Summary Background Telemedicine is a rapidly expanding technology involving the exchange of medical information to assist diagnosis and treatment at a distance. Within the field of plastic surgery, ...where visual examination contributes heavily to patient management decision-making, telemedicine has great potential. However, privacy and medico-legal issues must be considered when using electronic communication to assist our clinical practice. Methods A comprehensive literature review of manuscripts published on telemedicine was performed. Articles were selected for relevance to plastic and reconstructive surgery and reviewed for applications, benefits and complications of telemedicine. In addition, the manuscripts were reviewed for conforming to current legal guidelines for the electronic transfer of patient information. Results Twenty-nine articles met the inclusion criteria (11 trauma and burns, 4 hand, 5 wound-care, 5 maxillofacial, 1 digital replantation, 2 free-flap monitoring, and 1 technical application). Twenty-eight (96%) manuscripts reported a benefit of telemedicine (commonly including increased access to expertise and costs saved through reduction of unnecessary transfers). However only five (17%) reported a statistical benefit compared to a standard treatment cohort (face-to-face interactions). Fifteen (51%) reported on adverse effects, which included misdiagnosis, time consumption, training, technical and cost issues. Only four manuscripts (14%) discussed conforming to legal guidelines within their institution. Conclusions Telemedicine can improve access to the specialty of plastic surgery by facilitating the provision of expertise at remote sites. Its application can be used in many situations and between a variety of healthcare professionals. However, there is little critical analysis on the benefits and risks of telemedicine. In addition, its legal implications need to be carefully considered if it is to be safely integrated into our daily practice.
The number of therapeutic modalities available to the hand surgeon has greatly increased over the past several decades. A field once predicated only on heat, massage, and cold therapy now uses ...electrical stimulators, ultrasound, biofeedback, iontophoresis, phonophoresis, mirror therapy, lasers, and a number of other modalities. With this expansion in choices, there has been a concurrent effort to better define which modalities are truly effective. In this review, we aim to characterize the commonly used modalities and provide the evidence available that supports their continued use.
Secondary breast deformities following breast augmentation constitute some of the most challenging and difficult problems to correct. Although the application and efficacy of human acellular dermal ...matrix in breast reconstruction has been previously reported, there is little information in the literature relating to its indications, results, or cost in aesthetic breast surgery.
This study retrospectively reviewed a single surgeon's experience in correcting secondary deformities with human acellular dermal matrix after breast augmentation from 2005 to 2009. A total of 23 patients (38 breasts) were included in the study.
There were 28 breasts with surface irregularities and 22 breasts with implant malposition (12 had both). On average, 1.13 sheets of human acellular dermal matrix were used per breast per operation. At the authors' institution, this material equates to a cost to the patient of $3536 to $4856 per breast (depending on sheet size and thickness). Twenty of 23 patients (87 percent) 32 of 38 breasts (84 percent) had improvement in their breast deformity after breast revision surgery. Three patients (six breasts) needed another cosmetic breast operation before the end of the follow-up period: two because of persistent surface irregularities and one with a request for larger implants. One patient (3 percent) had an infection in one breast, requiring removal of the human acellular dermal matrix.
Human acellular dermal matrix is a useful and safe adjunct for correction of contour deformities after breast augmentation. Its high cost, however, may be a deterrent to widespread use in self-pay patients.
Academic institutions receive many patients transferred specifically for hand surgery evaluation. The purpose of this study was to evaluate the demographics and insurance status of patients ...transferred for this reason.
A retrospective review was performed of 155 transferred and 1017 nontransferred patients with a primary hand diagnosis during 3 summer months at two urban academic institutions. Patients were evaluated for insurance status/type, medical comorbidities, employment status, and reason for transfer. Insurance was defined as present/absent and favorable/unfavorable, with unfavorable defined as Medicaid or state-sponsored insurance. Reason for transfer or presenting diagnosis was separated by category.
The mean age was similar between groups, but a higher percentage of transfer patients were men (69.9 percent versus 59.7 percent; p < 0.05). The percentage of insured patients was similar (92.9 percent versus 93.2 percent), but the number with no insurance or undesirable insurance was greater for transferred patients (30.1 percent versus 22.9 percent; p < 0.05). Patients with poor or no insurance were twice as likely to be inappropriately transferred (OR, 2.17; p = 0.03). Transferred patients were less likely to be employed (55.1 percent versus 64.8 percent; p < 0.05); however, the percentages of workers' compensation (13.5 percent versus 14.6 percent) and diabetes (6.41 percent versus 6.10 percent) cases were similar. Common reasons for transfer were closed fractures/dislocations (21.9 percent), infection (17.4 percent), and amputation/devascularization (17.4 percent).
Patients transferred to tertiary care centers for emergency upper extremity evaluation have a higher rate of undesirable or no insurance and are more likely to be male or unemployed.
Purpose To compare patients with acute upper extremity injuries and infections presenting initially to the emergency department with patients transferred from outside institutions, and to evaluate ...triage guidelines for the appropriate transfer of these patients. Methods We reviewed the records of 1,172 consecutive patients with acute upper extremity injuries or infections presenting to 2 level 1 trauma centers over 3-month periods. We analyzed demographics, transfer details, injury characteristics, intervention received, follow-up, and complications. Triage guidelines were established by a board of academic upper extremity and emergency physicians and retrospectively applied to patient data. Results Of 1,172 patients, 155 (13%) arrived via transfer from outside facilities. Transferred patients had more complex injuries by our guidelines, but many did not require level 1 emergent care. The receiving emergency department discharged 26% of the transferred patients without upper extremity specialist evaluation, and 24% of the transferred patients received no procedural intervention at any point. Only 10% went to the operating room emergently. Implementing our guidelines for appropriate triage, we found that 53% of transfers did not require emergent transfer to a level 1 facility. These nonemergent transfers spent an average of 15.2 hours from the time of initial evaluation at the outside facility to discharge from the level 1 emergency department, compared with 3.1 hours in patients who arrived primarily. Retrospectively, our triage guidelines had a 2% undertriage rate and a 3% overtriage rate. Conclusions Over half of the patients transferred with upper extremity injuries and infections for specialized evaluation may be transferred unnecessarily. Guidelines for the care and transfer of patients with acute upper extremity injuries or infections may lead to better use of resources. Type of study/level of evidence Prognostic III.
Long-Term Results of Periarterial Sympathectomy Hartzell, Tristan L., MD; Makhni, Eric C., BS; Sampson, Christian, MD
The Journal of hand surgery (American ed.),
10/2009, Volume:
34, Issue:
8
Journal Article
Peer reviewed
Purpose To compare long-term results (minimum follow-up of 23 months) of periarterial sympathectomy for patients with digital vasospasm secondary to either an autoimmune disease or generalized ...atherosclerotic disease. Patients with posttraumatic or localized occlusive disease and vasospasm were not evaluated. Methods Twenty-eight patients had periarterial sympathectomy at 1 hospital by 1 senior surgeon. Periarterial sympathectomy was targeted to the areas of ulceration. Twenty patients (with 24 involved extremities and 42 ulcerated digits) had a documented autoimmune disease; 17 patients had scleroderma or an undifferentiated mixed connective tissue disorder, 2 had systemic lupus erythematosus, and 1 had rheumatoid arthritis. Eight patients (with 9 involved extremities and 17 ulcerated digits) had atherosclerotic disease. The primary outcomes were complete healing of all ulcers, a decrease in the number of ulcers, and need for amputation by the end of follow-up. Statistical analysis was done using the Fischer exact t -test. Results The average follow-up for all patients was 96 months (90 months for the autoimmune group and 113 months for the atherosclerotic group). Fifteen of the 20 patients (28 of 42 digits) in the autoimmune group had complete healing or decrease in ulcer number. Conversely, only 1 of the 8 patients (2 of 17 digits) in the atherosclerotic group had complete healing or decrease in ulcer number. Eleven of the 42 (26%) digits treated in the autoimmune group required amputation. In contrast, 10 of the 17 (59%) digits treated in the atherosclerotic group ultimately required amputation. Conclusions Periarterial sympathectomy can lead to complete healing and decrease in ulcer number in autoimmune disease patients with digital ischemia from vasospasm. However, our data suggest that periarterial sympathectomy may be of little or no benefit in patients with chronic digital ischemia and vasospasm secondary to severe atherosclerotic disease. Type of study/level of evidence Therapeutic III.
We have reported previously that tumors expressing wild-type epidermal growth factor receptor (EGFR) in a murine model are sensitive to the EGFR tyrosine kinase inhibitor gefitinib, whereas tumors ...expressing mutant EGFR variant III (EGFRvIII) are resistant. Determination of how this differential inhibition occurs may be important to patient selection and treatment criteria, as well as the design of future therapeutics for glioblastoma multiforme.
We have determined and quantified how treatment with gefitinib at commonly used, noncytotoxic doses affects neoplastic functions ascribed to EGFRvIII, including downstream signaling by Akt, DNA synthesis, and cellular invasion. In doing so, we have tested and compared a series of wild-type and mutant EGFRvIII-expressing fibroblast and glioblastoma cell lines in vitro after treatment with gefitinib.
The results of these experiments demonstrate that short-term treatment with gefitinib (approximately 24 h) does not reduce phosphorylation of EGFRvIII, whereas EGFR phosphorylation is inhibited in a dose-dependent manner. However, after daily treatment with gefitinib, phosphorylation declines for EGFRvIII by day 3 and later. Nevertheless, after 7 days of daily treatment, cells that express and are dependent on EGFRvIII for tumorigenic growth are not effectively growth inhibited. This may be due in part to phosphorylation of Akt, which is inhibited in EGFR-expressing cells after treatment with gefitinib, but is unaffected in cells expressing EGFRvIII. Cell cycle analysis shows that nascent DNA synthesis in EGFR-expressing cells is inhibited in a dose-dependent manner by gefitinib, yet is unaffected in EGFRvIII-expressing cells with increasing dosage. Furthermore, cells expressing EGFRvIII demonstrate greater invasive capability with increasing gefitinib concentration when compared with cells expressing EGFR after treatment.
We conclude that the neoplastic phenotype of EGFRvIII is relatively resistant to gefitinib and requires higher doses, repeated dosing, and longer exposure to decrease receptor phosphorylation. However, this decrease does not effectively inhibit the biologically relevant processes of DNA synthesis, cellular growth, and invasion in cells expressing EGFRvIII.
As emergency departments (EDs) become increasingly overwhelmed and specialist coverage in some EDs decreases, patients may be transferred to tertiary or quaternary facilities for specialized care to ...decrease patient load at transferring facilities. Our objective was to determine whether facilities that transferred patients for hand surgery had hand surgery coverage and to evaluate any nonmedical factors that might have been associated with transfer.
A retrospective review was conducted for 1167 visits of hand and wrist patients seen in the EDs of two urban level-I trauma centers. The hand surgery capacity of referring facilities was determined by phone calls to the EDs. Univariate and multivariable analyses were conducted to identify nonmedical factors that could potentially affect the decision to transfer.
A total of 155 (13.3%) of 1167 patients arrived from other facilities for specialized hand care. These patients were significantly more likely to be male (p = 0.02), have noncommercial insurance (p = 0.04), require an interpreter (p = 0.01), and arrive between 6:00 p.m. and midnight (p = 0.03). In a multivariable analysis, sex and insurance status were significantly associated with transfer (p < 0.05). The subset of ninety-five patients who were transferred from other EDs was significantly more likely to be male (p < 0.01) and arrive on weekends (p < 0.01) or between 6:00 p.m. and midnight (p < 0.01). Of these patients, seventy-seven (81%) were transferred from an ED that reported partial or full hand surgery coverage. However, only eight (10.4%) received a hand surgery evaluation prior to transfer.
The low percentage of patients receiving hand surgery evaluations prior to transfer suggests that referring hospitals are not using their own hand surgeon resources. Nonmedical factors, including noncommercial insurance and off-hour time of initial arrival, may be associated with the decision to transfer patients.
Identifying nonmedical factors associated with patient transfers and referrals can enlighten efforts to improve the quality and appropriate use of transfers for specialty care.
Does the gatekeeper model work in hand surgery? Hartzell, Tristan L; Shahbazian, Jonathan H; Pandey, Amit ...
Plastic and reconstructive surgery (1963),
2013-September, Volume:
132, Issue:
3
Journal Article
Peer reviewed
Open access
Most managed care plans use a physician "gatekeeper" to control referrals to hand surgeons. The appropriateness of this model for upper extremity complaints has never been challenged. The purpose of ...this study was to evaluate the prior management of patients with elective hand disorders who present to a hand surgery clinic.
All patients presenting to a tertiary, academic medical center for a new-patient hand surgery evaluation from February 3, 2011, to June 15, 2011, were prospectively enrolled. Patients were evaluated for prior provider, diagnosis, treatment, and complications. Actual diagnosis, recommended workup, and appropriate treatment were determined independently by two experienced hand examiners. Traumatic injuries and surgeon disagreements in diagnosis and treatment were excluded, leaving 125 patients.
Ninety-eight percent of patients had been evaluated by a primary care provider. Overall, the correct diagnosis was established 34 percent of the time. Nerve compression syndromes were diagnosed with the greatest accuracy (64 percent), whereas stenosing tenosynovitis was diagnosed correctly only 15 percent of the time. Before presentation, 74 percent of patients had undergone a study or intervention. On review, 70 percent of studies/interventions were deemed unnecessary. Advanced imaging was unwarranted in 90 percent of patients who received it. Seventeen percent of patients experienced a complication. Most (67 percent) were caused by a delay in diagnosis, whereas 33 percent resulted from an intervention.
Health care providers less familiar with an examination of the hand often misdiagnose and mistreat common problems. A referral system may not be the most efficient means of delivering care to patients with elective hand maladies.
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