The Supply of Surgical Specialists and Subspecialists to the U.S. Medicare Population: National Trends From 2013 to 2019

PURPOSE

The U.S. population is rapidly aging. The supply of surgeons needed to meet this demand should be evaluated. This study evaluated the trends in supply of Medicare surgeons by specialty and by U.S. state and region.

METHOD

All surgeons associated with a National Provider Identifier for cardiothoracic surgery, colorectal surgery, general surgery, gynecologic oncology, hand surgery, neurosurgery, obstetrics-gynecology, ophthalmology, oral and maxillofacial surgery, orthopedic surgery, otolaryngology, plastic and reconstructive surgery, surgical oncology, urology, and vascular surgery from 2013 to 2019 on the Centers for Medicare & Medicaid Services website were included. The absolute number of physicians was adjusted per 100,000 Medicare beneficiaries. Annual change was calculated by linear regression model, and the compound annual growth rate (CAGR) was calculated per specialty.

RESULTS

The absolute number of physicians per 100,000 beneficiaries increased in 6 of 15 specialties during the study period. Vascular surgery had the largest annual increase (+0.23; CAGR, +2.75%), and obstetrics-gynecology had the largest annual decrease (-1.08; CAGR, -1.44%). Surgical oncology showed the largest positive CAGR (+4.20%). Oral and maxillofacial surgery had the largest negative CAGR (-2.86%). The Northeast was above the national average in supply for each specialty. The Midwest had the most specialties with positive CAGRs. The South did not meet the national average for physicians in any specialty.

CONCLUSIONS

This analysis of 15 surgical specialties provides important context to predicted physician shortages to the Medicare population. The study found geographic variation by region across specialty, which has important implications for health care planning from the level of undergraduate medical education to provision of hospital resources. Overall, the supply of surgeons across all specialties may not be sufficient to meet the demand of the rapidly aging U.S. population. Future study is needed to evaluate why surgeons are leaving the Medicare program.

Breast Cancer Method of Detection: 5 Year Outcomes Across a Multisite Healthcare Enterprise

PURPOSE

To investigate the feasibility and accuracy of radiologists categorizing the method of detection (MOD) when performing image-guided breast biopsies.

METHODS

This retrospective, observational study was conducted across a healthcare enterprise that provides breast imaging services at 18 imaging sites across 4 US states. Radiologists utilized standardized templates to categorize the MOD, defined as the first test, sign, or symptom that triggered the subsequent workup and recommendation for biopsy. All image-guided breast biopsies since the implementation of the MOD-inclusive standardized template from October 31, 2017 to July 6, 2023 were extracted. A random sample of biopsy reports was manually reviewed to evaluate the accuracy of MOD categorization.

RESULTS

29,999 biopsies were analyzed. MOD was reported in 29,423 (98.1%) biopsies at a sustained rate that improved over time. The 10 MOD categories in this study included mammogram 15,184 (51.6%), MRI 4,561 (15.5%), US 3,473 (11.8%), self exam 2,382 (8.1%), tomosynthesis 2,073 (7.0%), clinical exam 432 (1.5%), MBI 421 (1.4%), other 357 (1.2%), CEDM 338 (1.1%), and PET 202 (0.7%). Original assignments of the MOD agreed with author assignments in 87% of manually reviewed biopsies (n=100, 95% CI: [80.4%, 93.6%]).

CONCLUSIONS

This study demonstrates that US radiologists can consistently and accurately categorize the MOD over an extended time across a healthcare enterprise.

Transcatheter Aortic Valve Replacement: Variations in Use, Charges, and Geography in the United States

The use of transcatheter aortic valve replacement (TAVR) in the United States has been increasing but with variability. We used a 100% sample of Medicare beneficiaries (MBs), from the Centers for Medicare and Medicaid Services database, who underwent TAVR by cardiologists between 2015 and 2019. We stratified data by geographic region, rural/urban areas, and provider's gender. We examined the average number of TAVRs performed per 100,000 MBs, the average number of TAVRs performed per individual cardiologist, and the average submitted charge (ASC) per procedure. The number of TAVR per 100,000 MBs was significantly variable among regions in all years (all P≤0.028), except in 2015 (P=0.103), with the highest rates being in the Northeast and the lowest being in the West. The number of TAVRs per cardiologist was significantly different among regions only in 2019 (P=0.04), with the Northeast showing the highest numbers and the South showing the lowest. The ASC was also significantly variable among regions in all years (all P≤0.01). The highest ASC was in the Midwest for all years, whereas the lowest was in the West in 2015 to 2016 and in the South in 2017 to 2019. In all years, the number of TAVRs per cardiologist was higher in urban areas than in rural areas (all P<0.05); however, rural cardiologists had higher ASCs (all P<0.05). The number of TAVR procedures per cardiologist was not significantly different between male and female cardiologists (all P>0.1). Female cardiologists had a significantly higher ASC only in 2015 (P=0.034). In conclusion, there are variations in TAVR use and charges for MBs according to geographic, urban, and rural regions and the performing cardiologist's gender.

Consolidative Radiotherapy for Residual PET-Avid Disease on Day +30 Post CAR T-Cell Therapy in Non-Hodgkin Lymphoma

PURPOSE/OBJECTIVE(S)

Up to30% of non-Hodgkin lymphoma (NHL) patients achieve a partial response (PR) to anti-CD19 Chimeric Antigen Receptor T-cell Therapy (CART) on day +30. Most PR patients relapse and only 30% achieve spontaneous complete response (CR) without additional therapies. This study is the first to report on the role of consolidative radiotherapy (cRT) for PR PET-avid disease on day +30 post-CART in NHL.

MATERIALS/METHODS

Aretrospective review across 3 institutions from 2018 to 2022 identified 60 patients with B-cell NHL who received CART and achieved PR (Deauville 4-5) with <5 PET-avid disease sites on day +30. Progression-free survival (PFS) was defined from CART infusion to any disease progression. Overall survival (OS) was defined from CART infusion to death. Local relapse-free survival (LRFS), calculated based on the total number of PR sites, was defined from CART infusion to local relapse (LR) in the PR site identified on day +30. cRT was defined as comprehensive (compRT) - treated all PR PET-avid sites - or focal (focRT).

RESULTS

Followingday +30 PET scan, 45 PR patients were observed and 15 received cRT. Only one patient received consolidative systemic therapy and belonged to the cRT group. Prior to CART, bridging RT was given to 13 patients (9 in observation group and 4 in cRT group). There were no significant differences in the pre-CART and day +30 baseline characteristics, including the median size and SUVmax of the PR sites, between the two groups. However, the median number of PR sites on day +30 was higher in the cRT group (2 [range 1-3] vs 1 [range 1-3], p = 0.003). The median equivalent 2 Gy dose was 39.1 (Interquartile range 36.8-41) Gy, and the most common cRT regimen was 37.5 Gy in 15 fractions. The median follow-up was 21 months. Among the observed patients, 15 (33%) achieved spontaneous CR, and 27 (60%) experienced disease progression with all relapses involving the initial PR sites. Among patients who received cRT, 10 (67%) achieved CR, and 3 (20%) had disease progression with no relapses in the radiated PR sites. None of the 10 cRT patients achieving CR relapsed or required subsequent therapies. The 2-year PFS was 80% and 37% (p = 0.012) and the 2-year OS was 78% and 43% (p = 0.12) in the cRT and observation groups, respectively. Patients consolidated with compRT (n = 12) had superior 2-year PFS (92% vs 37%, p = 0.003) and 2-year OS (86% vs 43%, p = 0.048) compared to observed or focRT patients (n = 48). There were no grade 3+ RT-related toxicities. A total of 90 PR sites were identified; 64 were observed and 26 received cRT. Fourteen (22%) observed PR sites achieved spontaneous sustained CR and 42 (66%) experienced LR. Twenty-four (92%) PR sites consolidated with cRT achieved sustained CR and none experienced LR. The 2-year LRFS was 100% in the cRT sites and 31% in the observed sites (p<0.001).

CONCLUSION

NHL patients who achieve PR by PET to CART are at high risk of local progression. cRT for residual PET-avid disease on day +30 post-CART appears to alter the pattern of relapse and improve LRFS and PFS.

Variations in Atrial Fibrillation Ablation Use and Charges in a Modern Cohort of Medicare Beneficiaries

Catheter ablation of atrial fibrillation (CAF) is increasingly being used in the United States. This study aimed to identify variations in CAF use among Medicare beneficiaries (MBs) over a 6-year period (2013 to 2019). Using the Center of Medicare and Medicaid Services database, a 100% sample of MBs who underwent CAF from 2013 to 2019 was included. We stratified CAF use data geographically (Northeast, South, West, and Midwest) and identified the number of CAFs per 100,000 MBs, number of electrophysiologists performing CAFs per 100,000 MBs, number of CAFs per individual electrophysiologist, and average submitted charge for CAF. In addition, we stratified the data per urban versus rural areas and gender of the operator. We found that the mean atrial fibrillation (AF) prevalence, rates of CAFs, number of electrophysiologists performing CAFs, and number of CAFs per electrophysiologist have increased steadily in all regions. The mean AF prevalence was different among regions, with the highest prevalence in the Northeast (p <0.001); however, there was a pattern of higher CAFs rates in the West and the South (p ≥0.057). The number of electrophysiologists performing CAFs was not different among regions; however, the number of CAFs per electrophysiologist was higher in the West and the South (p <0.001). The average submitted charge for CAF has decreased over years and was the lowest in the West and the South (p <0.001). There was no major difference in these variables regarding operator gender. In conclusion, there are significant variations in CAF use among MBs in the United States according to geographic and urban versus rural regions. These variations have the potential to impact the outcomes in MBs diagnosed with AF.

Medicare Reimbursement in Colorectal Surgery: A Growing Problem

BACKGROUND

Medicare reimbursement rates have decreased across various specialties but have not yet been studied in colorectal surgery.

OBJECTIVE

This study aimed to analyze Medicare reimbursement trends in colorectal surgery.

DESIGN

Observational study.

SETTING

The Centers for Medicare and Medicaid Services' Physician Fee Schedule was evaluated for reimbursement data for the 20 most common colorectal surgery procedures from 2006 to 2020.

MAIN OUTCOME MEASURES

Inflation-adjusted annual percentage change, compound annual growth rate, and total percentage change were the outcome measures. A subanalysis was performed comparing the changes in reimbursement between 2006 to 2016 and 2016 to 2020 because of legislative changes that went into effect in 2016.

RESULTS

During the study period, the inflation-unadjusted mean Medicare reimbursement rate for the 20 most common colorectal surgery procedures increased by +15.6%. This rise was surpassed by the inflation rate of +31.3%. Consequently, the inflation-adjusted reimbursement rate decreased by -11%. The adjusted reimbursement rates decreased the most at -33.8% for a flexible colonoscopy with biopsy and increased the most at +45.3% for a diagnostic rigid proctosigmoidoscopy. Annual percentage change was -0.79%, and the compound annual growth rate was -0.98%. There was an accelerated decrease in annual reimbursement rates from 2016 to 2020 at -2.23% compared to 2006 to 2016 at -0.22% ( p = 0.03). The only procedure that had an increase in adjusted reimbursement rate from 2016 to 2020 was the injection of sclerosing solution for hemorrhoids.

LIMITATIONS

Only Medicare reimbursement data were analyzed.

CONCLUSIONS

Medicare reimbursements for colorectal surgery procedures are decreasing at an accelerating rate. Although this study is limited to Medicare data, it still presents a representation of overall reimbursement changes because Medicare policies have a ripple effect in the commercial insurance market. It is vital to understand the financial trends to be able to structure future patient care teams and to advocate for the sustainability of colorectal surgery practices in the United States. See Video Abstract at http://links.lww.com/DCR/C136 .

REEMBOLSO DE MEDICARE EN CIRUGA COLORRECTAL UN PROBLEMA CRECIENTE

ANTECEDENTES: Las tasas de reembolso de Medicare han disminuido en varias especialidades, pero aún no han sido estudiado en cirugía colorrectal.OBJETIVO: Analizar las tendencias de reembolso de Medicare en cirugía colorrectal.DISEÑO: Estudio observacional.CONTEXTO: Se evaluó el programa de tarifas médicas de los Centros de Servicios de Medicare y Medicaid para obtener datos de reembolso de los 20 procedimientos más comunes en cirugía colorrectal entre los años 2006 y 2020.PRINCIPALES MEDIDAS DE RESULTADO: Variación porcentual anual ajustada por inflación, tasa de crecimiento anual compuesta y variación porcentual total. Se realizó un subanálisis comparando los cambios en el reembolso entre los años 2006 a 2016 y 2016 a 2020 debido a los cambios legislativos que entraron en vigencia en 2016.RESULTADOS: Durante el período de estudio, la tasa media de reembolso de Medicare sin ajuste por inflación para los 20 procedimientos más comunes en cirugía colorrectal aumentó en +15,6 %. Esta suba fue superada por la tasa de inflación del +31,3%. En consecuencia, la tasa de reembolso ajustada por inflación disminuyó un -11%. Lo máximo que disminuyeron las tasas ajustadas de reembolso fue a -33,8% para una colonoscopia flexible con biopsia y aumentaron más a +45,3% para una proctosigmoidoscopia rígida de diagnóstico. El cambio porcentual anual fue -0,79% y la tasa de crecimiento anual compuesto fue -0,98%. Hubo una disminución acelerada en las tasas de reembolso anual de 2016 a 2020 a -2,23 % en comparación con 2006 a 2016 a -0,22% ( p = 0,03). El único procedimiento que tuvo un aumento en la tasa de reembolso ajustada de 2016 a 2020 fue la inyección de solución esclerosante para las hemorroides.LIMITACIONES: Solo se analizaron los datos de reembolso de Medicare.CONCLUSIONES: Los reembolsos de Medicare por procedimientos en cirugía colorrectal están disminuyendo a un ritmo acelerado. Aunque este estudio se limita a los datos de Medicare, aún presenta una representación de los cambios generales en los reembolsos, ya que las pólizas de Medicare tienen un efecto dominó en el mercado de seguros comerciales. Es fundamental comprender las tendencias financieras para poder estructurar futuros equipos de atención de pacientes y abogar por la sostenibilidad de las prácticas de cirugía colorrectal en los Estados Unidos. Consulte Video Resumen video en https://links.lww.com/DCR/C136 . (Traducción-Dr. Osvaldo Gauto ).

Trends in Medicare Reimbursement for Interventional Radiology Procedures: 2007-2020

PURPOSE

Declining physician reimbursement has been occurring across multiple specialties due to changes in Medicare legislation, including the Deficit Reduction Omnibus Reconciliation Act (DRA), the Balanced Budget Act, and the Sustainable Growth Rate. The purpose of this study was to evaluate trends in Medicare reimbursement rates for various procedural classes in interventional radiology from 2007 to 2020.

METHODS

Common interventional radiology procedures were selected across multiple procedural classes: gastrointestinal, biliary, urinary, fallopian dilatation, other injection/change/removal, iliac vascular, femoral/popliteal vascular, tibial/peroneal vascular, hepatobiliary, and vascular emergency. The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for current procedural terminology (CPT) codes to extract reimbursement data. All monetary data were adjusted for inflation using the United States consumer price index (CPI). The compound annual growth rate (CAGR) and average annual change in reimbursement were calculated based on these adjusted trends.

RESULTS

Aside from urinary and vascular emergency procedures, all other procedural classes experienced decreases in inflation-adjusted Medicare reimbursement from 2007 to 2020. The greatest mean decrease in reimbursement rates was observed in biliary procedures (-$21.25), while the largest mean increase in reimbursement rates was observed in vascular emergency procedures ($3.23). All procedures with increases in reimbursement rates and 36.8% of procedures with decreases in reimbursement rates have a CPT code change between 2007 and 2020.

CONCLUSION

After accounting for inflation, reimbursement rates were shown to decline for all procedural classes except for urinary and vascular emergencies. Congressional policies, such as the Deficit Reduction Act (DRA) and the Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act of 2015, may clarify some of these trends.

Supply of obstetrician-gynecologists and gynecologic oncologists to the US Medicare population: a state-by-state analysis

BACKGROUND

The supply of obstetrician-gynecologists and gynecologic oncologists across the United States has been described. However, these studies focused on reproductive-age patients and did not assess the growing demand for services to the advanced-age female population.

OBJECTIVE

This study aimed to evaluate the supply of obstetrician-gynecologists and gynecologic oncologists who serve the US Medicare population per 100,000 female Medicare beneficiaries, over time and by state and region.

STUDY DESIGN

The supply of obstetrician-gynecologists and gynecologic oncologists was extracted from the Physician and Other Supplier Public Use File database of Medicare Part B claims submitted to the US Centers for Medicare & Medicaid Services. Data were only available from 2012 to 2019. The supply of providers was divided by the number of original female Medicare beneficiaries obtained from the Kaiser Family Foundation; all values reported are providers per 100,000 female beneficiaries by state. Trends over time were assessed as the difference in provider-to-beneficiary ratio and the percentage change from 2012 to 2019. All data were collected in 2021. All analyses were performed with SAS, version 9.4. This study was exempt from institutional review board approval.

RESULTS

In 2019, the average number of obstetrician-gynecologists per 100,000 female beneficiaries across all states was 121.32 (standard deviation±33.03). The 3 states with the highest obstetrician-gynecologist-to-beneficiary ratio were the District of Columbia (268.85), Connecticut (204.62), and Minnesota (171.60), and the 3 states with the lowest were Montana (78.37), West Virginia (82.28), and Iowa (83.92). The average number of gynecologic oncologists was 4.48 (standard deviation±2.08). The 3 states with the highest gynecologic oncologist-to-beneficiary ratio were the District of Columbia (11.30), Rhode Island (10.58), and Connecticut (9.24), and the 3 states with the lowest were Kansas (0.82), Vermont (1.41), and Mississippi (1.47). The number of obstetrician-gynecologists per 100,000 female beneficiaries decreased nationally by 8.4% from 2012 to 2019; the difference in provider-to-beneficiary ratio from 2012 to 2019 ranged from +29.97 (CT) to -82.62 (AK). Regionally, the Northeast had the smallest decrease in the number of obstetrician-gynecologists per 100,000 female beneficiaries (-3.8%) and the West had the largest (-18.2%). The number of gynecologic oncologists per 100,000 female beneficiaries increased by 7.0% nationally during the study period; this difference ranged from +8.96 (DC) to -3.39 (SD). Overall, the West had the smallest increase (4.7%) and the Midwest had the largest (15.4%).

CONCLUSION

There is wide geographic variation in the supply and growth rate of obstetrician-gynecologists and gynecologic oncologists for the female Medicare population. This analysis provides insight into areas of the country where the supply of obstetrician-gynecologists and gynecologic oncologists may not meet current and future demand. The national decrease in the number of obstetrician-gynecologists is alarming, especially because population projections estimate that the proportion of elderly female patients will grow. Future work is needed to determine why fewer providers are available to see Medicare patients and what minimum provider-to-enrollee ratios are needed for gynecologic and cancer care. Once such ratios are established, our results can help determine whether specific states and regions are meeting demand. Additional research is needed to assess the effect of the COVID-19 pandemic on the supply of women's health providers.

Establishing a telemedicine program for interventional radiology: a study of patient opinion and experience

PURPOSE The COVID-19 pandemic forced healthcare officials to implement new policies, such as the use of virtual consultations over office-based medical appointments, to reduce the transmission of the virus. The purpose of this study is to quantitatively compare patients' experiences with virtual outpatient telemedicine encounters at a single academic institution in Interventional Radiology (IR) and in-person visits during the course of the COVID-19 pandemic. METHODS The TeleENT Satisfaction Questionnaire and the Medical Communication Competence Scale (MCCS) were used to survey patients' satisfaction with both in-person and virtual office visits. RESULTS Ninety respondents (38 in-person, 52 virtual) acknowledged numerous benefits of virtual visits versus in-person office visits including reductions in time, cost, and potential viral transmission risk during the COVID-19 pandemic. No statistically significant difference was noted, based on a Likert scale from 1 to 7, between in-person and virtual visits (all p > 0.05) for scheduling related factors. No statistically significant difference was noted in any of the MCCS subscales between the two cohorts in regards to medical information communication (all p > 0.05). A majority of patients with virtual encounters (82.7%) stated that it was easy to obtain an electronic device for use during the telemedicine visit, and 73.1% of patients felt that setting up the telemedicine encounter was easy. CONCLUSION This study demonstrates that telemedicine is an acceptable alternative to in-office appointments and could increase access to IR care outside of the traditional physician-patient interaction. With telemedicine visits, patients can communicate their concerns and obtain information from the doctor with noninferior communication compared to in-person visits.

Variations in atrial fibrillation ablation utilization and reimbursement among medicare beneficiaries: an observational study from 2013 to 2019

Background

Atrial fibrillation (AF) pulmonary vein isolation ablation has been utilized increasingly yet variably in the USA.

Purpose

To identify variations in AF ablation utilization and reimbursement among Medicare beneficiaries (MB).

Methodology

We used a 100% sample of MB who underwent AF ablation from 2013 to 2019. We stratified data geographically (Northeast, South, West, and Midwest), identified the mean AF prevalence and the number of AF ablations per 100,000 MB, and examined the correlation between AF prevalence and ablation. We also examined the number of cardiologists performing AF ablation per 100,000 MB and the average number of AF ablation per individual cardiologist (ablation/cardiologist), as well as average submitted charge (ASC) for AF ablation. Additionally, we stratified data per urban versus rural areas as well as the gender of performing cardiologists and examined ablation/cardiologist and the ASC.

Results

Geographic analysis: The mean AF prevalence, the rates AF ablation per 100,000 MB, the number of cardiologists per 100,000 MB, and ablation/cardiologist have shown a steady increase in all regions across years. In all years, the mean AF prevalence was significantly different among regions with the highest prevalence in the Northeast and the lowest in the West (all P&lt;0.001), however, there was no significant difference in the rates of AF ablation per 100,000 MB (all P≥0.056). There was significant correlation between AF prevalence and ablation only in the Midwest and the West, with 46.4% and 43.4% positive correlation respectively (P≤0.0001). The number of cardiologists performing AF ablation per 100,000 MB was not significantly different among regions in all years (All P≥0.48), however, ablation/cardiologist was significantly higher in the West and the South compared to the Northeast and the Midwest (All P&lt;0.0001). On the contrary, the ASC has shown steady decrease in all regions. The ASC was significantly different among regions in all year (all P≤0.003) with higher ASC in the Midwest and the Northeast compared to the south and the West.

Urban vs rural analysis: Ablation/cardiologist was not significantly different between urban and rural areas in all years (all P≥0.068) except in 2013 when it was significantly higher in urban areas (P=0.004). The ASC was significantly higher in rural areas only in 2015 and 2019 (P=0.037 and P=0.029 respectively) however, there was no significant difference in the rest of the years (P≥0.07).

Gender analysis: Ablation/cardiologist was not significantly different between male and female cardiologists in all years (P≥0.056) except in 2017 when the average was significantly higher per male cardiologists (P=0.007). The ASC was not significantly different in all years (P≥0.362).

Conclusion

There are variations in AF ablation utilization and reimbursement among MB in the USA according to geographic, urban and rural regions, and the gender of performing cardiologists.

Funding Acknowledgement

Type of funding sources: None.

Interventional Management of Acquired Lymphatic Disorders

The lymphatic system is a complex network of tissues, vessels, and channels found throughout the body that assists in fluid balance and immunologic function. When the lymphatic system is disrupted related to idiopathic, iatrogenic, or traumatic disorders, lymphatic leaks can result in substantial morbidity and/or mortality. The diagnosis and management of these leaks is challenging. Modern advances in lymphatic imaging and interventional techniques have made radiology critical in the multidisciplinary management of these disorders. The authors provide a review of conventional and clinically relevant variant lymphatic anatomy and recent advances in diagnostic techniques such as MR lymphangiography. A detailed summary of technical factors related to percutaneous lymphangiography and lymphatic intervention is presented, including transpedal and transnodal lymphangiography. Traditional transabdominal access and retrograde access to the central lymph nodes and thoracic duct embolization techniques are outlined. Newer techniques including transhepatic lymphangiography and thoracic duct stent placement are also detailed. For both diagnostic and interventional radiologists, an understanding of lymphatic anatomy and modern diagnostic and interventional techniques is vital to the appropriate treatment of patients with acquired lymphatic disorders. ^©RSNA, 2022.

201 Compliance to New BOAST's Guidelines for Paediatric Supracondylar Fractures in the Middle of COVID Pandemic

Aim

Amid COVID pressures, standards of surgical practices need constant reviewing to maintain patient safety and streamline care pathways. Newly published BOAST (British Orthopaedic Association Standards for Trauma and Orthopaedics) guidelines for paediatric supracondylar fractures became a benchmark against which a restructured DGH trauma unit's performance can be appraised.

Method

Theatre records were analysed between April-2020 and September-2020. Data were collected to reveal time to theatre, operative techniques, documentations of ulnar nerve protection, complications, follow-up plans, time to first post-op radiograph and to wire removal.

Results

90% of patients underwent operations within 24–48 hour. Although there was no incidence of iatrogenic nerve injury, documentation of ulnar nerve protection was not identified in 45% of crossed wire fixations. Wire size was not mentioned in 14%. 33% did not have first follow-up with radiograph within 4–10 days, and 43% of patients did not have the wires removed till 4 weeks post op.

Conclusion

This re-audit highlights the need to improve in documentation for ulnar nerve protection and to identify the delays in follow-up appointments. Although BOAST no longer recommends a fixed timeframe for follow-up plan, first radiograph within 4–10 days and wire removal within 4 weeks are still reasonable locally.

Geographic Variations in Growth of Radiologists and Medicare Enrollees From 2012 to 2019

OBJECTIVE

Analyze changes in the number of Medicare-serving radiologists and Medicare enrollees nationwide and by geographic region and state from 2012 to 2019 to understand variations in allocation of imaging health care services over the past decade.

METHODS

The number of radiologists submitting claims to Medicare was extracted from the CMS Physician and Other Supplier Public Use File Database. The number of Medicare enrollees by state was obtained from the Kaiser Family Foundation. National-, regional-, and state-level changes in rates of growth of radiologists, Medicare enrollees, and radiologists per 100,000 Medicare enrollees from 2012 to 2019 were tabulated.

RESULTS

The overall number of radiologists per 100,000 Medicare enrollees was 79.7 in 2012, increasing to 79.9 in 2019. In 2012, the number of radiologists per 100,000 enrollees was lower than the national average in the South (66.9; 16% lower) and Midwest (79.1; 0.7% lower) and higher in the Northeast (98.3; 23% higher) and West (88.8; 11% higher). In 2019, the number of radiologists per 100,000 enrollees was lower than the national average in the South (69.8; 12% lower) only and was higher in the Midwest (81.4; 1.9% higher), Northeast (99.3; 24% higher), and West (80.2; 0.4% higher). By state, there was a 4.2-fold variation in the number of radiologists per 100,000 Medicare enrollees, ranging from 38.8 in Wyoming to 161.4 in Minnesota (200.5 in Washington, DC).

DISCUSSION

The growth of Medicare-serving radiologists and Medicare enrollees was stable nationally and demonstrated tremendous variations by US region and state. These variations bring to light potential implications for patient access to care and distribution of health care resources.

Systemic anti-inflammatory effects of mesenchymal stem cells in burn: A systematic review of animal studies

Background

Despite the advances in burn care, severe burns still impose significant morbidity and mortality. Severe burns are associated with an inflammatory response that ranges from alterations in vital signs to shock, multiorgan failure, and death. Mesenchymal stem cells (MSCs) are known for their anti-inflammatory and immunomodulatory effects. Therefore, MSCs were investigated for their potential benefits in modulating burn-induced inflammation and organ damage in several studies.

Aim

We have conducted a systematic review of the literature to evaluate the efficacy of MSCs in modulating burn-induced systemic inflammation and organ damage in animal models.

Methods

Four databases were searched: PubMed, Cumulative Index of Nursing and Allied Health Literature, Scopus, and Web of Science. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis as our basis of organization.

Results

Eight studies were included in the study. Bone marrow derived MSCs, umbilical cord derived MSCs (UC-MSCs), and UC-MSCs exosomes were used to modulate the burn-induced inflammation. MSCs therapy reduced serum levels of pro-inflammatory cytokines, improved renal function, inhibited tissue damage, and improved survival after burn. Furthermore, MSCs reversed all the burn-induced pathological changes in blood brain barrier (BBB).

Conclusion

MSCs may attenuate the burn-induced inflammation by decreasing serum levels of inflammatory cytokines. However, the effect on anti-inflammatory cytokines is conflicting and mandates more substantial evidence. Furthermore, MSCs reduce tissue inflammation, tissue damage, and apoptosis in the lungs and kidneys. In addition, MSCs reversed the burn-induced pathophysiologic changes in the BBB. The underlying mechanisms of these effects are poorly understood and should be the focus of future stem cell research.

Relevance to Patients

Severe burn patients are liable to systemic inflammation due to the release of inflammatory cytokines into the circulation. This inflammatory response has a broad spectrum of severity that ranges from alterations in vital signs to multiorgan failure and death. Despite the advances in burn care, burn-induced inflammation still imposes significant morbidity and mortality. This systematic review evaluates the potential benefits of stem cells in modulating burn-induced systemic inflammation in animal burn models.

Identification of Transportation Barriers in Patient Portal Messages via Deep Semantic Embeddings and Clustering

Patient portals have been widely used by patients to enable timely communications with their providers via secure messaging for various issues including transportation barriers. The large volume of portal messages offers an invaluable opportunity for studying transportation barriers reported by patients. In this work, we explored the feasibility of cutting-edge deep learning techniques for identifying transportation issues mentioned in patient portal messages with deep semantic embeddings. The successful creation of annotated corpus and identification of 7 transportation issues showed the feasibility of this strategy. The developed annotated corpus could aid in developing an artificial intelligence tool to automatically identify transportation issues from millions of patient portal messages. The identified specific transportation issues and the analysis of patient demographics could shed light on how to reduce transportation gaps for patients.

Patient Portal Messaging for Asynchronous Virtual Care During the COVID-19 Pandemic: Retrospective Analysis

BACKGROUND

During the COVID-19 pandemic, patient portals and their message platforms allowed remote access to health care. Utilization patterns in patient messaging during the COVID-19 crisis have not been studied thoroughly. In this work, we propose characterizing patients and their use of asynchronous virtual care for COVID-19 via a retrospective analysis of patient portal messages.

OBJECTIVE

This study aimed to perform a retrospective analysis of portal messages to probe asynchronous patient responses to the COVID-19 crisis.

METHODS

We collected over 2 million patient-generated messages (PGMs) at Mayo Clinic during February 1 to August 31, 2020. We analyzed descriptive statistics on PGMs related to COVID-19 and incorporated patients' sociodemographic factors into the analysis. We analyzed the PGMs on COVID-19 in terms of COVID-19-related care (eg, COVID-19 symptom self-assessment and COVID-19 tests and results) and other health issues (eg, appointment cancellation, anxiety, and depression).

RESULTS

The majority of PGMs on COVID-19 pertained to COVID-19 symptom self-assessment (42.50%) and COVID-19 tests and results (30.84%). The PGMs related to COVID-19 symptom self-assessment and COVID-19 test results had dynamic patterns and peaks similar to the newly confirmed cases in the United States and in Minnesota. The trend of PGMs related to COVID-19 care plans paralleled trends in newly hospitalized cases and deaths. After an initial peak in March, the PGMs on issues such as appointment cancellations and anxiety regarding COVID-19 displayed a declining trend. The majority of message senders were 30-64 years old, married, female, White, or urban residents. This majority was an even higher proportion among patients who sent portal messages on COVID-19.

CONCLUSIONS

During the COVID-19 pandemic, patients increased portal messaging utilization to address health care issues about COVID-19 (in particular, symptom self-assessment and tests and results). Trends in message usage closely followed national trends in new cases and hospitalizations. There is a wide disparity for minority and rural populations in the use of PGMs for addressing the COVID-19 crisis.

Decline in Medicare Utilization and Reimbursement Rates in Ophthalmic Plastic and Reconstructive Surgery: 2010-2019

BACKGROUND

Analysis of current and past reimbursement patterns for federally funded programs is crucial to develop sustainable future payment models.

METHODS

The Centers for Medicare and Medicaid Services Physician Fee Schedule was used to evaluate 26 common ophthalmic plastic and reconstructive surgery (OPRS) procedures. From 2010 to 2019, compound annual growth rate, total percent change, and annual percent change were calculated using inflation-adjusted reimbursement rates. Centers for Medicare and Medicaid Services' Physician/Supplier Procedure Summary was used to assess the surgical volume of the 26 procedures in ophthalmology and plastic surgery services.

RESULTS

From 2010 to 2019, total billed surgical procedures in OPRS decreased by 57.0%, affecting both ophthalmologists (-54.3%) and plastic surgeons (-80.1%). Over the study period, inflation-adjusted reimbursement rates decreased by 5.6%. Compound annual growth rate was -0.66%, and annual percent change was -0.62%. From 2010 to 2013, reimbursement rates increased by 1.8% each year. In contrast, from 2013 to 2019, reimbursement rates decreased by 1.7% each year (P < 0.0001).

CONCLUSIONS

From 2010 to 2019, Medicare utilization has substantially declined for OPRS procedures. Inflation-adjusted Medicare reimbursement rates have decreased for the majority of common procedures since 2013. Surgeons and policymakers need to be aware of these trends to ensure future availability of subspecialty surgical services.

'Mind if I record this?' Patients making audio-visual recordings of consultations: a survey of surgeons' experiences

INTRODUCTION

Audio-visual recordings made by patients of their clinical encounters are increasingly common. This may be done with or without their doctors' knowledge or consent and is considered admissible legal evidence. Many surgeons may feel uncomfortable with being recorded and lack knowledge regarding the legal implications. The aim of this study was to gauge how surgeons react to being recorded, and what specific medico-legal insight they have regarding these matters.

METHODS

In total, 150 surveys were distributed to surgeons in two hospitals in South Wales by email, Survey Monkey and paper copy between 28 October 2019 and 9 March 2020. The survey was anonymous and recorded level of training, as well as four simple questions regarding how surgeons may react to being recorded and what they felt their legal rights were.

RESULTS

There were 91 respondents: 28 consultants, 36 registrars and 27 junior surgical trainees. Of the respondents, 56% were uncomfortable with being recorded and 23% would stop a consultation if their patient insisted on recording it. These issues were most marked for junior surgical trainees. Sixty-two per cent of respondents were unaware of their legal rights and 21% believed they were legally able to refuse to continue a consultation. This belief was particularly marked among consultants.

CONCLUSION

Many surgeons are uncomfortable with being recorded and lack knowledge regarding their medico-legal standing. Education and guidance from the Royal Colleges would help address this issue and avoid misunderstanding when surgeons are faced with these potentially difficult scenarios.

Emerging approaches to pre-hospital hemorrhage control: a narrative review

In the United States, trauma claims the lives of over 150,000 civilians each year. In military settings, trauma and exsanguination result in 50% of combat related deaths. The majority of these deaths result from uncontrolled non-compressible hemorrhage. Non-compressible hemorrhage often results from deep vascular injuries within the torso, however can also occur secondary to penetrating injuries that involve the extremities. Given the high mortality rates for non-compressible hemorrhage, rapid and effective management of patients suffering from hemorrhage is essential to good patient outcomes. Consequently, there has been increasing interest in solutions for point-of-injury hemorrhage control in trauma and military medicine. Undoubtedly there is a great need for prehospital hemostatic interventions that can be deployed by trained and untrained personnel. Since 2001, various hemostatic agents have been developed, each with its advantages based upon the type and severity of injury, wound size, wound location, accessibility to injury site, and the coagulation status of the patient. These agents are often used in the military setting as a temporizing measure prior to definitive therapy and include techniques such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and bioengineered agents including ResQFoam, RevMedx’s XSTAT, Tranexamic acid (TXA), and QuikClot Combat Gauze (QCG). Here, we review the indications, composition, technique, efficacy, and outcomes of these hemostatic agents.

Endovascular interventions in the management of acute extremity trauma: a narrative review

Minimally invasive endovascular interventions including stenting and embolization have been widely adopted for the treatment of emergent and traumatic thoracoabdominal injuries. In recent years, these techniques have been utilized in the setting of extremity vascular trauma with promising outcomes. By allowing for the rapid diagnosis and subsequent treatment of penetrating or blunt vascular extremity trauma, these techniques can help to minimize blood loss, reduce operative complications, and potentially prevent limb amputation. Here, we present a narrative review of the ever-increasing role of minimally invasive interventions in the management of extremity trauma and compare its use and outcomes to open surgical repair. A special focus is placed on diagnostic imaging modalities in trauma and the role of interventional radiologists in the work-up and treatment of extremity trauma. We discuss diagnostic imaging modalities that aid in the triaging of extremity trauma, such as Doppler sonography, CT angiography, and catheter-based angiography. We present an overview on the literature related to endovascular interventions such as embolotherapy and stent grafting as well as the technical challenges associated with each technique. Finally, we present our own cases on the workup and endovascular treatment of extremity trauma, including CT angiography, particulate and coil embolization, and stent graft placement.

Initial Experience with Proton Beam Therapy for Differentiated Thyroid Cancer

Purpose

External beam radiotherapy is used in a subset of high-risk patients with differentiated thyroid cancer (DTC). Recurrent, radioactive iodine (RAI)-refractory DTC carries a poor prognosis. We report our initial experience of intensity-modulated proton therapy (IMPT) for recurrent, RAI-refractory DTC.

Patients and Methods

Fourteen patients with recurrent, RAI-refractory DTC were consecutively treated with IMPT from November 2016 to March 2020 at our multisite institution. Patient, tumor, and treatment characteristics were recorded. Overall survival and local-regional recurrence-free survival were recorded and estimated using the Kaplan-Meier method. Acute and late treatment-related toxicities were recorded based on the Common Terminology Criteria for Adverse Events version 5.0. Patients completed the European Organization for Research and Treatment of Cancer Quality of Life Head and Neck Module at baseline and after IMPT. Eleven patients were included in the final analysis.

Results

Median follow-up was 8 months (range, 3-40) for all patients. Median age at treatment with IMPT was 64 years (range, 40-77), and the majority were men (64%). Recurrent histologies included papillary (55%), Hurthle cell (36%), and poorly differentiated (9%) carcinoma; 1 patient had tall cell variant. Concurrent chemotherapy was not administered for any patient in this cohort. At 8 months, all patients were alive without local-regional failure. Acute grade 3 toxicities were limited to 1 patient with dysphagia, requiring feeding tube placement. Two patients experienced late grade 3 esophageal stenosis requiring dilation. There were no grade 4 or 5 toxicities. There were no differences in pretreatment versus posttreatment patient-reported outcomes in terms of dysphagia or hoarseness.

Conclusion

In our early experience, IMPT provided promising local-regional control for recurrent, RAI-refractory DTC. Further study is warranted to evaluate the long-term efficacy and safety of IMPT in this patient population.

Probing Patient Messages Enhanced by Natural Language Processing: A Top-Down Message Corpus Analysis

Background. Patients increasingly use asynchronous communication platforms to converse with care teams. Natural language processing (NLP) to classify content and automate triage of these messages has great potential to enhance clinical efficiency. We characterize the contents of a corpus of portal messages generated by patients using NLP methods. We aim to demonstrate descriptive analyses of patient text that can contribute to the development of future sophisticated NLP applications. Methods. We collected approximately 3,000 portal messages from the cardiology, dermatology, and gastroenterology departments at Mayo Clinic. After labeling these messages as either Active Symptom, Logistical, Prescription, or Update, we used NER (named entity recognition) to identify medical concepts based on the UMLS library. We hierarchically analyzed the distribution of these messages in terms of departments, message types, medical concepts, and keywords therewithin. Results. Active Symptom and Logistical content types comprised approximately 67% of the message cohort. The "Findings" medical concept had the largest number of keywords across all groupings of content types and departments. "Anatomical Sites" and "Disorders" keywords were more prevalent in Active Symptom messages, while "Drugs" keywords were most prevalent in Prescription messages. Logistical messages tended to have the lower proportions of "Anatomical Sites,", "Disorders,", "Drugs,", and "Findings" keywords when compared to other message content types. Conclusions. This descriptive corpus analysis sheds light on the content and foci of portal messages. The insight into the content and differences among message themes can inform the development of more robust NLP models.

Medicare Reimbursement Trends for Hospital-Based Oral Maxillofacial Surgery Procedures: 2003 to 2020

PURPOSE

To evaluate recent trends in Medicare reimbursement rates for common hospital-based oral-maxillofacial surgery procedures.

METHODS

Physician Fee Schedule Look-Up Tool by the Centers for Medicare and Medicaid Services was searched for reimbursement rates for the 20 most performed oral-maxillofacial surgery procedures between 2003 and 2020. Total percent change, annual percent change, and compound annual growth rate (CAGR) were calculated using the adjusted reimbursement rates over the study period. Annual changes in reimbursement rates before and after 2016 were compared.

RESULTS

After adjusting for inflation, average reimbursement rates for procedures decreased by 13.4%. Annual percent change and CAGR were -0.79 and -0.88%, respectively. Annual reimbursements decreased more between 2016 to 2020 (-1.83%,) than from 2003 to 2016 (-0.49%; P value = .003).

CONCLUSION

Inflation-adjusted Medicare reimbursement rates for oral-maxillofacial surgery procedures have decreased from 2003 to 2020. The rate of reimbursement decreases has accelerated in recent years.

Comprehensiveness of Breast Radiology Fellowship Online Content

OBJECTIVE

The content of websites for fellowship programs is an important source of information for residents applying to breast imaging fellowship programs (BIFPs). The purpose of this study is to evaluate the comprehensiveness of online content of BIFPs.

METHODS

A list of BIFPs was obtained from the Society of Breast Imaging website. Each program's website was evaluated for the presence of 19 training-relevant content variables. Impact of program characteristics on comprehensiveness scores was determined. For statistical analysis, Kruskal-Wallis tests were used to assess differences in comprehensiveness scores based upon region, and two-tailed t-tests were used to compare based upon program size.

RESULTS

A total of 79 BIFP websites were analyzed. The mean comprehensiveness score of BIFP websites based on meeting the 19 criteria was 44.1% (8.4 ± 2.7/19). Program coordinator contact information (72/79, 91.1%), application requirements (71/79, 89.9%), and faculty information (56/79, 70.9%) appeared on >70% of websites. The majority of fellowships had a dedicated webpage for their program (71/79, 89.9%). Information regarding 12 of the 19 criteria appeared on fewer than 50% of websites. Program region (P = 0.32) and size (P = 0.16) were not associated with any differences in mean comprehensiveness score. Additionally, there was no significant difference in scores associated with filling all available positions for the 2020 match cycle (P = 0.77).

CONCLUSION

There is a paucity of information commonly sought out by applicants on the websites of most BIFPs. Both programs and applicants may mutually benefit from increasing comprehensive online content.

Symphytum officinale augments osteogenesis in human bone marrow-derived mesenchymal stem cells in vitro as they differentiate into osteoblasts

ETHNOPHARMACOLOGICAL RELEVANCE

Mesenchymal stem cells (MSCs) are multipotent stem cells possessing regenerative potential. Symphytum officinale (SO) is a medicinal plant and in homoeopathic literature, believed to accelerate bone healing.

AIM OF THE STUDY

This study aimed to determine if homoeopathic doses of SO could augment osteogenesis in MSCs as they differentiate into osteoblasts in vitro.

MATERIALS AND METHODS

Bone marrow samples were obtained from patients who underwent bone grafting procedures (n = 15). MSCs were isolated, expanded and characterized by flow cytometry (CD90, CD105). Cytotoxicity of SO was evaluated by MTT assay. Osteogenic differentiation was induced in MSCs with β-glycerophosphate, ascorbic acid and dexamethasone over 2 weeks. Different homoeopathic doses of SO (MT, 3C, 6C, 12C and 30C) were added to the basic differentiation medium (BDM) and efficiency of MSCs differentiating into osteoblasts were measured by evaluating expression of Osteocalcin using flow cytometry, and alkaline phosphatase activity using ELISA. Gene expression analyses for osteoblast markers (Runx-2, Osteopontin and Osteocalcin) were evaluated in differentiated osteoblasts using qPCR.

RESULTS

Flow cytometry (CD90, CD105) detected MSCs isolated from bone marrow (93-98%). MTT assay showed that the selected doses of SO did not induce any cytotoxicity in MSCs (24 hours). The efficiency of osteogenic differentiation (2 weeks) for different doses of Symphytum officinale was determined by flow cytometry (n = 10) for osteoblast marker, Osteocalcin, and most doses of Symphytum officinale enhanced osteogenesis. Interestingly, gene expression analysis for Runx-2 (n = 10), Osteopontin (n = 10), Osteocalcin (n = 10) and alkaline phosphatase activity (n = 8) also showed increased osteogenesis with the addition of Symphytum officinale to BDM, specially mother tincture.

CONCLUSIONS

Our findings suggest that homoeopathic dose (specially mother tincture) of Symphytum officinale has the potential to enhance osteogenesis.

NIMG-37. PREDICTING SEIZURE IN GLIOMA PATIENTS USING A RANDOM FOREST CLASSIFIER TRAINED ON SEX-SPECIFIC AND MIXED COHORTS

PURPOSE

Brain tumor related epilepsy (BTE) is a major co-morbidity in patients with glioma. It is difficult to determine whether the use of anti-epileptic drugs is necessary. We attempted to build a machine-learning model to predict the probability of seizure presentation (SP) with glioma.

METHODS

We trained a random forest classifier using the following variables: volumetric data of pre-treatment MR images (T1Gd and T2-FLAIR sequences), patient demographics (age; sex), and measurements of tumor proliferation (log(ρ)), invasiveness (log(D)) and their relative ratio (log(ρ/D)). Our cohort consisted of 221 patients total. Using an 80-20 ratio, we used 176 patients (76 SP, 100 nSP) for training and the remaining 45 patients (19 SP, 26 nSP) were used for testing. We also trained on male-only and female-only cohorts to evaluate any sex differences in prediction. For training, 108 males (53 SP, 55 nSP) were used and 28 for testing (14 SP, 14 nSP). We used 72 females (21 SP, 49 nSP) for training and 15 (7 SP, 8 nSP) for testing. We corrected for class imbalance in the female cohort before training. Using 10-fold cross-validation and a separate testing set, we measured performance by ROC curve (AUC), accuracy, sensitivity, and specificity of predictions (average of folds in cross validation).

RESULTS

The female model achieved the highest AUC (0.853) followed by the mixed model (0.726) and the male model (0.651). In the validation set, the accuracy/sensitivity/specificity of the three cohorts were as follows: mixed (0.726/0.696/0.750), female (0.853/0.830/0.875), and male (0.651/0.577/0.722). The performance of the testing set, in terms of accuracy/sensitivity/specificity were: mixed (0.733/0.74/0.73), female (0.8/0.57/1), and male (0.714/0.64/0.79).

CONCLUSION

We found a negative correlation between seizure probability and size and invasiveness of tumors. Our model shows promising performance on testing set data. Further cohort studies and training is warranted.

A Prognosis for Health Systems Science Courses: Observations From Current Students

Certain medical schools have begun teaching courses in health systems science (HSS) to train medical students in skills aimed to improve health care in the United States. Although substantial research has been done on the potential benefit of HSS courses, reactions from students have not been reported. In this Invited Commentary, five medical students who have completed the first year of a longitudinal HSS course at the Arizona campus of the Mayo Clinic School of Medicine offer their observations of how early exposure to HSS affected their reactions to subsequent course work and current events in health care. The authors describe the HSS course and outline three benefits they have observed from their experience so far: (1) thinking more critically about health care delivery during all educational experiences, (2) gaining a better understanding of the complexity of the health care system, and (3) having a greater consideration for the many facets of health care delivery. The HSS course helped the authors identify health systems problems, develop solutions that incorporated diverse domains of health care delivery, and recognize the role and responsibility of the physician as an agent of change in a health care system.

Degree of Left Renal Vein Compression Predicts Nutcracker Syndrome

Nutcracker syndrome (NS) refers to symptomatic compression of the left renal vein (LRV) between the abdominal aorta and superior mesenteric artery with potential symptoms including hematuria, proteinuria, left flank pain, and renal venous hypertension. No consensus diagnostic criteria exist to guide endovascular treatment. We aimed to evaluate the specificity of LRV compression to NS symptoms through a retrospective study including 33 NS and 103 control patients. The size of the patent lumen at point of compression and normal portions of the LRV were measured for all patients. Multiple logistic regression analyses (MLR) assessing impact of compression, body mass index (BMI), age, and gender on the likelihood of each symptom with NS were obtained. NS patients presented most commonly with abdominal pain (72.7%), followed by hematuria (57.6%), proteinuria (39.4%), and left flank pain (30.3%). These symptoms were more commonly seen than in the control group at 10.6, 11.7, 6.8, and 1.9%, respectively. The degree of LRV compression for NS was 74.5% and 25.2% for controls (p < 0.0001). Higher compression led to more hematuria (p < 0.0013), abdominal pain (p < 0.006), and more proteinuria (p < 0.002). Furthermore, the average BMI of NS patients was 21.4 and 27.2 for controls (p < 0.001) and a low BMI led to more abdominal pain (p < 0.005). These results demonstrate a strong correlation between the degree of LRV compression on imaging in diagnosing NS.

Management of neglected ACL avulsion fractures: a case series and systematic review

INTRODUCTION

Neglected tibial eminence avulsion fractures of the anterior cruciate ligament (ACL) are uncommonly seen in modern times, but are fairly common due to a missed diagnosis/mismanagement in developing countries.

OBJECTIVES

To determine the outcomes after open reduction and internal fixation of late presenting ACL avulsion fractures, and to review the literature for similar cases, in an attempt to evaluate the ideal surgical management in this unique scenario.

STUDY DESIGN

Retrospective observational study and systematic review MATERIALS: The study included 10 male and 2 female cases (mean age 29.9 years). Patients were assessed for the pre-operative knee range-of-motion (ROM), flexion deformity and stability; functional assessment was conducted using the Lysholm scale, both pre and post-operatively. Open reduction and internal fixation with two partially threaded screws (via a mini anterior approach) was performed in all 12 cases. All patients were clinically followed up for a minimum duration of 12 months. We searched PubMed, Embase and Cochrane databases from the period of inception to January 15, 2017 for similar case series/reports involving management of chronic/neglected ACL avulsion fractures and systematically reviewed these studies following standard PRISMA guidelines.

RESULTS

The median duration of presentation after injury was 12 months (range 3 to 312 months; mean 45.3 months). The mean follow-up duration was 24.1 months (range 12-48 months). All patients achieved normal knee extension except one patient who had a residual 5° flexion contracture. On physical examination, Lachman and pivot-shift tests were negative in all but 1 patient. No case required ACL reconstruction, and the fractures united radiologically within 12 weeks; all patients regained former activity levels.

DISCUSSION

Eleven published studies, mainly case reports, reported on the management of chronic/neglected ACL avulsion fractures. Arthroscopic suture/wire fixation, arthroscopic debridement of avulsed fragment and open reduction, internal fixation (ORIF) with screws are the described techniques for this uncommon entity. However, anatomic reduction of ACL avulsion fractures is difficult arthroscopically as crater depth assessment and repositioning of the avulsed fragment become a problem; the avulsed fragment may also hypertrophy, and some contractures in ACL may develop. A mini-open procedure does not add to the morbidity, overcomes reduction obstacles and allows easy fixation with screws, and can be done even in centers that do not have arthroscopic experience. The key point is accurate reduction and rigid fixation, ensuring no impingement on full extension CONCLUSIONS: Mini-open fixation allows accurate, anatomic reduction and stable fixation with screws, and should be the preferred method of fixation for late presenting ACL avulsion fractures; embedding the fragment deep into the crater or size reduction are key to preventing extension deficits.

Abstract P5-03-10: Development of a novel HER2 testing strategy, using image-based cell-sorting to isolate pure cell populations from FFPE upstream of FISH

Fluorescent in Situ Hybridization (FISH) guidelines defined by American Society of Clinical Oncology (ASCO) and the College of American Pathologists for determining HER2 status are set to improve accuracy and usefulness as a diagnostic marker in breast cancer. Despite these guidelines, many factors can influence HER2 testing results such as sample preparation, assay-conditions and interpretation of test results due to heterogeneous breast cancer samples. In this multi-site study, sample preparation was carried out using the DEPArray™ to recover pure tumor cell populations from formalin-fixed, paraffin-embedded (FFPE) breast tumor samples. We then compared HER2/CEP17 ratios obtained from the DEPArray™ processed samples from each laboratory to routine FISH on tissue sections.

Methods: Eight breast FFPE tumor tissue biopsies were obtained from commercial tissue banks. From the paraffin tissue blocks, four consecutive tissue curls (each 50 microns thick) were prepared. One curl from each of the 8 patient samples was distributed to four different laboratories for analysis following DEPArray™ based sample preparation. After an initial disassociation of each curl into a single-cell suspension, intact cells were sorted and then recovered based on cytokeratin/ vimentin/DAPI staining using the DEPArray™. Cytokeratin+/Vimentin-/DAPI+ tumor (~250) and Cytokeratin-/Vimentin+/DAPI+ stromal (~250) recovered cells were then deposited onto glass slides prior to standard dual-color HER2/CEP17 FISH analysis for comparison to conventional HER2 FISH result.

Results: Serially sectioned breast tumors from 8 negative/positive cases: 7 infiltrating ductal carcinoma (IDC) and 1 metastatic carcinoma were studied. All four sites demonstrated 100% concordance between FISH results compared to the conventional HER2 FISH result. Overall, &gt;60% of DEPArray™ isolated cells were recovered from FFPE samples that ranged from 1- 15 years of age and reported to contain 60% to 80% tumor content. The use of pure sorted cells permitted the accurate determination of HER2 amplification status in only the tumor cells while the stromal cells consistently yielded a more normalized ratio of HER2 to centromere 17.

Conclusion: The preliminary results of this multi-site study demonstrate that use of DEPArray™ for sorted pure populations is reproducible as well as reliable method for subsequent analysis of HER2 by FISH on FFPE derived tumor cells. Given that traditional FFPE-based HER2 FISH results may be influenced by the tissue sectioning procedure, tissue heterogeneity and/or the scattering of few HER2 amplified tumor cells among normal stromal cells. The DEPArray™ allows analysis of immunofluorescence images and DNA content to isolate and recover pure and intact cell populations. This isolation of pure cell populations prior to FISH analysis is attractive for achieving precise determination of HER2 status on equivocal cases. A more formal analytical validation of this approach through CLIA is currently underway.

Citation Format: Gerber A, Konig L, Millner L, Strotoman L, Khurana A, Kasimir-Bauer S, Moore MW, Cotter PD, Bischoff F. Development of a novel HER2 testing strategy, using image-based cell-sorting to isolate pure cell populations from FFPE upstream of FISH [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-03-10.

Dealing with sub-trochanteric fracture in a child with osteopetrosis : A case report

Osteopetrosis is a rare hereditary condition which may have autosomal recessive or autosomal dominant inheritance. Patients tend to present most commonly with fractures but involvement of cranial nerves and hematopoetic system is not uncommon. Patients with infantile and intermediate type tend to present more often with problems other than orthopaedic problems. While diagnosis can be made on the basis of radiographs, management needs to be customized for every patient. Non operative and operative management both have their advantages and disadvantages. We are here reporting a case of sub-trochanteric fracture in an eight-year-old child which was managed successfully with a dynamic hip screw (DHS). Surgery could be performed successfully by taking precautions during reduction, drilling and screw placement. At the latest follow up, which was after one and half years of surgery, the fracture had united well and the child faced no limitations of activities. Thus, open reduction and fixation with DHS can be considered as an effective management modality for pediatric sub-trochanteric fractures in osteopetrosis.

Effect of narrow band ultraviolet B phototherapy on T helper 17 cell specific cytokines (interleukins-17, 22 and 23) in psoriasis vulgaris

BACKGROUND

Psoriasis is mediated by a T helper 17 (Th17) cell inflammatory process. This study describes the changes in serum levels of IL-17, 22 and 23 in patients of psoriasis vulgaris treated with narrow band ultraviolet B (NBUVB).

METHODS

The serum levels of IL-17, 22 and 23 were compared with a control group (n = 30) before and after NBUVB. In addition, post-NBUVB levels were compared with healthy controls. Psoriasis Area Severity Score (PASI) and Body Surface Area scoring were used to evaluate severity of disease.

RESULTS

When compared with the non-psoriasis control group, IL-17, 22 and 23 were higher in psoriasis patients (p < 0.05, p < 0.001, p < 0.001, respectively). The serum levels of all three interleukins strongly correlated with severity of disease. Although IL-17, 22 and 23 decreased after NBUVB, decline in IL-17 was not significant after phototherapy as compared to controls (p = 0.634). IL-22 and 23 continued to remain elevated post-phototherapy when compared with control group (p < 0.05, p < 0.0001, respectively).

CONCLUSIONS

The serum levels of IL-17, 22 and 23 decrease after phototherapy in psoriasis. Post-phototherapy only the IL-17 levels decrease to that of non-psoriasis controls. Our study supports the role of T helper 17 cell specific cytokines in psoriasis and a possible mechanism of action of NBUVB via inhibition of these cytokines.

Tuberculosis lymphadenitis in a well managed case of sarcoidosis

Differentiation between tuberculosis (TB) and sarcoidoisis is sometimes extremely difficult. Sequential occurrence of sarcoidosis and TB in the same patient is uncommon. We present the case of a young man, with a proven diagnosis of sarcoidosis who later developed TB after completion of treatment for sarcoidosis. A 32-year-old male patient presented with low-grade fever since two months. Physical examination revealed cervical lymphadenopathy. Initial fine needle aspiration cytology (FNAC) of the cervical lymph node was suggestive of granulomatous inflammation; the chest radiograph was normal. Repeat FNAC from the same lymph node was suggestive of reactive lymphoid hyperplasia. The patient was treated with antibiotics and followed-up. He again presented with persistence of fever and lymphadenopathy and blurring of vision. Ophthalmological examination revealed uveitis, possibly due to a granulomatous cause. His repeat Mantoux test again was non-reactive; serum angiotensin converting enzyme (ACE) levels were raised. This time an excision biopsy of the lymph node was done which revealed discrete, non-caseating, reticulin rich granulomatous inflammation suggestive of sarcoidosis. The patient was treated with oral prednisolone and imporved symptomatically. Subsequently, nearly nine months after completion of corticosteroid treatment, he presented with low-grade, intermittent fever and a lymph node enlargement in the right parotid region. FNAC from this lymph node showed caseating granulomatous inflammation and the stain for acid-fast bacilli was positive. He was treated with Category I DOTS under the Revised National Tuberculosis Control Programme and improved significantly. The present case highlights the need for further research into the aetiology of TB and sarcoidosis.