The Need for Clinical Hand Education in Emergency Medicine Residency Programs.

BACKGROUND: Complaints related to the hands, wrists, and fingers comprise approximately 3.7 million emergency department visits annually. The complexity of this subject can confound timely diagnosis and treatment, particularly if the treating physician has not received specialized training. We set out to determine whether emergency medicine training in the USA provides adequate preparation for dealing with the identification, management, and treatment of hand, wrist, and finger injuries. METHODS: The curricula for 160 accredited U.S. emergency medicine programs were obtained. Each of these was examined to see whether a clinical "hand" rotation was included as a required module. Clinical hand rotations were then classified by length of rotation, the postgraduate years in which they were offered, and if they were offered as stand-alone modules or combined with other rotations. RESULTS: Of the 160 programs, 21 (13.1%) require a clinical hand rotation. Sixteen offer a dedicated module, and five are part of another rotation. The mean amount of time dedicated to hand education was 3 weeks. The 16 dedicated hand rotations had a mean duration of 2.69 weeks; combined rotations were 4 weeks. Four incorporated hand education in the first postgraduate year (PGY-1), 13 into the second (PGY-2), and 3 into the third (PGY-3). CONCLUSIONS: Despite the preponderance of hand injuries seen by emergency physicians, the clinical and legal pitfalls that accompany these conditions, and the benefits to be gained from specialized training, very few programs emphasize clinical hand training in an equivalent fashion.

Does Time Affect Patient Satisfaction and Health-Related Quality of Life After Reduction Mammoplasty?

OBJECTIVE: A total of 62,611 patients with breast hypertrophy underwent breast reduction surgery in 2013 in the United States to improve their symptoms and health-related quality of life. While multiple studies utilizing various outcome instruments demonstrate the efficacy of reductive surgery, it is presently unknown how the postoperative course affects patient satisfaction and health-related quality of life as measured by the BREAST-Q. Our objective was to determine the temporal relationship of patient satisfaction and health-related quality of life after reduction mammoplasty. METHODS: Patients prospectively completed the BREAST-Q reduction mammoplasty module at 3 time points during their treatment: preoperatively, at less than 3 months postoperatively, and at more than 3 months (<12 months) postoperatively. A single surgeon (N.P.P.) performed all of the breast reduction procedures. RESULTS: Each time point contained 20 questionnaires. Mean preoperative BREAST-Q scores were significantly lower than scores at the less than 3-month postoperative time point for the scales Satisfaction With Breasts, Psychosocial Well-being, Sexual Well-being, and Physical Well-being (P < .001). There was no significant difference in BREAST-Q scores between the postoperative time points in these measures. CONCLUSION: Breast reduction surgery offers a vast improvement in patients' satisfaction and health-related quality of life that is maintained throughout the postoperative period. These findings can assist surgeons in managing patient expectations after reduction mammoplasty and help improve the probability of obtaining prior authorization for insurance coverage.

An Algorithm for Building an Electronic Database.

OBJECTIVE: We propose an algorithm on how to create a prospectively maintained database, which can then be used to analyze prospective data in a retrospective fashion. Our algorithm provides future researchers a road map on how to set up, maintain, and use an electronic database to improve evidence-based care and future clinical outcomes. METHODS: The database was created using Microsoft Access and included demographic information, socioeconomic information, and intraoperative and postoperative details via standardized drop-down menus. A printed out form from the Microsoft Access template was given to each surgeon to be completed after each case and a member of the health care team then entered the case information into the database. RESULTS: By utilizing straightforward, HIPAA-compliant data input fields, we permitted data collection and transcription to be easy and efficient. Collecting a wide variety of data allowed us the freedom to evolve our clinical interests, while the platform also permitted new categories to be added at will. CONCLUSION: We have proposed a reproducible method for institutions to create a database, which will then allow senior and junior surgeons to analyze their outcomes and compare them with others in an effort to improve patient care and outcomes. This is a cost-efficient way to create and maintain a database without additional software.

The use of the multi-island vertical rectus abdominis myocutaneous flap in head and neck reconstruction.

BACKGROUND: Head and neck cancer extirpation frequently creates complex 3-dimensional defects involving both intraoral and external tissues. Reconstruction can be accomplished either with 2 free flaps, a simultaneous free and pedicle flap, or a single double-island folded free flap. Herein, the outcomes and rationale for reconstruction of multilaminar head and neck defects using the multi-island vertical rectus abdominis myocutaneous (MI-VRAM) flap are reported. METHODS: A retrospective review was performed of a prospectively collected database of all head and neck reconstructions completed by a single surgeon between 1992 and 2011. Forty-six patients were identified who underwent reconstruction of composite defects using MI-VRAM flaps. Oncologic defects were classified into 3 categories based on anatomic location, namely, the midface, lower face, and neck. Indications and outcomes were reviewed. RESULTS: Patients' ages ranged from 7 to 84 years with two thirds being male; 45% received preoperative radiation. Average MI-VRAM skin paddle size was 9×25.5 cm. Of the 46 reconstructions, 27 (59%) were performed in the midface, 14 (30%) in the lower face, and 5 (11%) in the neck region. There were no complete flap loses; however, 1 patient lost the external skin island, requiring pectoralis flap coverage. Of these cases, 15% had surgically related complications. Ten patients required secondary contouring procedures to revise bulky flaps. CONCLUSIONS: The MI-VRAM flap is a safe and reliable technique for reconstruction of complex defects throughout the head and neck region. Compared to 2 simultaneous free flaps or a free flap combined with a regional flap, it saves time and eliminates a second donor site. LEVEL OF EVIDENCE: Level IV. Clinical question addressed in this paper is whether a multi-island VRAM flap is a safe technique in head and neck reconstruction.

A new dimension: robotic reconstruction in plastic surgery.

BACKGROUND: Robot-assisted surgery was first approved by the Federal Drug Administration in 1994. The robotic system has the advantages of three-dimensional visualization of the operating field, 7° range of motion, tremor elimination, 360°of freedom at 10-mm distance, and a comfortable, seated operating posture. The purpose of this paper is to present a new surgical tool, the robot, for use in reconstructive surgery. METHODS: A case is presented in which the robotic system was used to elevate a pedicled, myocutaneous latissimus dorsi flap for shoulder reconstruction. RESULTS: The robot was used successfully to harvest a pedicled latissimus dorsi flap. Since this case, we have used the robotic system to harvest one other pedicled latissimus flap for breast reconstruction as well as to perform the microvascular anastomoses in a radial forearm and rectus abdominus free flaps to the lower extremity. CONCLUSION: There is great potential for the use of robot as a surgical tool in the field of plastic surgery. The advantages are numerous, including superior visibility, greater range of motion as a more comfortable position for the operating surgeon. The limitations include the learning curve and the lack of biofeedback.

Treatment of keratoacanthoma: Is intralesional methotrexate an option?

BACKGROUND: Keratoacanthomas (KAs) are a variant of squamous cell carcinomas. Some KAs have shown aggressive behaviour, leading to metastasis and death. Surgical excision is the treatment of choice for most KA patients. Intralesional methotrexate (MTX) may also be a potential treatment option for KAs. OBJECTIVE: To evaluate intralesional MTX as a treatment modality for KA. METHODS: A retrospective chart review of nine patients with KAs treated with intralesional MTX was performed. Each patient had biopsy-proven KA. The lesion was initially debulked, and MTX was injected at the base. Patients were seen weekly in the office, and reinjected with intralesional MTX depending on the response of the lesion. Each patient was evaluated for their response to the intralesional MTX injections, the number of injections required and complications. RESULTS: Patients required approximately two to four intralesional injections (12.5 mg to 25 mg per injection) before KA resolution. Eight of nine (88.9%) patients experienced complete resolution of their tumours. One patient experienced treatment failure, and underwent surgical excision of the KA. The average follow-up period was 2.8 years, and there were no recurrences. CONCLUSION: The results from the present retrospective study show that intralesional MTX injection is an effective treatment option for KAs. The authors propose that intralesional MTX injection with initial debulking of the KA should be used as a first line of treatment when KAs present on the extremities, in cosmetically sensitive areas and in elderly patients with multiple comorbities.

Median cleft of the upper lip: a rare case.

Median cleft lip is a midline vertical cleft through the upper lip. This is a rare anomaly with very few cases described in the literature. Median cleft lip has been thought to be associated with hypertelorism or hypotelorism. It is caused by the failure of fusion of the medial nasal prominences. In this case report, a 4½-year-old girl with a median cleft is presented. The patient has no other anomalies of the nose or alveolus. The patient has normotelorism. A shortened bifid frenulum of the upper lip is present. A technique using an elliptical excision of the cleft with muscle approximation is described.

Keloid treatment: is there a role for acellular human dermis (Alloderm)?

BACKGROUND: Keloid management is faced with high recurrence rates. Keloid fibroblasts lack the normal negative feedback mechanism resulting in an exuberant scar formation. Alloderm doesn't undergo the same proliferative process as keloidal scar dermis. OBJECTIVE: To evaluate Alloderm as a treatment modality for keloids METHODS: A retrospective chart review of six patients with a total of eight large recurrent keloids was performed. Patients were treated with excision of the keloid followed by placement of Alloderm. Each patient was evaluated for recurrence and complications. RESULTS: During follow-up ranging from 1 month to 4(1/2) years there were 0% recurrences. Two out of 8 (25%) had residual induration. one of the two patients with residual induration, required an intralesional injection of kenalog at 6 months post-op. CONCLUSION: Our results from this small study show that with the use of Alloderm after keloid excision, recurrence is low. Further study is warranted.

Comparison of wound education in medical schools in the United States, United kingdom, and Germany.

OBJECTIVE: Millions of patients are treated annually in the United States, United Kingdom, and Germany with either acute or chronic wounds. The purpose of this study is to compare how the medical education systems in the United States, Germany, and United Kingdom have prepared their physician trainees to deal with clinical issues of wounds. METHODS: A retrospective study was performed in the United States by obtaining medical school curriculum data from the American Association of Medical Colleges, 2005. In the United Kingdom, data were obtained from the individual medical schools listed in the Royal Society of Medicine. In Germany, data were collected from a questionnaire sent to all the medical schools. RESULTS: The total hours of required wound education received in the United States was 9.2 hours in the 4 years of medical school. In the United Kingdom, the total time devoted to wound-related issues equaled 4.9 hours over 5 years. In Germany, a total of 9 hours of wound education was provided over 6 years. CONCLUSIONS: Chronic wounds represent a serious problem for patients in terms of quality of life, lost employment time, and loss of income. Our comparison of the required wound education among the medical schools of United States, United Kingdom, and Germany demonstrated that all 3 systems are deficient in preparing future physicians to treat wound problems. We recommend that medical schools throughout the world devote a portion of their core curriculum to educating student physicians in the understanding of wound pathophysiology and treatment.

Wound education: American medical students are inadequately trained in wound care.

Millions of patients are treated annually in the United States with either acute or chronic wounds, costing billions of dollars. This is a retrospective study designed to quantify the directed education that medical students receive in their 4 years of training on 3 wound-related topics: physiology of tissue injury, physiology of wound healing, and clinical wound healing. The mean hours of education in physiology of tissue injury at 50 American medical schools are 0.5 hours and 0.2 hours, respectively, in the first year and second years and none in the third and fourth years. The mean hours of directed education in the physiology of wound healing are 2.1 hours and 1.9 hours in the first and second years. The data in our study show there is scant directed education in relevant wound topics in American medical schools. Considering the immense economic and social impact of wounds in our society, more attention should be paid to the education of our physician trainees on this important topic.

Uncommon leg ulcers in the lower extremity.

OBJECTIVE: To determine the prevalence of uncommon ulcers, unrelated to venous or arterial etiology, in patients presenting to vascular clinics. METHODS: This was a multicenter prospective study of consecutive patients presenting with lower extremity ulceration. The settings were university hospital outpatient centers and venous clinics. A total of 799 limbs in 710 patients with leg ulcers were evaluated. Patients with venous ulcer disease and with evidence of arterial disease with an ankle-brachial index less than 0.7 were excluded from the study. Out of 710 patients, 17 patients with a total of 21 limbs fit the criteria for inclusion. All limbs included in this study underwent physical examination, ankle-brachial index measurements, duplex ultrasonography, and skin biopsies. RESULTS: The mean age of patients with uncommon ulcers was 65.6 years, and the mean duration was 5.5 years. A total of 2.1% of all leg ulcers seen were due to uncommon etiology unrelated to venous or arterial pathology. Most of these ulcers were located in the medial lower calf (n = 19). In six patients with ulcers, the histology did not reveal any specific cause; five had a neoplasia, three had chronic inflammation, two had sickle cell disease, two had vasculitis, one had rheumatoid arthritis, one had pyoderma gangrenosum, and one had ulcer due to hydroxyurea. CONCLUSIONS: The prevalence of leg ulcers unrelated to arterial and venous disease that presented with signs and symptoms of chronic venous disease was 2.1%. Their etiology is variable, most often including vasculitis, neoplasia, metabolic disorders, infection, and other rare causes. Early identification of uncommon ulcers may facilitate timely and appropriate management.

Current management of venous ulceration.

It has been estimated that chronic venous insufficiency affects 10 to 35 percent of the entire U.S. population and that 4 percent of people older than 65 have active venous ulcers. The high prevalence of the disease results in an annual expenditure of more than 1 billion dollars a year to the U.S. health care system. To have a rational approach toward patients with venous ulcers, it is important to understand the pathophysiology and clinical characteristics of the disease process, in order to initiate appropriate treatment and prevent venous ulcer recurrence.