Faculty Bibliography

BACKGROUND: There is uncertainty regarding which outcomes tools should be used to report the results of treatment for patients with foot and ankle disorders. This study compared the responsiveness of the Foot Function Index (FFI), American Orthopaedic Foot and Ankle Society (AOFAS) Clinical Rating Systems, and Medical Outcomes Study Short Form-36 (SF-36) in patients with foot and ankle surgery. METHODS: Twenty-five patients were recruited at a tertiary referral foot and ankle practice. The mean age of the patient sample was 40 years (range 21 to 69) and 19 were women (76%). Thirteen patients (52%) had conditions affecting the ankle, hindfoot, or midfoot, while 12 patients (48%) had conditions affecting the forefoot. Patients completed packets preoperatively and 6-months postoperatively which included informed consent forms, the FFI, the AOFAS, and the SF-36 questionnaires. Standardized response means (SRM) and effect sizes (ES) were used as the measures of responsiveness and were calculated for the AOFAS scores, the three domains of the FFI, the eight SF-36 sub-scales, and the two SF-36 summary scales. RESULTS: The standardized response mean (SRM) for the AOFAS scores was 1.10 and the effect size (ES) was 1.12. The SRM for the three FFI domains ranged from -0.39 to -0.83, while the ES ranged from -0.55 to -0.86. The SRM for the SF-36 ranged from 0.09 to 0.72 (ES ranged from 0.09 to 0.77) with the highest values occurring with the Bodily Pain sub-scale (SRM 0.72, ES 0.77) and Physical Component Summary scale (SRM 0.76, ES 0.68). CONCLUSIONS: This study demonstrated increased responsiveness of foot and ankle specific outcomes tools compared to the SF-36. However, the Bodily Pain sub-scale and Physical Component Summary scale of the SF-36 had levels of responsiveness approaching those of the FFI and AOFAS Systems after foot and ankle surgery. This suggests that the SF-36 may be used alone to monitor the outcomes in these patients without sacrificing adequate sensitivity to clinical change.

BACKGROUND: There is uncertainty regarding which outcomes tools should be used to report the results of treatment for patients with foot and ankle disorders. This study evaluates the validity of the Foot Function Index (FFI) by examining its level of correlation to the Medical Outcomes Study Short Form-36 (SF-36). The SF-36 is an extensively validated outcomes tool that has been used as a benchmark in examining the validity of several orthopaedic outcomes tools. METHODS: Seventy-three patients were recruited at a tertiary referral foot and ankle practice. Patients completed packets which included informed consent forms, the FFI, and the SF-36 questionnaires. The questionnaires were scored and Pearson correlation coefficients were determined between the three domains of the FFI and the eight SF-36 sub-scales, as well as the two SF-36 summary scales. RESULTS: Sixty-nine patients completed an adequate number of items to be included in the study. The mean age of the patient sample was 46 (range 16 to 82) years and 44 were women (64%). Twenty-one patients (30%) had conditions affecting the forefoot, while 48 patients (70%) had conditions affecting the ankle or hindfoot. All three FFI domains had moderate to high levels of correlation to many of the SF-36 scales. The Disability domain of the FFI had the most consistent level of correlation to the SF-36 with Pearson coefficients in the range of -0.23 to -0.69. The Activity Limitation (r=-0.28 to -0.64) and Pain domains (r=-0.10 to -0.61) also demonstrated moderate levels of correlation to several of the SF-36 scales. CONCLUSIONS: The consistently moderate to high levels of correlation of the FFI to the SF-36 seen in this study support the FFI as a valid measure of health status. This suggests that the FFI is a reasonable method to monitor patient outcomes. Future studies should focus on determining if the FFI improves responsiveness to clinical change when used in combination with generic instruments like the SF-36.

BACKGROUND: Reconstruction is an important adjunct to breast cancer management. This study evaluated the frequency of major and minor complications in the largest reported series of consecutive mastectomy patients treated with free tissue transfer for breast reconstruction. METHODS: All patients treated with microvascular breast reconstruction at the University of California, Los Angeles, Medical Center over an 11-year period were identified using a retrospective analysis. Frequency of complications was assessed. RESULTS: A total of 1195 breast reconstructions were performed in 952 patients. Transverse rectus abdominis musculocutaneous flaps were used in most cases (81.8 percent), whereas the superior gluteal musculocutaneous flap (10.1 percent) and other free flaps were used in the remaining patients. The overall complication rate was 27.9 percent and consisted primarily of minor complications (21.7 percent). Major complications were noted in 7.7 percent, including six total flap losses (0.5 percent). Obesity was a major predictor of complications. Smoking was not associated with increased rates of overall or microsurgical complications. Neoadjuvant chemotherapy was also an independent predictor of complications and was associated with wound-healing problems and fat necrosis. Prior abdominal surgery in transverse rectus abdominis musculocutaneous flap patients increased the risk of partial flap loss, fat necrosis, and donor-site complications. CONCLUSIONS: Microsurgical breast reconstruction is a safe and highly effective technique. Complications tend to be minor and do not affect postreconstruction adjuvant therapy. Obesity is a major predictor of flap and donor-site complications, and these patients should be appropriately counseled. Similarly, neoadjuvant preoperative chemotherapy and prior abdominal surgery increase the rates of minor complications.

The decision to replant a severed part is based on the numerous factors that influence survival of the part and the functional and aesthetic benefits gained from replanting. Not all amputees will benefit from or are candidates for replantation. The decision to proceed is therefore made by the surgeon who must consider the mechanism and extent of injury, the age of the patient, the presence of other medical or surgical conditions, the likely functional outcomes, and the patient's motivation to undergo a difficult procedure, which is followed by a lengthy recovery. This is a meta-analysis of the available studies that tracks the outcomes, based on 9 criteria, after the amputation of a total of 1803 digits in 1299 patients. By combining the data from numerous sources, a statistically significant picture emerges which may be used to educate patients and help guide the surgeon in the decision to replant.

We conducted case-control and prospective longitudinal studies to examine risk factors and predictors of disease progression for ALS. Ninety-five subjects with ALS and 106 healthy control subjects were enrolled. All subjects completed a risk factor questionnaire at enrollment. The ALS subjects were prospectively followed for one year to define factors that influence the rate of disease progression, measured by rate of change in percent predicted forced vital capacity (%FVC) and the ALS functional rating scale (ALSFRS) score. The association of each potential risk factor with ALS was determined using univariate logistic regression. A random slope model was used to determine the association of each risk factor with disease progression. The demographic characteristics of ALS subjects and controls at enrollment did not differ. Significant risk factors for ALS included reported exposure to lead (p = 0.02) and pesticides (p = 0.03). Disease progression was faster in the ALS subjects having bulbar onset and a shorter time period between onset of symptoms and diagnosis. Pertinent variables not associated with either causation or progression of ALS included physical activity, cigarette smoking and a history of physical trauma or other clinical disorders.

This research is designed to share valuable experiences and transferable principles from program staff of the Legacy/Community Voices initiative who have been involved in planning, implementing, evaluating, and sustaining tobacco control activities in underserved communities. Interviews were conducted with 13 front line staff from 9 sites: Alameda County, California; Detroit, Michigan; El Paso, Texas; Ingham County, Michigan; Miami, Florida; New Mexico; North Carolina; Northern Manhattan; and West Virginia. A model emerged from these interviews that places the life cycle of a program in a central position, with many of the identified themes (working with local champions, obtaining support from multiple partners, increasing organizational capacity) repeated throughout, albeit in different forms at different stages. Reflecting upon wisdom gained and identifying best processes for such work may help ensure that tobacco control programs are developed that are culturally safe and effective in meeting the needs of diverse communities throughout the United States.

The purpose of this project was to define education and training requirements for hospital-based dentists to efficiently and meaningfully participate in a hospital disaster response. Eight dental faculty with hospital-based training and/or military command and CBRNE (chemical, biological, radiological, nuclear, and explosive) expertise were recruited as an expert panel. A consensus set of recommended educational objectives for hospital-based dentists was established using the following process: 1) identify assumptions supported by all expert panelists, 2) determine current advanced dental educational training requirements, and 3) conduct additional training and literature review by various panelists and discussions with other content and systems experts. Using this three-step process, educational objectives that the development group believed necessary for hospital-based dentists to be effective in treatment or management roles in times of a catastrophic event were established. These educational objectives are categorized into five thematic areas: 1) disaster systems, 2) triage/medical assessment, 3) blast and burn injuries, 4) chemical agents, and 5) biological agents. Creation of training programs to help dentists acquire these educational objectives would benefit hospital-based dental training programs and strengthen hospital surge manpower needs. The proposed educational objectives are designed to stimulate discussion and debate among dental, medical, and public health professionals about the roles of dentists in meeting hospital surge manpower needs.