Retrospective Cohort Analysis on the Use of Hydrolyzed Collagen Powder in Back Reconstruction Following Spinal Instrumentation.

Background: Nearly half a million interbody fusions are estimated to be performed in the US each year, many of which involve complex reconstruction. The ability to limit seroma formation is vital to a seamless postoperative recovery. Methods: A retrospective review was performed for patients undergoing fusion procedures along with flap reconstruction over a period of 20 months. Cohorts reflect a temporal practice shift where use of hydrolyzed collagen powder (HCP) was initiated for hypothesized seroma prevention. Outcomes and associated metrics were used for intergroup comparison. Results: The study included 76 patients, of whom 47 were treated with HCP and 29 were not. Control patients had significantly fewer postoperative seromas than experimental ones (6.9% vs 27.7%; P = .03). The cohorts had no significant differences in time until final drain removal or in number of spinal levels involved (7.8 vs 7.1 days; P = .33, 8.5 vs 8.4 levels; P = .90). Rates of wound dehiscence, hematoma, or infection did not differ significantly between control and experimental patients (3.4% vs 12.8%, P = .17; 0% vs 0%; and 6.9% vs 10.6%, P = .58, respectively). Conclusions: The use of HCP led to a 4-fold increase in postoperative seromas in patients undergoing spinal fusion with flap reconstruction. This was regardless of all analyzed demographic and procedural factors, with the exception of age, whereby control patients were found to be on average slightly younger than experimental counterparts.

A Prospective Cohort Study Re-examining Tissue Oximetry Monitoring in Microsurgical Breast Reconstruction.

BACKGROUND: The goal of inpatient monitoring after microsurgical breast reconstruction is to detect vascular compromise before flap loss. Near-infrared tissue oximetry (NITO) is commonly used for this purpose, but recent reports challenge its specificity and utility in current practice. Fifteen years after Keller published his initial study using this technology at our institution, we re-evaluate the role and limitations of this popular monitoring device. METHODS: A 1-year prospective study was performed for patients undergoing microsurgical breast reconstruction and monitored postoperatively using NITO. Alerts were evaluated, and clinical endpoints relating to an unplanned return to the operating room or flap loss were recorded. RESULTS: A total of 118 patients reconstructed with 225 flaps were included within the study. There were no cases of flap loss at the time of discharge. There were 71 alerts relating to a drop in oximetry saturation. Of these, 68 (95.8%) were deemed to be of no significance. In 3 cases (positive predictive value of 4.2%), the alert was significant, and there were concerning clinical signs apparent at that point. A sensor in an inframammary fold position was associated with nearly twice the average number of alerts as compared with areolar or periareolar positions ( P = 0.01). In 4 patients (3.4%), a breast hematoma required operative evacuation, and these cases were detected by nursing clinical examination. CONCLUSIONS: The monitoring of free flaps after breast reconstruction through tissue oximetry shows a poor positive predictive value for flap compromise and requires clinical corroboration of alerts but missed no pedicle-related adverse events. With a high sensitivity for pedicle-related issues, NITO may be helpful postoperatively, but the exact timeframe for use must be weighed at the institutional level.

The Effects of Autologous Fat Transfer in an In Vitro Model of Basal Joint Osteoarthritis.

PURPOSE: Basal joint osteoarthritis (OA) is a highly prevalent and debilitating condition. Recent clinical evidence suggests that autologous fat transfer (AFT) may be a promising, minimally invasive treatment for this condition. However, the mechanism of action is not fully understood. It is theorized that AFT reduces inflammation in the joint, functions to regenerate cartilage, or acts as a mechanical buffer. The purpose of this study was to better understand the underlying mechanism of AFT using an in vitro model. We hypothesize that the addition of stromal vascular fraction (SVF) cells will cause a reduction in markers of inflammation. METHODS: Articular chondrocytes were expanded in culture. Liposuction samples were collected from human subjects and processed similarly to AFT protocols to isolate SVF rich in adipose-derived stem cells. A control group was treated with standard growth media, and a positive control group (OA group) was treated with inflammatory cytokines. To mimic AFT, experimental groups received inflammatory cytokines and either a low or high dose of SVF. Expression of relevant genes was measured, including interleukin (IL)-1ß, IL-1 receptor antagonist, and matrix metalloproteinases (MMP). RESULTS: Compared to the OA group, significant decreases in IL-1ß, MMP3, and MMP13 expression on treatment day 3 were found in the high-dose SVF group, while MMP13 expression was also significantly decreased in the low-dose SVF group on day 3. CONCLUSIONS: In this study, we found that SVF treatment reduced expression of IL-1ß, MMP3, and MMP13 in an in vitro model of OA. These results suggest that an anti-inflammatory mechanism may be responsible for the clinical effects seen with AFT in the treatment of basal joint OA. CLINICAL RELEVANCE: An anti-inflammatory mechanism may be responsible for the clinical benefits seen with AFT for basal joint arthritis.

Internal Mammary Lymph Node Biopsy during Microsurgical Breast Reconstruction: A Prospective Study.

BACKGROUND: Accurate assessment of regional lymph node basins is critical for oncological management of breast cancer. The internal mammary lymph node (IMLN) basin directly drains the medial pole of the breast, but biopsy is not commonly performed. While the axillary sentinel lymph node sample remains the standard of care, the majority of patients who have been found to have a positive IMLN biopsy have simultaneously had negative axillary sentinel lymph nodes. This study prospectively examines routine IMLN biopsy during microsurgical breast reconstruction. METHODS: An IRB-approved study of routine IMLN biopsies in 270 consecutive patients who underwent microsurgical breast reconstruction was performed from July 1, 2018, to June 1, 2021. Recorded data included unilateral or bilateral breast reconstruction, unilateral or bilateral IMLN sampling, patient demographics, disease stage, and pathologic findings of IMLN. RESULTS: The majority of patients, 240 of 270 patients (88.9%), had bilateral reconstruction. Overall, 5 out of 270 (1.9%) patients had positive IMLN; one of these patients had positive axillary sentinel lymph nodes. The IMLN biopsy results in two of the five patients affected the clinical course as they were upstaged and required chemoradiation. CONCLUSION: Direct visualization of the internal mammary lymph nodes during dissection of the recipient vessels for microsurgical breast reconstruction allows for convenient sampling, with minimal donor site morbidity and enhances the therapeutic management of patients in whom nodal involvement is present. As such, the authors recommend IMLN sampling.

Conflict of Interest at Microsurgery Conferences: Disclosure of Its Extent and Nature.

BACKGROUND: Industry relationships and conflicts of interest can impact research funding, topics, and outcomes. Little research regarding the role of biomedical companies at microsurgery conferences is available. This study evaluates the role of industry at conferences by comparing payments received by speakers at the American Society for Reconstructive Microsurgeons (ASRM) meeting with those received by speakers at the American Society of Aesthetic Plastic Surgeons (ASAPS) meeting, the American Society of Plastic Surgeons (ASPS) meeting, and an average plastic surgeon. It also compares payments made by different companies. METHODS: General payments received by speakers at the 2017 ASAPS, ASPS, and ASRM conferences were collected from the Open Payments Database. Mean payments received at each conference were calculated and the Mann-Whitney U test evaluated differences between conference speakers and the average plastic surgeon. The total amount of payments from each company was collected through the Open Payments Database, and Z-tests identified which companies paid significantly more than others. RESULTS: The mean (and median) general payments made to conference speakers at ASAPS (n = 75), ASPS (n = 247), and ASRM (n = 121) were $75,577 ($861), $27,562 ($1,021), and $16,725 ($652), respectively. These payments were significantly greater (p < 0.001 for all) than those of the average plastic surgeon ($4,441 and $327), but not significantly different from each other. Allergan contributed significantly more than other companies to speakers at ASPS and ASAPS, while LifeCell Corporation, Zimmer Biomet Holdings, and Axogen contributed significantly more to speakers at ASRM. CONCLUSION: Payments to physicians at ASRM were significantly higher than those of an average plastic surgeon but not significantly different from those of speakers at ASAPS and ASPS. Certain companies paid significantly more than their peers at each conference. Given these findings, speakers should strive to make clear the nature and extent of their conflicts of interest when presenting at conferences.

Joint-Venture Ambulatory Surgery Centers: The Perfect Partnership.

BACKGROUND: Ambulatory surgery growth has increased in the last few decades as ambulatory surgery centers have been shown to succeed in cost efficiencies through their smaller size and breadth, specialization of care, and ability to quickly participate in perioperative process improvement and education. METHODS: A 5-year retrospective fiscal review was performed for all Northwell Health-physician ambulatory surgery center joint ventures. The outcome measures studied included model of ownership, specialty types, and gross revenue. Additional facility characteristics were studied, including growth trajectory, facility size, and cost to build a de novo facility. RESULTS: Eleven free-standing ambulatory surgery centers were identified at Northwell Health during the 5-year study period. The total gross revenue for all Northwell clinical joint ventures for 2019 alone was $102,854,000. Northwell Health is a majority stakeholder in eight of their joint venture ambulatory surgery centers, with an average Northwell ownership of 53 percent and an average number of physician owners per facility of 11. The number of hospital-physician joint-venture ambulatory surgery centers grew from two to 11 facilities during the study period (450 percent). Surgical volume followed a similar trajectory, increasing 295 percent over the same time period. CONCLUSIONS: The ambulatory surgery center setting provides a vast number of possibilities for key stakeholders, including patients themselves, to benefit from financial and clinical efficiencies. Ambulatory surgery centers have been popular, as they meet patient expectations for convenience of elective surgery, reduce payer and clinical pressures to minimize length of stay in hospitals, and achieve similar or higher quality care with less intense resources.

Evaluation of internal mammary lymph node biopsy during microsurgical breast reconstruction: An analysis of 230 consecutive patients.

INTRODUCTION: Clinical significance of internal mammary (IM) lymph node biopsy during microvascular free flap breast reconstruction remains controversial. Some microsurgeons may choose to biopsy an IM lymph node during routine IM vessel dissection. The authors reviewed the results of IM lymph node biopsy during autologous breast reconstruction. METHODS: A retrospective chart review of patients who underwent autologous breast reconstruction during a seven-year period (January 2010 to January 2017) was performed. Patient demographic data, disease staging, flap details, pathology reports, and adjuvant treatment were evaluated. RESULTS: A total of 230 patients with a mean age of 52.1 (SD 9.3) underwent IM lymph node biopsy (n = 297). Single IM lymph node was removed in 169 patients, 2 nodes were removed in 56 patients, 3 nodes in 4 patients, and 4 nodes in a single patient. Histopathologic analysis demonstrated presence of IM lymph node metastasis in 16 patients (7.0%). Thirteen patients were found to have metastatic IM lymph nodes in the setting of immediate reconstruction. Three patients were found to have metastatic IM lymph nodes in the setting of delayed. Five out of 16 patients (31.3%) had negative axillary sentinel lymph node biopsy and IM lymph nodes were the only site of nodal metastases. All five of these patients were upstaged accordingly and received adjuvant therapy based on the discussion at the multidisciplinary breast tumor conference. CONCLUSIONS: Opportunistic internal mammary lymph node sampling during autologous breast reconstruction can be performed with minimal morbidity and has significant impact on the disease staging and adjuvant treatment.

Plastic Surgery Chairs and Program Directors: Are the Qualifications Different for Men and Women?

BACKGROUND: The gender disparity between the number of female and male chairs and program directors has been previously established. The aim of this study was to determine whether any differences in objective credentials existed between male and female plastic surgery department chairs/division chiefs and program directors. METHODS: Information about each plastic surgery program director and chair/chief was extracted from the websites of all institutions affiliated with a plastic surgery residency program. For each individual, information about the length of their career, number of fellowships completed, and number of publications was recorded. The two-tailed t test was used to compare differences between male and female chairs and program directors. RESULTS: A total of 99 chairs were recorded, of which nine (9.1 percent) were female. Of the 99 program directors, 13 (13.1 percent) were female. There was no difference in the number of years in practice or number of fellowships between men and women for either position. On average, male chairs had significantly fewer publications than female chairs (71.9 versus 128; p < 0.05). There was no significant difference in the number of publications between male and female program directors. Compared to program directors, chairs had significantly more years in practice and numbers of publications, which held true for both men and women. CONCLUSIONS: Women are not only underrepresented in the department chair and program director positions, but also possess higher qualifications that may reflect differences in standards for promotion and appointment. Additional research is needed to elucidate the reasons behind the observed differences in qualifications.

The State of Plastic Surgery Education Outside of the Operating Room.

BACKGROUND: Plastic surgery education consists of technical skills, surgical decision-making, and the knowledge necessary to provide safe patient care. Competency in these modalities is ensured by requiring case minimums and oral and written examinations. However, there is a paucity of information detailing what teaching modalities residency programs use outside of the operating room. METHODS: A 16-question survey was sent to all integrated and independent program directors. Information regarding nonsurgical resident education was collected and analyzed. RESULTS: There were 44 responses (46 percent). Most programs had six to 10 faculty (43 percent), and a majority (85 percent) required faculty to participate in resident education outside of the operating room. Residents most commonly had 3 to 4 hours (43 percent) of protected educational time 1 day per week (53 percent). Nonsurgical education consisted of weekly lectures by attending physicians (44 percent) and residents (54 percent), in addition to weekly CoreQuest (48 percent), teaching rounds (38 percent), and Plastic Surgery Education Network lectures (55 percent). Monthly activities included morbidity and mortality conference (81 percent) and journal club (86 percent). Indications conference was either monthly (41 percent) or weekly (39 percent). Cadaver laboratories, visiting professors, board preparation, in-service review, and meetings with the program director occurred yearly or several times per year. Forty-nine percent of programs sponsor one educational course per resident. In addition, most programs (65 percent) do not receive outside funding for education. CONCLUSIONS: These findings improve understanding of the current state of nonsurgical resident education in plastic surgery. They illustrate that residents participate in a diverse number of nonsurgical educational activities without any significant standardization.

The COVID-19 Pandemic: Crisis Management for Plastic Surgeons.

The worldwide outbreak of coronavirus disease 2019 (COVID-19) has forced health care systems across the United States to undertake broad restructuring to address the ongoing crisis. The framework of crisis management can assist plastic surgeons navigate the dynamic environment of the COVID-19 pandemic. This article outlines crisis management tools at a number of different levels, from hospital-wide to plastic surgeon-specific, and it offers a practical discussion of the coronavirus situation as it affects plastic surgeons. Although there are innumerable ways that this virus is currently changing plastic surgeons' practices, it is crucial to remember that these changes are temporary, and they will be best met by being confronted head-on.

Is There Gender Inequality in Plastic Surgery? Evaluation of Society Leadership and Composition of Editorial Boards.

BACKGROUND: Women now constitute 40.5 percent of integrated plastic surgery residents; however, in 2007, women represented only 11.3 percent of the leadership positions in plastic surgery societies and journal editorial boards. The authors analyzed female representation in these societies and editorial boards over the past 10 years. METHODS: Names of board members from the major plastic surgery societies (American Society of Plastic Surgeons, The Plastic Surgery Foundation, and American Society for Aesthetic Plastic Surgery, among others) for the past 10 years and the major plastic journals (Plastic and Reconstructive Surgery, Annals of Plastic Surgery, and so on) from the past 5 years were extracted from their websites. The yearly percentage of female plastic surgery residents was obtained from Accreditation Council for Graduate Medical Education published data. The proportions of women in society leadership, editorial boards, and residency were compared with data analyses of time series trend and linear and Auto Regressive Integrated Moving Average time series modeling. RESULTS: Over the past 10 years, the percentage of female residents has grown steadily, from 21.84 percent to 37.31 percent. Similarly, female representation in society leadership has grown from 6.78 percent to 20.29 percent. Both growth coefficients were statistically significant and showed no statistical difference between the two. In contrast, editorial board leadership over the past 5 years showed statistically insignificant growth and showed a statistically significant difference when compared to the growth of the percentage of female residents and female representation in society leadership. CONCLUSION: Female representation in plastic surgery society leadership shows promising growth, whereas their representation on editorial boards showed significantly less growth, which may reflect the slower turnover on these boards.

Postoperative Upper Extremity Function in Implant and Autologous Breast Reconstruction.

BACKGROUND: After mastectomy and breast reconstruction, many patients experience upper extremity complications, such as pain, restriction in motion, and lymphedema. Despite an aesthetically satisfactory outcome, these occurrences can diminish a patient's postoperative quality of life. Several studies have investigated the causes and incidence of these complications. However, there is currently a paucity of data comparing postoperative upper extremity function according to reconstruction technique. METHODS: A review was performed of patients enrolled in a physical therapy (PT) program after mastectomy and immediate breast reconstruction. PT initial encounter evaluations were used to gather data on patients' postoperative upper extremity function. Hospital records were used to gather surgical and demographic data. For each patient, data were collected for each upper extremity that was ipsilateral to a reconstructed breast. Data were then compared between patients who underwent implant-based versus autologous deep inferior epigastric perforator flap reconstruction. RESULTS: A total of 72 patients were identified, including 39 autologous and 33 implant-based reconstruction cases. Proportions of patients who underwent sentinel lymph node biopsies and axillary lymph node dissections were similar between the two groups. The autologous-based reconstruction patients had significantly higher arm pain at rest (p = 0.004) and with activity (p = 0.031) compared with implant patients. Shoulder range of motion and manual muscle test results were similar between groups, with the exception of elbow flexion, which was weaker in implant patients (p = 0.030). Implant patients were also more likely to report "severe difficulty" or "inability" to perform activities of daily living (p = 0.022). Edema/swelling, axillary cording, and lymphedema girth measurements were similar between the two groups. CONCLUSION: Different techniques of breast reconstruction can result in different postoperative upper extremity complications. These data show specific areas where postoperative care and PT can be customized according to reconstruction type. Investigation is currently underway to determine the effect of PT on upper extremity function in these patients.

Conflict of Interest at Plastic Surgery Conferences: Is It Significant?

BACKGROUND: The Physician Payment Sunshine Act requires biomedical companies to disclose financial relationships between themselves and physicians. The authors compared the amount of money received by speakers at the American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery annual conferences with that received by the average plastic surgeon. METHODS: General payments data were gathered from the Open Payments database for physicians listed as a presenter, moderator, panelist, lecturer, or instructor at the 2017 annual American Society of Plastic Surgeons and American Society for Aesthetic Plastic Surgery conferences. Means and medians of payments to speakers were calculated for each conference. One-tail t tests were used to evaluate differences. RESULTS: The mean and median for general payments made to conference speakers at American Society for Aesthetic Plastic Surgery (n = 75) and American Society of Plastic Surgeons (n = 249) meeting were $75,577 and $861 and $27,562 and $1021, respectively. In comparison with the average general payment received by plastic surgeons (mean, $4788; median, $3209), these differences were significant (American Society for Aesthetic Plastic Surgery, p = 0.015; American Society of Plastic Surgeons, p = 0.0004). CONCLUSIONS: The significant difference in payments to speakers at conferences compared with the average plastic surgeon suggests that biomedical companies may have influence over some of the conference content. Speakers must make clear the full extent of industry relationships that could potentially bias their presentations.

The Public Face of Rhinoplasty: Impact on Perceived Attractiveness and Personality.

BACKGROUND: The authors assess the impact of rhinoplasty on public perception of a patient's appearance and personality. METHODS: A survey was created using standardized before-and-after photographs of 10 Caucasian women who had undergone primary rhinoplasty. Photographs of two additional women who had not undergone facial surgery were randomly included as controls, for a total of 12 survey items. Preoperative and postoperative photographs were placed side by side. The survey was administered by means of crowd-sourcing. Respondents were asked to evaluate which photograph better represented 11 traits of appearance or personality, according to a seven-point Likert scale. A score of 1 meant the preoperative photograph was much better, 7 meant the postoperative photograph was much better, and 4 meant no difference. T tests and analyses of variance were used to evaluate rating changes for each trait and differences between demographic groups. RESULTS: There were 264 responses received. Averaged scores across the 10 survey patients produced a value for each appearance or personality trait. In 10 of 11 categories (i.e., symmetry, youthfulness, facial harmony, likeability, trustworthiness, confidence, femininity, attractiveness, approachability, and intelligence), the postoperative photograph was significantly favorable compared with the preoperative photograph (p < 0.00001). The preoperative photograph was rated higher only in aggressiveness (p < 0.001). The same scores were calculated for the controls; no significant difference in any category was seen except confidence, where the right image was viewed as more confident (mean, 4.19; p < 0.005). CONCLUSION: Aesthetic rhinoplasty improves the public perception of a person's appearance and personality in multiple aspects.

Factors Influencing Patient Satisfaction in Plastic Surgery: A Nationwide Analysis.

BACKGROUND: Patient satisfaction surveys are an increasingly important part of health care, influencing the practice of physicians. Press Ganey has developed tools to assess physician and department performance that are used by 50 percent of hospitals in the United States and over 10,000 health care organizations. The authors sought to evaluate the factors that influence patient satisfaction in plastic surgery patients both locally and nationally. METHODS: A 24-item Press Ganey survey was distributed to patients of 686 participating plastic surgeons nationwide, including those at the authors' home institution. The responses from January to December of 2016 were analyzed retrospectively with Pearson correlation coefficients. The items "likelihood to recommend provider" and "likelihood to recommend practice" were correlated to all other items of the survey, as these items have been shown to be surrogates for overall satisfaction. RESULTS: There were 411 survey responses from patients in the Northwell Health System and 36,836 responses from patients nationally. Items that were not well correlated (r < 0.5) with "likelihood to recommend practice" or "provider" were items such as wait time and courtesy of registration staff. The items that were best correlated (r > 0.8) with "likelihood to recommend practice" or "provider" were the patient's confidence in the care provider and the provider's concern for questions. All correlations were statistically significant (p < 0.001). CONCLUSION: In an evolving patient centric culture, the patient's confidence and trust of the provider is more important than perception of the provider's office environment to maintaining patient loyalty and market share.

Routine Pathologic Evaluation of Plastic Surgery Specimens: Are We Wasting Time and Money?

BACKGROUND: Recent health care changes have encouraged efforts to decrease costs. In plastic surgery, an area of potential cost savings includes appropriate use of pathologic examination. Specimens are frequently sent because of hospital policy, insurance request, or habit, even when clinically unnecessary. This is an area where evidence-based guidelines are lacking and significant cost-savings can be achieved. METHODS: All specimen submitted for pathologic examination at two hospitals between January and December of 2015 were queried for tissue expanders, breast implants, fat, skin, abdominal pannus, implant capsule, hardware, rib, bone, cartilage, scar, and keloid. Specimens not related to plastic surgery procedures were excluded. Pathologic diagnosis and cost data were obtained. RESULTS: A total of 759 specimens were identified. Of these, 161 were sent with a specific request for gross examination only. There were no clinically significant findings in any of the specimens. There was one incidental finding of a seborrheic keratosis on breast skin. The total amount billed in 2015 was $430,095. CONCLUSIONS: The infrequency of clinically significant pathologic examination results does not support routine pathologic examination of all plastic surgery specimens. Instead, the authors justify select submission only when there is clinical suspicion or medical history that warrants evaluation. By eliminating unnecessary histologic or macroscopic examination, significant cost savings may be achieved.

Melanoma Extirpation with Immediate Reconstruction: The Oncologic Safety and Cost Savings of Single-Stage Treatment.

BACKGROUND: The timing of reconstruction following melanoma extirpation remains controversial, with some advocating definitive reconstruction only when the results of permanent pathologic evaluation are available. The authors evaluated oncologic safety and cost benefit of single-stage neoplasm extirpation with immediate reconstruction. METHODS: The authors reviewed all patients treated with biopsy-proven melanoma followed by immediate reconstruction during a 3-year period (January of 2011 to December of 2013). Patient demographic data, preoperative biopsies, operative details, and postoperative pathology reports were evaluated. Cost analysis was performed using hospital charges for single-stage surgery versus theoretical two-stage surgery. RESULTS: During the study period, 534 consecutive patients were treated with wide excision and immediate reconstruction, including primary closure in 285 patients (55 percent), local tissue rearrangement in 155 patients (30 percent), and skin grafting in 78 patients (15 percent). The mean patient age was 67 years (range, 19 to 98 years), and the median follow-up time was 1.2 years. Shave biopsy was the most common diagnostic modality, resulting in tumor depth underestimation in 30 patients (6.0 percent). Nine patients (2.7 percent) had positive margins on permanent pathologic evaluation. The only variables associated with positive margins were desmoplastic melanoma (p = 0.004) and tumor location on the cheek (p = 0.0001). The mean hospital charge for immediate reconstruction was $22,528 compared with the theoretical mean charge of $35,641 for delayed reconstruction, leading to mean savings of 38.5 percent (SD, 7.9 percent). CONCLUSION: This large series demonstrates that immediate reconstruction can be safely performed in melanoma patients with an acceptable rate of residual tumor requiring reoperation and significant health care cost savings. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.