A role delineation study of hand surgery.

Variation in practice patterns and resource utilization surrounding management of intussusception at freestanding Children's Hospitals

Regional Variation in Procedural and Clinical Outcomes Among Patients With ST Elevation Myocardial Infarction With Cardiogenic Shock

INTRODUCTION: There are currently 29 craniofacial surgery fellowship training programs in the United States and Canada endorsed by the American Society of Craniofacial Surgeons and participating in the San Francisco Match. This number has increased over the last decade despite limited demand. The authors sought to evaluate the practice types and patterns of craniofacial fellowship trained surgeons. METHODS: After Institutional Review Board approval, a 20-question survey was designed to evaluate craniofacial surgeons and their practice patterns. The survey was sent to surgeons who completed accredited craniofacial fellowships in the United States or Canada from 2010 to 2018. The survey was created and distributed electronically through a private survey research center. RESULTS: There were 61 respondents (26.5% response rate), 68.8% male, and 85.2% 36–45 years old. 54.1% trained in integrated plastic surgery residency before fellowship, and 39.1% trained in general surgery followed by plastic surgery fellowship. Some had previously completed fellowships: 8 (13.1%) pediatric plastic surgery, 5 (8.2%) microsurgery, 4 (6.6%) esthetic surgery, 3 (4.9%) hand surgery, and 2 (3.3%) burn surgery. Forty-five surgeons (75%) have been in practice ≤5 years. Practice profiles were academic (49.2%), private (23.0%), and hospital employed (9.8%) with 18% in various hybrid practices. Percentage of practice dedicated to craniofacial surgery was <25% for 21 (34.4%), 25%–50% for 10 (16.4%), 51%–75% for 13 (21.3%), and >76% for 17 surgeons (27.9%) with 63.8% desiring an increase in craniofacial case volume. Surgeons’ patient populations are 14.8% pediatric only, 6.6% adult only, and 78.7% combined. They perform craniofacial trauma reconstruction (88.5%), general plastic surgery reconstruction (83.6%), cleft lip and palate repair (75.4%), craniosynostosis reconstruction (68.9%), breast surgery (54.1%), microtia reconstruction (50.8%), orthognathic surgery (50.8%), cosmetic surgery (50.8%), microsurgery (45.9%), hand surgery (36.1%), and facial reanimation (32.7%). Forty-six (75.4%) work as members of a craniofacial team. Twenty-six (42.6%) do not have any craniofacial trained partners. Twelve surgeons (19.7%) had jobs secured before beginning craniofacial fellowship, and 44 (72.1%) were able to find jobs in their desired geographic area. Forty-one (67.2%) would recommend completing a craniofacial fellowship. CONCLUSION: Craniofacial surgeons trained within the last decade are primarily in academic practice, operate on adults and children, and perform a variety of procedures. Limitations include low response rate and likelihood that surgeons who do not perform craniofacial surgery did not respond. Respondents were able to find employment in their desired location, work on a craniofacial team, and would recommend a craniofacial fellowship.

The principal objective of medical educators is, and has always been, to prepare future physicians to meet the needs and expectations of the society they are pledged to serve. Today’s medical educators face many challenges in trying to meet that objective. In addition to ensuring that medical students and residents acquire the knowledge and skills required of competent clinicians, they also must deal with a host of novel issues raised by the complexities and turbulence of contemporary medical practice. Among those issues are: continued escalation in health care costs rapid advances in complex medical technologies explosion of scientific knowledge wide racial and ethnic disparities in health and health care large gaps in the quality of health care service widespread concern about patient safety inequities in access to health care services unexplained variations in patterns of practice

The origins of hand surgery as a distinct surgical field in the United States are often credited to the pioneering efforts of Asa Sterling Bunnell around the time of the Second World War1. It has since evolved into an increasingly complex specialty involving hand transplantation, joint arthroplasty, and microsurgery2-6. Recognizing the need for oversight to ensure proper training and education, the orthopaedic, plastic, and surgery primary boards jointly approved a Certificate of Added Qualification in Hand Surgery in 1985, and the first examination for certification in hand surgery was administered in 19897. Because of the continually emerging complexities in this field, it has become increasingly important to evaluate the training of orthopaedic residents in order to ensure that their education and understanding of hand surgery is adequate prior to graduation and possible application for fellowship. The Orthopaedic In-Training Examination (OITE) was established as a measure for orthopaedic resident education and knowledge in the 1960s8. The OITE provides a standardized format to evaluate the hand knowledge of orthopaedic residents. This examination is designed to focus on evidence-based knowledge and skills that a surgeon should know in order to be able to practice effectively. Recent orthopaedic publications are often recommended as one of the main sources of information for surgeons in training, and it has recently been reported that there is a positive correlation between performance on the OITE and frequent review of current orthopaedic journals9. However, we know of no published study that has assessed the correlation between the literature and the hand surgery content tested in the OITE. The primary questions in the present study were: (1) What literature should be recommended to orthopaedic residents who are receiving training and instruction regarding hand surgery and are preparing for …

Examination of practice patterns compared to existing evidence identifies knowledge to practice gaps. To describe the utilization of pharmacological, patient education, primary psychological interventions and relaxation therapies in patients with neck pain by clinicians. An international cross-sectional survey was conducted to determine the use of these interventions amongst 326 clinicians treating patients with neck pain. Nineteen countries participated. Results were analyzed by usage amongst physical therapists (39%) and chiropractors (35%), as they were the predominant respondents. Patient education (95%) and relaxation therapies (59%) were the most utilized interventions. Tests of subgroup differences determined that physical therapists used patient education significantly more than chiropractors. Use of medications and primary psychological interventions were reported by most to be outside of scope of practice. The high rate of patient education is consistent with supporting evidence. However, usage of relaxation therapies is contrary to evidence suggesting no benefit for improved pain or function for chronic neck pain. This survey indicates that patient education and relaxation therapies are common treatments provided by chiropractors and physical therapists for patients with neck pain. Future research should address gaps associated with variable practice patterns and knowledge translation to reduce usage of interventions shown to be ineffective.

Practice Variation in Umbilical Hernia Repair Demonstrates a Need for Best Practice Guidelines

MP23-15 EXPLORING PRACTICE PATTERNS AND REGIONAL PARTICIPATION OF UROLOGISTS IN ONCOLOGY CARE MODEL

Comparing different patterns for managing febrile children in the ED between emergency and pediatric physicians: impact on patient outcome

Introduction Understanding and addressing sexual dysfunction is of paramount importance to enhance the overall well-being and quality of life of individuals worldwide. While significant progress has been made in the field of sexual medicine, variability in practice patterns among healthcare professionals remains a potential barrier to optimal patient care. To bridge this knowledge gap and identify the prevailing trends in sexual dysfunction management, we conducted an international survey targeting urologists specializing in Andrology, Sexual Medicine, and related fields. Objective This international survey aimed to assess male and female sexual dysfunction management practices among sexual medicine physicians across to globe to identify variability in practice patterns. Methods A survey was distributed globally to urologists specializing in Andrology, Sexual Medicine, and related fields who are members of International Society for Sexual Medicine (ISSM) or affiliated regional societies (SMSNA, ESSM, MESSM, APSSM, SASSM, SLAMS, ISSWSH, SIU). Demographic information (age, gender, specialty, and practice setting) and treatment approaches for male and female sexual dysfunction were collected. Respondents also reported the percentage of their practice dedicated to sexual dysfunction and whether treatments were covered by health insurance. Results A total of 200/3000 practitioners participated, with 101 (50.7%) identifying as urologists. The majority were male (72.9%) and worked in private practice or community hospitals (32.7%) or a mixture of both (34.2%). Male sexual dysfunction was treated by 71.4% of respondents, with 25.7% dedicating 75–100% of their practice to it. Female sexual dysfunction was treated by 36.9% of respondents, with 64% dedicating 0–25% of their practice to it. Health insurance covered 25–49% of their care for 41.2% of respondents, predominantly provided by private companies (45.9%). The most common treatments for erectile dysfunction were oral medications (86.5%), injections (61.7%), and inflatable penile prostheses (45.1). For Peyronie's disease, oral therapies (59.1%) and penile traction therapy (34.4%) were most frequently offered, while surgical treatment for Peyronie's disease was offered by 58.2% of respondents, with penile prostheses being the primary choice (79.7%). Regarding female sexual dysfunction, 58.4% of respondents offered treatments for genitourinary syndrome of menopause/atrophic vaginitis, with vaginal estrogen being the most common choice (50%). For dyspareunia due to vaginismus/hypertonic pelvic floor dysfunction, 50.3% of respondents offered treatment, with pelvic floor exercise/physiotherapy being the most recommended (66%). Conclusions This study provides valuable insights for healthcare professionals, policymakers, and researchers regarding the current landscape of sexual dysfunction management. The results underscore the importance of continuous efforts to develop comprehensive and individualized approaches, ensuring that both male and female patients receive effective and accessible care for their sexual health concerns. By addressing issues related to insurance coverage and fostering interdisciplinary collaboration, the medical community can collectively work towards improving sexual well-being and quality of life for patients worldwide. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Advisory board and speaker for Coloplast; consultant for Cynosure; advisory board and speaker for Halozyme; intellectual property with Masimo; advisory board for Promescent; consultant for Sprout; advisory board for Xialla.

When faced with challenging clinical situations, we often ask our colleagues: Can I pick your brain? As clinicians, we aim to provide evidence-based care, often presented as standardized protocols and guidelines. However, practice differences are frequently encountered when discussing challenging cases with peers. These may be more frequent among clinicians of different institutions and/or countries. The reasons for these variations are endless: lack of enough evidence, disparities in access to resources, local population characteristics, among others. Understanding these variations is important for a few key reasons. It can help us clarify the extent of equipoise vs consensus on different aspects of challenging or controversial topics in neurologic care or practice. It can reveal remarkable practice patterns that may have become entrenched despite an evidence vacuum. For researchers, innovators, and policymakers, it can reveal regional variations in practice patterns that will need to be accommodated or addressed when considering large-scale trials, quality improvement initiatives, or introducing new workflows or technologies. Yet few individuals or groups have access to a sufficiently widespread population of neurology practitioners—sampling within one's own personal or professional network can be misleading. So, what if you could pick the brains of neurology practitioners around the world?

Microbial keratitis is a major cause of corneal opacity and loss of vision worldwide, and topical antimicrobial therapy is a critical component in its management. The study by Austin et...

We explored the management of Dupuytren's disease (DD) using a surgeon survey and patient chart review. Twelve countries participated: Denmark, Finland, Sweden (Nordic region); Czech Republic, Hungary, Poland (East); France, Germany, the Netherlands, United Kingdom (West); Italy, Spain (Mediterranean). A random sample of orthopaedic/plastic surgeons (N = 687) with 3-30 years' experience was asked about Dupuytren's contracture procedures performed during the previous 12 months. Information ≤ 5 consecutive patients per surgeon was extracted from patient charts (N = 3357). Overall, 84% of participants were orthopaedic surgeons; 56% of surgeons were hand specialists. Deciding factors for fasciectomy and dermofasciectomy were consistent across regions: metacarpophalangeal (MP) or proximal interphalangeal contracture > 45°, recurrent contracture, and high expectations for success. Deciding factors for percutaneous needle fasciotomy were less consistent across regions, but the leading factor was MP flexion < 20°. Overall, 49% of diagnoses and 55% of referrals were made by a general practitioner (GP), with regional variation: 31-77% for GP diagnoses and 36-81% for GP referrals. There were also differences in admission status (e.g. 9% of Nordic patients and 80% of Eastern patients were treated as inpatients). Most patients were treated in public hospitals and most procedures were covered by public health insurance. We found regional variations in surgical practice, patient characteristics and referral patterns. Understanding current diagnosis and treatment patterns, in relation to regional differences in health economics, may improve physicians' diagnosis of DD and guide patients towards appropriate, customised management plans.

Sir: After the initiative by Plastic and Reconstructive Surgery and the American Society of Plastic Surgeons to promote evidence-based medicine1 and to strive for high levels of reporting quality,2 it is current belief that randomized controlled trials are the key to guiding and helping clinical decision making. The broad field of plastic surgery with its subdisciplines reconstructive surgery, burn surgery, aesthetic surgery, and hand surgery often lacks a fair amount of published randomized controlled trials. However, to date, there is no comparative analysis on the recent developments of randomized controlled trials in reconstructive, burn, aesthetic, and hand surgery. Furthermore, reporting quality of randomized controlled trials was addressed by the Consolidated Standards of Reporting Trials group first in 1996, and was updated in 2001 and very recently in 2010.3 The Consolidated Standards of Reporting Trials items aim to improve the reporting quality of randomized controlled trials in full article and in abstract form.4 Using the Consolidated Standards of Reporting Trials items, one can compare the reporting quality of randomized controlled trial conference abstracts, which was a second aim of this analysis. To analyze up to date, we decided to analyze various conferences rather than full articles, given the fact that not all randomized controlled trials presented as abstracts will find their way to a full article within the next 5 years. We analyzed 65 oral abstracts and 94 poster abstracts from the 2008 meeting of the American Society of Plastic Surgeons by two independent researchers. In addition, 152 oral and 100 poster presentations from the 2008 meeting of the American Burn Association were analyzed, as were102 abstracts from the American Society for Surgery of the Hand annual meeting. We determined the evidence-based medicine level of evidence for study design. Furthermore, the level of reporting quality according to the Consolidated Standards of Reporting Trials recommendations was determined with a maximum score of 17 of 17 points. We found that at the American Society of Plastic Surgeons 2008 meeting, 9 percent (5 percent oral and 4 percent poster abstracts) of presentations were randomized controlled trials. Reporting quality at the American Society of Plastic Surgeons meeting was 6.7 ± 1.2 for oral randomized controlled trials and 7.3 ± 1 for poster randomized controlled trials (p = 0.498; 95 percent confidence interval, –2.62 to 1.46) of 17 achievable points according to Consolidated Standards of Reporting Trials criteria. At the American Burn Association Annual Meeting, 7 percent randomized controlled trials were presented, with 5 percent oral and 2 percent poster presentations. Reporting quality according to Consolidated Standards of Reporting Trials criteria was not significantly different for oral versus poster randomized controlled trials (7.2 ± 1.4 versus 6.5 ± 1 of 17 points, p = 0.552; 95 percent confidence interval, –1.78 to 3.06). We identified 10 percent randomized controlled trials at the American Society for Surgery of the Hand meeting. Consolidated Standards of Reporting Trials reporting quality was 8.2 ± 1.4 of 17, somewhat higher than for randomized controlled trials presented at the American Society of Plastic Surgeons meeting. Our results indicate that the amount of randomized controlled trials presented either in oral or poster abstract form at American Society of Plastic Surgeons, American Burn Association, and American Society for Surgery of the Hand meetings is still below 10 percent of all presentations. Given the fact that not every conference abstract will be followed by a full article, these numbers should be discussed. In 1996, Amadio and colleagues studied the rate of full article randomized controlled trials from volume 1 to volume 19 (1994) of The Journal of Hand Surgery. From 3107 articles, letters, and abstracts, they identified 25 controlled clinical trials and eight randomized controlled trials (0.26 percent).5 A 10-year analysis of publications in Plastic and Reconstructive Surgery, Annals of Plastic Surgery, and Aesthetic Surgery Journal revealed a randomized controlled trial publication rate of 3.2 percent.6 A 16-year analysis of all articles published in Aesthetic Plastic Surgery revealed only a 1 percent randomized controlled trial publication rate (11 of 1048 original articles).7 In Plastic and Reconstructive Surgery, the number of randomized controlled trials published increased from 1983 to 2003 from 0 percent to 7 percent.8 As far as reporting quality is concerned, all conference abstracts presented at American Society of Plastic Surgeons, American Burn Association, and American Society for Surgery of the Hand meetings have plenty of room for improvement, with the Consolidated Standards of Reporting Trials statement to be endorsed substantially. Karsten Knobloch, M.D. Uzung Yoon Peter M. Vogt, M.D., Ph.D. Plastic, Hand, and Reconstructive Surgery Hannover Medical School Hannover, Germany

The objective of this study was to understand the frequency and types of complications, and the associated postoperative outcomes within the first 5 years of practice after hand and upper extremity surgery fellowship. This was a retrospective observational study of all patients seen and surgically treated by a single surgeon at a single institution from August 2014 to September 2019. This corresponded to the first 5 years of practice after fellowship. Data collected included patient demographics, perioperative data, complication type, and outcome of the complication (better/same/worse than preoperative status). Complications were classified using the Clavien-Dindo system and a unique, self-derived system. In total, 3301 surgeries were performed during the first 5 years of practice. The overall complication rate was 7.9% (261 complications from 239 patients). The 30-day complication rate was 5.2% (171/3301). Eleven (4.2%) of the 261 complications occurred intraoperatively. The total number of complications significantly declined during the first 5 years of practice as follows: 74, 71, 46, 37, and 33 (P = .010, R2 = .92). Hand and wrist were the most frequent anatomic locations involved and bone pathology was the predominant indication. The overall surgical complication rate for hand and upper extremity surgery was 7.9%, with a 30-day complication rate of 5.2% (171/3301). The rate of complications after fellowship declined over the first 5 years of independent practice. Superficial infections were the most common complication. More than 90% of patients ultimately improved after addressing the complication. IV.