Comparing Graduating Plastic Surgery Residents' Case Logs With Accreditation Council for Graduate Medical Education Requirements, Content at National Meetings, and In-Service Examination Test Items.

BACKGROUND: The importance of adaptable and up-to-date plastic surgery graduate medical education (GME) has taken on new meaning amidst accelerating surgical innovation and increasing calls for competency-based training standards. We aimed to examine the extent to which the procedures plastic surgery residents perform, as represented in case log data, align with 2 core standardized components of plastic surgery GME: ACGME (Accreditation Council for Graduate Medical Education) minimum procedure count requirements and the PSITE (Plastic Surgery In-Service Training Examination). We also examined their alignment with procedural representation at 2 major plastic surgery meetings. METHODS: Nine categories of reconstructive and aesthetic procedures were identified. Three-year averages for the number of procedures completed in each category by residents graduating in 2019-2021 were calculated from ACGME national case log data reports. The ACGME procedure count minimum requirements were also ascertained. The titles and durations of medical programming sessions scheduled for Plastic Surgery The Meeting (PSTM) 2022 and the Plastic Surgery Research Council (PSRC) Annual Meeting 2022 were retrieved from online data. Finally, test items from the 2020 to 2022 administrations of the PSITE were retrieved. Conference sessions and test items were assigned to a single procedure category when possible. Percent differences were calculated for comparison. RESULTS: The distribution of procedures on plastic surgery resident case logs differs from those of the major mechanisms of standardization in plastic surgery GME, in-service examination content more so than ACGME requirements. Meeting content at PSTM and PSRC had the largest percent differences with case log data, with PSTM being skewed toward aesthetics and PSRC toward reconstructive head and neck surgery. DISCUSSION: The criteria and standards by which plastic surgery residents are evaluated and content at national meetings differ from the procedures they actually complete during their training. Although largely reflecting heterogeneity of the specialty, following these comparisons will likely prove useful in the continual evaluation of plastic surgery residency training, especially in the preparation of residents for the variety of training and practice settings they pursue.

Evaluation of hydroxocobalamin use for the treatment of suspected cyanide toxicity secondary to smoke inhalation.

Hydroxocobalamin is used for cyanide toxicity after smoke inhalation, but diagnosis is challenging. Retrospective studies have associated hydroxocobalamin with acute kidney injury (AKI). This is a retrospective analysis of patients receiving hydroxocobalamin for suspected cyanide toxicity. The primary outcome was the proportion of patients meeting predefined appropriate use criteria defined as ≥1 of the following: serum lactate ≥8 mmol/L, systolic blood pressure (SBP) <90 mmHg, new-onset seizure, cardiac arrest, or respiratory arrest. Secondary outcomes included incidence of AKI, pneumonia, resolution of initial neurologic symptoms, and in-hospital mortality. Forty-six patients were included; 35 (76%) met the primary outcome. All met appropriate use criteria due to respiratory arrest, 15 (43%) for lactate, 14 (40%) for SBP, 12 (34%) for cardiac arrest. AKI, pneumonia, and resolution of neurologic symptoms occurred in 30%, 21%, and 49% of patients, respectively. In-hospital mortality was higher in patients meeting criteria, 49% vs. 9% (95% CI 0.16, 0.64). When appropriate use criteria were modified to exclude respiratory arrest in a post-hoc analysis, differences were maintained, suggesting respiratory arrest alone is not a critical component to determine hydroxocobalamin administration. Predefined appropriate use criteria identify severely ill smoke inhalation victims and provides hydroxocobalamin treatment guidance.

Altmetric Attention Score: Evaluating the Social Media Impact of Burn Research.

Traditional measures of scholarly impact (ie, impact factor, citation rate) do not account for the role of social media in knowledge dissemination. The Altmetric Attention Score (AAS) tracks the online sharing activity of articles on platforms such as Twitter and Facebook. All 285 original scientific articles published in Journal of Burn Care & Research and Burns from January to December 2017 were obtained from official journal websites. Article characteristics extracted include AAS; number of Twitter, Facebook, and news outlet mentions; subject of study and study design; number of citations; number of authors and academic institutions; and others. The average AAS for all articles was 6.1 (SD: 48; range: 0 to 611) in which 156 (55%) of those had Twitter mentions. The mean AAS for Journal of Burn Care & Research and Burns were 7.7 (SD: 54; range: 0 to 536) and 5.3 (SD: 45; range: 0 to 611), respectively. There was a weak, positive correlation between AAS and citation count for all articles (ρ = 0.12; P = .049), and this finding was consistent for Journal of Burn Care & Research (ρ = 0.21; P = .039) and Burns (ρ = 0.15; P = .038) individually. The weak correlation between the two metrics supports that AAS and citation count capture the attention of different audiences. In addition, studies discussing skin grafting were associated with higher average AAS (ß: 29 [95% CI: 4.2 to 54]; P = .022). Overall, our findings support using both AAS and traditional bibliometrics to assess article impact.

Airbag Burns: An Unfortunate Consequence of Motor Vehicle Safety.

Thousands of people are injured in motor vehicle collisions daily and the mandated installation of airbags protects passengers but can also cause injuries from deployment including cutaneous burns. We sought to characterize the patterns and outcomes of burns resulting from airbag deployment by performing a retrospective review of all patients evaluated by the burn service from May 1, 2015 to April 30, 2019. Inclusion criteria were patients of all ages with burn injuries related to airbag deployment. Demographic data, burn characteristics, and outcomes were reviewed. Seventeen patients met the inclusion criteria: 82.4% female and 17.6% male. The average age was 40.4 years. Fifteen patients had second-degree and two had third-degree burns. The average TBSA was 0.45%. The hands or upper extremity (88%) were most often injured, but there were two chest, one neck, and one anterior thigh burns. Eight patients suffered multiple burns. Burn etiology (chemical vs thermal) was often not specified. No patients required hospitalization or surgical intervention, and all wounds healed with wound care. The average time to re-epithelialization was 11 days. Although airbags prevent mortality and serious injury, the exothermic chemical reaction that inflates the airbag is responsible for deployment-related burns. Since there is a chemical and thermal component, all airbag-related burns should undergo chemical decontamination on the initial presentation. Burns related to airbag deployment tend to be small and do not require grafting; however, patients suffer from associated pain, scarring, and burn management can be a financial and time burden to the patient.

Fractionally Ablative Er: YAG Laser Resurfacing for Thermal Burn Scars: a Split-Scar, Controlled, Prospective Cohort Study.

BACKGROUND: Thermal burn scars can have catastrophic impact on the quality of life and personal image, and over time can lead to profound physical and psychological debilitation. There are no established treatments to significantly improve burn scars. OBJECTIVE: To demonstrate the safety, efficacy, and tolerability of fractionally ablative Er:YAG resurfacing of mature burn scars. METHODS: Sixteen subjects were enrolled and received 3 treatments of fractionally ablative Er:YAG resurfacing at monthly intervals. Twelve completed the study. Scars were scored with the Vancouver Scar Scale (VSS) by the patient and physician before and after treatment. Blinded photographic analysis (Visual Analog Scale [VAS]) and blinded histologic analysis of tissue before and after treatment was also performed. RESULTS: Significant Improvement in VSS scores were seen in all 12 patients, reported by patients and the evaluating physician alike. Photographic analysis demonstrated subjective improvement in all 12 patients. Histologically, there was significant improvement in collagen architecture and the number of vessels per high-power field. The treatments were tolerated well by patients, and 1 superficial skin infection occurred. CONCLUSION: Fractionally ablative Er:YAG laser resurfacing is a safe and effective modality in the treatment of thermal burn scars with subjective and objective improvement as seen from the patient and physician.

Thin and Ultra-Thin Split-Thickness Skin Grafts Are Safe and Efficacious in the Burn Population.

Split-thickness skin-grafts are a mainstay of burn management. Studies suggest no benefit to using thick (0.025 inch) over standard (0.012-0.020 inch) grafts, and some support the use of thin (0.008 inch) over standard thickness. Data on the use of even thinner grafts is scarce. This study reviewed outcomes of burn patients treated with thin (0.008-0.011 inch) and ultra-thin (≤0.007 inch) grafts. Retrospective review of records from July 2012 to June 2016 included patients who sustained operative burns treated by a single surgeon. Patients were excluded for nonoperative injuries, inhalational injuries, or prolonged hospitalizations. Outcome measures were compared between thin and ultra-thin groups. One-hundred twenty-eight patients met inclusion criteria; 35 received thin split-thickness skin-grafts while 93 received ultra-thin. Cohort analysis demonstrated equivalent graft-take, time to reepithelialization, and functional outcomes. Time to donor-site healing was significantly faster in the ultra-thin cohort (P = .04). Of those with functional outcomes recorded, 88.1% had good-excellent function and 11.9% retained a limitation in function as designated in physical therapy notes. There were fewer complications overall (P = .004) and a lower incidence of hypertrophic scarring (P = .025) in the ultra-thin cohort. This study presents a single-surgeon experience with thin and ultra-thin split-thickness skin-grafts. These grafts are exhibit excellent graft-take and few complications. There was no correlation between thickness and functional outcome at the time of physical therapy discharge. Donor-site reepithelialization was faster with ultra-thin grafts, which may be important in patients with large burns and limited donor sites.

Self-inflicted burn injuries: Etiologies, risk factors and impact on institutional resources.

INTRODUCTION: Self-inflicted burns are a rare cause of injury, accounting for only 1.0% of burns in the United States. While rare, the physical and psychosocial ramifications of these injuries are lasting. The goal of this study was to examine the etiologies, risk factors and outcomes of self-inflected burns in an urban setting. METHODS: Records of all patients presented to a regional burn center from July 2011 to June 2015 were reviewed. Those who sustained a self-inflected burn were identified and included in this study. Demographic data, psychiatric history, previous self-harm records, insurance status, injury circumstance, burn characteristic [location and total body surface area (TBSA)], need for excision and grafting, graft-take and duration of hospital stay and costs were reviewed. This group was then compared to a cohort of 166 patients with non-intentional burn during the same time frame matched for age and TBSA%. RESULTS: There were 34 patients with a mean (SD) age of 31 (15.2) who sustained a self-inflicted burn during the study period. The mean TBSA% was 2.8 (SD=5.1), with most injuries in the upper and lower extremities. Fifty three percent of the patients presented with altered mental status secondary to either psychiatric illness or intoxication. Twenty-four percent of incidents were claimed as suicide attempts and suicidal ideation was present in 47% of cases. Twenty-six percent of patients with a previous psychiatric diagnosis were not on a psychiatric medication prior to incident. There was record of previous self-harm in 26% of patients. When compared to control group of 166 patient with non-intentional burn, patients with self-inflicted burn had higher rates of substance abuse (35% vs. 13%, p<0.05), longer stay in the hospital (11.3 vs. 5.3 days, p<0.01), longer stay in the intensive care unit (1.8 vs. 0.2 days, p<0.01), and lower rates of insurance (15% vs. 42%, p<0.001). These patients also exhibited a higher need for excision and grafting (41% vs. 20%, p<0.01). CONCLUSIONS: Patients with self-inflected burn have a higher rate of previous self-harm behavior, psychiatric comorbidities and substance abuse. These patients are more likely to require surgical excision and grafting and expanded institutional resources compared to those with non-intentional burn with similar degree and size of burn. Increased counseling of at-risk populations may help to decrease this potentially preventable method of injury.

A rare case of a superior lumbar hernia secondary to penetrating injury.

Lumbar hernias are rare occurrences, with only 300 cases reported in the literature. We present a unique case of a superior lumbar hernia secondary to penetrating trauma to the right flank. We performed a herniorrhaphy using porcine mesh, and provided additional support by mobilizing the external oblique and latissimus dorsi into the defect. At follow up three months after repair, the patient was asymptomatic and exam revealed an intact lumbar abdominal wall with normal contour. Although literature displays a consensus on the need for lumbar hernia repair, specific repair techniques must be tailored to defect etiology, size, location, and contents.

Epidemiology and Outcomes of Auricular Burn Injuries.

Auricular burns represent a unique type of injury. The acute management and clinical course of these injuries can be different from other facial burns. There is a paucity of literature pertaining to the epidemiology and acute management of auricular burns. Most studies focus on deformity reconstruction. The aim of this study was to characterize the epidemiology, treatment, and outcomes of auricular burns. Data from all patients presenting to a regional burn center in a 4-year period were reviewed and those with auricular burns were identified. Demographic data, burn mechanism, insurance status, method of treatment, need for skin grafting, percentage graft-take, time to reepithelialization and incidence of deformity were reviewed. During the study period, 593 facial burns were evaluated and 132 (22%) sustained burns to the auricle. The most common mechanisms of injury were flame (65.1%) and scalding (22.5%). Auricular burns were mostly second degree (88%), involved both ears in 44%, and involved only the ventral aspect of the ear in 57%. The majority of patients healed well with conservative management; none suffered from chondritis. Of the 89 patients followed to healing, 1 patient (1.1%) received full-thickness skin grafts to the auricle, resulting in excellent graft-take. All other patients were managed nonoperatively, and none suffered from ear deformities. Auricular burns occur with surprising frequency in patients presenting to burn centers. Careful acute management of these injuries can eliminate development of chondritis and minimize the rate of deformity and need for reconstruction. The majority of wounds heal with conservative management, but time to reepithelialization can be prolonged.

Use of a home vacuum-assisted closure device in the burn population is both cost-effective and efficacious.

INTRODUCTION: The vacuum assisted closure device (VAC) improves wound-healing when utilized as a bolster to secure split thickness skin grafts (STSG). Patients typically remain hospitalized for VAC therapy; however, home VACs (hVAC) are now available. Limited studies examine burns treated with hVAC as a STSG bolster. METHOD: A retrospective study of records from an ABA verified regional burn center was conducted over 23 months. Patients included STSGs for burn. Data points included demographics, burn mechanism and location, graft characteristics, hospital length of stay (LOS), and time to heal. RESULTS AND DISCUSSION: Fifty patients were included, with average age of 39 years (range <1-83years). Average burn TBSA was 1.27±1.42 (range 0.05-8.18). Grafted area average was 102.9±128.1cm2. The most commonly treated areas were the leg/foot, thigh, and torso (53%, 16%, and 16%, respectively). Average LOS was 1.1±1.2 days. Mean graft-take was 99.2±2.8% with one patient undergoing repeat STSG. Average post-operative time to heal was 16±6 days. A 5-day inpatient stay with a VAC costs an average of $34,635, compared to $9134 for an hVAC over the same period. CONCLUSIONS: The hVAC is a cost-effective STSG bolster in the burn population for appropriate candidates. Excellent graft-take and low morbidity rates imply that this is an efficacious alternative for STSG bolster.

Jewelry Ring-Associated Electrothermal Burn Injuries: A Nine-Patient Case Series.

Ring-associated burns are infrequent, comprising only a small fraction of burn consults and admissions. However, because of the location of these burns and the propensity for circumferential wounds, small burn size may belie the severity of resultant injuries. Herein, the authors present their experience with this potentially severe type of burn. Records from a regional burn center were retrospectively analyzed during a 36-month period. All patients who sustained ring burns were included. Data points included demographics, burn location, need for surgical intervention, grafted area, hospital days (length of stay), percent graft take, complications, and time to re-epithelialization. Nine patients sustained ring-associated burns during the study period, accounting for 1.4% of all patients with burns seen during the same period. Average age was 41 years (range: 29-52 years). Seven (77%) ring-associated burns involved contact with a battery. All injuries were circumferential. Average burn TBSA was 0.07%. Two patients (22%) had third-degree injuries, both of which received split-thickness skin grafts. Grafted area was 4 and 5 cm, respectively. Average length of stay was 2.8 days. Mean graft take was 99.5 ± 1.5%. Average time to complete re-epithelialization was 12 days. One patient suffered temporary disability. No patients suffered from compartment syndrome. Ring-associated burns are an uncommon source of injury in the burn population. Despite small burn TBSA, these patients are more likely to require split-thickness skin grafts and suffer dysfunction compared with similarly-sized burns in other body regions. Expedient treatment and coordination with occupational therapy should be undertaken to achieve optimal outcomes.

Accidental Burn by Intentional Laxative Use.

OBJECTIVE: The purpose of this study was to present a case report and review the relevant literature on laxative-induced dermatitis being mistaken for scald injury and child abuse. CASE: A 33-month-old girl presented with partial thickness burn to the buttocks and perineum, which were suspected to be caused by child abuse. On further investigation, the parents had been administering large doses of laxatives to the child for chronic constipation. DISCUSSION: Child abuse by burning has characteristic physical examination findings, which differ from the pattern of laxative-induced dermatitis that has been reported in the literature. Diapers appear to be a risk factor for laxative-induced dermatitis. Surprisingly, the dose of laxative does not correlate with the severity of the burn injury. All physicians must be aware of the possibility of laxative-induced dermatitis mimicking scald burn injury to the buttocks. Parents should be educated about the risk of administering over-the-counter laxatives to children.

Tweens feel the burn: "salt and ice challenge" burns.

PURPOSE: To review our institution's experience with frostbite injury secondary to "salt and ice challenge" (SIC) participation. METHODS: We conducted a retrospective analysis of intentional freezing burns from 2012 to 2014. Demographics, depth and location of burn, total body surface area of burn, treatment, time to wound healing, length of stay, complications, and motives behind participation were analyzed. RESULTS: Five patients were seen in the emergency department for intentional freezing burns that resulted from SIC (all females; mean age: 12.3 years; range age: 10.0-13.2 years). Mean total body surface area was 0.408%. Salt and ice was in contact with skin for >10 min for two patients, >20 min for two patients, and an unknown duration for one patient. Complications included pain and burn scar dyschromia. Four patients cited peer pressure and desire to replicate SIC as seen on the Internet as their motivation in attempting the challenge. CONCLUSION: SIC has become a popular, self-harming behavior among youths. Increased public education, and provider and parent awareness of SIC are essential to address this public health concern.

The Evolving Role of Members of the American Board of Plastic Surgery in Burn Surgery.

INTRODUCTION: Outcomes for patients with burn injuries are optimized by multidisciplinary care in a specialized burn center. Plastic surgeons traditionally have played a significant role in the care of burn patients; however, this may be evolving. We aim to examine the role and employment satisfaction of plastic surgeons in burn surgery. METHODS: Members of the American Society of Plastic Surgery with available contact information and US senior plastic surgery residents were asked to complete a survey examining practice profiles and employment satisfaction. Responses were analyzed between groups stating that their practice did and did not involve burn surgery. RESULTS: Of the 573 attending respondents, 135 (23.6%) indicated that part of their practice included burn surgery. Nineteen (41.9%) residents indicated they desired their practice to include burn surgery. About 41.9% of respondents with less than 3 years of experience, 25% with between 3 and 10 years of experience, and 21.7% with greater than 10 years of experience practiced burn surgery. Twenty-one (15.3%) respondents were completely satisfied with their practice, 62 (45.3%) were mostly satisfied, and 36 (26.3%) were satisfied. Fourteen (10.2%) respondents were mostly dissatisfied and 4 (2.9%) were completely dissatisfied (P = 0.0315). CONCLUSIONS: Despite residents' interest and junior plastic surgeons' involvement in burn surgery, the role of burn surgery in responding plastic surgeons' practices diminished over time. Those practicing burn surgery are less likely to be satisfied and more likely to be dissatisfied with their practice. Plastic surgeons should therefore examine their role in burn surgery to optimize their desired involvement and satisfaction within the field.

Employment Satisfaction in Plastic and Reconstructive Surgery and Its Influence on Graduating Residents in an Evolving Health Care Climate.

BACKGROUND: The current state of employment satisfaction in plastic surgery has not been defined. Similarly, the factors influencing residents as they search for employment and the role of attending surgeons as mentors in this process have not been elicited. The authors aim to elucidate these measures through a survey of attending surgeons and senior residents. METHODS: A survey was created assessing employment satisfaction and was distributed to members of the American Society of Plastic Surgeons with available contact information. Responses were analyzed, with values of p < 0.05 deemed significant. RESULTS: A total of 616 plastic surgeons and senior plastic surgery residents responded. Compared with attending surgeons in private practice, those in academic practice were more satisfied with their case mix (p = 0.0005; OR, not significant) and less satisfied with their incentive structure (p = 0.0001; OR, 0.3155) and payor mix (p = 0.0005; OR, 0.6156). Employment change occurred in 225 surgeons (39.2 percent) since beginning practice. Surgeons that changed employment ranked base salary (p = 0.0031), earning potential (p = 0.0001), and incentive structure (p = 0.0001) as most important. Those that did not change employment ranked lifestyle (p = 0.0048), location (p = 0.0001), and desire to teach (p = 0.0002) as more important. Residents ranked location (p = 0.0030), desired case mix (p = 0.0131), and desire or lack of desire to teach residents (p = 0.0329) as more important than attending surgeons felt they should be, and guaranteed salary (p = 0.0178) and incentive structure (p = 0.0069) as less important. CONCLUSIONS: In an evolving health care environment, plastic surgeons' employment satisfaction is significantly dependent on a myriad of factors. Residents and their attending mentors differ significantly in perceived importance of these factors.

Prevention of hypophosphatemia after burn injury with a protocol for continuous, preemptive repletion.

Severe burn injury has been shown to result in hypophosphatemia. Hypophosphatemia can cause cardiac, hematologic, immunologic, and neuromuscular dysfunction. This study compares serum phosphate levels and outcomes in patients who were administered a continuous, preemptive phosphate repletion protocol vs those who only received phosphate supplementation after they developed hypophosphatemia. Records of patients with greater than 19% TBSA burn admitted to the intensive care unit from 2006 to 2010 were reviewed. Patients were divided into two groups: historical controls who received responsive repletion when serum phosphate levels were less than 2.5 mg/dl (2006-2008) and the experimental group that received 30 mmol intravenous every 6 hours starting at approximately 24 hours after injury as long as serum phosphate levels were less than 4 mg/dl (2008-2010). Patients with chronic kidney disease or acute kidney injury were excluded. Data collected included age, weight, burn size, age, all serum phosphate levels, and total amount of phosphate administered. Differences in groups were compared with Mann-Whitney U test and Fisher's exact test. A total of 30 patients were included in the study, 20 in the responsive repletion group and 10 in the continuous repletion group. No significant difference was detected in age, sex, burn size, or full thickness burn size between groups. The continuous group had a statistically lower percentage of hypophosphatemic lab values compared with the responsive group, 13 ± 14% vs 45 ± 21% (P < .0001). No difference was found in percent of observations reflecting hyperphosphatemia (median of 2% in each group, P = .7). Four patients in the continuous group suffered cardiac and/or infectious complications compared with 16 in the responsive group (P = .04). Continuous, pre-emptive repletion of phosphate prevents hypophosphatemia after severe burn injury when compared with responsive repletion in historical controls. The protocol resulted in less hypophosphatemia without increasing the risk of hyperphosphatemia. This study also suggests that continuous repletion may result in fewer complications, but this needs to be confirmed in larger, prospective studies.

Firefighter safety: rampant unsafe practices as documented in mainstream media.

More than 30,000 firefighters are injured on the fireground each year. Literature suggests that injury often occurs when protective gear is not used properly. According to firefighters, failure to correctly wear protective equipment occurs for several reasons: (1) gear not used because of haste, (2) cumbersome gear can sometimes interfere with performance, and (3) cultural factors. The purpose of this study is to quantify improper gear and tactic use in a publicly available, online video repository in order to better understand unsafe firefighting. This was an Institutional Review Board-exempt study of public video records. A search for "fire fighting videos" was conducted at YouTube (www.youtube.com). The first 50 videos that contained volunteer or career firefighters at work fighting fires were selected evaluated for appropriate use of personal protective equipment and for safe behavior. The videos were evaluated by two highly experienced professional firefighters. Of the 50 videos reviewed, 25 (50%) demonstrated violations of firefighting safety principles. Of the unsafe videos, 21 (42%) displayed firefighters improperly using gear, while the other 4 (8%) were related to unsound tactics. The most common problem was failure to wear or properly secure a self-contained breathing apparatus when appropriate (14 videos or 28%). The second most common failure was lack of helmet, hood, or approved gloves (11 videos or 22%). In conclusion, firefighting as documented on YouTube is often unsafe because of failure to properly use personal protective equipment. Half of the videos reviewed contained unsafe practices. With such a shockingly high rate of unsafe firefighting, the profession is in need of additional education and reform. In response to this epidemic, a multidisciplinary educational program has been developed to improve firefighter awareness of gear limitations and burn injury risk. Effectiveness of educational programs should be documented in additional prospective studies.