A Review of Meta-Analyses in Plastic Surgery: Need for Adequate Assessment of Publication Bias

INTRODUCTION

Publication bias describes a phenomenon in which significant positive results have a higher likelihood of being published compared to negative or nonsignificant results. Publication bias can confound the estimated therapeutic effect in meta-analyses and needs to be adequately assessed in the surgical literature.

METHODS

A review of meta-analyses published in five plastic surgery journals from 2002 to 2022 was conducted. The inclusion criteria for meta-analyses were factors that demonstrated an obligation to assess publication bias, such as interventions with comparable treatment groups and enough power for statistical analysis. Acknowledgment of publication bias risk, quality of bias assessment, methods used in assessment, and individual article factors were analyzed.

RESULTS

318 unique meta-analyses were identified in literature search, and after full-text reviews, 143 met the inclusion criteria for obligation to assess publication bias. 64% of eligible meta-analyses acknowledged the confounding potential of publication bias, and only 46% conducted a formal assessment. Of those who conducted an assessment, 49% used subjective inspection of funnel plots alone, while 47% used any statistical testing in analysis. Overall, only 9/143 (6.3%) assessed publication bias and attempted to correct for its effect. Journals with a higher average impact factor were associated with mention and assessment of publication bias, but more recent publication year and higher number of primary articles analyzed were not.

CONCLUSIONS

This review identified low rates of proper publication bias assessment in meta-analyses published in five major plastic surgery journals. Assessment of publication bias using objective statistical testing is necessary to ensure quality literature within surgical disciplines.

Surgical Fellowships Demonstrate Variable Improvement in Gender Representation Despite Greater Female Enrollment in General Surgery Residencies

OBJECTIVE

Despite increasing female representation in General Surgery (GS) residency training programs, proportional improvement of female enrollment in surgical fellowships has yet to be quantified. We aimed to assess if female enrollment in surgical fellowships has improved at an equivalent rate in 7 different surgical fellowship options after GS.

DESIGN AND SETTING

Data were collected from Accreditation Council for Graduate Medical Education (ACGME) resources which disclosed active resident and fellow characteristics. Gender identification was self-reported by residents to ACGME. Gender data collected for GS programs and surgical fellowships including Surgical Critical Care, Colon, and Rectal Surgery, Pediatric Surgery, Plastic Surgery, Surgical Oncology, Thoracic Surgery, and Vascular Surgery from annual reports. Pearson Chi-squared analysis was conducted between GS residencies and fellowship programs in their corresponding years using Stata15 software.

RESULTS

In all years examined, fellowships in Vascular, Thoracic, and Plastic Surgery had significantly lower female enrollment in proportion to the number of female GS residents (p = <0.02). In all years examined, Surgical Oncology, Pediatric, Colon and Rectal, and Surgical Critical Care had female enrollment that was, at minimum, proportional to female enrollment in GS residency, indicating equitable gender representation. Surgical Oncology (2016), Pediatric (2020) and Surgical Critical Care (2016) fellowships each had 1 year where female enrollment was significantly higher than General Surgery.

CONCLUSIONS

The enrollment of female surgeons in Plastic, Vascular, and Thoracic Surgery fellowships has not improved proportionally despite an increase in female GS residents. These results suggest the possibility of persistent factors that deter female enrollment in Vascular, Thoracic and Plastic Surgery fellowships that are not present to the same degree in fields with equitable fellowship female enrollment. Female representation in surgical fellowships is vital to improving gender diversity in all disciplines of surgery, particularly academic surgery.

Operative management of immune checkpoint colitis following in-transit melanoma: Case report

Immune checkpoint inhibitors are increasingly used as powerful anti-neoplastic therapies in the setting of melanoma. Colitis is a known complication of immune checkpoint inhibitors that if often medically managed. We present a patient with stage IV melanoma with demonstrated in-transit disease undergoing immune checkpoint inhibitor therapy. The patient subsequently developed recalcitrant severe colitis that necessitated operative intervention and bowel resection. The association of immune check point inhibitors and immune related adverse effects are discussed as well as treatments of advanced colitis, including the possibility of surgical management in the setting of severe colitis with complications.

Oxygenation and Respiratory System Compliance Associated With Pulmonary Contusion

BACKGROUND

Blunt pulmonary contusions are associated with severe chest injuries and are independently associated with worse outcomes. Previous preclinical studies suggest that contusion progression precipitates poor pulmonary function; however, there are few current clinical data to corroborate this hypothesis. We examined pulmonary dynamics and oxygenation in subjects with pulmonary contusions to evaluate for impaired respiratory function.

METHODS

A chest injury database was reviewed for pulmonary contusions over 5 years at an urban trauma center. This database was expanded to capture mechanical ventilation parameters for the first 7 days on all patients with pulmonary contusion and who were intubated. Daily [Formula: see text]:[Formula: see text], oxygenation indexes (OI), and dynamic compliances were calculated. Pulmonary contusions were stratified by severity. The Fisher exact and chi square tests were performed on categorical variables, and Mann-Whitney U-tests were performed on continuous variables. Significance was assessed at a level of 0.05.

RESULTS A TOTAL OF

1,176 patients presented with pulmonary contusions, of whom, 301 subjects (25.6%) required intubation and had available invasive mechanical ventilation data. Of these, 144 (47.8%) had mild-moderate pulmonary contusion and 157 (52.2%) had severe pulmonary contusion. Overall injury severity score was high, with a median injury severity score of 29 (interquartile range, 22-38). The median duration of mechanical ventilation for mild-moderate pulmonary contusion was 7 d versus 10 d for severe pulmonary contusion (P = .048). All the subjects displayed moderate hypoxemia, which worsened until day 4-5 after intubation. Severe pulmonary contusion was associated with significantly worse early hypoxia on day 1 and day 2 versus mild-moderate pulmonary contusion. Severe pulmonary contusion also had a higher oxygenation index than mild-moderate pulmonary contusion. This trend persisted after adjustment for other factors, including transfusion and fluid administration.

CONCLUSIONS

Pulmonary contusions played an important role in the course of subjects who were acutely injured and required mechanical ventilation. Contusions were associated with hypoxemia not fully characterized by [Formula: see text]: [Formula: see text], and severe contusions had durable elevations in the oxygenation index despite confounders.

Intercostal liposomal bupivacaine injection for rib fractures: A prospective randomized controlled trial

BACKGROUND

Blunt chest wall injury accounts for 15% of trauma admissions. Previous studies have shown that the number of rib fractures predicts inpatient opioid requirements, raising concerns for pharmacologic consequences, including hypotension, delirium, and opioid dependence. We hypothesized that intercostal injection of liposomal bupivacaine would reduce analgesia needs and improve spirometry metrics in trauma patients with rib fractures.

METHODS

A prospective, double-blinded, randomized placebo-control study was conducted at a Level I trauma center as a Food and Drug Administration investigational new drug study. Enrollment criteria included patients 18 years or older admitted to the intensive care unit with blunt chest wall trauma who could not achieve greater than 50% goal inspiratory capacity. Patients were randomized to liposomal bupivacaine or saline injections in up to six intercostal spaces. Primary outcome was to examine pain scores and breakthrough pain medications for 96-hour duration. The secondary endpoint was to evaluate the effects of analgesia on pulmonary physiology.

RESULTS

One hundred patients were enrolled, 50 per cohort, with similar demographics (Injury Severity Score, 17.9 bupivacaine 17.6 control) and comorbidities. Enrolled patients had a mean age of 60.5 years, and 47% were female. Rib fracture number, distribution, and targets for injection were similar between groups. While both groups displayed a decrease in opioid use over time, there was no change in mean daily pain scores. The bupivacaine group achieved higher incentive spirometry volumes over Days 1 and 2 (1095 mL, 1063 mL bupivacaine vs. 900 mL, 866 mL control). Hospital and intensive care unit lengths of stay were similar and there were no differences in postinjection pneumonia, use of epidural catheters or adverse events bet ween groups.

CONCLUSION

While intercostal liposomal bupivacaine injection is a safe method for rib fracture-related analgesia, it was not effective in reducing pain scores, opioid requirements, or hospital length of stay. Bupivacaine injection transiently improved incentive spirometry volumes, but without a reduction in the development of pneumonia.

LEVEL OF EVIDENCE

Therapeutic/care management, Level II.

The Association Between Pulmonary Contusion Severity and Respiratory Failure

BACKGROUND

Pulmonary contusions (PCs) have historically been viewed as a serious complicating factor in thoracic injury. Recently, there has been conflicting evidence regarding the influence of PCs on outcomes; however, many studies do not stratify contusions by severity and may miss clinical associations. We sought to identify if contusion severity is associated with worse outcomes.

METHODS

A previously published chest wall injury database at an urban Level I trauma center was retrospectively reviewed. All severely injured subjects (defined as Injury Severity Score [ISS] ≥ 15) with moderate to severe thoracic injury (defined as a chest wall Abbreviated Injury Scale [AIS] ≥ 3) who required mechanical ventilation for > 24 h were stratified by contusion severity. Moderate to severe contusions were defined as AIS contusion ≥ 3 and Blunt Pulmonary Contusion 18 (BPC18) score ≥ 3.

RESULTS

Over 5 y, 3,836 patients presented with chest wall injuries, of which 1,176 (30.6%) had concomitant contusions. When screened for inclusion criteria, 339 subjects with contusions and 211 subjects without contusions (no-PC) were identified. Of these, 234 had moderate to severe contusions defined by AIS contusion ≥ 3 (PC-A) and 230 had moderate to severe contusions by BPC18 ≥ 3 (PC-B). Compared to no-PC, both PC-A and PC-B groups had significantly lower mortality (17.9% and 17.4%, respectively, vs 28.9%); however, PC-A and PC-B groups had longer durations of mechanical ventilation (6 and 7 d, respectively, vs 5 d), longer ICU length of stay (10 and 10 vs 8 d), and longer overall hospital length of stay (15 and 15 vs 13 d).

CONCLUSIONS

In severely injured polytrauma patients, PCs are seen with more severe chest injuries. Furthermore, moderate to severe contusions are associated with longer durations of mechanical ventilation, ICU length of stay, and hospital length of stay. Despite practice pattern changes, contusions appear to contribute significantly to the clinical course of the blunt chest wall injured patients.

What's in a Name? Provider Perception of Injured John Doe Patients

BACKGROUND

We previously demonstrated that unidentified aliased patients, John Doe's (DOEs), are one of the highest risk and most medically fragile populations of injured patients. Aliasing can result in misplaced information and confusion that must be overcome by health care professionals. DOE alias use is institutionally dependent and not uniform, which may lead to significant variation in perception of confusion and error. We sought to determine if health care practitioners experience confusion that may result in compromised care when caring for injured DOE patients.

METHODS

After obtaining institutional review board approval, we surveyed critical care nurses, nurse practitioners, resident physicians, and surgeons who care for DOE patients at two academic level I trauma centers with separate DOE alias practices. Surveys asked whether caring for DOE patients created possible or actual confusion and possible or actual patient care errors. In one institution (Selective DOE), only unidentified patients were given an alias that was reconciled when information became available. At the other institution (All DOE), all trauma patients were admitted with an alias that was reconciled within 24 h. Respondents were invited to complete an anonymous questionnaire regarding the care for DOE patients. Results were analyzed with Wilcoxon rank-sum tests, and significance was assessed at a level of 0.05.

RESULTS

Of 176 total respondents, 120 (68.2%) reported from Selective DOE and 56 (31.8%) from All DOE. Overall 53.1% reported that DOE use can cause serious confusion. Specifically, 31.3% reported experiencing actual confusion, although only 4% reported actual errors. Nurses had significantly higher perceived risk of confusion in the system of All DOE versus Selective DOE assignment (17.9% versus 4.2%, P < 0.01). Resident physicians reported significantly more frequent actual mistakes within the All DOE versus Selective DOE (24.1% versus 6.6%, P < 0.01), despite finding no significant difference in resident perception of confusion (21.4% versus 12.5%, respectively, P = 0.18).

CONCLUSIONS

Our study sheds light on clinical consequences of EMR use and aliases for end users. We show that nurses perceive that there are greater potential complications associated with DOE aliases use, and this varies depending on the system used for managing unidentified patients. Minimizing DOE alias use may help to minimize provider confusion, risk for error, and patient safety.

Medication Errors in Injured Patients

Trauma patients are vulnerable to medication error given multiple handoffs throughout the hospital. The purpose of this study was to assess trends in medication errors in trauma patients and the role these errors play in patient outcomes. Injured adults admitted from 2009 to 2015 to a Level I trauma center were included. Medication errors were determined based on a nurse-driven, validated, and prospectively maintained database. Multivariable logistic regression modeling was used to control for differences between groups. Among 15,635 injured adults admitted during the study period, 132 patients experienced 243 errors. Patients who experienced errors had significantly worse injury severity, lower Glasgow Coma Scale scores and higher rates of hypotension on admission, and longer lengths of stay. Before adjustment, mortality was similar between groups but morbidity was higher in the medication error group. After risk adjustment, there were no significant differences in morbidity or mortality between the groups. Medication errors in trauma patients tend to occur in significantly injured patients with long hospital stays. Appropriate adjustment when studying the impact of medical errors on patient outcomes is important.

Medication Errors in Injured Patients

Trauma patients are vulnerable to medication error given multiple handoffs throughout the hospital. The purpose of this study was to assess trends in medication errors in trauma patients and the role these errors play in patient outcomes. Injured adults admitted from 2009 to 2015 to a Level I trauma center were included. Medication errors were determined based on a nurse-driven, validated, and prospectively maintained database. Multivariable logistic regression modeling was used to control for differences between groups. Among 15,635 injured adults admitted during the study period, 132 patients experienced 243 errors. Patients who experienced errors had significantly worse injury severity, lower Glasgow Coma Scale scores and higher rates of hypotension on admission, and longer lengths of stay. Before adjustment, mortality was similar between groups but morbidity was higher in the medication error group. After risk adjustment, there were no significant differences in morbidity or mortality between the groups. Medication errors in trauma patients tend to occur in significantly injured patients with long hospital stays. Appropriate adjustment when studying the impact of medical errors on patient outcomes is important.