Lower Intraoperative and Immediate Postoperative Complications in Robotic Versus Conventional Primary Total Hip Arthroplasty: A Retrospective Cohort Analysis of Over 360,000 Patients.

PURPOSE: Although a trend of an improved alignment with robotic total hip arthroplasty (THA) over conventional methods has surfaced from recent series, it is unknown whether these results translate into meaningful enhancements in postoperative outcomes. To address this lack in the literature, we compared the perioperative morbidity and mortality with robotic and conventional THA in a large national cohort of 367,894 patients. We hypothesized that no significant differences would exist in the outcomes between the two groups. METHODS: Records were extracted from 2016-2019 from the National Inpatient Sample (NIS) database Healthcare Cost and Utilization Project which is the largest in-patient database in the United States. From 367,894 THAs, robotics were employed for 7,863 patients. The remaining 360,031 conventional THAs served as controls. The two groups were compared for demographics, admission, and hospital stay details including costs, and mortality and morbidity data including medical and surgical complications. Descriptive statistics were used for demographic data while analytical statistics including t-tests, chi-squared tests, Fischer exact test, and Pearson chi-squared tests were used for perioperative outcomes. Statistical significance was set at p<0.005. RESULTS: Demographic distributions between robotic and conventional THA groups displayed similar age and sex characteristics. Shorter mean lengths of stay (1.87 days) were seen in robotic THA versus conventional THA (2.33 days) while higher costs were noted for the former (mean $68,686.71 vs $66,840.39) (p<0.005). Low overall mortality (0.03% robotic, 0.09% conventional) was seen in both groups (p>0.005). Higher comparative incidences of anemia, acute renal failure, and pneumonia were seen in conventional THA (p<0.005) while no significant differences were noted for other complications including myocardial infarction, pulmonary embolism, deep vein thrombosis, and cardiac arrest (p>0.005). Among others, lower dislocation rates, mechanical complications, periprosthetic joint infection, and periprosthetic fractures were seen with robotic THA (p<0.005). Wound complications and superficial infection rates did not differ between the two groups (p>0.005). CONCLUSIONS: Evidence has emerged from our results to support more routine adaptation of the robotic option of performing a THA. These can be based on lower local, systemic, and mechanical complications as demonstrated by the present study. Further evaluation of these results in follow-up would help establish the foothold of robotic surgery in total hip replacement in the modern context.

Measurable residual disease conversion rate with consolidation chemotherapy in acute myeloid leukemia.

The rate of MRD clearance in AML with standard consolidation chemotherapy is not well defined. A multi-institution retrospective analysis was performed on 107 consecutively treated AML patients in morphologic complete remission with detectable MRD post-induction therapy who received standard chemotherapy consolidation. In response to standard intermediate/high-dose cytarabine consolidation therapy, 26 of 60 patients (43.3%) with MRD threshold of detection of at least 0.1% converted to MRD-negative status (undetectable with assay used), and 6 of 47 patients (12.8%) with MRD threshold of detection > 0.1% converted to MRD-negative status. Multivariable logistic regression for patients with MRD threshold of detection of at least 0.1% showed that, when controlling for age, ELN risk category, dose of cytarabine, and use of a combination agent, treatment with 1 cycle of consolidation cytarabine versus ≥2 cycles decreased the odds of conversion of AML to MRD-negative (OR = 0.24, 95% CI 0.07-0.85, p = 0.03).

The clinical, molecular, and prognostic features of the 2022 WHO and ICC classification systems for myelodysplastic neoplasms.

Myelodysplastic neoplasms (MDS) are clonal disorders of bone marrow failure exhibiting a variable risk of progression to acute myeloid leukemia. MDS exhibit certain prognostic genetic or cytogenetic abnormalities, an observation that has led to both the pathologic reclassification of MDS in the 2022 World Health Organization (WHO) and International Consensus Classification (ICC) systems, as well as to an updated prognostic schema, the Molecular International Prognostic Scoring System (IPSS-M). This single-institution study characterized the molecular patterns and clinical outcomes associated with the 2022 WHO and ICC classification schemas to assess their clinical utility. Strikingly, with the exception of one individual, all 210 patients in our cohort were classified into analogous categories by the two pathologic/diagnostic schemas. Most patients (70%) were classified morphologically while the remaining 30% had genetically classified disease by both criteria. Prognostic risk, as assessed by the IPSS-M score was highest in patients with MDS with biallelic/multi-hit TP53 mutations and lowest in pts with MDS-SF3B1. Median leukemia-free survival (LFS) was shortest for those with MDS with biallelic/multi-hit TP53 (0.7 years) and longest for those with MDS with low blasts (LFS not reached). These data demonstrate the clear ability of the 2022 WHO and ICC classifications to organize MDS patients into distinct prognostic risk groups and further show that both classification systems share more similarities than differences. Incorporation of the IPSS-M and IPSS-R features provide additive prognostic and survival components to both the WHO and ICC classifications, which together enhance their utility for evaluating and treating MDS patients.

Ependymoma, NOS and anaplastic ependymoma incidence and survival in the United States varies widely by patient and clinical characteristics, 2000-2016.

BACKGROUND: Ependymoma is a rare CNS tumor arising from the ependymal lining of the ventricular system. General differences in incidence and survival have been noted but not examined on a comprehensive scale for all ages and by histology. Despite the rarity of ependymomas, morbidity/mortality associated with an ependymoma diagnosis justifies closer examination. METHODS: Incidence data were obtained from the Central Brain Tumor Registry of the United States in collaboration with the Centers for Disease Control and Prevention and the National Cancer Institute, and survival data from Surveillance Epidemiology and End Results, from 2000 to 2016 for anaplastic ependymoma and ependymoma, not otherwise specified (NOS). Age-adjusted incidence rates (IRs) per 100 000 person-years were analyzed by age, sex, race, and location. Survival analysis was performed with Kaplan-Meier curves and multivariable Cox proportional hazards models. RESULTS: Incidence of anaplastic ependymoma was highest in ages 0 to 4 years. African American populations had lower incidence but had a 78% increased risk of death compared to white populations (hazard ratio [HR]: 1.78 [95% CI, 1.30-2.44]). Incidence was highest for anaplastic ependymoma in the supratentorial region. Adults (age 40+ years) had almost twice the risk of death compared to children (ages 0-14 years) (HR: 1.97 [95% CI, 1.45-2.66]). For ependymoma, NOS, subtotal resection had a risk of mortality 1.86 times greater than gross total resection ([HR: 1.86 [95% CI, 1.32-2.63]). CONCLUSIONS: African American populations experienced higher mortality rates despite lower incidence compared to white populations. Extent of resection is an important prognostic factor for survival. This highlights need for further evaluation of treatment patterns and racial disparities in the care of patients with ependymoma subtypes.

Genomic landscape of neutrophilic leukemias of ambiguous diagnosis.

Chronic neutrophilic leukemia (CNL), atypical chronic myeloid leukemia (aCML), and myelodysplastic/myeloproliferative neoplasms, unclassifiable (MDS/MPN-U) are a group of rare and heterogeneous myeloid disorders. There is strong morphologic resemblance among these distinct diagnostic entities as well as a lack of specific molecular markers and limited understanding of disease pathogenesis, which has made diagnosis challenging in certain cases. The treatment has remained empirical, resulting in dismal outcomes. We, therefore, performed whole-exome and RNA sequencing of these rare hematologic malignancies and present the most complete survey of the genomic landscape of these diseases to date. We observed a diversity of combinatorial mutational patterns that generally do not cluster within any one diagnosis. Gene expression analysis reveals enrichment, but not cosegregation, of clinical and genetic disease features with transcriptional clusters. In conclusion, these groups of diseases represent a continuum of related diseases rather than discrete diagnostic entities.

When can I go home after my knee replacement? Factors affecting the duration of in-hospital stay after knee replacement.

BACKGROUND: Despite a sevenfold decline in the number of postoperative nights (21-3) after a total knee arthroplasty (TKA) over the last four decades, predictors of length of stay (LOS) are not fully understood. We attempted to ascertain these factors by analyzing a large cohort of patients. METHODS: Prospectively collected data between January 2016 and March 2017 were retrospectively analyzed at our institute. Charts of 1663 consecutive, simple primary unilateral and bilateral TKAs were reviewed for the LOS excluding staggered bilateral, complex primary and revision knees. STATISTICAL ANALYSIS: Preoperative variables [demographics, cash/credit status, historical, clinical, laboratory findings, Knee Society Function Scores and Oxford Knee Scores (OKSs)] were scrutinized by multivariate regression to identify significant factors affecting LOS and formulate model equations for patients and health caregivers. Results were incorporated into an iOS application, which was tested for accuracy. RESULTS: Among 1524 unilateral and 139 bilateral TKAs, mean LOS was 4.4 and 5.2 days, respectively. Five factors, namely insurance, flexion/hyperextension deformity, preoperative OKS and a rheumatoid etiology, were significantly associated with prolonged LOS in unilateral knees. The impact of these independent variables on LOS could be calculated by: [Formula: see text]For bilateral cases, the only significant variable extending LOS was a low preoperative OKS and the equation is given as follows: [Formula: see text]The iOS-app-predicted LOS and actual LOS were similar (p > 0.05) for 115 prospectively operated knees. CONCLUSION: Poor preoperative OKS, rheumatoid etiology, flexion and hyperextension deformity and delays in insurance affected unilateral TKR LOS, while poor preoperative OKS alone affected LOS in bilateral cases.

Nonmalignant and malignant meningioma incidence and survival in the elderly, 2005-2015, using the Central Brain Tumor Registry of the United States.

BACKGROUND: Meningioma incidence increases significantly with age. In the expanding elderly population, we lack complete understanding of population-based trends in meningioma incidence/survival. We provide an updated, comprehensive analysis of meningioma incidence and survival for individuals aged over 65. METHODS: Data were obtained from the Central Brain Tumor Registry of the United States (CBTRUS) from 2005-2015 for nonmalignant and malignant meningioma. Age-adjusted incidence rates per 100000 person-years were analyzed by age, sex, race, ethnicity, location, and treatment modalities. Survival was analyzed using Kaplan-Meier and multivariable Cox proportional hazards models for a subset of CBTRUS data. RESULTS: Nonmalignant meningioma incidence doubled from adults age 65-69 years to adults over age 85 years and was significantly greater in females than males for all ages. Malignant meningioma incidence did not differ by sex for any age grouping. Nonmalignant and malignant meningioma incidence was significantly greater in black populations versus others. Nonmalignant meningioma survival was worse with age, in black populations, and in males, including when analyzed by 5-year age groups. Surgical resection and radiation did not improve survival compared with resection alone in nonmalignant meningioma. CONCLUSIONS: This study reports increasing nonmalignant meningioma incidence in the elderly, increased incidence in black populations, and in females. In contrast, malignant meningioma incidence did not differ between sexes. Risk of death was higher for black individuals and males. Additionally, radiation did not confer a survival advantage when combined with resection for nonmalignant meningioma. Thus, we identify clinically relevant discrepancies in meningioma incidence/survival that require further study.

Comparison between Multisite Infiltration Analgesia versus Adductor Canal Block for Pain Management in Total Knee Arthroplasty: A Prospective Study.

BACKGROUND: Severe acute postoperative pain after total knee arthroplasty (TKA) may cause significant morbidity to patients. Recent techniques such as peripheral nerve blocks have shown promising hope in providing appropriate pain control without systemic side effects. Adductor canal block (ACB) and multisite infiltration analgesia (MIA) are two techniques that are proven to be effective individually. AIM: This study aims to compare the efficacy of ACB versus MIA in postoperative analgesia and functional recovery after unilateral knee arthroplasty. SETTINGS AND DESIGN: A prospective study was conducted between July 2016 and December 2016 involving 200 patients undergoing unilateral TKA. MATERIALS AND METHODS: Patients were either administered MIA (Group I, n = 100 patients) or ACB (Group II, n = 100 patients). All the patients were assessed for severity of pain by visual analog scale (VAS) at 8, 24, and 48 h postoperatively and knee range of motion (ROM) at 48 h after surgery. STATISTICAL ANALYSIS: The Statistical Package for the Social Sciences (SPSS 19.0, SPSS Inc., Chicago, IL, USA) was used for descriptive and inferential analysis. RESULTS: Patients who received MIA showed significantly better VAS scores 8, 24, and 48 h after surgery. Furthermore, this subset of patients showed a marginally better ROM postoperatively. However, there was no difference number of patients requiring rescue analgesia for breakthrough pain or technique-related problems between both groups. CONCLUSION: This study demonstrates that MIA is a safe technique that provides effective analgesia at 8, 24, and 48 h postoperatively. This leads to faster rehabilitation compared to ACB in patients undergoing TKA.

Validating the Role of Steroid in Analgesic Cocktail Preparation for Local Infiltration in Total Knee Arthroplasty: A Comparative Study.

BACKGROUND: Pain control after total knee arthroplasty (TKA) through local analgesic cocktail preparation has gained widespread popularity in recent times. Local steroids have potent anti-inflammatory effect leading to reduced postoperative swelling and pain which might increase the efficacy and duration of local infiltration analgesia. AIM: The aim is to evaluate whether the addition of local steroid to an injectable analgesic cocktail for periarticular infiltration leads to better pain control and knee range of motion (ROM) in the immediate postoperative period compared to patients who do not receive steroid in their cocktail. SETTINGS AND DESIGNS: A prospective study was conducted in a group of 140 patients undergoing unilateral TKA between June 2017 and December 2017. MATERIALS AND METHODS: All the patients in the study group received either periarticular infiltration with an analgesic cocktail (Group I, n = 70) or analgesic cocktail with 100 mg methylprednisolone (Group II, n = 70) for postoperative pain with ultrasound-guided adductor canal block (ACB). Patients were evaluated with visual analog scale (VAS) for pain at 8, 24, and 48 h postoperatively and ROM at 48 h after surgery. STATISTICAL ANALYSIS: The SPSS 19.0 software (SPSS Inc., Chicago, IL, USA) was used for the statistical analysis. Student t-test has been used to find the pairwise significance. RESULTS: Group II had a statistically significant decrease in VAS scores at 8 h (P = 0.096), first postoperative day (P = 0.0001) and second postoperative day (P = 0.0001) as compared to Group I. However, there was no statistically significant difference seen with early ROM in both the groups at 48 h (P < 0.361). CONCLUSION: Patients who received steroid cocktail infiltration plus ACB had an improved and better postoperative analgesia in an early postoperative period of 24-48 h; however, there was no significant difference in clinical ROM and functional outcome when compared to the study group.

Molecularly targeted drug combinations demonstrate selective effectiveness for myeloid- and lymphoid-derived hematologic malignancies.

Translating the genetic and epigenetic heterogeneity underlying human cancers into therapeutic strategies is an ongoing challenge. Large-scale sequencing efforts have uncovered a spectrum of mutations in many hematologic malignancies, including acute myeloid leukemia (AML), suggesting that combinations of agents will be required to treat these diseases effectively. Combinatorial approaches will also be critical for combating the emergence of genetically heterogeneous subclones, rescue signals in the microenvironment, and tumor-intrinsic feedback pathways that all contribute to disease relapse. To identify novel and effective drug combinations, we performed ex vivo sensitivity profiling of 122 primary patient samples from a variety of hematologic malignancies against a panel of 48 drug combinations. The combinations were designed as drug pairs that target nonoverlapping biological pathways and comprise drugs from different classes, preferably with Food and Drug Administration approval. A combination ratio (CR) was derived for each drug pair, and CRs were evaluated with respect to diagnostic categories as well as against genetic, cytogenetic, and cellular phenotypes of specimens from the two largest disease categories: AML and chronic lymphocytic leukemia (CLL). Nearly all tested combinations involving a BCL2 inhibitor showed additional benefit in patients with myeloid malignancies, whereas select combinations involving PI3K, CSF1R, or bromodomain inhibitors showed preferential benefit in lymphoid malignancies. Expanded analyses of patients with AML and CLL revealed specific patterns of ex vivo drug combination efficacy that were associated with select genetic, cytogenetic, and phenotypic disease subsets, warranting further evaluation. These findings highlight the heuristic value of an integrated functional genomic approach to the identification of novel treatment strategies for hematologic malignancies.

Incidence and survival trends for medulloblastomas in the United States from 2001 to 2013.

Population-based data examining recent epidemiological trends in medulloblastoma, the most common pediatric brain malignancy, are limited. Therefore, we sought to examine recent population-level trends in medulloblastoma incidence and survival. Central Brain Tumor Registry of the United States (CBTRUS) data were analyzed from 2001 to 2013. Age-adjusted incidence rates (IR) and annual percent changes (APCs) with 95% confidence intervals (CI) were calculated by age, sex, and race. Relative survival rates were calculated by age, sex, and race using Surveillance, Epidemiology and End-Results (SEER) registries; subsets of CBTRUS data. Kaplan-Meier and Cox proportional hazards models were used to examine survival differences. Medulloblastoma incidence remained relatively stable from 2001 to 2013, with minor fluctuations from 2001 to 2009 (APC = 2.2, 95% CI 0.8, 3.5) and 2009-2013 (APC = -4.1, 95% CI -7.5, -0.6). Incidence was highest in patients aged 1-4 years at diagnosis, but patients aged 10-14 years showed increased incidence from 2000 to 2013 (APC = 3.2, 95% CI 0.6, 5.8). Males displayed higher IR relative to females (males: 0.16 vs. females: 0.12), except in patients <1 year-old. Compared to Whites, Blacks displayed a non-significant increase in incidence (APC = 1.7, 95% CI -0.4, 4.0) and in mortality risk (hazard ratio for survival = 0.74; p = 0.09). The current study reports no overall change in medulloblastoma incidence from 2001 to 2013. Male and female patients <1 year-old had equal medulloblastoma incidence rates and poor 5-year relative survival compared to other ages. Non-significant trends in the data suggest disparities in medulloblastoma incidence and survival by race. Thus, analysis of tumor-specific trends by demographic variables can uncover clinically informative trends in cancer burden.

Incidence and survival trends in oligodendrogliomas and anaplastic oligodendrogliomas in the United States from 2000 to 2013: a CBTRUS Report.

Measuring tumor-specific trends in incidence is necessary to elucidate tumor-type contribution to overall cancer burden in the US population. Recently, there have been conflicting reports concerning the incidence of oligodendrogliomas (OD) and anaplastic oligodendrogliomas (AOD). Therefore, our goal was to examine trends in OD and AOD incidence and survival by age, gender and race. Data was analyzed from the Central Brain Tumor Registry of the United States (CBTRUS) from 2000 to 2013. Age-adjusted incidence rates per 100,000 person-years with 95% confidence intervals (CI) and annual percent changes (APCs) with 95% CI were calculated for OD and AOD by age, sex and race. Survival rates were calculated for age, sex and race using a subset of the CBTRUS data. OD and AOD incidence peaked at 36-40 and 56-60 years, respectively. AOD:OD ratio increased up to age 75. Overall, OD and AOD incidence decreased [OD: APC -3.2 (2000-2013), AOD: -6.5 (2000-2007)]. OD incidence was highest in Whites but decreased significantly (2000-2013: APC -3.1) while incidence in Black populations did not significantly decrease (2000-2013: APC -1.6). Survival rates decreased with advancing age for OD, while persons aged 0-24 had the lowest survival for AOD. The current study reports a decrease in overall OD and AOD incidence from 2000 to 2013. Furthermore, AOD makes up an increasing proportion of oligodendroglial tumors up to age 75. Lower AOD survival in 0-24 years old may indicate molecular differences in pediatric cases. Thus, surveillance of tumor-specific trends by age, race and sex can reveal clinically relevant variations.

Rotator cuff tears: An evidence based approach.

Lesions of the rotator cuff (RC) are a common occurrence affecting millions of people across all parts of the globe. RC tears are also rampantly prevalent with an age-dependent increase in numbers. Other associated factors include a history of trauma, limb dominance, contralateral shoulder, smoking-status, hypercholesterolemia, posture and occupational dispositions. The challenge lies in early diagnosis since a high proportion of patients are asymptomatic. Pain and decreasing shoulder power and function should alert the heedful practitioner in recognizing promptly the onset or aggravation of existing RC tears. Partial-thickness tears (PTT) can be bursal-sided or articular-sided tears. Over the course of time, PTT enlarge and propagate into full-thickness tears (FTT) and develop distinct chronic pathological changes due to muscle retraction, fatty infiltration and muscle atrophy. These lead to a reduction in tendon elasticity and viability. Eventually, the glenohumeral joint experiences a series of degenerative alterations - cuff tear arthropathy. To avert this, a vigilant clinician must utilize and corroborate clinical skill and radiological findings to identify tear progression. Modern radio-diagnostic means of ultrasonography and magnetic resonance imaging provide excellent visualization of structural details and are crucial in determining further course of action for these patients. Physical therapy along with activity modifications, anti-inflammatory and analgesic medications form the pillars of nonoperative treatment. Elderly patients with minimal functional demands can be managed conservatively and reassessed at frequent intervals. Regular monitoring helps in isolating patients who require surgical interventions. Early surgery should be considered in younger, active and symptomatic, healthy patients. In addition to being cost-effective, this helps in providing a functional shoulder with a stable cuff. An easily reproducible technique of maximal strength and sturdiness should by chosen among the armamentarium of the shoulder surgeon. Grade 1 PTTs do well with debridement while more severe lesions mandate repair either by trans-tendon technique or repair following conversion into FTT. Early repair of repairable FTT can avoid appearance and progression of disability and weakness. The choice of surgery varies from surgeon-to-surgeon with arthroscopy taking the lead in the current scenario. The double-row repairs have an edge over the single-row technique in some patients especially those with massive tears. Stronger, cost-effective and improved functional scores can be obtained by the former. Both early and delayed postoperative rehabilitation programmes have led to comparable outcomes. Guarded results may be anticipated in patients in extremes of age, presence of comorbidities and severe tear patters. Overall, satisfactory results are obtained with timely diagnosis and execution of the appropriate treatment modality.

Clinical Management of Type 2 Diabetes Mellitus after Bariatric Surgery.

Bariatric surgery has emerged as an effective treatment for type 2 diabetes in the setting of obesity, with recent clinical trials demonstrating biochemical remission (i.e., euglycemia) in up to 40 % of subjects at 3 years post-surgery. Conversely, these trials also highlight that a significant proportion of individuals undergoing bariatric surgery experience residual diabetes (i.e., they do not achieve remission or experience diabetes recurrence). The management of residual diabetes following surgery requires personalized attention, yet limited evidence exists on which to base clinical decisions. Hence, we aim to review the evidence that does exist and propose clinical management strategies in patients with persistent hyperglycemia following bariatric surgery.

Adults with long-duration type 2 diabetes have blunted glycemic and ß-cell function improvements after bariatric surgery.

OBJECTIVE: This study investigated the effect of type 2 diabetes duration on glucose regulation 24 months post-bariatric surgery. METHODS: Twenty-seven adults with short- (<5 years) and long-duration (≥10 years) type 2 diabetes received a mixed-meal tolerance test at baseline and 24 months postsurgery. Body weight, insulin sensitivity, first- and second-phase meal-stimulated insulin secretion, disposition index (i.e., DI or pancreatic ß-cell function), and incretin responses were examined. RESULTS: Adults with short-duration type 2 diabetes had better HbA(1c), greater insulin secretory capacity, and greater DI compared with adults with long-duration type 2 diabetes, despite similar weight loss and incretin responses. Diabetes duration correlated with smaller improvements in HbA(1c) and DI but not weight loss. CONCLUSIONS: Enhanced ß-cell function characterizes the effect of bariatric surgery in adults with diabetes for <5 years, independent of weight loss or incretins. Additional therapy postsurgery may be required to improve glycemia for people with long-standing type 2 diabetes.

"WhatsApp"ening in orthopedic care: a concise report from a 300-bedded tertiary care teaching center.

Smartphones have emerged as essential tools providing assistance in patient care, monitoring, rehabilitation, communication, diagnosis, teaching, research and reference. Among innumerable communication apps, WhatsApp has been widely popular and cost effective. The aim of our study was to report the impact of introduction of a smartphone app "WhatsApp" as an intradepartmental communication tool on (1) awareness of patient-related information, (2) efficiency of the handover process and (3) duration of traditional morning handovers among orthopedic residents in a 300-bedded tertiary care teaching center. Written handovers and paging used for communication at our center led to occasional inefficiencies among residents. Widespread use, low cost, availability and double password protection (phone lock and WhatsApp lock) made WhatsApp's group conversation feature an ideal tool for intradepartmental patient-related communication. Twenty-five consecutive admissions before and after WhatsApp (BW, AW) were included in the study. Eight orthopedic residents attempted fifty randomly arranged questions based on the twenty-five patients in each study period. A null hypothesis that introduction of WhatsApp group would neither increase the awareness of patient-related information nor improve the efficiency of the handovers among residents was assumed. A significant improvement observed in scores obtained by residents in the AW group led to rejection of the null hypothesis. The residents also reported swifter and efficient handovers after the introduction of WhatsApp. Our results indicate that the introduction of a smartphone app "WhatsApp" as an intradepartmental communication tool can bring about an improvement in patient-related awareness, communication and handovers among orthopedic residents.

Durable Disease Control with MEK Inhibition in a Patient with NRAS-mutated Atypical Chronic Myeloid Leukemia.

Atypical chronic myeloid leukemia (aCML) and chronic neutrophilic leukemia (CNL) are rare hematologic neoplasms characterized by leukocytosis and a hypercellular bone marrow. Although recurrent mutations in the colony-stimulating factor 3 receptor (CSF3R) are frequently observed in patients with (CNL), the mutational landscape in (aCML) is less well-defined. In this report, we describe an 81-year-old male who was diagnosed with aCML. He presented with leukocytosis and anemia but no significant clinical symptoms. Standard laboratory studies revealed the absence of the Philadelphia chromosome. Massively parallel sequencing demonstrated no mutations in CSF3R, but the presence of a heterozygous NRAS-G12D variant (47% allele frequency). The patient was started on treatment with trametinib, an MEK1/2 inhibitor with Food and Drug Administration approval for malignant melanoma. Therapy with trametinib resulted in exceptional improvements in his blood counts and continued disease control with 14 months of follow-up. This case highlights the need for clinical trials evaluating the safety and efficacy of MEK1/2 as a therapeutic target for the treatment of patients with NRAS-mutated aCML/CNL.