Implementation of postoperative opioid prescribing guidelines after carpal tunnel release: a quality collaborative study.

Opioid prescribing after carpal tunnel release (CTR) is not well understood. We assessed CTR opioid prescribing within a quality collaborative after the dissemination of guidelines. Post guidelines, the odds of receiving a prescription decreased by 67%. Quality collaboratives can change practice patterns.Level of evidence: III.

Employer-Sponsored Medicare Advantage Plans and the 2018 Therapy Cap Repeal: Reduced Overall Spending Does Not Constrain Out-of-Pocket Costs.

BACKGROUND: Policy impacting traditional Medicare beneficiaries may have unintended effects for privately insured patients. After the repeal of a longstanding $1500 outpatient therapy cap in 2018, we aimed to evaluate if this policy change was associated with differences in use of cost of postoperative therapy after common hand surgeries, including carpal tunnel release, trigger finger release, ganglion cyst excision, De Quervain tenosynovitis release, carpometacarpal arthroplasty, and distal radius fracture open reduction/internal fixation or percutaneous pinning. METHODS: The Medicare Supplement and Coordination of Benefits files from Marketscan were used. Frequency of therapy appointments, overall costs, and out-of-pocket costs were obtained. A segmented interrupted time series with Poisson and log-transformed linear regression was performed. RESULTS: No significant monthly change in odds of therapy use was found in the postpolicy period for patients who underwent trigger finger release, carpal tunnel release, Ganglion cyst excision, De Quervain tenosynovitis release, carpometacarpal arthroplasty, or distal radius fracture, pinning, or open reduction/internal fixation. Overall cost decreased in the postpolicy period by 2% for comprehensive plans (95% confidence interval [CI]: -0.03 to -0.01, P < 0.001), by 7% for those with exclusive provider organizations (95% CI: -0.10 to -0.04, P < 0.001), by 1% for HMOs (95% CI: -0.01 to 0.002, P = 0.01), and by 3% for preferred provider organizations (95% CI: -0.03 to -0.02, P < 0.001). In the postpolicy period, no monthly change in out-of-pocket cost was observed for patients with comprehensive, exclusive provider organization, health maintenance organization, preferred provider organization, or point of service with capitation insurance plans. CONCLUSIONS: Patients with employer-sponsored Medicare Advantage plans experienced increased out-of-pocket costs for therapy despite lower net costs. These data highlight an urgent need for policy ensuring that patients benefit when overall costs of care decrease.

Postoperative hand therapy and the 2018 Medicare therapy cap repeal: Appraising cost and use changes.

BACKGROUND: Therapy use is common following carpal tunnel release (CTR), trigger finger release, ganglion cyst excision, De Quervain tenosynovitis release, carpometacarpal arthroplasty, and distal radius fracture, open reduction internal fixation or percutaneous pinning (DRF). Policy that improves coverage influences the cost and use of health care services. PURPOSE: This study aims to evaluate changes to the cost and use of postoperative hand therapy by race and procedure following the repeal of a longstanding annual Medicare outpatient therapy cap. STUDY DESIGN: Retrospective cohort study. METHODS: This is a longitudinal retrospective cohort study using a quasi-experimental interrupted time series design, including patients who underwent common hand surgeries from January 1, 2016-December 31, 2019. RESULTS: This study included 203,672 patients with a mean age of 71.4 years. Neither White (1.00, 95% confidence interval [CI]: 0.999-1.007, p = 0.45) nor non-White (1.00, 95% CI: 1.00-1.01, p = 0.06) patients experienced monthly changes in therapy use before policy implementation. Therapy frequency increased following CTR (odds ratio [OR] 1.12, 95% CI: 1.11-1.14, p < 0.001), trigger finger release (OR 1.09, 95% CI: 1.07-1.10, p < 0.001), and DRF (OR 1.05, 95% CI: 1.03-1.06, p < 0.001) following implementation. CONCLUSIONS: This study found that improved coverage was associated with increased postoperative therapy use among some subsets, including CTR and DRF, suggesting the need to optimize coverage by means such as prior authorization or bundled payments, rather than only increasing coverage benefits.

Post-Bariatric Panniculectomy: Postoperative Complications by Weight Loss Surgery Type.

BACKGROUND: Over 250,000 patients undergo bariatric surgery each year in the United States. Approximately 21% will undergo subsequent body contouring after massive weight loss. Patients with prior bariatric surgery are at a greater risk for complications relative to the general population. However, it is unknown if bariatric surgery type is associated with differential complication risk after panniculectomy. METHODS: A retrospective chart review of post-bariatric who underwent abdominal panniculectomy at a single large quaternary care center was performed. Postoperative complications were graded according to the Clavien-Dindo classification. Descriptive statistics, multivariable logistic regression, and power calculations were performed. RESULTS: In total, 216 patients were included. Restrictive bariatric surgery accounted for 48.6% while 51.3% had a history of malabsorptive bariatric surgery. The overall rate of complications was 34.3% (restrictive: 36.2%; malabsorptive: 32.8%, p=0.66). Wound complications were observed in 25.5% (n=55) of patients. Systemic complications occurred in 11.1% of patients overall, with statistically similar rates between restrictive and malabsorptive groups. After adjusting for both patient and operative factors, no significant difference in total complications (OR=1.15, 95% CI: 0.47 to 2.85, p=0.76), systemic complications (OR=0.26, 95% CI: 0.05 to 1.28, p=0.10), or wound complications (OR=2.31, 95% CI: 0.83 to 6.41, p=0.11) was observed. CONCLUSIONS: Complications following panniculectomy in bariatric surgery patients is high and predominantly related to wound healing. No significant difference between type of bariatric surgery and complication risk was found.

Impact of consensus guideline publication on the timing of elective pediatric umbilical hernia repair.

BACKGROUND: The American Academy of Pediatrics published consensus guidelines advising observation of asymptomatic umbilical hernias until age 4 or 5, given unnecessary risks of early intervention and substantial practice variation. Yet, the impact of guidelines on early repair (age <4) or if certain groups remain at risk for avoidable intervention is unclear. METHODS: This retrospective study used data from children's hospitals participating in the Pediatric Health Information System database. Children aged 17 years and younger who underwent umbilical hernia repair from July 2017 to August 2022 were eligible for inclusion. Children with recurrent hernias, an emergency, or urgent presentation were excluded. An interrupted time series using segmented multivariable logistic regression estimated the association of guideline publication in November 2019 with the odds of guideline-adherent repair (age ≥4) after adjusting for sociodemographic characteristics and hospital-level random effects. RESULTS: 16,544 children underwent repair, of which 3,115 (18.8%) were children <4 years old. After adjustment, guideline publication was associated with an immediate increase in guideline-adherent repairs (odds ratio = 1.25 95% confidence interval = 1.05-1.49). The interrupted time series found that each month after publication was associated with a 2% increase in the odds of guideline-adherent repair (odds ratio = 1.02, 95% confidence interval = 1.01-1.03). Children with public insurance were nearly 20% less likely to receive guideline-adherent repair than privately insured children (odds ratio = 0.82, 95% confidence interval = 0.74-0.91). Children in the Midwest had lower odds of guideline-adherent repair (Midwest versus Northeast: odds ratio = 0.45. 95% confidence interval = 0.24-0.84). CONCLUSION: Guideline publication was associated with greater odds of guideline-adherent repair, yet public insurance coverage and Midwest location remain significant predictors of early repair against recommendations.

Predictors and Variation in Steroid Injection Use for Carpal Tunnel Syndrome from a Multicenter Quality Collaborative.

BACKGROUND: Steroid injections are commonly used as first-line treatment for carpal tunnel syndrome (CTS); however, research has shown that their benefit is generally short-term and many patients go on to receive carpal tunnel release. The study purpose was to determine the variation in steroid injection use by hand surgeons. METHODS: We analyzed data from a 9-center hand surgery quality collaborative. Data from 1,586 patients (2,381 hands) were included if they underwent elective CTR at one of the sites. Mixed effects logistic regression models were used to examine the association of receipt of steroid injection and association of receipt of more than one steroid injection among patient-level covariates. RESULTS: Steroid injection use significantly varied by practice, ranging from 12-53% of patients. The odds of receiving a steroid injection were 1.4 times higher for females (p<0.01), 1.6 times higher for patients with chronic pain syndrome (p<0.01), 0.5 times lower for patients with moderate electromyography (EMG) and 0.4 times lower for patients with severe EMG classification (both p<0.01). Patients with high CTS-6 scores (p=0.02) and patients with moderate (p=0.04) or severe EMG (p=0.05) had lower odds of receiving multiple steroid injections. Complete symptomatic improvement after steroid injection was significantly reported by patients with high CTS-6 score (p=0.03) or patients with severe EMG classification (p=0.02). CONCLUSIONS: We found wide patient-level and practice-level variation in the use of steroid injections prior to undergoing CTR. These findings underscore the need for improved data and standard practice guidelines regarding which patients benefit from steroid injection.

Compound Muscle Action Potential Amplitude as a Predictor of Functional and Patient-Reported Outcomes in Ulnar Neuropathy at the Elbow.

BACKGROUND: Ulnar neuropathy at the elbow (UNE) is a debilitating upper extremity condition that often leaves patients with residual symptoms even after surgical treatment. The role of electrodiagnostic studies in guiding the treatment of UNE is not well established, and conventional electrodiagnostic parameters may not reflect the severity of disease. Compound muscle action potential (CMAP) amplitude is a parameter that corresponds with axonal injury and motor symptoms and may more accurately predict the severity of neurologic injury. METHODS: This prospective multicenter study recruited 78 patients in the Surgery of the Ulnar Nerve project. Patients underwent electrodiagnostic testing and clinical assessment of motor and sensory function, and completed patient-reported outcome questionnaires, including the Michigan Hand Outcome Questionnaire; the Disabilities of the Arm, Shoulder and Hand questionnaire; and the Carpal Tunnel Questionnaire (CTQ). Correlations were measured among each of the electrodiagnostic parameters and outcomes and predictive models for each outcome were subsequently developed. RESULTS: Of all the electrodiagnostic parameters measured, only CMAP amplitude was predictive of scores on the Michigan Hand Outcome Questionnaire; Disabilities of the Arm, Shoulder and Hand questionnaire; CTQ function scale, and motor impairment in grip and pinch strength. None of the parameters were predictive of scores on the CTQ symptom scale or sensory impairments as measured with two-point discrimination or Semmes-Weinstein monofilament testing. CONCLUSIONS: CMAP amplitude, but not other conventional electrodiagnostic parameters, is predictive of functional outcomes in UNE. This electrodiagnostic measurement can alert the clinician to severe cases of UNE and inform surgical decision-making. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Electrodiagnostic Predictors of Outcomes After In Situ Decompression of the Ulnar Nerve.

PURPOSE: Patients with severe ulnar neuropathy at the elbow frequently experience suboptimal surgical outcomes. Clinical symptoms alone may not accurately represent the severity of underlying nerve injury, calling for objective assessment tools, such as electrodiagnostic studies. The goal of our study was to determine whether specific electrodiagnostic parameters can be used to predict the outcomes after in situ decompression of the ulnar nerve. METHODS: This prospective study enrolled consecutive patients aged ≥18 years diagnosed with ulnar neuropathy at the elbow. Patients completed a baseline battery of motor, sensory, functional, and electrodiagnostic tests before undergoing in situ decompression of the ulnar nerve. They were reassessed at 6 weeks, 3 months, 6 months, and 12 months after surgery. Forty-two patients completed at least 2 follow-up assessments and were included in the study. RESULTS: When controlling for other electrodiagnostic measurements and demographic factors, none of the electrodiagnostic parameters were predictive of outcomes at 12 months after surgery. Patients with decreased compound muscle action potential amplitudes demonstrated slower trends of recovery in grip strength, pinch strength, and overall scores on the Michigan Hand Outcomes Questionnaire as well as its function, work, and activities of daily living subscales, Disabilities of the Arm, Shoulder, and Hand questionnaire, and the Carpal Tunnel Questionnaire. Decreased motor nerve conduction velocity was predictive of slower recovery of 2-point discrimination and pinch strength. CONCLUSIONS: Compound muscle action potential amplitude, but not other conventional electrodiagnostic parameters, was predictive of functional outcomes after in situ decompression of the ulnar nerve. This parameter should play a role in determining the timing and prognosis of treatment for ulnar neuropathy at the elbow. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Association Between Daytime vs Overnight Digit Replantation and Surgical Outcomes.

Importance: Recent evidence suggests that select delayed replantation may not adversely affect digit survival; however, whether surgical timing (overnight or daytime) is associated with digit replantation outcomes is unknown. Objective: To assess whether digit survival, complication rate, and duration of surgery are associated with time of replantation. Design, Setting, and Participants: This retrospective case series study included all replantations performed at a single tertiary referral academic center between January 1, 2000, and August 1, 2021. Data were analyzed between October 2, 2021, and January 1, 2022. Four daytime surgery intervals were selected based on literature review. Daytime replantations started within the intervals whereas overnight replantations began outside the intervals. For each case, the procedure difficulty score and the attending surgeon expertise score were calculated. Logistic and linear regressions adjusting for confounders including procedure difficulty score and expertise score were used to assess surgical timing and outcomes. Participants were adults (aged ≥18 years) undergoing digit replantations between January 2000 and August 2021 with at least 1-month follow-up. Replantation was defined as the reattachment of a completely amputated digit that necessitated anastomosis of both artery and vein. Exposures: Daytime or overnight digit replantation. Main Outcomes and Measures: Viable replanted digit at 1-month follow-up, number of complications, and duration of surgery. Results: A total of 98 patients (mean [SD] age, 39.5 [15.3] years; 136 [93%] men) and 147 digits met inclusion criteria. Overall success rate was 55%. Between 4 pm and 7 am, overnight replantations were associated with 0.4 fewer complications (ß, -0.4; 95% CI, -0.8 to -0.1) and 90.7 minutes shorter operative time (ß, -90.7; 95% CI, -173.6 to -7.7). A 1-point increase in surgeon expertise score was associated with 1.7 times increased odds of replantation success for all intervals (adjusted odds ratio, 1.7; 95% CI, 1.2 to 2.4; P = .002). There were no differences in digit survival by surgical time. Conclusions and Relevance: In this case series study of digit replantations, time of operation was not associated with replantation success. Overnight replantation was associated with fewer complications and shorter duration of surgery compared with daytime surgery. Results of this study suggest that overnight replantations may be performed with outcomes comparable to daytime replantations at a tertiary care academic center.

Selenite and selenate showed contrasting impacts on the fate of arsenic in rice (Oryza sativa L.) regardless of the formation of iron plaque.

The different effects of selenite and selenate on the fate of As and the function of iron plaque in the interaction between Se and As are poorly understood. Rice seedlings (Oryza sativa L.) were selected as experimental plants in this study, the hydroponic experiments were conducted to investigate the possible regulatory roles of selenite and selenate on the uptake, translocation, and transformation of arsenite or arsenate accompanied by iron plaque. In arsenite- and arsenate-treated rice, the Fe30 treatments stimulated root uptake by 12.4-39.8% and 18.6-37.0%, respectively, but inhibited the movement of As from iron plaque to the roots, resulting in the absorption of a considerable amount of As on iron plaque. Regardless of the iron plaque formation, selenite (selenate) significantly increased (decreased) the root uptake of arsenite and arsenate by 28.1-53.0% and 40.0%-61.7%, respectively (45.6-56.3% and 42.5-47.7%, respectively). Interestingly, the supply of selenite significantly reduced root-to-shoot As translocation by 71.9-77.3% and 66.2-67.7%, respectively, in arsenite- and arsenate-treated rice seedlings; however, a significant increase (90.5-122.9%) was induced by selenate was found only in the arsenate-treated plants. Furthermore, the translocation of As from iron plaque to the roots was significantly increased (decreased) by selenite (selenate). As and Fe in iron plaque were significantly positively correlated in all As-treated rice plants, and this correlation was more profound than that in the shoots and roots. However, neither Fe treatments nor inorganic Se addition affected the interconversion between As(III) and As(V) obviously; and As(III) was the dominant species in both shoots (68.3-84.9%) and roots (90.7-98.2%). Our results indicate selenite and selenate are effective in reducing the As accumulation in an opposite way, and the presence of iron plaque had no obvious impact on the interaction between Se and As in rice plants.

Accumulation of potentially toxic elements in Chinese tea (Camellia sinensis): Towards source apportionment and health risk assessment.

Tea (Camellia sinensis) is a popular beverage that is consumed globally. However, a better understanding of potentially toxic elements (PTEs) content in tea leaves and infusion is necessary to minimize risk on human health. Therefore, 249 tea samples (grown in different areas) covering six types of tea were collected in China to investigate the PTEs contents, identify their potential source and assess the health risk associated with drinking tea. PTE contents in tea leaves across six tea types were ND-0.900 (Cd), 0.005-2.133 (As), ND-5.679 (Pb), ND-13.86 (Cr), 1.601-22.93 (Ni), ND-2.048 (Se), 0.109-622.4 (F), 13.02-269.9 (Rb), 1.845-50.88 (Sr), and 2.796-53.23 (Ba) mg/kg. The result of tea infusion showed that 14.3 %-44.1 % (green tea), 14.5 %-46.7 % (black tea), 10.5 %-25.3 % (dark tea), 13.6 %-34.2 % (oolong tea), 16.9 %-40.7 % (yellow tea), and 19.9 %-35.1 % (white tea) of F were released. All tea types, except green tea, exhibited comparatively low leachability of Cd, As, Pb and Cr in tea infusion. The source apportionment revealed that PTEs in tea leaves mainly originated from soil parental materials, while industrial activities, fertilizer application, and manufacturing processes may contribute to exogenous Se, Cd, As, and Cr accumulation. Health risk assessment indicated that F in tea infusion dominated the health risk. Humans may be exposed to a higher health risk by drinking green tea compared to that of other tea types. Nevertheless, the long-term tea consumption is less likely to contribute to pronounced non-carcinogenic and carcinogenic risks. This study confirmed that tea consumption is an important and direct pathway of PTEs uptake in humans. The health risk associated with drinking tea should be of concern.

Bilirubin oxidation end product B prevents CoCl2-induced primary cortical neuron apoptosis by promoting cell survival Akt/mTOR/p70S6K signaling pathway.

Bilirubin oxidation end products (BOXes) are associated with the late-developing neurological deficits after subarachnoid hemorrhage (SAH) possibly by direct constricting the cerebral arteries, but their specific impacts on neurons especially in the state of hypoxia, a prominent feature during the late stage of SAH, remain unclear. Here, we explored the effects of BOXes on the primary cortical neurons subjected to CoCl2-induced hypoxia by evaluating the morphological and apoptotic changes of neurons. The present study showed that Z-BOX B but not Z-BOX A greatly alleviated CoCl2-induced neuronal cell deterioration and apoptosis. Immunocytochemical staining assay showed Z-BOX B significantly increased neurite length, the numbers of both secondary and tertiary branches, and the protein level of Synaptophysin. Caspase 3/7 apoptosis assay and DAPI staining showed that Z-BOX B markedly reduced primary cortical neurons apoptosis. The expression of cleaved Caspase-3 was suppressed by Z-BOX B treatment, while the expression of Bcl-xL was upregulated. To further discover the mechanism of the neuroprotective effect observed in Z-BOX B, we found Z-BOX B increased the expression of p-mTOR, p-Akt, and p-p70S6K. In general, our results implicated Z-BOX B may prevent CoCl2-induced primary cortical neurons apoptosis by activating sAkt/mTOR/p70S6K signaling pathway. Hence, the present data may provide new insights into the pathophysiological mechanism of delayed neurological dysfunction after SAH and novel targets for treating SAH.

The risks of sulfur addition on cadmium accumulation in paddy rice under different water-management conditions.

Recently, the application of sulfur (S) has been recommended to control the accumulation of cadmium (Cd) in rice in contaminated paddy soil. However, the effects of exogenous S on Cd transfer in paddy rice systems under different water-management practices have not been systematically investigated. Pot experiments were performed to monitor the composition of soil pore water and the Cd accumulation in iron plaque and rice tissue were compared under different S (0 and 200 mg/kg Na2SO4) and water (continuous and discontinuous flooding) treatments. Sulfur application significantly increased Cd concentrations in soil pore water under discontinuous flooding conditions, but slightly reduced them under continuous flooding. Moreover, the oxidation/reduction potential (Eh) was the most critical factor that affected the Cd levels. When the Eh exceeded -42.5 mV, S became the second critical factor, and excessive S application promoted Cd dissolution. In addition, S addition elevated the Cd levels in iron plaque and reduced the Cd transfer from the iron plaque to rice roots. In rice, S addition inhibited Cd transfer from the rice roots to the straw; thus, more Cd was stored in the rice roots. Nevertheless, additional S application increased the Cd content in the rice grains by 72% under discontinuous flooding, although this effect was mitigated by continued flooding. Under simulated practical water management conditions, S addition increased the risk of Cd contamination in rice, suggesting that S application should be reconsidered as a paddy fertilization strategy.

Comparative responses of cadmium accumulation and subcellular distribution in wheat and rice supplied with selenite or selenate.

Cadmium (Cd) contamination of crop plants has aroused a worldwide concern because of the threats posed to human health through accumulation in the food chains. Selenium (Se) can alleviate the Cd-induced phytotoxicity, but the relevant underlying mechanisms are not fully understood. Therefore, with wheat (Triticum aestivum L.) and rice (Oryza sativa L.) chosen as the target plants in this study, the effects of selenite or selenate on Cd accumulation and subcellular distribution were investigated through greenhouse hydroponic experiments; and simultaneously, the effects of pre-Se treatment with selenite or selenate on Cd accumulation and root-to-shoot translocation in the studied plants were also included. Results showed the addition of Se slightly changed the Cd content in plant roots in a time-dependent manner; however, with the obvious decreasing trend on the Cd transfer factor (TF), its content in plant shoots was significantly reduced by selenite or selenate in a plant species-dependent manner. At 48 h of exposure, the supplementation of selenite and selenate significantly decreased the Cd content by 40.4% and 38.0% in wheat shoots, and by 72.2% and 40.9% in rice shoots, respectively. Additionally, the order of Cd proportion distributed to the different subcellular fractions of plant tissues was as follows: cell wall > soluble cytosol > organelle, irrespective of the Se treatments or the plant species. However, selenate increased the Cd percentage in soluble cytosol of wheat shoots, while selenite increased that percentage in the cell wall of rice shoots; and the Cd proportion in soluble cytosol of the studied plant roots was significantly enhanced owing to selenite or selenate addition. Moreover, similar to the co-application, the pre-Se treatment with inorganic Se also reduced the Cd accumulation and translocation both in wheat and rice. Our results proved that the inorganic Se could decline the Cd accumulation and translocation in the crop plants, although selenite was found more effective than selenate regarding such effects.

Structural optimization and additional targets identification of antisense oligonucleotide G3139 encapsulated in a neutral cytidinyl-lipid combined with a cationic lipid in vitro and in vivo.

Antisense oligonucleotides (ASOs) usually contain a fully phosphorothioate (PS) backbone, which possibly interact with many genes and proteins under intracellular conditions. G3139 is an ASO that targets Bcl-2 mRNA and induces cell apoptosis. Here, we report a kind of cytidinyl-lipid combined with a cationic lipid (DNCA/CLD, molar ration, 28:3, named mix), which may interact with oligonucleotides via H-bond formation, pi-stacking and electrostatic interaction, accompanied by low zeta potentials. The IC50 value of G3139 delivered by mix-lipid reduced from above 20 µM to 0.158 µM for MCF-7/ADR, and exhibited stronger antiproliferation upon other cancer cell lines. In addition, PS modification in the 3'-half of G3139 (especially at positions 13-16) enhanced serum stability, target specificity and anticancer activity. Also, a locked nucleic acid (LNA) gapmer G3139 (LNA-G3139) showed superior antiproliferation (78.5%) and Bcl-2 mRNA suppression effects (85.5%) at 200 nM, mainly due to its high complementary RNA affinity. More apoptosis-associated targets were identified, and a lower level of non-specific protein binding (HSA) revealed that both antisense and aptamer mechanisms might simultaneously exist. A combination of a new delivery system and chemical modifications, such as in LNA-G3139, may have potential clinical application prospects in the future.