Bio


Dr. Catherine Curtin is a plastic/hand surgeon. Her clinical focus is peripheral nerve surgery and upper limb reconstruction. She attended Wellesley college and Yale University for medical school. She did her residency at the University of Michigan and her hand fellowship at Stanford University. She completed the Robert Wood Johnson Clinical Scholars Fellowship. Dr. Curtin has specialized in hand surgery and peripheral nerve surgery. She has a particular interest in improving the upper limb function for people with spinal cord injury. She is also interested in nerve pain and the role of surgery to help this pain. Her research focuses on both these areas: upper limb function for spinal cord injury and treatment of neuropathic pain.

Clinical Focus


  • Peripheral Nerves
  • Brachial Plexus
  • Plastic and Reconstructive Surgery
  • Plastic Surgery
  • Hand
  • Tendon Injuries
  • Entrapment Neuropathies
  • Neuroma
  • headache surgery
  • Spinal Cord Injury

Academic Appointments


Administrative Appointments


  • Chief of Hand Surgery, Palo Alto VA (2016 - Present)
  • Plastic Surgery Hand Fellowship Driector, Stanford Plastic Surgery (2017 - Present)
  • Medical Student Clerkship Director, Stanford Plastic Surgery (2008 - Present)

Honors & Awards


  • Career Development Award, VA (11/08)

Boards, Advisory Committees, Professional Organizations


  • Executive committee, American Society of Peripheral Nerve (2020 - Present)
  • Program Committee, American Society of Peripheral Nerve (2017 - Present)
  • Member, Migraine Surgery Society (2021 - Present)
  • Chair Grants Committee, American Society of Peripheral Nerve (2019 - Present)

Professional Education


  • Board Certification: American Board of Plastic Surgery, Surgery of the Hand (2011)
  • Medical Education: Yale School Of Medicine (1998) CT
  • Fellowship: Stanford University Hand Surgery Fellowship (2007) CA
  • Residency: University of Michigan Plastic Surgery Residency (2006) MI
  • Internship: University of Michigan Plastic Surgery Residency (1999) MI
  • Board Certification: American Board of Plastic Surgery, Plastic Surgery (2008)
  • RWJ Clinical Scholar, Robert Wood Johnson Foundation, Heath Services Research (2004)
  • BA, Wellsely College, Russian studies (1993)
  • MD, Yale University (1998)

Current Research and Scholarly Interests


Maintaining and optimizing upper limb function in people with spinal cord injury and other nerve disorders.
We are looking at different treatment modalities from tendon transfers to nerve transfers. We are assessing issues with access to care and optimizing surgical outcomes

Improving pain and general well being after severe hand injuries.

Improving treatment and recognition of pain.
We are using big data to assess what are the factors associated with reduced pain. We are interested in developing guidelines for surgeons on the best strategies to reduce post operative pain.

Clinical Trials


  • [18F]FTC-146 PET/MRI in Healthy Volunteers and in CRPS and Sciatica Not Recruiting

    Chronic pain can result from injured or inflamed nerves, as occurs in people suffering from sciatica and CRPS. These nerve injuries or regions of nerve irritation are often the cause of pain in these conditions, but the current diagnostic tools are limited in pinpointing the area of origin. Several studies have implicated involvement of sigma-1 receptors in the generation and perpetuation of chronic pain conditions, others are investigating anti sigma-1 receptor drugs for the treatment of chronic pain. Using the sigma-1 receptor (S1R) detector and experimental radiotracer [18F]FTC-146 and positron emission tomography/magnetic resonance imaging (PET/MRI) scanner, the researchers may potentially identify the source of pain generation in patients suffering from complex regional pain syndrome (CRPS) and chronic sciatica. The ultimate goal is to assist in the optimization of pain treatment regimens using an [18F]FTC-146 PET/MRI scan. The study is not designed to induce any physiological/pharmacological effect.

    Stanford is currently not accepting patients for this trial. For more information, please contact Sandip Biswal, MD, 650-725-8018.

    View full details

  • Supporting Patient Decisions About UE Surgery in Cervical SCI Not Recruiting

    The goal of this study is to collect and describe patient and caregiver reported outcomes regarding surgical and non-surgical treatment for improving hand and arm function in the setting of cervical spinal cord injury. Eligible study participants will be recruited across the 4 sites and the investigators plan to recruit the following groups and numbers of participants: 1. Nerve or tendon transfer recipients: people who have elected to undergo nerve (N=10) or tendon (N=10) transfer surgery to restore some hand and arm function as part of their standard clinical care and their caregiver (N=20) 2. Non-surgical control group: people with cervical SCI (N=20) and their caregiver (N=20)

    Stanford is currently not accepting patients for this trial. For more information, please contact Catherine Curtin, MD, 650-725-7181.

    View full details

  • Use of PET/MR Imaging in Chronic Pain Not Recruiting

    The investigators are studying the ability of PET/MR imaging (using the PET tracer [18F]FDG) to objectively identify and characterize pain generators in patients suffering from chronic pain.

    Stanford is currently not accepting patients for this trial.

    View full details

Projects


  • Supporting Patient Decisions About Upper-Extremity Surgery in Cervical Spinal Cord Injury, Department of Defense (1/1/2018 - February 1, 2020)

    Location

    palo alto

2023-24 Courses


All Publications


  • Towards global model generalizability: independent cross-site feature evaluation for patient-level risk prediction models using the OHDSI network. Journal of the American Medical Informatics Association : JAMIA Naderalvojoud, B., Curtin, C. M., Yanover, C., El-Hay, T., Choi, B., Park, R. W., Tabuenca, J. G., Reeve, M. P., Falconer, T., Humphreys, K., Asch, S. M., Hernandez-Boussard, T. 2024

    Abstract

    Predictive models show promise in healthcare, but their successful deployment is challenging due to limited generalizability. Current external validation often focuses on model performance with restricted feature use from the original training data, lacking insights into their suitability at external sites. Our study introduces an innovative methodology for evaluating features during both the development phase and the validation, focusing on creating and validating predictive models for post-surgery patient outcomes with improved generalizability.Electronic health records (EHRs) from 4 countries (United States, United Kingdom, Finland, and Korea) were mapped to the OMOP Common Data Model (CDM), 2008-2019. Machine learning (ML) models were developed to predict post-surgery prolonged opioid use (POU) risks using data collected 6 months before surgery. Both local and cross-site feature selection methods were applied in the development and external validation datasets. Models were developed using Observational Health Data Sciences and Informatics (OHDSI) tools and validated on separate patient cohorts.Model development included 41 929 patients, 14.6% with POU. The external validation included 31 932 (UK), 23 100 (US), 7295 (Korea), and 3934 (Finland) patients with POU of 44.2%, 22.0%, 15.8%, and 21.8%, respectively. The top-performing model, Lasso logistic regression, achieved an area under the receiver operating characteristic curve (AUROC) of 0.75 during local validation and 0.69 (SD = 0.02) (averaged) in external validation. Models trained with cross-site feature selection significantly outperformed those using only features from the development site through external validation (P < .05).Using EHRs across four countries mapped to the OMOP CDM, we developed generalizable predictive models for POU. Our approach demonstrates the significant impact of cross-site feature selection in improving model performance, underscoring the importance of incorporating diverse feature sets from various clinical settings to enhance the generalizability and utility of predictive healthcare models.

    View details for DOI 10.1093/jamia/ocae028

    View details for PubMedID 38412331

  • The Urgent Need to Define HbA1C Cutoffs in Hand Surgery. Hand (New York, N.Y.) Griffin, M. F., Curtin, C. 2024: 15589447241233358

    View details for DOI 10.1177/15589447241233358

    View details for PubMedID 38388391

  • Upper Extremity Surgery in Cervical Spinal Cord Injury: A Prospective Comparative Mixed Methods Study. Plastic and reconstructive surgery Skladman, R., Francoisse, C. A., L'Hotta, A. J., Novak, C. B., Curtin, C. M., Ota, D., Stenson, K. C., Tam, K., Kennedy, C. R., James, A., Fox, I. K. 2024

    Abstract

    Cervical spinal cord injury (SCI) is a devastating injury. Restoring upper extremity function is a top priority, which can be accomplished by tendon transfer (TT) and nerve transfer (NT) surgeries. The purpose of this prospective comparative study was to assess long-term changes in UE function between surgical (TT or NT) and non-surgical groups through a comprehensive mixed methods approach.This multicenter, cohort study compared data among three groups: those undergoing 1) no surgery 2) TT surgery, or 3) NT surgery. Quantitative data, the Spinal Cord Independence Measure (SCIM) and Short Form Health Survey (SF-36), was collected at baseline and long-term follow-up (6-24 months). Qualitative semi-structured interview data was also obtained from these participants and their identified caregivers at baseline, early follow-up (1 month), and long-term follow-up (6-24 months).Thirty-one participants had quantitative data across all timepoints: no surgery (n=14), TT (n=7), and NT (n=10). SCIM scores improved in TT and NT groups compared to the no surgery group (p<0.05). SF-36 scores did not differ among groups. Qualitative data analysis (n=168 interviews) corroborated SCIM findings: surgical participants and their caregivers reported improvement in transfers and ability to perform activities of daily living, including grooming and self-catheterization. Improved use of electronics and ability to operate a motor vehicle were also reported. Post-operative therapy was identified as a critical component of achieving gains.Both TT and NT surgery leads to quantitative and qualitative functional gains as compared to the no surgery group. This comparative information should be used to help surgeons discuss treatment options.

    View details for DOI 10.1097/PRS.0000000000011352

    View details for PubMedID 38346159

  • Peripheral nerve stimulation for saphenous neuralgia. Regional anesthesia and pain medicine McCullough, M., Kenney, D., Curtin, C., Ottestad, E. 2023

    Abstract

    Injury to saphenous nerve branches is frequent during knee surgery and can result in chronic pain. This saphenous neuralgia remains challenging to treat. Peripheral nerve stimulation (PNS) is a new potential non-pharmacologic treatment option. We present our outcomes experience using this technology in 12 patients.We retrospectively reviewed PNS placement for saphenous neuralgia between 2000 and 2022 at a single institution. Demographic information was collected as well as response to the device. Four-question short-form Patient-Reported Outcome Measurement Information System (PROMIS) Scores were collected before and 2 weeks, 6 weeks, and 6 months postprocedure. Specific scores included pain interference and behavior, functional mobility, depression, anxiety, and sleep impairment. Change in pain interference measured by the short-form PROMIS tool at 6 months was chosen as the primary outcome.Twelve patients met inclusion criteria, with 10 patients having the full 6-month follow-up. In these 10 patients, the mean change from baseline in the short-form adjusted pain interference score (greater difference means improved pain) at 6 months was 5.8 (SD 6.5). Among all patients, average follow-up was 11.5 months (range 3-35 months). Most patients' symptoms developed after knee surgery (84%). Prior to PNS, patients underwent other treatments including cryoablation (8%), radiofrequency ablation (16%), saphenous neurectomy (16%), or surgical release of adjacent nerves (25%). Ten patients (83%) reported any improvement in symptoms while two reported no benefit. Complications occurred in four patients (33%). Two patients had the device removed and a third discontinued use. PROMIS Scores for pain, functional mobility, mood, and sleep impairment all improved.Limited effective treatments exist for saphenous neuralgia. Our case series demonstrates the potential of PNS as a treatment for saphenous neuralgia. Comparative effectiveness studies are warranted to assess whether our effect size is clinically relevant.

    View details for DOI 10.1136/rapm-2023-104538

    View details for PubMedID 38050145

  • Postoperative opioid prescribing patients with diabetes: Opportunities for personalized pain management. PloS one Zammit, A., Coquet, J., Hah, J., El Hajouji, O., Asch, S. M., Carroll, I., Curtin, C. M., Hernandez-Boussard, T. 2023; 18 (8): e0287697

    Abstract

    Opioids are commonly prescribed for postoperative pain, but may lead to prolonged use and addiction. Diabetes impairs nerve function, complicates pain management, and makes opioid prescribing particularly challenging.This retrospective observational study included a cohort of postoperative patients from a multisite academic health system to assess the relationship between diabetes, pain, and prolonged opioid use (POU), 2008-2019. POU was defined as a new opioid prescription 3-6 months after discharge. The odds that a patient had POU was assessed using multivariate logistic regression controlling for patient factors (e.g., demographic and clinical factors, as well as prior pain and opiate use).A total of 43,654 patients were included, 12.4% with diabetes. Patients with diabetes had higher preoperative pain scores (2.1 vs 1.9, p<0.001) and lower opioid naïve rates (58.7% vs 68.6%, p<0.001). Following surgery, patients with diabetes had higher rates of POU (17.7% vs 12.7%, p<0.001) despite receiving similar opioid prescriptions at discharge. Patients with Type I diabetes were more likely to have POU compared to other patients (Odds Ratio [OR]: 2.22; 95% Confidence Interval [CI]:1.69-2.90 and OR:1.44, CI: 1.33-1.56, respectively).In conclusion, surgical patients with diabetes are at increased risk for POU even after controlling for likely covariates, yet they receive similar postoperative opiate therapy. The results suggest a more tailored approach to diabetic postoperative pain management is warranted.

    View details for DOI 10.1371/journal.pone.0287697

    View details for PubMedID 37616195

    View details for PubMedCentralID PMC10449216

  • Caregiving for People With Spinal Cord Injury Undergoing Upper Extremity Reconstructive Surgery: A Prospective Exploration of Lived Experiences, Perioperative Care, and Change Across Time. Topics in spinal cord injury rehabilitation Desai, R. H., L'Hotta, A., Kennedy, C., James, A. S., Stenson, K., Curtin, C., Ota, D., Kenney, D., Tam, K., Novak, C., Fox, I. 2023; 29 (3): 58-70

    Abstract

    Nerve transfer (NT) and tendon transfer (TT) surgeries can enhance upper extremity (UE) function and independence in individuals with cervical spinal cord injury (SCI). Caregivers are needed to make this surgery possible, yet caregivers experience their own set of challenges.This comparative study explored the perioperative and nonoperative experiences of caregivers of individuals with cervical SCI, focusing on daily life activities, burden, and mental health.Caregivers of individuals with cervical SCI were recruited and grouped by treatment plan for the person with SCI: (1) no surgery (NS), (2) TT surgery, and (3) NT surgery. Semistructured interviews were conducted at baseline/preoperative, early follow-up/postoperative, and late follow-up/postoperative. Caregivers were asked about their daily life, mental health, and challenges related to caregiving. Interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis. Quantitative, single-item standardized burden score (0-100) data were collected at each timepoint.Participants included 23 caregivers (18 family members, 4 friends, 1 hired professional). The surgeries often brought hope and motivation for caregivers. Caregivers reported increased burden immediately following surgery (less for the NT compared to TT subgroup) yet no long-term changes in the amount and type of care they provided. NS caregivers discussed social isolation, relationship dysfunction, and everyday challenges.Health care providers should consider the changing needs of SCI caregivers during perioperative rehabilitation. As part of the shared surgical decision-making approach, providers should educate caregivers about the postoperative process and the extent and potential variability of short- and long-term care needs.

    View details for DOI 10.46292/sci22-00063

    View details for PubMedID 38076291

    View details for PubMedCentralID PMC10644855

  • Prediction of opioid-related outcomes in a medicaid surgical population: Evidence to guide postoperative opiate therapy and monitoring. PLoS computational biology El Hajouji, O., Sun, R. S., Zammit, A., Humphreys, K., Asch, S. M., Carroll, I., Curtin, C. M., Hernandez-Boussard, T. 2023; 19 (8): e1011376

    Abstract

    BACKGROUND: Treatment of surgical pain is a common reason for opioid prescriptions. Being able to predict which patients are at risk for opioid abuse, dependence, and overdose (opioid-related adverse outcomes [OR-AE]) could help physicians make safer prescription decisions. We aimed to develop a machine-learning algorithm to predict the risk of OR-AE following surgery using Medicaid data with external validation across states.METHODS: Five machine learning models were developed and validated across seven US states (90-10 data split). The model output was the risk of OR-AE 6-months following surgery. The models were evaluated using standard metrics and area under the receiver operating characteristic curve (AUC) was used for model comparison. We assessed calibration for the top performing model and generated bootstrap estimations for standard deviations. Decision curves were generated for the top-performing model and logistic regression.RESULTS: We evaluated 96,974 surgical patients aged 15 and 64. During the 6-month period following surgery, 10,464 (10.8%) patients had an OR-AE. Outcome rates were significantly higher for patients with depression (17.5%), diabetes (13.1%) or obesity (11.1%). The random forest model achieved the best predictive performance (AUC: 0.877; F1-score: 0.57; recall: 0.69; precision:0.48). An opioid disorder diagnosis prior to surgery was the most important feature for the model, which was well calibrated and had good discrimination.CONCLUSIONS: A machine learning models to predict risk of OR-AE following surgery performed well in external validation. This work could be used to assist pain management following surgery for Medicaid beneficiaries and supports a precision medicine approach to opioid prescribing.

    View details for DOI 10.1371/journal.pcbi.1011376

    View details for PubMedID 37578969

  • Surgical Treatment of Symptomatic End-Neuroma With a New Bioresorbable Copolyester Nerve Capping Device: A Multicenter Prospective Cohort Study. Annals of plastic surgery Power, D., Curtin, C., Bellemère, P., Nyman, E., Pajardi, G., Isaacs, J., Levin, L. S. 2023; 91 (1): 109-116

    Abstract

    Neuroma-induced neuropathic pain is associated with loss of function and reduced quality of life. No consistently effective standard-of-care treatment has been defined. Neurocap, a bioresorbable nerve capping device, has been designed to isolate the nerve stump from surrounding tissues to reduce development of symptomatic end-neuromas.Patients with peripheral symptomatic end-neuromas were included in a prospective, multicenter, single-arm design. Data were collected presurgery up till 24 months postsurgery. Eligible patients with neuromas were identified based on blocks using anesthetic. Intervention included surgical excision and capping of the transected proximal nerve end with the Neurocap. Main outcome measures were pain, function, recurrence of symptomatic neuroma, use of analgesics, and adverse events.In total, 73 patients with 50 upper-extremity and 23 lower-extremity end-neuromas were enrolled. End-neuromas were predominately located in the digits and lower leg. Statistical power of the study outcomes was preserved by 46 of 73 patients completing 24-month follow-up. The mean VAS-Pain score at baseline was 70.2 ± 17.8 (scale 0-100) and decreased significantly to 31 ± 32.5 (P < 0.001). Function significantly improved over time. The recurrence rate of confirmed symptomatic neuroma was low (2 of 98 capped nerves). Adverse event rate was low and included pain and infection; there were no unexpected device-related adverse events. Most patients reported lower use of nonsteroidal anti-inflammatory drugs, opioids, and antineuropathic medications at last follow-up compared with baseline.End-neuroma treatment with excision and capping resulted in long-term significant reduction in reported pain, disability, and analgesic medication use. Adverse event rate was low.

    View details for DOI 10.1097/SAP.0000000000003596

    View details for PubMedID 37450869

  • Median and Ulnar Nerve Compressions: Simplifying Diagnostics and Surgery at the Elbow and Hand. Plastic and reconstructive surgery Hagert, E., Curtin, C. 2023; 152 (1): 155e-165e

    Abstract

    After studying this article, the participant should be able to: 1. Understand the anatomy of the median and ulnar nerves. 2. Perform clinical examination of the upper limb. 3. Analyze examination results to diagnose level of nerve compression.Numbness and loss of strength are common complaints in the hand surgery clinic. Two nerves that are commonly entrapped (median and ulnar nerves) have several potential sites of entrapment, and in busy clinical practice, the less common sites may be overlooked, leading to wrong or missed diagnoses. This article reviews the anatomy of the median and ulnar nerves, provides tips to assist the busy clinician in diagnosis of site of entrapment(s), and discusses how to simplify surgery. The goal is to help the clinician be as efficient and accurate as possible when evaluating the patient with numbness or loss of strength in their hand.

    View details for DOI 10.1097/PRS.0000000000010268

    View details for PubMedID 37382919

  • The Impact of Virtual Reality on the Patients and Providers Experience in Wide-Awake, Local-Only Hand Surgery. Journal of hand surgery global online McCullough, M., Osborne, T. F., Rawlins, C., Reitz, R. J., Fox, P. M., Curtin, C. 2023; 5 (3): 290-293

    Abstract

    Virtual reality (VR) is an emerging technology with the potential to enhance patient care by reducing pain and anxiety for a variety of medical procedures. The aim of this study was to evaluate an immersive VR program as a nonpharmacologic intervention to reduce anxiety and increase satisfaction in patients undergoing wide-awake, local-only hand surgery. The secondary aim was to assess providers' experience with the program.An implementation evaluation was employed to assess the experience of 22 patients who used VR during outpatient, wide-awake hand surgery at a veterans affairs hospital. We assessed the patients' anxiety scores and vital signs before and after the procedure as well as postprocedural satisfaction measures. The providers' experience was also assessed.Patients who used VR exhibited lower anxiety scores after the procedure compared with what they exhibited before the procedure and had high satisfaction levels with their VR experience. Surgeons who used the system reported that VR improved their ability to teach learners and better focus on the procedure.Virtual reality, as a nonpharmacologic intervention, reduced anxiety and contributed to the patients' perioperative satisfaction with wide-awake, local-only hand surgery. As a secondary finding, VR positively impacted the providers' experience by increasing their ability to concentrate on tasks during the surgery.Virtual reality represents a novel technology that can reduce anxiety and contribute to a positive experience for both patients and providers during wide-awake, local-only hand procedures.

    View details for DOI 10.1016/j.jhsg.2023.01.014

    View details for PubMedID 37323984

    View details for PubMedCentralID PMC10264860

  • Management of Brachial Plexus Birth Palsies: The Stanford Experience SEMINARS IN PLASTIC SURGERY Park, E., Fox, P. M., Curtin, C., Hentz, V. R. 2023
  • Is Hand Surgery in the Procedure Room Setting Associated with Increased Surgical Site Infection? A Cohort Study of 2,717 Patients in the Veterans Affairs Population. The Journal of hand surgery Zhuang, T., Fox, P., Curtin, C., Shah, K. N. 2023

    Abstract

    Procedure rooms (PRs) are increasingly used for hand surgeries, but few studies have directly compared surgical site infection (SSI) rates between the PR and operating room. We tested the hypothesis that procedure setting is not associated with an increased SSI incidence in the VA population.We identified carpal tunnel, trigger finger, and first dorsal compartment releases performed at our VA institution from 1999 to 2021 of which 717 were performed in the main operating room and 2,000 were performed in the PR. The incidence of SSI, defined as signs of wound infection within 60 days of the index procedure, which was treated with oral antibiotics, intravenous antibiotics, and/or operating room irrigation and debridement, was compared. We constructed a multivariable logistic regression analysis to assess the association between procedure setting and SSI incidence, adjusting for age, sex, procedure type, and comorbidities.Surgical site infection incidence was 55/2,000 (2.8%) in the PR cohort and 20/717 (2.8%) in the operating room cohort. In the PR cohort, five (0.3%) cases required hospitalization for intravenous antibiotics of which two (0.1%) cases required operating room irrigation and debridement. In the operating room cohort, two (0.3%) cases required hospitalization for intravenous antibiotics of which one (0.1%) case required operating room irrigation and debridement. All other SSIs were treated with oral antibiotics alone. The procedure setting was not independently associated with SSI (adjusted odds ratio, 0.84 [95% confidence interval, 0.49, 1.48]). The only risk factor for SSI was trigger finger release (odds ratio, 2.13 [95% confidence interval, 1.32, 3.48] compared with carpal tunnel release), which was independent of setting.Minor hand surgeries can be performed safely in the PR without an increased rate of SSI.Prognostic II.

    View details for DOI 10.1016/j.jhsa.2023.03.001

    View details for PubMedID 36973100

  • Impact of Adding Carpal Tunnel Release or Trigger Finger Release to Carpometacarpal Arthroplasty on Postoperative Complications". Plastic and reconstructive surgery Trinh, P., Luan, A., Tawfik, V. L., Sheckter, C., Rochlin, D., Fox, P., Curtin, C. 2023

    Abstract

    BACKGROUND: This study assessed whether adding trigger finger or carpal tunnel release at the time of thumb carpometacarpal (CMC) arthroplasty would increase postoperative opioid use, readmissions, complications, and development of CRPS.METHODS: Using the IBM MarketScan Research Databases from 2012 to 2016, we identified a two groups of CMC arthroplasty patients. The "CMC only" group only had a CMC arthroplasty on the day of operation. The "multiple procedures" group had a CMC arthroplasty and concurrent carpal tunnel and / or trigger finger release. Between the two groups, we compared persistent opioid use, 30-day readmissions, 30-day complications, and diagnosis of complex regional pain syndrome (CRPS).RESULTS: The CMC only group consisted of 18,010 patients. The multiple procedures group consisted of 4,064 patients. These patients received a CMC arthroplasty and a carpal tunnel release (74%), a trigger finger release (20%), or both (6%). CMC only patients had lower rates of persistent opioid use compared to patients who underwent multiple procedures (16% vs 18%). Readmission rates were also lower for CMC only patients (3% vs 4%). CMC only patients had decreased odds of persistent opioid use (OR=0.85; 95% CI, 0.75-0.97, p=0.013) and readmissions (OR=0.80; 95% CI, 0.67-0.96, p=0.016). The most common reason for readmission was pain (16%).CONCLUSIONS: Adding another procedure to a CMC arthroplasty slightly increases the odds of adverse outcomes such as persistent opioid use and readmission. Patients and providers should weigh the efficiency of doing these procedures concurrently against the risk of performing multiple procedures at once.CLINICAL QUESTION / LEVEL OF EVIDENCE: Risk, II.

    View details for DOI 10.1097/PRS.0000000000010144

    View details for PubMedID 36728633

  • Assessment of a wearable fall prevention system at a veterans health administration hospital. Digital health Osborne, T. F., Veigulis, Z. P., Arreola, D. M., Vrublevskiy, I., Suarez, P., Curtin, C., Schalch, E., Cabot, R. C., Gant-Curtis, A. 2023; 9: 20552076231187727

    Abstract

    Objective: In-hospital falls are a significant cause of morbidity and mortality. The Veterans Health Administration (VHA) has designated fall prevention as a major focus area. The objective of this report is to assess the performance of a new sensor-enabled wearable system to prevent patient falls.Methods: An integrated sensor-enabled wearable SmartSock system was utilized to prevent falls at the acute care wards of a large VA hospital. Individual patients were only provided the SmartSocks when they were determined to be at high risk of falling. All fall count rates, with and without using the SmartSock, were evaluated and compared for individual patients. SmartSock sensor and electronic health record data were combined to assess the system's performance from February 10, 2021, through October 31, 2021.Results: There were 20.7 falls per 1000 ward days of care (WDOC) for those not using the SmartSocks compared to 9.2 falls per 1000 WDOC for patients using the SmartSocks. This represents a reduction of falls by more than half. These findings are further confirmed with a negative binomial regression model, which showed the use of the SmartSock had a statistically significant effect on the rate of falls (p=0.03) when length of stay was held constant and demonstrated the odds of fall incident rate of 0.48 (95% CI, 0.24-0.92), that is less than half compared to when patients were not wearing the SmartSock.Conclusion: The use of a sensor-enabled wearable SmartSock fall prevention system resulted in a clinically meaningful and statistically significant decrease in falls in the acute care setting.

    View details for DOI 10.1177/20552076231187727

    View details for PubMedID 37485327

  • MEANINGFUL DIFFERENCE IN PERFORMANCE (MDP): A PROPOSED METHOD TO IMPROVE EVALUATION OF MEANINGFUL VARIATION HEALTHCARE QUALITY MEASURE Sox-Harris, A., Finlay, A. K., Schmidt, E. M., Curtin, C. M., Sears, E. D., Yoshida, R., Lashgari, D., Nuckols, T. K., Kamal, R. N. ELSEVIER SCIENCE INC. 2022: S357
  • Thinking Outside the Operating Room: Guidance on Designing a Safe and Effective Minor Procedure Room. The Journal of hand surgery Silverstein, M., Fox, P. M., Curtin, C. 2022

    Abstract

    The minor procedure room (MPR) offers numerous advantages over the traditional operating room for performing many common hand surgeries. MPRs require less space, are subject to more practical architectural design standards, and facilitate more judicious use of disposable materials and unnecessary instruments than common hand surgeries. MPRs reduce costs to the system and patient at every step of the surgical workflow and improve efficiency by removing preoperative and postoperative monitoring requirements. Hand surgeons sometimes face resistance when attempting surgery in MPRs, often because of confusion about their design characteristics and capabilities. This article aims to clarify many of the major requirements for establishing an MPR and provide a guide to hand surgeons for performing safe, efficient surgery outside the operating room.

    View details for DOI 10.1016/j.jhsa.2022.10.005

    View details for PubMedID 36351850

  • An overview of common peroneal nerve dysfunction and systematic assessment of its relation to falls. International orthopaedics Capodici, A., Hagert, E., Darrach, H., Curtin, C. 2022

    Abstract

    Compression of the peroneal nerve is recognized as a common cause of falls. The superficial course of the peroneal nerve exposes it to trauma and pressure from common activities such as crossing of legs. The nerve can be exposed also to distress due to metabolic problems such as diabetes. The purpose of our manuscript is to review common peroneal nerve dysfunction symptoms and treatment as well as provide a systematic assessment of its relation to falls.We pooled the existing literature from PubMed and included studies (n = 342) assessing peroneal nerve damage that is related in any way to falls. We excluded any studies reporting non-original data, case reports and non-English studies.The final systematic assessment included 4 articles. Each population studied had a non-negligible incidence of peroneal neuropathy. Peroneal pathology was found to be consistently associated with falls.The peroneal nerve is an important nerve whose dysfunction can result in falls. This article reviews the anatomy and care of the peroneal nerve. The literature review highlights the strong association of this nerve's pathology with falls.

    View details for DOI 10.1007/s00264-022-05593-w

    View details for PubMedID 36169699

  • Analysis of Website Accessibility and Content for All 92 Accredited Hand Surgery Fellowship Programs in the United States: An Update. Journal of hand surgery global online Cohen, S. A., Xiao, M., Curtin, C. M., Yao, J. 2022; 4 (5): 269-275

    Abstract

    Purpose: The internet is an important information source for hand surgery fellowship applicants. A previous analysis of hand fellowship websites in 2014 demonstrated they were often inaccessible and incomplete. Given the increased importance of virtual information, we performed an updated assessment of the accessibility and content of hand fellowship program websites.Methods: Websites of 92 accredited hand surgery fellowship programs were evaluated for the following: (1) accessibility; and (2) the presence of 13 fellow recruitment and 13 fellow education criteria, as defined in prior studies. We used Mann-Whitney U and Kruskal-Wallis tests to assess whether the geographic region, number of fellows, or affiliation with a top orthopedic hospital or medical school were associated with website content.Results: Functional website links that redirect to the appropriate fellowship program website are provided for 47 (51.1%) of 92 programs on the American Society for Surgery of the Hand fellowship directory. All missing websites were accessible via independent Google searches. Fellowship program websites contained an average of 13.9 ± 4.4 total criteria (range, 3-23). Of the 15 criteria examined in both 2014 and 2021, there were significant (P < .05) increases in the prevalences of 4: current fellow(s), salary, social media links, and operative experience.Conclusions: Despite a slight increase in accessibility since 2014, nearly half of hand surgery fellowship program websites remain inaccessible from the American Society for Surgery of the Hand directory. Program websites averaged approximately half of the criteria analyzed, with many websites failing to provide information deemed important by applicants.Clinical relevance: Our study provides an impetus for improving the accessibility and content of hand surgery fellowship websites. A website that incorporates criteria examined in this study can serve as an effective recruitment tool by providing consistent baseline information that may help applicants decide which programs align with personal values and future career goals.

    View details for DOI 10.1016/j.jhsg.2022.05.004

    View details for PubMedID 36157307

  • Peripheral Nerve Injury After Upper-Extremity Surgery Performed Under Regional Anesthesia: A Systematic Review. Journal of hand surgery global online Silverstein, M. L., Tevlin, R., Higgins, K. E., Pedreira, R., Curtin, C. 2022; 4 (4): 201-207

    Abstract

    Purpose: Peripheral nerve injury (PNI) is a known adverse event following upper-limb surgery performed under brachial plexus regional anesthesia (RA). When PNI is noted after surgery, patients and providers often have questions about which factors might have contributed to this complication. This systematic review evaluates the literature on hand and shoulder surgeries performed under ultrasound-guided, plexus RA to identify factors potentially associated with PNI, including the surgery location and block type. We hypothesized that shoulder surgery might be associated with an increased risk of PNI compared to hand surgery.Methods: A systematic review of the relevant literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only prospective studies on the use of ultrasound-guided, preoperative, brachial plexus RA for hand or shoulder surgery on adult patients were included. Study groups were categorized according to surgery location and block type and compared across a number of factors via univariate and multivariate analyses.Results: A total of 3,037 abstracts were screened; 192 full-text articles were independently reviewed by 2 of the authors; and 53 studies were included in the systematic review analysis. Following hand surgery, PNI was reported at an average rate of 1.35% ± 3.21% across 836 subjects in 40 study groups; after shoulder surgery, the average rate was 0.50% ± 1.57% across 3,383 subjects in 15 study groups. There was no statistically significant correlation between the incidence of PNI and surgery location (P=.70) or any of the most common approaches for brachial plexus anesthesia in the multivariate analysis.Conclusions: This systematic review of over 50 articles on upper-limb surgery performed under RA shows no association between the incidence of PNI and the location of surgery or type of brachial plexus block.Type of study/level of evidence: Diagnostic II.

    View details for DOI 10.1016/j.jhsg.2022.04.011

    View details for PubMedID 35880155

  • Surgery to Restore Upper Extremity Function in Tetraplegia-Preferences for Early and Frequent Access to Information. PM & R : the journal of injury, function, and rehabilitation L'Hotta, A. J., James, A. S., Curtin, C. M., Kennedy, C., Kenney, D., Tam, K., Ota, D., Stenson, K., Novak, C. B., Fox, I. K. 2022

    Abstract

    INTRODUCTION: People with cervical spinal cord injury (SCI) identify improving upper extremity (UE) function as a top priority. In addition to comprehensive rehabilitation, UE surgeries, including nerve and tendon transfers, enhance function. However, barriers exist to disseminating information about surgical options to enhance UE function.OBJECTIVE: To assess the experiences and preferences of people with cervical SCI and their caregivers in accessing information about surgery to enhance UE function.DESIGN: Prospective cohort study. Participants were followed for 24 months and completed up to three interviews.SETTING: Tertiary care at academic and affiliated Veterans Administration Health Care Centers.PARTICIPANTS: Adults with cervical SCI (n=35) ages 18 to 80years with mid-cervical SCI American Spinal Injury Association Impairment Scale A, B, or C (at least six months post-injury) and their caregivers (n=23) were eligible to participate. Participants were enrolled in three groups: nerve transfer, tendon transfer, or no UE reconstructive surgery.INTERVENTIONS: Not applicable.MAIN OUTCOME MEASURE: Semi-structured interviews about surgical knowledge and experiences.RESULTS: Data were analyzed and three themes were identified. First, providing information about UE surgical options early post-injury was recommended. The acute or inpatient rehabilitation phases of recovery were the preferred times to receive surgical information. Second, challenges with information dissemination were identified. Participants learned about UE surgery through independent research, medical provider interactions, or peers. Third, peers were identified as valuable resources for SCI needs and surgical information.CONCLUSIONS: Following cervical SCI, information about UE reconstructive surgeries should be a standard component of education during rehabilitation. An increased understanding of the reconstructive options available to improve UE function is necessary to educate stakeholders. Future research is needed to support the development of strategies to effectively present surgical information to individuals with SCI and healthcare providers. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/pmrj.12862

    View details for PubMedID 35665476

  • Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: A Randomized Clinical Trial (vol 153, pg 303, 2018) JAMA SURGERY Hah, J., Mackey, S. C., Schmidt, P. 2022
  • Do Proposed Quality Measures for Carpal Tunnel Release Reveal Important Quality Gaps and Are They Reliable? Clinical orthopaedics and related research Harris, A. H., Ding, Q., Trickey, A. W., Finlay, A. K., Schmidt, E. M., Curtin, C. M., Sears, E. D., Yoshida, R., Lashgari, D., Nuckols, T. K., Kamal, R. N. 2022

    Abstract

    BACKGROUND: The American Academy of Orthopaedic Surgeons recently proposed quality measures for the initial surgical treatment of carpal tunnel syndrome (CTS). One measure addressed avoidance of adjunctive surgical procedures during carpal tunnel release; and a second measure addressed avoidance of routine use of clinic-based occupational and/or physical therapy (OT/PT) after carpal tunnel release. However, for quality measures to serve their intended purposes, they must be tested in real-world data to establish that gaps in quality exist and that the measures yield reliable performance information.QUESTIONS/PURPOSES: (1) Is there an important quality gap in clinical practice for avoidance of adjunctive surgical procedures during carpal tunnel release? (2) Is there an important quality gap in avoiding routine use of clinic-based occupational and/or physical therapy after carpal tunnel release? (3) Do these two quality measures have adequate beta-binomial signal-to-noise ratio (SNR) and split-sample reliability (SSR)?METHODS: This retrospective comparative study used a large national private insurance claims database, the 2018 Optum Clinformatics Data Mart. Ideally, healthcare quality measures are tested within data reflective of the providers and payors to which the measures will be applied. We previously tested these measures in a large public healthcare system and a single academic medical center. In this study, we sought to test the measures in the broader context of patients and providers using private insurance. For both measures, we included the first carpal tunnel release from 28,083 patients performed by one of 7236 surgeons, irrespective of surgical specialty (including, orthopaedic, plastic, neuro-, and general surgery). To calculate surgeon-level descriptive and reliability statistics, analyses were focused on the 66% (18,622 of 28,083) of patients who received their procedure from one of the 24% (1740 of 7236) of surgeons with at least five carpal tunnel releases in the database. No other inclusion/exclusion criteria were applied.To determine whether the measures reveal important gaps in treatment quality (avoidance of adjunctive procedures and routine therapy), we calculated descriptive statistics (median and interquartile range) of the performance distribution stratified by surgeon-level annual volume of carpal tunnel releases in the database (5+, 10+, 15+, 20+, 25+, and 30+). Like the Centers for Medicare & Medicaid Services (CMS), we considered a measure "topped out" if median performance was greater than 95%, meaning the opportunity for further quality improvement is low. We calculated the surgeon-level beta-binomial SNR and SSR for each measure, each stratified by the number of carpal tunnel releases performed by each surgeon in the database. These are standard measures of reliability in health care quality measurement science. The SNR quantifies the proportion of variance that is between rather than within surgeons, and the SSR is the correlation of performance scores when each surgeons' patients are split into two random samples and then corrected for sample size.RESULTS: We found that 2% (308 of 18,622) of carpal tunnel releases involved an adjunctive procedure. The results showed that avoidance of adjunctive surgical procedures during carpal tunnel release had a median (IQR) performance of 100% (100% to 100%) at all case volumes. Only 8% (144 of 1740) of surgeons with at least five cases in the database had less than 100% performance, and only 5% (84 of 1740) had less than 90% performance. This means adjunctive procedures were rarely performed and an important quality gap does not exist based on the CMS criterion. Regarding the avoidance of routine therapy, there was a larger quality gap: For surgeons with at least five cases in the database, median performance was 89% (75% to 100%), and 25% (435 of 1740) of these surgeons had less than 75% performance. This signifies that the measure is not topped out and may reveal an important quality gap. Most patients receiving clinic-based OT/PT had only one visit in the 6 weeks after surgery. Median (IQR) SNRs of the first measure, which addressed avoidance of adjunctive surgical procedures, and the second measure, which addresses avoidance of routine use clinic-based OT/PT, were 1.00 (1.00 to 1.00) and 0.86 (0.67 to 1.00), respectively. The SSR for these measures were 0.87 (95% CI 0.85 to 0.88) and 0.75 (95% CI 0.73 to 0.77), respectively. All of these reliability statistics exceed National Quality Forum's emerging minimum standard of 0.60.CONCLUSION: The first measure, the avoidance of adjunctive surgical procedures during carpal tunnel release, lacked an important quality gap suggesting it is unlikely to be useful in driving improvements. The second measure, avoidance of routine use of clinic-based OT/PT, revealed a larger quality gap and had very good reliability, suggesting it may be useful for quality monitoring and improvement purposes.CLINICAL RELEVANCE: As healthcare systems and payors use the second measure, avoidance of routine use of clinic-based OT/PT, to encourage adherence to clinical practice guidelines (such as provider profiling, public reporting, and payment policies), it will be critically important to consider what proportion of patients receiving OT/PT should be considered routine practice and therefore inconsistent with guidelines. The value or potential harm of this measure depends on this judgement.

    View details for DOI 10.1097/CORR.0000000000002175

    View details for PubMedID 35274625

  • Real-time infection prediction with wearable physiological monitoring and AI to aid military workforce readiness during COVID-19. Scientific reports Conroy, B., Silva, I., Mehraei, G., Damiano, R., Gross, B., Salvati, E., Feng, T., Schneider, J., Olson, N., Rizzo, A. G., Curtin, C. M., Frassica, J., McFarlane, D. C. 2022; 12 (1): 3797

    Abstract

    Infectious threats, like the COVID-19 pandemic, hinder maintenance of a productive and healthy workforce. If subtle physiological changes precede overt illness, then proactive isolation and testing can reduce labor force impacts. This study hypothesized that an early infection warning service based on wearable physiological monitoring and predictive models created with machine learning could be developed and deployed. We developed a prototype tool, first deployed June 23, 2020, that delivered continuously updated scores of infection risk for SARS-CoV-2 through April 8, 2021. Data were acquired from 9381 United States Department of Defense (US DoD) personnel wearing Garmin and Oura devices, totaling 599,174 user-days of service and 201 million hours of data. There were 491 COVID-19 positive cases. A predictive algorithm identified infection before diagnostic testing with an AUC of 0.82. Barriers to implementation included adequate data capture (at least 48% data was needed) and delays in data transmission. We observe increased risk scores as early as 6 days prior to diagnostic testing (2.3 days average). This study showed feasibility of a real-time risk prediction score to minimize workforce impacts of infection.

    View details for DOI 10.1038/s41598-022-07764-6

    View details for PubMedID 35260671

    View details for PubMedCentralID PMC8904796

  • Prescription quantity and duration predict progression from acute to chronic opioid use in opioid-naive Medicaid patients. PLOS digital health Johnson, D. G., Ho, V. T., Hah, J. M., Humphreys, K., Carroll, I., Curtin, C., Asch, S. M., Hernandez-Boussard, T. 2022; 1 (8)

    Abstract

    Opiates used for acute pain are an established risk factor for chronic opioid use (COU). Patient characteristics contribute to progression from acute opioid use to COU, but most are not clinically modifiable. To develop and validate machine-learning algorithms that use claims data to predict progression from acute to COU in the Medicaid population, Adult opioid naive Medicaid patients from 6 anonymized states who received an opioid prescription between 2015 and 2019 were included. Five machine learning (ML) Models were developed, and model performance assessed by area under the receiver operating characteristic curve (auROC), precision and recall. In the study, 29.9% (53820/180000) of patients transitioned from acute opioid use to COU. Initial opioid prescriptions in COU patients had increased morphine milligram equivalents (MME) (33.2 vs. 23.2), tablets per prescription (45.6 vs. 36.54), longer prescriptions (26.63 vs 24.69 days), and higher proportions of tramadol (16.06% vs. 13.44%) and long acting oxycodone (0.24% vs 0.04%) compared to non- COU patients. The top performing model was XGBoost that achieved average precision of 0.87 and auROC of 0.63 in testing and 0.55 and 0.69 in validation, respectively. Top-ranking prescription-related features in the model included quantity of tablets per prescription, prescription length, and emergency department claims. In this study, the Medicaid population, opioid prescriptions with increased tablet quantity and days supply predict increased risk of progression from acute to COU in opioid-naive patients. Future research should evaluate the effects of modifying these risk factors on COU incidence.

    View details for DOI 10.1371/journal.pdig.0000075

    View details for PubMedID 36203857

  • Changes in postoperative opioid prescribing across three diverse healthcare systems, 2010-2020. Frontiers in digital health Coquet, J., Zammit, A., Hajouji, O. E., Humphreys, K., Asch, S. M., Osborne, T. F., Curtin, C. M., Hernandez-Boussard, T. 2022; 4: 995497

    Abstract

    Objective: The opioid crisis brought scrutiny to opioid prescribing. Understanding how opioid prescribing patterns and corresponding patient outcomes changed during the epidemic is essential for future targeted policies. Many studies attempt to model trends in opioid prescriptions therefore understanding the temporal shift in opioid prescribing patterns across populations is necessary. This study characterized postoperative opioid prescribing patterns across different populations, 2010-2020.Data Source: Administrative data from Veteran Health Administration (VHA), six Medicaid state programs and an Academic Medical Center (AMC).Data extraction: Surgeries were identified using the Clinical Classifications Software.Study Design: Trends in average daily discharge Morphine Milligram Equivalent (MME), postoperative pain and subsequent opioid prescription were compared using regression and likelihood ratio test statistics.Principal Findings: The cohorts included 595,106 patients, with populations that varied considerably in demographics. Over the study period, MME decreased significantly at VHA (37.5-30.1; p=0.002) and Medicaid (41.6-31.3; p=0.019), and increased at AMC (36.9-41.7; p<0.001). Persistent opioid users decreased after 2015 in VHA (p<0.001) and Medicaid (p=0.002) and increase at the AMC (p=0.003), although a low rate was maintained. Average postoperative pain scores remained constant over the study period.Conclusions: VHA and Medicaid programs decreased opioid prescribing over the past decade, with differing response times and rates. In 2020, these systems achieved comparable opioid prescribing patterns and outcomes despite having very different populations. Acknowledging and incorporating these temporal distribution shifts into data learning models is essential for robust and generalizable models.

    View details for DOI 10.3389/fdgth.2022.995497

    View details for PubMedID 36561925

  • Use of Hand Therapy After Distal Radius Fracture: A National Perspective. The Journal of hand surgery Trinh, P., Rochlin, D., Sheckter, C., Moore, W., Fox, P., Curtin, C. 2021

    Abstract

    PURPOSE: To assess whether certain distal radius fracture (DRF) patients, such as opioid users or complex regional pain syndrome (CRPS) patients, receive more hand therapy.METHODS: Using the IBM MarketScan Research Databases from January 1, 2012, to December 31, 2016, we identified a cohort of DRF patients and created 4 subgroups of interest: frequent follow-up patients, persistent opioid users, prior opioid users, and patients with CRPS. We measured rates and demographic characteristics associated with therapy use in our populations of interest.RESULTS: In this cohort of 87,313 patients, 21% received hand therapy after primary DRF treatment. Patients with CRPS had a higher rate of therapy than non-CRPS patients (44% vs 21%, respectively). Frequent follow-up patients used more therapy than those with less follow-up (30% vs 17%, respectively). Persistent opioid users demonstrated slightly increased therapy use compared to the remaining population (25% vs 22%, respectively). Prior opioid users underwent less therapy than patients without prior opioid use (19% vs 22%, respectively). Female sex, residing in the Northeast, being on a preferred provider organization plan, and having more intense surgical treatments were associated with increased therapy use.CONCLUSIONS: This study showed variations in therapy use after DRF in subpopulations of interest. Patients with CRPS, persistent opioid use, and frequent follow-ups had higher rates of therapy. Patients with prior opioid use had lower rates of therapy.CLINICAL RELEVANCE: Therapy is more common in patients with DRF with CRPS, persistent opioid use, or more follow-up visits.

    View details for DOI 10.1016/j.jhsa.2021.08.018

    View details for PubMedID 34666936

  • Effect of Immersive Virtual Reality on Pain and Anxiety at a Veterans Affairs Health Care Facility FRONTIERS IN VIRTUAL REALITY Rawlins, C. R., Veigulis, Z., Hebert, C., Curtin, C., Osborne, T. F. 2021; 2
  • Gaps in standardized postoperative pain management quality measures: A systematic review. Surgery Joseph, J. M., Gori, D., Curtin, C., Hah, J., Ho, V. T., Asch, S. M., Hernandez-Boussard, T. 2021

    Abstract

    BACKGROUND: The goal of this study was an assessment of availability postoperative pain management quality measures and National Quality Forum-endorsed measures. Postoperative pain is an important clinical timepoint because poor pain control can lead to patient suffering, chronic opiate use, and/or chronic pain. Quality measures can guide best practices, but it is unclear whether there are measures for managing pain after surgery.METHODS: The National Quality Forum Quality Positioning System, Agency for Healthcare Research and Quality Indicators, and Centers for Medicare and Medicaid Services Measures Inventory Tool databases were searched in November 2019. We conducted a systematic literature review to further identify quality measures in research publications, clinical practice guidelines, and gray literature for the period between March 11, 2015 and March 11,2020.RESULTS: Our systematic review yielded 1,328 publications, of which 206 were pertinent. Nineteen pain management quality measures were identified from the quality measure databases, and 5 were endorsed by National Quality Forum. The National Quality Forum measures were not specific to postoperative pain management. Three of the non-endorsed measures were specific to postoperative pain.CONCLUSION: The dearth of published postoperative pain management quality measures, especially National Quality Forum-endorsed measures, highlights the need for more rigorous evidence and widely endorsed postoperative pain quality measures to guide best practices.

    View details for DOI 10.1016/j.surg.2021.08.004

    View details for PubMedID 34538340

  • Optimizing Treatment of Hand Infections: Is MRSA Coverage Always Necessary? Plastic and reconstructive surgery. Global open Oliver, J. D., Pridgen, B. C., desJardins-Park, H. E., Curtin, C., Fox, P. M. 2021; 9 (6): e3619

    Abstract

    Multiple publications have highlighted the prevalence of methicillin resistant Staphylococcus aureus (MRSA) as a cause of hand infections. We hypothesized that these publications have shifted the empiric treatment of hand infections. The aim of this study was to identify the current standard of care, the most common causative bacteria, and factors leading to extended length of stay for hand infection patients at a suburban hospital to improve treatment and establish an optimized care protocol.Methods: Retrospective cohort analysis was conducted to identify all patients admitted for hand infections over an 8-year period. A comprehensive chart review of each patient's hospital course was completed.Results: A total of 70 patients were included. Maximum white blood cell count ≥ 12 was associated with a significantly longer hospital length of stay (9.1 days versus 5.4 days) compared to WBC values < 12 (P < 0.05). Also, 11 out of 23 (47.8%) underwent two or more incision and drainages (I&D's), compared with patients with maximum WBC < 12. Vancomycin use as an empiric antibiotic was widespread (68 patients, 97.1%), despite only 14 (20%) having MRSA positive cultures. Univariate analysis identified a significant increased likelihood for increased length of stay (P < 0.05) and rise in creatinine (P < 0.05) in patients with an initial vancomycin trough level > 20.Conclusions: This analysis of hand infection treatment in a suburban hospital demonstrates the incidence of MRSA hand infections may not be universally high across institutions. Each hospital should review its own data to optimize hand infection treatment and its associated costs.

    View details for DOI 10.1097/GOX.0000000000003619

    View details for PubMedID 34150420

  • Acute Pain Predictors of Remote Postoperative Pain Resolution After Hand Surgery. Pain and therapy Hah, J. M., Nwaneshiudu, C. A., Cramer, E. M., Carroll, I. R., Curtin, C. M. 2021

    Abstract

    INTRODUCTION: Chronic postsurgical pain (CPSP) is a global issue with high prevalence. This study compared acute pain descriptors among patients undergoing carpal tunnel release (CTR) or trigger finger release (TFR). We hypothesized worst pain intensity on postoperative day (POD) 10 would be best to predict the time to pain resolution.METHODS: In this secondary analysis of a negative, randomized, double-blind placebo-controlled trial, adult veterans undergoing CTR or TFR were enrolled January 2012-January 2014, with data analysis February 2020-October 2020. Participants were randomized to receive minocycline 200mg or placebo 2 h prior to the operation, then minocycline 100mg or placebo twice daily for 5days. The Brief Pain Inventory, assessed daily, captured three pain scores: average and worst pain over the past 24h, and current pain intensity. Fifteen acute pain descriptors based on the pain scores (clusters, mean, median, pain scores on POD 10, and linear slopes) were compared as predictors of time to pain resolution.RESULTS: Of 131 randomized participants, 114 (83 CTR, 31 TFR) were included. Average pain over the last 24h reported on POD 10 best predicted time to pain cessation. Every one-point increase in the average pain score was associated with a 36.0% reduced rate of pain cessation (HR, 0.64, 95% CI 0.55-0.74, p<0.001). Average pain on POD 10 was significantly associated with the development of CPSP at 90days (OR 1.74, 95% CI 1.30-2.33, pvalue<0.001). The optimal cutoff score for the high-risk group was determined as average pain on POD 10≥3.CONCLUSIONS: This study validates prior work and demonstrates the importance of assessing pain severity on POD 10 to identify patients at high risk for CPSP who are most likely to benefit from early pain intervention. Future research in diverse surgical cohorts is needed to further validate pain assessment on POD 10 as a significant predictor of CPSP.

    View details for DOI 10.1007/s40122-021-00263-y

    View details for PubMedID 33870479

  • Characteristics of Patients With Complex Limb Pain Evaluated Through an Interdisciplinary Approach Utilizing Magnetic Resonance Neurography Frontiers in Pain Research Johnson, E. M., Yoon, D., Biswal, S., Curtin, C., Fox, P., Wilson, T. J., Carroll, I., Lutz, A., Tawfik, V. 2021
  • Neurovascular, muscle, and skin changes on [18F]FDG PET/MRI in complex regional pain syndrome of the foot: A Prospective Clinical Study. Pain medicine (Malden, Mass.) Yoon, D., Xu, Y., Cipriano, P. W., Alam, I. S., Mari Aparici, C. A., Tawfik, V. L., Curtin, C. M., Carroll, I. R., Biswal, S. 2021

    Abstract

    The goal of this study is to demonstrate the feasibility of simultaneous [18F]-fluorodeoxyglucose (FDG) positron emission tomography (PET) and magnetic resonance imaging (MRI) for non-invasive visualization of muscular, neurovascular, and skin changes secondary to complex regional pain syndrome (CRPS).Seven adult patients with CRPS of the foot and seven healthy adult controls participated in our [18F]FDG PET/MRI study.All participants received whole-body PET/MRI scans one hour after the injection of 370MBq [18F]FDG. Resulting PET/MRI images were reviewed by two radiologists. Metabolic and anatomic abnormalities identified, were grouped into muscular, neurovascular, and skin lesions. The [18F]FDG uptake of each lesion was compared with that of corresponding areas in controls using a Mann-Whitney U-test.On PET images, muscular abnormalities were found in five patients, neurovascular abnormalities in four patients, and skin abnormalities in two patients. However, on MRI images, no muscular abnormalities were detected. Neurovascular abnormalities and skin abnormalities in the affected limb were identified on MRI in one and two patients, respectively. The difference in [18F]FDG uptake between the patients and the controls was significant in muscle (p = 0.018) and neurovascular bundle (p = 0.0005).The increased uptake of [18F]FDG in the symptomatic areas likely reflects the increased metabolism due to the inflammatory response causing pain. Therefore, our approach combining metabolic [18F]FDG PET and anatomic MR imaging may offer non-invasive monitoring of the distribution and progression of inflammatory changes associated with CRPS.

    View details for DOI 10.1093/pm/pnab315

    View details for PubMedID 34718774

  • Association of mortality and aspirin prescription for COVID-19 patients at the Veterans Health Administration. PloS one Osborne, T. F., Veigulis, Z. P., Arreola, D. M., Mahajan, S. M., Röösli, E. n., Curtin, C. M. 2021; 16 (2): e0246825

    Abstract

    There is growing evidence that thrombotic and inflammatory pathways contribute to the severity of COVID-19. Common medications such as aspirin, that mitigate these pathways, may decrease COVID-19 mortality. This retrospective assessment was designed to quantify the correlation between pre-diagnosis aspirin and mortality for COVID-19 positive patients in our care. Data from the Veterans Health Administration national electronic health record database was utilized for the evaluation. Veterans from across the country with a first positive COVID-19 polymerase chain reaction lab result were included in the evaluation which comprised 35,370 patients from March 2, 2020 to September 13, 2020 for the 14-day mortality cohort and 32,836 patients from March 2, 2020 to August 28, 2020 for the 30-day mortality cohort. Patients were matched via propensity scores and the odds of mortality were then compared. Among COVID-19 positive Veterans, preexisting aspirin prescription was associated with a statistically and clinically significant decrease in overall mortality at 14-days (OR 0.38, 95% CI 0.32-0.46) and at 30-days (OR 0.38, 95% CI 0.33-0.45), cutting the odds of mortality by more than half. Findings demonstrated that pre-diagnosis aspirin prescription was strongly associated with decreased mortality rates for Veterans diagnosed with COVID-19. Prospective evaluation is required to more completely assess this correlation and its implications for patient care.

    View details for DOI 10.1371/journal.pone.0246825

    View details for PubMedID 33571280

  • Separating Fact From Fiction: A Nationwide Longitudinal Examination of Complex Regional Pain Syndrome Following Treatment of Dupuytren Contracture. Hand (New York, N.Y.) Rochlin, D. H., Sheckter, C. C., Satteson, E. S., Swan, C. C., Fox, P. M., Curtin, C. 2020: 1558944720963915

    Abstract

    BACKGROUND: One of the most feared complications following treatment of Dupuytren contracture is complex regional pain syndrome (CRPS). This study aims to provide a national perspective on the incidence of CRPS following treatment of Dupuytren contracture and identify patient factors to target for risk reduction.METHODS: Using the Truven MarketScan databases from 2007 to 2016, individuals aged ≥18 years who developed CRPS within 1 year of treatment of Dupuytren contracture were identified using the International Classification of Disease diagnosis code for CRPS. Predictor variables included: age, sex, employment status, region, type of procedure, and concurrent carpal tunnel surgery. Multivariable logistic regression was used to analyze outcomes.RESULTS: In all, 48327 patients received treatment for Dupuytren contracture, including collagenase injection (13.6%); percutaneous palmar fasciotomy (10.3%); open palmar fasciotomy (3.9%); palmar fasciectomy with 0 (10.8%), 1 (29.2%), or multiple (19.6%) digit releases; or a combination of these procedures (12.8%). One hundred forty-five patients (0.31%) were diagnosed with CRPS at a mean of 3.4 months (standard deviation, 2.3) following treatment. Significant predictors of CRPS included female sex (odds ratio [OR], 2.02; P < .001), Southern region (OR, 1.80; P = .022), long-term disability status (OR, 4.73; P = .035), palmar fasciectomy with release of 1 (OR, 5.91; P = .003) or >1 digit (OR, 13.32; P < .001), or multiple concurrent procedures for Dupuytren contracture (OR, 8.23; P = .001).CONCLUSIONS: Based on national commercial claims data, there is a lower incidence of CRPS following treatment of Dupuytren contracture than previously reported. Risk factors identified should help with preoperative counseling and assist clinicians in targeting risk reduction measures.

    View details for DOI 10.1177/1558944720963915

    View details for PubMedID 33081519

  • Determining the Optimal Location for Minor Procedures-Goldilocks Medicine and the Just-Right Surgical Setting. JAMA network open Curtin, C. M. 2020; 3 (10): e2016127

    View details for DOI 10.1001/jamanetworkopen.2020.16127

    View details for PubMedID 33048124

  • 18F-FDG PET/MRI of patients with chronic pain alters management. Cipriano, P., Yoon, D., Carroll, I., Curtin, C., Tawfik, V., Xu, Y., Biswal, S. SOC NUCLEAR MEDICINE INC. 2020
  • Sigma-1 receptor PET/MRI for identifying nociceptive sources of radiating low back pain Yoon, D., Cipriano, P., Carroll, I., Curtin, C., Roh, E., Wilson, T., Biswal, S. SOC NUCLEAR MEDICINE INC. 2020
  • Descriptive Overview of Primary Cleft Palate Surgeries in the Low- and Middle-Income Countries. The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association Min, J. G., Khosla, R. K., Curtin, C. 2020: 1055665620911556

    Abstract

    OBJECTIVE: To increase access to high-quality and multiregional databases in global epidemiology of cleft surgeries through partnership with an NGO.DESIGN: The study retrospectively analyzes 34 801 primary palate surgeries in 70+ countries from the 2016 electronic health records of an non-governmental organization (NGO). The study also utilizes the Kids' Inpatient Database to compare the epidemiology of primary cleft palate surgeries in the United States.PARTICIPANTS: Patient records of those undergoing primary cleft palate surgeries only.MAIN OUTCOME MEASURES: Region, age, sex, type of cleft, laterality of cleft.RESULTS: Key findings show that average age of those receiving primary cleft palate surgery in the low- and middle-income countries (LMICs) was 1.95 years. The distribution of males and females receiving surgery corresponds to the US national data. More hard cleft palates were on the left side (66.18%) than the right side (33.82%), independent of gender and region.CONCLUSIONS: Databases from an established NGO can be used to enhance our understanding of the disease characteristics in these regions. By increasing the information available regarding cleft surgeries in the LMIC, we hope to increase awareness of the similarities and differences in surgeries across various regions, as part of an effort to inform the goals set by Global Surgery 2030 initiative by the Lancet Commission.

    View details for DOI 10.1177/1055665620911556

    View details for PubMedID 32207319

  • The rise of non-traumatic extremity compartment syndrome in light of the opioid epidemic. The American journal of emergency medicine Sheckter, C. C., Cebron, U., Suarez, P., Rochlin, D., Tedesco, D., Hernandez-Boussard, T., Curtin, C. 2020

    View details for DOI 10.1016/j.ajem.2020.01.020

    View details for PubMedID 32005410

  • Acute pain after breast surgery and reconstruction: A two-institution study of surgical factors influencing short-term pain outcomes. Journal of surgical oncology Azad, A. D., Bozkurt, S. n., Wheeler, A. J., Curtin, C. n., Wagner, T. H., Hernandez-Boussard, T. n. 2020

    Abstract

    Acute postoperative pain following surgery is known to be associated with chronic pain development and lower quality of life. We sought to analyze the relationship between differing breast cancer excisional procedures, reconstruction, and short-term pain outcomes.Women undergoing breast cancer excisional procedures with or without reconstruction at two systems: an academic hospital (AH) and Veterans Health Administration (VHA) were included. Average pain scores at the time of discharge and at 30-day follow-up were analyzed across demographic and clinical characteristics. Linear mixed effects modeling was used to assess the relationship between patient/clinical characteristics and interval pain scores with a random slope to account for differences in baseline pain.Our study included 1402 patients at AH and 1435 at VHA, of which 426 AH and 165 patients with VHA underwent reconstruction. Pain scores improved over time and were found to be highest at discharge. Time at discharge, 30-day follow-up, and preoperative opioid use were the strongest predictors of high pain scores. Younger age and longer length of stay were independently associated with worse pain scores.Younger age, preoperative opioid use, and longer length of stay were associated with higher levels of postoperative pain across both sites.

    View details for DOI 10.1002/jso.26070

    View details for PubMedID 32563208

  • Diagnosis and Successful Management of an Unusual Presentation of Chronic Foot Pain Using Positron Emission Tomography/Magnetic Resonance Imaging and a Simple Surgical Procedure CLINICAL JOURNAL OF SPORT MEDICINE Cipriano, P., Yoon, D., Holley, D., Hargreaves, B., Carroll, I., Curtin, C., Biswal, S. 2020; 30 (1): E11–E14
  • Testing proposed quality measures for treatment of carpal tunnel syndrome: feasibility, magnitude of quality gaps, and reliability. BMC health services research Harris, A. H., Meerwijk, E. L., Ding, Q. n., Trickey, A. W., Finlay, A. K., Schmidt, E. M., Curtin, C. M., Sears, E. D., Nuckols, T. K., Kamal, R. N. 2020; 20 (1): 861

    Abstract

    The American Academy of Orthopaedic Surgeons and American Society for Surgery of the Hand recently proposed three quality measures for carpal tunnel syndrome (CTS): Measure 1 - Discouraging routine use of Magnetic resonance imaging (MRI) for diagnosis of CTS; Measure 2 - Discouraging the use of adjunctive surgical procedures during carpal tunnel release (CTR); and Measure 3 - Discouraging the routine use of occupational and/or physical therapy after CTR. The goal of this study were to 1) Assess the feasibility of using the specifications to calculate the measures in real-world healthcare data and identify aspects of the specifications that might be clarified or improved; 2) Determine if the measures identify important variation in treatment quality that justifies expending resources for their further development and implementation; 3) Assess the facility- and surgeon-level reliability of measures.The measures were calculated using national data from the Veterans Health Administration (VA) Corporate Data Warehouse for three fiscal years (FY; 2016-18). Facility- and surgeon-level performance and reliability were examined. To expand the testing context, the measures were also tested using data from an academic medical center.The denominator of Measure 1 was 132,049 VA patients newly diagnosed with CTS. The denominators of Measures 2 and 3 were 20,813 CTRs received by VA patients. The median facility-level performances on the three measures were 96.5, 100, and 94.7%, respectively. Of 130 VA facilities, none had < 90% performance on Measure 1. Among 111 facilities that performed CTRs, only 1 facility had < 90% performance on Measure 2. In contrast, 21 facilities (18.9%) and 333 surgeons (17.8%) had lower than 90% performance on Measure 3 (Median facility- and surgeon-level reliability for Measure 3 were very high (0.95 and 0.96 respectively).Measure 3 displayed adequate facility- and surgeon-level variability and reliability to justify its use for quality monitoring and improvement purposes. Measures 1 and 2 lacked quality gaps, suggesting they should not be implemented in VA and need to be tested in other healthcare settings. Opportunities exist to refine the specifications of Measure 3 to ensure that different organizations calculate the measure in the same way.

    View details for DOI 10.1186/s12913-020-05704-6

    View details for PubMedID 32917188

  • Automated EHR score to predict COVID-19 outcomes at US Department of Veterans Affairs. PloS one Osborne, T. F., Veigulis, Z. P., Arreola, D. M., Röösli, E. n., Curtin, C. M. 2020; 15 (7): e0236554

    Abstract

    The sudden emergence of COVID-19 has brought significant challenges to the care of Veterans. An improved ability to predict a patient's clinical course would facilitate optimal care decisions, resource allocation, family counseling, and strategies for safely easing distancing restrictions. The Care Assessment Need (CAN) score is an existing risk assessment tool within the Veterans Health Administration (VA), and produces a score from 0 to 99, with a higher score correlating to a greater risk. The model was originally designed for the nonacute outpatient setting and is automatically calculated from structured data variables in the electronic health record. This multisite retrospective study of 6591 Veterans diagnosed with COVID-19 from March 2, 2020 to May 26, 2020 was designed to assess the utility of repurposing the CAN score as objective and automated risk assessment tool to promptly enhance clinical decision making for Veterans diagnosed with COVID-19. We performed bivariate analyses on the dichotomized CAN 1-year mortality score (high vs. low risk) and each patient outcome using Chi-square tests of independence. Logistic regression models using the continuous CAN score were fit to assess its predictive power for outcomes of interest. Results demonstrated that a CAN score greater than 50 was significantly associated with the following outcomes after positive COVID-19 test: hospital admission (OR 4.6), prolonged hospital stay (OR 4.5), ICU admission (3.1), prolonged ICU stay (OR 2.9), mechanical ventilation (OR 2.6), and mortality (OR 7.2). Repurposing the CAN score offers an efficient way to risk-stratify COVID-19 Veterans. As a result of the compelling statistical results, and automation, this tool is well positioned for broad use across the VA to enhance clinical decision-making.

    View details for DOI 10.1371/journal.pone.0236554

    View details for PubMedID 32716922

  • Surgical Treatment of Osteonecrosis of the Jaw: An Emerging Problem in the Era of Bisphosphonates. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons Hung, K. S., Sheckter, C. C., Gaudilliere, D. n., Suarez, P. n., Curtin, C. n. 2020

    View details for DOI 10.1016/j.joms.2019.12.018

    View details for PubMedID 32004467

  • Preoperative Factors Associated with Remote Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: Post Hoc Analysis of a Perioperative Gabapentin Trial. Journal of pain research Hah, J. M., Hilmoe, H. n., Schmidt, P. n., McCue, R. n., Trafton, J. n., Clay, D. n., Sharifzadeh, Y. n., Ruchelli, G. n., Hernandez Boussard, T. n., Goodman, S. n., Huddleston, J. n., Maloney, W. J., Dirbas, F. M., Shrager, J. n., Costouros, J. G., Curtin, C. n., Mackey, S. C., Carroll, I. n. 2020; 13: 2959–70

    Abstract

    Preoperative patient-specific risk factors may elucidate the mechanisms leading to the persistence of pain and opioid use after surgery. This study aimed to determine whether similar or discordant preoperative factors were associated with the duration of postoperative pain and opioid use.In this post hoc analysis of a randomized, double-blind, placebo-controlled trial of perioperative gabapentin vs active placebo, 410 patients aged 18-75 years, undergoing diverse operations underwent preoperative assessments of pain, opioid use, substance use, and psychosocial variables. After surgery, a modified Brief Pain Inventory was administered over the phone daily up to 3 months, weekly up to 6 months, and monthly up to 2 years after surgery. Pain and opioid cessation were defined as the first of 5 consecutive days of 0 out of 10 pain or no opioid use, respectively.Overall, 36.1%, 19.8%, and 9.5% of patients continued to report pain, and 9.5%, 2.4%, and 1.7% reported continued opioid use at 3, 6, and 12 months after surgery. Preoperative pain at the future surgical site (every 1-point increase in the Numeric Pain Rating Scale; HR 0.93; 95% CI 0.87-1.00; P=0.034), trait anxiety (every 10-point increase in the Trait Anxiety Inventory; HR 0.79; 95% CI 0.68-0.92; P=0.002), and a history of delayed recovery after injury (HR 0.62; 95% CI 0.40-0.96; P=0.034) were associated with delayed pain cessation. Preoperative opioid use (HR 0.60; 95% CI 0.39-0.92; P=0.020), elevated depressive symptoms (every 5-point increase in the Beck Depression Inventory-II score; HR 0.88; 95% CI 0.80-0.98; P=0.017), and preoperative pain outside of the surgical site (HR 0.94; 95% CI 0.89-1.00; P=0.046) were associated with delayed opioid cessation, while perioperative gabapentin promoted opioid cessation (HR 1.37; 95% CI 1.06-1.77; P=0.016).Separate risk factors for prolonged post-surgical pain and opioid use indicate that preoperative risk stratification for each outcome may identify patients needing personalized care to augment universal protocols for perioperative pain management and conservative opioid prescribing to improve long-term outcomes.

    View details for DOI 10.2147/JPR.S269370

    View details for PubMedID 33239904

    View details for PubMedCentralID PMC7680674

  • Integrating Adjuvant Analgesics into Perioperative Pain Practice: Results from an Academic Medical Center PAIN MEDICINE Chin, K., Carroll, I., Desai, K., Asch, S., Seto, T., McDonald, K. M., Curtin, C., Hernandez-Boussard, T. 2020; 21 (1): 161–70

    View details for DOI 10.1093/pm/pnz053

    View details for Web of Science ID 000522867400020

  • Patient Electronic Health Records Score for Preoperative Risk Assessment Before Total Knee Arthroplasty. JB & JS open access Osborne, T. F., Suarez, P. n., Edwards, D. n., Hernandez-Boussard, T. n., Curtin, C. n. 2020; 5 (2): e0061

    Abstract

    Current preoperative risk assessment tools are often cumbersome, have limited accuracy, and are poorly adopted. The Care Assessment Need (CAN) score, an existing tool developed for primary care providers in the U.S. Veterans Administration health-care system (VA), is automatically calculated for individual patients using electronic health record data. Therefore, it could present an efficient preoperative risk assessment tool. The aim of this project was to determine if the CAN score can be repurposed as a preoperative risk assessment tool for patients undergoing total knee arthroplasty (TKA).A multicenter retrospective observational study was conducted using national VA data from 2013 to 2016. The cohort included veterans who underwent TKA identified through ICD-9 (International Classification of Diseases, Ninth Revision), ICD-10, and CPT (Current Procedural Terminology) codes. The focus of the study was the preoperative patient CAN score, a single numerical value ranging from 0 to 99 (with a higher score representing greater risk) that is automatically calculated each week using multiple data points in the VA electronic health record. Study outcomes of interest were 90-day readmission, prolonged hospital stay (>5 days), 1-year mortality, and non-routine patient discharge.The study included 17,210 veterans. Their median preoperative CAN score was 75, although there was substantial variability in patient CAN scores among different facilities. A preoperative CAN score of >75 was significantly associated with mortality (odds ratio [OR] = 3.54), prolonged length of stay (OR = 1.97), 90-day readmission (OR = 1.65), and non-routine discharge (OR = 1.57). The CAN score had good accuracy with a receiver operating characteristic (ROC) curve value of >0.7 for all outcomes except 90-day readmission.The CAN score can be leveraged as an extremely efficient way to risk-stratify patients before TKA, with results that surpass other commonly available and labor-intensive alternatives. As a result, this simple and efficient solution is well positioned for broad adoption as a standardized decision support tool.Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

    View details for DOI 10.2106/JBJS.OA.19.00061

    View details for PubMedID 33123663

    View details for PubMedCentralID PMC7418912

  • The association of burn patient volume with patient safety indicators and mortalityin the US. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Pham, C., Rochlin, D., Maan, Z. N., Karanas, Y., Curtin, C. 2019

    Abstract

    INTRODUCTION: Clinical volume has been associated with rate of complications and mortality for various conditions and procedures. We aim to analyze the relationship between annual hospital burn admission, patient safety indicators (PSI), line infections, and inpatient mortality. We hypothesize that high facility volume will correlate with better outcomes.METHODS: All burn admissions with complete data for total body surface area (TBSA) and depth were extracted from the Nationwide Inpatient Sample from 2002-2011. Predictor variables included age, gender, comorbidities, %TBSA, burn depth, and inhalation injury. Surgically relevant PSIs were drawn from the Healthcare Cost & Utilization Project and included: sepsis, venous thromboembolic disease, hemorrhage, pneumonia, and wound complications. Outcomes were analyzed with regression models.RESULTS: Of the 57,468 encounters included, 3.1% died, 6.3% experienced >1 PSI event, and 0.3% experienced a catheter-associated urinary tract infections or central line associated blood stream infections. The most frequent PSI was pneumonia followed by sepsis and VTE. Annual hospital burn admission volume was independently associated with decreased odds of mortality (OR 0.99, 95% CI 0.99-0.99, p<0.001) and PSIs (OR 0.99, 95% CI 0.99-0.99, p=0.031). There was no significant correlation with line infections. In both mortality and PSI models, age, %TBSA, inhalation injuries, and Elixhauser comorbidity score were significantly associated with adverse outcomes (p<0.05).CONCLUSION: There was a significant association between higher hospital volume and decreased likelihood of patient safety indicators and mortality. There was no observed relationship with line infections. These findings could inform future verification policies of US burn centers.

    View details for DOI 10.1016/j.burns.2019.11.009

    View details for PubMedID 31843281

  • Association of Preoperative Patient Frailty and Operative Stress With Postoperative Mortality. JAMA surgery Shinall, M. C., Arya, S., Youk, A., Varley, P., Shah, R., Massarweh, N. N., Shireman, P. K., Johanning, J. M., Brown, A. J., Christie, N. A., Crist, L., Curtin, C. M., Drolet, B. C., Dhupar, R., Griffin, J., Ibinson, J. W., Johnson, J. T., Kinney, S., LaGrange, C., Langerman, A., Loyd, G. E., Mady, L. J., Mott, M. P., Patri, M., Siebler, J. C., Stimson, C. J., Thorell, W. E., Vincent, S. A., Hall, D. E. 2019: e194620

    Abstract

    Importance: Patients with frailty have higher risk for postoperative mortality and complications; however, most research has focused on small groups of high-risk procedures. The associations among frailty, operative stress, and mortality are poorly understood.Objective: To assess the association between frailty and mortality at varying levels of operative stress as measured by the Operative Stress Score, a novel measure created for this study.Design, Setting, and Participants: This retrospective cohort study included veterans in the Veterans Administration Surgical Quality Improvement Program from April 1, 2010, through March 31, 2014, who underwent a noncardiac surgical procedure at Veterans Health Administration Hospitals and had information available on vital status (whether the patient was alive or deceased) at 1 year postoperatively. A Delphi consensus method was used to stratify surgical procedures into 5 categories of physiologic stress.Exposures: Frailty as measured by the Risk Analysis Index and operative stress as measured by the Operative Stress Score.Main Outcomes and Measures: Postoperative mortality at 30, 90, and 180 days.Results: Of 432 828 unique patients (401 453 males [92.8%]; mean (SD) age, 61.0 [12.9] years), 36 579 (8.5%) were frail and 9113 (2.1%) were very frail. The 30-day mortality rate among patients who were frail and underwent the lowest-stress surgical procedures (eg, cystoscopy) was 1.55% (95% CI, 1.20%-1.97%) and among patients with frailty who underwent the moderate-stress surgical procedures (eg, laparoscopic cholecystectomy) was 5.13% (95% CI, 4.79%-5.48%); these rates exceeded the 1% mortality rate often used to define high-risk surgery. Among patients who were very frail, 30-day mortality rates were higher after the lowest-stress surgical procedures (10.34%; 95% CI, 7.73%-13.48%) and after the moderate-stress surgical procedures (18.74%; 95% CI, 17.72%-19.80%). For patients who were frail and very frail, mortality continued to increase at 90 and 180 days, reaching 43.00% (95% CI, 41.69%-44.32%) for very frail patients at 180 days after moderate-stress surgical procedures.Conclusions and Relevance: We developed a novel operative stress score to quantify physiologic stress for surgical procedures. Patients who were frail and very frail had high rates of postoperative mortality across all levels of the Operative Stress Score. These findings suggest that frailty screening should be applied universally because low- and moderate-stress procedures may be high risk among patients who are frail.

    View details for DOI 10.1001/jamasurg.2019.4620

    View details for PubMedID 31721994

  • Electromyographic Analysis of Grip ORTHOPEDICS Fox, P. M., Oliver, J. D., Viet Nguyen, Hentz, V. R., Curtin, C. M. 2019; 42 (6): E555–E558

    Abstract

    This prospective cohort study used video electromyography synchronized analysis to determine the dynamic use of extrinsic and intrinsic finger flexion during grasp. Light fist formation primarily involved the flexor digitorum profundus with either the flexor digitorum superficialis or intrinsics. In contrast, both the flexor digitorum superficialis and intrinsics were recruited in all tight fist video electromyography. However, the sequence of recruitment differed between patients in tight fist formation. Injured patients demonstrated a unique pattern of recruitment based on injury. The authors conclude that the flexor digitorum profundus is the workhorse in composite fist formation but the roles of the flexor digitorum superficialis and the intrinsic muscles are less consistent across patients. [Orthopedics. 2019; 42(6):e555-e558.].

    View details for DOI 10.3928/01477447-20190812-06

    View details for Web of Science ID 000498511000012

    View details for PubMedID 31408520

  • Trajectory analysis for postoperative pain using electronic health records: A nonparametric method with robust linear regression and K-medians cluster analysis. Health informatics journal Weng, Y., Tian, L., Tedesco, D., Desai, K., Asch, S. M., Carroll, I., Curtin, C., McDonald, K. M., Hernandez-Boussard, T. 2019: 1460458219881339

    Abstract

    Postoperative pain scores are widely monitored and collected in the electronic health record, yet current methods fail to fully leverage the data with fast implementation. A robust linear regression was fitted to describe the association between the log-scaled pain score and time from discharge after total knee replacement. The estimated trajectories were used for a subsequent K-medians cluster analysis to categorize the longitudinal pain score patterns into distinct clusters. For each cluster, a mixture regression model estimated the association between pain score and time to discharge adjusting for confounding. The fitted regression model generated the pain trajectory pattern for given cluster. Finally, regression analyses examined the association between pain trajectories and patient outcomes. A total of 3442 surgeries were identified with a median of 22 pain scores at an academic hospital during 2009-2016. Four pain trajectory patterns were identified and one was associated with higher rates of outcomes. In conclusion, we described a novel approach with fast implementation to model patients' pain experience using electronic health records. In the era of big data science, clinical research should be learning from all available data regarding a patient's episode of care instead of focusing on the "average" patient outcomes.

    View details for DOI 10.1177/1460458219881339

    View details for PubMedID 31621460

  • Acute Extensor Tenosynovitis due to Disseminated Gonococcal Infection PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN Zhou, J. Y., Mittermiller, P. A., Nishimoto, S. K., Johannet, P., Curtin, C. 2019; 7 (9)
  • Homelessness and Inpatient Burn Outcomes in the United States JOURNAL OF BURN CARE & RESEARCH Kiwanuka, H., Maan, Z. N., Rochlin, D., Curtin, C., Karanas, Y., Sheckter, C. C. 2019; 40 (5): 633–38
  • Variations in access to specialty care for children with severe burns. The American journal of emergency medicine Ewbank, C., Sheckter, C. C., Warstadt, N. M., Pirrotta, E. A., Curtin, C., Newton, C., Wang, N. E. 2019: 158401

    Abstract

    BACKGROUND: Pediatric burns account for 120,000 emergency department visits and 10,000 hospitalizations annually. The American Burn Association has guidelines regarding referrals to burn centers; however there is variation in burn center distribution. We hypothesized that disparity in access would be related to burn center access.METHODS: Using weighted discharge data from the Nationwide Inpatient Sample 2001-2011, we identified pediatric patients with International Classification of Diseases-9th Revision codes for burns that also met American Burn Association criteria. Key characteristics were compared between pediatric patients treated at burn centers and those that were not.RESULTS: Of 54,529 patients meeting criteria, 82.0% (n = 44,632) were treated at burn centers. Patients treated at burn centers were younger (5.6 versus 6.7 years old; p < 0.0001) and more likely to have burn injuries on multiple body regions (88% versus 12%; p < 0.0001). In urban areas, 84% of care was provided at burn centers versus 0% in rural areas (p < 0.0001), a difference attributable to the lack of burn centers in rural areas. Both length of stay and number of procedures were significantly higher for patients treated at burn centers (7.3 versus 4.4 days, p < 0.0001 and 2.3 versus 1.1 procedures, p < 0.0001; respectively). There were no significant differences in mortality (0.7% versus 0.8%, p = 0.692).CONCLUSION: The majority of children who met criteria were treated at burn centers. There was no significant difference between geographical regions. Of those who were treated at burn centers, more severe injury patterns were noted, but there was no significant mortality difference. Further study of optimal referral of pediatric burn patients is needed.

    View details for DOI 10.1016/j.ajem.2019.158401

    View details for PubMedID 31474377

  • 18F-FDG PET/MRI of patients with chronic pain alters management. Cipriano, P., Yoon, D., Carroll, I., Curtin, C., Tawfik, V., Xu, Y., Biswal, S. SOC NUCLEAR MEDICINE INC. 2019
  • Musculoskeletal changes on [18F]FDG PET/MRI from complex regional pain syndrome in foot Yoon, D., Xu, Y., Cipriano, P., Tawfik, V., Curtin, C., Carroll, I., Biswal, S. SOC NUCLEAR MEDICINE INC. 2019
  • Which Stitch? Replacing Anecdote with Evidence in Minor Hand Surgery PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN Rochlin, D. H., Sheckter, C. C., Curtin, C. M. 2019; 7 (4)
  • Metformin prescription status and abdominal aortic aneurysm disease progression in the US veteran population JOURNAL OF VASCULAR SURGERY Itoga, N. K., Rothenberg, K. A., Suarez, P., Ho, T., Mell, M. W., Xu, B., Curtin, C. M., Dalman, R. L. 2019; 69 (3): 710-+
  • Factors Associated With Acute Pain Estimation, Postoperative Pain Resolution, Opioid Cessation, and Recovery: Secondary Analysis of a Randomized Clinical Trial. JAMA network open Hah, J. M., Cramer, E., Hilmoe, H., Schmidt, P., McCue, R., Trafton, J., Clay, D., Sharifzadeh, Y., Ruchelli, G., Goodman, S., Huddleston, J., Maloney, W. J., Dirbas, F. M., Shrager, J., Costouros, J. G., Curtin, C., Mackey, S. C., Carroll, I. 2019; 2 (3): e190168

    Abstract

    Importance: Acute postoperative pain is associated with the development of persistent postsurgical pain, but it is unclear which aspect is most estimable.Objective: To identify patient clusters based on acute pain trajectories, preoperative psychosocial characteristics associated with the high-risk cluster, and the best acute pain predictor of remote outcomes.Design, Setting, and Participants: A secondary analysis of the Stanford Accelerated Recovery Trial randomized, double-blind clinical trial was conducted at a single-center, tertiary, referral teaching hospital. A total of 422 participants scheduled for thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, or shoulder arthroscopy were enrolled between May 25, 2010, and July 25, 2014. Data analysis was performed from January 1 to August 1, 2018.Interventions: Patients were randomized to receive gabapentin (1200 mg, preoperatively, and 600 mg, 3 times a day postoperatively) or active placebo (lorazepam, 0.5 mg preoperatively, inactive placebo postoperatively) for 72 hours.Main Outcomes and Measures: A modified Brief Pain Inventory prospectively captured 3 surgical site pain outcomes: average pain and worst pain intensity over the past 24 hours, and current pain intensity. Within each category, acute pain trajectories (first 10 postoperative pain scores) were compared using a k-means clustering algorithm. Fifteen descriptors of acute pain were compared as predictors of remote postoperative pain resolution, opioid cessation, and full recovery.Results: Of the 422 patients enrolled, 371 patients (≤10% missing pain scores) were included in the analysis. Of these, 146 (39.4%) were men; mean (SD) age was 56.67 (11.70) years. Two clusters were identified within each trajectory category. The high pain cluster of the average pain trajectory significantly predicted prolonged pain (hazard ratio [HR], 0.63; 95% CI, 0.50-0.80; P<.001) and delayed opioid cessation (HR, 0.52; 95% CI, 0.41-0.67; P<.001) but was not a predictor of time to recovery in Cox proportional hazards regression (HR, 0.89; 95% CI, 0.69-1.14; P=.89). Preoperative risk factors for categorization to the high average pain cluster included female sex (adjusted relative risk [ARR], 1.36; 95% CI, 1.08-1.70; P=.008), elevated preoperative pain (ARR, 1.11; 95% CI, 1.07-1.15; P<.001), a history of alcohol or drug abuse treatment (ARR,1.90; 95% CI, 1.42-2.53; P<.001), and receiving active placebo (ARR, 1.27; 95% CI, 1.03-1.56; P=.03). Worst pain reported on postoperative day 10 was the best predictor of time to pain resolution (HR, 0.83; 95% CI, 0.78-0.87; P<.001), opioid cessation (HR, 0.84; 95% CI, 0.80-0.89; P<.001), and complete surgical recovery (HR, 0.91; 95% CI, 0.86-0.96; P<.001).Conclusions and Relevance: This study has shown a possible uniform predictor of remote postoperative pain, opioid use, and recovery that can be easily assessed. Future work is needed to replicate these findings.Trial Registration: ClinicalTrials.gov Identifier: NCT01067144.

    View details for PubMedID 30821824

  • Predicting inadequate postoperative pain management in depressed patients: A machine learning approach PLOS ONE Parthipan, A., Banerjee, I., Humphreys, K., Asch, S. M., Curtin, C., Carroll, I., Hernandez-Boussard, T. 2019; 14 (2)
  • Increasing ambulatory treatment of pediatric minor burns-The emerging paradigm for burn care in children Sheckter, C. C., Kiwanuka, H., Maan, Z., Pirrotta, E., Curtin, C., Wang, N. E. ELSEVIER SCI LTD. 2019: 165–72
  • The impact of skin allograft on inpatient outcomes in the treatment of major burns 20-50% total body surface area - A propensity score matched analysis using the nationwide inpatient sample BURNS Sheckter, C. C., Li, A., Pridgen, B., Trickey, A. W., Karanas, Y., Curtin, C. 2019; 45 (1): 146–56
  • Disparities in Access to Care Following Traumatic Digit Amputation. Hand (New York, N.Y.) Long, C., Suarez, P. A., Hernandez-Boussard, T., Curtin, C. 2019: 1558944718824700

    Abstract

    BACKGROUND: Care of digit amputations ranges from revision amputation to replantation. Many factors determine the treatment type. We looked at the epidemiology of amputation and factors associated with escalation of care after presenting to the emergency department (ED). We hypothesized that disparities in care following digit amputation exist.METHODS: We queried the State ED Databases and State Inpatient Databases of the Healthcare Cost and Utilization Project and developed a cohort using the diagnosis codes for thumb and finger amputation. Escalation of care was defined as patients whose disposition from the ED was referral to a higher level hospital or inpatient admission. Bivariate and multivariable analyses were conducted to identify the characteristics associated with escalation of care.RESULTS: Our cohort included 45 586 patients, of which 37 539 (82.4%) were men; 7130 (15.6%) and 38 456 (84.4%) suffered a thumb or finger amputation, respectively. The mean age was 39.3 ± 20.4 years, and 7487 (16.4%) received escalated care. Female sex (odds ratio [OR] = 0.7) was a negative independent predictor of escalation of care, while high income (OR = 1.1), machinery-related mechanism (OR = 1.8), self-harm (OR = 4.2), thumb amputation (OR = 1.7), Medicaid (OR = 1.3) or Medicare (OR = 1.1) insurance, trauma hospitals (OR = 1.3), and metropolitan teaching hospitals (OR = 1.2) were positive predictors.CONCLUSIONS: Male patients who suffered a thumb and/or self-inflicted amputation, are from a higher income zip code, have Medicaid or Medicare insurance, and present to a teaching trauma center are more likely to receive escalated care. This highlights differences in care that can serve as a starting point for work on barriers to access.

    View details for PubMedID 30701984

  • Predicting inadequate postoperative pain management in depressed patients: A machine learning approach. PloS one Parthipan, A., Banerjee, I., Humphreys, K., Asch, S. M., Curtin, C., Carroll, I., Hernandez-Boussard, T. 2019; 14 (2): e0210575

    Abstract

    Widely-prescribed prodrug opioids (e.g., hydrocodone) require conversion by liver enzyme CYP-2D6 to exert their analgesic effects. The most commonly prescribed antidepressant, selective serotonin reuptake inhibitors (SSRIs), inhibits CYP-2D6 activity and therefore may reduce the effectiveness of prodrug opioids. We used a machine learning approach to identify patients prescribed a combination of SSRIs and prodrug opioids postoperatively and to examine the effect of this combination on postoperative pain control. Using EHR data from an academic medical center, we identified patients receiving surgery over a 9-year period. We developed and validated natural language processing (NLP) algorithms to extract depression-related information (diagnosis, SSRI use, symptoms) from structured and unstructured data elements. The primary outcome was the difference between preoperative pain score and postoperative pain at discharge, 3-week and 8-week time points. We developed computational models to predict the increase or decrease in the postoperative pain across the 3 time points by using the patient's EHR data (e.g. medications, vitals, demographics) captured before surgery. We evaluate the generalizability of the model using 10-fold cross-validation method where the holdout test method is repeated 10 times and mean area-under-the-curve (AUC) is considered as evaluation metrics for the prediction performance. We identified 4,306 surgical patients with symptoms of depression. A total of 14.1% were prescribed both an SSRI and a prodrug opioid, 29.4% were prescribed an SSRI and a non-prodrug opioid, 18.6% were prescribed a prodrug opioid but were not on SSRIs, and 37.5% were prescribed a non-prodrug opioid but were not on SSRIs. Our NLP algorithm identified depression with a F1 score of 0.95 against manual annotation of 300 randomly sampled clinical notes. On average, patients receiving prodrug opioids had lower average pain scores (p<0.05), with the exception of the SSRI+ group at 3-weeks postoperative follow-up. However, SSRI+/Prodrug+ had significantly worse pain control at discharge, 3 and 8-week follow-up (p < .01) compared to SSRI+/Prodrug- patients, whereas there was no difference in pain control among the SSRI- patients by prodrug opioid (p>0.05). The machine learning algorithm accurately predicted the increase or decrease of the discharge, 3-week and 8-week follow-up pain scores when compared to the pre-operative pain score using 10-fold cross validation (mean area under the receiver operating characteristic curve 0.87, 0.81, and 0.69, respectively). Preoperative pain, surgery type, and opioid tolerance were the strongest predictors of postoperative pain control. We provide the first direct clinical evidence that the known ability of SSRIs to inhibit prodrug opioid effectiveness is associated with worse pain control among depressed patients. Current prescribing patterns indicate that prescribers may not account for this interaction when choosing an opioid. The study results imply that prescribers might instead choose direct acting opioids (e.g. oxycodone or morphine) in depressed patients on SSRIs.

    View details for PubMedID 30726237

  • The impact of hospital volume on patient safety indicators following post-mastectomy breast reconstruction in the US. Breast cancer research and treatment Sheckter, C. C., Rochlin, D. n., Kiwanuka, H. n., Curtin, C. n., Momeni, A. n. 2019

    Abstract

    Despite the growing spotlight on value-based care and patient safety, little is known about the influence of patient-, reconstruction-, and facility-level factors on safety events following breast reconstruction. The purpose of this study is to characterize postoperative complications in light of hospital-level risk factors.Using the National Inpatient Sample, all patients who underwent free flap and prosthetic breast reconstruction from 2012 to 2014 were identified. Predictor variables included patient demographic and clinical characteristics, type and timing of reconstruction, annual hospital reconstructive volume, hospital bed size, hospital setting (rural vs. urban), and length of stay. Patient safety indicators (PSIs) were based on the Agency for Healthcare Research and Quality's designation of preventable hospital complications: venous thromboembolism, bleeding, wound complications, pneumonia, and sepsis. Logistic models were used to analyze outcomes.The sample included 103,301 women, of which 27,695 (26.8%) underwent free flap reconstruction. 3.6% of patients experienced ≥ 1 PSI, most commonly wound PSI (4.9% and 2.5% for free flap and prosthetic reconstruction, respectively). Significant predictors of PSIs included rural setting (p < 0.01) and Elixhauser score ≥ 4 (p < 0.01) for the free flap group, and delayed reconstruction (p < 0.01) for the prosthetic group. Annual reconstructive facility volume was not associated with increased odds of PSIs in either prosthetic or free flap reconstruction (p > 0.05).PSIs were associated with rural hospitals and greater comorbidities for patients undergoing reconstruction with free flaps. Annual reconstructive facility volume was not associated with adverse inpatient outcomes with either method of reconstruction.

    View details for DOI 10.1007/s10549-019-05361-2

    View details for PubMedID 31338643

  • Patient Preferences for Shared Decision Making: Not All Decisions Should Be Shared. The Journal of the American Academy of Orthopaedic Surgeons E Lindsay, S. n., Alokozai, A. n., Eppler, S. L., Fox, P. n., Curtin, C. n., Gardner, M. n., Avedian, R. n., Palanca, A. n., Abrams, G. D., Cheng, I. n., Kamal, R. N. 2019

    Abstract

    To assess bounds of shared decision making in orthopaedic surgery, we conducted an exploratory study to examine the extent to which patients want to be involved in decision making in the management of a musculoskeletal condition.One hundred fifteen patients at an orthopaedic surgery clinic were asked to rate preferred level of involvement in 25 common theoretical clinical decisions (passive [0], semipassive [1 to 4], equally shared involvement between patient and surgeon [5], semiactive [6 to 9], active [10]).Patients preferred semipassive roles in 92% of decisions assessed. Patients wanted to be most involved in scheduling surgical treatments (4.75 ± 2.65) and least involved in determining incision sizes (1.13 ± 1.98). No difference exists in desired decision-making responsibility between patients who had undergone orthopaedic surgery previously and those who had not. Younger and educated patients preferred more decision-making responsibility. Those with Medicare desired more passive roles.Despite the importance of shared decision making on delivering patient-centered care, our results suggest that patients do not prefer to share all decisions.

    View details for DOI 10.5435/JAAOS-D-19-00146

    View details for PubMedID 31567900

  • The scratch collapse test: A systematic review JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Cebron, U., Curtin, C. M. 2018; 71 (12): 1693–1703
  • Trends and inpatient outcomes for palliative care services in major burn patients: A 10-year analysis of the nationwide inpatient sample BURNS Sheckter, C. C., Hung, K. S., Rochlin, D., Maan, Z., Karanas, Y., Curtin, C. 2018; 44 (8): 1903–9
  • The scratch collapse test: A systematic review. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Čebron, U., Curtin, C. M. 2018; 71 (12): 1693-1703

    Abstract

    The diagnosis of nerve compression relies on collecting diagnostic clues from the history, physical examination, imaging and diagnostic testing. There are several provocative tests to aid in the diagnosis of nerve compression. The 'Scratch Collapse Test' (SCT) has emerged as a new provocative test to assist in the localisation of peripheral nerve compression. This study aims to perform a systematic review of literature to assess the data on the reliability of the SCT as a diagnostic test for entrapment neuropathy. Ten articles were reviewed. Five articles had sufficient numerical data for analysis, and in these five articles, the positive predictive values and specificity were high, i.e. between 0.71 and 0.99 and 0.6 and 0.99, respectively, whereas other values were very variable, i.e. individual negative predictive values ranged from 0.15 to 0.92 and the sensitivity values ranged from 0.24 to 0.77. Another main finding was the versatility of the test in that it can be used for various nerve entrapments and to localise the exact level of compression. Literature suggests that SCT has potential to be used as a clinical diagnostic tool for entrapment neuropathy. However, wide variations in early literature suggest that SCT should not be used as a sole diagnostic tool but as an adjunct to a surgeon's diagnostic repertoire.

    View details for DOI 10.1016/j.bjps.2018.09.003

    View details for PubMedID 33054988

  • Regional Variation and Trends in the Timing of Lower Extremity Reconstruction: A 10-Year Review of the Nationwide Inpatient Sample. Plastic and reconstructive surgery Sheckter, C. C., Pridgen, B., Li, A., Curtin, C., Momeni, A. 2018; 142 (5): 1337-1347

    Abstract

    The ideal timing of soft-tissue coverage for open lower extremity fractures remains controversial. Using U.S. national data, this study aims to characterize secular trends and regional variation in the timing of soft-tissue coverage.Using discharge data from the Nationwide Inpatient Sample (2002 to 2011), the authors identified 888 encounters admitted from the emergency department with isolated open lower extremity fractures treated with pedicled or free tissue transfer. Soft-tissue coverage timing was assessed by patient factors, hospital characteristics, and fracture patterns. Statistical significance and secular trends were analyzed with generalized linear models.The mean day of soft-tissue reconstruction was at 6.64 days. Over the 10-year period, the day of reconstruction increased significantly (from 6.12 days in 2002 to 12.50 days in 2011; coefficient, 0.09; 95 percent CI, 0.05 to 0.12; p < 0.001). Demographic and facility factors did not significantly impact timing. Elixhauser comorbidity scores greater than 2 were associated with later coverage (10.13 days versus 6.29 days; p = 0.001) along with multisite fractures (8.35 days; p = 0.022) and external fixators (8.78 days; p < 0.001). The U.S. Census division showed significant variation in timing ranging from 0.94 days (East North Central) to 9.84 days (Pacific).A progressive delay in the timing of soft-tissue reconstruction was noted and may be attributed to negative-pressure wound therapy. The timing of soft-tissue coverage varied by region after adjusting for patient and hospital factors. Additional studies are needed to understand the impact of delayed soft-tissue coverage on patient outcomes and health services utilization.

    View details for DOI 10.1097/PRS.0000000000004885

    View details for PubMedID 30511989

  • Regional Variation and Trends in the Timing of Lower Extremity Reconstruction: A 10-Year Review of the Nationwide Inpatient Sample PLASTIC AND RECONSTRUCTIVE SURGERY Sheckter, C. C., Pridgen, B., Li, A., Curtin, C., Momeni, A. 2018; 142 (5): 1337–47
  • Thirty-day unplanned postoperative inpatient and emergency department visits following thoracotomy. The Journal of surgical research Shaffer, R., Backhus, L., Finnegan, M. A., Remington, A. C., Kwong, J. Z., Curtin, C., Hernandez-Boussard, T. 2018; 230: 117–24

    Abstract

    BACKGROUND: Unplanned visits to the emergency department (ED) and inpatient setting are expensive and associated with poor outcomes in thoracic surgery. We assessed 30-d postoperative ED visits and inpatient readmissions following thoracotomy, a high morbidity procedure.MATERIALS AND METHODS: We retrospectively analyzed inpatient and ED administrative data from California, Florida, and New York, 2010-2011. "Return to care" was defined as readmission to inpatient facility or ED within 30 d of discharge. Factors associated with return to care were analyzed via multivariable logistic regressions with a fixed effect for hospital variability.RESULTS: Of 30,154 thoracotomies, 6.3% were admitted to the ED and 10.2% to the inpatient setting within 30 d of discharge. Increased risk of inpatient readmission was associated with Medicare (odds ratio [OR] 1.30; P<0.001) and Medicaid (OR 1.31; P<0.0001) insurance status compared to private insurance and black race (OR 1.18; P=0.02) compared to white race. Lung cancer diagnosis (OR 0.83; P<0.001) and higher median income (OR 0.89; P=0.04) were associated with decreased risk of inpatient readmission. Postoperative ED visits were associated with Medicare (OR 1.24; P<0.001) and Medicaid insurance status (OR 1.59; P<0.001) compared to private insurance and Hispanic race (OR 1.19; P=0.04) compared to white race.CONCLUSIONS: Following thoracotomy, postoperative ED visits and inpatient readmissions are common. Patients with public insurance were at high risk for readmission, while patients with underlying lung cancer diagnosis had a lower readmission risk. Emphasizing postoperative management in at-risk populations could improve health outcomes and reduce unplanned returns to care.

    View details for PubMedID 30100026

  • Increasing ambulatory treatment of pediatric minor burns-The emerging paradigm for burn care in children. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Kiwanuka, H., Maan, Z., Pirrotta, E., Curtin, C., Wang, N. E. 2018

    Abstract

    INTRODUCTION: Innovations in topical burn treatment along with a drive toward value-based care are steering burn care to the outpatient setting. Little is known regarding what characteristics predict outpatient treatment of pediatric minor burns and whether there is a temporal trend toward this treatment paradigm.METHODS: A retrospective cohort study was performed using California's Office of Statewide Health Planning and Development linked emergency department and inpatient database (2005-2013). All patients under 18years of age with a primary burn diagnosis were extracted. Using patient and facility level variables, we used regression modeling to evaluate predictors of outpatient burn treatment and temporal trends.RESULTS: There were 16,480 pediatric minor burn encounters during the period. 56.4% were male, 85.3% had <10% total body surface area (TBSA), 76.3% were scald or contact, and 77.3% were at deepest depth 2nd degree. Multiple variables predicted an increased likelihood of discharge home including older age(p<0.001), smaller TBSA(p<0.001), and superficial/partial thickness burns(<0.001). Children of Hispanic and Black race were less likely to be discharged home compared to White and Asian peers(p=<0.001). On Poisson modeling, the incidence rate ratio over the 9-year period for home discharge was 1.004 (95% CI 1.001-1.008, p=0.032).CONCLUSION: Older patients and those with more superficial burns were more likely to be treated as outpatients. Black and non-white Hispanic race was associated with inpatient admission. There is a growing trend toward ambulatory treatment of minor burns in the pediatric population. Further research is needed to assess whether outpatient treatment of pediatric minor burns results in greater readmissions.

    View details for PubMedID 30236815

  • Metformin prescription status and abdominal aortic aneurysm disease progression in the U.S. veteran population. Journal of vascular surgery Itoga, N. K., Rothenberg, K. A., Suarez, P., Ho, T., Mell, M. W., Xu, B., Curtin, C. M., Dalman, R. L. 2018

    Abstract

    BACKGROUND: Identification of a safe and effective medical therapy for abdominal aortic aneurysm (AAA) disease remains a significant unmet medical need. Recent small cohort studies indicate that metformin, the world's most commonly prescribed oral hypoglycemic agent, may limit AAA enlargement. We sought to validate these preliminary observations in a larger cohort.METHODS: All patients with asymptomatic AAA disease managed in the Veterans Affairs Health Care System between 2003 and 2013 were identified by International Classification of Diseases, Ninth Revision codes. Those with a concomitant diagnosis of diabetes mellitus who also received two or more abdominal imaging studies (computed tomography, magnetic resonance imaging, or ultrasound) documenting the presence and size of an AAA, separated by at least 1year, were included for review. Maximal AAA diameters were determined from radiologic reports. Further data acquisition was censored after surgical AAA repair, when performed. Comorbidities, active smoking status, and outpatient medication records (within 6months of AAA diagnosis) were also queried. Yearly AAA enlargement rates, as a function of metformin treatment status, were compared using two statistical models expressed in millimeters per year: a multivariate linear regression (model 1) and a multivariate mixed-effects model with random intercept and random slope (model 2).RESULTS: A total of 13,834 patients with 58,833 radiographic records were included in the analysis, with radiology imaging follow-up of 4.2± 2.6years (mean± standard deviation). The average age of the patients at AAA diagnosis was 69.8± 7.8years, and 39.7% had a metformin prescription within±6months of AAA. The mean growth rate for AAAs in the entire cohort was 1.4± 2.0mm/y by model 1 analysis and 1.3± 1.6mm/y by model 2 analysis. The unadjusted mean rate of AAA growth was 1.2± 1.9mm/y for patients prescribed metformin compared with 1.5± 2.2mm/y for those without (P< .001), a 20% decrease. This effect remained significant when adjusted for variables relevant on AAA progression: metformin prescription was associated with a reduction in yearly AAA growth rate of-0.23mm (95% confidence interval,-0.35 to-0.16; P< .001) by model 1 analysis and 0.20mm/y (95% confidence interval,-0.26 to-0.14; P< .001) by model 2 analysis. A subset analysis of 7462 patients with baseline AAA size of 35 to 49mm showed a similar inhibitory effect (1.4± 2.0mm/y to 1.7± 2.2mm/y; P< .001). Patients' factors associated with an increased yearly AAA growth rate were baseline AAA size, metastatic solid tumors, active smoking, chronic obstructive pulmonary disease, and chronic renal disease. Factors associated with decreased yearly AAA growth rates included prescriptions for angiotensin II type 1 receptor blockers or sulfonylureas and the presence of diabetes-related complications.CONCLUSIONS: In a nationwide analysis of diabetic Veterans Affairs patients, prescription for metformin was associated with decreased AAA enlargement. These findings provide further support for the conduct of prospective clinical trials to test the ability of metformin to limit progression of early AAA disease.

    View details for PubMedID 30197158

  • Utilization and effectiveness of multimodal discharge analgesia for postoperative pain management. The Journal of surgical research Desai, K., Carroll, I., Asch, S. M., Seto, T., McDonald, K. M., Curtin, C., Hernandez-Boussard, T. 2018; 228: 160–69

    Abstract

    BACKGROUND: Although evidence-based guidelines recommend a multimodal approach to pain management, limited information exists on adherence to these guidelines and its association with outcomes in a generalized population. We sought to assess the association between discharge multimodal analgesia and postoperative pain outcomes in two diverse health care settings.METHODS: We evaluated patients undergoing four common surgeries associated with high pain in electronic health records from an academic hospital (AH) and Veterans Health Administration (VHA). Multimodal analgesia at discharge was characterized as opioids in combination with acetaminophen (O+A) and nonsteroidal antiinflammatory (O+A+N) drugs. Hierarchical models estimated associations of analgesia with 45-d follow-up pain scores and 30-d readmissions.RESULTS: We identified 7893 patients at AH and 34,581 at VHA. In both settings, most patients were discharged with O+A (60.6% and 54.8%, respectively), yet a significant proportion received opioids alone (AH: 24.3% and VHA: 18.8%). Combining acetaminophen with opioids was associated with decreased follow-up pain in VHA (Odds ratio [OR]: 0.86, 95% confidence interval [CI]: 0.79, 0.93) and readmissions (AH OR: 0.74, CI: 0.60, 0.90; VHA OR: 0.89, CI: 0.82, 0.96). Further addition of nonsteroidal antiinflammatory drugs was associated with further decreased follow-up pain (AH OR: 0.71, CI: 0.53, 0.96; VHA OR: 0.77, CI: 0.69, 0.86) and readmissions (AH OR: 0.46, CI: 0.31, 0.69; VHA OR: 0.84, CI: 0.76, 0.93). In both systems, patients receiving multimodal analgesia received 10%-40% less opioids per day compared to opioids only.CONCLUSIONS: A majority of surgical patients receive a multimodal pain approach at discharge yet many receive only opioids. Multimodal regimen at discharge was associated with better follow-up pain and all-cause readmissions compared to the opioid-only regimen.

    View details for PubMedID 29907207

  • Secondary use of electronic medical records for clinical research: Challenges and Opportunities. Convergent science physical oncology Yim, W. W., Wheeler, A. J., Curtin, C. n., Wagner, T. H., Hernandez-Boussard, T. n. 2018; 4 (1)

    Abstract

    With increasingly ubiquitous electronic medical record (EMR) implementation accelerated by the adoption of the HITECH Act, there is much interest in the secondary use of collected data to improve outcomes and promote personalized medicine. A plethora of research has emerged using EMRs to investigate clinical research questions and assess variations in both treatments and outcomes. However, whether because of genuine complexities of modeling disease physiology or because of practical problems regarding data capture, data accuracy, and data completeness, the state of current EMR research is challenging and gives rise to concerns regarding study accuracy and reproducibility. This work explores challenges in how different experimental design decisions can influence results using a specific example of breast cancer patients undergoing excision and reconstruction surgeries from EMRs in an academic hospital and the Veterans Health Administration (VHA) We discuss emerging strategies that will mitigate these limitations, including data sharing, application of natural language processing, and improved EMR user design.

    View details for PubMedID 29732166

    View details for PubMedCentralID PMC5933881

  • Successful treatment of chronic knee pain following localization by a sigma-1 receptor radioligand and PET/MRI: a case report JOURNAL OF PAIN RESEARCH Cipriano, P., Lee, S., Yoon, D., Shen, B., Tawfik, V., Curtin, C., Dragoo, J. L., James, M., Mccurdy, C., Chin, F., Biswal, S. 2018; 11: 2353–56

    Abstract

    The ability to accurately diagnose and objectively localize pain generators in chronic pain sufferers remains a major clinical challenge since assessment relies on subjective patient complaints and relatively non-specific diagnostic tools. Developments in clinical molecular imaging, including advances in imaging technology and radiotracer design, have afforded the opportunity to identify tissues involved in pain generation based on their pro-nociceptive condition. The sigma-1 receptor (S1R) is a pro-nociceptive receptor upregulated in painful, inflamed tissues, and it can be imaged using the highly specific radioligand 18F-FTC-146 with PET.A 50-year-old woman with a 7-year history of refractory, left-knee pain of unknown origin was referred to our pain management team. Over the past several years, she had undergone multiple treatments, including a lateral retinacular release, radiofrequency ablation of a peripheral nerve, and physical therapy. While certain treatments provided partial relief, her pain would inevitably return to its original state. Using simultaneous positron emission tomography/magnetic resonance imaging (PET/MRI) with the novel radiotracer 18F-FTC-146, imaging showed increased focal uptake of 18F-FTC-146 in the intercondylar notch, corresponding to an irregular but equivocal lesion identified in the simultaneously acquired MRI. These imaging results prompted surgical removal of the lesion, which upon resection was identified as an inflamed, intraarticular synovial lipoma. Removal of the lesion relieved the patient's pain, and to date the pain has not recurred.We present a case of chronic, debilitating knee pain that resolved with surgery following identification of the pathology with a novel clinical molecular imaging approach that detects chronic pain generators at the molecular and cellular level. This approach has the potential to identify and localize pain-associated pathology in a variety of chronic pain syndromes.

    View details for PubMedID 30349360

  • Effect of Medicare's Nonpayment Policy on Surgical Site Infections Following Orthopedic Procedures. Infection control and hospital epidemiology Kwong, J. Z., Weng, Y., Finnegan, M., Schaffer, R., Remington, A., Curtin, C., McDonald, K. M., Bhattacharya, J., Hernandez-Boussard, T. 2017: 1-6

    Abstract

    OBJECTIVE Orthopedic procedures are an important focus in efforts to reduce surgical site infections (SSIs). In 2008, the Centers for Medicare and Medicaid (CMS) stopped reimbursements for additional charges associated with serious hospital-acquired conditions, including SSI following certain orthopedic procedures. We aimed to evaluate the CMS policy's effect on rates of targeted orthopedic SSIs among the Medicare population. DESIGN We examined SSI rates following orthopedic procedures among the Medicare population before and after policy implementation compared to a similarly aged control group. Using the Nationwide Inpatient Sample database for 2000-2013, we estimated rate ratios (RRs) of orthopedic SSIs among Medicare and non-Medicare patients using a difference-in-differences approach. RESULTS Following policy implementation, SSIs significantly decreased among both the Medicare and non-Medicare populations (RR, 0.7; 95% confidence interval [CI], 0.6-0.8) and RR, 0.8l; 95% CI, 0.7-0.9), respectively. However, the estimated decrease among the Medicare population was not significantly greater than the decrease among the control population (RR, 0.9; 95% CI, 0.8-1.1). CONCLUSIONS While SSI rates decreased significantly following the implementation of the CMS nonpayment policy, this trend was not associated with policy intervention but rather larger secular trends that likely contributed to decreasing SSI rates over time. Infect Control Hosp Epidemiol 2017;1-6.

    View details for DOI 10.1017/ice.2017.86

    View details for PubMedID 28487001

  • A Randomized Trial of Perioperative Gabapentin to Promote Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort Hah, J., Mackey, S., Efron, B., Mccue, R., Goodman, S., Curtin, C., Carroll, I. LIPPINCOTT WILLIAMS & WILKINS. 2017: 813–17
  • A Double-Blind Placebo Randomized Controlled Trial of Minocycline to Reduce Pain After Carpal Tunnel and Trigger Finger Release. journal of hand surgery Curtin, C. M., Kenney, D., Suarez, P., Hentz, V. R., Hernandez-Boussard, T., Mackey, S., Carroll, I. R. 2017; 42 (3): 166-174

    Abstract

    Minocycline is a microglial cell inhibitor and decreases pain behaviors in animal models. Minocycline might represent an intervention for reducing postoperative pain. This trial tested whether perioperative administration of minocycline reduced time to pain resolution (TPR) after standardized hand surgeries with known prolonged pain profiles: carpal tunnel release (CTR) and trigger finger release (TFR).This double-blinded randomized controlled trial included patients undergoing CTR or TFR under local anesthesia. Before surgery, participants recorded psychological and pain measures. Participants received oral minocycline, 200 mg, or placebo 2 hours prior to procedure, and then 100 mg of minocycline or placebo 2 times a day for 5 days. After surgery, participants were called daily assessing their pain. The primary end point of TPR was when participants had 3 consecutive days of 0 postsurgical pain. Futility analysis and Kaplan-Meier analyses were performed.A total of 131 participants were randomized and 56 placebo and 58 controls were analyzed. Median TPR for CTR was 3 weeks, with 15% having pain more than 6 weeks. Median TPR for TFR was 2 weeks with 18% having pain more than 6 weeks. The overall median TPR for the placebo group was 2 weeks (10% pain > 6 weeks) versus 2.5 weeks (17% pain > 6 weeks) for the minocycline group. Futility analysis found that the likelihood of a true underlying clinically meaningful reduction in TPR owing to minocycline was only 3.5%. Survival analysis found minocycline did not reduce TPR. However, subgroup analysis of those with elevated posttraumatic distress scores found the minocycline group had longer TPR.Oral administration of minocycline did not reduce TPR after minor hand surgery. There was evidence that minocycline might increase length of pain in those with increased posttraumatic stress disorder symptoms.Therapeutic I.

    View details for DOI 10.1016/j.jhsa.2016.12.011

    View details for PubMedID 28259273

  • Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: A Randomized Clinical Trial. JAMA surgery Hah, J. n., Mackey, S. C., Schmidt, P. n., McCue, R. n., Humphreys, K. n., Trafton, J. n., Efron, B. n., Clay, D. n., Sharifzadeh, Y. n., Ruchelli, G. n., Goodman, S. n., Huddleston, J. n., Maloney, W. J., Dirbas, F. M., Shrager, J. n., Costouros, J. n., Curtin, C. n., Carroll, I. n. 2017

    Abstract

    Guidelines recommend using gabapentin to decrease postoperative pain and opioid use, but significant variation exists in clinical practice.To determine the effect of perioperative gabapentin on remote postoperative time to pain resolution and opioid cessation.A randomized, double-blind, placebo-controlled trial of perioperative gabapentin was conducted at a single-center, tertiary referral teaching hospital. A total of 1805 patients aged 18 to 75 years scheduled for surgery (thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, and shoulder arthroscopy) were screened. Participants were enrolled from May 25, 2010, to July 25, 2014, and followed up for 2 years postoperatively. Intention-to-treat analysis was used in evaluation of the findings.Gabapentin, 1200 mg, preoperatively and 600 mg, 3 times a day postoperatively or active placebo (lorazepam, 0.5 mg) preoperatively followed by inactive placebo postoperatively for 72 hours.Primary outcome was time to pain resolution (5 consecutive reports of 0 of 10 possible levels of average pain at the surgical site on the numeric rating scale of pain). Secondary outcomes were time to opioid cessation (5 consecutive reports of no opioid use) and the proportion of participants with continued pain or opioid use at 6 months and 1 year.Of 1805 patients screened for enrollment, 1383 were excluded, including 926 who did not meet inclusion criteria and 273 who declined to participate. Overall, 8% of patients randomized were lost to follow-up. A total of 202 patients were randomized to active placebo and 208 patients were randomized to gabapentin in the intention-to-treat analysis (mean [SD] age, 56.7 [11.7] years; 256 (62.4%) women and 154 (37.6%) men). Baseline characteristics of the groups were similar. Perioperative gabapentin did not affect time to pain cessation (hazard ratio [HR], 1.04; 95% CI, 0.82-1.33; P = .73) in the intention-to-treat analysis. However, participants receiving gabapentin had a 24% increase in the rate of opioid cessation after surgery (HR, 1.24; 95% CI, 1.00-1.54; P = .05). No significant differences were noted in the number of adverse events as well as the rate of medication discontinuation due to sedation or dizziness (placebo, 42 of 202 [20.8%]; gabapentin, 52 of 208 [25.0%]).Perioperative administration of gabapentin had no effect on postoperative pain resolution, but it had a modest effect on promoting opioid cessation after surgery. The routine use of perioperative gabapentin may be warranted to promote opioid cessation and prevent chronic opioid use. Optimal dosing and timing of perioperative gabapentin in the context of specific operations to decrease opioid use should be addressed in further research.clinicaltrials.gov Identifier: NCT01067144.

    View details for PubMedID 29238824

  • Nerve entrapment as a cause of shoulder pain in the spinal cord injured patient. Spinal cord series and cases Curtin, C. M., Hagert, C. G., Hultling, C. n., Hagert, E. n. 2017; 3: 17034

    Abstract

    Many people with chronic spinal cord injury (SCI) develop shoulder pain, which can adversely impact transfers and independence. Yet effective treatments remain elusive.This report presents two patients with tetraplegia who had long-standing shoulder pain. Our exam showed muscle weakness and point tenderness, suggestive of nerve entrapments of the radial and axillary nerves in the posterior shoulder. These nerves were surgically decompressed and post-operatively the patients' pain resolved.Shoulder nerve entrapments are uncommon but SCI patients may be at more risk due to their unique upper extremity demands. SCI providers should consider proximal nerve entrapments as a possible cause of shoulder pain.

    View details for PubMedID 28616261

    View details for PubMedCentralID PMC5463175

  • Emergency Department Visits Following Elective Total Hip and Knee Replacement Surgery: Identifying Gaps in Continuity of Care. The Journal of bone and joint surgery. American volume Finnegan, M. A., Shaffer, R. n., Remington, A. n., Kwong, J. n., Curtin, C. n., Hernandez-Boussard, T. n. 2017; 99 (12): 1005–12

    Abstract

    Major joint replacement surgical procedures are common, elective procedures with a care episode that includes both inpatient readmissions and postoperative emergency department (ED) visits. Inpatient readmissions are well studied; however, to our knowledge, little is known about ED visits following these procedures. We sought to characterize 30-day ED visits following a major joint replacement surgical procedure.We used administrative records from California, Florida, and New York, from 2010 through 2012, to identify adults undergoing total knee and hip arthroplasty. Factors associated with increased risk of an ED visit were estimated using hierarchical regression models controlling for patient variables with a fixed hospital effect. The main outcome was an ED visit within 30 days of discharge.Among the 152,783 patients who underwent major joint replacement, 5,229 (3.42%) returned to the inpatient setting and 8,883 (5.81%) presented to the ED for care within 30 days. Among ED visits, 17.94% had a primary diagnosis of pain and 25.75% had both a primary and/or a secondary diagnosis of pain. Patients presenting to the ED for subsequent care had more comorbidities and were more frequently non-white with public insurance relative to those not returning to the ED (p < 0.001). There was a significantly increased risk (p < 0.05) of isolated ED visits with regard to type of insurance when patients with Medicaid (odds ratio [OR], 2.28 [95% confidence interval (CI), 2.04 to 2.55]) and those with Medicare (OR, 1.38 [95% CI, 1.29 to 1.47]) were compared with patients with private insurance and with regard to race when black patients (OR, 1.38 [95% CI, 1.25 to 1.53]) and Hispanic patients (OR, 1.12 [95% CI, 1.03 to 1.22]) were compared with white patients. These increases in risk were stronger for isolated ED visits for patients with a pain diagnosis.ED visits following an elective major joint replacement surgical procedure were numerous and most commonly for pain-related diagnoses. Medicaid patients had almost double the risk of an ED or pain-related ED visit following a surgical procedure. The future of U.S. health-care insurance coverage expansions are uncertain; however, there are ongoing attempts to improve quality across the continuum of care. It is therefore essential to ensure that all patients, particularly vulnerable populations, receive appropriate postoperative care, including pain management.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

    View details for PubMedID 28632589

  • Drug-Free Interventions to Reduce Pain or Opioid Consumption After Total Knee Arthroplasty: A Systematic Review and Meta-analysis. JAMA surgery Tedesco, D. n., Gori, D. n., Desai, K. R., Asch, S. n., Carroll, I. R., Curtin, C. n., McDonald, K. M., Fantini, M. P., Hernandez-Boussard, T. n. 2017: e172872

    Abstract

    There is increased interest in nonpharmacological treatments to reduce pain after total knee arthroplasty. Yet, little consensus supports the effectiveness of these interventions.To systematically review and meta-analyze evidence of nonpharmacological interventions for postoperative pain management after total knee arthroplasty.Database searches of MEDLINE (PubMed), EMBASE (OVID), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Web of Science (ISI database), Physiotherapy Evidence (PEDRO) database, and ClinicalTrials.gov for the period between January 1946 and April 2016.Randomized clinical trials comparing nonpharmacological interventions with other interventions in combination with standard care were included.Two reviewers independently extracted the data from selected articles using a standardized form and assessed the risk of bias. A random-effects model was used for the analyses.Postoperative pain and consumption of opioids and analgesics.Of 5509 studies, 39 randomized clinical trials were included in the meta-analysis (2391 patients). The most commonly performed interventions included continuous passive motion, preoperative exercise, cryotherapy, electrotherapy, and acupuncture. Moderate-certainty evidence showed that electrotherapy reduced the use of opioids (mean difference, -3.50; 95% CI, -5.90 to -1.10 morphine equivalents in milligrams per kilogram per 48 hours; P = .004; I2 = 17%) and that acupuncture delayed opioid use (mean difference, 46.17; 95% CI, 20.84 to 71.50 minutes to the first patient-controlled analgesia; P < .001; I2 = 19%). There was low-certainty evidence that acupuncture improved pain (mean difference, -1.14; 95% CI, -1.90 to -0.38 on a visual analog scale at 2 days; P = .003; I2 = 0%). Very low-certainty evidence showed that cryotherapy was associated with a reduction in opioid consumption (mean difference, -0.13; 95% CI, -0.26 to -0.01 morphine equivalents in milligrams per kilogram per 48 hours; P = .03; I2 = 86%) and in pain improvement (mean difference, -0.51; 95% CI, -1.00 to -0.02 on the visual analog scale; P < .05; I2 = 62%). Low-certainty or very low-certainty evidence showed that continuous passive motion and preoperative exercise had no pain improvement and reduction in opioid consumption: for continuous passive motion, the mean differences were -0.05 (95% CI, -0.35 to 0.25) on the visual analog scale (P = .74; I2 = 52%) and 6.58 (95% CI, -6.33 to 19.49) opioid consumption at 1 and 2 weeks (P = .32, I2 = 87%), and for preoperative exercise, the mean difference was -0.14 (95% CI, -1.11 to 0.84) on the Western Ontario and McMaster Universities Arthritis Index Scale (P = .78, I2 = 65%).In this meta-analysis, electrotherapy and acupuncture after total knee arthroplasty were associated with reduced and delayed opioid consumption.

    View details for PubMedID 28813550

  • Opioid Abuse And Poisoning: Trends In Inpatient And Emergency Department Discharges. Health affairs (Project Hope) Tedesco, D. n., Asch, S. M., Curtin, C. n., Hah, J. n., McDonald, K. M., Fantini, M. P., Hernandez-Boussard, T. n. 2017; 36 (10): 1748–53

    Abstract

    Addressing the opioid epidemic is a national priority. We analyzed national trends in inpatient and emergency department (ED) discharges for opioid abuse, dependence, and poisoning using Healthcare Cost and Utilization Project data. Inpatient and ED discharge rates increased overall across the study period, but a decline was observed for prescription opioid-related discharges beginning in 2010, while a sharp increase in heroin-related discharges began in 2008.

    View details for PubMedID 28971919

  • Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic. Anesthesia and analgesia Hah, J. M., Bateman, B. T., Ratliff, J. n., Curtin, C. n., Sun, E. n. 2017; 125 (5): 1733–40

    Abstract

    Physicians, policymakers, and researchers are increasingly focused on finding ways to decrease opioid use and overdose in the United States both of which have sharply increased over the past decade. While many efforts are focused on the management of chronic pain, the use of opioids in surgical patients presents a particularly challenging problem requiring clinicians to balance 2 competing interests: managing acute pain in the immediate postoperative period and minimizing the risks of persistent opioid use after the surgery. Finding ways to minimize this risk is particularly salient in light of a growing literature suggesting that postsurgical patients are at increased risk for chronic opioid use. The perioperative care team, including surgeons and anesthesiologists, is poised to develop clinical- and systems-based interventions aimed at providing pain relief in the immediate postoperative period while also reducing the risks of opioid use longer term. In this paper, we discuss the consequences of chronic opioid use after surgery and present an analysis of the extent to which surgery has been associated with chronic opioid use. We follow with a discussion of the risk factors that are associated with chronic opioid use after surgery and proceed with an analysis of the extent to which opioid-sparing perioperative interventions (eg, nerve blockade) have been shown to reduce the risk of chronic opioid use after surgery. We then conclude with a discussion of future research directions.

    View details for PubMedID 29049117

  • Cost-Minimization Analysis of Open and Endoscopic Carpal Tunnel Release. journal of bone and joint surgery. American volume Zhang, S., Vora, M., Harris, A. H., Baker, L., Curtin, C., Kamal, R. N. 2016; 98 (23): 1970-1977

    Abstract

    Carpal tunnel release is the most common upper-limb surgical procedure performed annually in the U.S. There are 2 surgical methods of carpal tunnel release: open or endoscopic. Currently, there is no clear clinical or economic evidence supporting the use of one procedure over the other. We completed a cost-minimization analysis of open and endoscopic carpal tunnel release, testing the null hypothesis that there is no difference between the procedures in terms of cost.We conducted a retrospective review using a private-payer and Medicare Advantage database composed of 16 million patient records from 2007 to 2014. The cohort consisted of records with an ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis of carpal tunnel syndrome and a CPT (Current Procedural Terminology) code for carpal tunnel release. Payer fees were used to define cost. We also assessed other associated costs of care, including those of electrodiagnostic studies and occupational therapy. Bivariate comparisons were performed using the chi-square test and the Student t test.Data showed that 86% of the patients underwent open carpal tunnel release. Reimbursement fees for endoscopic release were significantly higher than for open release. Facility fees were responsible for most of the difference between the procedures in reimbursement: facility fees averaged $1,884 for endoscopic release compared with $1,080 for open release (p < 0.0001). Endoscopic release also demonstrated significantly higher physician fees than open release (an average of $555 compared with $428; p < 0.0001). Occupational therapy fees associated with endoscopic release were less than those associated with open release (an average of $237 per session compared with $272; p = 0.07). The total average annual reimbursement per patient for endoscopic release (facility, surgeon, and occupational therapy fees) was significantly higher than for open release ($2,602 compared with $1,751; p < 0.0001).Our data showed that the total average fees per patient for endoscopic release were significantly higher than those for open release, although there currently is no strong evidence supporting better clinical outcomes of either technique.Value-based health-care models that favor delivering high-quality care and improving patient health, while also minimizing costs, may favor open carpal tunnel release.

    View details for PubMedID 27926678

  • Second commentary on "Multifocal Neuropathy: Expanding the Scope of Double Crush Syndrome" JOURNAL OF HAND SURGERY-AMERICAN VOLUME Curtin, C. 2016; 41 (12): 1177

    View details for PubMedID 27916150

  • Analyzing treatment aggressiveness and identifying high-risk patients in diabetic foot ulcer return to care. Wound repair and regeneration Remington, A. C., Hernandez-Boussard, T., Warstadt, N. M., Finnegan, M. A., Shaffer, R., Kwong, J. Z., Curtin, C. 2016; 24 (4): 731-736

    Abstract

    Rates of diabetes and its associated comorbidities have been increasing in the United States, with diabetic foot ulcer treatment representing a large cost to the patient and healthcare system. These ulcers often result in multiple hospital admissions. This study examined readmissions following inpatient care for a diabetic foot ulcer and identified modifiable factors associated with all-cause 30-day readmissions to the inpatient or emergency department (ED) setting. We hypothesized that patients undergoing aggressive treatment would have lower 30-day readmission rates. We identified patient discharge records containing International Classification of Disease ninth revision codes for both diabetes mellitus and distal foot ulcer in the State Inpatient and Emergency Department databases from the Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project in Florida and New York, 2011-2012. All-cause 30-day return to care visits (ED or inpatient) were analyzed. Patient demographics and treatment characteristics were evaluated using univariate and multivariable regression models. The cohort included 25,911 discharges, having a mean age of 63 and an average of 3.8 comorbidities. The overall rate of return to care was 30%, and 21% of subjects underwent a toe or midfoot amputation during their index stay. The most common diagnosis codes upon readmission were diabetes mellitus (19%) and infection (13%). Patients with a toe or midfoot amputation procedure were less likely to be readmitted within 30 days (odds ratio: 0.78; 95% confidence interval: 0.73, 0.84). Presence of comorbidities, black and Hispanic ethnicities, and Medicare and Medicaid payer status were also associated with higher odds of readmission following initial hospitalization (p < 0.05). The study suggests that there are many factors that affect readmission rates for diabetic foot ulcer patients. Understanding patients at high-risk for readmission can improve counseling and treatment strategies for this fragile patient population.

    View details for DOI 10.1111/wrr.12439

    View details for PubMedID 27144893

  • Understanding and Overcoming Barriers to Upper Limb Surgical Reconstruction After Tetraplegia: The Need for Interdisciplinary Collaboration ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION Punj, V., Curtin, C. 2016; 97 (6): S81-S87

    Abstract

    There are approximately 300,000 persons with spinal cord injury living in the United States, and nearly 60% of these persons have suffered tetraplegia with resultant alterations in body function, activity, and therefore participation. Restoring hand function can improve independence, and various studies have shown that persons with tetraplegia rate restoration of arm and hand function higher than bowel and bladder control, walking, or sexuality. There are conservative options to improve upper limb function in this population (eg, orthoses, neuroprostheses). Surgical interventions are also available, and 70% of surgical patients report satisfaction and improvement in various activities of daily living after surgery to restore arm and hand function. Despite these positive surgical outcomes, <10% of the eligible population of 60% to 70% undergo tendon transfer surgery to restore function. Underutilization of surgical interventions can be explained by population-, provider-, and health care systems-specific barriers. With further education of providers and patients and team building across disciplines these barriers can be overcome, ultimately leading to reduced disability and improved quality of life for persons with tetraplegia.

    View details for DOI 10.1016/j.apmr.2015.11.022

    View details for Web of Science ID 000377237200003

    View details for PubMedID 27233595

  • Electronic Health Records and Quality of Care: An Observational Study Modeling Impact on Mortality, Readmissions, and Complications MEDICINE Yanamadala, S., Morrison, D., Curtin, C., McDonald, K., Hernandez-Boussard, T. 2016; 95 (19)

    Abstract

    Electronic health records (EHRs) were implemented to improve quality of care and patient outcomes. This study assessed the relationship between EHR-adoption and patient outcomes.We performed an observational study using State Inpatient Databases linked to American Hospital Association survey, 2011. Surgical and medical patients from 6 large, diverse states were included. We performed univariate analyses and developed hierarchical regression models relating level of EHR utilization and mortality, readmission rates, and complications. We evaluated the effect of EHR adoption on outcomes in a difference-in-differences analysis, 2008 to 2011.Medical and surgical patients sought care at hospitals reporting no EHR (3.5%), partial EHR (55.2%), and full EHR systems (41.3%). In univariate analyses, patients at hospitals with full EHR had the lowest rates of inpatient mortality, readmissions, and Patient Safety Indicators followed by patients at hospitals with partial EHR and then patients at hospitals with no EHR (P < 0.05). However, these associations were not robust when accounting for other patient and hospital factors, and adoption of an EHR system was not associated with improved patient outcomes (P > 0.05).These results indicate that patients receiving medical and surgical care at hospitals with no EHR system have similar outcomes compared to patients seeking care at hospitals with a full EHR system, after controlling for important confounders.To date, we have not yet seen the promised benefits of EHR systems on patient outcomes in the inpatient setting. EHRs may play a smaller role than expected in patient outcomes and overall quality of care.

    View details for DOI 10.1097/MD.0000000000003332

    View details for Web of Science ID 000376927000010

    View details for PubMedID 27175631

    View details for PubMedCentralID PMC4902473

  • Management of Pain in Complex Nerve Injuries HAND CLINICS Davis, G., Curtin, C. M. 2016; 32 (2): 257-?

    Abstract

    Traumatic nerve injuries can be devastating and life-changing events, leading to functional morbidity and psychological stress and social constraints. Even in the event of a successful surgical repair with recovered motor function, pain can result in continued disability and poor quality of life. Pain after nerve injury can also prevent recovery and return to preinjury life. It is difficult to predict which patients will develop persistent pain; once incurred, pain can be even challenging to manage. This review seeks to define the types of pain following peripheral nerve injuries, investigate the pathophysiology and causative factors, and evaluate potential treatment options.

    View details for DOI 10.1016/j.hcl.2015.12.011

    View details for Web of Science ID 000376330500014

    View details for PubMedID 27094896

  • Preface Pain Management HAND CLINICS Curtin, C. 2016; 32 (1): IX-X

    View details for PubMedID 26611394

  • Pain Examination and Diagnosis HAND CLINICS Curtin, C. 2016; 32 (1): 21-+

    Abstract

    Pain is a clinical challenge to health care providers who care for hand disorders. Pathologic pain that prevents recovery leads to dissatisfaction for both patients and providers. Despite pain being common, the root cause is often difficult to diagnose. This article reviews the examination and diagnostic tools that are helpful in identifying pathologic and neuropathic pain. This article provides tools to speed recognition of these processes to allow earlier intervention and better patient outcomes.

    View details for DOI 10.1016/j.hcl.2015.08.006

    View details for Web of Science ID 000366955600004

    View details for PubMedID 26611385

  • Identification Of Targets To Improve 30-Day Returns To Emergency Department And Inpatient Care Among Thoracotomy Procedure Patients Shaffer, R., Tsai, C., Backhus, L., Curtin, C., Hernandez-Boussard, T. AMER THORACIC SOC. 2016
  • Digital Sympathectomy in Patients With Scleroderma: An Overview of the Practice and Referral Patterns and Perceptions of Rheumatologists. Annals of plastic surgery Chiou, G., Crowe, C., Suarez, P., Chung, L., Curtin, C., Chang, J. 2015; 75 (6): 637-643

    Abstract

    Periarterial sympathectomy is a treatment option for patients with systemic sclerosis (SSc) suffering from digital vasculopathy. Despite potential benefits of ulcer healing, pain improvement, and amputation prevention, this operation appears to be infrequently performed. The aims of our study are as follows: (1) to assess national digital sympathectomy rates in patients with SSc and (2) to improve our understanding of referring physicians' perceptions of operative management and access to hand surgeons. Our hypothesis is that rheumatologists' practices largely influence their referral patterns for digital sympathectomy.To determine the rates and demographics of hospitalized patients with SSc who had undergone digital sympathectomy, we queried the Nationwide Inpatient Sample from 2006 to 2010. Additionally, we mailed a self-administered survey to a national sample of 500 board-certified rheumatologists to elicit their practice patterns and perceptions of digital sympathectomy. Using logistic regression, we analyzed potential predictor variables associated with rheumatologists performing the following: (1) routinely counseling patients about digital sympathectomy and (2) expressing the desire to refer these patients for operative evaluation.Of 348,539 hospitalizations associated with a diagnosis of SSc, only 0.2% were for digital sympathectomy. Our questionnaire revealed that only 50% of rheumatologists routinely counseled, whereas 67% expressed the desire to refer. Factors associated with increased rheumatologists' interest in surgical management for patients with SSc included positive perception of the operation's efficacy, comfort with postoperative management, and interdisciplinary relationship with a hand surgeon.Critical components to increasing appropriate utilization of digital sympathectomy include enhancing rheumatologists' understanding of the operation, comfort with postoperative management, and promoting strong, interdisciplinary relationships with hand surgeons. Increasing education and awareness, as well as establishing a solid referral network of hand surgeons may thereby improve patient access to digital sympathectomy.

    View details for DOI 10.1097/SAP.0000000000000614

    View details for PubMedID 26418780

  • Optical Biopsy of Peripheral Nerve Using Confocal Laser Endomicroscopy: A New Tool for Nerve Surgeons? Archives of plastic surgery Crowe, C. S., Liao, J. C., Curtin, C. M. 2015; 42 (5): 626-629

    Abstract

    Peripheral nerve injuries remain a challenge for reconstructive surgeons with many patients obtaining suboptimal results. Understanding the level of injury is imperative for successful repair. Current methods for distinguishing healthy from damaged nerve are time consuming and possess limited efficacy. Confocal laser endomicroscopy (CLE) is an emerging optical biopsy technology that enables dynamic, high resolution, sub-surface imaging of live tissue. Porcine sciatic nerve was either left undamaged or briefly clamped to simulate injury. Diluted fluorescein was applied topically to the nerve. CLE imaging was performed by direct contact of the probe with nerve tissue. Images representative of both damaged and undamaged nerve fibers were collected and compared to routine H&E histology. Optical biopsy of undamaged nerve revealed bands of longitudinal nerve fibers, distinct from surrounding adipose and connective tissue. When damaged, these bands appear truncated and terminate in blebs of opacity. H&E staining revealed similar features in damaged nerve fibers. These results prompt development of a protocol for imaging peripheral nerves intraoperatively. To this end, improving surgeons' ability to understand the level of injury through real-time imaging will allow for faster and more informed operative decisions than the current standard permits.

    View details for DOI 10.5999/aps.2015.42.5.626

    View details for PubMedID 26430636

    View details for PubMedCentralID PMC4579176

  • The Effect of Moving Carpal Tunnel Releases Out of Hospitals on Reducing United States Health Care Charges. journal of hand surgery Nguyen, C., Milstein, A., Hernandez-Boussard, T., Curtin, C. M. 2015; 40 (8): 1657-1662

    Abstract

    To better understand how perioperative care affects charges for carpal tunnel release (CTR).We developed a cohort using ICD9-CM procedure code 04.43 for CTR in the National Survey of Ambulatory Surgery 2006 to test perioperative factors potentially associated with CTR costs. We examined factors that might affect costs, including patient characteristics, payer, surgical time, setting (hospital outpatient department vs. freestanding ambulatory surgery center), anesthesia type, anesthesia provider, discharge status, and adverse events. Records were grouped by facility to reduce the impact of surgeon and patient heterogeneity. Facilities were divided into quintiles based on average total facility charges per CTR. This division allowed comparison of factors associated with the lowest and highest quintile of facilities based on average charge per CTR.A total of 160,000 CTRs were performed in 2006. Nearly all patients were discharged home without adverse events. Mean charge across facilities was $2,572 (SD, $2,331-$2,813). Patient complexity and intraoperative duration of surgery was similar across quintiles (approximately 13 min). Anesthesia techniques were not significantly associated with patient complexity, charges, and total perioperative time. Hospital outpatient department setting was strongly associated with total charges, with $500 higher charge per CTR. Half of all CTRs were performed in hospital outpatient departments. Facilities in the lowest quintile charge group were freestanding ambulatory surgery centers.Examination of charges for CTR suggests that surgical setting is a large cost driver with the potential opportunity to lower charges for CTRs by approximately 30% if performed in ASCs.Economic/decision analysis II.

    View details for DOI 10.1016/j.jhsa.2015.04.023

    View details for PubMedID 26070229

  • Interpositional Nerve Grafting of the Prostatic Plexus after Radical Prostatectomy. Plastic and reconstructive surgery. Global open Kung, T. A., Waljee, J. F., Curtin, C. M., Wei, J. T., Montie, J. E., Cederna, P. S. 2015; 3 (7)

    Abstract

    Injury to the prostatic plexus may occur during radical prostatectomy even with the use of minimally invasive techniques. Reconstruction of these nerves by interpositional nerve grafting can be performed to reduce morbidity. Although the feasibility of nerve reconstruction has been shown, long-term functional outcomes are mixed, and the role of nerve grafting in these patients remains unclear.A retrospective study was performed on 38 consecutive patients who underwent immediate unilateral or bilateral nerve reconstruction after open prostatectomy. Additionally, 53 control patients who underwent unilateral, bilateral, or non-nerve-sparing open prostatectomy without nerve grafting were reviewed. Outcomes included rates of urinary continence, erections sufficient for sexual intercourse, and ability to have spontaneous erections. Analysis was performed by stratifying patients by D'Amico score and laterality of nerve involvement.Unilateral nerve grafting conferred no significant benefit compared with unilateral nerve-sparing prostatectomy. Bilateral nerve-sparing patients demonstrated superior functional outcomes compared with bilateral non-nerve-sparing patients, whereas bilateral nerve-grafting patients displayed a trend toward functional improvement. With increasing D'Amico score, there was a trend toward worsening urinary continence and erectile function regardless of nerve-grafting status.In the era of robotic prostatectomy, interpositional nerve reconstruction is not a routine practice. However, the substantial morbidity experienced in patients with bilateral nerve resections remains unacceptable, and therefore, nerve grafting may still improve functional outcomes in these patients. Further investigation is needed to improve the potential of bilateral nerve grafting after non-nerve-sparing prostatectomy.

    View details for DOI 10.1097/GOX.0000000000000422

    View details for PubMedID 26301141

    View details for PubMedCentralID PMC4527626

  • Patient safety in plastic surgery: identifying areas for quality improvement efforts. Annals of plastic surgery Hernandez-Boussard, T., McDonald, K. M., Rhoads, K. F., Curtin, C. M. 2015; 74 (5): 597-602

    Abstract

    Improving quality of health care is a global priority. Before quality benchmarks are established, we first must understand rates of adverse events (AEs). This project assessed risk-adjusted rates of inpatient AEs for soft tissue reconstructive procedures.Patients receiving soft tissue reconstructive procedures from 2005 to 2010 were extracted from the Nationwide Inpatient Sample. Inpatient AEs were identified using patient safety indicators (PSIs), established measures developed by Agency for Healthcare Research and Quality.We identified 409,991 patients with soft tissue reconstruction and 16,635 (4.06%) had a PSI during their hospital stay. Patient safety indicators were associated with increased risk-adjusted mortality, longer length of stay, and decreased routine disposition (P < 0.01). Patient characteristics associated with a higher risk-adjusted rate per 1000 patients at risk included older age, men, nonwhite, and public payer (P < 0.05). Overall, plastic surgery patients had significantly lower risk-adjusted rate compared to other surgical inpatients for all events evaluated except for failure to rescue and postoperative hemorrhage or hematoma, which were not statistically different. Risk-adjusted rates of hematoma hemorrhage were significantly higher in patients receiving size-reduction surgery, and these rates were further accentuated when broken down by sex and payer.In general, plastic surgery patients had lower rates of in-hospital AEs than other surgical disciplines, but PSIs were not uncommon. With the establishment of national basal PSI rates in plastic surgery patients, benchmarks can be devised and target areas for quality improvement efforts identified. Further prospective studies should be designed to elucidate the drivers of AEs identified in this population.

    View details for DOI 10.1097/SAP.0b013e318297791e

    View details for PubMedID 24108144

  • Access to surgical upper extremity care for people with tetraplegia: an international perspective SPINAL CORD Fox, P. M., Suarez, P., Hentz, V. R., Curtin, C. M. 2015; 53 (4): 302-305

    Abstract

    Survey.To determine whether upper extremity reconstruction in patients with tetraplegia is underutilized internationally and, if so, what are the barriers to care.International-attendees of a meeting in Paris, France.One hundred and seventy attendees at the Tetrahand meeting in Paris in 2010 were sent a 13-question survey to determine the access and utilization of upper limb reconstruction in tetraplegic patients in their practice.Respondents ranged the globe including North America, South America, Europe, Asia and Australia. Fifty-nine percent of respondents had been practicing for more than 10 years. Sixty-four percent of respondents felt that at least 25% of people with tetraplegia would be candidates for surgery. Yet the majority of respondents found that <15% of potential patients underwent upper extremity reconstruction. Throughout the world direct patient referral was the main avenue of surgeons meeting patients with peer networking a distant second. Designated as the top three barriers to this care were lack of knowledge of surgical options by patients, lack of desire for surgery and poor referral patterns to appropriate upper extremity surgeons.The results of this survey, of a worldwide audience, indicate that many of the same barriers to care exist regardless of the patient's address. This was a preliminary opinion survey and thus the results are subjective. However, these results provide a roadmap to improving access to care by improving patient education and interdisciplinary physician communication.

    View details for DOI 10.1038/sc.2015.3

    View details for Web of Science ID 000352725500008

    View details for PubMedID 25687516

  • Comparative Effectiveness of Infraclavicular and Supraclavicular Perineural Catheters for Ultrasound-Guided Through-the-Catheter Bolus Anesthesia. Journal of ultrasound in medicine Harrison, T. K., Kim, T. E., Howard, S. K., Funck, N., Wagner, M. J., Walters, T. L., Curtin, C., Chang, J., Ganaway, T., Mariano, E. R. 2015; 34 (2): 333-340

    Abstract

    Using a through-the-needle local anesthetic bolus technique, ultrasound-guided infraclavicular perineural catheters have been shown to provide greater analgesia compared to supraclavicular catheters. A through-the-catheter bolus technique, which arguably "tests" the anesthetic efficacy of the catheter before initiating an infusion, has been validated for infraclavicular catheters but not supraclavicular catheters. This study investigated the through-the-catheter bolus technique for supraclavicular catheters and tested the hypothesis that infraclavicular catheters provide faster onset of brachial plexus anesthesia.Preoperatively, patients were randomly assigned to receive either a supraclavicular or an infraclavicular catheter using an ultrasound-guided nonstimulating catheter insertion technique with a mepivacaine bolus via the catheter and ropivacaine perineural infusion initiated postoperatively. The primary outcome was time to achieve complete sensory anesthesia in the ulnar and median nerve distributions. Secondary outcomes included procedural time, procedure-related pain and complications, and postoperative pain, opioid consumption, sleep disturbances, and motor weakness.Fifty patients were enrolled in the study; all but 2 perineural catheters were successfully placed per protocol. Twenty-one of 24 (88%) and 24 of 24 (100%) patients in the supraclavicular and infraclavicular groups, respectively, achieved complete sensory anesthesia by 30 minutes (P= .088). There was no difference in the time to achieve complete sensory anesthesia. Supraclavicular patients reported more sleep disturbances postoperatively, but there were no statistically significant differences in other outcomes.Both supraclavicular and infraclavicular perineural catheters using a through-the-catheter bolus technique provide effective brachial plexus anesthesia.

    View details for DOI 10.7863/ultra.34.2.333

    View details for PubMedID 25614407

  • Readmissions After Treatment of Distal Radius Fractures JOURNAL OF HAND SURGERY-AMERICAN VOLUME Curtin, C. M., Hernandez-Boussard, T. 2014; 39 (10): 1926-1932

    Abstract

    To assess the rates and associated diagnoses of readmissions for patients having received an intervention for treatment of distal radius fracture.We analyzed patient discharges from 2005-2011 for California, Florida, and New York. We used Agency for Healthcare Research and Quality data sets: (1) State Inpatient Database, (2) State Ambulatory Surgery Database, and (3) State Emergency Department Database. We examined inpatient, outpatient, and emergency room treatment locations. We identified patients by diagnosis code for distal radius fracture (813.41). Patients were stratified based on procedure codes for open reduction, closed reduction, and external fixation. The cohort was followed for 30 days to examine all-cause 30-day inpatient admissions and emergency department visits.We identified 35,241 discharges with a primary diagnosis of distal radius facture. Of those, 18,388 patients underwent a procedure for their fracture, and 1,679 (9%) were readmitted within 30 days of discharge. Readmission rates varied by procedure type: internal fixation 8%, closed reduction 14%, and external fixation 11%. The most common diagnosis codes associated with readmission were general distal radius fracture codes (11%) and pain diagnoses (10%). Open procedures had higher odds of having a readmission associated with pain compared with closed treatment and external fixation.Readmissions after treatment of distal radius fracture care are common. Our results show many distal radius fracture patients return to the health care system for pain-related issues. As more emphasis is placed on quality health care delivery, implementation of better pain management will be important to health care providers and patients.This study highlights that improved perioperative pain control may improve patient care and reduce readmissions.

    View details for DOI 10.1016/j.jhsa.2014.07.041

    View details for Web of Science ID 000342733500006

  • Readmissions after treatment of distal radius fractures. journal of hand surgery Curtin, C. M., Hernandez-Boussard, T. 2014; 39 (10): 1926-1932

    Abstract

    To assess the rates and associated diagnoses of readmissions for patients having received an intervention for treatment of distal radius fracture.We analyzed patient discharges from 2005-2011 for California, Florida, and New York. We used Agency for Healthcare Research and Quality data sets: (1) State Inpatient Database, (2) State Ambulatory Surgery Database, and (3) State Emergency Department Database. We examined inpatient, outpatient, and emergency room treatment locations. We identified patients by diagnosis code for distal radius fracture (813.41). Patients were stratified based on procedure codes for open reduction, closed reduction, and external fixation. The cohort was followed for 30 days to examine all-cause 30-day inpatient admissions and emergency department visits.We identified 35,241 discharges with a primary diagnosis of distal radius facture. Of those, 18,388 patients underwent a procedure for their fracture, and 1,679 (9%) were readmitted within 30 days of discharge. Readmission rates varied by procedure type: internal fixation 8%, closed reduction 14%, and external fixation 11%. The most common diagnosis codes associated with readmission were general distal radius fracture codes (11%) and pain diagnoses (10%). Open procedures had higher odds of having a readmission associated with pain compared with closed treatment and external fixation.Readmissions after treatment of distal radius fracture care are common. Our results show many distal radius fracture patients return to the health care system for pain-related issues. As more emphasis is placed on quality health care delivery, implementation of better pain management will be important to health care providers and patients.This study highlights that improved perioperative pain control may improve patient care and reduce readmissions.

    View details for DOI 10.1016/j.jhsa.2014.07.041

    View details for PubMedID 25257486

  • Analysis of Efficacy and Safety of Treatment With Collagenase Clostridium histolyticum Among Subgroups of Patients With Dupuytren Contracture. Annals of plastic surgery Raven, R. B., Kushner, H., Nguyen, D., Naam, N., Curtin, C. 2014; 73 (3): 286-290

    Abstract

    Collagenase Clostridium histolyticum (CCH) injection is a nonoperative treatment of hand contractures from Dupuytren disease. This study assessed the efficacy and safety of CCH in several subgroups of patients with increased surgical risk.Data were pooled from 3 randomized, placebo-controlled, double-blind trials. This analysis included 271 patients with metacarpophalangeal (n = 167) or proximal interphalangeal (n = 104) joint contractures greater than or equal to 20 degrees treated with CCH (0.58 mg collagenase per injection). Subgroups included age, sex, and diabetes status. End points included rate of clinical success (reduction in contracture to 0-5 degrees of normal) and percentage of adverse events.There was no significant difference in clinical success by age, diabetes status, or sex with 63% reaching the end point. There was no difference in adverse events among the subgroups, with peripheral edema, contusion, and injection-site hemorrhage being most common.High-risk subgroups do not demonstrate differences in efficacy or safety with CCH treatment of Dupuytren-related contractures.

    View details for DOI 10.1097/SAP.0b013e31827ae9d0

    View details for PubMedID 23511746

  • Analysis of Efficacy and Safety of Treatment With Collagenase Clostridium histolyticum Among Subgroups of Patients With Dupuytren Contracture ANNALS OF PLASTIC SURGERY Raven, R. B., Kushner, H., Dat Nguyen, D., Naam, N., Curtin, C. 2014; 72 (3): 286-290

    Abstract

    Collagenase Clostridium histolyticum (CCH) injection is a nonoperative treatment of hand contractures from Dupuytren disease. This study assessed the efficacy and safety of CCH in several subgroups of patients with increased surgical risk.Data were pooled from 3 randomized, placebo-controlled, double-blind trials. This analysis included 271 patients with metacarpophalangeal (n = 167) or proximal interphalangeal (n = 104) joint contractures greater than or equal to 20 degrees treated with CCH (0.58 mg collagenase per injection). Subgroups included age, sex, and diabetes status. End points included rate of clinical success (reduction in contracture to 0-5 degrees of normal) and percentage of adverse events.There was no significant difference in clinical success by age, diabetes status, or sex with 63% reaching the end point. There was no difference in adverse events among the subgroups, with peripheral edema, contusion, and injection-site hemorrhage being most common.High-risk subgroups do not demonstrate differences in efficacy or safety with CCH treatment of Dupuytren-related contractures.

    View details for DOI 10.1097/SAP.0b013e31827ae9d0

    View details for Web of Science ID 000341079300006

  • A reflection of outcomes research and its impact on the practice of hand surgery. journal of hand surgery, European volume Curtin, C. M., Chung, K. C. 2014; 39 (7): 790-793

    View details for DOI 10.1177/1753193414524138

    View details for PubMedID 25139931

  • Quality Assessment in Hand Surgery HAND CLINICS Waljee, J. F., Curtin, C. 2014; 30 (3): 329-?

    Abstract

    Measuring quality assessment in hand surgery remains an underexplored area. However, measuring quality is becoming increasingly transparent and important. Patients now have direct access to hospital and physician metrics and large payers have linked financial incentives to quality metrics. It is critical for hand surgeons to understand the essential elements of quality and its assessment. This article reviews several areas of hand surgery quality assessments including safety, outcomes, satisfaction, and cost.

    View details for DOI 10.1016/j.hcl.2014.04.009

    View details for Web of Science ID 000340735100008

    View details for PubMedID 25066851

  • Squamous cell carcinoma in a patient with dystrophic epidermolysis bullosa: a wound management strategy. Dermatologic surgery Ng, F. Y., Nguyen, C., Curtin, C. M. 2014; 40 (8): 918-920

    View details for DOI 10.1097/DSS.0000000000000088

    View details for PubMedID 25022710

  • Cleft palate surgery: an evaluation of length of stay, complications, and costs by hospital type. Cleft palate-craniofacial journal Nguyen, C., Hernandez-Boussard, T., Davies, S. M., Bhattacharya, J., Khosla, R. K., Curtin, C. M. 2014; 51 (4): 412-419

    Abstract

    Objective : The purpose of this study was to assess length of stay (LOS), complication rates, costs, and charges of cleft palate repair by various hospital types. We hypothesized that pediatric hospitals would have shorter LOS, fewer complications, and lower costs and charges. Methods : Patients were identified by ICD-9-CM code for cleft palate repair (27.62) using databases from the Agency for Health Research and Quality Healthcare Cost and Utilization Project Kids' Inpatient Database from 1997, 2000, 2003, and 2006. Patient characteristics (age, race, gender, insurer, comorbidities) and facility resources (hospital beds, cleft palate surgery volume, nurse-to-bed ratio, pediatric intensive care unit [PICU], PICU intensivist, burn unit) were examined. Hospitals types included pediatric hospitals, general hospitals, and nonaccredited children's hospital. For each hospital type, mean LOS, extended LOS (LOS > 2), and complications were assessed. Results : A total of 14,153 patients had cleft repair with a mean LOS of 2 days (SD, 0.04), mortality 0.01%, transfusion 0.3%, and complication <3%. Pediatric hospitals had fewer patients with extended hospital stays. Patients with an LOS >2 days were associated with fourfold higher complications. Comorbidities increased the relative rate of LOS >2 days by 90%. Pediatric hospitals had the highest comorbidities, yet 35% decreased the relative rate of LOS >2 days. Median total charges of $10,835 increased to $15,104 with LOS >2 days; median total costs of $4367 increased to $6148 with a LOS >2 days. Conclusion : Pediatric hospitals had higher comorbidities yet shorter LOS. Pediatric resources significantly decreased the relative rate of LOS >2 days. Median costs and charges increased by 41% with LOS >2 days. Further research is needed to understand additional aspects of pediatric hospitals associated with lower LOS.

    View details for DOI 10.1597/12-150

    View details for PubMedID 24063682

  • Multiple Collagenase Injections Are Safe for Treatment of Dupuytren's Contractures. Orthopedics Gajendran, V. K., Hentz, V., Kenney, D., Curtin, C. M. 2014; 37 (7): e657-60

    Abstract

    The authors report the case of a 65-year-old, right-hand-dominant man who had severe Dupuytren's disease with multiple cords and flexion contractures of the metacarpophalangeal and proximal interphalangeal joints of both hands and underwent repeated collagenase injections for treatment. Collagenase has been shown to be safe and effective in the treatment of Dupuytren's contractures when administered as a single dose, but the results of multiple injections over a prolonged period are unknown. Antibodies to collagenase develop in all patients after several treatments, raising concerns about safety and efficacy as a result of sensitization from repeated exposures. The antibodies generated as a result of repeated exposure to collagenase could theoretically render it less effective with time and could also lead to immune reactions as severe as anaphylaxis. The authors present the case of a single patient who experienced continued correction of his contractures with only minor and self-limited adverse reactions after administration of 12 collagenase doses through 15 injections during a 4-year period. Over time, the injections continued to be effective at correcting metacarpophalangeal joint contractures, but less effective at correcting proximal interphalangeal joint contractures. The patient did eventually require a fasciectomy, but the safety and modest success of the repeated collagenase injections shows promise for a less invasive treatment with a better risk profile than open fasciectomy. Although further studies are needed, repeated administration of collagenase appears to be safe and modestly effective for severe Dupuytren's contractures, although a fasciectomy may ultimately be required in the most severe cases.

    View details for DOI 10.3928/01477447-20140626-64

    View details for PubMedID 24992063

  • Needle aponeurotomy for the treatment of Dupuytren's disease. Hand clinics Diaz, R., Curtin, C. 2014; 30 (1): 33-38

    Abstract

    Surgical treatment of Dupuytren's disease includes radical fasciectomy, limited fasciectomy, percutaneous needle aponeurotomy (PNA), and treatment with collagenase injections. The most commonly performed procedure is limited fasciectomy. However, techniques such as PNA and collagenase injections are being performed with higher frequency because they are minimally invasive. PNA is generally recommended for older patients with less severe contractures who desire a faster recovery with a low complication rate. Patients undergoing PNA should be informed that recurrence rates appear to be higher with PNA in comparison with limited fasciectomy.

    View details for DOI 10.1016/j.hcl.2013.09.005

    View details for PubMedID 24286740

  • Minimally invasive hand surgery. Preface. Hand clinics Curtin, C. 2014; 30 (1): ix-x

    View details for DOI 10.1016/j.hcl.2013.09.007

    View details for PubMedID 24286748

  • Soft-Tissue Coverage of the Hand: A Case-Based Approach PLASTIC AND RECONSTRUCTIVE SURGERY Eberlin, K. R., Chang, J., Curtin, C. M., Sammer, D. M., Saint-Cyr, M., Taghinia, A. H. 2014; 133 (1): 91-101

    Abstract

    Adequate soft-tissue coverage of the hand is paramount to achieve optimal aesthetic and functional results in patients with complex hand defects. In this article, the authors present four illustrative clinical cases and discuss potential reconstructive modalities. For each scenario, two surgical options are discussed: one established and one nontraditional method of reconstruction. The authors' preferred method and technical pearls for execution are presented.

    View details for DOI 10.1097/01.prs.0000436831.73323.88

    View details for Web of Science ID 000329164900044

    View details for PubMedID 24105089

  • Surgical versus nonsurgical treatment of femur fractures in people with spinal cord injury: an administrative analysis of risks. Archives of physical medicine and rehabilitation Bishop, J. A., Suarez, P., DiPonio, L., Ota, D., Curtin, C. M. 2013; 94 (12): 2357-2364

    Abstract

    To assess the risks associated with surgical and nonsurgical care of femur fractures in people with spinal cord injury (SCI).Retrospective cohort study; an analysis of Veterans Affairs (VA) data from the National Patient Care Database.Administrative data from database.The cohort was identified by searching the administrative data from fiscal years 2001 to 2006 for veterans with a femur fracture diagnosis using the International Classification of Diseases, 9th Revision, Clinical Modification codes. This group was subdivided into those with (n=396) and without (n=13,350) SCI and those treated with and without surgical intervention.Not applicable.Rates of mortality and adverse events.The SCI group was younger with more distal fractures than the non-SCI group. In the non-SCI population, 78% of patients had associated surgical codes compared with 37% in the SCI population. There was higher mortality in the non-SCI group treated nonoperatively. In the SCI population, there was no difference in mortality between patients treated nonoperatively and operatively. Overall adverse events were similar between groups except for pressure sores in the SCI population, of which the nonoperative group had 20% and the operative had 7%. Rates of surgical interventions for those with SCI varied greatly among VA institutions.We found lower rates of surgical intervention in the SCI population. Those with SCI who had surgery did not have increased mortality or adverse events. Surgical treatment minimizes the risks of immobilization and should be considered in appropriate SCI patients.

    View details for DOI 10.1016/j.apmr.2013.07.024

    View details for PubMedID 23948614

  • A national study on craniosynostosis surgical repair. Cleft palate-craniofacial journal Nguyen, C., Hernandez-Boussard, T., Khosla, R. K., Curtin, C. M. 2013; 50 (5): 555-560

    Abstract

    Objective :  Our study aimed to use national data to assess the perioperative outcomes of craniosynostosis surgical repair. Design :  Data were obtained from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Kids Inpatient Database from 1997, 2000, 2003, and 2006. Setting :  Community hospitals in the United States. Patients :  The cohort was identified using the ICD-9-CM procedure codes for craniosynostosis surgical repair (2.01, 2.03, 2.04, 2.06). Main Outcome Measures(s) :  We determined patient and hospital characteristics. We clustered patients by age group (<7 months, 7 to 12 months, 1 to 3 years) and assessed mortality, comorbidities, mean length of stay (LOS), and total charge. We performed logistic regression with our dependent variable being longer average hospital stay: LOS >4.2 days. Results :  We found 3426 patients. Average age at the time of surgery was 181 days (SD 84). Average length of stay was 4.2 days. The majority of the patients were boys (66%), white (71%), and insured (93%). Nearly all patients underwent surgery in a teaching hospital (98%) in urban centers (99%). Approximately 10% of patients experienced an acute complication, most commonly hemorrhages or hematomas and airway or respiratory failure. Patients ages 1 to 3 years had the highest rates of comorbidities and a longer LOS. Mortality rate was <1%. Conclusions :  Craniosynostosis surgery is safe with low rates of mortality and acute complications. LOS >4.2 appears to be associated more with comorbidities than with complications. Higher rates of comorbidities and LOS >4.2 days for patients age 1 to 3 years warrant addition research to assess potential barriers to care.

    View details for DOI 10.1597/11-324

    View details for PubMedID 23030675

  • A National Study on Craniosynostosis Surgical Repair CLEFT PALATE-CRANIOFACIAL JOURNAL Christine Nguyen, C., Hernandez-Boussard, T., Khosla, R. K., Curtin, C. M. 2013; 50 (5): 555-560

    Abstract

    Objective :  Our study aimed to use national data to assess the perioperative outcomes of craniosynostosis surgical repair. Design :  Data were obtained from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Kids Inpatient Database from 1997, 2000, 2003, and 2006. Setting :  Community hospitals in the United States. Patients :  The cohort was identified using the ICD-9-CM procedure codes for craniosynostosis surgical repair (2.01, 2.03, 2.04, 2.06). Main Outcome Measures(s) :  We determined patient and hospital characteristics. We clustered patients by age group (<7 months, 7 to 12 months, 1 to 3 years) and assessed mortality, comorbidities, mean length of stay (LOS), and total charge. We performed logistic regression with our dependent variable being longer average hospital stay: LOS >4.2 days. Results :  We found 3426 patients. Average age at the time of surgery was 181 days (SD 84). Average length of stay was 4.2 days. The majority of the patients were boys (66%), white (71%), and insured (93%). Nearly all patients underwent surgery in a teaching hospital (98%) in urban centers (99%). Approximately 10% of patients experienced an acute complication, most commonly hemorrhages or hematomas and airway or respiratory failure. Patients ages 1 to 3 years had the highest rates of comorbidities and a longer LOS. Mortality rate was <1%. Conclusions :  Craniosynostosis surgery is safe with low rates of mortality and acute complications. LOS >4.2 appears to be associated more with comorbidities than with complications. Higher rates of comorbidities and LOS >4.2 days for patients age 1 to 3 years warrant addition research to assess potential barriers to care.

    View details for DOI 10.1597/11-324

    View details for Web of Science ID 000327536100011

  • Breast reconstruction national trends and healthcare implications. breast journal Hernandez-Boussard, T., Zeidler, K., Barzin, A., Lee, G., Curtin, C. 2013; 19 (5): 463-469

    Abstract

    Breast reconstruction improves quality-of-life of breast cancer patients. Different reconstructive options exist, yet commentary in the plastic surgery literature suggests that financial constraints are limiting access to autologous reconstruction (AR). This study follows national trends in breast reconstruction and identifies factors associated with reconstructive choices. Data were obtained from the Nationwide Inpatient Sample from 1998 to 2008. Patients were categorized as having either implant or ARs. Bivariate and multivariate regression analysis identified variables associated with receiving implants versus AR. Physician fee schedules were analyzed using national average Medicare physician reimbursement rates. From 1998 to 2008, 324,134 breast reconstructions were performed. Reconstructions increased 4% per year. The proportion of implant reconstructions increased 11% per year, whereasARs decreased 5% per year (p < 0.05). Our model showed that the odds of having implant-based versus AR were significantly associated with age, disease severity, payer type, hospital teaching status, and year of surgery. Year of surgery was the strongest predictor of implant reconstruction; patients receiving breast reconstructive surgery in 2009 were three times more likely to have implant breast reconstructive surgery compared with similar patients in 2002. Medicare reimbursement steadily declined for AR over a similar time frame. From 1998 to 2008, autologous breast reconstruction has significantly declined, parallel to a decrease in physician reimbursement. Our data found no significant change in patient characteristics supporting the lack of choice of AR. Further research is warranted to better understand this shift to implant reconstruction and to ensure future access of these complex reconstructive procedures.

    View details for DOI 10.1111/tbj.12148

    View details for PubMedID 23758582

  • Management of Chronic Pain Following Nerve lnjuries/CRPS Type II HAND CLINICS Carroll, I., Curtin, C. M. 2013; 29 (3): 401-?

    Abstract

    Chronic pain affects quality of life and adversely affects functional outcomes. Chronic postoperative pain is a frustrating problem for the surgeon because it ruins a technically perfect procedure, and the surgeon may be unsure of treatment strategies. There is much information on chronic pain and its treatment, but it is often published outside of surgery and diffusion of this information across disciplines is slow. This article synthesizes some of this literature and provides a systematic presentation of the evidence on pain associated with peripheral nerve injury. It highlights the use of perioperative and early intervention to decrease this debilitating problem.

    View details for DOI 10.1016/j.hcl.2013.04.009

    View details for Web of Science ID 000323627800009

    View details for PubMedID 23895720

  • Perioperative interventions to reduce chronic postsurgical pain. Journal of reconstructive microsurgery Carroll, I., Hah, J., Mackey, S., Ottestad, E., Kong, J. T., Lahidji, S., Tawfik, V., Younger, J., Curtin, C. 2013; 29 (4): 213-222

    Abstract

    Approximately 10% of patients following a variety of surgeries develop chronic postsurgical pain. Reducing chronic postoperative pain is especially important to reconstructive surgeons because common operations such as breast and limb reconstruction have even higher risk for developing chronic postsurgical pain. Animal studies of posttraumatic nerve injury pain demonstrate that there is a critical time frame before and immediately after nerve injury in which specific interventions can reduce the incidence and intensity of chronic neuropathic pain behaviors-so called "preventative analgesia." In animal models, perineural local anesthetic, systemic intravenous local anesthetic, perineural clonidine, systemic gabapentin, systemic tricyclic antidepressants, and minocycline have each been shown to reduce pain behaviors days to weeks after treatment. The translation of this work to humans also suggests that brief perioperative interventions may protect patients from developing new chronic postsurgical pain. Recent clinical trial data show that there is an opportunity during the perioperative period to dramatically reduce the incidence and severity of chronic postsurgical pain. The surgeon, working with the anesthesiologist, has the ability to modify both early and chronic postoperative pain by implementing an evidence-based preventative analgesia plan.

    View details for DOI 10.1055/s-0032-1329921

    View details for PubMedID 23463498

  • Perioperative Interventions to Reduce Chronic Postsurgical Pain JOURNAL OF RECONSTRUCTIVE MICROSURGERY Carroll, I., Hah, J., Mackey, S., Ottestad, E., Kong, J. T., Lahidji, S., Tawfik, V., Younger, J., Curtin, C. 2013; 29 (4): 213-222

    Abstract

    Approximately 10% of patients following a variety of surgeries develop chronic postsurgical pain. Reducing chronic postoperative pain is especially important to reconstructive surgeons because common operations such as breast and limb reconstruction have even higher risk for developing chronic postsurgical pain. Animal studies of posttraumatic nerve injury pain demonstrate that there is a critical time frame before and immediately after nerve injury in which specific interventions can reduce the incidence and intensity of chronic neuropathic pain behaviors-so called "preventative analgesia." In animal models, perineural local anesthetic, systemic intravenous local anesthetic, perineural clonidine, systemic gabapentin, systemic tricyclic antidepressants, and minocycline have each been shown to reduce pain behaviors days to weeks after treatment. The translation of this work to humans also suggests that brief perioperative interventions may protect patients from developing new chronic postsurgical pain. Recent clinical trial data show that there is an opportunity during the perioperative period to dramatically reduce the incidence and severity of chronic postsurgical pain. The surgeon, working with the anesthesiologist, has the ability to modify both early and chronic postoperative pain by implementing an evidence-based preventative analgesia plan.

    View details for DOI 10.1055/s-0032-1329921

    View details for Web of Science ID 000317597000001

    View details for PubMedID 23463498

  • Changes resembling complex regional pain syndrome following surgery and immobilization. journal of pain Pepper, A., Li, W., Kingery, W. S., Angst, M. S., Curtin, C. M., Clark, J. D. 2013; 14 (5): 516-524

    Abstract

    The study of complex regional pain syndrome (CRPS) in humans is complicated by inhomogeneities in available study cohorts. We hoped to characterize early CRPS-like features in patients undergoing hand surgery. Forty-three patients were recruited from a hand surgery clinic that had elective surgeries followed by cast immobilization. On the day of cast removal, patients were assessed for vasomotor, sudomotor, and trophic changes, and edema and pain sensitization using quantitative sensory testing. Pain intensity was assessed at the time of cast removal and after 1 additional month, as was the nature of the pain using the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS). Skin biopsies were harvested for the analysis of expression of inflammatory mediators. We identified vascular and trophic changes in the surgical hands of most patients. Increased sensitivity to punctate, pressure, and cold stimuli were observed commonly as well. Moreover, levels of IL-6, TNF-alpha, and the mast cell marker tryptase were elevated in the skin of hands ipsilateral to surgery. Moderate-to-severe pain persisted in the surgical hands for up to 1 month after cast removal. Exploratory analyses suggested interrelationships between the physical, quantitative sensory testing, and gene expression changes and pain-related outcomes.This study has identified CPRS-like features in the limbs of patients undergoing surgery followed by immobilization. Further studies using this population may be useful in refining our understanding of CRPS mechanisms and treatments for this condition.

    View details for DOI 10.1016/j.jpain.2013.01.004

    View details for PubMedID 23453564

  • Ultrasound-guided Continuous Median Nerve Block to Facilitate Intensive Hand Rehabilitation CLINICAL JOURNAL OF PAIN Maxwell, B. G., Hansen, J. A., Talley, J., Curtin, C. M., Mariano, E. R. 2013; 29 (1): 86-88

    Abstract

    Continuous brachial plexus blocks for postoperative analgesia after upper extremity surgery are well described, but they can result in undesirable motor block and lack of specificity for minor hand procedures. We present the use of extended-duration continuous local anesthetic infusion through an ultrasound-guided median nerve catheter inserted at the forearm to facilitate hand physical therapy in a patient who had previously failed rehabilitation due to pain unrelieved by systemic opioids.A 54-year-old man presented with an inability to flex his index finger after proximal phalangeal fracture. He underwent hardware removal and extensive scar release. He had severe postoperative pain that limited his ability to comply with hand therapy, which is required to achieve functional goals after surgery. A perineural catheter was placed under ultrasound guidance adjacent to the median nerve in the proximal forearm; then a continuous infusion of ropivacaine 0.2% was initiated and maintained for 11 days. The patient had focused sensory loss in the median nerve distribution but maintained active flexion of the fingers. He subsequently was able to participate in hand physical therapy and discontinued the use of oral opioid medications.Ultrasound-guided perineural catheters targeting terminal branch nerves may have potential benefits beyond the immediate postoperative period and in nonoperative management of patients requiring physical therapy and rehabilitation.

    View details for DOI 10.1097/AJP.0b013e318246d1ca

    View details for Web of Science ID 000311945500014

    View details for PubMedID 22751029

  • Advances in the Management of Dupuytren Disease Collagenase HAND CLINICS Hentz, V. R., Watt, A. J., Desai, S. S., Curtin, C. 2012; 28 (4): 551-?

    Abstract

    Dupuytren disease (DD) is a benign, generally painless connective tissue disorder affecting the palmar fascia that leads to progressive hand contractures. Mediated by myofibroblasts, the disease most commonly begins as a nodule in the palm or finger, and can progress where pathologic cords form leading to progressive flexion deformity of the involved fingers. The palmar skin overlying the cords may become excessively calloused and contracted and involved joints may develop periarticular fibrosis. Although there is no cure, the sequellae of this affliction can be corrected. This article focuses on the role of collagen in DD and the development of a collagen-specific enzymatic treatment for DD contractures.

    View details for DOI 10.1016/j.hcl.2012.08.003

    View details for Web of Science ID 000311875800011

    View details for PubMedID 23101605

  • Who are the women and men in Veterans Health Administration's current spinal cord injury population? Journal of rehabilitation research and development Curtin, C. M., Suarez, P. A., Di Ponio, L. A., Frayne, S. M. 2012; 49 (3): 351-360

    Abstract

    Spinal cord injury (SCI) care is a high priority for the Veterans Health Administration (VHA). Aging Veterans, new cases of SCI from recent conflicts, and increasing numbers of women Veterans have likely changed the profile of the VHA SCI population. This study characterizes the current Veteran population with SCI with emphasis on healthcare utilization and women Veterans. We analyzed VHA administrative data from 2002-2003 and 2007-2008, analyzing composition, demographics, and healthcare use. The population is mostly male (>97%) and largely between 45 and 64 years old. Over 30% are over the age of 65. They are frequent users of healthcare, with an average of 21 visits per year. Women Veterans with SCI form a small but distinct subpopulation, being younger and less likely to be married and having a higher burden of disease. We must understand how the VHA population with SCI is changing to anticipate and provide the best care for these complex patients.

    View details for PubMedID 22773195

  • Is carpal tunnel release under-utilized in veterans with spinal cord injury? JOURNAL OF SPINAL CORD MEDICINE Barr, C., Suarez, P., Ota, D., Curtin, C. M. 2011; 34 (6): 563-568

    Abstract

    Carpal tunnel syndrome (CTS) is a common disorder among individuals with spinal cord injury (SCI). Although carpal tunnel release is highly effective, the procedure may be under-utilized in this population. This study attempts to identify if CTS is under-treated in Veterans with SCI.The Veterans Affairs (VA) National Patient Care Database was used for data compilation within fiscal years 2007 and 2008. Using ICD-9-CM diagnoses codes, individuals with SCIs were identified, including those diagnosed with CTS. Current procedural terminology (CPT) codes further showed those who had undergone surgical intervention including open and endoscopic release of the transverse carpal ligament. The VA SCI cohort was compared to the general VA population with regard to demographics, diagnosis, surgical intervention, and treatment location.A total of 19 296 veterans with SCI were identified within the 2-year period. The prevalence of CTS within this cohort was 3.5%, compared to 2.1% in the general VA population. The rate of transverse carpal ligament release was similar between the VA SCI cohort and general population (0.24 and 0.17%, respectively). The majority of surgical treatment (89%) occurred within the VA 'hub-and-spoke' system of SCI care.CTS appears to be under-diagnosed and under-treated in veterans with SCI.

    View details for DOI 10.1179/2045772311Y.0000000031

    View details for Web of Science ID 000298669100006

    View details for PubMedID 22330111

    View details for PubMedCentralID PMC3237282

  • Chronic Psychological and Functional Sequelae After Emergent Hand Surgery JOURNAL OF HAND SURGERY-AMERICAN VOLUME Richards, T., Garvert, D. W., McDade, E., Carlson, E., Curtin, C. 2011; 36A (10): 1663-1668

    Abstract

    Several studies have shown that upper extremity trauma has serious, acute psychological effects after injury. This study's goal was to assess the psychological outcomes, including symptoms of major depression, posttraumatic stress disorder (PTSD), and other psychosocial variables, as well as the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) results, after severe hand trauma. We hypothesized that hand trauma would have persistent psychological sequelae long after the physical injury.We performed a cross-sectional survey of 34 patients who had emergency hand surgery at a Level 1 trauma center an average of 16 months (range, 7-32 mo) earlier. The hand disability measure was the QuickDASH, and the psychological measures included the Center for Epidemiologic Studies Depression Scale, the Screen for Posttraumatic Stress Symptoms, the Medical Outcomes Study Social Support Survey Form, the Social Constraints Survey (to assess interpersonal stressors), and the Perceived Stress Scale.The overall QuickDASH score was 27. The mean score for PTSD was 13 (above the clinical threshold for PTSD), and 29% of respondents had high levels of both depression and PTSD. High pain scores on the QuickDASH were strongly correlated with both depression and PTSD symptoms.This study found high levels of psychological distress in patients after hand trauma. Hand disability was strongly related to pain, depression, and PTSD symptoms. This study shows that the psychological sequelae of hand trauma can persist long after the physical injury.Therapeutic IV.

    View details for DOI 10.1016/j.jhsa.2011.06.028

    View details for Web of Science ID 000295855800015

  • Flexor tendon rupture after collagenase injection for Dupuytren contracture: case report. journal of hand surgery Zhang, A. Y., Curtin, C. M., Hentz, V. R. 2011; 36 (8): 1323-1325

    Abstract

    Rupture of both flexor tendons after collagenase injection for Dupuytren contracture is a rare and problematic complication. We performed a 2-stage tendon reconstruction to treat this problem, with an acceptable result.

    View details for DOI 10.1016/j.jhsa.2011.05.016

    View details for PubMedID 21705158

  • Flexor Tendon Rupture After Collagenase Injection for Dupuytren Contracture: Case Report JOURNAL OF HAND SURGERY-AMERICAN VOLUME Zhang, A. Y., Curtin, C. M., Hentz, V. R. 2011; 36A (8): 1323-1325

    Abstract

    Rupture of both flexor tendons after collagenase injection for Dupuytren contracture is a rare and problematic complication. We performed a 2-stage tendon reconstruction to treat this problem, with an acceptable result.

    View details for DOI 10.1016/j.jhsa.2011.05.016

    View details for Web of Science ID 000293669400011

  • Adverse events following digital replantation in the elderly. journal of hand surgery Barzin, A., Hernandez-Boussard, T., Lee, G. K., Curtin, C. 2011; 36 (5): 870-874

    Abstract

    The decision to proceed with digital replantation in the elderly can be challenging. In addition to success of the replanted part, perioperative morbidity and mortality must be considered. The purpose of this study was to compare adverse events in patients less than 65 years of age compared with those 65 years and older after digital replantation. We hypothesize that there is an increased incidence of mortality and sentinel adverse events in patients aged 65 and older.We obtained data from the Nationwide Inpatient Sample over a 10-year period from 1998 to 2007. Replantation was identified using International Classification of Diseases-9 procedure codes for finger and thumb reattachment (84.21 and 84.22). Adverse events were identified using Patient Safety Indicators (PSI) to identify adverse events occurring during hospitalization. We used the Charlson index to study medical comorbidities and bivariate statistics.During the study period 15,413 finger and thumb replantations were performed in the United States, with 616 performed on patients age 65 and older. The overall in-hospital mortality was 0.04% with no statistical difference when factoring age. For the entire group, the percentage of PSI was 0.6%, the most common being postoperative deep venous thrombosis and pulmonary embolus. Overall, there was no difference in PSI between the 2 groups. The older group had a higher rate of transfusion, 4% versus 8% (p < .05) and were more likely to have a nonroutine disposition (ie, nursing home) (p < .001). We found no correlation between the Charlson index and PSI.This study found no difference in sentinel perioperative complications or mortality when comparing replantation patients under 65 years of age and those age 65 and older. Age alone should not be an absolute contraindication to finger replantation. Instead, the patient's functional demands, type of injury, general state of health, and rehabilitative potential should drive the decision of whether to proceed with replantation.

    View details for DOI 10.1016/j.jhsa.2011.01.031

    View details for PubMedID 21489718

  • Adverse Events Following Digital Replantation in the Elderly JOURNAL OF HAND SURGERY-AMERICAN VOLUME Barzin, A., Hernandez-Boussard, T., Lee, G. K., Curtin, C. 2011; 36A (5): 870-874

    Abstract

    The decision to proceed with digital replantation in the elderly can be challenging. In addition to success of the replanted part, perioperative morbidity and mortality must be considered. The purpose of this study was to compare adverse events in patients less than 65 years of age compared with those 65 years and older after digital replantation. We hypothesize that there is an increased incidence of mortality and sentinel adverse events in patients aged 65 and older.We obtained data from the Nationwide Inpatient Sample over a 10-year period from 1998 to 2007. Replantation was identified using International Classification of Diseases-9 procedure codes for finger and thumb reattachment (84.21 and 84.22). Adverse events were identified using Patient Safety Indicators (PSI) to identify adverse events occurring during hospitalization. We used the Charlson index to study medical comorbidities and bivariate statistics.During the study period 15,413 finger and thumb replantations were performed in the United States, with 616 performed on patients age 65 and older. The overall in-hospital mortality was 0.04% with no statistical difference when factoring age. For the entire group, the percentage of PSI was 0.6%, the most common being postoperative deep venous thrombosis and pulmonary embolus. Overall, there was no difference in PSI between the 2 groups. The older group had a higher rate of transfusion, 4% versus 8% (p < .05) and were more likely to have a nonroutine disposition (ie, nursing home) (p < .001). We found no correlation between the Charlson index and PSI.This study found no difference in sentinel perioperative complications or mortality when comparing replantation patients under 65 years of age and those age 65 and older. Age alone should not be an absolute contraindication to finger replantation. Instead, the patient's functional demands, type of injury, general state of health, and rehabilitative potential should drive the decision of whether to proceed with replantation.

    View details for DOI 10.1016/j.jhsa.2011.01.031

    View details for Web of Science ID 000290185700017

  • Posterior Interosseous Nerve: An Alternative to Sural Nerve Biopsy PLASTIC AND RECONSTRUCTIVE SURGERY Richards, T. A., Curtin, C. M. 2010; 126 (4): 213E-214E

    View details for DOI 10.1097/PRS.0b013e3181ea92fb

    View details for Web of Science ID 000282559100072

    View details for PubMedID 20885232

  • Referring physicians' knowledge of hand surgery. Hand (New York, N.Y.) Curtin, C. M., Yao, J. 2010; 5 (3): 278-285

    Abstract

    Hand surgeons rely on referrals from general providers. Appropriate referral is dependent upon referring physicians having an understanding of the problem and available treatments. This study evaluates the referring physicians' knowledge and perceptions of basic hand problems and their treatment. This study also evaluates the impact of a brief lecture on our referring physicians' understanding of hand issues. A survey instrument was administered to referring physicians. The instrument addressed general hand knowledge and perceptions toward hand surgery. The physicians also attended a lecture on general hand problems and their treatments. The survey was repeated 2 weeks post-lecture. Subjects had a pre-lecture knowledge score of 65% correct and post-lecture a score of 85%, p < 0.05. The participants were knowledgeable about common hand problems, such as carpal tunnel syndrome. Knowledge gaps did exist, for example, only 37% recognized the symptoms of basilar thumb arthritis. Initially, the referring physicians had less positive views about surgical interventions, such as surgery to help the pain of basilar thumb arthritis. After the lecture, the responders had significantly more favorable attitudes toward surgery. This study found that referring physicians had variable knowledge about common hand problems, and they had doubts relating to the efficacy of some hand surgeries. This study also found that a directed lecture improved these providers' knowledge and their perceptions of hand surgical interventions. Hand surgeons can improve their referring physicians understanding and perceptions of hand surgery through a directed grand rounds type lecture.

    View details for DOI 10.1007/s11552-009-9256-x

    View details for PubMedID 21886547

    View details for PubMedCentralID PMC2920387

  • Collagenase injection as nonsurgical treatment of Dupuytren's disease: 8-year follow-up. journal of hand surgery Watt, A. J., Curtin, C. M., Hentz, V. R. 2010; 35 (4): 534-?

    Abstract

    Collagenase has been investigated in phase II and phase III clinical trials for the treatment of Dupuytren's disease. The purpose of this study is to report 8-year follow-up results in a subset of patients who had collagenase injection for the treatment of Dupuytren's contracture.Twenty-three patients who participated in the phase II clinical trial of injectable collagenase were contacted by letter and phone. Eight patients were enrolled, completed a Dupuytren's disease questionnaire, and had independent examination of joint motion by a single examiner.Eight patients completed the 8-year follow-up study: 6 had been treated for isolated metacarpophalangeal (MCP) joint contracture, and 2 had been treated for isolated proximal interphalangeal (PIP) joint contracture. Average preinjection contracture was 57 degrees in the MCP group. Average contracture was 9 degrees at 1 week, 11 degrees at 1 year, and 23 degrees at 8-year follow-up. Four of 6 patients experienced recurrence, and 2 of 6 had no evidence of disease recurrence at 8-year follow-up. Average preinjection contracture was 45 degrees in the PIP group. Average contracture was 8 degrees at 1 weeks, 15 degrees at 1 year, and 60 degrees at 8-year follow-up. Both patients experienced recurrence at 8-year follow-up. No patients had had further intervention on the treated finger in either the MCP or the PIP group. Patients subjectively rated the overall clinical success at 60%, and 88% of patients stated that they would pursue further injection for the treatment of their recurrent or progressive Dupuytren's disease.Enzymatic fasciotomy is safe and efficacious, with initial response to injection resulting in reduction of joint contracture to within 0 degrees -5 degrees of normal in 72 out of 80 patients. Initial evaluation of long-term recurrence rates suggests disease recurrence or progression in 4 out of 6 patients with MCP contractures and 2 patients with PIP contractures; however, recurrence was generally less severe than the initial contracture in the MCP group. In addition, patient satisfaction was high.

    View details for DOI 10.1016/j.jhsa.2010.01.003

    View details for PubMedID 20353858

  • Collagenase Injection as Nonsurgical Treatment of Dupuytren's Disease: 8-Year Follow-Up JOURNAL OF HAND SURGERY-AMERICAN VOLUME Watt, A. J., Curtin, C. M., Hentz, V. R. 2010; 35A (4): 534-539

    Abstract

    Collagenase has been investigated in phase II and phase III clinical trials for the treatment of Dupuytren's disease. The purpose of this study is to report 8-year follow-up results in a subset of patients who had collagenase injection for the treatment of Dupuytren's contracture.Twenty-three patients who participated in the phase II clinical trial of injectable collagenase were contacted by letter and phone. Eight patients were enrolled, completed a Dupuytren's disease questionnaire, and had independent examination of joint motion by a single examiner.Eight patients completed the 8-year follow-up study: 6 had been treated for isolated metacarpophalangeal (MCP) joint contracture, and 2 had been treated for isolated proximal interphalangeal (PIP) joint contracture. Average preinjection contracture was 57 degrees in the MCP group. Average contracture was 9 degrees at 1 week, 11 degrees at 1 year, and 23 degrees at 8-year follow-up. Four of 6 patients experienced recurrence, and 2 of 6 had no evidence of disease recurrence at 8-year follow-up. Average preinjection contracture was 45 degrees in the PIP group. Average contracture was 8 degrees at 1 weeks, 15 degrees at 1 year, and 60 degrees at 8-year follow-up. Both patients experienced recurrence at 8-year follow-up. No patients had had further intervention on the treated finger in either the MCP or the PIP group. Patients subjectively rated the overall clinical success at 60%, and 88% of patients stated that they would pursue further injection for the treatment of their recurrent or progressive Dupuytren's disease.Enzymatic fasciotomy is safe and efficacious, with initial response to injection resulting in reduction of joint contracture to within 0 degrees -5 degrees of normal in 72 out of 80 patients. Initial evaluation of long-term recurrence rates suggests disease recurrence or progression in 4 out of 6 patients with MCP contractures and 2 patients with PIP contractures; however, recurrence was generally less severe than the initial contracture in the MCP group. In addition, patient satisfaction was high.

    View details for DOI 10.1016/j.jhsa.2010.01.003

    View details for Web of Science ID 000276604600002

  • Invasive Aspergillosis of the Hand Caused by Aspergillus ustus: a Case Report. Hand (New York, N.Y.) Olorunnipa, O., Zhang, A. Y., Curtin, C. M. 2010; 5 (1): 102-105

    Abstract

    This is a case report of a 61-year-old cardiac transplant patient who developed a disseminated infection involving the upper extremity with a rare fungus known as Aspergillus ustus. The patient was successfully treated with aggressive serial debridements, antifungal medications, and reduction of immunosuppression. With these interventions, the patient avoided amputation despite the aggressive nature of this infection.

    View details for DOI 10.1007/s11552-009-9211-x

    View details for PubMedID 19568818

    View details for PubMedCentralID PMC2820612

  • Population-based utilities for upper extremity functions in the setting of tetraplegia. journal of hand surgery Ram, A. N., Curtin, C. M., Chung, K. C. 2009; 34 (9): 1674-81 e1

    Abstract

    People with tetraplegia face substantial physical and financial hardships. Although upper extremity reconstruction has been advocated for people with tetraplegia, these procedures are markedly underused in the United States. Population-based preference evaluation of upper extremity reconstruction is important to quantify the value of these reconstructive procedures. This study sought to establish the preferences for 3 health states: tetraplegia, tetraplegia with corrected pinch function, and tetraplegia with corrected elbow extension function.A computer-based, time trade-off survey was administered to a cohort of 81 able-bodied second-year medical students who served as a surrogate for the general public. This survey instrument has undergone pilot testing and has established face validity to evaluate the 3 health states of interest. Utilities were calculated based on an estimated 20 years of remaining life.The mean utility for the tetraplegic health state was low. On average, respondents gave up 10.8 +/- 5.0 out of a hypothetical 20 years for perfect health, for a utility of tetraplegia equal to 0.46. For recovery of pinch function, respondents gave up an average of 6.5 +/- 4.3 years, with a corresponding health utility of 0.68. For recovery of elbow extension function, respondents gave up an average of 7.6 +/- 4.5 years, with a corresponding health utility of 0.74.This study established the preferences for 2 upper extremity surgical interventions: tetraplegia with pinch and tetraplegia with elbow extension. The findings from this study place a high value on upper-limb reconstructive procedures with tetraplegia.

    View details for DOI 10.1016/j.jhsa.2009.07.003

    View details for PubMedID 19896010

  • Population-Based Utilities for Upper Extremity Functions in the Setting of Tetraplegia JOURNAL OF HAND SURGERY-AMERICAN VOLUME Ram, A. N., Curtin, C. M., Chung, K. C. 2009; 34A (9): 1674-1681

    Abstract

    People with tetraplegia face substantial physical and financial hardships. Although upper extremity reconstruction has been advocated for people with tetraplegia, these procedures are markedly underused in the United States. Population-based preference evaluation of upper extremity reconstruction is important to quantify the value of these reconstructive procedures. This study sought to establish the preferences for 3 health states: tetraplegia, tetraplegia with corrected pinch function, and tetraplegia with corrected elbow extension function.A computer-based, time trade-off survey was administered to a cohort of 81 able-bodied second-year medical students who served as a surrogate for the general public. This survey instrument has undergone pilot testing and has established face validity to evaluate the 3 health states of interest. Utilities were calculated based on an estimated 20 years of remaining life.The mean utility for the tetraplegic health state was low. On average, respondents gave up 10.8 +/- 5.0 out of a hypothetical 20 years for perfect health, for a utility of tetraplegia equal to 0.46. For recovery of pinch function, respondents gave up an average of 6.5 +/- 4.3 years, with a corresponding health utility of 0.68. For recovery of elbow extension function, respondents gave up an average of 7.6 +/- 4.5 years, with a corresponding health utility of 0.74.This study established the preferences for 2 upper extremity surgical interventions: tetraplegia with pinch and tetraplegia with elbow extension. The findings from this study place a high value on upper-limb reconstructive procedures with tetraplegia.

    View details for DOI 10.1016/j.jhsa.2009.07.003

    View details for Web of Science ID 000271598000013

  • Cutaneous neuroma physiology and its relationship to chronic pain. journal of hand surgery Curtin, C., Carroll, I. 2009; 34 (7): 1334-1336

    View details for DOI 10.1016/j.jhsa.2009.04.003

    View details for PubMedID 19481362

    View details for PubMedCentralID PMC2935247

  • Cutaneous Neuroma Physiology and Its Relationship to Chronic Pain JOURNAL OF HAND SURGERY-AMERICAN VOLUME Curtin, C., Carroll, I. 2009; 34A (7): 1334-1336
  • Pinch and elbow extension restoration in people with tetraplegia: a systematic review of the literature. journal of hand surgery Hamou, C., Shah, N. R., DiPonio, L., Curtin, C. M. 2009; 34 (4): 692-699

    Abstract

    We conducted a systematic review of the literature to summarize the available data on reconstructive surgeries involving pinch reconstruction and elbow extension restoration in people with tetraplegia.English-language and French-language articles and abstracts published between 1966 and February 2007, identified through MEDLINE and EMBASE searches, bibliography review, and expert consultation, were reviewed for original reports of outcomes with pinch reconstruction and elbow extension restoration in tetraplegic patients after a spinal cord injury. Two reviewers independently extracted data on patient characteristics, surgical methods, and patient outcomes.Our search identified 765 articles, of which 37 met eligibility criteria (one article contained information on both elbow and pinch procedures). Results from 377 pinch reconstructions in 23 studies and 201 elbow extension restorations in 14 studies were summarized. The mean Medical Research Council score for elbow extension went from 0 to 3.3 after reconstruction. The overall mean postoperative strength measured after surgery for pinch reconstruction was 2 kg.More than 500 patients having these procedures experienced a clinically important improvement for both procedures-one restoring elbow extension, and the other, pinch strength. Upper-limb surgeries markedly improved the hand function of people with tetraplegia.Therapeutic IV.

    View details for DOI 10.1016/j.jhsa.2008.12.002

    View details for PubMedID 19345872

    View details for PubMedCentralID PMC2794307

  • Pinch and Elbow Extension Restoration in People With Tetraplegia: A Systematic Review of the Literature JOURNAL OF HAND SURGERY-AMERICAN VOLUME Hamou, C., Shah, N. R., DiPonio, L., Curtin, C. M. 2009; 34A (4): 692-699

    Abstract

    We conducted a systematic review of the literature to summarize the available data on reconstructive surgeries involving pinch reconstruction and elbow extension restoration in people with tetraplegia.English-language and French-language articles and abstracts published between 1966 and February 2007, identified through MEDLINE and EMBASE searches, bibliography review, and expert consultation, were reviewed for original reports of outcomes with pinch reconstruction and elbow extension restoration in tetraplegic patients after a spinal cord injury. Two reviewers independently extracted data on patient characteristics, surgical methods, and patient outcomes.Our search identified 765 articles, of which 37 met eligibility criteria (one article contained information on both elbow and pinch procedures). Results from 377 pinch reconstructions in 23 studies and 201 elbow extension restorations in 14 studies were summarized. The mean Medical Research Council score for elbow extension went from 0 to 3.3 after reconstruction. The overall mean postoperative strength measured after surgery for pinch reconstruction was 2 kg.More than 500 patients having these procedures experienced a clinically important improvement for both procedures-one restoring elbow extension, and the other, pinch strength. Upper-limb surgeries markedly improved the hand function of people with tetraplegia.Therapeutic IV.

    View details for DOI 10.1016/j.jhsa.2008.12.002

    View details for Web of Science ID 000264998800013

    View details for PubMedCentralID PMC2794307

  • Perceptions of people with tetraplegia regarding surgery to improve upper-extremity function. journal of hand surgery Wagner, J. P., Curtin, C. M., Gater, D. R., Chung, K. C. 2007; 32 (4): 483-490

    Abstract

    In the United States, more than 100,000 Americans live with the disability of tetraplegia. These individuals must struggle through long and complicated rehabilitations. Upper-extremity reconstructive surgery can improve use of the upper limb for appropriate candidates; however, a prior national study showed that these procedures rarely are performed. This cross-sectional survey identified the attitudes and beliefs of people with tetraplegia that may dissuade potential candidates from receiving these procedures.An oral survey was designed to determine priorities of reconstruction in individuals with tetraplegia. This survey was administered to 50 people with tetraplegia.Among those surveyed, 13 (26%) had never heard of upper-extremity reconstructive surgery, but 22 (44%) were interested in upper-extremity reconstruction. People with tetraplegia who had a negative first impression of these procedures were far less likely to want reconstruction 0 (0%) vs. 11 (45%). Of patients who learned about these procedures from their physicians, 10 (67%) had a negative first impression after the physician consultation.Although many people with tetraplegia understand the benefits of upper-extremity reconstruction, a large number of them are unaware of or have unfavorable attitudes toward these procedures. These negative attitudes may account for the marked underuse of upper-extremity reconstructive procedures in the United States.

    View details for PubMedID 17398358

  • Perceptions of people with tetraplegia regarding surgery to improve upper-extremity function JOURNAL OF HAND SURGERY-AMERICAN VOLUME Wagner, J. P., Curtin, C. M., Gater, D. R., Chung, K. C. 2007; 32A (4): 483-490

    Abstract

    In the United States, more than 100,000 Americans live with the disability of tetraplegia. These individuals must struggle through long and complicated rehabilitations. Upper-extremity reconstructive surgery can improve use of the upper limb for appropriate candidates; however, a prior national study showed that these procedures rarely are performed. This cross-sectional survey identified the attitudes and beliefs of people with tetraplegia that may dissuade potential candidates from receiving these procedures.An oral survey was designed to determine priorities of reconstruction in individuals with tetraplegia. This survey was administered to 50 people with tetraplegia.Among those surveyed, 13 (26%) had never heard of upper-extremity reconstructive surgery, but 22 (44%) were interested in upper-extremity reconstruction. People with tetraplegia who had a negative first impression of these procedures were far less likely to want reconstruction 0 (0%) vs. 11 (45%). Of patients who learned about these procedures from their physicians, 10 (67%) had a negative first impression after the physician consultation.Although many people with tetraplegia understand the benefits of upper-extremity reconstruction, a large number of them are unaware of or have unfavorable attitudes toward these procedures. These negative attitudes may account for the marked underuse of upper-extremity reconstructive procedures in the United States.

    View details for DOI 10.1016/j.jhsa.2007.01.015

    View details for Web of Science ID 000245641400008

  • Opinions on the treatment of people with tetrapleqia: Contrasting perceptions of physiatrists and hand surgeons American-Spinal-Injury-Association/45th Annual Meeting of the International-Spinal-Cord-Society Curtin, C. M., Wagner, J. P., Gater, D. R., Chung, K. C. AMER PARAPLEGIA SOC. 2007: 256–62

    Abstract

    Upper-extremity reconstruction for people with tetraplegia is underused, and we felt that physicians' beliefs could be contributing to this phenomenon. This research sought to determine whether (a) physicians underestimate the importance of upper-extremity function for people with tetraplegia, (b) physiatrists and hand surgeons disagree on the quality of life of those with tetraplegia, (c) surgeons believe that social issues make people with tetraplegia poor surgical candidates, and (d) the 2 specialties disagree on the benefits of upper-extremity reconstruction.A self-administered questionnaire was mailed to a national sample of 384 physiatrists and 379 hand surgeons. The data were analyzed with bivariate statistics.The response rate was 62%. 65% of surgeons and 49% of physiatrists (P < 0.001) ranked upper-extremity function as the most important rehabilitative goal for people with tetraplegia. Both specialties believed the quality of life with tetraplegia was low (less than 60 on a scale of 0 to 100, with 100 representing perfect health). The 2 specialties have significantly different opinions regarding patient compliance, social support, and the effectiveness of surgery.The majority of physicians believe that upper-extremity function is a rehabilitative priority for people with tetraplegia. However, physiatrists and hand surgeons have significantly different views about people with tetraplegia and the benefits of reconstructive surgery. Physician preconceptions and interdisciplinary divergence may be contributing to the underuse of these procedures, and these issues should be considered when designing programs to improve access to these procedures.

    View details for Web of Science ID 000247888700008

    View details for PubMedID 17684892

  • Upper extremity reconstruction in the tetraplegic population, a national epidermiologic study JOURNAL OF HAND SURGERY-AMERICAN VOLUME Curtin, C. M., Gater, D. R., Chung, K. C. 2005; 30A (1): 94-99

    Abstract

    More than 100,000 Americans live with the disability of tetraplegia. For these people their level of independence often is related to the function of the upper extremity. Reconstructive procedures can improve the use of the upper limb and multiple case series have shown benefit from these procedures for appropriate candidates. Discussions with patients and surgeons, however, suggest that these procedures rarely are performed. This study attempted to assess whether upper extremity reconstruction for the tetraplegic population is being used properly.Data from 2 inpatient national databases were used (the National Inpatient Sample and Veterans Affairs patient treatment files) for 1988, 1989, 1999, and 2000. Patients were selected by International Classification of Diseases (ICD-9) diagnosis codes for tetraplegia and procedure codes that could represent upper extremity reconstruction. The recommended rate of these surgeries was based on the annual incidence of tetraplegia (5,000) and expert opinion that suggests at least 50% of these people would benefit from upper extremity surgery.Our health care data analysis showed that fewer than 355 of these surgeries were performed in the United States in any year queried. The calculated recommended rate was 2,500 procedures a year, meaning that only 14% of appropriate candidates were receiving upper extremity reconstruction. We also found changes in the expected primary payor, with Medicaid paying for far fewer procedures in 2000 compared with 1988 claims. Finally over the course of time it appears that far fewer of these procedures are being performed.Functional upper extremity reconstruction for the tetraplegic population is profoundly underused in the United States. Various factors could be causing this disparity of care and we recommend further research into the potential barriers to health care for this vulnerable population.

    View details for Web of Science ID 000226917200014

  • Physician perceptions of upper extremity reconstruction for the person with tetraplegia JOURNAL OF HAND SURGERY-AMERICAN VOLUME Curtin, C. A., Hayward, R. A., Kim, H. M., Gater, D. R., Chung, K. C. 2005; 30A (1): 87-93

    Abstract

    Upper extremity reconstruction for people with tetraplegia can improve upper-limb function substantially and enhance independence; however, these surgical procedures rarely are performed. This study attempted to identify barriers preventing appropriate candidates from receiving these procedures.A questionnaire was mailed to a national sample of 379 hand surgeons and 384 physiatrists with an interest in spinal cord medicine. The statistical model assessed 2 main outcomes of the physician survey: (1) whether the provider had been involved in at least one of these procedures in the past year and (2) whether the provider desired to be more involved. We hypothesized that these outcomes were associated with provider attitudes and beliefs and failures of the health care system referral networks.Most hand surgeons and physiatrists believed that these procedures were beneficial; however, few had either performed or referred even one case over the past year. Multivariable models suggested that a predominant factor in whether these procedures were being performed was the presence of a relationship between the surgeon and physiatrist.A lack of coordinated cross-specialty relationships appears to present the largest barrier to the appropriate use of upper extremity reconstruction for people with tetraplegia.

    View details for DOI 10.1016/j.jhsa.2004.08.014

    View details for Web of Science ID 000226917200013

  • Physician perceptions of upper extremity reconstruction for the person with tetraplegia. journal of hand surgery Curtin, C. M., Hayward, R. A., Kim, H. M., Gater, D. R., Chung, K. C. 2005; 30 (1): 87-93

    Abstract

    Upper extremity reconstruction for people with tetraplegia can improve upper-limb function substantially and enhance independence; however, these surgical procedures rarely are performed. This study attempted to identify barriers preventing appropriate candidates from receiving these procedures.A questionnaire was mailed to a national sample of 379 hand surgeons and 384 physiatrists with an interest in spinal cord medicine. The statistical model assessed 2 main outcomes of the physician survey: (1) whether the provider had been involved in at least one of these procedures in the past year and (2) whether the provider desired to be more involved. We hypothesized that these outcomes were associated with provider attitudes and beliefs and failures of the health care system referral networks.Most hand surgeons and physiatrists believed that these procedures were beneficial; however, few had either performed or referred even one case over the past year. Multivariable models suggested that a predominant factor in whether these procedures were being performed was the presence of a relationship between the surgeon and physiatrist.A lack of coordinated cross-specialty relationships appears to present the largest barrier to the appropriate use of upper extremity reconstruction for people with tetraplegia.

    View details for PubMedID 15680561

  • Upper extremity reconstruction in the tetraplegic population, a national epidemiologic study. journal of hand surgery Curtin, C. M., Gater, D. R., Chung, K. C. 2005; 30 (1): 94-99

    Abstract

    More than 100,000 Americans live with the disability of tetraplegia. For these people their level of independence often is related to the function of the upper extremity. Reconstructive procedures can improve the use of the upper limb and multiple case series have shown benefit from these procedures for appropriate candidates. Discussions with patients and surgeons, however, suggest that these procedures rarely are performed. This study attempted to assess whether upper extremity reconstruction for the tetraplegic population is being used properly.Data from 2 inpatient national databases were used (the National Inpatient Sample and Veterans Affairs patient treatment files) for 1988, 1989, 1999, and 2000. Patients were selected by International Classification of Diseases (ICD-9) diagnosis codes for tetraplegia and procedure codes that could represent upper extremity reconstruction. The recommended rate of these surgeries was based on the annual incidence of tetraplegia (5,000) and expert opinion that suggests at least 50% of these people would benefit from upper extremity surgery.Our health care data analysis showed that fewer than 355 of these surgeries were performed in the United States in any year queried. The calculated recommended rate was 2,500 procedures a year, meaning that only 14% of appropriate candidates were receiving upper extremity reconstruction. We also found changes in the expected primary payor, with Medicaid paying for far fewer procedures in 2000 compared with 1988 claims. Finally over the course of time it appears that far fewer of these procedures are being performed.Functional upper extremity reconstruction for the tetraplegic population is profoundly underused in the United States. Various factors could be causing this disparity of care and we recommend further research into the potential barriers to health care for this vulnerable population.

    View details for PubMedID 15680562

  • Autonomic dysreflexia: A plastic surgery primer ANNALS OF PLASTIC SURGERY Curtin, C. M., Gater, D. R., Chung, K. C. 2003; 51 (3): 325-329

    Abstract

    Plastic surgeons are integral to the management team for patients with spinal cord injuries, with responsibilities including pressure sore management and upper extremity reconstruction. Injury to the spinal cord profoundly disrupts the body's ability to maintain homeostasis. In particular, the autonomic system can become unregulated, resulting in a massive sympathetic discharge called autonomic dysreflexia. Autonomic dysreflexia occurs in the majority of patients with injuries above the sixth thoracic vertebra and causes sudden, severe hypertension. If left untreated, autonomic dysreflexia can result in stroke or death. Because this syndrome causes morbidity and mortality, it is crucial for plastic surgeons to be able to recognize and treat autonomic dysreflexia. This article reviews the etiology, symptoms, and treatment of this syndrome.

    View details for Web of Science ID 000185324300018

    View details for PubMedID 12966249