Incorporating aspects of programmatic assessment into examinations: Aggregating rich information to inform decision-making.

CONTEXT: A programmatic approach to assessment entails gathering and aggregating 'rich information' on candidates to inform progress decisions. However, there is little guidance on how such an approach might be implemented in practice. OBJECTIVE: We describe an approach to aggregating rich information across assessment formats to inform committee decision-making in a specialist medical college. METHODS: Each item (n = 272) for every examination was blueprinted to 15 curriculum modules and 7 proficiencies. We developed a six-point holistic rating scale with detailed rubrics outlining expected performance standards for every item. Examiners used this rating scale in making judgements for each item, generating rich performance data for each candidate. RESULTS: A colour-coded 'mosaic' of patterns of performance across modules and proficiencies was generated along with frequency distributions of ratings. These data allowed examiners to easily visualise candidate performance and to use these data to inform deliberations on borderline candidates. Committee decision-making was facilitated by maintaining the richness of assessment information throughout the process. Moreover, the data facilitated detailed and useful feedback to candidates. CONCLUSIONS: Our study demonstrates that incorporating aspects of programmatic thinking into high-stakes examinations by using a novel approach to aggregating information is a useful first step in reforming an assessment program.

Early return to sport post maxillofacial fracture injury in the professional athlete: A systematic review.

INTRODUCTION: To summarize the current literature on return to sport times post-maxillofacial fracture injury in the professional athlete. MATERIALS AND METHODS: A literature search on six databases for articles relating to maxillofacial fractures, professional athletes, and return to sport times. Study design, clinical data, and author recommendations were analysed. RESULTS: 17 studies were retrieved. One prospective study returned 17 athletes to competitive rugby union and soccer at 3 weeks post injury without complication. Two large retrospective studies (n = 278) returned patients to sport at approximately 7 weeks without complication. 64% (n = 7) of patients from case based studies returned to sport at 3-14 days, 4 of which utilized protective facemasks. Athletes generally returned to competition earlier for lower grade (3-10 days) compared to higher grade contact sport (21 days at least). 2 articles recommended a 3 months recovery period for combat sports. 8 articles supported the utility of protective facemasks. CONCLUSION: Early return to sport (<6 weeks) in the professional athlete post maxillofacial fracture injury is achievable. The optimal clinical approach may be to grade the sport according to its impact forces, discuss an early return with reference to the available literature, the potential utility of facemasks, risks of refracture and its operative implications.

Supraclavicular flap repair in the free flap era.

BACKGROUND: Supraclavicular flap (SCF) repair is widely reported in head and neck surgery in select patients and defects. The authors' objective is to present our series of 30 patients who underwent SCF repair for varying defects and to review the scope and outcome of SCF repair in the literature. METHODS: The authors contributed primary evidence of 30 cases of SCF repair. Our outcomes are compared with those reported in the last 5 years' literature; 33 articles published between January 2012 and January 2017 that present original clinical experience of 528 SCFs. RESULTS: SCF is suitable for a wide variety of oral cavity, pharyngeal, skull base and cutaneous defects. Consistent with our experience, SCF is highly reliable even in previously irradiated or dissected necks, so long as the supraclavicular artery is intact. Our case series shows minor complications in 3/30 (10%) and flap loss in 1/30 (3.3%) cases. The literature reports a similar rate of complete flap failure of 3.4% and a slightly higher average minor complication rate of 24.6%. CONCLUSION: We add our experience of 30 cases of SCF repair to the international literature. We experienced a complication rate lower than the reported average, and maintain that the SCF is an excellent reconstructive option in patients with previously irradiated necks or comorbidities that affect microvasculature and anaesthetic resilience.

Elderly patients with maxillofacial trauma: the effect of an ageing population on a maxillofacial unit's workload.

The purpose of this study was to identify the aetiology and management of facial fractures in patients over 60 years old and to identify potential trends in caseload to assist with planning of resources for maxillofacial services in the coming decades. We made a prospective study over 2 years (2009-2010), during which all injured patients referred to the oral and maxillofacial surgery unit at The Canberra Hospital, Australia were recruited. The patients were classified into two groups: less than 60 years old (younger group); or 60 years old or more (older group). Factors studied included sex, age, aetiology, site of fractures, severity scored using the Maxillofacial Injury Severity Score (MFISS), and management. Based on current trends, the expected workload was extrapolated. A total of 470 patients were recruited (younger: n=430 and older: n=40). Falls were the most common cause of fracture in the older group (85%) and the zygoma (40%) was the bone most commonly fractured. The mean (SD) MFISS for the older group was 3.8 (2.2) (17% of these maxillofacial injuries were operated on) and 6.0 (5.0) for the younger group (72% of these were operated on). In Australia, population trends suggest that older people as a proportion of the total population will rise from about 20% of 22 million to 26% of 30 million by 2034. As the older group increases there will be a corresponding increase in the number of older people who present with trauma to maxillofacial units. The overall maxillofacial surgical workload will probably not increase much because the injuries tend to be less severe and are less likely to require operation.

Alcohol and interpersonal violence may increase the severity of facial fracture.

The association between alcohol and interpersonal violence has been established in studies from a number of countries. We aimed to determine whether alcohol was a contributing factor in the incidence or severity of facial trauma. For 15 months we prospectively studied patients with facial fractures who presented for oral and maxillofacial review. Severity of injury was assessed using the maxillofacial injury severity score (MFISS). Of the 255 patients with facial trauma who presented to our tertiary referral centre, 202 had fractures of the facial skeleton. Most presentations were secondary to interpersonal violence (n=105, 52%), and 91 (87%) of these involved alcohol. Overall, alcohol was involved in 53% of cases (n=107). The relative risk of requiring surgical intervention when alcohol was involved was 1.61 (CI=1.12-2.32). Alcohol significantly increased the severity of facial fracture for both MFISS: alcohol (n=107) mean (SD) 11.43 (7.63); no alcohol (n=95) mean (SD) 6.87 (6.22) (p<0.05). Interpersonal violence also increased the severity of facial fracture: interpersonal violence (n=105) mean (SD) 11.06 (6.68), no interpersonal violence (n=97) mean (SD) 7.37 (7.59) (p<0.05). Patients whose facial fractures are the result of interpersonal violence have more severe injuries and are more likely to require surgery if alcohol is involved. This results in a heavier surgical workload, and is an economic and social burden to the community. Primary prevention strategies will have an important role in reducing such injuries.