Detection of circulating tumor DNA with ultradeep sequencing of plasma cell-free DNA for monitoring minimal residual disease and early detection of recurrence in early-stage lung cancer.

BACKGROUND: In early-stage non-small cell lung cancer (NSCLC), recurrence is frequently observed. Circulating tumor DNA (ctDNA) has emerged as a noninvasive tool to risk stratify patients for recurrence after curative intent therapy. This study aimed to risk stratify patients with early-stage NSCLC via a personalized, tumor-informed multiplex polymerase chain reaction (mPCR) next-generation sequencing assay. METHODS: This retrospective cohort study included patients with stage I-III NSCLC. Recruited patients received standard-of-care management (surgical resection with or without adjuvant chemotherapy, followed by surveillance). Whole-exome sequencing of NSCLC resected tissue and matched germline DNA was used to design patient-specific mPCR assays (Signatera, Natera, Inc) to track up to 16 single-nucleotide variants in plasma samples. RESULTS: The overall cohort with analyzed plasma samples consisted of 57 patients. Stage distribution was 68% for stage I and 16% each for stages II and III. Presurgery (i.e., at baseline), ctDNA was detected in 15 of 57 patients (26%). ctDNA detection presurgery was significantly associated with shorter recurrence-free survival (RFS; hazard ratio [HR], 3.54; 95% confidence interval [CI], 1.00-12.62; p = .009). In the postsurgery setting, ctDNA was detected in seven patients, of whom 100% experienced radiological recurrence. ctDNA positivity preceded radiological findings by a median lead time of 2.8 months (range, 0-12.9 months). Longitudinally, ctDNA detection at any time point was associated with shorter RFS (HR, 16.1; 95% CI, 1.63-158.9; p < .0001). CONCLUSIONS: ctDNA detection before surgical resection was strongly associated with a high risk of relapse in early-stage NSCLC in a large unique Asian cohort. Prospective studies are needed to assess the clinical utility of ctDNA status in this setting.

Valorization of waste engine oil to mono- and di-rhamnolipid in a sustainable approach to circular bioeconomy.

This study aims to valorize waste engine oil (WEO) for synthesizing economically viable biosurfactants (rhamnolipids) to strengthen the circular bioeconomy concept. It specifically focuses on investigating the influence of key bioprocess parameters, viz. agitation and aeration rates, on enhancing rhamnolipid yield in a fed-batch fermentation mode. The methodology involves conducting experiments in a stirred tank bioreactor (3 L) using Pseudomonas aeruginosa gi |KP 163922| as the test organism. Central composite design and response surface methodology (CCD-RSM) are employed to design the experiments and analyze the effects of agitation and aeration rates on various parameters, including dry cell biomass (DCBM), surface tension, tensoactivity, and rhamnolipid yield. It is also essential to determine the mechanistic pathway of biosurfactant production followed by the strain using complex hydrophobic substrates such as WEO. The study reveals that optimal agitation and aeration rates of 200 rpm and 1 Lpm result in the highest biosurfactant yield of 29.76 g/L with minimal surface tension (28 mN/m). Biosurfactant characterization using FTIR, 1H NMR, and UPLC-MS/MS confirm the presence of dominant molecular ion peaks m/z 543.9 and 675.1. This suggests that the biosurfactant is a mixture of mono- and di-rhamnolipids (RhaC10C10, RhaRhaC10C12:1, RhaRhaC12:1C10). The findings present a sustainable approach for biosurfactant production in a fed-batch bioreactor. This research opens the possibility of exploring the use of pilot or large-scale bioreactors for biosurfactant production in future investigations.

Elevated preoperative blood pressure and its relationship to intraoperative mean arterial pressure and blood loss in posterior spinal fusion for adolescent idiopathic scoliosis.

PURPOSE: The relationship between preoperative blood pressure (BP) and intraoperative mean arterial pressure (MAP) and estimated blood loss (EBL) in pediatric spine surgery is currently unknown. The objectives of this study were to determine if elevated preoperative BP is associated with elevated intraoperative MAP, EBL, and percentage estimated blood volume (EBV) lost, and to determine if intraoperative MAP is associated with percentage of EBV lost during posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). METHODS: This is a retrospective cohort analysis of 209 patients undergoing PSF for AIS between 2016 and 2019 by a single surgeon. Data extracted included demographic characteristics, preoperative systolic and diastolic BP, continuous intraoperative MAP measured by arterial line, EBL, radiographic, and surgical characteristics. Time points of interest for MAP included incision and exposure. Elevated BP was defined as > 1 standard deviation above the mean BP of patients included in the study, and elevated MAP was defined as > 65 mmHg. RESULTS: Elevated preoperative systolic BP was associated with elevated MAP at incision (p = 0.002). Patients with elevated preoperative diastolic BP had significantly higher MAP at exposure and throughout the procedure (p = 0.04). MAP > 65 at incision was associated with a 5% increase in EBV lost (p < 0.001). CONCLUSIONS: Patients with elevated preoperative BP parameters have increased MAPs at incision, exposure, and throughout surgery. Elevated MAP at incision is associated with an increased percentage of EBV lost in a small number of patients undergoing PSF for AIS.

Implementation of the Maryland Global Budget Revenue Model and Variation in the Expenditures and Outcomes of Surgical Care: A Systematic Review and Meta-analysis.

OBJECTIVE: To assess the effect of the Global Budget Revenue (GBR) program on outcomes after surgery. BACKGROUND: There is limited data summarizing the effect of the GBR program on surgical outcomes as compared with traditional fee-for-service systems. METHODS: The Medline, Embase, Scopus, and Web of Science databases were used to conduct a systematic literature search on April 5, 2022. We identified full-length reports of comparative studies involving patients who underwent surgery in Maryland after implementation of the GBR program. A random effects model calculated the overall pooled estimate for each outcome which included complications, rates of readmission and mortality, length of stay, and costs. RESULTS: Fourteen studies were included in the qualitative synthesis, with 8 unique studies included in the meta-analysis. Our analytical sample was comprised of 170,011 Maryland patients, 78,171 patients in the pre-GBR group, and 91,840 patients in the post-GBR group. The pooled analysis identified modest reductions in costs [standardized mean difference (SMD) -0.34; 95% CI, -0.42, -0.25; P <0.001], complications [odds ratio (OR): 0.57; 95% CI, 0.36-0.92, P =0.02], readmission (OR: 0.78; 95% CI, 0.72-0.85, P <0.001), mortality (OR: 0.58; 95% CI, 0.47-0.72, P <0.001), and length of stay (standardized mean difference: -0.26; 95% CI, -0.32, -0.2, P <0.001) after surgery. CONCLUSIONS: Implementation of the GBR program is associated with improved outcomes and reductions in costs among Maryland patients who underwent surgical procedures. This is particularly salient given the increasing need to disseminate and scale population-based payment models that improve patient care while controlling health care costs.

Is the Centralization of Complex Surgical Procedures an Unintended Spillover Effect of Global Capitation? - Insights from the Maryland Global Budget Revenue Program.

OBJECTIVE: To determine if global budget revenue (GBR) models incent the centralization of complex surgical care. SUMMARY BACKGROUND: In 2014, Maryland initiated a statewide GBR model. While prior research has shown improvements in cost and outcomes for surgical care post-GBR implementation, the mechanism remains unclear. METHODS: Utilizing state inpatient databases, we compared the proportion of adults undergoing elective complex surgeries (gastrectomy, pneumonectomy/lobectomy, proctectomies, and hip/knee revision) at high-concentration hospitals (HCHs) in Maryland and control states. Annual concentration, per procedure, was defined as hospital volume divided by state volume. HCHs were defined as hospitals with a concentration at least at the 75 th percentile in 2010. We estimated the difference-in-differences (DiD) of the probability of patients undergoing surgery at HCHs before and after GBR implementation. FINDINGS: Our sample included 122,882 surgeries. Following GBR implementation, all procedures were increasingly performed at HCHs in Maryland. States satisfied the parallel trends assumption for the centralization of gastrectomy and pneumonectomy/lobectomy. Post-GBR, patients were more likely to undergo gastrectomy (DiD: 5.5 p.p., 95% CI [2.2, 8.8]) and pneumonectomy/lobectomy (DiD: 12.4 p.p., 95% CI [10.0, 14.8]) at an HCH in Maryland compared with control states. For our hip/knee revision analyses, we assumed persistent counterfactuals and noted a positive DiD post-GBR implementation (DiD: 4.8 p.p., 95% CI [1.3, 8.2]). No conclusion could be drawn for proctectomy due to different pre-GBR trends. CONCLUSIONS: GBR implementation is associated with increased centralization for certain complex surgeries. Future research is needed to explore the impact of centralization on patient experience and access.

Development of Effective Siglec-9 Antibodies Against Cancer.

PURPOSE OF REVIEW: This study aims to review state-of-the-art advances in Siglec-9-directed antibodies and to highlight specific aspects of Siglec-9 antibodies that are suitable to mount anti-tumor immunity. RECENT FINDINGS: Controversies surrounding studies on Siglec-9 antibodies can confound future studies. In this review, we have highlighted some controversies, explained the distinction between Siglec-9 agonistic and antagonistic (endocytic) antibodies, and discussed their suitability in sustaining anti-tumor immunity. Siglec-9 is an immune checkpoint target and an immunoinhibitory receptor that can engage either sialic acid ligands or agonistic antibodies. Through Siglec-9 sialic acid interactions, activated immunoreceptor tyrosine-based inhibitory signaling of the immune cells can lead to unfavorable immunosuppression. To overcome tumor-related immunosuppression, different types of Siglec-9 antibody blockade need to be developed. However, whether a Siglec-9-directed antibody is agonistic or antagonistic is probably affinity-dependent and not epitope-dependent. Additionally, unlike immune-modulatory antibodies such as agonistic antibodies (OX40, CD28, ICOS, and 4-1BB) or Fc-inert antibodies (PD1 and PD-L1) directed against cancer cells, the nature of antagonistic Siglec-9 antibodies is more suitable to enhance anti-tumor immunity and will be discussed.

Production, characterization, and kinetic modeling of biosurfactant synthesis by Pseudomonas aeruginosa gi |KP 163922|: a mechanism perspective.

Kinetic studies and modeling of production parameters are essential for developing economical biosurfactant production processes. This study will provide a perspective on mechanistic reaction pathways to metabolize Waste Engine Oil (WEO). The results will provide relevant information on (i) WEO concentration above which growth inhibition occurs, (ii) chemical changes in WEO during biodegradation, and (iii) understanding of growth kinetics for the strain utilizing complex substrates. Laboratory scale experiments were conducted to study the kinetics and biodegradation potential of the strain Pseudomonas aeruginosa gi |KP 163922| over a range (0.5-8% (v/v)) of initial WEO concentration for 168 h. The kinetic models, such as Monod, Powell, Edward, Luong, and Haldane, were evaluated by fitting the experimental results in respective model equations. An unprecedented characterization of the substrate before and after degradation is presented, along with biosurfactant characterization. The secretion of biosurfactant during the growth, validated by surface tension reduction (72.07 ± 1.14 to 29.32 ± 1.08 mN/m), facilitated the biodegradation of WEO to less harmful components. The strain showed an increase in maximum specific growth rate (µmax) from 0.0185 to 0.1415 h-1 upto 49.92 mg/L WEO concentration. Maximum WEO degradation was found to be ~ 94% gravimetrically. The Luong model (adj. R2 = 0.97) adapted the experimental data using a non-linear regression method. Biochemical, 1H NMR, and FTIR analysis of the produced biosurfactant revealed a mixture of mono- and di- rhamnolipid. The degradation compounds in WEO were identified using FTIR, 1H NMR, and GC-MS analysis to deduce the mechanism.

Association of a novel 27-gene immuno-oncology assay with efficacy of immune checkpoint inhibitors in advanced non-small cell lung cancer.

BACKGROUND: Immune checkpoint inhibitor (ICI) therapies represent a major advance in treating a variety of advanced-stage malignancies. Nevertheless, only a subset of patients benefit, even when selected based on approved biomarkers such as PD-L1 and tumor mutational burden. New biomarkers are needed to maximize the therapeutic ratio of these therapies. METHODS: In this retrospective cohort, we assessed a 27-gene RT-qPCR immuno-oncology (IO) gene expression assay of the tumor immune microenvironment and determined its association with the efficacy of ICI therapy in 67 advanced-stage NSCLC patients. The 27-gene IO test score (IO score), programmed cell death ligand 1 immunohistochemistry tumor proportion score (PD-L1 TPS), and tumor mutational burden (TMB) were analyzed as continuous variables for response and as binary variables for one-year progression free survival. The threshold for the IO score was prospectively set based upon a previously described training cohort. Prognostic implications of the IO score were evaluated in a separate cohort of 104 advanced-stage NSCLC patients from The Cancer Genome Atlas (TCGA) who received non-ICI therapy. RESULTS: The IO score was significantly different between responders or non-responders (p = 0.007) and associated with progression-free survival (p = 0.001). Bivariate analysis established that the IO score was independent of PD-L1 TPS and TMB in identifying patients benefiting from ICI therapy. In a separate cohort of late-stage NSCLC patients from TCGA, the IO score was not prognostic of outcome from non-ICI-treated patients. CONCLUSIONS: This study is the first application of this 27-gene IO RT-qPCR assay in a clinical cohort with outcome data. IO scores were significantly associated with response to ICI therapy and prolonged progression-free survival. Together, these data suggest the IO score should be further studied to define its role in informing clinical decision-making for ICI treatment in NSCLC.

Lyme Neuroborreliosis with Intracranial Hypertension and Erythema Multiforme: A Rare Presentation.

A 9-year-old previously healthy boy presented with high-grade intermittent fever, severe headache associated with neck stiffness for 5 days, rash over trunk and extremities for 4 days, vomiting for 3 days and diplopia for 2 days. There was no history of seizures, abnormal body movements, altered sensorium or focal deficits. On examination, he had maculopapular erythematous rashes over the trunk and extremities and erythema multiforme. He had bilateral abducens nerve palsy and the rest of the cranial nerve, sensory and motor examination was normal. He had neck stiffness and positive Kernig's sign. Fundus examination showed grade 4 papilledema. Cerebrospinal fluid workup revealed elevated opening pressure, lymphocytic pleocytosis, normal protein and glucose levels. Neuroimaging showed features suggestive of intracranial hypertension. Borrelia IgM and IgG antibodies came positive. The uniqueness of our case lies with two rare presenting manifestations of Lyme neuroborreliosis in the same child.

Development and Validation of SCFE Percutaneous Pinning Surgical Simulation.

BACKGROUND: In situ screw fixation with a single percutaneously placed femoral screw remains widely accepted for femoral head fixation in adolescent patients with slipped capital femoral epiphysis (SCFE). Given the potential risks involved with this procedure, a simulation whereby surgical skills could be refined before entering the operating room may be of benefit to orthopaedic trainees. METHODS: We developed a synthetic model for the simulated treatment of SCFE. Five orthopaedic attendings and twenty trainees were recorded performing an in situ percutaneous fixation on the SCFE model. Time, radiation exposure, and final anteroposterior and lateral radiographs of the SCFE model were recorded. After completion, the attendings and trainees answered a Likert-based questionnaire regarding the realism and utility of the simulation, respectively. Two blinded orthopaedic surgeons rated each participant's skill level based on previously described assessment tools, including a Global Rating Scale (GRS) of technical proficiency and radiographic grading index for screw placement. Performance metrics and survey responses were evaluated for construct validity, face validity, and interrater reliability. RESULTS: The attendings demonstrated superior technical proficiency compared with trainees in terms of higher GRS scores (27.9±1.9 vs. 14.7±5.0, P<0.001) and better radiographic grading of screw placement on lateral views (P=0.019). Similarly, compared with the trainees, the orthopaedic attendings demonstrated shorter operative times (11.0±4.1 vs. 14.7±6.2 min, P=0.035) and less radiation exposure (3.7±1.7 vs. 9.5±5.7 mGy, P=0.037). The interrater reliability was excellent for both the GRS scoring (intraclass correlation coefficient=0.973) and radiographic grading (weighted κ=1.000). The attendings and trainees rated the realism and teaching utility of the simulation as "very good," respectively. CONCLUSION: Our surgical simulation for in situ percutaneous fixation of SCFE represents a valid and reliable measure of technical competency and demonstrates much promise for potential use as a formative educational tool for orthopaedic residency programs. LEVEL OF EVIDENCE: Level II.

Height Gain After Spinal Fusion for Idiopathic Scoliosis: Which Model Fits Best?

BACKGROUND: Patients will often inquire about the magnitude of height gain after scoliosis surgery. Several published models have attempted to predict height gain using preoperative variables. Many of these models reported good internal validity but have not been validated against an external cohort. We attempted to test the validity of 5 published models against an external cohort from our institution. Models included were Hwang, Van Popta, Spencer, Watanabe, and Sarlak models. METHODS: We retrospectively queried our institution's records from 2006 to 2019 for patients with adolescent idiopathic scoliosis treated with posterior spinal fusion. We recorded preoperative and postoperative variables including clinical height measurements. We also performed radiographic measurements on preoperative and postoperative radiographic studies. We then tested the ability of the models to predict height gain by evaluating Pearson correlation coefficient, root mean square error, Akaike Information Criterion for each model. RESULTS: A total of 387 patients were included. Mean clinical height gain was 3.1 (±1.7) cm.All models demonstrated a moderate positive Pearson correlation coefficient, except the Hwang model, which demonstrated a weak correlation. The Spencer model was the only model with acceptable root mean square error (≤0.5) and was also the best fitting with the lowest Akaike Information Criterion (-308). The mean differences in height gain predictions between all models except the Hwang model was ≤1 cm. CONCLUSIONS: Four of the 5 models demonstrated moderate correlation and had good external validity compared with their development cohorts. Although the Spencer model was the best fitting, the clinical significance of the difference in height predictions compared with other models was low. The Watanabe model was the second best fitting and had the simplest formula, making it the most convenient to use in a clinical setting. We offer a simplified equation to use in a preoperative clinical setting based on this data-ΔHeight (mm)=0.77*(preoperative coronal angle-postoperative coronal angle). LEVEL OF EVIDENCE: Not Applicable.

Factors Driving Rapid Adoption of Telemedicine in an Academic Orthopedic Surgery Department.

Introduction: With the COVID-19 epidemic ever-expanding, nonemergent access to health care resources has been reduced to decrease the exposure for patients and health care providers. Alternatives to in-office outpatient medical evaluations are necessary. We aimed to analyze how quickly orthopedic surgery providers at a large academic institution adopted telemedicine, and identify any factors that were associated with earlier or "faster" telemedicine adoption. Methods: We analyzed the telemedicine activity of 39 providers within the Department of Orthopedic Surgery between March 16, 2020, and May 30, 2020, and constructed logistic regression models to identify characteristics with significant association to earlier or faster telemedicine adoption. Results: No significant predictors of percentage of visits conducted via telemedicine were found. However, increased experience and practice at multiple locations was associated with slower telemedicine adoption time, while Professor level academic rank was associated with a faster time to achieving 10% of pre-COVID visit volumes via telemedicine. Higher pre-COVID visit volumes were also significantly associated with faster telemedicine adoption. Demographic factors, including, age, gender, practice locations, academic degrees, pediatric specialty, and use of physician assistants/nurse practitioners, were not found to have significant associations with telemedicine use. Conclusions: These results indicate that telemedicine has an important role to play within academic orthopedic surgery practices, with a wide and diverse range of orthopedic surgery providers choosing to utilize it during the COVID-19 pandemic. Given the rapid expansion and urgency driving the adoption of telemedicine, these results illustrate the importance of considering provider-side characteristics in ensuring that providers are well equipped to utilize telemedicine.

Age and Racial Disparities in Telemedicine Utilization in an Academic Orthopedic Surgery Department.

Introduction: The COVID-19 pandemic has highlighted significant racial and age-related health disparities. In response to pandemic-related restrictions, orthopedic surgery departments have expanded telemedicine use. We analyzed data from a tertiary care institute during the pandemic to understand potential racial and age-based disparities in access to care and telemedicine utilization. Materials and Methods: Data on patient race and age, and numbers of telemedicine visits, in-person office visits, and types of telemedicine were extracted for time periods during and preceding the pandemic. We calculated odds ratios for visit occurrence and type across race and age groups. Results: Patients ages 27-54 were 1.3 (95% confidence interval [CI] 1.1-1.4, p < 0.01) and 1.2 (95% CI 1.0-1.3, p < 0.05) times more likely to be seen than patients <27 during the pandemic, versus the 2019 and 2020 controls. Patients 54-82 were 1.3 (95% CI 1.1-1.5, p < 0.001) times more likely to be seen than patients <27 during the pandemic versus the 2019 control. Patients 27-54, 54-82, and 82+, respectively, were 3.3 (95% CI 2.6-4.2, p < 1e-20), 3.5 (95% CI 2.8-4.4, p < 1e-24), and 1.9 (95% CI 1.1-3.4, p < 0.05) times more likely to be seen by telemedicine than patients <27. Among pandemic telemedicine appointments, Black patients were 1.5 (95% CI 1.2-1.9, p < 1e-3) times more likely to be seen by audio-only telemedicine than White patients, as compared with video telemedicine. Conclusions: Telemedicine access barriers must be reduced to ensure that disparities during the pandemic do not persist.

An Unusual Case of Pancytopenia: The Lessons Learnt.

Pancytopenia is a common hematological abnormality encountered in clinical practice. We here report a 36-year-old male who presented to emergency department with complaints of weakness of bilateral lower limbs, burning sensation in all four limbs with history of loose stools, and vomiting 5 days back. The complete blood count of patient showed pancytopenia with no circulating atypical cells. Bone marrow examination performed showed nonspecific but characteristic findings. After excluding the possibility of infective etiology, a possibility of heavy metal toxicity was suspected in multidisciplinary meeting. The urine and blood levels of arsenic done came out very high, and a diagnosis of arsenic poisoning was made. Patient had multisystemic involvement with features characteristic of arsenic poisoning. The present case was a diagnostic challenge in face of nonforthcoming history. This case beautifully highlighted the importance of multidepartmental approach in such cases to arrive at unerring diagnosis and the unique bone marrow findings, although nonspecific were sufficient enough to indicate the possibility of acute insult to the hematopoiesis. How to cite this article: Nair RR, Singh PK, Sharma J, Gambhir I, Khanna S, Jain AK, et al. An Unusual Case of Pancytopenia: The Lessons Learnt. Indian J Crit Care Med 2022;26(1):141-144.

The Impact of the COVID-19 Pandemic on Elective Inpatient Surgical Admissions: Evidence From Maryland.

BACKGROUND: The COVID-19 pandemic led to large-scale cancellation and deferral of elective surgeries. We quantified volume declines, and subsequent recoveries, across all hospitals in Maryland. MATERIALS AND METHODS: Data on elective inpatient surgical volumes were assembled from the Maryland Health Service Cost Review Commission for years 2019-2020. The data covered all hospitals in the state. We compared the volume of elective inpatient surgeries in the second (Q2) and fourth quarters (Q4) of 2020 to those same quarters in 2019. Analysis was stratified by patient, hospital, and service characteristics. RESULTS: Surgical volumes were 55.8% lower in 2020 Q2 than in 2019 Q2. Differences were largest for orthopedic surgeries (74.3% decline), those on Medicare (61.4%), and in urban hospitals (57.3%). By 2020 Q4, volumes for most service lines were within 15% of volumes in 2019 Q4. Orthopedic surgery remained most affected (44.5% below levels in 2019 Q4) and Plastic Surgery (21.9% lower). CONCLUSIONS: COVID-19 led to large volume declines across hospitals in Maryland followed by a partial recovery. We observed large variability, particularly across service lines. These results can help contextualize case-specific experiences and inform research studying potential health effects of these delays and cancellations.

Treatment of Neck Pain with Opioids in the Primary Care Setting: Trends and Geographic Variation.

OBJECTIVE: Neck pain is a leading cause of years lived with disability and is often managed with opioid medications in primary care settings, though this is contraindicated by national guidelines. The aim of this study was to determine the prevalence of opioid prescription for neck pain at a primary care visit and to analyze the geographic variation and trends in opioid prescriptions between 2011 and 2017. METHODS: Using a prescription drug claims database, we identified 591,961 adult patients who presented for neck pain in primary care settings between 2011 and 2017. Patients who had outpatient specialty visits within 1 year before presentation, a concomitant diagnosis of a non-musculoskeletal cause of neck pain, or preexisting chronic opioid use were excluded. RESULTS: The mean age of the patients was 45 ± 12 years, and 64% were female. Fifteen percent of patients were prescribed opioids within 30 days of their encounter. Eleven percent of patients were prescribed moderate- to high-dose opioids (>20 morphine milligram equivalents). From 2011-2017, the proportion of both overall opioid prescriptions and moderate- to high-dose prescriptions given to first time presenters to an outpatient clinic for neck pain was highest in Mississippi (20%) and lowest in New Mexico (6%) (P < 0.001). In 2017, the proportion of both overall opioid prescriptions and moderate- to high-dose prescriptions was highest in the Midwest (10.4%) and lowest in the Northeast (4.9%). The proportion of patients with filled opioid prescriptions declined between 2011 (19%) and 2017 (13%) (P < 0.001), and the proportion of patients with moderate- to high-dose prescriptions declined from 2011 (13%) to 2017 (8%) (P < 0.001). first-time presenters of neck pain to an outpatient clinic. CONCLUSIONS: Opioid medication use for neck pain in the primary care setting is significant. Although opioid prescriptions are declining, there remains a need for further standardization in prescription practices.

Factors responsible for difficult to treat superficial fungal infections: A study from a tertiary healthcare centre in India.

BACKGROUND: Recurrent and clinically unresponsive dermatophytosis is being increasingly observed in India. However, there is little information regarding the extent of the problem and the factors responsible for these difficult to treat superficial fungal infections. AIM: To identify factors contributing to difficult to treat recurrent superficial fungal infections. MATERIALS AND METHODS: This prospective cross-sectional study enrolled 105 patients of all age groups presenting with either recurrent or long-standing dermatophyte infection attending the outpatient department of Dermatology, Venerology and Leprosy of Bharati Hospital, Pune, India, between September 2018 and March 2020. Patients were clinically examined, clinical history was taken and questions were asked regarding their current complaints and recorded in a proforma. Data were analysed using the SPSS software package. RESULTS: The males outnumbered females (74.3% vs 25.7%). A strong association was observed between the presence of past history and duration of disease (p = .007). The association of use of topical steroids or keratolytic agents with the duration of disease was statistically significant (p = .022). There was a statistically significant inverse association of duration of disease with dermatologist consultation (p < .001). The association between consultation with non-dermatologist and the duration of disease was statistically significant (p = .035). CONCLUSION: Hyperhidrosis, obesity, positive family history, tight clothing and chronic diseases may be considered important factors in acquiring dermatophytic infection. However, when it comes to difficult to treat tinea infections, irrational usage of topical steroids, treatment from non-dermatologists and a past history of tinea appear to be more critical causative factors. Treatment of dermatophytosis by dermatologists/ trained physicians and increasing general awareness of the public regarding the current situation about tinea in the country would help to alleviate the current crisis.

Geographic Variation in Physician Payments from Private Insurers for Commonly Performed Inpatient Orthopaedic Surgeries in the United States.

We investigated geographic variation in percentage of private insurance payments to United States physicians for commonly performed orthopaedic procedures. We queried a private administrative claims database for patients who underwent inpatient total knee arthroplasty (TKA), total hip arthroplasty (THA), single-level anterior cervical discectomy and fusion (ACDF), and posterior lumbar fusion (PLF) from 2010 to 2017. Percentage of total payments to physician (PPP) was calculated by dividing physician payments by total payments. Analysis of variance was used to determine geographic differences in PPP. A total of 542,530 patients were included, mean age was 55 ± 8. PPP significantly varied between states for all four procedures (p < 0.001); Colorado and Alabama had the lowest and highest PPP, respectively. There was a significant annual decrease in PPP across all regions in all procedures. There was significant variation in percentage of total payments to physicians across geographic regions in the United States for TKA, THA, ACDF and PLF. (Journal of Surgical Orthopaedic Advances 30(1):014-019, 2021).

Evaluation and quantification of airway changes in Class II division 1 patients undergoing myofunctional therapy using twin block appliance.

BACKGROUND: The purpose of the present study was to determine the airway changes in skeletal class II division 1 malocclusion patients with mandibular retrognathism, treated with Twin-Block (TB) appliance. METHODS: Airway assessment was carried for twelve patients (mean age 11.7 ± 1.1 years) who underwent myofunctional therapy using TB appliance for correction of skeletal class II division 1 malocclusion with mandibular retrognathism. Acoustic pharyngometry (AP) was used to assess and quantify the comparative changes in the upper airway, pretreatment and posttreatment. RESULTS: Data acquired was subjected to appropriate statistical analysis. The paired 't' test was used to compare pre-treatment (T0) and after the positive pterygoid response (T1). TB appliance increased mean minimum airway area by 0.28 ± 0.25 cm2 and mean airway by 0.47 ± 0.44 cm2 with 95% CI. Posttreatment minimum airway and mean area changes were found to be statistically significant (P-value<0.01). CONCLUSION: TB appliance therapy has a positive effect on upper airway and is beneficial for the treatment of sleep-related disorders associated with Class II division 1 malocclusion for achieving positive functional changes, esthetics, and healthier quality of life.

Use of Imaging During Emergency Department Visits for Low Back Pain.

OBJECTIVE. Back pain is one of the most common reasons for adult patients 18-65 years old to seek emergency care. Use of imaging for patients without so-called red flags (trauma, malignancy, or infection) may result in potentially unnecessary costs and radiation exposure. The aim of this study was to investigate the use of imaging for patients with emergency visits for low back pain. MATERIALS AND METHODS. Emergency department visits for patients with low back pain billed to insurance were identified by querying a national commercial claims and encounters database for patients 18-64 years old. Patients with concomitant encounter diagnoses suggestive of trauma or those with prior visits for back pain were excluded. Imaging modalities (radiography, CT, and MRI) were identified by Current Procedural Terminology codes. RESULTS. A total of 134,624 encounters met inclusion criteria. Imaging was obtained in 44,405 (33.7%) visits and decreased from 34.4% to 31.9% between 2011 and 2016 (odds ratio per year, 0.98 [95% CI, 0.98-0.99]; p < 0.001). During the study period, 30.9% of patients underwent radiography, 2.7% of patients underwent CT, and 0.8% of patients underwent MRI for evaluation of low back pain. The use of imaging varied significantly by geographic region (p < 0.001), with patients in the southern United States undergoing 10% more imaging than patients in the western United States. CONCLUSION. The use of imaging for the initial evaluation of patients with low back pain in the emergency department continues to occur at a high rate, in approximately one in three new emergency visits for low back pain in the United States.