Combined Targeted Muscle Reinnervation With Regenerative Peripheral Nerve Interfaces Decreases Long-Term Narcotic Use in Amputees: A Case Control Study.

PURPOSE: Combined targeted muscle reinnervation with regenerative peripheral nerve interfaces ("TMRpni") is a recently described nerve management strategy that leverages beneficial elements of targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) techniques. This study aimed to evaluate the effect of TMRpni on long-term opioid consumption after amputation. We hypothesize that TMRpni decreases chronic opioid consumption in amputees. METHODS: This is a retrospective cohort study of all patients who underwent TMRpni between 2019 and 2021. These patients were age-matched at a 1:1 ratio with a control group of patients who underwent amputation without TMRpni. Statistical analysis was performed using SPSS Version 28.0. RESULTS: Thirty-one age-matched pairs of patients in the TMRpni and control groups were included. At 30 days after surgery, there was no significant difference in number of patients who required an additional refill of their opioid prescriptions (45% vs 55%, P = 0.45) or patients who continued to actively use opioids (36% vs 42%, P = 0.60). However, at 90 days after surgery, there was a significantly lower number of patients from the TMRpni group who reported continued opioid use compared with the control group (10% vs 32%, P = 0.03). CONCLUSIONS: This study demonstrates that TMRpni may translate to decreased rates of chronic opiate use. Continued study is indicated to optimize TMRpni techniques and patient selection and to determine its long-term efficacy.

Rare Case of a Cutaneous Fingertip Schwannoma: A Case Report and Review of Literature.

Background: Soft tissue masses of the hand are common and mostly benign, including ganglion cysts, glomus tumors, lipomas, and giant cell tumors of the tendon sheath. Schwannomas are benign nerve sheath tumors but are rarely found on the distal parts of the digits. The authors present a case of a schwannoma located at the tip of the finger. Methods: An otherwise healthy 26-year-old man presented because of a 10-year history of a slowly growing mass on the tip of his right little finger that significantly interfered with his right hand function. The patient underwent hand radiographs and surgical excision of the tumor. Results: Pathologic evaluation determined that the mass was a schwannoma with positive immunohistochemistry for S-100 and SOX-10. The patient reported complete resolution of symptoms associated with the tumor and his satisfaction with the surgical outcome. Conclusions: Imaging studies, such as radiographs, ultrasound, and magnetic resonance imaging, are critical in the diagnostic workup of soft tissue masses of the hand to better understand involvement of the tumor to musculature, vasculature, and other pertinent bony structures. Although quite common, schwannomas may be hard to differentiate from other soft tissue tumors, and a review of the literature demonstrates the importance of providers utilizing imaging and other diagnostics before proceeding to treatment.

Threatened Ventricular Assist Devices: Meta-analysis of Negative Pressure Therapy and Flap Reconstruction Outcomes.

Infected Ventricular Assist Device (VAD)-associated wounds are common and associated with significant morbidity and mortality. The efficacy of hardware salvage utilizing flaps and negative pressure wound therapy (NPWT) remains understudied. We hypothesized that patients treated with flaps and/or NPWT would have higher hardware salvage rates compared with other surgical management strategies. Methods: A meta-analysis study evaluating VAD-associated wounds was performed following PRISMA guidelines. Primary predictor variables were flap-reconstruction (FR), NPWT, no FR, and infection location (mediastinum versus driveline). Primary outcomes were hardware retention (salvage) versus explantation, infection recurrence, or death. Twenty-nine studies were included. Standard statistical methods included logistic regression analysis. Results: Seventy-four subjects with nonsignificant demographic differences between cohorts were identified. Overall salvage was 59.5% in both driveline and mediastinum cohorts. Overall, NPWT significantly improved salvage compared with no NPWT [77.4% versus 46.5% respectively (P = 0.009)], and FR significantly improved salvage compared with no FR [68.6% versus 39.1% respectively (P = 0.022)]. Logistic regression analysis predicting odds of salvage by FR (area under curve = 0.631) was significantly three times higher (95% CI: 1.2-9.5) and predicting the odds for salvage by NPWT (area under curve = 0.656) was significantly four times higher (95% CI: 1.4-11.1) compared with other treatment. Conclusions: NPWT or flap reconstruction for treatment of threatened VAD hardware was associated with a significantly improved device salvage compared with other surgical strategies. Further study should focus on subgroup analysis of flaps utilized and synergistic treatment benefits.

Corneal Neurotization: A Meta-analysis of Outcomes and Patient Selection Factors.

BACKGROUND: Corneal neurotization describes reinnervation of the anesthetic or severely hypoesthetic cornea with a healthy local nerve or graft. Preliminary evidence has shown corneal neurotization to improve corneal sensation, visual acuity, and ocular surface health. Factors that improve patient selection and lead to better neurotization outcomes have yet to be elucidated, limiting ability to optimize perioperative decision-making guidelines. METHODS: A systematic review with meta-analysis was performed of the MEDLINE and Embase databases using variations of "corneal," "nerve transfer," "neurotization," and "neurotization." The primary outcomes of interest were corrected visual acuity, NK Mackie stage, and central corneal sensation. Regression analyses were performed to identify the effects of surgical technique, duration of denervation, patient age, and etiology of corneal pathology on neurotization outcomes. RESULTS: Seventeen studies were included. Corneal neurotization resulted in significant improvement in NK Mackie stage (0.84 vs 2.46, P < 0.001), visual acuity (logarithm of minimum angle of resolution scale: 0.98 vs 1.36, P < 0.001), and corneal sensation (44.5 vs 0.7, P < 0.001). Nerve grafting was associated with greater corneal sensation improvement than nerve transfer (47.7 ± 16.0 vs 35.4 ± 18.76, P = 0.03). Denervation duration was predictive of preneurotization visual acuity (logarithm of minimum angle of resolution scale; R2 = 0.25, P = 0.001), and older age (ß = 0.30, P = 0.03) and acquired etiology (ß = 0.30, P = 0.03) were predictive of improved visual acuity. CONCLUSIONS: Corneal neurotization provides significant clinical improvement in visual acuity, NK Mackie staging, and corneal sensation in patients who experience NK. Both nerve grafting and nerve transfer are likely to yield similar levels of benefit and ideally should be performed early to limit denervation time.

Outpatient Parotidectomy, a Safety and Financial Review.

OBJECTIVE: The objective of this study is to investigate the safety, efficacy, and potential cost-savings of the outpatient parotidectomy procedure. METHODS: This is a retrospective chart review of all patients who underwent a parotidectomy at a large academic center from 2015 through 2019 including demographic data, postoperative complications, drain placement, readmission, and financial cost. A comparison was performed between patients who underwent an outpatient vs inpatient parotidectomy. RESULTS: A total of 335 patients underwent parotidectomy (136 outpatient; 199 inpatient). Comparison of patient demographics, common comorbidities, tumor size, tumor type, postoperative complications, and readmission rate was similar between the inpatient and outpatient cohorts. The overall mean cost difference between inpatient parotidectomy and outpatient parotidectomy for all years was $1528.58 (95%CI: $1139-$1916). CONCLUSION: The outpatient parotidectomy procedure has a comparable safety profile to the inpatient procedure while providing a significant cost-savings benefit.

Evaluating the Effects of Enhanced Recovery Pathways in Craniosynostosis: National Trends in Hospitalization Charges and Length of Stay in Craniosynostosis Surgery.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) pathways are multimodal approaches aimed at minimizing postoperative surgical stress, reducing hospitalization time, and lowering hospitalization charges. Enhanced Recovery After Surgery is broadly and increasingly implemented in hospitals across the country. Early reports have shown ERAS to reduce length of stay (LOS) after commonly performed pediatric surgeries. However, LOS and hospital charges after craniosynostosis have not been studied. We hypothesized that extended hospital LOS is correlated with increased hospitalization charges associated with open cranial vault surgery (CVS) and that over a multiyear timeframe, LOS and cost would decrease because of the increased adoption of ERAS in pediatric surgery. METHODS: The Healthcare Cost and Utilization Project's National Inpatient Sample database was analyzed from January 2007 to December 2014. All patients who were diagnosed with craniosynostosis who underwent CVS were included. Variables of interest included demographic data, hospital characteristics, hospitalization data, and total hospital charges. Univariate and generalized linear regression models were used to examine associations between selected variables and the hospitalization charges. RESULTS: There were 54,583 patients diagnosed with craniosynostosis between 2007 and 2014. Of these patients, 22,916 (41.9%) received CVS. The median total hospital charge was $66,605.77 (interquartile range, $44,095.60-$101,071.17). The median LOS was 3 days (interquartile range, 2-4 days), and there was no significant change in LOS by year (P = 0.979). However, despite a stable LOS, mean hospitalization charge increased significantly by year (P < 0.01). Regression analysis demonstrated the proportion of eligible patients who underwent CVS substantially increased over the selected timeframe (P < 0.01). Most procedures were performed in urban teaching hospitals and high-volume hospitals. There was no significant association between hospital volume and hospitalization charge (P = 0.331). CONCLUSIONS: Increasing hospital charges despite constant LOS for craniosynostosis CVS procedures was observed between 2007 and 2014. Although ERAS has reduced LOS for common pediatric surgical procedures, no decrease in LOS for CVS has been observed. The charges significantly increased over the same period including high-volume centers. Further study to safely lower LOS and hospitalization charges for this procedure may reduce the overall health care burden.

Systematic Review of Telehealth Cost Minimization for Patients and Health Systems in Otolaryngology.

OBJECTIVE/HYPOTHESIS: The COVID-19 pandemic has resulted in telehealth becoming commonplace in many health care fields. Telehealth benefits include improving access, decreasing costs, and elevating patient's experience. A review of cost minimization (CM) analyses was performed in order to explore scientific studies associated with integrating tele-otolaryngology in clinical practice. Our primary objective was to evaluate published literature for cost related to the implementation of telemedicine across otolaryngology, and to determine CM when compared to in-person visits. STUDY DESIGN: Systematic Literature Review. METHODS: We performed a systematic review using PubMed, EMBASE, and Cochrane in May 2020, to identify studies with a cost analysis of tele-otolaryngology care. Inclusion criteria focused on articles citing CM data from telehealth services. Literature quality was assessed using the MINORS scoring system. RESULTS: From 380 original articles screened only nine evaluated cost in otolaryngology. CM in the US ranged from $68 to $900 per visit. Cost was evaluated in general otolaryngology, sleep medicine, otology, and head and neck cancer surgery, the latter had the most benefit. The most common types of telehealth visits were routine follow-up and screening. Data were insufficient for meta-analysis. CONCLUSIONS: Telemedicine has been trialed across various otolaryngology subspecialties; its incorporation is projected to have a meaningful impact on access to specialty care. This research suggests that the delivery of virtual care reduces cost with the potential of increasing net revenue across multiple otolaryngology subspecialties. Further studies are needed to better discern the entirety of cost savings and the best settings for integration. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:1741-1748, 2021.

Utilization of surgical treatment for sleep apnea: A study of health disparities.

OBJECTIVE: Barriers to surgical treatment for sleep apnea remain understudied. In this study, we sought to evaluate whether specific demographic and socioeconomic characteristics are associated with whether or not patients receive surgery for sleep apnea management. METHODS: The National Inpatient Sample (NIS) database was analyzed for 2007-2014. Patients aged 18 or older with primary or secondary diagnoses of sleep apnea were selected. Patients were sub-categorized by whether they received related soft-tissue removal or skeletal modifying procedures. Age, race, gender, region, insurance, comorbidities, procedure type, and procedure setting were analyzed between surgical and nonsurgical groups. RESULTS: A total of 449,705 patients with a primary or secondary diagnosis of sleep apnea were identified, with 27,841 (5.8%) receiving surgical intervention. Compared with the non-surgical group, patients in the surgical cohort were more likely to be younger, male (74.4% vs. 59.0%), Hispanic (10.2% vs. 6.2%), Asian (3.6% vs. 1.0%) (p < 0.001), and have less clinical comorbidities. Those receiving surgery were more likely to be in the highest income bracket (36.1% versus 25.1%) and utilize private insurance (76.3% vs. 50.8%). Soft-tissue surgeries comprised 88.5% of total procedures while skeletal modifying procedures constituted 11.5% (p < 0.001). CONCLUSIONS: This study identified multiple demographic, socioeconomic, and clinical discrepancies in the utilization of surgical versus nonsurgical management of sleep apnea in the United States. Future studies should examine the causes for these health disparities in the ultimate effort to provide more equitable healthcare in the United States.

National Trends in Hospitalization Charges for Autologous Free Flap Breast Reconstruction.

BACKGROUND: There is significant cost variation among patients undergoing autologous free flap breast reconstruction. Previous studies hypothesize that factors like length of stay and hospital volume are key drivers of cost; however, how these factors have affected cost have not been well studied. Our study analyzes the factors influencing hospital charges relating to these procedures and their trends over a multiyear time frame. METHODS: The Healthcare Cost and Utilization Project's National Inpatient Sample database was analyzed from January 2009 to December 2014. All female patients who were diagnosed with breast cancer or at a high risk for breast cancer who underwent autologous free flap breast reconstruction were included. Variables of interest included demographic data, hospital characteristics, hospitalization data, and total hospital charges. Univariate and generalized linear models were used to examine associations between selected variables and the hospitalization charges, as well as trends in these factors over the years included. RESULTS: There were 659,220 female patients diagnosed with breast cancer or had a high risk of breast cancer between 2009 and 2014. Of these patients, 20,050 (3.0%) received autologous free flap breast reconstruction and were included. The mean total hospital charge was US $98,839.33 (SD = US $61,532.04). Regression analysis showed that the proportion of procedures to the total population of potential patients significantly increased over the selected time frame (P = 0.02). The average total charges also increased significantly (P < 0.01), despite a decrease in length of stay (P = 0.05). Procedures performed in the west were associated with significantly higher charges when compared with other regions (US $147,855.42, P < 0.001). Higher hospital charges were also associated with urban hospitals, regardless of teaching status. CONCLUSIONS: The overall demand for the autologous free flap breast reconstruction is increasing within the patient population, in conjunction with increasing associated hospital charges. This increase in cost is seen despite an overall decrease in length of stay, originally thought to be the main contributor to regional cost variation. Further studies should be done to develop strategies to better target increased hospitalization charges, because the overall health care burden of this procedure is expected to rise if current trends continue.

Zinc-coated carbonate apatite derived from avian eggshell for potential use as bone substitute. Part I: preparation and properties.

PURPOSE: To develop antibacterial bone substitutes derived from avian eggshell using microwave processing to convert natural calcium carbonate (CaCO3) into zinc-coated carbonate apatite (CHA). METHODS: Zinc-coated carbonate apatite was prepared using domestic microwave and then characterized with scanning electron microscopy (SEM), x-ray diffraction (XRD), Fourier transform infrared spectroscopy (FT-IR), and energy dispersive x-ray analysis (EDXA). The trial animal study was conducted by filling different bone substitutes into 5-mm-diameter standard defects on the parietal bone of New Zealand rabbits to observe new bone formation for 8 weeks. RESULTS: SEM, XRD, FT-IR, and EDXA confirmed characteristics of zinc-coated CHA derived from avian eggshell using microwave method. Histological analysis demonstrated that the defects filled with carbonate apatite had more calcified bone and less uncalcified bone formation than other groups. CONCLUSIONS: The present research demonstrated the efficient use of microwave in the conversion of natural CaCO3 into CHA with zinc coating. The examined properties showed the potential use of the new material as an antibacterial bone substitute in oral surgery. The trial animal study implied favorable osteoconductive ability of carbonate apatite in new bone formation.