Alar cartilage—an alternative for spreader graft in primary rhinoplasty

Abstract

Background

Alar cartilage can be very useful for tip and dorsum grafts. Depending on its size and thickness, it can be an important alternative for spreader grafts to improve endonasal functional deficiencies, correct deviated noses, and prevent inverted "V" deformities. Caucasian patients with bulbous tips are the most common candidates to achieve such benefits. It is easy to obtain and to frame into a desired graft.

Methods

The authors describe a surgical technique using the alar cartilages as spreader grafts. All Caucasian patients with bulbous tips who underwent primary rhinoplasty were included. All patients have been evaluated after 3 to 4 months and after 1 and 2 years by aesthetical and functional criteria.

Results

Thirty-four patients (28 female and 6 male) underwent this procedure between 2001 and 2015: 94% reported a better airflow, 91% reported very good aesthetic results and were very satisfied 2 years postoperatively, and 12% had nasal deviations that were corrected with a one side double-layered spreader grafts. Two patients presented supra-tip deformities and one patient had a columella scar that was revised surgically. No cases of inverted "V" deformity were reported 2 years postoperatively.

Conclusions

Patients with functional satisfaction and with a straight and smooth dorsum seem to be the most important benefits that were achieved with this technique using alar cartilage spreader grafts, an alternative that can be offered to improve airflow and to prevent deviated and inverted "V" deformities.

Level of Evidence: IV, therapeutic study.

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The Best Thing I Saw at ASCO

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Randomized Controlled Trial of a Home‐Based Walking Program to Reduce Moderate to Severe Aromatase Inhibitor‐Associated Arthralgia in Breast Cancer Survivors

AbstractBackground.In postmenopausal women diagnosed with breast cancer (BC), most BC tumors are hormone receptor positive and guidelines recommend adjuvant endocrine therapy that includes an aromatase inhibitor (AI). This study investigates the impact of a 6‐week, home‐based, self‐directed walking program on the commonly reported side effect of AI‐associated arthralgia (AIAA).Materials and Methods.In this phase II trial, consented BC patients were randomized to walking Intervention (n = 31) or Wait List Control (WLC; n = 31). Eligibility criteria included: stage 0–III BC, on AI for at least 4 weeks, ≥3 on a 5‐point scale inquiring about joint symptom intensity "at its worst," and exercising ≤150 minutes per week. Outcomes were self‐reported joint symptoms and psychosocial measures. Analyses comparing Intervention and WLC groups were conducted on an intention‐to‐treat basis to assess intervention impact at 6 weeks (postintervention) and at 6‐months follow‐up. Adjusted means were calculated to assess differences in two groups.Results.In our final sample (n = 62), mean age was 64 years, 74% were white, and 63% had a body mass index of 30 or higher. At postintervention, Intervention group participants reported significantly increased walking minutes per week, reduced stiffness, less difficulty with activities of daily living (ADL), and less perceived helplessness in managing joint symptoms. At 6‐months follow‐up (postwalking period in both Intervention and WLC), walking minutes per week had decreased significantly; however, improvements in stiffness and difficulty with ADLs were maintained.Conclusion.This study adds to the growing evidence base suggesting exercise as a safe alternative or adjunct to medications for the management of AIAA.Implications for Practice.Breast cancer survivors whose adjuvant endocrine treatment includes an aromatase inhibitor (AI) often experience the side effect of AI‐associated arthralgia (AIAA). This study investigates the impact of a 6‐week, home‐based, self‐directed walking program in the management of AIAA. Compared with Wait List Control, women in the Intervention group reported significantly increased walking minutes per week, reduced stiffness, less difficulty with activities of daily living, and less perceived helplessness in managing joint symptoms. This study adds to the growing evidence base suggesting exercise as a safe alternative or adjunct to medications for the management of AIAA.

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Edge, height and visibility effects on nest predation by birds and mammals in the Brazilian cerrado

Publication date: August 2017
Source:Acta Oecologica, Volume 83
Author(s): Pavel Dodonov, Ingrid Toledo Paneczko, Marina Telles
Edge influence is one of the main impacts in fragmented landscapes; yet, most of studies on edge influence have focused on high-contrast edges, and the impacts of low-contrast edges and narrow linear openings are less understood. Edge influence often affects bird nest predation, but these effects are not ubiquitous and may depend on characteristics such as nest height and visibility. We performed an experiment on nest predation in a migratory passerine, Elaenia chiriquensis (Lesser Elaenia; Passeriformes: Tyrannidae), in a savanna vegetation of the Brazilian Cerrado biome in South-Eastern Brazil. We used 89 real E. chiriquensis nests, collected during previous reproductive seasons, with two plasticine eggs in each, and randomly distributed them at two locations (edge – up to 20 m from a firebreak edge and interior – approx. 150–350 m from the edge) and two heights (low – 60–175 cm and high – 190–315 cm above ground). We also measured leaf and branch density around each nest. We performed this study on two 15-days campaigns, checking the nests every 2–3 days and removing those with predation marks. We sorted the predation marks into those made by birds, mammals, or unidentified predators, and used generalized linear models to assess the effects of location, height and leaf density on survival time and predator type. Only four nests had not been predated during the experiment; 55 nests were predated by birds, 7 by mammals, and 23 by unidentified predators. Low nests in the interior tended to have larger survival times whereas high nests at the edge tended to be more predated by birds and less predated by mammals. Thus, even a low-contrast (firebreak) edge may significantly increase nest predation, which is also affected by the nest's height, mainly due to predation by birds. These effects may be due to predator movement along the edge as well as to edge-related changes in vegetation structure. We suggest that higher-contrast edges which may also be used as movement conduits, for example powerline openings, may have even stronger effects, demanding further studies.



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An Ocular Commensal Protects against Corneal Infection by Driving an Interleukin-17 Response from Mucosal γδ T Cells

Publication date: Available online 11 July 2017
Source:Immunity
Author(s): Anthony J. St. Leger, Jigar V. Desai, Rebecca A. Drummond, Abirami Kugadas, Fatimah Almaghrabi, Phyllis Silver, Kumarkrishna Raychaudhuri, Mihaela Gadjeva, Yoichiro Iwakura, Michail S. Lionakis, Rachel R. Caspi
Mucosal sites such as the intestine, oral cavity, nasopharynx, and vagina all have associated commensal flora. The surface of the eye is also a mucosal site, but proof of a living, resident ocular microbiome remains elusive. Here, we used a mouse model of ocular surface disease to reveal that commensals were present in the ocular mucosa and had functional immunological consequences. We isolated one such candidate commensal, Corynebacterium mastitidis, and showed that this organism elicited a commensal-specific interleukin-17 response from γδ T cells in the ocular mucosa that was central to local immunity. The commensal-specific response drove neutrophil recruitment and the release of antimicrobials into the tears and protected the eye from pathogenic Candida albicans or Pseudomonas aeruginosa infection. Our findings provide direct evidence that a resident commensal microbiome exists on the ocular surface and identify the cellular mechanisms underlying its effects on ocular immune homeostasis and host defense.

Graphical abstract

Teaser

Although the eye is a mucosal site, there has been a long-standing controversy regarding whether a resident microbiome exists on the ocular surface. St. Leger et al. show that a microorganism that lives on the conjunctiva tunes local mucosal immunity and protects the eye from pathogenic infection.


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Human Secretory IgM Emerges from Plasma Cells Clonally Related to Gut Memory B Cells and Targets Highly Diverse Commensals

Publication date: Available online 11 July 2017
Source:Immunity
Author(s): Giuliana Magri, Laura Comerma, Marc Pybus, Jordi Sintes, David Lligé, Daniel Segura-Garzón, Sabrina Bascones, Ada Yeste, Emilie K. Grasset, Cindy Gutzeit, Mathieu Uzzan, Meera Ramanujam, Menno C. van Zelm, Raquel Albero-González, Ivonne Vazquez, Mar Iglesias, Sergi Serrano, Lucía Márquez, Elena Mercade, Saurabh Mehandru, Andrea Cerutti
Secretory immunoglobulin A (SIgA) enhances host-microbiota symbiosis, whereas SIgM remains poorly understood. We found that gut IgM⁺ plasma cells (PCs) were more abundant in humans than mice and clonally related to a large repertoire of memory IgM⁺ B cells disseminated throughout the intestine but rare in systemic lymphoid organs. In addition to sharing a gut-specific gene signature with memory IgA⁺ B cells, memory IgM⁺ B cells were related to some IgA⁺ clonotypes and switched to IgA in response to T cell-independent or T cell-dependent signals. These signals induced abundant IgM which, together with SIgM from clonally affiliated PCs, recognized mucus-embedded commensals. Bacteria recognized by human SIgM were dually coated by SIgA and showed increased richness and diversity compared to IgA-only-coated or uncoated bacteria. Thus, SIgM may emerge from pre-existing memory rather than newly activated naive IgM⁺ B cells and could help SIgA to anchor highly diverse commensal communities to mucus.

Graphical abstract

Teaser

Magri et al. found that the human gut includes a large memory IgM⁺ B cell repertoire clonally related to plasma cells mounting SIgM responses against mucus-embedded commensals co-targeted by SIgA. Dually coated bacteria are detected in humans but not mice and show increased diversity and richness compared to SIgA-only-coated or uncoated bacteria.


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Identification of Natural Regulatory T Cell Epitopes Reveals Convergence on a Dominant Autoantigen

Publication date: Available online 11 July 2017
Source:Immunity
Author(s): John D. Leonard, Dana C. Gilmore, Thamotharampillai Dileepan, Wioletta I. Nawrocka, Jaime L. Chao, Mary H. Schoenbach, Marc K. Jenkins, Erin J. Adams, Peter A. Savage
Regulatory T (Treg) cells expressing the transcription factor Foxp3 are critical for the prevention of autoimmunity and the suppression of anti-tumor immunity. The major self-antigens recognized by Treg cells remain undefined, representing a substantial barrier to the understanding of immune regulation. Here, we have identified natural Treg cell ligands in mice. We found that two recurrent Treg cell clones, one prevalent in prostate tumors and the other associated with prostatic autoimmune lesions, recognized distinct non-overlapping MHC-class-II-restricted peptides derived from the same prostate-specific protein. Notably, this protein is frequently targeted by autoantibodies in experimental models of prostatic autoimmunity. On the basis of these findings, we propose a model in which Treg cell responses at peripheral sites converge on those self-proteins that are most susceptible to autoimmune attack, and we suggest that this link could be exploited as a generalizable strategy for identifying the Treg cell antigens relevant to human autoimmunity.

Graphical abstract

Teaser

The endogenous antigens recognized by thymus-derived Treg cells have remained largely undefined. Leonard et al. identify natural Treg cell ligands in mice, demonstrating that two recurrent Treg cell clones recognize distinct non-overlapping peptides derived from a single prostate-specific protein.


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Lymphatic Endothelial Cells Control Initiation of Lymph Node Organogenesis

Publication date: Available online 11 July 2017
Source:Immunity
Author(s): Lucas Onder, Urs Mörbe, Natalia Pikor, Mario Novkovic, Hung-Wei Cheng, Thomas Hehlgans, Klaus Pfeffer, Burkhard Becher, Ari Waisman, Thomas Rülicke, Jennifer Gommerman, Christopher G. Mueller, Shinichiro Sawa, Elke Scandella, Burkhard Ludewig
Lymph nodes (LNs) are strategically situated throughout the body at junctures of the blood vascular and lymphatic systems to direct immune responses against antigens draining from peripheral tissues. The current paradigm describes LN development as a programmed process that is governed through the interaction between mesenchymal lymphoid tissue organizer (LTo) cells and hematopoietic lymphoid tissue inducer (LTi) cells. Using cell-type-specific ablation of key molecules involved in lymphoid organogenesis, we found that initiation of LN development is dependent on LTi-cell-mediated activation of lymphatic endothelial cells (LECs) and that engagement of mesenchymal stromal cells is a succeeding event. LEC activation was mediated mainly by signaling through receptor activator of NF-κB (RANK) and the non-canonical NF-κB pathway and was steered by sphingosine-1-phosphate-receptor-dependent retention of LTi cells in the LN anlage. Finally, the finding that pharmacologically enforced interaction between LTi cells and LECs promotes ectopic LN formation underscores the central LTo function of LECs.

Graphical abstract

Teaser

Lymph node (LN) formation is thought to rely mainly on interactions between mesenchymal lymphoid tissue organizer cells and lymphoid tissue inducer cells. Onder et al. now show that LN formation is governed by RANK-dependent activation of lymphatic endothelial cells that control retention of lymphoid tissue inducer cells in embryonic LN anlagen.


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Predictive models for identifying the binding activity of structurally diverse chemicals to human pregnane X receptor

Abstract

Toxic chemicals entered into human body would undergo a series of metabolism, transport and excretion, and the key roles played in there processes were metabolizing enzymes, which was regulated by the pregnane X receptor (PXR). However, some chemicals in environment could activate or antagonize human pregnane X receptor, thereby leading to a disturbance of normal physiological systems. In this study, based on a larger number of 2724 structurally diverse chemicals, we developed qualitative classification models by the k-nearest neighbor method. Moreover, the logarithm of 20 and 50% effective concentrations (log EC ₂₀ and log EC ₅₀) was used to establish quantitative structure-activity relationship (QSAR) models. With the classification model, two descriptors were enough to establish acceptable models, with the sensitivity, specificity, and accuracy being larger than 0.7, highlighting a high classification performance of the models. With two QSAR models, the statistics parameters with the correlation coefficient (R ²) of 0.702–0.749 and the cross-validation and external validation coefficient (Q ²) of 0.643–0.712, this indicated that the models complied with the criteria proposed in previous studies, i.e., R ² > 0.6, Q ² > 0.5. The small root mean square error (RMSE) of 0.254–0.414 and the good consistency between observed and predicted values proved satisfactory goodness of fit, robustness, and predictive ability of the developed QSAR models. Additionally, the applicability domains were characterized by the Euclidean distance-based approach and Williams plot, and results indicated that the current models had a wide applicability domain, which especially included a few classes of environmental contaminant, those that were not included in the previous models.

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Water vapor variation and the effect of aerosols in China

Publication date: September 2017
Source:Atmospheric Environment, Volume 165
Author(s): Ke Gui, Huizheng Che, Quanliang Chen, Zhaoliang Zeng, Yu Zheng, Qichao Long, Tianze Sun, Xinyu Liu, Yaqiang Wang, Tingting Liao, Jie Yu, Hong Wang, Xiaoye Zhang
This study analyzes the annual and seasonal trends in precipitable water vapor (PWV) and surface temperature (Ts) over China from 1979 to 2015, and the relationships between PWV and Ts and between PWV and aerosol absorption optical depth (AAOD), using data from radiosonde stations, weather stations and multiple satellite observations. The results revealed a positive PWV trend between 1979 and 1999, and a negative PWV trend between 2000 and 2015. Analysis of the differences in the PWV trend among different stations types showed that the magnitude of the trends were in the order main urban stations > provincial capital stations > suburb stations, suggesting that anthropogenic activities have a strong influence on the PWV trend. The AAOD exhibited a significant positive trend in most regions of China from 2005 to 2015 (confidence level 95%). Using spatial correlation analysis, we showed that PWV trend derived from Moderate Resolution Imaging Spectroradiometer (MODIS) satellite observations is correlated with Ts, with an annual correlation coefficient of 0.596. In addition, the spatial correlation between PWV and AAOD showed a negative relationship, with the highest correlation coefficients of −0.76 and −0.71 observed in mid-eastern China and central northwest China, respectively, suggesting that the increase in AAOD in recent years may be one of the reasons for the decrease in PWV since the 2000s in China.



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Oligomerization reactions for precursors to secondary organic aerosol: Comparison between two formation mechanisms for the oligomeric hydroxyalkyl hydroperoxides

Publication date: October 2017
Source:Atmospheric Environment, Volume 166
Author(s): Qiangli Zhao, Weina Wang, Fengyi Liu, Jian Lü, Wenliang Wang
To better understand the formation mechanism of oligomeric hydroxyalkyl hydroperoxides HOROO(SCI)nH composed of stabilized Criegee intermediate (SCI) as a chain unit, the reactions of SCI with hydroxyalkyl hydroperoxides (HOROOH) and hydroxyalkylperoxy radical (HORO2) as well as HO2 radical were investigated. For the reactions of HORO2 + SCI, two preferred pathways involving a SCI insertion in HOROOH hydroperoxide bond can be found, and the formation of HOROO(SCI)H is the dominant pathway in the reaction of HOCH2(CH3)2COOH + (CH3)2COO. The structures of the HORO2, HOROOH as well as the SCIs play a crucial role in determining the reactivity of the oligomerization. Both the reactions of HORO2 + SCI + HO2 and HOROOH + SCI could be the source of the processors to the formation of secondary organic aerosol (SOA). But from the point of free energy barriers, the formation of HOROO(SCI)H prefers to follow the mechanism involving initiation by the reaction of a HORO2 and a SCI, sequential addition of SCIs, and termination by reaction with the HO2 radical. The rate coefficients show negative temperature dependence and vary in different systems depending on the reactants. The reaction process and constituents of the products can be regulated by temperature and reactants.

Graphical abstract

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Aerosol black carbon at an urban site-Srinagar, Northwestern Himalaya, India: Seasonality, sources, meteorology and radiative forcing

Publication date: September 2017
Source:Atmospheric Environment, Volume 165
Author(s): Mudasir Ahmad Bhat, Shakil Ahmad Romshoo, Gufran Beig
Black carbon (BC) mass concentration was measured first-time at a high altitude urban site-Srinagar (1600 m asl), in northwestern Himalaya, India using an Aethalometer during 2013 to study temporal variations (monthly, diurnal and seasonal), meteorological influences, source and its radiative forcing. Diurnal variations with two peaks (at 8–10 h and 20–23 h) and two dips (at 13–17 h and 0–3 h) were observed throughout the year with varying magnitude. November and April showed the highest (13.6 μg/m³) and the lowest (3.4 μg/m³) mean monthly BC concentration respectively. Seasonally, autumn displayed the highest (9.2 μg/m³) and spring the lowest (3.5 μg/m³) mean BC concentration. Annual average BC concentration was quite higher (6 μg/m³) than those reported for other high altitude stations. Wind speed, Minimum temperature and total precipitation showed a clear negative correlation with BC (r = −0.63, −0.51 and −0.55 respectively), while as, the evening relative humidity showed positive correlation (r = 0.56). During autumn, spring and winter seasons, the main source of BC at Srinagar is the biomass burning, while during summer season, equal contribution of BC is from fossil fuel and biomass burning. Back trajectory simulations revealed that, except summer, westerly air masses are the dominant winds, transporting BC from central Asia, west Asia, south Asia, Africa and some parts of Europe to Srinagar adding to its local sources. Clear-sky short wave radiative forcing of atmosphere due to BC was highest (58.2 W m^-2) during autumn which leads to the increase in lower atmospheric heating rate by 1.6 K/d. The high concentration of BC observed over the high-altitude Himalayan Kashmir region has serious implications for the regional climate, hydrology and cryosphere which needs to be investigated.



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Preparation of microscale zero-valent iron-fly ash-bentonite composite and evaluation of its adsorption performance of crystal violet and methylene blue dyes

Abstract

New microscale zero-valent iron adsorbent on fly ash and bentonite matrix for removal of crystal violet (CV) and methylene blue (MB) was synthesized through direct reduction of iron oxide using coke and palm kernel shell. The adsorbent was prepared as cylindrical shaped pellets to remove the CV and MB from the aqueous solution. Nitrogen adsorption-desorption isotherm and scanning electron microscopy (SEM) studies showed that the adsorbent is highly porous, and the iron particles are finely dispersed on the supporting material surfaces. FTIR and UV studies indicated that the C=C bonds in CV and C=N⁺(CH₃)₂ bonds in MB were affected in the adsorption process. MB switched to the reduced MBH₂ species while CV was reduced to two small-size molecular compounds, explaining the higher CV adsorption in comparison to that of MB. The reduction of these compounds was coupled to the oxidation of Fe⁰ to Fe₂O₃ as revealed by XRD characterization of the adsorbent after adsorption. CV and MB adsorption isotherms fitted well with the Langmuir adsorption model. Different adsorption and reduction kinetic models were examined for the MB and CV removal processes. A better fit of the experimental data with the pseudo-second-order model was observed. CV and MB adsorption increased with temperature in the 30–50 °C range. At 50 °C, adsorption capacities of CV and MB reached to 89.9 and 42.8 mg/g, respectively. This new adsorbent showed a superior adsorption capacity for CV and MB when compared to other adsorbents.

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Anesthesia for Kidney and Pancreas Transplantation

Publication date: Available online 10 July 2017
Source:Anesthesiology Clinics
Author(s): Aaron M. Mittel, Gebhard Wagener

Teaser

Kidney transplants are the most common solid organ abdominal transplant and are occasionally performed simultaneously with pancreas transplants in diabetic patients. Preoperative evaluation of potential transplant recipients should focus on the potential for occult cardiovascular disease while also screening for other signs of end-organ dysfunction. Intraoperatively, it is of utmost importance to ensure adequate graft perfusion to limit the risk of postoperative graft dysfunction or rejection. Postoperative care of the kidney or pancreas transplant patient should focus on ensuring normalization of volume status, electrolyte concentrations, and glycemic control.


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Anesthetic Management of Pediatric Liver and Kidney Transplantation

Publication date: Available online 10 July 2017
Source:Anesthesiology Clinics
Author(s): Nicholas R. Wasson, Jeremy D. Deer, Santhanam Suresh

Teaser

Pediatric patients with liver dysfunction and renal failure may exhibit many comorbidities. There are often associated congenital syndromes to be taken into account. Liver and renal transplantation offer a solution and substantial improvement in quality of life. Anesthetic management of pediatric liver and renal transplantation has not been well-described. There are key differences between adults and children undergoing these procedures, and acknowledgment of some key principles provide a solid foundation to optimize perioperative outcomes. This article provides an overview of the perioperative management and considerations in pediatric patients undergoing liver and renal transplantation.


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Anesthesia for Liver Transplantation

Publication date: Available online 10 July 2017
Source:Anesthesiology Clinics
Author(s): Dieter Adelmann, Kate Kronish, Michael A. Ramsay

Teaser

The provision of anesthesia for a liver transplant program requires a dedicated team of anesthesiologists. Liver transplant anesthesiologists must have an understanding of liver physiology and anatomy; the spectrum of clinical disease associated with liver dysfunction; the impact of warm and cold ischemia times, surgical techniques in liver transplantation, the impact of ischemia–reperfusion syndrome; and optimal practices to protect the liver. The team must provide a 24-hour service, be actively involved in the selection committee process, and stay current with advances in the subspecialty.


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Transfusion Medicine and Coagulation Management in Organ Transplantation

Publication date: Available online 10 July 2017
Source:Anesthesiology Clinics
Author(s): Jaswanth Madisetty, Cynthia Wang

Teaser

Organ transplantation recipients present unusual challenges with regard to blood transfusion. Although this patient population requires a larger proportion of blood product resources, liberal transfusion of allogeneic blood products can lead to a plethora of complications. Recent trends suggest that efforts to minimize bleeding, conserve products, and target transfusion to specific deficits and needs are increasingly becoming the standard practice. This must all occur with optimization of graft function and preservation in mind. With newer monitoring modalities and factor concentrates, the approach toward transfusion and bleeding in organ transplantation has rapidly improved in recent years.


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Organ Transplantation: A Systematic Review

Publication date: Available online 10 July 2017
Source:Anesthesiology Clinics
Author(s): Aman Mahajan, Christopher Wray




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Is it All About the Money? Not All Surgical Subspecialization Leads to Higher Lifetime Revenue when Compared to General Surgery

Publication date: Available online 10 July 2017
Source:Journal of Surgical Education
Author(s): Maria Baimas-George, Brian Fleischer, Douglas Slakey, Emad Kandil, James R. Korndorffer, Christopher DuCoin
ObjectiveIt is believed that spending additional years gaining expertise in surgical subspecialization leads to higher lifetime revenue. Literature shows that more surgeons are pursuing fellowship training and dedicated research years; however, there are no data looking at the aggregate economic impact when training time is accounted for. It is hypothesized that there will be a discrepancy in lifetime income when delay to practice is considered.DesignData were collected from the Medical Group Management Association's 2015 report of average annual salaries. Fixed time of practice was set at 30 years, and total adjusted revenue was calculated based on variable years spent in research and fellowship. All total revenue outcomes were compared to general surgery and calculated in US dollars.ParticipantsThe financial data on general surgeons and 9 surgical specialties (vascular, pediatric, plastic, breast, surgical oncology, cardiothoracic, thoracic primary, transplant, and trauma) were examined.ResultsWith fellowship and no research, breast and surgical oncology made significantly less than general surgery (−$1,561,441, −$1,704,958), with a difference in opportunity cost equivalent to approximately 4 years of work. Pediatric and cardiothoracic surgeons made significantly more than general surgeons, with an increase of opportunity cost equivalent to $5,301,985 and $3,718,632, respectively. With 1 research year, trauma surgeons ended up netting less than a general surgeon by $325,665. With 2 research years, plastic and transplant surgeons had total lifetime revenues approximately equivalent to that of a general surgeon.ConclusionsSignificant disparities exist in lifetime total revenue between surgical subspecialties and in comparison, to general surgery. Although most specialists do gross more than general surgeons, breast and surgical oncologists end up netting significantly less over their lifetime as well as trauma surgeons if they do 1 year of research. Thus, the economic advantage of completing additional training is dependent on surgical field and duration of research.



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Trainees as Agents of Change in the Opioid Epidemic: Optimizing the Opioid Prescription Practices of Surgical Residents

Publication date: Available online 10 July 2017
Source:Journal of Surgical Education
Author(s): Alexander S. Chiu, James M. Healy, Michael P. DeWane, Walter E. Longo, Peter S. Yoo
ObjectiveOpioid abuse has become an epidemic in the United States, causing nearly 50,000 deaths a year. Postoperative pain is an unavoidable consequence of most surgery, and surgeons must balance the need for sufficient analgesia with the risks of overprescribing. Prescribing narcotics is often the responsibility of surgical residents, yet little is known about their opioid-prescribing habits, influences, and training experience.DesignAnonymous online survey that assessed the amounts of postoperative opioid prescribed by residents, including type of analgesia, dosage, and number of pills, for a series of common general surgery procedures. Additional questions investigated influences on opioid prescription, use of nonnarcotic analgesia, degree of engagement in patient education on opioids, and degree of training received on analgesia and opioid prescription.SettingAccreditation Council for Graduate Medical Education accredited general surgery program at a university-based tertiary hospital.ParticipantsCategorical and preliminary general surgery residents of all postgraduate years.ResultsThe percentage of residents prescribing opioids postprocedure ranged from 75.5% for incision and drainage to 100% for open hernia repair. Residents report prescribing 166.3 morphine milligram equivalents of opioid for a laparoscopic cholecystectomy, yet believe patients will only need an average of 113.9 morphine milligram equivalents. The most commonly reported influences on opioid-prescribing habits include attending preference (95.2%), concern for patient satisfaction (59.5%), and fear of potential opioid abuse (59.5%). Only 35.8% of residents routinely perform a narcotic risk assessment before prescribing and 6.2% instruct patients how to properly dispose of excess opioids. More than 90% of residents have not had formal training in best practices of pain management or opioid prescription.Conclusion and RelevanceSurgical trainees are relying almost exclusively on opioids for postoperative analgesia, often in excessive amounts. Residents are heavily influenced by their superiors, but are not receiving formal opioid-prescribing education, pointing to a great need for increased resident education on postoperative pain and opioid management to help change prescribing habits.



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