 informational websites on a Google search for the term nose job. Websites were categorized as belonging to impartial sources and academic centers or private practices. Two independent reviewers evaluated websites on their quality, readability, reliability, and technical qualities using several validated measures. The Health on the Net code (HONcode) and DISCERN questionnaire were used to assess the quality and reliability of the information presented on the websites. Significance tests were performed using SPSS Version 25. RESULTS: Of the 42 websites, 23 were impartial sources or academic centers (54.8%) and 19 were private practice websites (47.6%). The mean (±SD) for the HONcode and DISCERN scores were 5.7 (±2.8) and 2.6 (±0.7), respectively. The mean (SD) HONcode scores for impartial sources and private practice websites were 7.1 (±2.9) and 4.1 (±1.5), respectively (P < 0.001). The mean (±SD) DISCERN scores were 2.9 (±0.7) and 2.3 (±0.5), respectively (P = 0.009). There was no statistically significant difference in scores for readability and technical qualities. CONCLUSIONS: While impartial sources and academic centers score higher on quality and reliability scores, their scores were also low. These findings are concerning as many consumers use the information provided by online websites to guide decisions regarding their health.

Comparison of mortality and medical complications between older and younger malignant melanoma inpatients.

Previous studies have identified older age as a negative prognostic factor in malignant melanoma patients. To compare comorbidities, medical complications, and inpatient mortality between younger and older malignant melanoma inpatients. All adult patient encounters with a diagnosis of cutaneous malignant melanoma were identified using the 2003 to 2012 National Inpatient Sample database. Concurrent comorbidities and inpatient medical complications were queried. Comparisons were made between older and younger adults, defined as ≥65 years and 18 to 64 years, respectively. In total, 8153 patient encounters were identified in the database (51.6% older and 48.4% younger). Older adults had a higher prevalence of numerous comorbidities, including chronic pulmonary disease, chronic renal failure, congestive heart failure, diabetes mellitus, hypertension, hypothyroidism, peripheral vascular disease, and pulmonary circulation disorder (P < .001). In contrast, younger adults were more likely to have obesity (P < .001) and coagulopathy (P = .005). On multivariable analysis of medical complications, older adult inpatients were more likely to experience urinary tract infection (OR = 1.54, P = .021), but less likely to experience acute respiratory failure (OR = 0.46, P = .012) and venous thromboembolism (OR = 0.44, P = .026). Notably, inpatient mortality did not significantly differ. Older adult inpatients with malignant melanoma have different comorbidities than younger patients and have a larger overall comorbidity burden. Surprisingly, however, the odds of most inpatient medical complications and mortality were found to be similar in younger vs older patients.

Gender differences in cutaneous melanoma: Demographics, prognostic factors, and survival outcomes.

Several recent studies have reported a considerably higher overall survival (OS) rate in females in various geographic regions This study further investigates the characteristics of melanoma that contribute to OS of women residing in the United States. Chi-square, Kaplan-Meier, and Cox regression models were used to analyze differences in demographics, treatment, and survival of invasive cutaneous melanoma in men and women diagnosed from 2004 to 2016 in the National cancer database. In 316 966 patients met inclusion criteria. Men had a significantly higher median age of diagnosis at 61 years (interquartile range or IQR: 51-72) in comparison to women where the median age of diagnosis was 55 years (IQR: 43-68) (P < .0001). The most common primary site for men was the trunk (35.5%), whereas the lower extremities were the most common primary site for women (30.3%). Women had a higher 5 year (82.6%) and 10 year (73.1%) OS compared to 5 year and 10 year OS of 72.2% and 58.7%, respectively, in men (P < .0001). When adjusting for confounders, female gender was independently associated with improved OS (ref: male HR = 0.791; 95% confidence interval 0.773-0.809; P < .0001). Overall, we conclude that female gender is an independent favorable prognostic factor for melanoma survival.

Prognostic nutritional index (PNI), independent of frailty is associated with six-month postoperative mortality.

INTRODUCTION: Prognostic Nutritional Index (PNI) is associated with disease and overall survival in patients with cancer. We aimed to assess the relationship between PNI, frailty, and six-month postoperative survival in older patients with cancer. METHODS: In this retrospective study, patients with cancer aged ≥75 who underwent geriatric preoperative evaluation and then proceeded with elective surgery with hospital length of stay of ≥1 day and had six-month follow-up were included. PNI is measured by preoperative [10 × albumin(gr/dl)] + [0.005 × absolute lymphocyte count (per mm3)]. Higher PNI is suggestive of better nutritional status. Frailty was assessed by geriatric assessment. PNI among patients with and without each age-related impairment was evaluated. Pearson correlation coefficient was used to assess the correlation between the number of age-related impairments and PNI. Multivariable regression analysis was used to assess the relationship between six-month mortality and PNI. RESULTS: PNI ranged from 19 to 49 (average 40) among 1025 patients (average age 80). Patients with impairment in Karnofsky Performance Status, falls in the past year, prolonged timed up and go test, limited social activity, significant weight loss, polypharmacy, polycomorbid conditions, depression, and dependent for basic and instrumental activities of daily living had lower PNI than fit patients. The correlation coefficient between PNI and number of aging impairments was -0.28 (p < .001). Each unit increase in PNI was associated with 10% reduction in 6-month mortality (OR = 0.90, p < .001). CONCLUSION: PNI independent of frailty, age, American Society of Anesthesiologist Performance Scale (ASA-PS), and metastatic disease is associated with six-month postoperative mortality. Future studies should assess the interventions aimed at improving PNI and its impact on surgical outcomes.