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Abstracts: In Other Archives Journals
Jul/Aug 2009

Abstracts: In Other Archives Journals

Arch Facial Plast Surg. 2009;11(4):274-275. doi:
Archives of Dermatology
Variation in Care for Recurrent Nonmelanoma Skin Cancer in a University-Based Practice and a Veterans Affairs Clinic
Objective

To learn if treatment of recurrent nonmelanoma skin cancer (NMSC) varied in different practice settings.

Design

Prospective cohort study of consecutive patients with recurrent NMSC.

Setting

A university-based dermatology practice and the dermatology clinic at the affiliated Veterans Affairs Medical Center (VAMC). Conventional therapies for NMSC were available at both sites.

Patients

All 191 patients diagnosed as having recurrent NMSC in 1999 and 2000 were included in the study. Data were collected from medical record review and surveys mailed to patients.

Main Outcome Measure

Performance of Mohs micrographic surgery (Mohs).

Results

Patients at the VAMC were older, less educated, poorer, and had more comorbid illnesses, but their tumors were similar to those of patients at the university-based practice. Treatment choices differed at the 2 sites: the proportions of tumors treated in the VAMC and university sites were 60% and 14%, respectively, for excisional surgery; and 24% and 61%, respectively, for Mohs (P < .001). In multivariate analyses adjusting for patient, tumor, and physician features that may have affected treatment choice, tumors treated at the university-based site remained significantly more likely to be treated with Mohs (odds ratio, 8.68 [95% confidence interval, 3.66-20.55]; P < .001).

Conclusions

Substantial variation existed in the treatment of recurrent NMSC in different practice settings. This variation was not explained by measured clinical characteristics of the patients or the tumors.

Archives of Pediatrics & Adolescent Medicine
Medical Error Disclosure Among Pediatricians: Choosing Carefully What We Might Say to Parents
Objective

To determine whether and how pediatricians would disclose serious medical errors to parents.

Design

Cross-sectional survey.

Setting

St Louis, Missouri, and Seattle, Washington.

Participants

University-affiliated hospital and community pediatricians and pediatric residents.

Main Exposure

Anonymous 11-item survey administered between July 1, 2003, and March 31, 2004, containing 1 of 2 scenarios (less or more apparent to the child's parent) in which the respondent had caused a serious medical error.

Main Outcome Measures

Physician's intention to disclose the error to a parent and what information the physician would disclose to the parent about the error.

Results

The response rate was 56% (205/369). Overall, 53% of all respondents (109) reported that they would definitely disclose the error, and 58% (108) would offer full details about how the error occurred. Twenty-six percent of all respondents (53) would offer an explicit apology, and 50% (103) would discuss detailed plans for preventing future recurrences of the error. Twice as many pediatricians who received the apparent error scenario would disclose the error to a parent (73% [75] vs 33% [34]; P < .001), and significantly more would offer an explicit apology (33% [34] vs 20% [20]; P = .04) compared with the less apparent error scenario.

Conclusions

This study found marked variation in how pediatricians would disclose a serious medical error and revealed that they may be more willing to do so when the error is more apparent to the family. Further research on the impact of professional guidelines and innovative educational interventions is warranted to help improve the quality of error disclosure communication in pediatric settings. 

Archives of Surgery
Occlusive vs Gauze Dressings for Local Wound Care in Surgical Patients: A Randomized Clinical Trial
Objective

To compare effectiveness and costs of gauze-based vs occlusive, moist-environment dressing principles.

Design

Randomized clinical trial.

Setting

Academic Medical Center, Amsterdam, the Netherlands.

Patients

Two hundred eighty-five hospitalized surgical patients with open wounds.

Intervention

Patients received occlusive (ie, foams, alginates, hydrogels, hydrocolloids, hydrofibers, or films) or gauze-based dressings until their wounds were completely healed.

Main Outcome Measures

Primary end points were complete wound healing, pain during dressing changes, and costs. Secondary end point was length of hospital stay.

Results

Time to complete wound healing did not differ significantly between occlusive (median, 66 days; interquartile range [IQR], 29-133 days) and gauze-based dressing groups (median, 45 days; IQR, 26-106 days; log-rank P = .31). Postoperative wounds (62% of the wounds included) healed significantly (P = .02) quicker using gauze dressings (median, 45 days; IQR, 22-93 days vs median, 72 days; IQR, 36-132 days). Median pain scores were low and similar in the occlusive (0.90; IQR, 0.29-2.34) and the gauze (0.64; IQR, 0.22-1.95) groups (P = .32). Daily costs of occlusive materials were significantly higher (occlusive, 6.34 [US $9.95] vs gauze, 1.85 [US $2.90]; P < .001), but nursing time costs per day were significantly higher when gauze was used (occlusive, 1.28 [US $2.01] vs gauze, 2.41 [US $3.78]; P < .001). Total cost for local wound care per patient per day during hospitalization was 7.48 (US $11.74) in the occlusive group and 3.98 (US $6.25) in the gauze-based group (P = .002).

Conclusions

The occlusive, moist-environment dressing principle in the clinical surgical setting does not lead to quicker wound healing or less pain than gauze dressings. The lower costs of less frequent dressing changes do not balance the higher costs of occlusive materials. 

Archives of Otolaryngology-Head & Neck Surgery
Single-Stage Choanal Atresia Repair in the Neonate
Objective

To evaluate the postoperative results of patients treated with and without the use of stents at the time of initial surgical treatment of choanal atresia (CA). Surgical treatment of CA in the neonatal period is complicated by postoperative stenosis, often necessitating multiple revision surgical procedures.

Design

Retrospective medical record review.

Setting

Tertiary care academic center.

Patients

The medical records of 9 patients treated for bilateral CA during the neonatal period were reviewed. All patients were treated with an endoscopic approach. Outcomes were compared for patients with and without stent use at the initial operation. Main Outcome Measures Medical records were analyzed for diagnostic modality, clinical symptoms, age at surgery, sex, surgical repair, placement of stents, reoccurrence of atresia, follow-up time, and postoperative outcomes.

Results

The mean age at initial surgery was 8 days (range, 5-15 days). Four patients had endotracheal tube stents placed at the time of initial surgery for a duration of 4 to 6 weeks. All patients required at least 1 additional surgery (mean, 2.6 procedures), and 3 (75%) had restenosis during infancy. The mean follow-up time for this group was 7.5 months. Five patients did not have stents placed at the time of initial surgery. None of these patients required additional surgical procedures during infancy, and none developed restenosis. The follow-up time for this group was 2.5 months.

Conclusions

This study suggests that the placement of stents for bilateral CA repair during the neonatal period results in a high rate of restenosis as well as the need for multiple subsequent procedures during infancy. The use of an endoscopic approach without stent placement appears to result in superior healing without the need for revision surgery.

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