Surgeon's Office Research Articles

Initiation of a novel text messaging system in total knee and hip arthroplasty

BackgroundThe primary objective of this study was to investigate whether using a novel text messaging system improves patient overall satisfaction compared to standard care. Secondary objectives included assessing the impact of the text messaging system on decreasing narcotic usage, the number of emergency department visits, the range of flexion and extension, and number of telephone calls to the surgeon’s office.MethodsWe enrolled 217 patients to either receive informative text messages (text messaging group, n = 86) or no additional text messages (conventional group, n = 131). Patients self-reported results on a questionnaire at the 6-week follow-up regarding the primary and secondary objectives. The active range of motion of total knee arthroplasty patients was recorded by the surgeon or treating physiotherapist.ResultsThere was no significant difference in overall satisfaction (P = 0.644), narcotic cessation (P = 0.185), range of motion (Flexion P = 0.521; Extension P = 0.515), and emergency department visits (P = 0.650) between the two groups. There was a statistically significant decrease in surgeon office calls favoring the text messaging group (P = 0.029). A subgroup analysis revealed that the statistical difference was mainly in the TKA group (P = 0.046).ConclusionsA novel text messaging system may help reduce the work burden by decreasing telephone calls to the surgeon’s office. While satisfaction, narcotic usage, emergency department visits, and range of motion did not significantly differ, patients endorsed the system for friends/family.

Improving Compliance With Evidence-Based Laboratory Testing Recommendations and Monitoring Associated Patient Outcomes.

A team comprising nursing, medical staff, and administrative leaders at an urban academic orthopedic hospital in the northeastern United States sought to revise a preoperative laboratory testing protocol based on evidence and practice guidelines. The goal was to decrease unnecessary tests by 20% without negatively affecting patient outcomes. After adding the revised protocol to the electronic health record, audits revealed that the target goal was not met and additional strategies were implemented, including educational webinars for surgeon office personnel who ordered tests, additional webinars for advanced practice professionals, and the creation of scorecards to track surgeons' progress. Overall, a downward trend in the ordering of unnecessary laboratory tests for patients without identified risks was observed, but a 20% reduction was not achieved. Surgical complications during the project were not associated with laboratory tests. Clinicians continue to use the revised preoperative laboratory testing protocol at the facility.

Factors influencing patient selection of orthopaedic surgeons for total hip (THA) and total knee arthroplasty (TKA).

The importance of identifying how patients choose their healthcare providers has grown with the prevalence of consumer-centric health insurance plans. There is currently a lack of studies exploring the factors associated with how patients select their hip and knee joint arthroplasty surgeons. The purpose of this study was to determine how patients find their arthroplasty providers and the relative importance of various arthroplasty surgeon characteristics. An electronic mail survey was sent to 3522 patients who had visited our institution for an arthroplasty surgeon office visit between August 2022 and January 2023. The survey consisted of multiple-choice questions, which aimed to inquire about the patients' referral sources for their current arthroplasty surgeon. In addition, patients were requested to rate the significance of 22 surgeon-related factors, on a scale of 1 (Not Important At All) to 5 (Very Important), in choosing their arthroplasty surgeon. Of the 3522 patients that received the survey, 538 patients responded (15.3%). The most common referral sources were physician referral (50.2%), family/friend referral (27.7%), and self-guided research (24.5%). Of those that were referred by a physician, 54.4% of respondents were referred by another orthopaedic provider. Patients rated board certification (4.72 ± 0.65), in-network insurance status (4.66 ± 0.71), fellowship training (4.50 ± 0.81), bedside manner/personality (4.32 ± 0.86), and facility appearance (4.26 ± 0.81) as the five most important factors in picking an arthroplasty surgeon. Television (1.42 ± 0.83), print (1.50 ± 0.88), and online (1.58 ± 0.93) advertisements, along with social media presence (1.83 ± 1.08), and practice group size (2.97 ± 1.13) were rated as the five least important factors. Patients are most likely to select an arthroplasty surgeon based on referral from other physicians, namely orthopedic surgeons, in addition to board certification status, in-network insurance, and fellowship training. Overall, these findings highlight the importance of physician credentials and reputation within the orthopaedic community in order to attract and retain patients.

Unplanned Postoperative Phone Calls and Electronic Messages for Patients With and Without Opioid Prescriptions After Carpal Tunnel Release

The purpose of our study was to compare unplanned postoperative patient communication in the form of phone calls and/or electronic patient portal messages (EPPM) after carpal tunnel release (CTR) for patients with and without a postoperative opioid prescription. We identified all patients ≥18 years of age who underwent primary CTR between 2017 and 2022 without an opioid ordered within 90 days prior to surgery. The following two groups were created: cases with and without an opioid prescribed on the day of surgery. We recorded baseline demographics for all patients and recorded all unplanned communication (phone calls and EPPM) sent from a patient to the surgeon's office within 14 days after surgery. Unadjusted associations between unplanned communication and case characteristics were evaluated. Multiple logistic regression models were used to assess the relationship between opioid status and unplanned communication. A total of 5,735 CTRs were included, and 54% of the patients were prescribed an opioid on the day of surgery. Forty-two percent of cases had unplanned postoperative communication, and 48.1% of cases, without an opioid prescription, had unplanned communication compared with 36.8% in the opioid group. Patients who were prescribed opioids were 0.62 times less likely to contact the surgeon's office via phone calls or EPPM (95% confidence interval [CI]: 0.56, 0.70). Increased age was associated with a reduction in the odds of unplanned contact (odds ratios [OR]= 0.95, 95% CI: 0.93, 0.97), whereas higher body mass index was significantly associated with increased communication (OR= 1.05, 95% CI: 1.01, 1.09). Patients prescribed opioids after CTR are 0.62 times less likely to contact the surgeon's office after surgery. Considering the 11% increase in unplanned postoperative communication after CTR, surgeons should consider alternative methods that have previously been demonstrated to reduce opioid consumption. Prognostic II.

An Observational Study of Sexual Assault Statistics in Karachi, Pakistan

Background: Rape against women has been a prevalent issue in Pakistan ever since its founding, with 11 reported cases daily. A bill, known widely as the Protection of Women’s Act, 2006 was approved to ensure a secure environment for the women of Pakistan. Aim: To observe and analyze Zina-Bil-Jabr cases registered after the legislation of Protection of Women’s Act, 2006. Methodology: In this retrospective observational study, data were collected from three main medico-legal centres associated with the Police Surgeon Office in Karachi from 2005 to 2021. A total of 6,580 rape cases were brought to the medico-legal centres, with 2717 of them being the offender and 3863 of them being the victims. Result: Protection of Women’s Act, 2006, a downfall was observed in the cases till 2010, when the lowest number of cases of all years were registered as 66, while after that, an upward trajectory has been witnessed with a total of 902 cases in 2021, the highest of all recorded ones. Conclusion: The current status of rape victims in the country is alarming and points out the flaws in the practical application of the laws. Keywords: Sexual assault, Rape victims, Zina-Bil-Jabr

Characterizing Methods for Surveying Partner Nation Medical Capabilities.

Medical capability surveys provide information about how U.S. forces can coordinate with partner nations to leverage partners' capabilities to deliver care to sick or injured U.S. service members. Rotating forces routinely conduct these surveys. Currently, medical capability surveys are conducted based on individual unit requirements and personnel expertise and stored locally on component-specific sites or individual computers. The lack of a systematic approach and a centralized survey depot may undermine the ability to access previous surveys, leading to redundant surveys and conflicting information, and may have critical implications for force health protection. Partner nation facilities could have capabilities that may be leveraged to care for U.S. service members when U.S. medical care is unavailable. A lack of understanding of medical capabilities at partner nation facilities may undermine the ability to plan missions that mitigate risks. This paper presents the results of 12 semi-structured focus groups with representatives from the U.S. Africa Command Surgeon's office, the U.S. Transportation Command Patient Movement Requirements Center-East, and 9 U.S. Africa Command service components, sub-unified commands, and force providers. The focus group discussions considered questions on the following four topics: (1) methods for conducting surveys, (2) guidance about how to conduct surveys, (3) nodes of care and ancillary services included in surveys, and (4) how medical capability surveys are used to inform medical planning. The team conducted thematic analysis to identify emergent themes and subthemes. The team identified five primary, overarching themes: (1) guidance for conducting medical capability surveys, (2) methods and tools for conducting surveys, (3) content and focus of medical capability surveys, (4) archiving and sharing surveys, and (5) uses of medical capability surveys. Implementing guidance and standardized templates for conducting medical capability surveys could improve the accuracy and completeness of surveys. Templates would likely increase the likelihood that surveyors collect relevant information on key medical capabilities. Training, along with guidance and templates, would provide a common understanding of how to conduct surveys. The lack of a DoD Global Health Engagement collaborative depot for storing and sharing surveys may undermine the ability to access previous surveys to inform future surveys and, thereby, results in inefficiencies in how surveys are conducted. The DoD should consider establishing a collaborative depot for medical capability surveys along with guidance or requirements for uploading surveys. Guidance, templates, training, and a collaborative depot could improve the effectiveness and efficiency of medical planning and thereby increase mission readiness.

Patient Experiences With Thyroid Nodules: A Qualitative Interview Survey.

To qualitatively explore the broad set of preferences and attitudes patients have about thyroid nodules, which influence the decision-making process. A descriptive survey design was administered as interviews. Outpatient thyroid surgery clinic. Semistructured interviews were conducted with 20 patients presenting for initial evaluation of thyroid nodules at a surgeon's office. Probative, open-ended questions were posed regarding diagnosis, treatment, risk attitudes, and the decision-making process. Thematic analysis was used to develop code-transcribed interviews, and an iterative refinement resulted in underlying themes. During the diagnostic process, patients integrated emotional responses (fear, anxiety, and shock) with rationale concerns (likelihood of cancer, risk assessment), and ultimately relied heavily on expert opinion and recommendation. Contextualization with other personal or familial health problems served as helpful touchstones for decision-making. Overtreatment and overdiagnosis were not commonly discussed. When thinking about potential therapies, there was a strong bias to action rather than surveillance among patients. Surgical risk and the possibility of lifelong medication, however, were strong motivators for a subset of patients to seek nonsurgical alternatives. Patients describe a decision-making process that incorporates emotional response and rational consideration of risks, contextualized within the personal experience and physician expertise. The bias for action and intervention is strong, and most patients strongly weighted physicians' recommendations. Themes from this qualitative analysis may serve as the backbone for future stated preference research pertaining to thyroid disease.

A new approach to postvasectomy semen analyses eliminates the need to evaluate a fresh specimen.

According to current guidelines, confirmation that vasectomy results in sterility depends on microscopic examination of postvasectomy semen for the presence of spermatozoa. Guidelines established in 2012 require examination of a fresh specimen within 2 h of collection, which necessitates the patient making an appointment with either the surgeon's office or a licensed clinical laboratory. Twenty-five to 42% of patients fail to comply with postvasectomy semen analysis (PVSA). To determine if an at-home semen collection kit can substitute for the evaluation of a fresh specimen and improve patient compliance with postvasectomy spermatozoa assessment. The kit contains a patented aldehyde-fixative that maintains spermatozoa and semen cells in suspension for quantitation. Patients order a PVSA kit to be delivered to their home and can collect a semen specimen and return it to the laboratory through regular US mail. From January 2011 through December 2018, 6096 men undergoing vasectomy by 184 urologists in 33 states in the US ordered PVSA kits, of which 5408 (89%) returned at least one for analysis. Of those, 398 men (7.4%) returned the first kit with greater than 10,000 spermatozoa/ml within a year of vasectomy, of which only 4.4% contained greater than 100,000 spermatozoa/ml 12 weeks postsurgery. This suggests that fewer than 5% of postvasectomy patients might need follow-up fresh semen analyses, greatly easing the logistical burden of PVSA. Ninety percent of surgeons returning a patient satisfaction questionnaire said their patients "never" complained about using PVSA kits. These data support the adoption of a new standard for PVSA that does not involve an initial evaluation of a fresh semen specimen.

High Satisfaction With a Virtual Assistant for Plastic Surgery Frequently Asked Questions.

Most of a surgeon's office time is dedicated to patient education, preventing an appropriate patient-physician relationship. Telephone-accessed artificial intelligent virtual assistants (AIVAs) that simulate a human conversation and answer preoperative frequently asked questions (FAQs) can be effective solutions to this matter. An AIVA capable of answering preoperative plastic surgery-related FAQs has previously been described by the authors. The aim of this paper was to determine patients' perception and satisfaction with an AIVA. Twenty-six adult patients from a plastic surgery service answered a 3-part survey consisting of: (1) an evaluation of the answers' correctness, (2) their agreement with the feasibility, usefulness, and future uses of the AIVA, and (3) a section on comments. The first part made it possible to measure the system's accuracy, and the second to evaluate perception and satisfaction. The data were analyzed with Microsoft Excel 2010 (Microsoft Corporation, Redmond, WA). The AIVA correctly answered the patients' questions 98.5% of the time, and the topic with the lowest accuracy was "nausea." Additionally, 88% of patients agreed with the statements of the second part of the survey. Thus, the patients' perception was positive and overall satisfaction with the AIVA was high. Patients agreed the least with using the AIVA to select their surgical procedure. The comments provided improvement areas for subsequent stages of the project. The results show that patients were satisfied and expressed a positive experience with using the AIVA to answer plastic surgery FAQs before surgery. The system is also highly accurate.

An Audit of Injuries Sustained in Two–Wheeler Accidents in the Metropolitan City of Karachi, Pakistan

Background: Road traffic accidents have major contribution in injury related mortality and disability in low income countries. Two-wheelers being a major mode of transportation due to absence of proper public transport system in Karachi hence most often reported accidents are related with two wheelers. In Karachi two wheelers are quite commonly being used as mode of transportation, number of two wheelers has increased to 10 folds since last 10 years because of lack of public transports and high fuel prices and easy availability on low monthly instalments. Objective: To analyze the injury pattern among two-wheeler riders in Karachi. Study Design: Retrospective study Place and Duration of Study: Three major medico-legal centres of Karachi (Civil, Jinnah, and Abbasi Shaheed Hospitals) from 1st January 2017 to 31st December 2021. Methodology: About 11444 two-wheeler incidents occurred on roads with the consent of Police Surgeon Office Karachi were enrolled. The patients' demographics, injuries sustained, date of the injuries, cause of the injuries, types of collision and outcomes were recorded. Results: Most of the riders engaged in accidents were between the ages of 18 and 30 years; 90.99% of the riders were men. The most frequent type of injuries found in two wheeler accidents were abrasions/grazes seen in (56.26%) cases followed by fractures (20.82%), head injuries (11.02%). Conclusion: Greater prevalence in the age group of 18-30 years, with male dominance analyzed. Fatal and non-fatal injuries were observed. Metro services mass transit programme to be encouraged so to decrease the traffic on road which will automatically reduce the number of accidents to wheeler as well as pillion riders strict efforts need to be made at both government and personal levels to reduce accidents in two-wheeler riders Keyword: Riders, Pillion, Road traffic accidents

Postacute Care Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities After Total Joint Arthroplasty.

Racial and socioeconomic disparities have been associated with complications and poorer patient-reported outcomes after THA and TKA, but little is known regarding the variation of postacute care resource utilization based on socioeconomic difference in the communities in which patients reside. Hip and knee arthroplasty are among the most common elective orthopaedic procedures. Therefore, understanding social factors provides insight into patients at risk for readmission and the way in which these patients use other postoperative resources. This knowledge can help surgeons better understand which patients are at risk for complications or preventable readmissions and how to anticipate when additional surveillance or intervention might reduce this risk. (1) Do patients from communities with a higher distress level experience higher rates of readmission after THA and TKA? (2) Do patients from distressed communities have increased postoperative resource utilization? Demographics, ZIP code of residence, and Charlson comorbidity index (CCI) were recorded for each patient undergoing TKA or THA between 2016 and 2019 at two high-volume hospitals. Patients were classified according to the Distressed Communities Index (DCI) score of their ZIP code of residence. The DCI combines seven metrics of socioeconomic well-being (high school graduation, poverty rate, unemployment, housing vacancy, household income, change in employment, and change in establishment) to create a single score. ZIP codes are then classified by scores into five categories based on national quintiles (prosperous, comfortable, mid-tier, at-risk, and distressed). The DCI was chosen because it provides a single composite measure of multiple important socioeconomic factors. Multivariate analysis with logistic, negative binomial regression, or Poisson was used to investigate the association of DCI category with postoperative resource utilization while controlling forage, gender, BMI, and comorbidities. The primary outcome was 90-day readmissions. Secondary outcomes included postoperative medication prescriptions from the orthopaedic team, patient telephone calls to the surgeon's office, physical therapy sessions attended, follow-up office visits, and emergency department visits. A total of 5077 patients who underwent TKA (mean age 66 ± 9 years, 59% [2983 of 5077] are women, and 69% [3519 of 5077] are White), and 5299 who underwent THA (mean age 63 ± 11 years, 50% [2654 of 5299] are women, and 74% [3903 of 5299] are White) were included. When adjusting for age, gender, race and CCI, readmission risk was higher in distressed communities compared with prosperous communities for patients undergoing TKA (odds ratio 1.6 [95% confidence interval 1.1 to 2.3]; p = 0.02) but not for THA. For secondary outcomes after TKA, at-risk communities had more postoperative prescriptions compared with prosperous communities, but no other differences were found. After THA, no major differences were found in the likelihood to utilize postoperative resources based on DCI category. Race was not associated with readmissions or resource utilization. We found that socioeconomic distress was associated with readmission after TKA, but, after controlling for relevant confounding variables, race had no association. Patients from these communities do not demonstrate an increased or decreased use of other resources after post-TKA discharge. Increased awareness of these disparities may allow for closer monitoring and improved patient education and communication, with the goal of reducing the frequency of complications and preventable readmissions. Level III, therapeutic study.

Patient-specific factors, but neither regional anesthesia nor hip-specific cryotherapy, predict postoperative opioid requirements after hip arthroscopy for femoroacetabular impingement (FAI) syndrome

BackgroundWe sought to determine whether regional nerve block, cryotherapy variant, or patient-specific factors predict postoperative opioid requirements and pain control following hip arthroscopy. Methods104 patients underwent hip arthroscopy with (n = 31) or without (n = 73) regional block and received cryotherapy with a universal pad [joint non-specific; no compression (n = 60)] or circumferential hip/groin wrap with intermittent compression (n = 44). Outcomes included total opioid prescription amounts, requests for refills, and unplanned clinical encounters for postoperative pain within 45 days of surgery. Multivariate modeling was used to determine the effect of perioperative regional nerve block and type of cryotherapy device on outcomes after adjusting for patient demographics, previous opioid use, mental health disorder history, and surgery length. ResultsThe average amount of 5 mg oxycodone pill equivalents prescribed within 45 days of surgery was 40.5 (SD 14.8); 36% requested refills, 20% presented to another physician, and 21% called the surgeon's office due to pain. Neither the hip-specific cryotherapy pad nor regional block was predictive of opioid amounts prescribed, refill requests, or unplanned clinical encounters due to pain. Refill requests within 45 days were more common with baseline opioid use (p < 0.001), increased age (p = 0.007), and mental health disorder history (p = 0.008). Total opioid amounts prescribed within 45 days were higher with workers compensation (p = 0.03), a larger initial opioid prescription (p < 0.001), baseline opioid use (p < 0.001), history of mental health disorder (p = 0.02), and increased age (p = 0.02). Together, these variables explained 61% of the variance in opioid amounts prescribed. ConclusionPatient factors are strong predictors of postoperative opioid requirements after hip arthroscopy. Postoperative opioid prescription amounts, opioid refill requests, and pain-related calls or office visits were not affected by use of a perioperative regional nerve block or type of cryotherapy delivery system. Level of evidenceIII, retrospective cohort study.

A surgeon’s perspective on the uncorrected skeletal deformity. Part I: Unintended consequences on facial structures and esthetic harmony

It is not uncommon for orthodontists to encounter patients whose malocclusion results, at least in part, from an underlying skeletal discrepancy. In many patients, these discrepancies can be fully corrected with growth modification with or without dental compensation to achieve a Class I occlusal relationship. A subset of patients with moderate skeletal deformities in whom surgery is ideally indicated but who choose to defer surgical treatment may be at risk for long-term adverse consequences on facial esthetics. As a surgeon who performs both orthognathic and facial esthetic surgery, the senior author has had the opportunity to appreciate the contributions of underlying skeletal deformities to his patients' esthetic concerns. These patients often present years after orthodontic treatment with complaints of early facial soft tissue laxity, facial disproportion, and overall dissatisfaction with facial appearance. The authors hope to illustrate to the orthodontic community the clinical picture of adult patients who present to the offices of surgeons dissatisfied with their appearance secondary to the uncorrected skeletal deformity. This paper aims to increase orthodontists' awareness of the long-term effects of uncorrected skeletal dysplasia on facial appearance. The ultimate goal is to allow the informed consent process to incorporate these esthetic consequences and to facilitate patient decision making. This article serves as Part I of a 2-part series reviewing a surgeon's approach to patients who present with facial skeletal disharmony after orthodontic treatment with dental compensation.

Emergency Drugs for the Oral and Maxillofacial Surgeon Office.

This article illustrates the indications and mechanism of action of core emergency medications as well as emergency medications for intravenous sedation in the oral and maxillofacial surgeon office. The recognition of medical emergencies and comprehensive knowledge of pharmaceutical medical intervention can prevent deterioration in medical emergencies. In addition, this article also reviews common dosages as well as administration techniques that should be regularly reviewed and be fundamental knowledge to the oral surgeon and staff.

Popliteal Nerve Catheters for Perioperative Pain Control in Charcot-Marie-Tooth Patients

Category:Hindfoot; OtherIntroduction/Purpose:The underlying neuropathy of Charcot-Marie-Tooth (CMT) disease often makes postoperative pain control difficult. Previous institutional regimens for outpatient foot and ankle surgery in this population included preoperative single-shot regional nerve blocks and oral narcotic analgesics, but still resulted in unplanned visits for uncontrolled pain, especially after block effects abated. Longer duration of regional anesthesia effects were desired to manage pain and reduce opioid intake. We aimed to investigate the safety and efficacy of ultrasound-guided placement of popliteal nerve catheters in CMT patients undergoing foot deformity correction surgery.Methods:Twelve CMT patients, average 28 (range 13-53) years old, undergoing reconstructive surgery by a single foot and ankle attending surgeon were consented for preoperative ultrasound-guided popliteal catheters and single-shot adductor canal blocks. Patients were separately consented for enrollment in this study and follow-up questionnaires as per Institutional Review Board protocol. Seven patients underwent joint sparing reconstruction and 5 patients had subtalar fusion. Patients were discharged on postoperative day (POD) 0. Popliteal catheters were maintained, providing continuous infusion and patient-controlled bolus doses until POD3, and then self-discontinued. Oral oxycodone 5 mg (#60-80 pills) was prescribed as needed for breakthrough pain.Daily visual analog scale (VAS) pain scores were collected by phone. Patient satisfaction (0-10) was surveyed on POD5. A pill count for opioid consumption occurred at the surgeon's office on POD14. Five-point sensory testing using a 10g Semmes- Weinstein monofilament was performed preoperatively and on POD14.Results:All patients tolerated the catheters well. There were no complications related to infection or catheter malfunction requiring replacement. Four of the twelve patients had pre-existing sensory deficits involving at least two areas on the five-point monofilament test (Table 1). Postoperative testing showed these deficits were unchanged and there were no instances of new sensory deficits. Postoperative VAS pain scores were typically low with the median value (interquartile range IQR) 3.7 (1.5 - 5.75) on POD1, 3.2 (1.75 - 4.25) on POD2, and 2.5 (1 - 3.5) on POD3 (Figure 1). At POD14, VAS pain was 1 (0.75-1). Patients consumed an average total of 25 oxycodone pills (IQR 9-42) over 2 weeks, less than half the prescribed number. Patient satisfaction was high with the mean (standard deviation) score of 9.1 (1.6). All patients reported they would choose to have a nerve catheter again for a similar surgery.Conclusion:Regional anesthesia using ultrasound-guided popliteal catheters was effective for pain control in this series of CMT patients undergoing deformity correction. Opioid consumption was reduced from historical levels and no patients required emergency treatment for uncontrolled pain. These catheters provided three days of local anesthetic infusion. No new sensory deficits were detected and patients with underlying preoperative sensory deficits remained unchanged. Patients were highly satisfied. This small study group provides preliminary evidence supporting nerve catheter usage in CMT patients. Utilizing ultrasound guidance to minimize nerve injury, nerve catheters may allow safe and successful outpatient correction of CMT foot deformity.

Minoxidil, Platelet-Rich Plasma (PRP), or Combined Minoxidil and PRP for Androgenetic Alopecia in Men: A Cost-Effectiveness Markov Decision Analysis of Prospective Studies.

BackgroundAndrogenetic alopecia (AGA) is the most common cause of hair loss in men. In this study, we evaluated the cost-effectiveness of minoxidil monotherapy, minoxidil and platelet-rich plasma (PRP) combined therapy, and PRP monotherapy for the long-term treatment of early-onset AGA Hamilton-Norwood stages I-V in men.MethodologyMarkov modeling was performed to analyze the base-case parameters from 18 level I/II studies. The model base-case assumes a healthy 25-year-old man presenting to a dermatologist or plastic surgeon’s office as a new patient for the evaluation and treatment of AGA Hamilton-Norwood stages I-V (non-severe AGA in men). Simulations began at an age of 25 years and ran over 35 years. Analyses were conducted from healthcare and societal perspectives. Outcomes included incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay (WTP) thresholds were set at $50,000 and $100,000. Deterministic and probabilistic sensitivity analyses were performed to evaluate uncertainty over 10,000 simulations.ResultsFrom a healthcare perspective, compared to minoxidil monotherapy, the ICER for minoxidil+PRP was $52,036/quality-adjusted-life-year (QALY) and the ICER for PRP monotherapy was $439,303/QALY. The NMB of minoxidil monotherapy was $914,887, minoxidil+PRP was $914,350, and PRP monotherapy was $904,572 at a WTP threshold of $50,000. When the WTP threshold was increased to $100,000, the NMB of minoxidil+PRP was $1,843,908, minoxidil monotherapy was $1,831,237, and PRP monotherapy was $1,822,246. Societal trends were similar.ConclusionsMinoxidil 5% topical twice-daily monotherapy provided cost-effective treatment for men with AGA Hamilton-Norwood stages I-V at a WTP threshold of $50,000, whereas combining minoxidil 5% with PRP provided cost-effective treatment at a WTP threshold of $100,000.Level of evidence: Level II.

Pacific Eclipse exercise: Value to US Indo-Pacific Command Surgeon’s Office

The United States Indo-Pacific Command Surgeon Office had the opportunity to participate in the Pacific Eclipse workshop in December 2019. This paper discusses the value of the exercise in pandemic and disaster planning for the US Indo-Pacific Command.

Time and Clerical Burden Posed by the Current Electronic Health Record for Orthopaedic Surgeons.

The electronic health record (EHR) has become an integral part of modern medical practice. The balance of benefit versus burden of a required EHR remains inconclusive, with many studies identifying increasing physician burnout and less face-to-face patient contact because of increasing documentation demands. Few studies have investigated EHR burden in orthopaedic surgery practice. This study aimed to characterize and compare EHR usage patterns and time allocation within EHR between orthopaedic surgeons, other surgeons, and medicine physicians at an academic medical center. EHR usage was digitally tracked within a large academic medical center. EHR usage data were compiled for all physicians seeing outpatients from April 2018 to June 2019. The tracking metrics included time spent answering messages, typing notes, reviewing laboratories and imaging, reading notes, and placing orders. Physicians were subdivided between orthopaedic surgeons, other surgeons, and nonsurgeon/medical specialties. Statistical comparisons using a two-sample t-test were done between orthopaedic surgeon EHR usage patterns and other surgeons, in addition to orthopaedic surgeons versus nonsurgeons. One thousand sixty physicians including 28 full-time orthopaedic surgeons, 134 other surgeons, and 898 nonsurgical medicine physicians met inclusion criteria. Orthopaedic surgeons saw on average 31 patients per office day compared with other surgeons at 18 patients per office day (P < 0.01) and nonsurgeons at 12 patients per office day (P < 0.01). Orthopaedic surgeons received more EHR messages while also being more efficient at answering EHR messages compared with other surgeons and nonsurgeons (P < 0.01). EHR tasks, including answering messages, placing orders, chart review, writing notes, and reviewing imaging, consumed 58% of an orthopaedic surgeon's scheduled office day with the largest contribution from required note writing. In academic orthopaedic practice, EHR use has surpassed face-to-face patient time, consuming 58% of orthopaedic surgeons' clinical days. With the previously shown correlation between EHR burden and physician burnout, targeted interventions to increase efficiency and off-load EHR burden are necessary to sustain a successful orthopaedic practice.

A model for the assessment, care, and treatment of suicidal risk within the military intelligence community

ABSTRACT This paper describes the development of a behavioral health and wellness model into the US Army Intelligence and Security Command (INSCOM) to address concerns about suicide within this community. In response to stresses existing within the intelligence community (IC), INSCOM partnered with the Army Public Health Center (APHC) to assess the health and wellbeing of Command personnel. A Community Health Assessment (CHA) survey was conducted (N = 2,704 Soldiers; N = 959 Civilians) that included focus groups across three installations and secondary source data. Six key areas were prioritized: suicide behavior, behavioral health access to care and health promotion, behavioral health stigma and maintaining clearances, workplace environment, sleep health, and overall fitness. Several actions were implemented to address the report’s findings and recommendations. A Command Surgeon office was established within INSCOM. An INSCOM Health Assessment and Readiness Team (I-HART) was established. The Deputy Undersecretary of the Army provided support to address suicide within INSCOM by approving 4 highly qualified experts (HQE’s) in behavioral health and clinical suicidology to provide research oversight and make recommendations. The Command General approved 8 behavioral health providers. There are planned research efforts within the command focusing on scalable and technology enabled care delivery to improve mental well-being and decrease suicides.

Breakin’ Up is Hard to Do! - Standardized Pre-Operative Phone Call

<h3>Background Information</h3> The University Hospitals Cleveland Medical Center (UH CMC) operative services perioperative nursing and reception departments identified concerns related to patient complaints of day-of surgery delays and cancellations. At UH CMC there are over 130 surgeons representing 20 specialties that perform over 25,000 surgeries annually. Each surgeon's office would call the surgical patients the day prior to their surgery with a surgical time, arrival time, and where to report for registration. There are two adult surgery centers located at UH CMC on different floors quite far from one other. Different sets of instructions were given from each specialty with conflicting instructions related to NPO guidelines, arrival times, correct surgical center, registration location, and personal items needed day-of-surgery. <h3>Objectives of Project</h3> Pre-operative phone call ownership and standardization was needed to improve patient satisfaction, reduce day-of-surgery cancellations, optimize first case on-time starts, as well as ensure patients and families were properly instructed for their surgical procedures. <h3>Process of Implementation</h3> Urology patients were identified as the single-service pilot population. The perioperative nurses created a script based on this population's pre-operative questions and concerns during the pre-op calls. After 4 weeks, a script was developed by the nurses who conducted the calls. The nurses conducting the calls educated their peers, as well as the department secretaries. The information was then shared with each surgical specialty, to include a soft and hard rollout date. <h3>Statement of Successful Practice</h3> One month after the hard rollout date, the perioperative nurses and secretaries are conducting approximately 75 pre-operative phone calls to surgical patients daily. Outcomes to celebrate include improved first case on-time starts, decreased day-of-surgery cancellations, and increased patient satisfaction. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> Having one owner and a standardized process for pre-operative phone calls and communication with our patients may lead to improved quality, safety, and satisfaction.