Search

: The US health care system is struggling with rising costs, poor outcomes, waste, and inefficiency. The Patient Protection and Affordable Care Act represents a substantial effort to improve access and emphasizes value-based care. Value in health care has been defined as health outcomes for the patient per dollar spent. However, given the opacity of health outcomes and cost, the identification and quantification of patient-centered value is problematic. These problems are magnified by highly technical, specialized care (eg, neurosurgery). This is further complicated by potentially competing interests of the 5 major stakeholders in health care: patients, doctors, payers, hospitals, and manufacturers. These stakeholders are watching with great interest as health care in the United States moves toward a value-based system. Market principles can be harnessed to drive costs down, improve outcomes, and improve overall value to patients. However, there are many caveats to a market-based, value-driven system that must be identified and addressed. Many excellent neurosurgical efforts are already underway to nudge health care toward increased efficiency, decreased costs, and improved quality. Patient-centered shared value can provide a philosophical mooring for the development of health care policies that utilize market principles without losing sight of the ultimate goals of health care, to care for patients.

Aim: The aim of this study is an analysis of the changing authorship patterns and publishing habits encountered in papers published in the European Journal of Pediatric Surgery (EJPS) over the past 10 years. Furthermore, it seeks to anticipate the trends in the years ahead., Materials and Methods: We conducted a retrospective review of articles published in the EJPS during a 10-year period (January 1, 2003-December 31, 2012). Each article was classified as an Original Report/Original Article (OR/OA) or as a Case Report/Case Gallery (CR/CG), and they were analyzed separately. For investigation of the percentage distribution of publications according to the number of authors per articles, papers were combined and into three groups (1-2, 3-5, and 6 ≤ authors). The analysis focused on whether the work was done by members of one institution, or in collaboration with other units of the same institution, or in collaboration with other national or multinational institutes., Results: In the past 10 years, the EJPS published 996 articles (616 ORs/OAs, 380 CRs/CGs). The one and two authored publications (125) have not decreased, the three to five authored articles (552) changed minimally, whereas the number of 6 ≤ authored publications (319) has increased. Of 996 publications, 348 were from single institutes and 648 were written in collaboration with two or more other institutes. In addition, in this 10-year period, the number of multinational articles has increased significantly from 24 to 59., Conclusion: Increase in cooperation within and between institutions is a positive trend, aiming with the goal of improving quality of publications., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: The splintering of general surgery into subspecialties in the past decade has brought into question the relevance of a continued emphasis on traditional general surgical training. With the majority of trainees now expressing a preference to subspecialise early, this study sought to identify if the requirement for proficiency in managing general surgical conditions has reduced over the past decade through comparison of general and specialty surgical admissions at a tertiary referral center., Methods: A cross-sectional review of all surgical admissions at Cork University Hospital was performed at three individual time points: 2002, 2007 & 2012. Basic demographic details of both elective & emergency admissions were tabulated & analysed. Categorisation of admissions into specialty relevant or general surgery was made using International guidelines., Results: 11,288 surgical admissions were recorded (2002:2773, 2007:3498 & 2012:5017), showing an increase of 81 % over the 10-year period. While growth in overall service provision was seen, the practice of general versus specialty relevant emergency surgery showed no statistically significant change in practice from 2002 to 2012 (p = 0.87). General surgery was mostly practiced in the emergency setting (84 % of all emergency admissions in 2012) with only 28 % elective admissions for general surgery. A reduction in length of stay was seen in both elective (3.62-2.58 bed days, p = 0.342) & emergency admissions (7.36-5.65, p = 0.026)., Conclusions: General surgical emergency work continues to constitute a major part of the specialists practice. These results emphasize the importance of general surgical training even for those trainees committed to sub-specialisation.

Aims of the Study: We hypothesized that there has been an increase in the number of successful litigation claims in pediatric surgery in England. Our aim was to report the incidence, causes, and costs of clinical negligence claims against the National Health Service (NHS) in relation to pediatric surgery., Materials and Methods: We queried the NHS Litigation Authority (NHSLA) on litigation claims among children undergoing pediatric surgery in England (2004-2012). We decided a priori to only examine closed cases (decision and payment made). Data included year of claim, year of payment of claim, payment per claim, paid-to-closed ratio, and severity of outcome of clinical incident., Results: Out of 112 clinical negligence claims in pediatric surgery, 93 (83%) were finalized-73 (65%) were settled and damages paid to the claimant and 20 (18%) were closed with no payment, and 19 (17%) remain open. The median payment was £13,537 (600-500,000) and median total cost borne by NHSLA was £31,445 (600-730,202). Claims were lodged at a median interval of 2 (0-13) years from time of occurrence with 55 (75%) cases being settled within the 3 years of being received. The commonest reasons for claims were postoperative complications (n=20, 28%), delayed treatment (n=16, 22%), and/or diagnosis (n=14, 19%). Out of 73, 17 (23%) closed claims resulted in case fatality. Conclusion: Two-thirds of all claims in pediatric surgery resulted in payment to claimant, and the commonest reasons for claims were postoperative complications, delayed treatment, and/or diagnosis. Nearly a quarter of successful claims were in cases where negligence resulted in case fatality. Pediatric surgeons should be aware of common diagnostic and treatment shortfalls as high-risk areas of increased susceptibility to clinical negligence claims., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Trauma and emergency surgery continues to evolve as a surgical niche. The simple fact that The Journal of Trauma is now entitled The Journal of Trauma and Acute Care Surgery captures this reality. We sought to characterize the niche that trauma and emergency surgeons have occupied during the maturation of the acute care surgery model., Methods: We analyzed the University Health System Consortium-Association of American Medical Colleges Faculty Practice Solutions Center database for the years 2007 to 2012 for specific current procedural terminology (CPT) codes. This database includes coding and billing data for more than 90 academic medical centers throughout the United States. We analyzed frequency counts and work relative value units (wRVUs) generated for specific codes to characterize the average trauma and emergency surgeon's work experience over time., Results: We found that acute care surgeons generated 42.4% of wRVUs from procedural work and 57.6% from cognitive work. For cognitive work, critical care services generated the most wRVUs per year (25.2% of total), and subsequent hospital care was the most frequently performed activity (1,236.6 codes generated per year). For procedural work, laparoscopic cholecystectomies produced the most wRVUs per year (2.4% of total), and placement of a nontunneled catheter was the most frequently performed procedure (42.2 times per year). The average acute care surgeon performed the following numbers of procedures per year: 29.6 cholecystectomies and 20.0 appendectomies; 7.7 wound vacuum device changes; 5.9 implantation of mesh procedures; 4.9 splenectomies and 0.4 splenorrhaphies; 2.6 perirectal abscess drainage procedures; less than one component separation fascial hernia repair; and less than one video-assisted thoracic surgery., Conclusion: The modern acute care surgeon is a hybrid of critical care medicine physician and ever-evolving surgical interventionist. Acute care surgeons continue to do traditional trauma work while increasingly performing acute care surgeries. The work of acute care surgeons serves a growing role and fills a valuable niche in our health care system.

Paediatric surgeons remain paediatric clinicians who have the unique skill set to treat children with surgical problems that may require operative intervention. Many of the advances in paediatric surgical care have occurred outside the operating theatre and have involved significant input from medical, nursing and allied health colleagues. The establishment of neonatal intensive care units, especially those focusing on the care of surgical infants, has greatly enhanced the survival rates and long-term outcomes of those infants with major congenital anomalies requiring surgical repair. Educational initiatives such as the advanced trauma life support and emergency management of severe burns courses have facilitated improved understanding and clinical care. Paediatric surgeons have led with the non-operative management of solid organ injury following blunt abdominal trauma. Nano-crystalline burn wound dressings have enabled a reduced frequency of painful dressing changes in addition to effective antimicrobial efficacy and enhanced burn wound healing. Burns care has evolved so that many children may now be treated almost exclusively in an ambulatory care setting or as day case-only patients, with novel technologies allowing accurate prediction of burn would outcome and planning of elective operative intervention to achieve burn wound closure., (© 2013 The Authors. Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians).)

This "What's new in instrumental dermatology" focuses on cutaneous oncologic surgery, base on a review of the 2012-2014 literature. First, the ability of dermatologists to make a good "oncologic reading of tumors" is the key of radical surgical treatment. Advantages and disadvantages of the biopsy are discussed. Then, the second message is the management of anticoagulants, that should not be interrupted for skin surgery. Despite recommendations, this practice is not followed in 40% of cases; this point is critical because bleeding complications are minor compared to potential morbidity of thrombotic events when stopping these medications. Regarding infection, nasal carriage of Staphylococcus aureus is identified as a risk factor for wound infection. A preoperative shower with chlorhexidine and mupirocin topical decolonization of nostril reduces this risk. Surgical techniques are trying to reach minimalism, by reducing undermining and scarring. On the trunk, using deep slow resorbable sutures improve scarring. In addition using adhesive sutures (strip) reduce the wideness of scar. On the face, the lower third of the nose is the most challenging because of the free edges, which are deformable. In this location bilobed or trilobed transposition flap offer the advantage of remaining in the nasal aesthetic unit and not disturbing the free edges of the nasal orifices. Regarding scarring, early hypertrophic scar is now well defined and linked with transposition flaps of the nasal region. An early treatment with intralesional corticosteroid injection appears to be effective. Finally, the biological mechanism of the effectiveness of compression in the prevention and treatment of dystrophic scar is now clear. The mechanotransduction explain how a mechanical stress of the skin activates biological cell pathways, which regulate the quality of collagen synthesis and the arrangement of skin fibrosis., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

The authors studied trends and patterns in the literature of research labeled as clinical (i.e., having the word "clinical" in their title) in the period between 1991 and 2010. The main findings are: 1. The growth of the literature under study was somewhat stronger than that of the overall medical literature. 2. The dominance of the USA is strong but is challenged by some of the most rapidly developing countries (particularly in the Far-East region: China, Korea) in total production, and by the developed European countries in highly cited publications. The eminence of Italy is remarkable. 3. In comparing the medical fields, the most striking tendencies are the increase of oncology and the attenuation of internal medicine. Surgery is steadily growing in size but decreasing in its citation influence. 4. Word frequency studies support the ever growing weight of oncology and also of genetics. 5. Beyond the thematic changes, word frequency studies also reveal a substantial change in attitude: in the period under study more and more effort was made on emphasizing the usefulness, efficiency and risks of the results in contrast with the more descriptive, investigative approach of the past. The role of therapy is growing, the role of diagnostics is decreasing. The knowledge of these trends and patterns may orient health and science policy makers to cope appropriately with the ever changing world of clinical research.

Background: Carotid endarterectomy (CEA) is currently performed by various surgical specialties with varying outcomes. This study analyzes different surgical practice patterns and their effect on perioperative stroke and cost., Methods: This is a retrospective analysis of prospectively collected data of 1000 consecutive CEAs performed at our institution by three different specialties: general surgeons (GS), cardiothoracic surgeons (CTS), and vascular surgeons (VS)., Results: VS did 474 CEAs, CTS did 404, and GS did 122. VS tended to operate more often on symptomatic patients than CTS and GS: 40% vs 23% and 31%, respectively (P < .0001). Preoperative workups were significantly different between specialties: duplex ultrasound (DUS) only in 66%, 30%, and 18%; DUS and computed tomography angiography in 27%, 35%, and 29%; and DUS and magnetic resonance angiography in 6%, 35%, and 52% for VS, CTS, and GS, respectively (P < .001). The mean preoperative carotid stenosis was not significantly different between the specialties. The mean heparin dosage was 5168, 7522, and 5331 units (P = .0001) and protamine was used in 0.2%, 19%, and 8% (P < .0001) for VS, CTS, and GS, respectively. VS more often used postoperative drains; however, no association was found between heparin dosage, protamine, and drain use and postoperative bleeding. Patching was used in 99%, 93%, and 76% (P < .0001) for VS, CTS, and GS, respectively. Bovine pericardial patches were used more often by CTS and ACUSEAL (Gore-Tex; W. L. Gore and Associates, Flagstaff, Ariz) patches were used more often by GS (P < .0001). The perioperative stroke/death rates were 1.3% for VS and 3.1% for CTS and GS combined (P = .055); and were 0.7% for VS and 3% for CTS and GS combined for asymptomatic patients (P < .034). Perioperative stroke rates for patients who had preoperative DUS only were 0.9% vs 3.3% for patients who had extra imaging (computed tomography angiography/magnetic resonance angiography; P = .009); and were 0.9% vs 3% for asymptomatic patients (P = .05). When applying hospital billing charges for preoperative imaging workups (cost of DUS only vs DUS and other imaging), the VS practice pattern would have saved $1180 per CEA over CTS and GS practice patterns; a total savings of $1,180,000 in this series., Conclusions: CEA practice patterns differ between specialties. Although the cost was higher for non-VS practices, the perioperative stroke/death rate was somewhat higher. Therefore, educating physicians who perform CEAs on cost-saving measures may be appropriate., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Ratios of women graduating from the only US military medical school and entering surgical internships were reviewed and compared with national trends., Methods: Data were obtained from the Uniformed Services University of the Health Sciences graduation announcements from 2002 to 2012., Results: There were 1,771 graduates from 2002 to 2012, with 508 female (29%) and 1,263 male (71%) graduates. Female graduates increased over time (21% to 39%; P = .014). Female general surgery interns increased from 3.9% to 39% (P = .025). Female overall surgical subspecialty interns increased from 20% in 2002 to 36% in 2012 (P = .046). Women were represented well in obstetrics (57%), urology (44%), and otolaryngology (31%), but not in neurosurgery, orthopedics, and ophthalmology (0% to 20%)., Conclusions: The sex disparity between military and civilian medical students occurs before entry. Once in medical school, women are just as likely to enter general surgery or surgical subspecialty as their male counterparts. Increased ratio of women in the class is unlikely to lead to a shortfall except in specific subspecialties., (Published by Elsevier Inc.)

Craniofacial surgery, in the strictest sense, is the surgery of structures above and behind the maxilla. Craniofacial surgery is not new to India and has been around for more than 4 decades now since the 1970s. Keeping in mind the promotion of the specialty in India, an Indian Craniofacial Foundation was launched in the year 2012 at the Annual Meeting of the Association of Plastic Surgeons of India. To develop a craniofacial center in India, the primary requirement is a source of funding. Several craniofacial centers, which are already running successfully in India, have amply demonstrated that this can be done in several ways. We would like to discuss here the 2 models of craniofacial service delivery and training that the authors have seen and experienced firsthand.

General surgery has become increasingly fragmented into subspecialties and diseases previously treated by general surgeons are now managed by "specialists". The Resident Education Committee of the Society for Surgery of the Alimentary Tract (SSAT) has reviewed the history of surgical training and factors that have contributed to this evolution to subsepcialization. As it is unlikely that this paradigm shift is reversible, a clear understanding of the contributing factors is essential. Herein, we present a timeline and taxonomy of forces in this evolution to subspecialization.

Background: There is significant lack of information regarding the Canadian pediatric surgery workforce., Methods: An IRB-approved survey aimed at assessing workforce issues was administered to pediatric surgeons and pediatric surgery chiefs in Canada in 2012., Results: The survey was completed by 98% of practicing surgeons and 13 of the 18 division chiefs. Only 6% of surgeons are older than 60 years, and only a fifth anticipate retirement over the next decade. The workforce is stable, with 82% of surgeons unlikely to change current positions. Surgical volume showed essentially no growth during the 5-year period 2006-2010. The majority of surgeons felt they were performing the right number or too few cases and anticipated minimal or no future growth in their individual practices or that of their group. Based on anticipated vacancies, the best estimate is a need for 20 new pediatric surgeons over the next decade. This need is significantly surpassed by the current output from the Canadian training programs., Conclusions: The Canadian pediatric surgery workforce is currently saturated. The mismatch between the number of graduating trainees and the available positions over the next decade has significant repercussions for current surgery and pediatric surgery residents wishing to practice in Canada., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Length of training (LOT), lifestyle, and decreasing reimbursement have been credited with contributing to the decline in applications to thoracic surgery (TS). Other surgical specialties share similarities in LOT and lifestyle; however, trends in applications for these specialties have not been compared. One cannot look at applications to TS without examining concurrent changes in the pool of residents finishing general surgery. To clarify the relative impact of LOT, lifestyle, applicant pool, and reimbursement on applications to TS, we analyzed these trends concurrently., Methods: National Resident Matching Program residency and fellowship match placement data (1997 to 2012) for general, TS, pediatric, transplant, and vascular surgery, including integrated TS and vascular surgery, were analyzed. Corresponding trends in reimbursement were analyzed from Medical Group Management Association data (1996 to 2010)., Results: During the study period, percentage of medical students matching into general surgery has remained relatively constant (4.9% to 5.5%). Applications for TS have declined since 1997. Applications for pediatric and transplant surgery have increased. Vascular surgery has remained relatively constant, with an applicant to position ratio approximately 1:1. Integrated programs (thoracic and vascular) have been popular; 3 to 7.4 applicants per position and 2 to 3.47 applicants per position, respectively. Cardiovascular surgery median salaries have remained largely the same; salaries for general thoracic, pediatric, transplant, and vascular surgery have increased (1.95% to 7.13% per year) although cardiovascular surgeons continue to have the highest median salary., Conclusions: Given the above data, it does not appear that LOT is the critical issue associated with the decline in fellowship applications for TS. The increased demand for integrated training programs may be reflective of other factors rather than LOT. The success of abbreviated programs in training competent thoracic surgeons has not yet been determined. Given that LOT does not appear to affect applications to surgical specialty, we may be able to maintain applications to the specialty without compromising LOT., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Little data exists on temporal changes in the care of children with common surgical conditions. We hypothesized that an increasing proportion of procedures are performed at pediatric hospitals over time, and that outcomes are superior at these centers., Methods: We conducted a retrospective cohort study using Washington State discharge records for children 0-17years old undergoing appendectomy (n=39,472) or pyloromyotomy (n=3,500). Pediatric hospitals were defined as centers with full-time pediatric surgeons. Outcomes were examined for two time periods (1987-2000, 2001-2009)., Results: From 1987 to 2009, the proportion of procedures performed at pediatric hospitals steadily increased. The percentage for appendectomies increased from 17% to 32%, and that for pyloromyotomies increased from 57% to 99%. For pyloromyotomy, care at a pediatric hospital was associated with decreased risk of postoperative complications (OR=0.36, p<0.001) for both time periods. Appendectomy outcomes did not differ significantly in the early time period, but in the later time period specialist care was associated with lower risk of complications in children <5years (OR=0.54, p=0.03)., Conclusion: There has been a shift towards pediatric hospitals for certain procedures, with a widening disparity in outcomes for younger children. These results suggest that procedures in younger patients may best be performed by providers familiar with these patient populations., (© 2014.)

Background: Scholarly activity is expected of program directors of Accreditation Council for Graduate Medical Education (ACGME)-accredited residency training programs. Anesthesiology residency programs are cited more often than surgical programs for deficiencies in academic productivity. We hypothesized that this may in part reflect differences in scholarly activity between program directors of anesthesiology and surgical trainings programs. To test the hypothesis, we examined the career track record of current program directors of ACGME-accredited anesthesiology and surgical residency programs at the same institutions using PubMed citations and funding from the National Institutes of Health (NIH) as metrics of scholarly activity., Methods: Between November 1, 2011 and December 31, 2011, we obtained data from publicly available Web sites on program directors at 127 institutions that had ACGME-accredited programs in both anesthesiology and surgery. Information gathered on each individual included year of board certification, year first appointed program director, academic rank, history of NIH grant funding, and number of PubMed citations. We also calculated the h-index for a randomly selected subset of 25 institution-matched program directors., Results: There were no differences between the groups in number of years since board certification (P = 0.42), academic rank (P = 0.38), or years as a program director (P = 0.22). However, program directors in anesthesiology had less prior or current NIH funding (P = 0.002), fewer total and education-related PubMed citations (both P < 0.001), and a lower h-index (P = 0.001) than surgery program directors. Multivariate analysis revealed that the publication rate for anesthesiology program directors was 43% (95% confidence interval, 0.31-0.58) that of the corresponding program directors of surgical residency programs, holding other variables constant., Conclusions: Program directors of anesthesiology residency programs have considerably less scholarly activity in terms of peer-reviewed publications and federal research funding than directors of surgical residency programs. As such, this study provides further evidence for a systemic weakness in the scholarly fabric of academic anesthesiology., Competing Interests: Name: Deborah J. Culley, MD Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript Attestation: Deborah J. Culley has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files Conflicts of Interest: Deborah J. Culley received honoraria from American Board of Anesthesiology Dr. Culley is a Director of the American Board of Anesthesiology and a member of the ACGME Anesthesiology RRC Name: Brenda G. Fahy, MD Contribution: This author helped design the study, conduct the study, and write the manuscript Attestation: Brenda G. Fahy has seen the original study data and approved the final manuscript Conflicts of Interest: Brenda G. Fahy received honoraria from American Board of Anesthesiology Dr. Fahy is a Director of the American Board of Anesthesiology and a member of the ACGME Anesthesiology RRC. Name: Zhongcong Xie, MD, PhD Contribution: This author helped write the manuscript Attestation: Zhongcong Xie has seen the original study data and approved the final manuscript Conflicts of Interest: The author has no conflicts of interest to declare. Name: Robert Lekowski, MD Contribution: This author helped conduct the study and write the manuscript Attestation: Robert Lekowski has seen the original study data and approved the final manuscript Conflicts of Interest: The author has no conflicts of interest to declare. Name: Sascha Buetler, MD, PhD Contribution: This author helped conduct the study and write the manuscript Attestation: Sascha Buetler has seen the original study data and approved the final manuscript Conflicts of Interest: The author has no conflicts of interest to declare. Name: Xiaoxia Liu, MS Contribution: This author helped with statistical support and rewriting of the manuscript Attestation: Xiaoxia Liu has seen the original study data and approved the final manuscript Conflicts of Interest: The author has no conflicts of interest to declare. Name: Neal H. Cohen, MD Contribution: This author helped design the study and write the manuscript Attestation: Neal H. Cohen has seen the original study data and approved the final manuscript Conflicts of Interest: Neal H. Cohen Former Chairman of the ACGME Anesthesiology RRC. Name: Gregory Crosby, MD Contribution: This author helped design the study, analyze the data, and write the manuscript Attestation: Gregory Crosby has seen the original study data, reviewed the analysis of the data, and approved the final manuscript Conflicts of Interest: The author has no conflicts of interest to declare.

Vascular surgery is evolving from being a sub-specialty of general surgery to becoming a separate surgical specialty. This will have implications in terms of the training, skill-set and workload of surgeons working in the NHS. There are implications for the military too, as a deploying trauma team must have both general and vascular surgical capabilities. This article explores the reasons for the changes occurring and discusses the wider implications.

Background: Demand for dermatologic care is increasing alongside a known shortage of physicians in the dermatology workforce. Changes in the volume of dermatologic procedures over time and the physician specialties involved in skin-related procedural care are not well characterized., Objective: To determine the frequency of dermatologic procedures performed in the United States between 1995 and 2010 and to analyze the changes in the procedures and physicians performing procedures over time., Methods: The annual volume of skin-related procedures performed by physician specialties and the rate of procedures performed per physician was determined from data from the National Ambulatory Medical Care Survey (NAMCS) between 1995 to 2004 and 2007 to 2010., Results: Dermatologists and primary care physicians performed most procedures (54.7% and 19.5%, respectively)., Conclusions: Dermatologists perform a larger volume of procedures than in the past, although the proportion of procedures performed by dermatologists is unchanged, and other physician specialties are performing more skin-related procedures to meet increasing demand., (© 2013 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.)

Since June 2013 a hybrid operation theatre is used interdisciplinary in the department for surgery of Ulm University. In this operation theatre a floor-based flat panel c-arm, which is mounted on a robotic arm that can be controlled by the surgeon in a sterile environment, is linked to the operating table. Furthermore for the first time it was possible to integrate a navigation system in this setting. The interdisciplinary utilization (trauma, neurosurgery, cardiac and vascular surgery) makes this hybrid operation theatre very time and cost effective. In the orthopedic trauma department this system is mainly used for traumatic and oncologic pelvic and spinal injuries. In these anatomical regions the excellent image quality and large field of view of the robotic flat panel detector based 3D imaging combined with an intraoperative navigation system is a huge advantage. The system can also be used for complex fractures of the extremities. In the future there will be an integration of further imaging modalities and referenced holding devices in this setting.

Objectives/hypothesis: (1) To determine the characteristics of outpatient otolaryngology offices with an electronic medical record (EMR) system, and (2) to compare those characteristics with the trends in surgical and medical specialties., Study Design: Cross-sectional analysis of U.S. representative data from the National Ambulatory Medical Care Survey (NAMCS)., Methods: The 2005 to 2010 NAMCS datasets were analyzed. Physicians' specialty was recoded as otolaryngology, all surgical specialties, and all specialties combined. Physician offices with all- or partial-EMR system adoption were then compared to offices without EMR systems with respect to year; geographic region; urban setting; office setting; practice type; practice ownership; employment status; and revenues from Medicare, Medicaid, private insurance, and patient payment., Results: Upon univariate analysis, EMR use was significantly higher among otolaryngology practices located in metropolitan areas and practices run or owned by larger groups of practitioners. Sources of patient revenue did not correlate with the likelihood of EMR use. Multivariate analysis revealed that EMR use by otolaryngologists was significantly associated with group practices and offices owned by institutions. Similar associations were observed with surgical specialties combined in addition to a higher EMR usage in practices with more than 25% of total revenue from private insurance., Conclusions: EMR utilization by otolaryngology practices appears similar to that of other specialties, and is more likely in metropolitan areas and larger practice settings. Despite the announcement of incentive programs under Medicare and Medicaid in 2009, EMR usage was not dependent on the percentage of physicians' total revenue from these sources., (Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Cosmetic procedures, particularly those that are minimally invasive, are in demand. The physician specialties performing these procedures are not well-characterized., Objective: To examine changes in the frequency of cosmetic dermatologic procedures performed in the United States from 1995 to 2010 and the physician specialties performing them., Methods: The volume of cosmetic procedures performed by physician specialties and the types of cosmetic procedures performed were determined from data from the National Ambulatory Medical Care Survey (NAMCS) from 1995 to 2010., Results: Cosmetic procedures constituted 8.7% of all skin procedures and have increased since 1995 (p < .001). Botulinum toxin injections were the most frequently performed cosmetic procedure and increased at the greatest rate over time. Plastic surgeons performed the largest proportion of cosmetic procedures (36.1%), followed by dermatologists (33.7%), but other specialties have been performing an increasing proportion of cosmetic procedures. This study was limited to the provision of outpatient procedures, and the nationally representative data of the NAMCS is subject to sample bias., Conclusions: Plastic surgeons and other physicians performed the majority of outpatient cosmetic procedures. Dermatologists performed one-third of ambulatory cosmetic procedures from 1995 to 2010. This broadening spectrum of physicians and nonphysicians providing cosmetic procedures may have important implications for patient safety., (© 2013 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.)

Objective: To develop a projection model to forecast the head count and full-time equivalent supply of surgeons by age, sex, and specialty in the United States from 2009 to 2028., Summary Background Data: The search for the optimal number and specialty mix of surgeons to care for the United States population has taken on increased urgency under health care reform. Expanded insurance coverage and an aging population will increase demand for surgical and other medical services. Accurate forecasts of surgical service capacity are crucial to inform the federal government, training institutions, professional associations, and others charged with improving access to health care., Methods: The study uses a dynamic stock and flow model that simulates future changes in numbers and specialty type by factoring in changes in surgeon demographics and policy factors., Results: : Forecasts show that overall surgeon supply will decrease 18% during the period form 2009 to 2028 with declines in all specialties except colorectal, pediatric, neurological surgery, and vascular surgery. Model simulations suggest that none of the proposed changes to increase graduate medical education currently under consideration will be sufficient to offset declines., Conclusions: The length of time it takes to train surgeons, the anticipated decrease in hours worked by surgeons in younger generations, and the potential decreases in graduate medical education funding suggest that there may be an insufficient surgeon workforce to meet population needs. Existing maldistribution patterns are likely to be exacerbated, leading to delayed or lost access to time-sensitive surgical procedures, particularly in rural areas.

Objective: To identify trends and characteristics of surgeon employment in the United States. Surgeons are increasingly choosing hospital or large group employment as their practice environment. DESIGN American Medical Association Physician Masterfile data were analyzed for the years 2001 to 2009., Setting: Surgeons identified within the American Medical Association Masterfile., Participants: Surgeons were defined using definitions from the American Medical Association specialty data and the American Board of Medical Specialties certification data and included active, nonfederal, and nonresident physicians younger than 80 years of age., Main Outcome Measures: Employment status and trends., Results: The number of surgeons who reported having their own self-employed practice decreased from 48% to 33% between 2001 and 2009, and this decrease corresponded with an increase in the number of employed surgeons. Sixty-eight percent of surgeons in the United States now self-identify their practice environment as employed. Between 2006 and 2011, there was a 32% increase in the number of surgeon in a full-time hospital employment arrangement. Younger surgeons and female surgeons increasingly favor employment in large group practices. Employment trends were similar for both urban and rural practices., Conclusions: General surgeons and surgical subspecialists are choosing hospital employment instead of independent practice. The trend is especially notable among younger surgeons and among female surgeons. The trend denotes a professional paradigm shift of major importance.

The introduction of the DRG (diagnosis-related groups) system as basis for reimbursement in the German health-care system has led to a mentality of quality orientation and verification of therapeutic results. An immediate result was the formation of medical "centres" on rather different levels and consequently the inauguration of institutions, authorities, and organisations to review these centres. Finally, a range of certifications was installed in order to stratify the rather diverse aims of different centres. This review critically evaluates the current situation in the field of general and abdominal surgery in Germany., (© Georg Thieme Verlag KG Stuttgart · New York.)

Vascular surgery is a subspecialty that attracts future surgeons with challenging technical procedures and complex decision making. Despite its appeal, continued promotion of the field is necessary to recruit and retain the best and brightest candidates. Recruitment of medical students and residents may be limited by the lifestyle inherent to vascular surgery and the length of residency training. The young adults of the current applicant and resident pool differ from prior generations in their desire for hands-on mentoring, aspirations to affect change daily, a penchant for technology, and strong emphasis on work-life balance. Furthermore, the percentage of women pursuing careers in vascular surgery is not representative of the eligible workforce. Women are now the majority of graduates in all of higher education, and thus, vascular surgery may need to make a concerted effort to appeal to women in order to attract the most talented young professionals to the field. Recruiting strategies for both men and women of Generation Y should target a diverse group of potential candidates with an awareness of the unique characteristics and needs of this generation of rising surgeons., (Copyright © 2013 Society for Vascular Surgery. All rights reserved.)