Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 749
Filtrar
2.
Plast Reconstr Surg ; 151(2): 255e-266e, 2023 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-36696321

RESUMO

BACKGROUND: Patients with Dupuytren contracture can receive a variety of surgical and nonsurgical treatments. The extent to which patients participate in the shared decision-making process is unclear. METHODS: An explanatory-sequential mixed-methods study was conducted. Participants completed the Nine-Item Shared Decision-Making Questionnaire and the brief Michigan Hand Outcomes Questionnaire before completing semi-structured interviews in which they described their experience with selecting treatment. RESULTS: Thirty participants [25 men (83%) and five women (17%); mean age, 69 years (range, 51 to 84 years)] received treatment for Dupuytren contracture (11 collagenase injection, six needle aponeurotomy, and 13 limited fasciectomy). Adjusted mean scores for the Shared Decision-Making Questionnaire and brief Michigan Hand Outcomes Questionnaire were 71 (SD 20) and 77 (SD 16), respectively, indicating a high degree of shared decision-making and satisfaction. Patients who received limited fasciectomy accepted invasiveness and prolonged recovery time because they believed it provided a long-term solution. Patients chose needle aponeurotomy and collagenase injection because the treatments were perceived as safer and more convenient and permitted rapid return to daily activities, which was particularly valued by patients who were employed or had bilateral contractures. CONCLUSIONS: Physicians should help patients choose a treatment that aligns with the patient's preferences for long-term versus short-term results, recovery period and postoperative rehabilitation, and risk of complications, because patients used this information to assist in their treatment selection. Areas of improvement for shared decision-making include equal presentation of all treatments and ensuring realistic patient expectations regarding the chronic and recurrent nature of Dupuytren contracture regardless of treatment received.


Assuntos
Contratura de Dupuytren , Procedimentos Ortopédicos , Masculino , Humanos , Feminino , Idoso , Contratura de Dupuytren/cirurgia , Colagenases , Procedimentos Ortopédicos/métodos , Fasciotomia/métodos , Injeções Intralesionais , Resultado do Tratamento
3.
Plast Reconstr Surg ; 151(1): 1-5, 2023 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-36576824
4.
Med Care ; 61(1): 36-44, 2023 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-36477618

RESUMO

BACKGROUND: Few performance measures assess presurgical value (quality and utilization). OBJECTIVES: Using carpal tunnel syndrome (CTS) as a case study: (1) develop a model to evaluate presurgical quality and utilization and (2) identify opportunities for value improvement. RESEARCH DESIGN: A retrospective cohort study utilizing Veterans Affairs (VA) national administrative data. SUBJECTS: Patients who were evaluated in a VA primary care clinic on at least 1 occasion for CTS and received carpal tunnel release over a 7-year period. MEASURES: We modeled facility-level performance on 2 outcomes: surgical delay (marker of quality) and number of presurgical encounters (utilization) for CTS, and examined association between patient, facility, and care process variables and performance. RESULTS: Among 41,912 Veterans undergoing carpal tunnel release at 127 VA medical centers, the median facility-level predicted probability of surgical delay was 48%, with 16 (13%) facilities having significantly less delay than the median and 13 (10%) facilities having greater delay. The median facility-level predicted number of presurgical encounters was 8.8 visits, with 22 (17%) facilities having significantly fewer encounters and 22 (17%) facilities having more. Care processes had a stronger association with both outcomes than structural variables included in the models. Processes associated with the greatest deviations in predicted delay and utilization included receipt of repeat electrodiagnostic testing, use of 2 or more nonoperative treatments, and community referral outside of VA. CONCLUSIONS: Using CTS as a test case, this study demonstrates the potential to assess presurgical value and identify modifiable care processes associated with presurgical delay and utilization performance.


Assuntos
Síndrome do Túnel Carpal , Humanos , Síndrome do Túnel Carpal/diagnóstico , Síndrome do Túnel Carpal/cirurgia , Estudos Retrospectivos
5.
JAMA Netw Open ; 5(12): e2246299, 2022 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-36508216

RESUMO

Importance: Although quality care markers exist for patients with rheumatoid arthritis (RA), the predictors of meeting these markers are unclear. Objective: To explore factors associated with quality care among patients with RA. Design, Setting, and Participants: A retrospective cohort study using insurance claims from 2009 to 2017 was conducted, and 6 sequential logistic regression models were built to evaluate quality care markers. Quality care markers were measured at 1 year post-RA diagnosis for each patient. The MarketScan Research Database, which contains commercial and Medicare Advantage administrative claims data from more than 100 million individuals in the US, was used to identify patients aged 18 to 64 years with a diagnosis claim for RA. Patients with conditions presenting similar to RA and missing demographic characteristics were excluded. Data analysis occurred between February 18 and May 5, 2022. Exposures: Success or failure to meet selected RA quality care markers within 1 year after RA diagnosis. Main Outcomes and Measures: Prevalence of meeting successive quality care markers for RA. Results: Among 581 770 patients, 430 843 (74.1%) were women and the mean (SD) age was 48.9 (11.3) years. Most patients (236 285 [40.6%]) resided in the South and had an income less than or equal to $45 200 (490 366 [84.3%]). Of the total study population, 399 862 individuals (68.7%) met at least 1 quality care marker and 181 908 (31.3%) met 0 markers. Most commonly, patients met annual laboratory testing (299 323 [51.5%]) and referral to a rheumatologist (256 765 [44.1%]) markers. The least met marker was receiving hepatitis B screening prior to initiation of disease-modifying antirheumatic drug (DMARD) therapy (18 548 [3.2%]). Women were most likely to meet all quality care markers except receiving DMARDs with hepatitis B screening (odds ratio, 1.14; 95% CI, 1.12-1.16). Individuals with lower median household income had lower odds of receiving a rheumatologist referral, an annual physical examination, or annual laboratory testing, but greater odds of receiving the other quality care markers. Patients with Medicare and those with comorbidities were generally less likely to meet quality care markers. Conclusions and Relevance: In this cohort study of patients with RA, findings indicated downstream associations with rheumatologist referral and receiving DMARDs and varied associations between meeting quality care markers and patient characteristics. These findings suggest that prioritizing early care, especially for vulnerable patients, will ensure that quality care continues.


Assuntos
Antirreumáticos , Artrite Reumatoide , Hepatite B , Adulto , Humanos , Idoso , Feminino , Estados Unidos/epidemiologia , Masculino , Estudos de Coortes , Estudos Retrospectivos , Medicare , Artrite Reumatoide/epidemiologia , Artrite Reumatoide/terapia , Artrite Reumatoide/diagnóstico , Antirreumáticos/uso terapêutico , Hepatite B/tratamento farmacológico
6.
Plast Reconstr Surg ; 150(6): 1175-1180, 2022 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-36445757
7.
Plast Reconstr Surg ; 150(6): 1383-1385, 2022 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-36445761
8.
Plast Reconstr Surg Glob Open ; 10(11): e4646, 2022 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-36405046

RESUMO

The increase in virtual conferences during the COVID-19 pandemic provided unexpected advantages such as increased accessibility, while also creating concern about the effectiveness of online networking and career development. Given that a variety of conference attributes are impacted by changes in conference format, we sought to investigate how plastic surgeons prioritize key aspects of conference conduct. Methods: We sent a survey based on conjoint analysis, a statistical method for evaluating consumer preferences, to active members of the American Society of Plastic Surgeons. Respondents were asked to choose between pairs of conference options, each with unique attributes. Their answers were used to calculate feature importance values and utility coefficients for the conference attributes. Subgroup analyses were conducted based on demographic factors. Results: A total of 263 respondents completed the survey. Respondents were mostly White (181 individuals [68.8%]) and men (186 [70.7%]). Nearly half (122 [46.4%]) had been practicing 20 or more years. Conference attributes with the highest feature importance values (SDs) were cost of attendance (30.4% [14.2%]) and conference format (28.8% [14.2%]). Equity initiatives (14.5% [10.1%]), reimbursement for cost (11.1% [5.7%]), and opportunities for networking (9.5% [6.0%]) had intermediate feature importance values. Environmental impact had the lowest feature importance (5.7% [3.8%]). Conclusions: Surgeons' conference preferences depend highly on format and the presence of equity initiatives, both of which can be incorporated or modified in future conferences to ensure inclusive and successful events. Meanwhile, environmental impact is less important to surgeons, suggesting a pressing need to bring sustainability issues to their attention.

9.
J Hand Surg Am ; 2022 Nov 09.
Artigo em Inglês | MEDLINE | ID: mdl-36371353

RESUMO

PURPOSE: Patients with severe ulnar neuropathy at the elbow frequently experience suboptimal surgical outcomes. Clinical symptoms alone may not accurately represent the severity of underlying nerve injury, calling for objective assessment tools, such as electrodiagnostic studies. The goal of our study was to determine whether specific electrodiagnostic parameters can be used to predict the outcomes after in situ decompression of the ulnar nerve. METHODS: This prospective study enrolled consecutive patients aged ≥18 years diagnosed with ulnar neuropathy at the elbow. Patients completed a baseline battery of motor, sensory, functional, and electrodiagnostic tests before undergoing in situ decompression of the ulnar nerve. They were reassessed at 6 weeks, 3 months, 6 months, and 12 months after surgery. Forty-two patients completed at least 2 follow-up assessments and were included in the study. RESULTS: When controlling for other electrodiagnostic measurements and demographic factors, none of the electrodiagnostic parameters were predictive of outcomes at 12 months after surgery. Patients with decreased compound muscle action potential amplitudes demonstrated slower trends of recovery in grip strength, pinch strength, and overall scores on the Michigan Hand Outcomes Questionnaire as well as its function, work, and activities of daily living subscales, Disabilities of the Arm, Shoulder, and Hand questionnaire, and the Carpal Tunnel Questionnaire. Decreased motor nerve conduction velocity was predictive of slower recovery of 2-point discrimination and pinch strength. CONCLUSIONS: Compound muscle action potential amplitude, but not other conventional electrodiagnostic parameters, was predictive of functional outcomes after in situ decompression of the ulnar nerve. This parameter should play a role in determining the timing and prognosis of treatment for ulnar neuropathy at the elbow. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

10.
J Hand Surg Eur Vol ; : 17531934221133992, 2022 Nov 03.
Artigo em Inglês | MEDLINE | ID: mdl-36329565

RESUMO

Multiple treatment options are available to patients with Dupuytren contracture, making shared decision-making complex. Our rigorous qualitative analysis sought to understand patient perceptions of shared decision-making in Dupuytren contracture treatment and create a conceptual framework to optimize patient-physician communication. We interviewed 30 patients with Dupuytren contracture to learn about their experience with treatment selection. The following themes were integral to shared decision-making for Dupuytren contracture treatment: discussing disease progression and treatment initiation, presenting all available treatment options, assessing patients' pre-existing biases towards treatment, patient values and preferences for treatment trade-offs, treatment risks and benefits, physician recommendation and active patient participation. This model can optimize communication about treatment options and expectations for relevant outcomes including, recovery time, contracture recurrence, complications, and treatment-related expenses.Level of evidence: V.

11.
Plast Reconstr Surg ; 150(5): 951-954, 2022 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-36288249
13.
Plast Reconstr Surg ; 2022 Oct 11.
Artigo em Inglês | MEDLINE | ID: mdl-36219862

RESUMO

SUMMARY: Intercarpal ligament injuries such as scapholunate and lunotriquetral tears are common causes of wrist pain. There is no shortage of surgical techniques, nor in the volume of literature exploring this topic. However, research progress has not led to a consensus regarding the optimal management of subacute and chronic injuries without articular wear. The senior author (KCC) has performed the spectrum of reconstructive techniques, including dorsal and volar approaches, tendon weaves, ligament tenodesis procedures, reduction and association procedures, and bone-ligament-bone techniques.1,2 In the absence of convincing, consistent outcomes, we began investigating a novel all-dorsal reconstructive technique using the Arthrex InternalBrace system. The complexity and unpredictable outcomes associated with traditional ligament tenodesis procedures led us to adopt the all-dorsal InternalBrace technique as our primary reconstructive approach. We have performed over 20 procedures with this technique since 2019. In an average tourniquet time of under 60 minutes, we are able to achieve predictable carpal stabilization, pain relief, and restoration of motion. This is the preferred reconstructive approach of the senior author.

14.
Hand Clin ; 38(4): 435-446, 2022 11.
Artigo em Inglês | MEDLINE | ID: mdl-36244711

RESUMO

Of the many treatments for Kienböck disease, only lunate revascularization procedures provide a direct mechanism for reversing the process of osteonecrosis. Owing to the redundant blood supply of the distal radius and carpus, pedicled flaps are versatile solutions for patients with bone loss but intact cartilage. With the advent of free vascularized flaps, the indications for lunate revascularization procedures are expanding. These flaps can be used when the articular cartilage has been compromised and are suitable options to restore native anatomy in patients previously thought to have unreconstructible disease.


Assuntos
Cartilagem Articular , Osso Semilunar , Osteonecrose , Transplante Ósseo/métodos , Humanos , Osso Semilunar/cirurgia , Osteonecrose/cirurgia , Rádio (Anatomia)/irrigação sanguínea , Rádio (Anatomia)/cirurgia
15.
Arch Plast Surg ; 49(5): 676-682, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-36159381

RESUMO

Background Virtual education is an evolving method for teaching medical learners. During the coronavirus disease 2019 pandemic, remote learning has provided a replacement for conferences, lectures, and meetings, but has not been described as a method for conducting a cadaver dissection. We aim to demonstrate how learners perceive a virtual cadaver dissection as an alternative to live dissection. Methods A virtual cadaver dissection was performed to demonstrate several upper extremity nerve procedures. These procedures were livestreamed as part of an educational event with multimedia and interactive audience questions. Participants were queried both during and after the session regarding their perceptions of this teaching modality. Results Attendance of a virtual dissection held for three plastic surgery training institutions began at 100 and finished with 70 participants. Intrasession response rates from the audience varied between 68 and 75%, of which 75% strongly agreed that they were satisfied with the virtual environment. The audience strongly agreed or agreed that the addition of multimedia captions (88%), magnified video loupe views (82%), and split-screen multicast view (64%) was beneficial. Postsession response rate was 27%, and generally reflected a positive perspective about the content of the session. Conclusions Virtual cadaver dissection is an effective modality for teaching surgical procedures and can be enhanced through technologies such as video loupes and multiple camera perspectives. The audience viewed the virtual cadaver dissection as a beneficial adjunct to surgical education. This format may also make in-person cadaver courses more effective by improving visualization and allowing for anatomic references to be displayed synchronously.

16.
Plast Reconstr Surg ; 150(6): 1287-1296, 2022 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-36112828

RESUMO

BACKGROUND: Electrodiagnostic studies are commonly used to diagnose carpal tunnel syndrome. However, these examinations are prone to false-positive and false-negative values. The authors evaluated the agreement of electrodiagnostic study severity, clinical assessment scores, and probability of carpal tunnel syndrome [Six-Item Carpal Tunnel Syndrome Evaluation Tool (CTS-6) scores. METHODS: This was a retrospective cohort study of 609 patients with carpal tunnel syndrome (941 hands). Data were collected from nine hand surgery practices in the Michigan Collaborative Hand Initiative for Quality in Surgery. Goodman and Kruskal gamma statistics (γ) measured the agreement between electrodiagnostic studies and clinical assessment scores and between electrodiagnostic studies and CTS-6 scores. The authors performed cumulative logistic regression with mixed effects to evaluate the association among electrodiagnostic study severity, clinical assessments, and patient characteristics. RESULTS: The concordance between electrodiagnostic study severity and CTS-6 scores was γ = 0.31 (95 percent CI, 0.21 to 0.40), with an accuracy of 43 percent. The concordance between electrodiagnostic study severity and clinical assessment scores was γ = 0.66 (95 percent CI, 0.58 to 0.74), with an accuracy of 58 percent. Wide site-level variation in the γ coefficient between electrodiagnostic studies and clinical assessment scores and between electrodiagnostic studies and CTS-6 was seen. Male sex, increasing age, and increasing body mass index were significantly associated with increased odds of electrodiagnostic study severity. CONCLUSIONS: Wide practice-level variation underscores the variability in diagnostic testing accuracy. Physicians should consider patient characteristics (e.g., sex, age, body mass index) when assessing carpal tunnel syndrome severity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.


Assuntos
Síndrome do Túnel Carpal , Humanos , Masculino , Síndrome do Túnel Carpal/diagnóstico , Síndrome do Túnel Carpal/cirurgia , Estudos Retrospectivos , Índice de Gravidade de Doença , Mãos , Índice de Massa Corporal
17.
Plast Reconstr Surg ; 150(5): 1151-1158, 2022 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-36067485

RESUMO

BACKGROUND: The E-value is a statistical measure that is used to quantify the degree of unmeasured confounding that is necessary to undermine the treatment-outcome associations established in observational studies. Despite the substantial amount of observational research that informs evidence-based practice in plastic surgery, sensitivity analyses based on the E-value have not been conducted in the field. METHODS: The authors performed a systematic search of the literature to identify meta-analyses of observational studies in plastic surgery. The authors calculated E-values for various treatment-outcome associations based on the risk, odds, or hazard ratios in each study, to assess unmeasured confounding effects that may influence the validity of the conclusions. The authors then analyzed the distribution of E-values from pooled versus individual studies. RESULTS: The authors identified 45 meta-analyses that met the inclusion criteria, with each containing an average of three pooled assessments of observational data. The E-value of the pooled effect estimates ranged from 1.11 to 19.49, with an average value of 3.82. As for the individual effect estimates from each primary study within the meta-analyses, the E-values ranged from 1.00 to 321.50, with an average value of 8.74. CONCLUSIONS: The authors determined that E-values vary substantially across the literature and that unmeasured confounding may be present in a high number of observational studies. Although extant statistical techniques will continue to be necessary to control for measured confounding, the E-value is a novel concept that can facilitate more robust sensitivity analyses in plastic surgery research.


Assuntos
Cirurgia Plástica , Humanos , Viés , Resultado do Tratamento
19.
Plast Reconstr Surg ; 150(4): 941-945, 2022 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-36170441
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...