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Research and Discovery Pathways Programs
Medical Student Research Program Overview

Surgery 2020 Projects

Project Title: Laparoscopic Toupet fundoplication for lung transplant recipients: outcomes and effects on quality of life

Faculty Mentor: Alexander Ayzengart 
Email: Joshua.Yarrow@va.gov  

Student: Russell Wnek 
Email: wnekrd@ufl.edu  

Research Project Description:

Lung transplant, an effective treatment option for patients with end-stage lung diseases, has 5-year and 10-year survival rates of 54% and 31% respectively, with chronic lung allograft dysfunction (CLAD) being the greatest threat to long-term survival 1. Of the myriad of factors that trigger the onset and progression of CLAD, gastroesophageal reflux disease (GERD) and esophageal dysmotility have been shown to induce chronic obliterative bronchiolitis (BOS) or obstructive CLAD, ultimately resulting in allograft rejection and death 2. GERD, proposed to be a cause of idiopathic pulmonary fibrosis, presents frequently in patients with advanced pulmonary disease undergoing transplant evaluation. Furthermore, there is a high incidence of GERD in lung transplant patients due to vagal nerve damage, and immunosuppression 3. The micro-aspiration from GERD seems to play a role in lung rejection and fundoplications have been shown to prevent allograft dysfunction and protect against GERD-induced damage4,5.

Laparoscopic Nissen Fundoplication (LNF), a total 360° posterior wrap, has been the procedure of choice for anti-reflux surgeries for years. Patients with more severe esophageal dysmotility generally benefit from Laparoscopic Toupet Fundoplication (LTF), a posterior 270° wrap. In the general population, it is believed that LTF is as effective as LNF in terms of controlling GERD symptoms, however, LNF is associated with higher lower esophageal sphincter (LES) pressure, bloating, and higher rates of short-term dysphagia 6,7. To date, not much is known about LTF in post-lung transplant patients in terms of efficacy of controlling GERD and the rate of postoperative complications and adverse symptoms.

Patient with end-stage lung disease spend a long time on the waitlist for lung transplants due to the lack of suitable donor organs. In addition, this major surgery involves a long and tedious recovery time. As such, determining factors that will extend the survival of allograft and life expectancy of patients post-transplant is of utmost importance. This project is significant because determining if LTF could be the fundoplication of choice in lung transplant patients will greatly impact the treatment plan for our patients, especially if LTF indeed provides excellent control of GERD for our patients, but with a low rate of postoperative gastrointestinal side effects or complications.

At the University of Florida, we have observed that patients who have undergone LTF post-lung transplant seem to have excellent control of GERD, based on pH testing, and low rates of gastrointestinal complaints. We hypothesize that LTF provides excellent rates of GERD control, comparable to the published outcomes of LNF in the same patient population, with a low rate of postoperative complications.

We will present a case series determining the outcomes of LTF in post-lung transplant patients, in which, we will examine objectives measures of gastrointestinal function and other quantitative measures of lung damage and correlate these to patients’ lung function.

References:

  1. Castor JM, Wood RK, Muir AJ, Palmer SM, Shimpi RA. Gastroesophageal reflux and altered motility in lung transplant rejection. Neurogastroenterol Motil. 2010;22(8):841-850. doi:10.1111/j.1365-2982.2010.01522.x.
  2. Patti MG, Vela MF, Odell DD, Richter JE, Fisichella PM, Vaezi MF. The Intersection of GERD, Aspiration, and Lung Transplantation. J Laparoendosc Adv Surg Tech A. 2016;26(7):501-505. doi:10.1089/lap.2016.0170.
  3. Hathorn KE, Chan WW, Lo W-K. Role of gastroesophageal reflux disease in lung transplantation. World J Transplant. 2017;7(2):103-116. doi:10.5500/wjt.v7.i2.103.
  4. Fisichella PM, Davis CS, Kovacs EJ. A review of the role of GERD-induced aspiration after lung transplantation. Surg Endosc. 2012;26(5):1201-1204. doi:10.1007/s00464-011-2037-y.
  5. Biswas Roy S, Elnahas S, Serrone R, et al. Early fundoplication is associated with slower decline in lung function after lung transplantation in patients with gastroesophageal reflux disease. J Thorac Cardiovasc Surg. 2018;155(6):2762–2771.e1. doi:10.1016/j.jtcvs.2018.02.009.
  6. Lund RJ, Wetcher GJ, Raiser F, et al. Laparoscopic Toupet fundoplication for gastroesophageal reflux disease with poor esophageal body motility. J Gastrointest Surg. 1997;1(4):301–8–discussion308.
  7. Du X, Hu Z, Yan C, Zhang C, Wang Z, Wu J. A meta-analysis of long follow-up outcomes of laparoscopic Nissen (total) versus Toupet (270°) fundoplication for gastro-esophageal reflux disease based on randomized controlled trials in adults. BMC Gastroenterol. 2016;16(1):88–11. doi:10.1186/s12876-016-0502-8.

Project Title: Does Trapeziectomy Reduce the Risk of Carpal Tunnel Syndrome?

Faculty Mentor: Ellen Satteson 
Email: ellen.satteson@surgery.ufl.edu 

Student: Michael Padgett and Nicholas Schofield 
Email: mpadgett1@ufl.edu; schofieldn@ufl.edu 

Research Project Description:

This project will evaluate the effect of trapziectomy, removal of the trapezium bone commonly performed for basilar thumb arthritis, on the volume of the carpal tunnel. Clinically, this will be evaluated to see if the rates of carpal tunnel syndrome are lower in patients who have undergone trapeziectomy compared to those who have not using data from a large, national patient database. Anatomically, this will be evaluated by comparing the carpal tunnel volume in patients with and without a history of carpal tunnel syndrome using ultrasound.

Patients with thumb carpometacarpal (CMC) arthritis have been identified as having a higher prevalence of concurrent CTS. Over 50% of the radial insertion of the transverse carpal ligament (TCL) attaches to the trapezium. Thus, it has been suggested that removal of the trapezium results in a partial release of the TCL4 and subsequently reduces the compression from the carpal ligament on the median nerve which is the cause of CTS.

Patients that have undergone a trapeziectomy will have a lower incidence of carpal tunnel syndrome when compared to the general population. Patients that have had the surgery will also display an increased volume of the carpal tunnel when compared to a cadaver with an intact trapezium. This is due to the fact that the carpal ligament has a large attachment point on the trapezium and a trapeziectomy partially releases the carpal ligament. The disease mechanism of CTS is due to the carpal ligament compressing the median nerve indicating that a partial release from a trapeziectomy could be a preventative factor in developing CTS.

Specific Aims:

  1. To evaluate the rate of subsequent carpal tunnel syndrome (CTS) in patients who have undergone trapeziectomy—Does the partial release of the transverse carpal ligament from trapeziectomy decrease the likelihood of subsequently developing CTS?
  2. To evaluate the volume of the carpal tunnel in patients who have undergone trapeziectomy compared to control on ultrasound (US).

References:

. Bueno-Gracia E, Pérez-Bellmunt A, López-de-Celis C, et al. Dimensional changes of the carpal tunnel and median nerve during manual mobilization of the carpal bones — Anatomical study. Clin Biomech. 2018;59(September):56-61. doi:10.1016/j.clinbiomech.2018.09.001

  1. Cho MS, Means KR, Shrout JA, Segalman KA. Carpal tunnel volume changes of the wrist under distraction. J Hand Surg Eur Vol. 2008;33(5):648-652. doi:10.1177/1753193408092037
  2. Goldfarb CA, Kiefhaber TR, Stern PJ, Bielecki DK. The relationship between basal joint arthritis and carpal tunnel syndrome: An MRI pilot study. J Hand Surg Am. 2003;28(1):21-27. doi:10.1053/jhsu.2003.50014
  3. Kato T, Kuroshima N, Okutsu I, Ninomiya S. Effects of endoscopic release of the transverse carpal ligament on carpal canal volume. J Hand Surg Am. 1994;19(3):416-419. doi:10.1016/0363-5023(94)90055-8
  4. Mani B, Sarawagi R, Cherian RA. Review of the dimensions of the median nerve and carpal tunnel using sonography in asymptomatic adults. J Med Imaging Radiat Oncol. 2011;55(2):126-131. doi:10.1111/j.1754-9485.2010.02225.x
  5. Mogk JPM, Keir PJ. Wrist and carpal tunnel size and shape measurements: Effects of posture. Clin Biomech. 2008;23(9):1112-1120. doi:10.1016/j.clinbiomech.2008.05.009
  6. Pavlidis L, Chalidis BE, Demiri E, Dimitriou CG. The effect of transverse carpal ligament lengthening on carpal tunnel volumetry: A comparison between four techniques. Ann Plast Surg. 2010;65(5):480-484. doi:10.1097/SAP.0b013e3181d9ab44
  7. Richman JA, Gelberman RH, Rydevik BL, Gylys-Morin VM, Hajek PC, Sartoris DJ. Carpal tunnel volume determination by magnetic resonance imaging three-dimensional reconstruction. J Hand Surg Am. 1987;12(5):712-717. doi:10.1016/S0363-5023(87)80054-0
  8. Shin CH, Paik NJ, Lim JY, et al. Carpal tunnel syndrome and radiographically evident basal joint arthritis of the thumb in elderly Koreans. J Bone Jt Surg – Ser A. 2012;94(16):e120(1). doi:10.2106/JBJS.K.00839

Project Title: Comparison of Speech Outcomes using Furlow palatoplasty, pharyngeal flap, or simultaneous Furlow palatoplasty and pharyngeal flap for treatment of velopharyngeal incompetence

Faculty Mentor: Jessica Ching  
Email: jessica.ching@surgery.ufl.edu 

Student: Coulter Small
Email: colt.pauzar@ufl.edu 

Research Project Description:

Cleft palate is a common condition, with incidence of approximately 1 in 700, affecting newborns that affects multiple aspects of oral function. Therefore, cleft palate repair requires a multi-disciplinary approach involving, surgeons, dentists, and speech therapists. Although there are multiple outcomes to assess, speech outcomes are a crucial measure of success following cleft palate repair. Furthermore, as there is variability in the structure of the deformity, multiple methods of repair exist, including the Furlow palatoplasty and pharyngeal flap; however, a novel procedure of the Furlow palatoplasty with simultaneous pharyngeal flap has also been performed.

Documentation of the difference in speech outcomes between Furlow palatoplasty, pharyngeal flap, and Furlow palatoplasty with a simultaneous pharyngeal flap has not been specifically or cohesively studied. A better understanding of the relationship between the type of procedure performed and speech outcomes may guide future decisions by both parents and surgeons. Furthermore, analysis of each candidate, the type of procedure performed, and the outcome may elucidate the defining features of the optimal candidate for each procedure. Therefore, the improvement of speech based on the type of procedure—either Furlow palatoplasty, pharyngeal flap, or Furlow palatoplasty with simultaneous pharyngeal flap –and quantitative aspects of the deformity, based upon fluoroscopy, must be assessed. The aim of this retrospective cohort is to evaluate the difference in speech outcomes between Furlow palatoplasty, pharyngeal flap, and Furlow palatoplasty with simultaneous pharyngeal flap.

The hypothesis of this study is that there is a difference in speech outcomes of the pediatric population between Furlow palatoplasty, pharyngeal flap, and Furlow palatoplasty with simultaneous pharyngeal flap. To reduce confounding variables, fluoroscopy data will be compared between patients to ensure that there is no selection bias between the groups. The reason for this hypothesis is that the Furlow palatoplasty with simultaneous pharyngeal flap is a novel procedure that has not been widely studied and found to produce the same results.

Specific Aims:

To determine the difference if there is a significant difference in speech outcomes between Furlow palatoplasty, pharyngeal flap, and Furlow palatoplasty with simultaneous pharyngeal flap. Speech outcomes will be assessed through hyper/hyponasality, nasal air emission, and articulation data from speech pathologist assessment.

References:

  1. Lindsey, W. H., and P. T. Davis. “Correction of Velopharyngeal Insufficiency With Furlow Palatoplasty.” Archives of Otolaryngology – Head and Neck Surgery, vol. 122, no. 8, 1996, pp. 881–884., doi:10.1001/archotol.1996.01890200069015.
  2. Tönz, Martin, et al. “Blinded Speech Evaluation Following Pharyngeal Flap Surgery by Speech Pathologists and Lay People in Children with Cleft Palate.” Folia Phoniatrica Et Logopaedica, vol. 54, no. 6, 2002, pp. 288–295., doi:10.1159/000066153.
  3. Afrooz, P. N., Macisaac, Z., Rottgers, S., Ford, M., Grunwaldt, L. J., & Kumar, A. R. (2015). A comparison of speech outcomes using radical intravelar veloplasty or Furlow palatoplasty for the treatment of velopharyngeal insufficiency associated with occult submucous cleft palate. Annals of Plastic Surgery, 74(2), 182-186. https://doi.org/10.1097/SAP.0b013e3182956632
  4. Sullivan S, Vasudavan S, Marrinan E, et al. Submucous cleft palate and Velopharyngeal insufficiency: comparison of speech outcomes using three operative techniques by one surgeon. Cleft Palate Craniofac J. 2011;48:561Y570
  5. Moll KL. ’Objective’ measures of nasality. Cleft Palate J 1964;35: 371–374
  6. Calis, Mert, et al. “Comparison of the Speech Results After Correction of Submucous Cleft Palate With Furlow Palatoplasty and Pharyngeal Flap Combined With Intravelar Veloplasty.” Journal of Craniofacial Surgery, vol. 29, no. 1, Jan. 2018, doi:10.1097/scs.0000000000003408.
  7. Park TS, Bae YC, Nam SB, et al. Postoperative speech outcomes and complications in submucous cleft palate patients. Arch Plast Surg 2016;43:254–257

Project Title: Pediatric Upper Extremity Firearm Injuries – Risk Factors, Treatment & Prevention

Faculty Mentor: Ellen Satteson 
Email: ellen.satteson@surgery.ufl.edu 

Student:Caroline King and Mitsy Audate
Email: caroline.king@ufl.edu; Mitsy.audate@ufl.edu

Research Project Description:

National data from the Centers for Disease Control (CDC) show that 5,790 children are treated for firearm injuries annually, resulting in nearly 1,300 deaths per year. Firearm injuries to the upper extremities may result in decreased hand function or even amputation, due to damage to neurovascular structures and soft tissue. This study will evaluate pediatric patients who received care at the University of Florida for firearm related injuries to the upper extremities to (a) identify at risk patient populations and (b) better understand the mechanisms/circumstances of injury. This information may help the development of preventative firearm safety campaigns, as well as treatment algorithms for firearm injuries when they do occur.

The incidence of pediatric upper extremity firearm injuries will not vary based on patient age, gender, race/ethnicity, location of residence, type of firearm, mechanism of firearm injury, or location of incident.

Specific Aims:

Aim 1: To characterize the epidemiology, risk factors, and circumstances associated with pediatric upper extremity firearm injuries.

Aim 2: Develop treatment algorithms and educational prevention resources for pediatric upper extremity firearm injuries.

References:

  1. Nellist CC. Childhood Firearm Injuries in the United States. Pediatrics. 2017;140(1). doi:10.1542/peds.2017

Relevant Literature:

  1. Aitken ME, Minster SD, Mullins SH, et al. Parents ’ Perspectives on Safe Storage of Firearms. J Community Health. 2019;Oct 17. doi:10.1007/s10900-019-00762-2
  2. Bayouth L, Lukens-Bull K, Gurien L, Tepas JJ, Crandall M. Twenty years of pediatric gunshot wounds in our community: Have we made a difference? J Pediatr Surg. 2019;54(1):160 164. doi:10.1016/j.jpedsurg.2018.10.003
  3. 2. Dabash S, Gerzina C, et al. Pediatric Gunshot Wounds of the Upper Extremity. Int J Orthop. 2018;5(2):910-915. doi:10.17554/j.issn.2311-5106.2018.05.269
  4. 3. Omid R, Stone MA, Zalavras CG, Marecek GS. Gunshot Wounds to the Upper Extremity. J Am Acad Orthop Surg. 2019;27(7):e301-e310. doi:10.5435/JAAOS-D-17-00676

Project Title: Plastic Surgery Postoperative Outcomes Based on Surgical Facility Type

Faculty Mentor: Ellen Satteson 
Email: Esatteson@ufl.edu 

Student: Jimmy Lee
Email: jimmylee@ufl.edu  

Research Project Description:

Over the past 30 years, an increasing number of surgical procedures have been performed in ambulatory surgery centers (ASCs) and office-based surgical suites (OBSSs) rather than in hospital operating rooms. Since the 1980s the percentage of procedures performed in a hospital setting have declined from 90% to 45%.1 Advantages of OBSS include physician autonomy, technological developments, and opportunity for increased revenue.2

With this transition of surgical procedures to the office setting, however, there is concern for potential patient safety risks due less oversight and fewer regulations compared to the hospital setting.1,2 Prior studies found that procedures performed in OBSSs were associated with higher complication rates and postoperative hospitalizations compared to those performed at ASCs.2,3 In the plastic surgery literature, one study reviewing data in the CosmetAssure database found that a lower risk of complications in the office setting compared to ASCs, however, this only included cosmetic procedures and did not evaluate potential confounding factors such as American Society of Anesthesiologist (ASA) classification and medical comorbidities other than diabetes mellitus.1

To further evaluate the safety of plastic surgery procedures performed in various surgical facility types, this study will compare postoperative outcomes of common procedures performed in the hospital, ambulatory surgery center, and office-based settings using data from the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database maintained by the American Society of Plastic Surgery (ASPS). There will be fewer postoperative complications among surgeries performed in the office setting compared to those performed in an ASC or hospital based on cases logged in the TOPS database. Plastic surgeons may be more likely to perform surgery on healthier, less complication-prone patients in the office compared to patients on whom they elect to perform surgery at an ASC or hospital.

Specific Aims:

Specific Aim 1 – To determine and compare complication rates of common plastic surgeries performed in an OBSS, ASC, and hospital.

Specific Aim 2 – To evaluate if ASA classification, BMI, smoking status, and/or medical comorbidities are confounding variables affecting complication rates at the different surgical facility types

References:

  1. Gupta V, Parikh R, Nguyen L, et al. Is Office-Based Surgery Safe? Comparing Outcomes of 183,914 Aesthetic Surgical Procedures Across Different Types of Accredited Facilities. Aesthetic Surg J. 2017;37(2):226-235. doi:10.1093/asj/sjw138
  2. Ohsfeldt RL, Li P, Schneider JE, Stojanovic I, Scheibling CM. Outcomes of Surgeries Performed in Physician Offices Compared With Ambulatory Surgery Centers and Hospital Outpatient Departments in Florida. Heal Serv Insights. 2017;10:117863291770102. doi:10.1177/1178632917701025
  3. Vila H, Soto R, Cantor AB, Mackey D. Comparative outcomes analysis of procedures performed in physician offices and ambulatory surgery centers. Arch Surg. 2003;138(9):991-995. doi:10.1001/archsurg.138.9.991

Project Title: Impact of Low-Dose CT Protocol Establishment and Physician Education on Referral Time to a Craniofacial Center for Treatment of Craniosynostosis

Faculty Mentor: Jessica Ching  
Email: jessica.ching@surgery.ufl.edu 

Student:Alyssa Nielsen
Email: alyniel@ufl.edu 

Research Project Description:

Given the importance of early referral for safe consideration of all craniosynostosis treatment options, investigation of the impact of “low-dose” CT protocols on referral time to a craniofacial center or specialist could reveal a change in time between diagnosis and surgical treatment of craniosynostosis with use of this imaging protocol. Imaging studies are often indicated for diagnosis and treatment of this condition, leading to increased radiation exposure and future risk of cancer among pediatric patients suspected of having craniosynostosis (1). In addition, ordering imaging before referral to a specialist has been associated with delayed evaluation of craniosynostosis along with increased radiation exposure (2). Multiple centers have since developed low-dose head CT protocols to limit radiation exposure among pediatric candidates for craniosynostosis without significantly compromising image quality and diagnostic utility (3,4,5); accordingly, the University of Florida Craniofacial Center has adopted a low-dose CT protocol over the past two years accompanied by regional physician training on the importance of referral prior to imaging. Examination of referral patterns to the UF Craniofacial Center for patients diagnosed with craniosynostosis will reveal the impact of a low-dose CT protocol on referral time and potentially identify other factors affecting delayed referral to a specialist.

Implementation of a low-dose CT protocol for primary evaluation of craniosynostosis and concurrent physician education on the importance of referral to a specialist prior to imaging is associated with a shorter time period prior to referral. Craniosynostosis is typically evaluated and treated within the first year of life, meaning that time to craniofacial specialist evaluation is a large factor in determining treatment feasibility. One study has directly identified imaging prior to referral to a specialist as a factor associated with delayed referral time (2); this study aims to further validate this claim and assess if the absence of prior imaging compounded with a low-dose CT protocol reduces time to primary assessment of craniosynostosis.

The purpose of this study is to examine the impact of implementation of a low-dose CT protocol accompanied by regional physician education on time to referral to a craniofacial specialist for the treatment of craniosynostosis. These results may inform future physician education efforts as well as further support the establishment of low-dose CT protocols as a standard for primary evaluation of craniosynostosis. Other factors affecting referral time such as distance from the child’s home to a craniofacial specialist, specialist of referring physician, and minority status of the child will also be explored and potentially yield new targets for physician education and quality improvement efforts.

References:

  1. Brenner D, Elliston C, Hall E, Berdon W (2001). Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 176:289-296
  2. Gandolfi BM, Sobol DL, Farjat AE, Allori AC, Muh CR, Marcus JR (2017). Risk factors for delayed referral to a craniofacial specialist for treatment of craniosynostosis. J Pediatr 186:165-171
  3. Morton RP, Reynolds RM, Ramakrishna R, Levitt MR, Hopper RA, Lee A, Browd SR (2013). Low-dose head computed tomography in children: a single institutional experience in pediatric radiation risk reduction: clinical article. J Neurosurg Pediatr 12(4):406-410
  4. Ernst CW, Hulstaert TL, Belsack D, Buls N, Van Gompel G, Nieboer KH, Buyl R, Verhelle F, De Maeseneer M, de Mey J (2016). Dedicated sub 0.1 mSv 3DCT using MBIR in children with suspected craniosynostosis: quality assessment. Eur Radiol 26(3):892-899
  5. Montoya JC, Eckel LJ, DeLone DR, Kotsenas AL, Diehn FE, Yu L, Bartley AC, Carter RE, McCollough CH, Fletcher JG (2017). Low-dose CT for craniosynostosis: preserving diagnostic benefit with substantial radiation dose reduction. AJNR Am J Neuroradiol 38(4):672-677
  6. Brown ZD, Bey AK, Bonfield CM, Westrick AC, Kelly K, Wellons JC 3rd (2016). Racial disparities in health care access among pediatric patients with craniosynostosis. J Neurosurg Pediatr 18(3):269-274

Project Title: Practice Trends in Plastic Hand Surgery

Faculty Mentor: Ellen Satteson 
Email: Esatteson@ufl.edu 

Student: Thomas King 
Email: thomascking@ufl.edu 

Research Project Description:

Plastic surgeons make up about 20% of all surgeons with a Subspecialty Certificate in surgery of the hand (SOTH) and about 20% of hand surgery fellows. The practice of hand surgery, however, is not limited to plastic surgeons with hand fellowship training or SOTH certification. A 2015 survey of American Council of Academic Plastic Surgeons (ACAPS) surgeons found that half of respondents reported taking hand call with 78% reporting that all plastic surgery faculty take hand call regardless of whether they have subspecialty hand training. A 2013 survey of plastic surgery residency program directors identified nine essential hand surgeries which residents should master prior graduation to be able to perform in practice, regardless of whether they pursue additional subspecialty training.

While hand surgery has been identified as an important part of plastic surgery training and practice, little data exists regarding how it is incorporated into clinical practice. This study seeks to identify trends in hand surgery practice among board certified plastic surgeons nationwide. This would include evaluating what percentage of plastic surgery cases involve surgery of the hand, as well as the specific types of surgeries performed.

The primary null hypothesis of this study is that there is no statistically significant change in the annual percentage of hand-related cased logged in the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database. The secondary null hypothesis is that there is no statistically significant difference between the percentage of soft tissue-related cases and fracture-related hand cases logged in the TOPS database.

Specific Aims:

This study will assess trends in the quantity and types of hand surgery cases being performed by plastic surgeons based on cases submitted to the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database maintained by the American Board of Plastic Surgeons (ASPS) since the database was launched in 2002.

References:

  1. Rios-Diaz AJ, Metcalfe D, Singh M, et al. Inequalities in Specialist Hand Surgeon Distribution across the United States. Plast Reconstr Surg. 2016;137(5):1516-1522. doi:10.1097/PRS.0000000000002103
  2. Brunworth LS, Chintalapani SR, Gray RR, Cardoso R, Owens PW. Resident selection of Hand Surgery Fellowships: A survey of the 2011, 2012, and 2013 Hand Fellowship graduates. Hand. 2013;8(2):164-171. doi:10.1007/s11552-013-9504-y
  3. Mehta K, Pierce P, Chiu DTW, Thanik V. The effect of residency and fellowship type on hand surgery clinical practice patterns. Plast Reconstr Surg. 2015;135(1):179-186. doi:10.1097/PRS.0000000000000786
  4. Lifchez SD, Friedrich JB, Scott Hultman C. The scope of practice of hand surgery within plastic surgery: The ACAPS national survey to assess current practice and develop educational guidelines. Ann Plast Surg. 2015;74(1):89-92. doi:10.1097/SAP.0000000000000365
  5. Noland SS, Fischer LH, Lee GK, Friedrich JB, Hentz VR. Essential hand surgery procedures for mastery by graduating plastic surgery residents: A survey of program directors. Plast Reconstr Surg. 2013;132(6):977-984. doi:10.1097/PRS.0b013e3182a8066b

Project Title: Medical student career choice: Who is the influencer?

Faculty Mentor:Janice Taylor 
Email: janice.taylor@surgery.ufl.edu  

Student: Kevin Hao
Email: khao2016@ufl.edu 

Research Project Description:

Medical specialty selection by fourth year medical students is a complex multifactorial process. A key factor considered by medical students is their experience on their clinical rotations [1, 2]. Clinical rotations expose medical students to the decision-making, patient interactions, and atmosphere of different specialties. During their rotations, medical student receiving mentorship and supervision from attending and resident physicians, both of whom may influence the student’s experience on their rotation.
While the attending physician is primarily responsible for supervising and educating medical students on rotations, resident physicians also play an important mentorship role. Residents interact extensively with medical students and it has been reported that up to 25% of resident activities are spent in a mentorship capacity [3, 4]. Consequently, studies have found medical students to perceive residents as teachers more than attendings [5, 6]. These findings are important because personality fit and identification of mentors have been identified as two of the most important influences on specialty choice [7].
Despite the established influence of both resident and attending physicians on the career choice of medical students, there is nothing yet published comparing their respective influence. While attendings have more experience, have a greater wealth of knowledge, and have career influence with recommendation letter writing, medical students often spend a greater amount of time with residents and find them more approachable.

The purpose of this study is to gain a better understanding of the comparative influence of resident and attending physicians on medical students’ specialty choices. Medical students’ interactions with resident and attending physicians during rotations substantially impact their experience and perception of the specialty. A deeper understanding of the influence of residents compared to attendings on medical students’ specialty choices would assist clerkship directors with improving student experiences and potentially play a role in institutional culture change regarding the clinical education of medical students.

Specific Aims:

Aim 1: To compare the influence of residents and attendings on medical student career choice by analyzing the results of a survey distributed to fourth year medical students.
Aim 2: Specifically for responses involving surgery as an anticipated or final career choice, determine negative and positive influences for the respondent.
Aim 3: To inform clerkship directors/program directors of possible focus areas to help improve student recruitment within their fields

References:

  1. Maiorova, T., et al., The impact of clerkships on students’ specialty preferences: what do. Med Educ, 2008. 42(6): p. 554-62 LID – 10.1111/j.1365-2923.2008.03008.x [doi].
  2. Ellsbury, K.E., et al., Influence of Third-Year Clerkships on Medical Student Specialty Preferences. Adv Health Sci Educ Theory Pract, 1998. 3(3): p. 177-186.
  3. Tonesk, X., The house officer as a teacher: what schools expect and measure. J Med Educ, 1979. 54(8): p. 613-6.
  4. Brown, R.S., House staff attitudes toward teaching. J Med Educ, 1970. 45(3): p. 156-9 FAU – Brown, R S.
  5. Whittaker, L.D., Jr., et al., The value of resident teaching to improve student perceptions of surgery. Am J Surg, 2006. 191(3): p. 320-4.
  6. Nguyen, S.Q. and C.M. Divino, Surgical residents as medical student mentors. Am J Surg, 2007. 193(1): p. 90-3.
  7. Cochran, A., L.A. Melby S Fau – Neumayer, and L.A. Neumayer, An Internet-based survey of factors influencing medical student selection of a. Am J Surg, 2005. 189(6): p. 742-6

Project Title: Outcomes analysis of textured versus smooth tissue expanders in breast reconstruction: A 5-year retrospective review

Faculty Mentor: Ellen Satteson 
Email: Esatteson@ufl.edu 

Student: Elizabeth Di Valerio and Adityanarayan Rao 
Email: edivalerio@ufl.edu; a.rao1@ufl.edu 

Research Project Description:

The objective of this project is to compare postoperative outcomes and complication rates among patients undergoing implant-based breast reconstruction with smooth versus textured tissue expanders. This study was prompted by ongoing concern of Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL), which is more commonly associated with textured breast implants and has, therefore, resulted in current trends shifting towards an increased use of smooth breast implants.1 While tissue expanders used in implant-based breast reconstruction in the United States have traditionally been textured, smooth expanders have been developed as a result of the BIA-ALCL concerns. Currently literature comparing smooth versus textured breast implants is available, but there is a lack of similar comparisons with tissue expanders.

Studies examining the incidence of BIA-ALCL suggest that as many as 50% of cases have been found in the presence of textured implant use compared to 4.2% that occurred in the case of smooth implants. 2 As a consequence, there has been an associated trend toward the use of smooth implants over textured, demonstrated by a recent study suggesting that 59.1% of sampled plastic surgeons only used smooth implants. 1

While the above studies show differences in outcomes between smooth and textured implants, there are also notable disparities in how textured vs non-textured expanders were implanted, which could affect complication rates. For example, in one study, most smooth expanders were placed in a biplanar or subglandular location, and most textured devices were implanted in a submuscular or biplanar location and often used Betadine, which was not used in the placement of smooth expanders. Both the use of an antiseptic for only one expander type and implanting in different locations based on texture, could affect postoperative complication rates. 3

Despite concerns regarding a higher risk of BIA-ALCL with textured implants and expanders, studies suggest that it remains an exceedingly rare malignancy . 2,4 Textured implants may also carry a lower risk of more common complications compared to smooth implants, particularly capsular contracture. 4 Such comparisons, however, have not yet been made regarding smooth versus textured tissue expanders. This study seeks to contribute to the literature regarding the safety profile and complication rates of the two types of expanders.

There will be no difference in the outcomes and complication rates between smooth and textured tissue expanders.

Specific Aim 1 – To determine and compare complication rates with the use of a smooth versus textured tissue expander.

Specific Aim 2 – To evaluate patient and surgical characteristics which may impact complication rates between the two tissue expander types.

References:

  1. Carr, L. W., Roberts, J., & Potochny, J. D. (2019). How breast implant surface type is influenced by breast implant-associated anaplastic large cell lymphoma: A survey of the American Society of Plastic Surgeons. Annals of plastic surgery, 82(4S), S208-S211.
  2. Srinivasa, D. R., Miranda, R. N., Kaura, A., Francis, A. M., Campanale, A., Boldrini, R., … & Nast, K. (2017). Global adverse event reports of breast implant–associated ALCL: an international review of 40 government authority databases. Plastic and reconstructive surgery, 139(5), 1029-1039.
  3. Khanna, J., Mosher, M., Whidden, P., Nguyen, S., Garzon, D., & Bhogal, M. (2019). Reoperation rate after primary augmentation with smooth, textured, high fill, cohesive, round breast implants (RANBI-I study). Aesthetic surgery journal, 39(12), 1342-1349.
  4. Calobrace, M. B., Schwartz, M. R., Zeidler, K. R., Pittman, T. A., Cohen, R., & Stevens, W. G. (2018). Long-term safety of textured and smooth breast implants. Aesthetic surgery journal, 38(1), 38-48.

Project Title: Evaluating Outcomes, Complications, and Cost of Initial Gastric Versus Postpyloric Feeding in Critically Ill Pediatric Patients

Faculty Mentor: Robin Petroze 
Email: robin.petroze@surgery.ufl.edu 

Student: Tyler Thompson  
Email: thompson.t@ufl.edu 

Research Project Description:

Providing adequate nourishment to critically ill pediatric patients is a high priority in their management. Malnourishment during hospitalization is linked to worse outcomes, more complications, and requires more resources compared to patients who meet nutritional requirements. 1,2 Often, critically ill pediatric patients are unable to meet their nutritional demands orally, and these situations require placement of a supplemental feeding tube. Non-surgical enteral tubes can feed into the stomach or into the small intestine via a postpyloric tube. While there are certainly indications for when one feeding tube method is preferred over the other, evidence is poor, and these indications are likely rooted in culture of the institution and preference of the provider based on experience. Thus, decisions may vary between institutions, and even between different units within the same institution. A study exploring provider decision making and the role of institutional culture at the University of Florida found that 82% of the providers interviewed (n=22) felt that institutional culture plays a role in their decision making, citing a lack of evidence, bias from personal experience, and trainees basing decisions off of superiors’ past decisions. 3 An empirical consensus demonstrating the optimal route of enteral feeding for critically ill pediatric patients is needed to pave the way for implementation of evidence-based guidelines that will improve both patient outcomes and resource utilization.
Pros and cons exist for both routes of enteral feeding. Benefits of gastric tube feeding includes preservation of normal gut flora and gastrointestinal integrity, prevention of mucosal atrophy, attenuation of injury-related physiological stress, and preservation of immunocompetence. 4 Additional benefits to gastric feeding include faster, easier placement and lower costs compared to postpyloric placement, which often requires fluoroscopic imaging guidance. 5 For these reasons, gastric access is generally the preferred initial feeding route among providers, but this is not the case in every instance and varies based on established institutional practices. The main cited concern surrounding gastric feeding is the risk of aspiration, but results of one clinical trial involving critically ill children randomized to receive enteral nutrition via either gastric or postpyloric routes found no significant difference in the incidence of microaspiration, tube displacement, or feeding intolerance between the two groups. 6,7
Postpyloric tube placement is often initiated instead to these patients deemed to have too high of a risk of aspiration. Patients grouped into this category include those with decreased gag reflex, diminished mental status, recurrent vomiting, GERD, and severe respiratory distress, among others. 4,5 However, current research fails to provide significant evidence establishing a proven advantage to pediatric patients compared to gastric access. In fact, one systematic review noted an increased mortality rate and a higher rate of feeding cessation due to gastrointestinal disturbance (abdominal distention, gastric bleeding, diarrhea, and vomiting) in preterm infants fed via postpyloric access compared to those receiving gastric feedings. 8 Furthermore, postpyloric tube placement is complicated by cost and resource limitation, as the availability of teams with the expertise and resources to perform this procedure can be restricted or nonexistent depending on the institution. At the University of Florida postpyloric tubes are placed by a special nursing team, and providers explicitly expressed availability of this team as a factor in their decision-making. 3
The decision to initiate enteral feeding via gastric versus postpyloric access is multifactorial in nature, dependent on factors such as patient presentation and risks, as well as culture of an institution and established practices. A recent case at the University of Florida in which empiric postpyloric tube placement in a patient with congenital heart disease led to a life-threatening small bowel perforation prompted us to evaluate our institutional practice with initial enteral feeding in critically ill neonates and children. The approach is multi-faceted and includes qualitative evaluation of provider decision making and retrospective review of indications, outcomes, and cost. 3 Our goal is to develop evidence-based protocols for future care based upon our own institutional data and review of the literature.

We hypothesize that postpyloric feeding is used more frequently than indicated as the initial enteral feeding option based upon the institutional culture at the University of Florida rather than patient symptomatology and is not associated with improved patient outcomes in comparison to gastric feeding.

Specific Aims:

  1. To evaluate the indications for choice of enteral feeding access
  2. To evaluate outcomes of different modes of feeding access, including final feeding modality, complications, and cost
  3. To develop evidence-based guidelines that improve both patient outcomes and resource utilization in enteral feeding

References:

  1. Naber TH, Schermer T, de Bree A, Nusteling K, Eggink L, Kruimel JW, Bakkeren J, van Heereveld H, Katan MB. Prevalence of malnutrition in nonsurgical hospitalized patients and its association with disease complications. Am J Clin Nutr. 1997 Nov;66(5):1232-9. doi: 10.1093/ajcn/66.5.1232. PubMed PMID: 9356543.
  2. Tappenden KA, Quatrara B, Parkhurst ML, Malone AM, Fanjiang G, Ziegler TR. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. J Acad Nutr Diet. 2013 Sep;113(9):1219-37. doi: 10.1016/j.jand.2013.05.015. Epub 2013 Jul 17. PubMed PMID: 23871528.
  3. Maya AM, Ehresmann KR, Mustafa MM, Taylor JA, Larson SD, Islam S, Petroze RT. Mode of initial enteral feeding: Decision making in critically-ill pediatric patients. American Journal of Surgery. [under review, March 2020].
  4. Prabhakaran S, Doraiswamy VA, Nagaraja V, Cipolla J, Ofurum U, Evans DC, Lindsey DE, Seamon MJ, Kavuturu S, Gerlach AT, Jaik NP, Eiferman DS, Papadimos TJ, Adolph MD, Cook CH, Stawicki SP. Nasoenteric tube complications. Scand J Surg. 2012;101(3):147-55. doi: 10.1177/145749691210100302. Review. PubMed PMID: 22968236.
  5. Mehta NM. Approach to enteral feeding in the PICU. Nutr Clin Pract. 2009 Jun-Jul;24(3):377-87. doi: 10.1177/0884533609335175. Review. PubMed PMID: 19483067.
  6. Malcolm WF, Smith PB, Mears S, Goldberg RN, Cotten CM. Transpyloric tube feeding in very low birthweight infants with suspected gastroesophageal reflux: impact on apnea and bradycardia. J Perinatol. 2009 May;29(5):372-5. doi: 10.1038/jp.2008.234. Epub 2009 Feb 26. PubMed PMID: 19242488; PubMed Central PMCID: PMC2827248.
  7. Meert KL, Daphtary KM, Metheny NA. Gastric vs small-bowel feeding in critically ill children receiving mechanical ventilation: a randomized controlled trial. Chest. 2004 Sep;126(3):872-8. doi: 10.1378/chest.126.3.872. PubMed PMID: 15364769.
  8. Watson J, McGuire W. Transpyloric versus gastric tube feeding for preterm infants. Cochrane Database Syst Rev. 2013 Feb 28;(2):CD003487. doi: 10.1002/14651858.CD003487.pub3. Review. PubMed PMID: 23450542.

Project Title: Outcomes of aortobifemoral bypass with and without simultaneous visceral artery bypass

Faculty Mentor: Samir Shah 
Email: Samir.Shah@surgery.ufl.edu 

Student: Dwayne Cole 
Email: dcole0195@ufl.edu 

Research Project Description:

Aortobifemoral bypass (ABF) is a complex operation used to treat extensive aortoiliac occlusive disease with or without associated aneurysmal degeneration (6). It is a high-risk operation with a 30-d morbidity and mortality of X and Y% (1). Patients sometimes also have accompanying clinically significant visceral occlusive disease (i.e. disease in the renal, celiac, or superior mesenteric arteries). This may manifest as uncontrolled hypertension or as mesenteric ischemia (2,4,3). Simultaneous bypass to one or more of these visceral vessels at the time of ABF has the advantage of addressing multiple problems but potentially at the cost of increasing risk of mortality and morbidity (5). It is unknown whether the outcomes of patients undergoing simultaneous visceral artery bypass at the time of ABF are similar to those undergoing ABF only, which is important for medical decision-making.

We hypothesize that patients undergoing ABF with visceral bypass (VB) will have higher rates of morbidity but similar mortality to those patients undergoing isolated ABF.

Specific Aims:

We will examine the outcomes of patients undergoing isolated ABF to those also undergoing VB. Outcomes of interest include 30-day mortality, morbidity, operative time, operative blood loss, and hospital length of stay.

References:

  1. Sharma G, Scully RE, Shah SK, Madenci AL, Arnaoutakis DJ, Menard MT, Ozaki CK, Belkin M. Thirty-year trends in aortofemoral bypass for aortoiliac occlusive disease. J Vasc Surg. 2018 Dec;68(6):1796-1804.e2. doi:10.1016/j.jvs.2018.01.067. Epub 2018 Jul 9. PubMed PMID: 30001912.
  2. Bredahl K, Jensen LP, Schroeder TV, Sillesen H, Nielsen H, Eiberg JP. Mortality and complications after aortic bifurcated bypass procedures for chronic aortoiliac occlusive disease. J Vasc Surg. 2015 Jul;62(1):75-82. doi:10.1016/j.jvs.2015.02.025. PubMed PMID: 26115920.
  3. Kulbaski MJ, Kosinski AS, Smith RB 3rd, Salam AA, Dodson TF, Lumsden AB, Chaikof EL. Concomitant aortic and renal artery reconstruction in patients on an intensive antihypertensive medical regimen: long-term outcome. Ann Vasc Surg. 1998 May;12(3):270-7. PubMed PMID: 9588515.
  4. Atnip RG, Neumyer MM, Healy DA, Thiele BL. Combined aortic and visceral arterial reconstruction: risks and results. J Vasc Surg. 1990 Dec;12(6):705-14; discussion 714-5. PubMed PMID: 2243407.
  5. Tsoukas AI, Hertzer NR, Mascha EJ, O’Hara PJ, Krajewski LP, Beven EG. Simultaneous aortic replacement and renal artery revascularization: the influence of preoperative renal function on early risk and late outcome. J Vasc Surg. 2001 Dec;34(6):1041-9. PubMed PMID: 11743558.
  6. DeCarlo C, Boitano LT, Schwartz SI, Lancaster RT, Conrad MF, Eagleton MJ, Brewster DC, Clouse WD. Operative Complexity and Prior Endovascular Intervention Negatively Impact Morbidity after Aortobifemoral Bypass in the Modern Era. Ann Vasc Surg. 2020 Jan;62:21-29. doi: 10.1016/j.avsg.2019.03.040. Epub 2019 Jun 13. PubMed PMID: 31201980.

Project Title: Pelvic Fracture outcomes in the Elderly

Faculty Mentor: Alicia Mohr 
Email: alicia.mohr@surgery.ufl.edu  

Student: Peace Ekakitie
Email: peace4love4@ufl.edu

Research Project Description:

As the average life expectancy in most industrialized nations continues to rise, the health status of the elderly population is increasingly a concern because of the physiological changes that accompany aging, as well as the increased risk of morbidity in this patient group (Southern, Lopez, & Jwayyed, 2017) (Banierink, et al., 2019). In a nationwide epidemiological analysis of 1,464,458 pelvic fracture injuries between 1990 and 2007, 67 percent of these fractures occurred in patients older than 55 years old (Buller, Best, & Quinnan, 2016). These patients also have higher mortality rates, reduced likelihood of returning to original place of domicile, and increased intensive care unit (ICU) and general hospital length of stay (LOS) despite receiving more aggressive management (Dechert, et al., 2009). These outcomes are important because they significantly impact patients’ quality of life during and after recovery. The most recent studies evaluating characteristics and outcomes of pelvic fractures particularly in elderly populations were conducted with data from 5–20 years ago, whereas our study will be conducted with data from 2014–2019. Furthermore, the main study that described the outcomes of geriatric pelvic fractures was conducted in the Netherlands; results from this study may not be applicable to our population of interest (National Research Council (US) Panel on a Research Agenda and New Data for an Aging World, 2001). Moreover, since these studies were conducted, the management of pelvic fractures, their complications, and consequently patient outcomes would have changed. If there are changes in the management of pelvic fractures, especially in elderly patients, they will also be described within our study.

Factors such as advanced age, increased transfusion needs, increased injury severity scores, high comorbidity index scores, increased LOS and lower fracture stability will be associated with adverse outcomes in all patients with pelvic fractures, especially elderly patients (Buller, Best, & Quinnan, 2016). Patients who sustain pelvic fractures and are older than 55 years old have reduced bone mineral density and quality due to osteoporosis or osteopenia which usually is undiagnosed until the pelvic fracture occurs (Demontiero, Vidal, & Duque, 2012) (Bukata, et al., 2011). These patients are also more likely to have pelvic ring fractures which typically involve 2 or more bony areas and have poorer prognosis.
The increased severity in pelvic fracture type, significant reduction in bone formation, and an increase in bone resorption in elderly patients complicates their recovery and predisposes them to more adverse outcomes (Bukata, et al., 2011). Therefore, increased pelvic fracture severity and advanced age should also be important discriminators of adverse outcomes in patients with pelvic fractures.

The aim of this study is to describe the differences in the characteristics, injury pattern, injury severity, transfusion needs, medical therapy utilization, comorbidities, complications, and outcome of pelvic fractures in older patients compared to younger patients. Additionally, correlations between patient demographics, especially age, and pelvic fracture outcomes will be assessed, as well as risk factors for adverse outcomes especially in elderly patients with pelvic fractures.

References:

  1. Banierink, H., Duis, K. T., de Vries, R., Wendt, K., Heineman, E., Reininga, I., & IJpma, F. (2019, May 28). Pelvic ring injury in the elderly: Fragile patients with substantial mortality rates and long-term physical impairment. PLOS one, 14(5), e0216809.
  2. Bukata, S. V., DiGiovanni, B. F., Friedman, S. M., Hoyen, H., Kates, A., Kates, S. L., . . . Tyler, W. K. (2011, January). A Guide to Improving the Care of Patients with Fragility Fractures. Geriatric Orthopaedic Surgery & Rehabilitation, 2(1), 5-37.
  3. Buller, L. T., Best, M. J., & Quinnan, S. M. (2016, March). A Nationwide Analysis of Pelvic Ring Fractures: Incidence and Trends in Treatment, Length of Stay, and Mortality. Geriatric Orthopaedic Surgery & Rehabilitation, 7(1), 9-17.
  4. Dechert, T. A., Duane, T. M., Frykberg, B. P., Aboutanos, M. B., Malhotra, A. K., & Ivatury, R. R. (2009, April). Elderly Patients with Pelvic Fracture: Interventions and Outcomes. American Journal of Surgery, 75(4), 291-295.
  5. Demontiero, O., Vidal, C., & Duque, G. (2012, April). Aging and bone loss: new insights for the clinician. Therapeutic Advances in Musculoskeletal Disease, 4(2), 61-76.
  6. National Research Council (US) Panel on a Research Agenda and New Data for an Aging World. (2001). Preparing for an Aging World: The Case for Cross-National Research. Washington, Washington: National Academies Press (US).
  7. Southern, A., Lopez, R., & Jwayyed, S. (2017, January 30). Geriatric Trauma. Treasure Island, Florida: StatPearls Publishing.

Project Title: Carpal Kinematics in Distal Radius Fractures

Faculty Mentor: Ellen Satteson
Email: ellen.satteson@surgery.ufl.edu 

Student: Mario Blondin
Email: marioblondinfern@ufl.edu

Research Project Description:

Distal radius fractures are common injuries affecting mainly the opposite ends of the age spectrum. Children and young adults are usually affected while engaging in physical activities such as sports, where they may suffer severe traumas. On the other hand, older adults are mainly affected by injuries arising from low-energy traumas, such as falls due to inclement weather conditions. In the long run, distal radius fractures lead to a significant decrease in the quality of life of these patients. One-third of distal radius fractures are associated with concomitant injuries to the intrinsic ligaments of the hand. These soft tissue lesions may be detected radiographically butoften are undiagnosed if they do not result in significant deformation. If these ligamentous injuries are left untreated, they may result in carpal instability, diminished carpal height, and advanced degenerative arthritis.

The purpose of this study is to determine the normal variance of intact intercarpal ligament laxity or diastasis associated with distal radius fractures. We will use cadaveric upper extremities with a standardized fracture pattern subjected to various degrees of shortening/angulation while measuring intercarpal distances with motion tracking devices.

The purpose of this study is to determine the normal variance of intact intercarpal ligament laxity or diastasis associated with distal radius fractures.

References:

  1. Ali, A., & Willett, K. (2015). What is the effect of the weather on trauma workload? A systematic review of the literature. Injury, 46(6), 945–953.
  2. Mehta, S., MacDermid, J., Richardson, J., MacIntyre, N., & Grewal, R. (2015). Baseline pain intensity is a predictor of chronic pain in individuals with distal radius fracture. Journal of Orthopaedic & Sports Physical Therapy, 45(2), 119–127.
  3. Nellans, K., Kowalski, E., & Chung, K. (2012). The epidemiology of distal radius fractures. Hand Clinics, 28(2), 113–125.
  4. Orces CH, Martinez FJ. Epidemiology of fall related forearm and wrist fractures among adults treated in US hospital emergency departments. Injury Prevention (1353-8047). 2011;17(1):33.
  5. Philip SS, Macdermid JC, Nair S, Walton D, Grewal R. What Factors Contribute to Falls-Related Distal Radius Fracture? Journal of Aging & Physical Activity. 2019;27(3):392-397.

Project Title: Readmissions for Secondary Infection in <15% TBSA Pediatric Burn Injury Patients

Faculty Mentor: Shawn Larson 
Email: shawn.larson@surgery.ufl.edu 

Student: Daniel Feuer  
Email: dfeuer97@ufl.edu 

Research Project Description:

Burn-related injuries in children are a common mechanism of injury leading to hospitalization and are a major contributor to morbidity and mortality.(5) While there has been great emphasis on improving the outcomes of these patients, the focus has largely been targeted at acute management priorities and infectious complications. Many published studies investigating infections examine sepsis and burn wound infections particularly in patients with larger total body surface area (TBSA) burns.(3,4) However, children’s pathophysiological responses to burn wound injury differ from adults.(5) To date, little attention has been aimed at determining if children with smaller burn injuries are at increased risk of developing secondary infections.

Research has shown that in both pediatric and adult patient populations, re-admissions are not uncommon and are typically due to infection, wound healing related complications, and pain.(1) In studies that target rates of pediatric burn readmissions, there is a statistically higher rate of readmission in those with a total body surface area (TBSA) burn of greater than ten percent and those with third degree burns.(2) The same study showed that of those re-admitted, about 15% had burn wound infections.

Based on clinical observations from the UF Health Pediatric Burn program, it has been noted that pediatric burn patients with relatively smaller burn wounds (<15% TBSA) are being re-admitted for secondary infections not related to burn wounds such as impetigo, herpes simplex virus, and influenza. While these infections are common, particularly in the pediatric population, it is clinically valuable to determine if pediatric burn patients are more pre-disposed to secondary infections. Determining the pathophysiological changes in children with small burn wounds is of paramount importance given the prevalence of these injuries. Information gained will be the foundation for future research into immune system changes in the pediatric patient population.

We hypothesize that in pediatric burn patients (<16 years of age), that there is an association between host response to the injury and higher rates of secondary infections not directly involving the burn wound. Furthermore, we believe that the rates of secondary infection will be inversely related to the child’s age and not directly to the TBSA.

This project will have 3 specific aims:

  1. We aim to characterize re-admission rates in children with a primary diagnosis of burn injury (<15% TBSA).
  2. We will examine the relationship of children re-admitted for any cause to determine the number related to non-burn wound infections. We will examine records for admissions with secondary bacterial, viral, or fungal infections.
  3. We will attempt to delineate any correlation with burn wound size, child age, secondary infections, and demographic factors

References:

  1. Tapking, C., et al. “A systematic review and meta-analysis of 30-day readmission rates following burns.” Burns (2019).
  2. Wheeler, Krista K., et al. “US pediatric burn patient 30-day readmissions.” Journal of Burn Care & Research 39.1 (2017): 73-81.
  3. Schlager, Theresa, et al. “Hospital-acquired infections in pediatric burn patients.” Southern medical journal 87.4 (1994): 481-484.
  4. Gülhan, Belgin, et al. “Infections in Pediatric Burn Patients: An Analysis of One Hundred Eighty-One Patients.” Surgical infections (2019).
  5. Sharma, Ramesh Kumar, and Atul Parashar. “Special considerations in paediatric burn patients.” Indian journal of plastic surgery 43.S 01 (2010): S43-S50.

Project Title: Neonatal blood transfusions are associated with increased incidence of necrotizing enterocolitis and poor clinical outcomes

Faculty Mentor: Shawn Larson 
Email: shawn.larson@surgery.ufl.edu   

Student: Omar Sharaf 
Email: omar.sharaf@ufl.edu 

Research Project Description:

Preterm (<37 weeks gestation) neonates are commonly transfused with red blood cells (RBCs) due to high blood sampling losses, with about 90% of extremely low birth weight infants receiving blood transfusions during their initial neonatal intensive care unit (NICU) admission [1]. While RBC transfusions aim to correct anemia to increase tissue oxygenation to ultimately prevent poor growth and decrease oxygen requirement, controversy exists whether blood transfusions increase the risk for certain complications. Complications include necrotizing enterocolitis (NEC), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP), all of which are thought to be caused in part by oxidative injury [2]. There is conflicting literature regarding neonatal blood transfusions, with some studies demonstrating increased risk of such complications [3, 4], while others suggest that there is no increased risk of NEC [5, 6].

There is currently no national consensus as to the optimal transfusion strategy for preterm infants [7]. Some institutions adopt a restrictive transfusion strategy in which a lower hemoglobin is permitted before transfusion, while others prefer a liberal transfusion strategy in which the threshold is higher. Studies comparing the two strategies differ in their findings [7-9]. The UF Health Shands NICU does not have an established protocol for blood transfusions—practices vary from provider to provider depending on the clinical context. The aim of this study is to evaluate clinical outcomes of premature neonates after blood transfusion at our quaternary referral NICU. To this end, we will retrospectively evaluate preterm neonatal outcomes in infants receiving blood transfusions compared to gestational age-matched controls not receiving blood. Results will provide the basis for future prospective research to determine the optimal transfusion strategy for preterm infants in the NICU.

Preterm neonates are a fragile group often requiring numerous interventions associated with greater blood loss and therefore higher rates of transfusion. Given the vulnerability of this population, we hypothesize that many providers will have a more liberal approach in transfusing patients and that this will be inversely proportional to the gestational age. We further hypothesize that increased blood transfusions in preterm neonates is associated with a higher frequency of adverse outcomes including increased mortality, NEC, BPD, and ROP.

Specific Aims:

  1. To determine if volume of blood transfused, controlling for other clinical parameters, is associated with differential outcomes in preterm infants.
  2. To delineate if type of blood transfusion (RBC, platelets, fresh frozen plasma, cryoprecipitate) is associated with differential outcomes in preterm infants.
  3. To compare, by gestational age and birth weight, whether differences in incidence of complications exist as a result of blood transfusion.
  4. To determine which congenital and perinatal morbidities influence outcomes following blood transfusion.

References:

  1. Banerjee J, Aladangady N. Biomarkers to decide red blood cell transfusion in newborn infants. Transfusion 2014;54(10):2574-82.
  2. Iskander IF, Salama KM, Gamaleldin RM, Seghatchian J. Neonatal RBC transfusions: Do benefits outweigh risks? Transfus Apher Sci 2018;57(3):431-6.
  3. dos Santos AM, Guinsburg R, de Almeida MF, Procianoy RS, Leone CR, Marba ST, et al. Red blood cell transfusions are independently associated with intra-hospital mortality in very low birth weight preterm infants. J Pediatr 2011;159(3):371-6.e1-3.
  4. Wang YC, Chan OW, Chiang MC, Yang PH, Chu SM, Hsu JF, et al. Red Blood Cell Transfusion and Clinical Outcomes in Extremely Low Birth Weight Preterm Infants. Pediatr Neonatol 2017;58(3):216-22.
  5. Patel RM, Knezevic A, Shenvi N, Hinkes M, Keene S, Roback JD, et al. Association of Red Blood Cell Transfusion, Anemia, and Necrotizing Enterocolitis in Very Low-Birth-Weight Infants. JAMA 2016;315(9):889-97.
  6. Wallenstein MB, Arain YH, Birnie KL, Andrews J, Palma JP, Benitz WE, et al. Red blood cell transfusion is not associated with necrotizing enterocolitis: a review of consecutive transfusions in a tertiary neonatal intensive care unit. J Pediatr 2014;165(4):678-82.
  7. Lopriore E. Updates in Red Blood Cell and Platelet Transfusions in Preterm Neonates. Am J Perinatol 2019;36(S 02):S37-S40.
  8. Chirico G, Beccagutti F, Sorlini A, Motta M, Perrone B. Red blood cell transfusion in preterm infants: restrictive versus liberal policy. J Matern Fetal Neonatal Med 2011;24 Suppl 1:20-2.
  9. Bell EF, Strauss RG, Widness JA, Mahoney LT, Mock DM, Seward VJ, et al. Randomized trial of liberal versus restrictive guidelines for red blood cell transfusion in preterm infants. Pediatrics 2005;115(6):1685-91.

Project Title: Evaluation of statins as cancer chemoprophylactic agents in chronic liver disease

Faculty Mentor: Ali Zarrinpar 
Email: Ali.Zarrinpar@surgery.ufl.edu 

Student: Natalia Pereira 
Email: npereira@ufl.edu 

Research Project Description:

Chronic liver diseases represent a problem of increasing global concern. In particular, nonalcoholic fatty liver disease (NAFLD) is the most common and fastest-growing liver disease and may progress to cirrhosis and hepatocellular carcinoma (HCC). Furthermore, nonalcoholic steatohepatitis (NASH) is now the second leading indication for liver transplant in the US and is expected to become the most common indication within the next decade. With an increasing transplant burden, there is urgent need for pharmacological intervention strategies. A growing body of evidence suggests that cholesterol-lowering statins may be related to a decreased risk of cancers including HCC. Further research is needed to understand this relationship, as well as the relationship of other chemoprophylactic drugs of interest, such as aspirin, which has been shown to reduce HCC incidence in viral hepatitis patients. In particular, there is also a need for research representative of the US population which investigates NAFLD and NASH in addition to other chronic liver diseases such as viral hepatitis.

We hypothesize that patients with Hyperlipidemia are started on statins which then reduce the risk of Hepatocellular carcinoma (HCC) development. Furthermore, we expect that this relationship will demonstrate dose- or duration-dependence. We also hypothesize that other medications such as aspirin and DM medications such as Metformin also will have a protective relationship against HCC development.

Multiple studies have suggested that cholesterol-lowering statins may decrease the risk of certain types of cancers, including HCC. In addition to lipid-lowering properties, statins have been shown to exhibit anti-cancer properties, such as being anti-proliferative, pro-apoptotic, anti-angiogenic, and radiosensitizing. Other medications such as aspirin and antidiabetic medications are also of interest and require further research. A thorough investigation of these drugs within this population of interest is urgently indicated, given the growing need. Furthermore, because these drugs are already approved and have a known safety profile, if they were found to be effective, they could have great therapeutic impact as they could be very quickly implemented as a clinical intervention.

Specific Aims:

Aim 1 is to generate a large dataset characterizing chronic liver disease and hepatocellular carcinoma (HCC). Using the OneFlorida i2b2 consortium, we will create a large database based on queries for patients with chronic liver diseases, including alcoholic liver disease (ALD), NAFLD, NASH, primary and secondary biliary cirrhosis, and viral hepatitis B (HBV) and C (HCV). We will also collect information on demographics and other important comorbidities and risk factors, including diabetes (especially T2DM), metabolic syndrome, obesity, smoking history, and hyperlipidemia.

Aim 2 is to characterize potential HCC chemoprophylactic agents. Using pharmacy data from the database, we will collect medication information. Statins and aspirin are of particular interest as described above. We will also collect information on metabolic drugs, lipid-lowering medications, other cardiovascular protective medications, vitamin E, and other drugs of interest for cancer chemoprophylaxis or liver toxicity such as NSAIDs and acetaminophen.

References:

  1. Pastori D, Polimeni L, Baratta F, Pani A, Del Ben M, Angelico F. The efficacy and safety of statins for the treatment of non-alcoholic fatty liver disease. Dig Liver Dis. Jan 2015;47(1):4-11.
  2. Zarrinpar A, Faltermeier CM, Agopian VG, et al. Metabolic factors affecting hepatocellular carcinoma in steatohepatitis. Liver Int. 03 2019;39(3):531-539.
  3. Loomba R, Lim JK, Patton H, El-Serag HB. AGA Clinical Practice Update on Screening and Surveillance for Hepatocellular Carcinoma in Patients with Nonalcoholic Fatty Liver Disease: Expert Review. Gastroenterology. Jan 2020.
  4. Singh S, Singh PP, Singh AG, Murad MH, Sanchez W. Statins are associated with a reduced risk of hepatocellular cancer: a systematic review and meta-analysis. Gastroenterology. Feb 2013;144(2):323- 332.
  5. Mantovani A, Scorletti E, Mosca A, Alisi A, Byrne CD, Targher G. Complications, morbidity and mortality of nonalcoholic fatty liver disease. Metabolism. Jan 2020:154170.
  6. Rinella ME. Nonalcoholic fatty liver disease: a systematic review. JAMA. Jun 2015;313(22):2263-2273.
  7. Anstee QM, Reeves HL, Kotsiliti E, Govaere O, Heikenwalder M. From NASH to HCC: current concepts and future challenges. Nat Rev Gastroenterol Hepatol. 07 2019;16(7):411-428.
  8. Tsan YT, Lee CH, Ho WC, Lin MH, Wang JD, Chen PC. Statins and the risk of hepatocellular carcinoma in patients with hepatitis C virus infection. J Clin Oncol. Apr 2013;31(12):1514-1521.
  9. Wang W, Zhao C, Zhou J, Zhen Z, Wang Y, Shen C. Simvastatin ameliorates liver fibrosis via mediating nitric oxide synthase in rats with non-alcoholic steatohepatitis-related liver fibrosis. PLoS One. 2013;8(10):e76538.
  10. El-Serag HB, Johnson ML, Hachem C, Morgana RO. Statins are associated with a reduced risk of hepatocellular carcinoma in a large cohort of patients with diabetes. Gastroenterology. May 2009;136(5):1601-1608.
  11. Zarrinpar A, David Cheng TY, Huo Z. What Can We Learn About Drug Safety and Other Effects in the Era of Electronic Health Records and Big Data That We Would Not Be Able to Learn From Classic Epidemiology? J Surg Res. 02 2020;246:599-604.
  12. Shenkman E, Hurt M, Hogan W, et al. OneFlorida Clinical Research Consortium: Linking a Clinical and Translational Science Institute With a Community-Based Distributive Medical Education Model. Acad Med. 03 2018;93(3):451-455.
  13. OneFlorida i2b2 User Guide. In: OneFlorida, ed. 11/2018 ed. https://onefloridaconsortium.org/front-door/onfli2b2/2018.

Project Title: FDA Approved Resorbable Polymers for use in Pediatric Patients – A Literature Review

Faculty Mentor: Jessica Ching
Email: jessica.ching@surgery.ufl.edu 

Student: Benjamin Billings 
Email: bbillings@ufl.edu 

Research Project Description:

Biomaterials, substances or objects that are compatible with the human body, have been used for a variety of medical purposes throughout human history. Some examples are applications as simple a catgut or sinew sutures, which have been documented in Egyptian records and used into modern times, metallic implants for joint arthroplasty procedures, and more recently resorbable polymers for use in tissue scaffold engineering and drug delivery. This latter category has been a region of high interest in the last decade and continues to be an area of rapid growth and innovation. While there have been many products which have reached the market that incorporate these materials, a up-to-date thorough review detailing the approved materials for use in the pediatric patient population has not been produced. Thus, the goal of this research is to compile information from various studies, products, and databases to provide an accurate review of approved pediatric biomaterials, with the focus on resorbable polymers for use in the pediatric setting.
Ultimately, the significance of this review would be that it could serve as an easy to interpret and concise review of available materials for use, their significant properties in relation to human body compatibility and behavior, and preferable materials for various applications for physicians and researchers to reference as needed. Having readily condensed information can be a vital time saver for many practitioners and better enable them to focus more time on caring for their patient population and less on searching for information.

Due to the ongoing development and innovation of the field of resorbable biopolymers, a vast array of material specific properties has become available. With specific polymers having unique strengths, degradation profiles, and suitable uses as well as co-polymers with specific formulations that can combine two or more materials and balance their property profiles, the variation presented to clinicians has the potential to be vast, especially as new products continue to emerge on the market. Thus, a review that can collect and organize information regarding the approved materials for a defined patient population, the pediatric age group, is of clinical use. More importantly, the rationale behind a review like this is that many implantable materials approved in adults may not be sufficient for use in children due to the state of growth and development during early life, that may require implants to regress or accommodate native tissue as the normal tissue expands or alters its conformation, as in normal bone growth.

Specific aims of this review as discussed above are thus to compile previously published knowledge, research, and information regarding approved biomaterials, specifically with interest in resorbable polymers. Additionally, there is the aim of refining these materials to include and examine those that are approved for pediatric uses. Finally, this review also aims to briefly yet thoroughly discuss the suitable uses and properties of the approved materials to aid in future decision making.

References:

  1. Center for Devices and Radiological Health. Medical Device Databases. U.S. Food and Drug Administration Available at: https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/medical-device-databases. (Accessed: 10th May 2020)
  2. Middleton, J. C. & Tipton, A. J. Synthetic biodegradable polymers as orthopedic devices. Biomaterials (2000). Available at: https://www.sciencedirect.com/science/article/pii/S0142961200001010. (Accessed: 10th May 2020)
  3. Patel, M. & Fisher, J. P. Biomaterial Scaffolds in Pediatric Tissue Engineering. Nature News Available at: https://www.nature.com/articles/pr2008101. (Accessed: 10th May 2020)
  4. Tevlin, R. et al. Biomaterials for craniofacial bone engineering. Journal of dental research (2014). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4237632/. (Accessed: 10th May 2020)
  5. Velde, K. V. de & Kiekens, P. Biopolymers: overview of several properties and consequences on their applications. Polymer Testing (2002). Available at: https://www.sciencedirect.com/science/article/pii/S0142941801001076. (Accessed: 11th May 2020)
  6. Wang, X. Overview on Biocompatibilities of Implantable Biomaterials. IntechOpen (2013). Available at: https://www.intechopen.com/books/advances-in-biomaterials-science-and-biomedical-applications/overview-on-biocompatibilities-of-implantable-biomaterials. (Accessed: 10th May 2020)
  7. Williams, D. F. Challenges With the Development of Biomaterials for Sustainable Tissue Engineering. Frontiers in bioengineering and biotechnology (2019). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6554598/. (Accessed: 10th May 2020)
  8. Pappalardo, D., Mathisen, T. & Finne-Wistrand, A. Biocompatibility of Resorbable Polymers: A Historical Perspective and Framework for the Future. Biomacromolecules 20, 1465–1477 (2019).