[Careers in plastic and aesthetic surgery: a review of habilitation and professorship of members of the DGPRAEC]. / Karriere in der Plastischen und Ästhetischen Chirurgie ­ Untersuchung zur Habilitation und Professur der Mitglieder der DGPRÄC.

Background Over the last few decades plastic and aesthetic surgery careers aimed at holding a chair as head of the department or clinical director. The current career trend shows a drain of academic teaching staff to peripheral hospitals with sole clinical focus. The achievement of a doctorate in German university medicine or obtaining the venia legendi appears to be the termination of academic careers. This brain drain with loss of expertise and scientific output imposes a problem to future progress in clinical and scientific plastic and reconstructive surgery. The causative role of our present work profile, workload and financial compensation will be discussed in this paper. Methods In order to understand this brain drain, the scientific and clinical developments of all habilitands, Assistant Professors and University Directors enlisted in our specialist society (DGPRAEC) were analyzed. The evaluation included the duration of the residency, the time span from being a specialist physician to habilitation, as well as gaining a leadership position after habilitation. Finally, the current activity of the members at university and non-university institutions was evaluated. Results A total of 1238 members were analyzed. Among these, 177 (14.3 %) members had completed the habilitation. In total, 114 (9.21 %) were included based on full available CVs. Of the listed members, 80 members (6,5 %) had an APL professorship/university professorship in April 2017. 88 CVs showed an average time span of 4.2 years from specialization to habilitation. 80 CVs revealed a 5 year time span to achieve an APL professorship/university professorship. After an average of 4.2 years, leadership positions were held. Of the analyzed habilitations, 60 % were active in peripheral hospitals at the time April 2017. Discussion The loss of scientific and clinical expertise should be prevented in order to preserve academic plastic surgery with focus on patient care, academic education and research. This could be achieved by creating more attractive working conditions.

Optimal Positioning of the Nipple-Areola Complex in Men Using the Mohrenheim-Estimated-Tangential-Tracking-Line (METT-Line): An Intuitive Approach.

INTRODUCTION: The reconstruction of the body shape after post-bariatric surgery or high-grade gynecomastia involves, besides skin tightening, the repositioning of anatomical, apparent landmarks. The surgeon usually defines these during the preoperative planning. In particular, the positions of the nipple-areola complexes (NAC) should contribute to the gender-appropriate appearance. While in the female breast numerous methods have been developed to determine the optimal position of the NACs, there are only a few, metric and often impractical algorithms for positioning the nipples and areoles in the male. With this study, we show the accuracy of the intuitive positioning of the nipple-areola complex in men. MATERIAL AND METHODS: From a pre-examined and measured quantity of 10 young and healthy men, six subjects were selected, which corresponded, on the basis of their chest and trunk dimensions, to the average of known data from the literature. The photographed frontal views were retouched in two steps. Initially, only the NACs were removed and the chest contours were left. In a second step, all contours and the navel were blurred. These pictures were submitted to resident and consultant plastic surgeons, who were asked to draw the missing NACs without any tools. The original positions of the nipples were compared with the inscriptions. Furthermore, the results were compared between the contoured and completely retouched pictures and between the residents and consultants. RESULTS: A total of 8 consultants and 7 residents were included. In the contoured and completely retouched images, a significant deviation of the marked positions of the missing features was found. The height of the NAC was determined somewhat more precisely than the vertical position. There was no significant difference between the contoured and completely retouched images, with a discretely more accurate tendency on the contoured images. In comparison with the professional experience, the consultants were tangentially more precise, but without a statistically significant impact. DISCUSSION: The intuitive determination of the NACs is a challenge for the plastic surgeon. In this study, a statistically significant deviation was seen in almost all dimensions, although the clinical relevance cannot be conclusively assessed. We found a positional relationship of the NAC to the infraclavicular groove ("Mohrenheim pit") in the vertical and 4-4.5 cm above the submammary fold. The position of the NAC can be satisfactorily determined by a combination of plastic surgical intuition, patient wishes and practical metric methods using the Mohrenheim-Estimated-Tangential-Tracking-Line (METT-Line). LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Patient experience of different regional models of urgent and emergency care: a cross-sectional survey study.

OBJECTIVES: To compare user experiences of 8 regional urgent and emergency care systems in the Republic of Ireland, and explore potential avenues for improvement. DESIGN: A cross-sectional survey. SETTING: Several distinct models of urgent and emergency care operate in Ireland, as system reconfiguration has been implemented in some regions but not others. The Urgent Care System Questionnaire was used to explore service users' experiences with urgent and emergency care. Linear regression and logistic regression were used to detect regional variation in each of the 3 domains and overall ratings of care. PARTICIPANTS: A nationally representative sample (N=8002) of the general population was contacted by telephone, yielding 1205 participants who self-identified as having used urgent and emergency care services in the previous 3 months. MAIN OUTCOME MEASURES: Patient experience was assessed across 3 domains: entry into the system, progress through the system and patient convenience of the system. Participants were also asked to provide an overall rating of the care they received. RESULTS: Service users in Dublin North East gave lower ratings on the entry into the system scale than those in Dublin South (adjusted mean difference=-0.18; 95% CI -0.35 to -0.10; p=0.038). For overall ratings of care, service users in the Mid-West were less likely than those in Dublin North East to give an excellent rating (adjusted OR 0.57; 95% CI 0.35 to 0.92; p=0.022). Survey items relating to communication, and consideration of patients' needs were comparatively poorly rated. The use of public emergency departments and out-of-hours general practice care was associated with poorer patient experiences. CONCLUSIONS: No consistent relationship was found between the type of urgent and emergency care model in different regions and patient experience. Scale-level data may not offer a useful metric for exploring the impact of system-level service change.

Biobrane versus topical agents in the treatment of adult scald burns.

BACKGROUND: Limited data is available for treatment of scald lesions in adults. The use of the biosynthetic matrix Biobrane® has been suggested as treatment option with more benefits over topical dressings. Application of Biobrane® in scalds in our center led to a perceived increase of infection, secondary deepening, surgery and length of stay. We therefore assessed the effect of different treatment options in adult scalds in our center. METHODS: We performed a retrospective cohort study of adult patients that have been admitted with scalds in our center between 2011 and 2014. We assessed two groups, group 1 with Biobrane® as initial treatment and group 2 with topical treatment using polyhexanid hydrogel and fatty gauze. Primary outcome variables were rate of secondary deepening, surgery, infection (defined as positive microbiological swabs and antibiotic treatment) and length of stay. Total body surface area (TBSA) as well as diabetes mellitus (DM), hypertension, smoking and alcohol consumption as potential confounders were included. RESULTS: A total of 52 patients were included in this study. 36 patients received treatment with Biobrane® and 16 with ointment and fatty gauze. No significant differences were found for age and TBSA whereas gender ratio was different (25/11 male/female in group 1 vs 4/12 in group 2, p=0.003). Rate of secondary deepening, surgery, infection as well as days of hospital stay (DOHS) were comparable. Logistic and multilinear regression showed TBSA to be a predictive factor for infection (p=0.041), and TBSA and age for length of stay (age p=0.036; TBSA p=0.042) in group 1. CONCLUSION: The use of Biobrane® in adult scald lesions is safe and non-inferior to topical treatment options. In elder patients and larger TBSA Biobrane® may increase the risk of infection or a prolonged stay in hospital. LEVEL OF EVIDENCE: Level 3 - retrospective cohort study.

The effectiveness of providing peer benchmarked feedback to hip replacement surgeons based on patient-reported outcome measures--results from the PROFILE (Patient-Reported Outcomes: Feedback Interpretation and Learning Experiment) trial: a cluster randomised controlled study.

OBJECTIVE: To test whether providing surgeons with peer benchmarked feedback about patient-reported outcomes is effective in improving patient outcomes. DESIGN: Cluster randomised controlled trial. SETTING: Secondary care--Ireland. PARTICIPANTS: Surgeons were recruited through the Irish Institute of Trauma and Orthopaedic Surgery, and patients were recruited in hospitals prior to surgery. We randomly allocated 21 surgeons and 550 patients. INTERVENTION: Surgeons in the intervention group received peer benchmarked patient-reported outcome measures (PROMs) feedback and education. MAIN OUTCOME VARIABLE: Postoperative Oxford Hip Score (OHS). RESULTS: Primary outcome data were available for 11 intervention surgeons with responsibility for 230 patients and 10 control surgeons with responsibility for 228 patients. The mean postoperative OHS for the intervention group was 40.8 (95% CI 39.8 to 41.7) and for the control group was 41.9 (95% CI 41.1 to 42.7). The adjusted effect estimate was -1.1 (95% CI -2.4 to 0.2, p=0.09). Secondary outcomes were the Hip Osteoarthritis Outcome Score (HOOS), EQ-5D and the proportion of patients reporting a problem after surgery. The mean postoperative HOOS for the intervention group was 36.2 and for the control group was 37.1. The adjusted effect estimate was -1.1 (95% CI -2.4 to 0.3, p=0.1). The mean postoperative EQ-5D for the intervention group was 0.85 and for the control group was 0.87. The adjusted effect estimate was -0.02 (95% CI -0.05 to 0.008, p=0.2). 27% of intervention patients and 24% of control patients reported at least one complication after surgery (adjusted OR=1.2, 95% CI 0.6 to 2.3, p=0.6). CONCLUSIONS: Outcomes for patients operated on by surgeons who had received peer benchmarked PROMs data were not statistically different from the outcomes of patients operated on by surgeons who did not receive feedback. PROMs information alone seems to be insufficient to identify opportunities for quality improvement. TRIAL REGISTRATION NUMBER: ISRCTN 69032522.

What to give the patient who has everything? A qualitative study of prescribing for multimorbidity in primary care.

BACKGROUND: Using clinical guidelines in the management of patients with multimorbidity can lead to the prescription of multiple and sometimes conflicting medications. AIM: To explore how GPs make decisions when prescribing for multimorbid patients, with a view to informing intervention design. DESIGN AND SETTING: In-depth qualitative interviews incorporating chart-stimulated recall with purposively sampled GPs in the Republic of Ireland. METHOD: Grounded theory analysis with iterative theory development. RESULTS: Twenty GPs were interviewed about 51 multimorbid cases. In these cases, GPs integrated information from multiple sources including the patient, specialists, and evidence-based medicine. Difficulties arose when recommendations or preferences conflicted, to which GPs responded by 'satisficing': accepting care that they deemed satisfactory and sufficient for a particular patient. Satisficing was manifest as relaxing targets for disease control, negotiating compromise with the patient, or making 'best guesses' about the most appropriate course of action to take. In multimorbid patients perceived as stable, GPs preferred to 'maintain the status quo' rather than rationalise medications, even in cases with significant polypharmacy. Proactive changes in medications were facilitated by continuity of care, sufficient consultation time, and open lines of communication with the patient, other healthcare professionals, and other GPs. CONCLUSION: GPs respond to conflicts in the management of multimorbid patients by making compromises between patient-centred and evidence-based care. These findings will be used to inform interventions that aim to care in multimorbidity.

Surgeon's experiences of receiving peer benchmarked feedback using patient-reported outcome measures: a qualitative study.

BACKGROUND: The use of patient-reported outcome measures (PROMs) to provide healthcare professionals with peer benchmarked feedback is growing. However, there is little evidence on the opinions of professionals on the value of this information in practice. The purpose of this research is to explore surgeon's experiences of receiving peer benchmarked PROMs feedback and to examine whether this information led to changes in their practice. METHODS: This qualitative research employed a Framework approach. Semi-structured interviews were undertaken with surgeons who received peer benchmarked PROMs feedback. The participants included eleven consultant orthopaedic surgeons in the Republic of Ireland. RESULTS: Five themes were identified: conceptual, methodological, practical, attitudinal, and impact. A typology was developed based on the attitudinal and impact themes from which three distinct groups emerged. 'Advocates' had positive attitudes towards PROMs and confirmed that the information promoted a self-reflective process. 'Converts' were uncertain about the value of PROMs, which reduced their inclination to use the data. 'Sceptics' had negative attitudes towards PROMs and claimed that the information had no impact on their behaviour. The conceptual, methodological and practical factors were linked to the typology. CONCLUSION: Surgeons had mixed opinions on the value of peer benchmarked PROMs data. Many appreciated the feedback as it reassured them that their practice was similar to their peers. However, PROMs information alone was considered insufficient to help identify opportunities for quality improvements. The reasons for the observed reluctance of participants to embrace PROMs can be categorised into conceptual, methodological, and practical factors. Policy makers and researchers need to increase professionals' awareness of the numerous purposes and benefits of using PROMs, challenge the current methods to measure performance using PROMs, and reduce the burden of data collection and information dissemination on routine practice.

The experiences of professionals with using information from patient-reported outcome measures to improve the quality of healthcare: a systematic review of qualitative research.

OBJECTIVES: To synthesise qualitative studies that investigated the experiences of healthcare professionals with using information from patient-reported outcome measures (PROMs) to improve the quality of care. DESIGN: A qualitative systematic review was conducted by searching PubMed, PsycINFO and CINAHL with no time restrictions. Hand searching was also performed. Eligible studies were evaluated using the Critical Appraisal Skills Programme toolkit for qualitative studies. A thematic synthesis identified common themes across studies. Study characteristics were examined to explain differences in findings. SETTING: All healthcare settings. PARTICIPANTS: Healthcare professionals. OUTCOMES: Professionals' views of PROMs after receiving PROMs feedback about individual patients or groups of patients. RESULTS: Sixteen studies met the inclusion criteria. Barriers and facilitators to the use of PROMs emerged within four main themes: collecting and incorporating the data (practical), valuing the data (attitudinal), making sense of the data (methodological) and using the data to make changes to patient care (impact). CONCLUSIONS: Professionals value PROMs when they are useful for the clinical decision-making process. Practical barriers to the routine use of PROMs are prominent when the correct infrastructure is not in place before commencing data collection and when their use is disruptive to normal work routines. Technology can play a greater role in processing the information in the most efficient manner. Improvements to the interpretability of PROMs should increase their use. Attitudes to the use of PROMs may be improved by engaging professionals in the planning stage of the intervention and by ensuring a high level of transparency around the rationale for data collection.

Capsular contracture by silicone breast implants: possible causes, biocompatibility, and prophylactic strategies.

The most common implanted material in the human body consists of silicone. Breast augmentation and breast reconstruction using silicone-based implants are procedures frequently performed by reconstructive and aesthetic surgeons. A main complication of this procedure continues to be the development of capsular contracture (CC), displaying the result of a fibrotic foreign body reaction after the implantation of silicone. For many years, experimental and clinical trials have attempted to analyze the problem of its etiology, treatment, and prophylaxis. Different theories of CC formation are known; however, the reason why different individuals develop CC in days or a month, or only after years, is unknown. Therefore, we hypothesize that CC formation, might primarily be induced by immunological mechanisms along with other reasons. This article attempts to review CC formation, with special attention paid to immunological and inflammatory reasons, as well as actual prophylactic strategies. In this context, the word "biocompatibility" has been frequently used to describe the overall biological innocuousness of silicone in the respective studies, although without clear-cut definitions of this important feature. We have therefore developed a new five-point scale with distinct key points of biocompatibility. Hence, this article might provide the basis for ongoing discussion in this field to reduce single-publication definitions as well as increase the understanding of biocompatibility.

Does providing feedback on patient-reported outcomes to healthcare professionals result in better outcomes for patients? A systematic review.

PURPOSE: To assess the impact of providing healthcare professionals with feedback on patient-reported outcome measures (PROMs). METHODS: This is a systematic review including controlled studies investigating the effectiveness of PROMs feedback, specifically examining the impact at a group-level and a patient-level. RESULTS: Only one study provided feedback at a group-level as a measure of professional performance, which found no intervention effect. At a patient-level, sixteen studies were identified and only one study found an overall significant difference in the PROM score. However, an additional six studies found a significant result favouring the intervention group for a particular subgroup or domain. The studies which demonstrated the greatest impact primarily used PROMs as a management tool in an outpatient setting on a specialised patient population. In contrast, there was weak evidence supporting with the use of PROMs as a screening tool. The studies which found a positive effect had a lower quality score on average. CONCLUSIONS: The effectiveness of PROMs feedback seems to be related to the function of the PROM. However, the evidence regarding the impact of PROMs feedback on patient outcomes is weak, and methodological issues with studies are frequent. The use of PROMs as a performance measure is not well investigated. Future research should focus on the appropriate application of PROMs by testing specific hypothesis related to cause and effect. Qualitative research is required to provide a deeper understanding of the practical issues surrounding the implementation of PROMs and the methodological issues associated with the effective use of the information.