Interest in global surgery rotations among oral and maxillofacial surgical residents in the United States.

PURPOSE: This study sought to assess interest in global surgery rotations among current United States (US)-based oral and maxillofacial surgery (OMS) residents. METHODS: An anonymous 23-question survey was distributed to 633 current OMS residents in the US to examine resident interest in global surgery rotations during residency. The primary outcome variable was resident interest in participating in global OMS rotations during residency training, whereas the primary predictor variable was the presence of residency faculty involved in global OMS work. Descriptive statistics were calculated for all study variables and univariate/multivariate logistic regression analyses were conducted to identify predictors of interest in global OMS rotations. RESULTS: A total of 120 residents with an average age of 30.4 ± 3.2 years responded to the survey. At present, 22 (18.5%) residents stated that their residency programs offer some sort of global OMS rotation and 21 (95.5%) of these claimed they were willing to participate in global OMS rotations at their residency program. Out of the residents who stated their program did not offer a global OMS rotation, 86 (87.8%) respondents stated they would be interested in adding a dedicated global OMS rotation to their residency curriculum. The presence of OMS residency faculty involved in global OMS work (p = 0.030) and a resident's willingness to dedicate vacation time to participate in a global surgery rotation (p = 0.005) were associated with increased interest in a global surgery rotation. CONCLUSION: The majority of respondents would welcome a dedicated global OMS rotation during their residency training.

A multi-disciplinary team approach to pediatric malignant mandibular tumors.

OBJECTIVE: Mandibular tumors in the pediatric population are rare. These malignancies are variable in their histology, and combined with their rarity, has made it difficult to describe their clinical course, and treatment guidelines. The aim of this paper is to describe the experience of Boston Children's Hospital, a pediatric tertiary referral center, with treating malignant mandibular malignancies, as well as provide multi-disciplinary team approach in managing this clinical entity. METHODS: A retrospective search was performed for mandibular malignancies in pediatric patients between 1995 and 2020 via the pathological database at Boston Children's Hospital. Only patients with malignant solid mandibular neoplasms were included, leaving 15 patients for final analysis. RESULTS: The median age at presentation was 10.1 ± 10.3 years. Nine of 15 patients (60%) presented with jaw mass which was the most common clinical presentation. The most commonly identified histological diagnosis was rhabdomayosarcoma and osteosarcoma (n = 4, 26% each). A mandibulectomy was performed in 12 (80%) cases. Reconstruction of the mandible was performed using a fibular free flap in 6 (40%) cases, and a plate in 3 (20%) cases. Mean follow-up was 4.6 ± 4.9 years. CONCLUSION: Malignant tumors most commonly present with a jaw mass, however asymptomatic and incidental presentations follow closely and pathologies can vary greatly. Surgical resection and reconstruction is often indicated, multidisciplinary tumor board review is required to determine when children are best treated with neo-/adjuvant treatment with chemo- and radiotherapy.

The global reach of social media in oral and maxillofacial surgery.

PURPOSE: Social media use among oral and maxillofacial surgeons (OMSs) has grown in recent years, serving as an important resource for the dissemination of medical/surgical knowledge, research, education, diplomacy, and advocacy. However, no studies have attempted to characterize the global reach of social media in OMS. METHODS: This study examined the profile activity, content performance, and demographic characteristics of followers from a single OMS-related Instagram account. Variables assessed include the total number of followers since the account's inception, profile views over the selected time period, and unique media content posts, as well as likes, comments, saves, impressions, and reach for all media content posts. The top 45 countries, cities, and languages based on each follower's geolocation and user settings were also included. RESULTS: There were 9569 followers of which 6208 (64.9%) were listed as public accounts. Of the 6208 followers with public accounts, 2496 (40.2%) were female. The countries with the most followers included the United States (31.7%), India (12.5%), Malaysia (5.3%), Mexico (4.0%), and Pakistan (3.6%). The cities with the most followers included New York, New York (8.9%), Boston, Massachusetts (5.2%), Cairo, Egypt (4.3%), Santiago, Chile (3.7%), and Karachi, Pakistan (3.5%). CONCLUSION: OMS-related social media is uniquely positioned to facilitate global collaboration and augment the dissemination of surgical knowledge and expertise. This information is critical in understanding the distribution and demographics of the OMS workforce, trainees, and affiliates around the world.

Assessment of global health programs at accredited dental schools in the United States.

PURPOSE: Oral diseases pose a serious global health challenge. As such, dental education must integrate global health with emphasis on scalable and sustainable solutions. The aim of our study was to capture the scope of global health programs offered to dental students in the United States and identify ways in which dental schools may modify their curricula to improve global health knowledge and accessibility for students. MATERIALS AND METHODS: For this cross-sectional, cohort study, the investigators sent a confidential and electronic survey to 213 faculty members at the 67 accredited dental schools in the United States. This voluntary survey was distributed in September and October of 2020 with answers being self-reported. RESULTS: A total of 40 different schools are represented in this study, representing 59.7% of accredited dental schools in the United States. Using descriptive statistics, the results present existing global health opportunities, barriers preventing schools from expanding global health education, and necessary resources that schools without a program need to establish one. CONCLUSION: Our results demonstrate promising findings, in relation to global health being a vital part of dental education. However, there is an urgent need for enhanced and more structured education in this space. As the global burden of oral disease contributes to the degree and severity of noncommunicable diseases worldwide, the development of a sustainable, preventive primary care approach must integrate oral health, making future dental professionals a crucial component of global health.

Simulation capacity building in rural Indian hospitals: a 1-year follow-up qualitative analysis.

Introduction: The benefits of simulation-based medical training are well described. The most effective way to plant and scale simulation training in rural locations remains undescribed. We sought to plant simulation training programmes for anaesthesia emergencies in two rural Indian hospitals. Methods: Two Indian consultant anaesthetists without experience in medical simulation underwent a 3-day course at the Boston Children's Hospital's (BCH) Simulator Program. They returned to their institutions and launched simulation programmes with an airway manikin and mock patient monitor. The 1-year experience was evaluated using individual, in-depth interviews of simulation facilitators. Three staff members (responsible for facilitating medical simulations over the prior year) at two rural hospitals in India were interviewed. None attended the BCH training; instead, they received on-the-job training from the BCH-trained, consultant anaesthetist colleagues. Results: Successes included organisational adoption of simulation training with exercises 1 year after the initial BCH-training, increased interdisciplinary teamwork and improved clinical competency in managing emergencies. Barriers to effective, local implementation of simulation programmes fell into three categories: time required to run simulations, fixed and rigid roles, and variable resources. Thematic improvement requests were for standardised resources to help train simulation facilitators and demonstrate to participants a well-run simulation, in addition to context-sensitive scenarios. Conclusion: An in-person training of simulation facilitators to promote medical simulation programmes in rural hospitals produced ongoing simulation programmes 1 year later. In order to make these programmes sustainable, however, increased investment in developing simulation facilitators is required. In particular, simulation facilitators must be prepared to formally train other simulation facilitators, too.

Calcifying synovial sarcoma of the tongue with SS18 rearrangement: a rare variant in a rare location.

Synovial sarcoma is a soft tissue malignancy harboring t(X;18) resulting in fusion of two genes SS8 (at 18q11) and SSX (1, 2 or 4 at Xp11) forming the gene fusion product SS18-SSX. It affects adults in their 3rd-4th decades, most frequently in the para-articular regions of the extremities. Less than 10% of the cases occur within the head and neck region and of these, 60% occur in the neck and only 10% occur in the oral cavity. We report a synovial sarcoma of the tongue in a 14-year-old female patient with unusual histology. The patient presented with a mass occupying most of the tongue with extension into the floor of mouth and the lingual gingiva of the anterior mandibular teeth. The tumor was composed of a highly cellular proliferation of spindle cells in a herringbone pattern with many small vessels but without glandular structures, and with extensive calcifications throughout the tumor. Tumor cells were positive for epithelial membrane antigen and transducin-like enhancer of split-1, and fluorescence in situ hybridization studies identified SS18 gene rearrangement. The patient was managed with two debulking procedures followed by chemoradiation and is currently alive with disease.

Desmoid tumors of the head and neck in the pediatric population: Has anything changed?

INTRODUCTION: Pediatric head and neck desmoid tumors are rare neoplasms that can cause significant morbidity due to infiltration of vital anatomic structures. The goal of this study is to review presentation, evaluation, and management of these tumors. METHODS: Retrospective study of children with head and neck desmoid tumors treated from 1999 to 2018 and literature review. RESULTS: 11 patients (5 boys, 6 girls) were included. Presentation included firm neck mass (n = 8), trismus (n = 2) and tongue lesion (n = 1). All patients had preoperative imaging with CT (n = 2), MRI (n = 1) or both (n = 8). Five patients underwent needle biopsy, five had open biopsy and one was diagnosed on pathology from primary excision. Seven patients were treated by primary surgical resection, with positive surgical margins in six cases due to proximity to vital neurovascular structures. None needed chemotherapy, had disease recurrence or progression. Three patients with unresectable disease were treated with chemotherapy. One patient was monitored with imaging without any treatment and did not have disease progression. Follow-up ranged from 6 months to 6 years (median 21 months). Ten patients (7 surgical, 2 chemotherapy, 1 observation) were either disease-free or had stable disease at last follow-up. CONCLUSION: Pediatric head and neck desmoid tumors, though rare and histologically benign, are locally infiltrative and aggressive. When feasible, surgical treatment results in good disease control despite positive margins. A balance between achieving negative margins and minimizing functional deficits should be considered. Chemotherapy can be successfully utilized in patients where surgery entails a high risk of morbidity and mortality.

Congenital Disseminated Pyogenic Granuloma: Characterization of an Aggressive Multisystemic Disorder.

OBJECTIVE: To describe the clinical, radiologic, and histopathologic features of "congenital disseminated pyogenic granuloma" involving various organs with high morbidity related to cerebral hemorrhagic involvement. STUDY DESIGN: We searched the database of the Vascular Anomalies Center at Boston Children's Hospital from 1999 to 2019 for patients diagnosed as having multiple vascular lesions, visceral vascular tumors, congenital hemangiomatosis, multiple pyogenic granulomas, or multiple vascular lesions without a definite diagnosis. A retrospective review of the medical records, photographs, histopathologic, and imaging studies was performed. Only patients with imaging studies and histopathologic diagnosis of pyogenic granuloma were included. RESULTS: Eight children (5 male, 3 female) had congenital multifocal cutaneous vascular tumors. Lesions also were found in the brain (n = 7), liver (n = 4), spleen (n = 3), muscles (n = 4), bone (n = 3), retroperitoneum (n = 3), and intestine/mesentery (n = 2). Less commonly affected were the spinal cord, lungs, kidneys, pancreas, and adrenal gland (n = 1 each). The mean follow-up period was 21.8 months. The cerebral and visceral lesions were hemorrhagic with severe neurologic sequelae. The histopathologic diagnosis was pyogenic granuloma with prominent areas of hemorrhage and necrosis. The endothelial cells had enlarged nuclei, pale cytoplasm and were immunopositive for CD31 and negative for D2-40 and glucose transporter 1. CONCLUSIONS: Congenital disseminated pyogenic granuloma is a distinct multisystemic aggressive disorder that primarily affects the skin, brain, visceral organs, and musculoskeletal system. Differentiation of this entity from other multiple cutaneous vascular lesions is critical because of possible cerebral hemorrhagic involvement.

Oral and Maxillofacial Surgery: An Opportunity to Improve Surgical Care and Advance Sustainable Development Globally.

Global health has evolved to focus on reducing health inequity and obtaining the highest attainable standard of health for all people. To do this, a range of actors now pursue interventions and policy with an eye toward global targets that place strong emphasis on improving health systems. Within global health, global surgery has sought to delineate the burden of surgical disease and propose policy to improve access to surgery. Oral and maxillofacial surgery has been underrepresented in global health but has a vital role in reducing the global health inequity attributable to the impact of oral and craniofacial conditions.

Does Fee-for-Service Medicare Reimbursement Incentivize Volume Over Value Among Oral and Maxillofacial Surgeons?

PURPOSE: National health care payment models have begun transitioning from fee-for-service to value-based reimbursement because of criticism of the former incentivizing quantity over quality. However, there has yet to be an evaluation of the influence of fee-for-service incentives among oral and maxillofacial surgery services. This study characterized service intensity among oral and maxillofacial surgeons (OMSs) serving Medicare beneficiaries in 2017 to determine if higher Medicare income among OMSs arises from higher service intensity or a higher volume of patients treated. PATIENTS AND METHODS: This cross-sectional study was composed of Medicare Provider Utilization and Payment Data from 2017. Providers were included if their specialty type was listed as "maxillofacial surgery." The predictor variables included service intensity, defined as the number of health care services administered per Medicare beneficiary, and Medicare beneficiary volume. The primary outcome variable was Medicare income. Descriptive statistics and pair-wise comparisons were computed at an α level of .05. RESULTS: The analysis cohort was composed of 696 distinct OMSs. A total of 69,959 services were recorded for 53,245 Medicare beneficiaries, with a mean service intensity of 1.12 services per beneficiary. A statistically significant difference in service intensity was found between Medicare payment deciles (P = .002). The magnitude of this difference was less relative to the difference in all medical specialties. CONCLUSIONS: There is a statistically significant difference in service intensity between low and high earners in oral-maxillofacial surgery; however, the magnitude of the difference is unlikely to be clinically or economically meaningful. Variation in service intensity is lower in oral-maxillofacial surgery relative to all medical specialties in aggregate. Given the changing reimbursement landscape in medicine and surgery, it is important to evaluate existing billing practices within the specialty to advocate for the profession in discussions of payment reform and ensure that patients are receiving only necessary services.

Surgathon: a new model for creating a surgical innovation ecosystem in low-resource settings.

Innovation ecosystems and emerging technologies can potentially accelerate the access to safe, affordable surgical care in low-resource settings. There is a need to develop localised innovation ecosystems that can establish an initial culture and catalyse the creation, adoption and diffusion of innovation. The surgathon model outlines one approach to seeding surgical innovation ecosystems. International academic institutions collaborated on six global surgery, innovation and ethics-themed hackathons ('surgathons') across India and Rwanda between 2016 and 2019. Over 1598 local multidisciplinary students participated, learning about challenges in the delivery of surgical care and ideating solutions that could leverage appropriate technology and resources for impact. Pursuing student ideas and evaluating their implementation past the surgathons continues to be an active effort. Surgathons have unfolded in different permutations based on local faculty, institution and health system context. The surgathon model is a novel method of priority setting challenges in global surgery and utilises locally driven expertise and innovation capacity to derive ethical solutions. The model offers a path for low-resource setting students and faculty to learn, advocate and innovate for improved surgical care.

Utilizing a Physician Scribe in a Pediatric Plastic Surgical Practice: A Time-driven Activity-based Costing Study.

BACKGROUND: To use time-driven activity-based costing methodology to compare the costs of routine pediatric plastic surgical patient visits with and without a physician scribe. METHODS: Pediatric plastic surgical clinic visits at a tertiary care facility with the following diagnoses were studied: skin lacerations, skin lesions, and plagiocephaly. Two plastic surgeons saw patients individually either with or without a scribe over a 10-month period. The time that the scribe and physician spent on the patient was recorded, including the duration of the clinic visit and time spent creating, dictating, reviewing, and signing the note. An average appointment activity time for each measurement component was produced, and a capacity cost rate was introduced to derive the cost per minute for a scribe and physician. Sensitivity analysis and paired t-test were conducted to analyze the results. RESULTS: A total of 45 cases with a physician scribe were observed with an average appointment activity time of 12.83 minutes (4.97 min for the scribe, 0.92 min for the physician, and 6.95 min combined). A total of 72 cases without a physician scribe were observed with an average appointment activity time of 12.01 minutes. The total attributable cost saving per appointment was $13.82 when a physician scribe was utilized. CONCLUSION: Time-driven activity-based costing methodology showed that the use of a physician scribe reduced cost per office visit by substituting physician time for a less expensive resource.

Reconstruction of Congenital Microtia and Anotia: Analysis of Practitioner Epidemiology and Postoperative Outcomes.

BACKGROUND: Microtia refers to a congenital malformation of the external ear that is associated with a range of functional, psychosocial, aesthetic, and financial burdens. The aim of this study was to analyze the epidemiology and postoperative complication profile of microtia reconstruction. METHODS: A retrospective review was conducted using data from the 2012-2017 the American College of Surgeons National Quality Improvement Program Pediatric databases. Patients with a diagnosis of microtia or anotia were identified using International Classification of Diseases codes. Demographics and postoperative complications were analyzed using Chi-square and t tests for categorical and continuous variables, respectively. Multivariable regression was performed to control for confounding variables. RESULTS: A total of 466 cases were analyzed, of which 290 (62.2%) were performed by plastic surgeons and 176 (37.8%) by otolaryngologists (ear, nose, and throat physicians [ENT]). Autologous reconstruction was the predominant approach [76.2% of cases (n = 355)] in this cohort. ENT physicians operated on a significantly younger patient population (mean age 8.4 ± 3.2 years versus 10.0 ± 3.2 years, P< 0.001) and had higher rates of concurrent atresia/middle ear repair [21.0% (n = 37) versus 3.7% (n = 17)] compared with plastic surgeons. The rate of all-cause complications was 5.9% (n = 17) in the plastic surgery cohort and 4.0% (n = 7) in the ENT cohort (P= 0.372). Multivariable regression did not reveal any statistically significant predictors for all-cause complications. CONCLUSIONS: Reconstruction of the external ear for patients with microtia/anotia is a safe procedure, with low rates of postoperative complications, readmissions, and reoperations. Autologous reconstruction remains the preferred modality for repair of the external ear and simultaneous atresiaplasty/middle ear repair does not increase the risk of complications.

How Often Do Oral Maxillofacial Surgeons Lose Malpractice Cases and Why?

PURPOSE: Although oral maxillofacial surgeons (OMSs) carry high legal risk in malpractice lawsuits, data elucidating the reason behind those claims and their outcomes are scarce. The purpose of the present study was to characterize the trends, analyze the payouts, and determine the etiology of malpractice cases against OMSs. MATERIALS AND METHODS: A retrospective case series study was performed using the Westlaw database to access medical malpractice cases filed against OMSs from 1980 to 2017. The inclusion criterion was that the defendants had included an OMS. Two of us independently collected the demographic data, verdicts, payouts, and etiology of the litigation. RESULTS: The study sample included 183 cases adjudicated from 1980 to 2017. The results highlighted the temporal and geographic trends, payout information, and etiology of the cases. The total number of malpractice cases had decreased by 60% from 2011 to 2015 compared with the previous 5 years. The greatest incidence of malpractice cases filed per 100 practicing OMSs was in New York, followed by California and Massachusetts. Ruling in favor of the defendant OMS was noted in 55% of the cases, of the plaintiffs in 40% of the cases, and had reached a settlement before trial in 3% of the cases. In the cases in which the ruling had favored the plaintiff, the average payment was $812,449.08, with a median payment of $250,000.00 (range, $13,750.00 to $14,887,525.95). Extraction cases represented 53% of all malpractice litigations. Of these, 65% had been third molar extractions that had resulted in lingual nerve injury (26%), postoperative infection (17%), wrong site extractions (15%), and death or brain damage (10%), among other injuries. CONCLUSIONS: Approximately one half of the malpractice cases favored the defendant OMS. Most cases were third molar extractions resulting in injuries ranging from lingual nerve injury to death. Complementary data from insurance companies would be helpful to provide more specific analysis of the etiology and trends of the malpractice cases.

Do Oral and Maxillofacial Surgeons Over-Prescribe Opioids After Extraction of Asymptomatic Third Molars?

PURPOSE: Opioid abuse is a public health concern. Oral opioids are prescribed after removal of third molars, but the amount needed for adequate postoperative analgesia is unknown. The purpose of this study was to quantify opioid need after third molar extractions. MATERIALS AND METHODS: This is a prospective cohort study of consecutive patients who had asymptomatic third molars extracted with intravenous sedation at the Boston Children's Hospital (Boston, MA) from June through October 2018 by 3 attending surgeons. To be included, patients had to have had 4 third molars removed. Patients were excluded if they had a concomitant procedure, preoperative infection, postoperative inflammatory complication, chronic pain condition, or did not complete the study. Postoperative prescriptions and instructions included 1) oxycodone 5-mg tablets with 1 tablet taken every 6 hours as needed (dispensed, 6); 2) ibuprofen 600-mg tablets with 1 tablet taken every 6 hours as needed (dispensed, 20); and 3) acetaminophen 325-mg tablets with 2 tablets taken every 6 hours as needed (dispensed, 40). Participants reported medication use by electronic questionnaire each day for 7 postoperative days (PODs). Descriptive statistics were calculated. RESULTS: Eighty-one patients (56% female; mean age, 19.4 ± 7.7 yr) were included. The average number of oxycodone tablets used was 0.04 ± 0.24, and the highest daily use of oxycodone was on POD 2 (1.0 ± 0.0 tablet). Oxycodone was taken by 3 patients (4%) on POD 1, 4 (5%) on POD 2, 2 (3%) on PODs 3 and 4, and 0 on PODs 5 to 7. Seventy-five patients (93%) used no postoperative oxycodone; 466 prescribed oxycodone tablets remained unfilled or unused. Ibuprofen 600 mg was used for 4.6 ± 2.2 PODs and acetaminophen 650 mg was used for 3.4 ± 1.9 PODs. CONCLUSIONS: Oral opioid use after third molar extractions is minimal. Caution is necessary to avoid over-prescribing.