Frailty as a Predictor of Post-Surgical Outcomes in Patients With Cutaneous Malignancies of the Scalp and Neck Requiring Flap Reconstruction.

BACKGROUND: Investigate the ability of frailty status to predict post-surgical outcomes in patients with cutaneous malignancies of the scalp and neck undergoing flap reconstruction. METHODS: National Surgical Quality Improvement Program database was used to isolate patients with cutaneous malignancies of the scalp and neck who underwent surgical resection between 2015 to 2019. Univariate and multivariate analyses were performed to determine if frailty score correlated with negative post-operative outcomes. Receiver operating characteristic (ROC) curves allowed testing of the discriminative performance of age versus frailty. RESULTS: This study demonstrated an independent correlation between frailty and major complications as well as non-home discharge. In ROC curve analysis, frailty demonstrated superior discrimination compared to age for predicting major complications. CONCLUSION: Our study demonstrated an association between increasing frailty and major complications as well as the likelihood of a non-home discharge. When compared to age, frailty was also shown to be a better predictor of major complications.

Occult Malignancy in Adult Tonsillectomy for Benign Indication.

OBJECTIVE: National pathology guidelines recommend full pathologic analysis for all adult tonsillectomy specimens. We evaluated the available data on occult malignancy in adult tonsillectomy for benign indication, and created a screening system to reduce the risk of missed malignancies if routine histopathologic examination were to be discontinued. STUDY DESIGN: Retrospective chart review and systematic review of the literature. SETTING: Tertiary care academic hospital and multi-hospital private healthcare system. SUBJECTS AND METHODS: A systematic literature review identified case series of adult tonsillectomy. Retrospective chart review at our institutions from 2000 to 2016 produced an additional case series. The pooled rate of occult malignancy was determined, and re-analyzed using criteria based on preoperative risk factors designed to identify patients requiring full pathologic analysis. The predicted effects of prospective application of the proposed criteria were calculated. Pooled occult malignancy prevalence was estimated. RESULTS: Literature review and our own case series yielded 12,094 total cases. Occult malignancy prevalence in the combined data was 0.033%, representing four occult malignancies. Three out of the four would have been selected for full pathology preoperatively with use of the proposed criteria. Statistical analysis indicates that the predicted frequency of occult malignancy incidence in cases negative for the criteria is 0.01%, or 1/10,000. CONCLUSION: Application of the proposed criteria to adults undergoing tonsillectomy for benign indication identifies a subset of patients with an estimated incidence of occult malignancy similar to that reported for pediatric tonsillectomy, and potentially may permit safe elimination of pathologic analysis of their tonsil specimens. LEVEL OF EVIDENCE: Pooled analysis of case series from the literature and a single institution, level 4.

Microvascular clamp technique as a reversible simulation of parathyroid gland excision.

INTRODUCTION: This study demonstrates the effectiveness of a microvascular clamp to simulate parathyroid adenoma excision with respect to intraoperative parathyroid hormone (ioPTH) changes in vivo. METHODS: Cases in which microvascular clamps were employed intraoperatively in conjunction with intraoperative parathyroid hormone(ioPTH) assays were reviewed. ioPTH values were recorded throughout these procedures to assess the efficacy and reversibility of tissue ischemia using microvascular clamps. RESULTS: Application of a microvascular clamp across the vascular pedicle of a parathyroid adenoma resulted in a significant ioPTH drop in 95% of cases (N = 20). Removal of the clamp resulted in complete or partial rebound of ioPTH in 90% of cases (N = 20). CONCLUSION: The use of a microvascular clamp to temporarily occlude a parathyroid gland's vascular pedicle is an effective simulation of gland excision with respect to ioPTH changes. Rebound of ioPTH levels after clamp removal demonstrates that this technique is generally reversible. LEVEL OF EVIDENCE: 2b, Retrospective cohort study.

A pilot study on providing ophthalmic training to medical students while initiating a sustainable eye care effort for the underserved.

IMPORTANCE: We present a method to reintroduce ophthalmic training into the medical school curriculum. OBJECTIVES: To evaluate knowledge and skills acquired when participating in a service project, the Community Vision Project, and to develop a quantitative method for testing skills with the direct ophthalmoscope in patients. DESIGN: Second-year medical students participated in the study. After 1 month, their knowledge was compared with that of peers and graduates (internal medicine residents). Also at 1 month, their direct ophthalmoscope skills were compared with those of upperclassmen who had completed all core clerkships. One year later, after the participants had completed their core clerkships, long-term ophthalmoscope skills retention was tested, and their performance was compared with that of their classmates. SETTING AND PARTICIPANTS: Training occurred in mobile eye clinics. Knowledge and skills assessments were performed in the hospital eye clinic among students and residents at The University of New Mexico School of Medicine. Patients were recruited from the hospital eye clinic. Participants attended a 3-hour training session held by an attending physician in the hospital eye clinic and took part in at least 1 mobile eye clinic. MAIN OUTCOMES AND MEASURES: A knowledge assessment quiz was administered to participants (n = 12), their classmates (n = 18), and internal medicine residents (n = 33). Skills assessment with the direct ophthalmoscope was performed at 1 month and at 1 year in 5 participants and 5 nonparticipants. Tonometer skills were assessed by comparing participants' readings with those of an ophthalmologist's obtained in patients at the mobile eye clinics. RESULTS Participants' median knowledge assessment scores were 48% higher than those of their classmates and 37% higher than those of internal medicine residents (P < .001 for both). Short-term (1 month) direct ophthalmoscopy median scores were 60% (quartile 1 to quartile 3 range, 40%-80%) for participants and 40% (quartile 1 to quartile 3 range, 20%-60%) for nonparticipating upperclassmen (P = .24). Long-term direct ophthalmoscopy median scores were 100% (quartile 1 to quartile 3 range, 75%-100%) for participants and 0% (quartile 1 to quartile 3 range, 0%-25%) for nonparticipating classmates (P = .11). Participants' tonometer readings were similar to those of the ophthalmologist's; their median reading was 2 mm Hg (quartile 1 to quartile 3 range, 0-4 mm Hg) higher than that of the ophthalmologist's (P = .05, sign test). CONCLUSIONS AND RELEVANCE: Service-based learning offered an efficient model for incorporating ophthalmic training into the medical school curriculum. A viable tool for quantitatively testing ophthalmoscope skills is presented.