Faculty Bibliography

Complications and undesired outcomes happen to some patients of virtually all physicians, at all stages in their careers. Bad outcomes can be a consequence of disease processes, the premorbid condition of the patient, or the errors that occur in the process of health care. These errors include, but are by no means confined to, surgeon error. Regardless of the reason for the bad outcome, the surgeon is obligated to discuss the event with the patient and the family. This article reviews the benefits, barriers, and legal implications of the discussion and describes the disclosure process.

Mesenchymal and hematopoietic tissues are important reservoirs of adult stem cells. The potential of tissue resident mesenchymal stem cells (MSCs) to differentiate into cells of mesodermal and ectodermal lineages has been reported previously. We examined the hypothesis that adherent adipose tissue resident mesenchymal stem cells (ASCs) are capable of generating cells with hematopoietic characteristics. When cultured in differentiation media, clonally isolated ASCs develop into cells with hematopoietic attributes. The hematopoietic differentiated cells (HD) express early hematopoietic (c-kit, PROM1, CD4) as well as monocyte/macrophage markers (CCR5, CD68, MRC1, CD11b, CSF1R). Additionally, HD cells display functional characteristics of monocyte/macrophages such as phagocytosis and enzymatic activity of α-Naphthyl Acetate Esterase. HD cells are also responsive to stimulation by IL-4 and LPS as shown by increased CD14 and HLA-DRB1 expressions and release of IL-2, IL10, and TNF. Taken together, this study characterizes the potential of ASCs to generate functional macrophages in vitro, and therefore paves way for their possible use in cell therapy applications.

BACKGROUND: Acute postoperative pain following craniofacial or esthetic surgery, or trauma is readily treated with medicinal regimens. Facial pain persisting for more than six months is defined as chronic and must be distinguished from nontraumatic atypical facial pain or "tic-douloureaux." Our surgical experience managing chronic facial (trigeminal) pain is reviewed to provide insight into the success of our current algorithm for managing patients with chronic facial pain. METHODS: We performed a retrospective review of nine consecutive patients operated for post-traumatic chronic trigeminal nerve pain. Most patients were women (mean age 41 years). Data evaluated included mechanism of nerve injury, physical exam, CT scans, computer-aided neurosensory testing, and diagnostic nerve blocks. Surgical management included hardware removal, neurolysis, and/or neuroma resection with nerve grafting when indicated. Primary outcome measurement included Likert pain scale score (range 0-10). Secondary outcome measurements included sensory exam, medication requirement, and return to work. Based on these outcome measures, results were defined as excellent, good, fair, or poor. RESULTS: Five of the nine patients had excellent outcomes, one was good, two were fair, and one was poor. The one patient with a poor result had temporary improvements, but later returned to baseline. No patient was made symptomatically worse or had operative complications. CONCLUSIONS: Successful treatment of chronic, post-traumatic trigeminal nerve pain can be expected using an algorithm that measures sensory function of the involved trigeminal nerve branch. Then either preserves that function through neurolysis or reconstruction with a nerve graft, or eliminates that function through neuroma resection.

Ninety-two children, the entire series of paediatric facial reanimation by a single surgeon over thirty years, are presented. The objective is to analyse the incidence and value of secondary revisions for functional and aesthetic refinements following the two main stages of reanimation. The reconstructive strategy varied according to the denervation time, the aetiology, and whether the paralysis was uni- or bilateral, complete or partial. Irrespective of these variables, 89% of the patients required secondary surgery. Post-operative videos were available in seventy-two cases. Four independent observers graded patients' videos using a scale from poor to excellent. The effect of diverse secondary procedures was measured computing a mean-percent-gain score. Statistical differences between treatment groups means were tested by the t-test and one-way ANOVA. Two-thirds of the corrective and ancillary techniques utilized granted significantly higher mean-scores post-secondary surgery. A comparison of pre- and post-operative data found valuable improvements in all three facial zones after secondary surgery. In conclusion, inherent to dynamic procedures is the need for secondary revisions. Secondary surgery builds in the potential of reanimation surgery, effectively augmenting functional faculties and aesthesis

BACKGROUND: Neonatal upper airway obstruction demands urgent attention. Tracheostomy can prove to be lifesaving but has morbidities. Recently, the authors found reduced morbidity/mortality when using a distraction decision tree model compared with conventional "case-by-case" management. In this current study, the authors assess the long-term costs of (1) a decision tree model versus conventional treatment and (2) tracheostomy versus distraction osteogenesis. METHODS: An inpatient cost-matrix analysis study on neonates with upper airway obstruction and micrognathia was performed (n=149). In Part I, conventionally treated neonates managed on a case-by-case basis received home monitoring or a tracheostomy. Decision tree model-managed newborns had specialist consultations and diagnostic testing to determine whether home monitoring, tracheostomy, or distraction osteogenesis would be implemented. In Part II, tracheostomy treatment was compared directly to distraction osteogenesis. RESULTS: In Part I (conventional versus decision tree model), taking into account the costs of the distraction, tracheostomy, hospital stay, diagnostic studies, physician fees, and emergency department visits, the total per patient treatment cost was 1.5 greater in the conventional treatment group ($332,673) compared with the decision tree model ($225,998) (p<0.05). In Part II (tracheostomy versus distraction osteogenesis), the total per-patient treatment cost in the tracheostomy group was two times greater than in the distraction group ($382,246 versus $193,128) (p<0.05). CONCLUSIONS: In treating newborns with micrognathia and upper airway obstruction, a decision tree model with mandibular distraction decreases long-term health care costs compared with conventional treatment. Furthermore, when comparing distraction to tracheostomy, similar decreases in long-term health care costs occurred.

PURPOSE: Diagnosis and treatment of frontal sinus fractures (FSFs) have progressed over the previous 30 years. Despite advances in computed tomography, there is no current diagnostic uniformity with regard to classification and treatment. We developed a statistically valid treatment protocol for FSFs based on injury pattern, nasofrontal outflow tract (NFOT) injury, and complication(s). These data outlined predictable injury patterns based on specific computed tomographic findings critical to the diagnosis and ultimate treatment of this potentially fatal injury. MATERIALS AND METHODS: A retrospective review was conducted on patients with FSF from 1979 to 2005 under institutional review board approval. All computed tomographic scans were reviewed by the authors and fractures categorized by location, displacement, comminution, and degree of NFOT injury. RESULTS: One thousand ninety-seven patients with FSF were identified, 87 expired and 153 had inadequate data, leaving a group of 857 patients. Simultaneous displacement of anterior-posterior tables constituted the largest group (38.4%). NFOT injury occurred in most patients (70.7%) and was strongly associated with anterior (92%) and posterior (88%) table involvement (comminuted 98%). Sixty-seven percent of patients with NFOT injury had obstruction. Five hundred four patients (59.6%) had surgery with 10.4% complications and 353 patients were observed with 3.1% complications. All but 1 patient with complications had NFOT injury (98.5%). CONCLUSIONS: Predictable patterns of injury based on specific computed tomographic data play a pivotal role in classification and surgical management of potentially fatal frontal sinus injuries. Radiologic diagnosis of NFOT injury in FSFs, particularly obstruction, plays a decisive role in surgical planning.

BACKGROUND: Resident duty hours have been restricted to 80 per week, a limitation thought to increase patient safety by allowing adequate sleep. Yet decreasing work hours increases the number of patient exchanges (so-called 'handoff') at the end of shifts. WHERE ARE WE NOW?: A greater frequency of handoff leads to an increased risk of physician error. Information technology can be used to minimize that risk. WHERE DO WE NEED TO GO?: A computer-based expert system can alleviate the problems of data omissions and data overload and minimize asynchrony and asymmetry. A smart system can further prompt departing physicians for information that improves their understanding of the patient's condition. Likewise, such a system can take full advantage of multimedia; generate a study record for self-improvement; and strengthen the interaction between specialists jointly managing patients. HOW DO WE GET THERE?: There are impediments to implementation, notably requirements of the Health Insurance Portability and Accountability Act; medical-legal ramifications, and computer programming costs. Nonetheless, the use of smart systems, not to supplant physicians' rational facilities but to supplement them, promises to mitigate the risks of frequent patient handoff and advance patient care. Thus, a concerted effort to promote such smart systems on the part of the Accreditation Council for Graduate Medical Education (the source of the duty hour restrictions) and the Association of American Medical Colleges (representing medical schools and teaching hospitals) may be effective. We propose that these organizations host a contest for the best smart handoff systems and vigorously promote the winners