Improved survival for dose-intensive chemotherapy in primary mediastinal B-cell lymphoma: a systematic review and meta-analysis of 4,068 patients.

Primary mediastinal B-cell lymphoma (PMBCL) is a distinct clinicopathologic entity. Currently, there is a paucity of randomized prospective data to inform on optimal front-line chemoimmunotherapy (CIT) and use of consolidative mediastinal radiation (RT). To assess if distinct CIT approaches are associated with disparate survival outcomes, we performed a systematic review and meta-analysis comparing dose-intensive (DI-CIT) versus standard CIT for the front-line treatment of PMBCL. Standard approach (S-CIT) was defined as R-CHOP-21/CHOP-21, with or without RT. DI-CIT were defined as regimens with increased frequency, dose, and/or number of systemic agents. We reviewed data on 4,068 patients (2,517 DI-CIT; 1,551 S-CIT) with a new diagnosis of PMBCL. Overall survival for DI-CIT patients was 88% (95% CI: 85-90) compared to 80% for the S-CIT cohort (95% CI: 74-85). Meta-regression revealed an 8% overall survival (OS) benefit for the DI-CIT group (P<0.01). Survival benefit was maintained when analyzing rituximab only regimens; OS was 91% (95% CI: 89-93) for the rituximab-DI-CIT arm compared to 86% (95% CI: 82-89) for the R-CHOP-21 arm (P=0.03). Importantly, 55% (95% CI: 43-65) of the S-CIT group received RT compared to 22% (95% CI: 15-31) of DI-CIT patients (meta-regression P<0.01). To our knowledge, this is the largest meta-analysis reporting efficacy outcomes for the front-line treatment of PMBCL. DI-CIT demonstrates a survival benefit, with significantly less radiation exposure, curtailing long-term toxicities associated with radiotherapy. As we await results of randomized prospective trials, our study supports the use of dose-intensive chemoimmunotherapy for the treatment of PMBCL.

Antibiotic prophylaxis for onabotulinum toxin A injections: systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: To our knowledge, there are no evidence-based recommendations regarding the optimal prophylactic antibiotic regimen for intradetrusor onabotulinum toxin type A (BTX) injections. This systematic review and meta-analysis was aimed at investigating the optimal prophylactic antibiotic regimen to decrease urinary tract infection (UTI) in patients undergoing BTX for overactive bladder syndrome (OAB). METHODS: A systematic search of MEDLINE, Embase, CINAHL, and Web of Science was conducted from inception through 30 June 2022. All randomized controlled trials and prospective trials with > 20 subjects undergoing BTX injections for OAB in adults that described prophylactic antibiotic regimens were included. Meta-analysis performed to assess UTI rates in patients with idiopathic OAB using the inverse variance method for pooling. RESULTS: A total of 27 studies (9 randomized controlled trials, 18 prospective) were included, representing 2,100 patients (69% women) with 19 studies of idiopathic OAB patients only, 6 of neurogenic only, and 2 including both. No studies directly compared antibiotic regimens for the prevention of UTI. Included studies favor the use of antibiotics in patients with idiopathic OAB and favor continuing antibiotics for 2-3 days after the procedure for prevention of UTI. Given the heterogeneity of the data, direct comparisons of antibiotic type or duration could not be performed. Meta-analysis found a 10% UTI rate at 4 weeks and 15% at 12 weeks post-injection. CONCLUSIONS: Although there are insufficient data to support the use of a specific antibiotic regimen, available studies favor the use of prophylactic antibiotics for 2-3 days in idiopathic OAB patients undergoing BTX injection. Future trials are needed to determine the optimal regimens to prevent UTI in patients undergoing BTX for OAB.

The Effect of Early Severe Hyperoxia in Adults Intubated in the Prehosptial Setting or Emergency Department: A Scoping Review.

BACKGROUND: The detrimental effects of hyperoxia exposure have been well-described in patients admitted to intensive care units. However, data evaluating the effects of short-term, early hyperoxia exposure in patients intubated in the prehospital setting or emergency department (ED) have not been systematically reviewed. OBJECTIVE: Our aim was to quantify and describe the existing literature examining the clinical outcomes in ED patients exposed to hyperoxia within the first 24 h of mechanical ventilation. METHODS: This review was performed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for scoping reviews. Two rounds of review using Rayyan QCRI software were performed for title and abstract screening and full-text search. Of the 2739 articles, 27 articles were retrieved after initial screening, of which 5 articles were excluded during the full-text screening, leaving 22 articles for final review and data extraction. RESULTS: Of 22 selected publications, 9 described patients with traumatic brain injury, 6 with cardiac arrest, 3 with multisystem trauma, 1 with stroke, 2 with septic shock, and 1 was heterogeneous. Three studies were randomized controlled trials. The available data have widely heterogeneous definitions of hyperoxia exposure, outcomes, and included populations, limiting conclusions. CONCLUSIONS: There is a paucity of data that examined the effects of severe hyperoxia exposure in the acute, post-intubation phase of the prehospital and ED settings. Further research with standardized definitions is needed to provide more detailed guidance regarding early oxygen titration in intubated patients.

Perioperative Quality Initiative and Enhanced Recovery After Surgery-Cardiac Society Consensus Statement on the Management of Preoperative Anemia and Iron Deficiency in Adult Cardiac Surgery Patients.

Preoperative anemia is common in patients presenting for cardiac surgery, with a prevalence of approximately 1 in 4, and has been associated with worse outcomes including increased risk of blood transfusion, kidney injury, stroke, infection, and death. Iron deficiency, a major cause of anemia, has also been shown to have an association with worse outcomes in patients undergoing cardiac surgery, even in the absence of anemia. Although recent guidelines have supported diagnosing and treating anemia and iron deficiency before elective surgery, details on when and how to screen and treat remain unclear. The Eighth Perioperative Quality Initiative (POQI 8) consensus conference, in conjunction with the Enhanced Recovery after Surgery-Cardiac Surgery Society, brought together an international, multidisciplinary team of experts to review and evaluate the literature on screening, diagnosing, and managing preoperative anemia and iron deficiency in patients undergoing cardiac surgery, and to provide evidence-based recommendations in accordance with Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria for evaluating biomedical literature.

Runs of homozygosity in killer whale genomes provide a global record of demographic histories.

Runs of homozygosity (ROH) occur when offspring inherit haplotypes that are identical by descent from each parent. Length distributions of ROH are informative about population history; specifically, the probability of inbreeding mediated by mating system and/or population demography. Here, we investigated whether variation in killer whale (Orcinus orca) demographic history is reflected in genome-wide heterozygosity and ROH length distributions, using a global data set of 26 genomes representative of geographic and ecotypic variation in this species, and two F1 admixed individuals with Pacific-Atlantic parentage. We first reconstructed demographic history for each population as changes in effective population size through time using the pairwise sequential Markovian coalescent (PSMC) method. We found a subset of populations declined in effective population size during the Late Pleistocene, while others had more stable demography. Genomes inferred to have undergone ancestral declines in effective population size, were autozygous at hundreds of short ROH (<1 Mb), reflecting high background relatedness due to coalescence of haplotypes deep within the pedigree. In contrast, longer and therefore younger ROH (>1.5 Mb) were found in low latitude populations, and populations of known conservation concern. These include a Scottish killer whale, for which 37.8% of the autosomes were comprised of ROH >1.5 Mb in length. The fate of this population, in which only two adult males have been sighted in the past five years, and zero fecundity over the last two decades, may be inextricably linked to its demographic history and consequential inbreeding depression.

Risk Factors Associated With the Progression From Acute to Chronic Neuropathic Pain After Burn-Related Injuries.

BACKGROUND: Pain, unrelated to the initial thermal trauma itself, can result after burn injury and prolong the recovery/rehabilitation phase of the patient's care. This pain, after discharge from the burn unit, may be acute and self-limiting or chronic and contribute to long-term patient morbidity. The purposes of this study were to compare burn patients who had, after discharge from the burn unit, only acute pain with burn patients who developed chronic, neuropathic pain (CNP) and to determine risks factors for progression from acute to chronic pain in the setting of a burn center. METHODS: A single-center, retrospective chart review of patients admitted to the adult burn center was performed from January 1, 2014, to January 1, 2019. Patients included were older than 15 years, sustained a burn injury, and admitted to the burn unit. Chronic pain was defined as pain lasting greater than 6 months after discharge from the burn unit. Pain descriptors included shooting, stabbing, sharp, burning, tingling, numbness, throbbing, pruritus, intermittent, and/or continuous dysesthetic sensations after the burn. Patients were excluded if they had preexisting neuropathic pain due to an underlying medical illness or previous surgery. RESULTS: During a 5-year period, of the 1880 admissions to the burn unit, 143 burn patients developed post-initial-onset pain as a direct result of their burn. Of the 143 patients with acute pain, pain resolved in 30 patients, whereas pain progressed to CNP in 113 patients (79%). Patient follow-up was a median (interquartile range [IQR]) of 26.5 (10-45) months. Patients whose pain progressed to CNP had significantly greater percent total body surface area burns (median [IQR], 6 [3-25] vs 3 [1-10]; P = 0.032), had more full-thickness burns (66/113 [58%] vs 8/30 [27%] patients, P = 0.004), had surgery (85/113 [75%] vs 16/30 [53%] patients, P = 0.042), had more surgical procedures (median [IQR], 2 [1-6] vs 1 [0-3], P = 0.002), and developed more complications (32/113 [28%] vs 2/30 [7%] patients, P = 0.014) compared with those with acute neuropathic pain, respectively. CONCLUSIONS: Burn patients who progressed from having acute to CNP had significantly greater percent total body surface area burns, had more full-thickness burns, had surgery, had more surgical procedures, and developed more complications compared with burn patients with only acute pain.

Oceanographic barriers, divergence, and admixture: Phylogeography and taxonomy of two putative subspecies of short-finned pilot whale.

Genomic phylogeography plays an important role in describing evolutionary processes and their geographic, ecological, or cultural drivers. These drivers are often poorly understood in marine environments, which have fewer obvious barriers to mixing than terrestrial environments. Taxonomic uncertainty of some taxa (e.g., cetaceans), due to the difficulty in obtaining morphological data, can hamper our understanding of these processes. One such taxon, the short-finned pilot whale, is recognized as a single global species but includes at least two distinct morphological forms described from stranding and drive hunting in Japan, the "Naisa" and "Shiho" forms. Using samples (n = 735) collected throughout their global range, we examine phylogeographic patterns of divergence by comparing mitogenomes and nuclear SNP loci. Our results suggest three types within the species: an Atlantic Ocean type, a western/central Pacific and Indian Ocean (Naisa) type, and an eastern Pacific Ocean and northern Japan (Shiho) type. mtDNA control region differentiation indicates these three types form two subspecies, separated by the East Pacific Barrier: Shiho short-finned pilot whale, in the eastern Pacific Ocean and northern Japan, and Naisa short-finned pilot whale, throughout the remainder of the species' distribution. Our data further indicate two diverging populations within the Naisa subspecies, in the Atlantic Ocean and western/central Pacific and Indian Oceans, separated by the Benguela Barrier off South Africa. This study reveals a process of divergence and speciation within a globally-distributed, mobile marine predator, and indicates the importance of the East Pacific Barrier to this evolutionary process.

Killer whale genomes reveal a complex history of recurrent admixture and vicariance.

Reconstruction of the demographic and evolutionary history of populations assuming a consensus tree-like relationship can mask more complex scenarios, which are prevalent in nature. An emerging genomic toolset, which has been most comprehensively harnessed in the reconstruction of human evolutionary history, enables molecular ecologists to elucidate complex population histories. Killer whales have limited extrinsic barriers to dispersal and have radiated globally, and are therefore a good candidate model for the application of such tools. Here, we analyse a global data set of killer whale genomes in a rare attempt to elucidate global population structure in a nonhuman species. We identify a pattern of genetic homogenisation at lower latitudes and the greatest differentiation at high latitudes, even between currently sympatric lineages. The processes underlying the major axis of structure include high drift at the edge of species' range, likely associated with founder effects and allelic surfing during postglacial range expansion. Divergence between Antarctic and non-Antarctic lineages is further driven by ancestry segments with up to four-fold older coalescence time than the genome-wide average; relicts of a previous vicariance during an earlier glacial cycle. Our study further underpins that episodic gene flow is ubiquitous in natural populations, and can occur across great distances and after substantial periods of isolation between populations. Thus, understanding the evolutionary history of a species requires comprehensive geographic sampling and genome-wide data to sample the variation in ancestry within individuals.

Are You on the Right Platform? A Conjoint Analysis of Social Media Preferences in Aesthetic Surgery Patients.

BACKGROUND: Social media has become an indispensable tool for patients to learn about aesthetic surgery. Currently, procedure-specific patient preferences for social media platforms and content are unknown. OBJECTIVES: The authors sought to evaluate social media preferences of patients seeking aesthetic surgery. METHODS: We utilized a choice-based conjoint analysis survey to analyze the preferences of patients seeking 3 common aesthetic procedures: breast augmentation (BA), facial rejuvenation (FR), and combined breast/abdominal surgery (BAB). Participants were asked to choose among social media platforms (Facebook, Twitter, Instagram, Snapchat, Pinterest, Tumblr, YouTube), information extent (basic, moderate, comprehensive), delivery mechanism (prerecorded video, live video, photographs, text description), messenger (surgeon, nurse/clinic staff, patient), and option for interactivity (yes/no). The survey was administered using an Internet crowdsourcing service (Amazon Mechanical Turk). RESULTS: A total of 647 participants were recruited: 201 in BA, 255 in FR, and 191 in BAB. Among attributes surveyed, participants in all 3 groups (BA, FR, BAB) valued social media platform as the most important (30.9%, 33.1%, 31.4%), followed by information extent (23.1%, 22.9%, 21.6%), delivery mechanism (18.9%, 17.4%, 18%), messenger (16%, 17%, 17.2%), and interactivity (11.1%, 9.8%, 11.8%). Within these attributes, Facebook ranked as the preferred platform, with comprehensive information extent, live video as the delivery mechanism, and surgeon as the messenger as most preferred. CONCLUSIONS: The choice of social media platform is the most important factor for patients, and they indicated a preference for comprehensive information delivered by the surgeon via live video on Facebook. Our study elucidates social media usage in common aesthetic populations, which can help improve aesthetic patient outreach.

Demography or selection on linked cultural traits or genes? Investigating the driver of low mtDNA diversity in the sperm whale using complementary mitochondrial and nuclear genome analyses.

Mitochondrial DNA has been heavily utilized in phylogeography studies for several decades. However, underlying patterns of demography and phylogeography may be misrepresented due to coalescence stochasticity, selection, variation in mutation rates and cultural hitchhiking (linkage of genetic variation to culturally-transmitted traits affecting fitness). Cultural hitchhiking has been suggested as an explanation for low genetic diversity in species with strong social structures, counteracting even high mobility, abundance and limited barriers to dispersal. One such species is the sperm whale, which shows very limited phylogeographic structure and low mtDNA diversity despite a worldwide distribution and large population. Here, we use analyses of 175 globally distributed mitogenomes and three nuclear genomes to evaluate hypotheses of a population bottleneck/expansion vs. a selective sweep due to cultural hitchhiking or selection on mtDNA as the mechanism contributing to low worldwide mitochondrial diversity in sperm whales. In contrast to mtDNA control region (CR) data, mitogenome haplotypes are largely ocean-specific, with only one of 80 shared between the Atlantic and Pacific. Demographic analyses of nuclear genomes suggest low mtDNA diversity is consistent with a global reduction in population size that ended approximately 125,000 years ago, correlated with the Eemian interglacial. Phylogeographic analysis suggests that extant sperm whales descend from maternal lineages endemic to the Pacific during the period of reduced abundance and have subsequently colonized the Atlantic several times. Results highlight the apparent impact of past climate change, and suggest selection and hitchhiking are not the sole processes responsible for low mtDNA diversity in this highly social species.

STARplasty for Reconstruction of the Burned Axilla.

BACKGROUND: Postburn axillary contractures are common and significantly impact quality of life. Simple release combined with split thickness skin grafting necessitates a donor site, requires immobilization, and may result in poor functional outcome. Common methods of adjacent tissue rearrangement are not well designed to treat broad linear contractures. Flaps from the back, flank, or arm can be used, but may come with significant donor site morbidity. We demonstrate the use of the STARplasty, a novel adjacent tissue rearrangement initially developed to treat neosyndactyly, as a useful reconstructive option for the release of Kurtzman type 1 posterior or anterior axillary contractures. METHODS: A retrospective review was performed to identify patients who underwent STARplasties for treatment of type 1 axillary burn contractures. All reconstructions were performed by a single surgeon at a single ABA burn center (April 2011 to December 2015). A version of the surgical STARplasty technique previously described for treatment of neosyndactyly was modified for use in the axilla. Patient and injury demographics, as well as complications and outcome, were collected. RESULTS: Twelve patients with upper extremity burns underwent 16 primary STARplasties for treatment of axillary contractures. Three patients underwent simultaneous bilateral procedures. The majority (15/16) of the primary procedures were used to address contractures of the anterior axillary fold. Mean patient age was 51 (R 38-63) and average burn size was 35% (R 18-80). Average time from initial injury to primary reconstruction was 11.1 months (R 3-54). One patient required revision for persistent contracture and another experienced wound dehiscence that ultimately required split-thickness skin grafting. No other significant complications were noted, and all remaining patients had closed wounds and full range of motion by 30 days postprocedure. CONCLUSIONS: Axillary contractures remain common despite improvements in physical/occupational therapy. While common techniques, such as z-plasty, continue to be helpful for the surgical release of narrow contractures with bilateral laxity, axillary contractures are typically broad based and often contain only unilateral unburned tissue. Based on our experience, the axillary STARplasty represents a safe and efficacious technique to be considered in the case of broad-based contractures involving either the anterior or posterior axillary fold.

Procedural Portfolio Planning in Plastic Surgery, Part 1: Strategic Changes in Clinical Practice to Increase Physician Revenue, Improve Operative Throughput, and Maintain Patient Satisfaction.

PURPOSE: Portfolio planning in health care represents the strategic prioritization of services that permits an organization to better achieve its goals of margin and mission. Because of recent volatility in the economy, declining reimbursement, and rising costs of providing care, such strategic planning has become increasingly important if physicians want to remain leaders in health care. This project assesses the financial impact of procedural portfolio planning on an academic plastic surgery practice from the physician's perspective. METHODS: We tracked the top 50 procedures, defined as total charges per CPT code, that were performed in our baseline year, for 6 providers in a stable plastic surgery practice. At the end of the first year, we implemented 3 types of strategic changes: growth of areas with high contribution margin (laser resurfacing of burn scars), curtailment of high-risk procedures with negative contribution margin (panniculectomy in smokers), and improved efficiency of mission-critical services with high resource consumption (free-flap breast reconstruction). During the 2-year study period, we had no turnover in faculty, did not pursue any formal marketing, did not change our surgical fees or billing system, provided care independent of payer mix, and maintained our commitment to indigent care. Outcome measures included procedural charges and revenue, collection rates, work relative value units, operating room times, idle times (room time less case time), receipts/minute in operating room, uncompensated charity care, and patient satisfaction (Press-Gainey scores). Before the study period, annual incremental growth in our practice was 1% to 2%, in terms of charges and receipts. RESULTS: After implementation of the portfolio planning project, the financial position of our division improved significantly, with patient satisfaction rates increasing from 85.5% to 94.1% and charity care remaining constant at US $400,000 per year. Encounters, work relative value units, charges, and receipts all increased by 16% to 27%, with receipts/minute increasing from US $5.60 per minute to US $7.28 per minute. Interestingly, but not surprisingly, highest margin cases did not correspond with highest volume or highest revenue cases; portfolio analysis helped us to align these parameters, without sacrificing patient satisfaction or commitment to indigent care. The highest receipt/minute procedure was laser ablation of vascular lesions (US $23.87), whereas one of the lowest receipt/minute cases was muscle free flap (US $3.07). CONCLUSIONS: Procedural portfolio analysis is a powerful tool that can guide strategy and positively impact the financial position and clinical value of the services provided by an academic plastic surgery practice. Identifying high margin procedures allows the surgeon to focus marketing efforts, target areas of future growth, and optimize the blend of margin and mission.

Procedural Portfolio Planning in Plastic Surgery, Part 2: Collaboration Between Surgeons and Hospital Administrators to Develop a Funds Flow Model for Procedures Performed at an Academic Medical Center.

INTRODUCTION: Although plastic surgeons make important contributions to the clinical, educational, and research missions of academic medical centers (AMCs), determining the financial value of a plastic surgery service can be difficult, due to complex cost accounting systems. We analyzed the financial impact of plastic surgery on an AMC, by examining the contribution margins and operating income of surgical procedures. METHODS: We collaborated with hospital administrators to implement 3 types of strategic changes: (1) growth of areas with high contribution margin, (2) curtailment of high-risk procedures with negative contribution margin, (3) improved efficiency of mission-critical services with high resource consumption. Outcome measures included: facility charges, hospital collections, contribution margin, operating margin, and operating room times. We also studied the top 50 Current Procedural Terminology codes (total case number × charge/case), ranking procedures for profitability, as determined by operating margin. During the 2-year study period, we had no turnover in faculty; did not pursue any formal marketing; did not change our surgical fees, billing system, or payer mix; and maintained our commitment to indigent care. RESULTS: After rebalancing our case mix, through procedural portfolio planning, average hospital operating income/procedure increased from $-79 to $+816. Volume and diversity of cases increased, with no change in payer mix. Although charges/case decreased, both contribution margin and operating margin increased, due to improved throughput and decreased operating room times. The 5 most profitable procedures for the hospital were hernia repair, mandibular osteotomy, hand skin graft, free fibula flap, and head and neck flap, whereas the 5 least profitable were latissimus breast reconstruction, craniosynostosis repair, free-flap breast reconstruction, trunk skin graft, and cutaneous free flap. Total operating income for the hospital, from plastic surgery procedures, increased from $-115,103 to $+1,277,040, of which $350,000 (25%) was returned to the practice plan as enterprise funds to support program development. CONCLUSIONS: Through focused strategic initiatives, plastic surgeons and hospital administrators can work together to unlock the latent value of a plastic surgery service to an AMC. Specific financial benefits to the hospital include increased contribution margin and operating income, the latter of which can be reinvested in the plastic surgery service through a gain-sharing model.

Fat Grafting for Neuropathic Pain After Severe Burns.

BACKGROUND: Chronic neuropathic pain after burn injury is a significant problem that affects up to 29% of burn patients. Neuropathic burn scar pain is a challenge for plastic and burn surgeons, who have limited solutions. Fat grafting, with its mechanical and regenerative qualities, can improve neuropathic pain from various traumatic and postsurgical etiologies, but its effectiveness in neuropathic burn scar pain has yet to be demonstrated. In this study, the possible role of lipotransfer in treating neuropathic burn scar pain is explored, focusing on safety, graft take, and short-term efficacy. METHODS: We performed an institutional review board-approved, retrospective case review of 7 patients with chronic, refractory neuropathic pain, who underwent fat grafting to burn scars. These patients had failed conventional therapy, which included pharmacologic, medical, and laser treatment of the burn scars. Each patient had 2 sessions of fat grafting, spaced 2 months apart. The Patient-Reported Outcomes Measurement Information System (PROMIS) was used to assess pain perception, with patients answering the questionnaire before and after fat grafting, to assess subjective outcomes. RESULTS: Six of 7 patients had improvement in neuropathic pain after fat grafting, permitting reduction in their neuropharmacologic regimen. Tinel sign, present in all patients preoperatively, was absent on examination in all patients at follow-up. Three of the 5 patients who completed PROMIS questionnaires had PROMIS scores indicating improvement in pain by 1-year follow-up. One patient had similar preoperative and postoperative PROMIS scores, and 1 patient had an increase in pain at follow-up; however, he had suffered an additional burn to the same extremity. Analysis of pooled mean PROMIS scores reflects a statistically significant improvement in subjective outcomes by 1-year follow-up. Donor-site seroma in 1 patient was the only complication, with no cases of infection, wound breakdown, or graft loss. CONCLUSIONS: Adipose tissue can be safely grafted into burn scars and may improve symptoms in patients with refractory neuropathic pain after burn injury. Further translational and clinical research is necessary to elucidate mechanisms of action, indications, optimal type of transfer, and long-term effectiveness.

Plastic Surgery Residents' Understanding and Attitudes Toward Biostatistics: A National Survey.

BACKGROUND: An understanding of biostatistics is a critical skill for the practicing plastic surgeon. The purpose of the present study was to assess plastic surgery residents' attitudes and understanding of biostatistics. METHODS: This was a cross-sectional study of plastic surgery residents. A survey assessing resident attitudes regarding biostatistics, confidence with biostatistical concepts, and objective knowledge of biostatistics was distributed electronically to trainees in plastic surgery programs in the United States. Bivariate and regression analyses were used to identify significant associations and adjust for confounders/effect modifiers. RESULTS: One hundred twenty-three residents responded to the survey (12.3% response rate). Respondents expressed positive attitudes regarding biostatistics in plastic surgery practice, but only moderate levels of confidence with various biostatistical concepts. Both attitudes and confidence were positively associated with the number of plastic surgery journals read monthly and formal coursework in biostatistics (P < 0.01). Resident attitudes were positively correlated with confidence (r = 0.33, P < 0.01). The mean percentage of correct responses on knowledge-assessments was 43.6% (20.8%). Integrated residents performed better than independent track residents (P = 0.04). Residents had difficulty with study design, the correct use of analysis of variance, regression analysis, and identifying a statistically significant result. Resident confidence was moderately correlated with performance (r = 0.31, P = 0.01). CONCLUSIONS: Plastic surgery residents place a high degree of importance on knowledge of biostatistics in the practice of plastic surgery but have only a fair understanding of core statistical concepts.

Implementation and Analysis of a Lean Six Sigma Program in Microsurgery to Improve Operative Throughput in Perforator Flap Breast Reconstruction.

PURPOSE: Perforator flaps have become a preferred method of breast reconstruction but can consume considerable resources. We examined the impact of a Six Sigma program on microsurgical breast reconstruction at an academic medical center. METHODS: Using methods developed by Motorola and General Electric, we applied critical pathway planning, workflow analysis, lean manufacturing, continuous quality improvement, and defect reduction to microsurgical breast reconstruction. Primary goals were to decrease preoperative-to-cut time and total operative time, through reduced variability and improved efficiency. Secondary goals were to reduce length of stay, complications, and reoperation. The project was divided into 3 phases: (1) Pre-Six Sigma (24 months), (2) Six Sigma (10 months), (3) and Post-Six Sigma (24 months). These periods (baseline, intervention, control) were compared by Student t test and χ analysis. RESULTS: Over a 5-year period, 112 patients underwent 168 perforator flaps for breast reconstructions, by experienced microsurgeons. Total operative time decreased from 714 to 607 minutes (P < 0.01), across the study period, with the greatest drop occurring in unilateral cases, from 672 to 498 minutes (P < 0.01). Length of stay decreased from 6.3 to 5.2 days (P = 0.01). Overall complication rates (35.9% vs 30%, not significant) and take-back rates (20.5% vs 23.9%, not significant) remained similar over the 5-year period. Physician revenue/minute increased from US $6.28 to US $7.59, whereas hospital revenue/minute increased from US $21.84 to US $25.11. CONCLUSIONS: A Six Sigma program in microsurgical breast reconstruction was associated with better operational and financial outcomes. These incremental gains were maintained over the course of the study, suggesting that these benefits were due, in part, to process improvements. However, continued reductions in total operative time and length of stay, well after the intervention period, support the possibility that "learning curve" phenomenon may have contributed to the improvement in these outcomes.

Professionalism in plastic surgery: attitudes, knowledge, and behaviors in medical students compared to surgeons in training and practice--one, but not the same.

INTRODUCTION: Professionalism is now recognized as a core competency of surgical education and is required for certification and licensure. However, best teaching methods remain elusive, because (1) ethical standards are not absolute, and (2) learning and teaching styles vary considerably-both of which are influenced by cultural and generational forces. We sought to compare attitudes, knowledge, and behaviors in fourth year medical students, compared to surgeons in training and practice, focusing on issues related to professionalism in plastic surgery. METHODS: Fourth year medical students participating in a capstone course (n = 160), surgical residents (n = 219), and attending surgeons (n = 99) at a single institution were asked to complete a questionnaire regarding surgical professionalism. Participants (1) identified components of professionalism, (2) cited examples of unprofessional behavior, (3) ranked the egregiousness of 30 scenarios, and (4) indicated best educational practices. Cohorts were compared using t test and χ, with statistical significance assigned to P values less than 0.05. RESULTS: Compared to surgeons in training or practice, medical students were younger (27.8 vs 38.0 years, P < 0.001) and more often female (51.1% vs 36.6%, P < 0.03). Both groups cited "a body of ethics" as the defining component of professionalism. Respondents from both groups agreed that professionalism could be taught, learned, and assessed. Surgeons (94.3%) had observed unprofessional behavior, as did 88.0% of students; "poor anger management," "dishonesty," and "bullying" were the most common examples. Compared to students, however, surgeons were more likely to witness substance and physical abuse (P < 0.05). From the list of 30 scenarios, both groups picked the following as the most egregious, although in different order: working while impaired, fraudulent billing, dating a patient, lying on rounds, self-prescribing, and sexual harassment. Both students and surgeons agreed that the following scenarios were unethical: "fraudulent billing while on a mission trip" (84% vs 90%, NS), "showing inaccurate preop/postop photos" (70% vs 75%, NS), and "failing to disclose a conflict of interest" (56% vs 57%). Students and surgeons disagreed that the following scenarios were egregious: "owning biotech stock in a company whose product the surgeon uses" (33% vs 13%, P < 0.01), and "offering a breast augmentation as part of a charity raffle" (45% vs 58%, P < 0.05). Both students and surgeons agreed "advertising on a highway billboard was NOT unprofessional (87% vs 85%, NS). CONCLUSIONS: Despite differences in age and sex, medical students and surgeons have similar attitudes about professionalism in plastic surgery, but differ in their knowledge and observations. Understanding cultural and generational factors may help educators teach and model cognitive and behavioral aspects of professionalism. The fact that some clearly egregious behaviors are not viewed as unethical by individual students, trainees, and surgeons, and that such behavior continues to be observed, indicates the need to improve our efforts in promoting professionalism in plastic surgery.

Efficacy of intense pulsed light for the treatment of burn scar dyschromias: a pilot study to assess patient satisfaction, safety, and willingness to pay.

INTRODUCTION: No treatment algorithms exist to reliably treat burn scar dyschromias. Intense pulsed light (IPL) has been used successfully to treat hyperpigmentation disorders, but has not been studied extensively in the treatment of burn scars. The purpose of this investigation was to assess clinical efficacy and patient satisfaction with IPL for the treatment of burn scar dyschromia. METHODS: Patients with burn scar dyschromias were treated using the Lume 1 platform (Lumenis) to target pigmented lesions, using fluences between 10 and 22 joules/cm and filters ranging from 560 to 650 nm. At the conclusion of the study, providers assessed changes in burn scar dyschromia, whereas patients were queried regarding satisfaction and perceived efficacy, using a 1 to 5 Likert scale. The patients, who were not charged for the IPL treatment, were queried regarding willingness to pay. RESULTS: Twenty patients (mean age, 35.4 years; mean total body surface area, 27.6%; mean composite Fitzpatrick score, 3.9) underwent IPL treatment of burn scar dyschromias, an average of 3.2 years after injury. Mean fluence was 15.4 J/cm (range, 10-22 J/cm), and the most common filter used was 590 nm (range, 560-650 nm). Mean area treated was 90.7 cm, with a range of 4 to 448 cm. Complications included pain (4), hyperpigmentation (1), and blistering (2). Sixteen patients noted mild to moderate improvement, reporting a 4.5 for efficacy and a 4.4 for satisfaction. Regarding willingness to pay, patients would spend a mean of U.S. $7429 to completely remove their scars, but only a median of U.S. $350 to get the actual results that they received. Mean length of follow-up was 3.8 months, with a standard deviation of 2.2 months. CONCLUSIONS: Patients perceived IPL as an efficacious modality in the treatment of burn scar dyschromia, with a high level of satisfaction, despite the potential for morbidity. However, we are reluctant to recommend IPL for routine treatment of burn scar dyschromias, given only minimal improvement observed, potential for complications, and a willingness to pay that is lower than the cost of providing care.