Is Chemotherapy Associated with Improved Overall Survival in Patients with Dedifferentiated Chondrosarcoma? A SEER Database Analysis.

BACKGROUND: Dedifferentiated chondrosarcoma is a chondrosarcoma subtype associated with high rates of recurrence and a poor prognosis. Others have proposed treatment of dedifferentiated chondrosarcoma using osteosarcoma protocols, including perioperative chemotherapy. However, the rarity of this condition poses difficulties in undertaking single- institution studies of sufficient sample size. QUESTION/PURPOSE: Is perioperative chemotherapy associated with improved overall survival in patients with dedifferentiated chondrosarcoma? METHODS: We queried the Surveillance, Epidemiology, and End Results (SEER) 1973 to 2016 database for patients with a diagnosis of dedifferentiated chondrosarcoma (n = 308). As dedifferentiated chondrosarcoma was only classified as a distinct entity in SEER starting in 2000, only patients treated in 2000 and later were included. We excluded from our analyses those patients with distant disease at diagnosis, a primary site of disease other than bone or joints, and those who did not receive cancer-directed surgery. These criteria yielded 185 dedifferentiated chondrosarcoma patients for inclusion. We used Kaplan-Meier analyses and Cox proportional hazards models to assess the association of clinical, demographic, and treatment characteristics on overall survival (OS). RESULTS: After controlling for confounding variables, including age, sex, tumor size, stage, grade, location, and radiation treatment status, and after adjusting for missing data, no overall survival benefit was associated with receipt of chemotherapy in patients with dedifferentiated chondrosarcoma (hazard ratio 0.75 [95% confidence interval 0.49 to 1.12]; p = 0.16). CONCLUSION: Chemotherapy treatment of dedifferentiated chondrosarcoma was not associated with improved OS. These results must be viewed cautiously, given the limited granularity of information on chemotherapy treatment, the concerns regarding chemotherapy misclassification in SEER data, and the small sample of patients with dedifferentiated chondrosarcoma, all of which limit the power to detect a difference. Our findings are nevertheless consistent with those of prior reports in which no benefit of chemotherapy could be detected. Lack of clear benefit from perioperative chemotherapy in dedifferentiated chondrosarcoma argues that it should be used only after careful consideration, and ideally in the context of a clinical trial. LEVEL OF EVIDENCE: Level III, therapeutic study.

An institutional review of splenic artery aneurysm in childbearing-aged females and splenic artery aneurysm rupture during pregnancy. Is screening justified?

OBJECTIVE: To determine the prevalence of splenic artery aneurysm (SAA) in women of childbearing age and the incidence of peripartum rupture to ascertain a possible benefit of screening this potentially high-risk population. METHODS: Patients diagnosed with SAA over a 6-year period were collected from a single institutional medical records database. Inclusion criteria included female gender and age between 15 and 49 years. The number of abdominal computed tomography studies performed on our study population during the study period was compared to the number of detected SAAs. The number of deliveries at our institution during the study period was compared to the number of peripartum SAA ruptures. The resultant data were used to calculate the prevalence of SAA in childbearing-aged females and the incidence of SAA rupture during pregnancy. RESULTS: The prevalence of SAA in childbearing-aged females and incidence of rupture during pregnancy were less than 0.1%. CONCLUSION: Radiologic screening of all childbearing-aged females is not warranted, but identification of those at greater risk of harboring an asymptomatic SAA, along with the early institution of treatment according to current guidelines, may prevent maternal and fetal mortality in the rare event of SAA rupture during pregnancy.

Long-term Outcomes for Extraskeletal Myxoid Chondrosarcoma: A SEER Database Analysis.

BACKGROUND: Extraskeletal myxoid chondrosarcoma (EMCS) is a rare tumor that typically has an indolent course but high rate of recurrence. We queried the Surveillance, Epidemiology, and End Results (SEER) database to assess factors associated with metastasis, treatment, and survival. METHODS: We queried the SEER 1973-2016 database for patients with myxoid chondrosarcoma (ICD-O-3: 9231/3). Kaplan-Meier analyses and Cox proportional hazard models assessed effects on overall survival (OS) of demographics and clinical characteristics. Logistic regression assessed associations between tumor location and distant disease. Primary analysis was a complete case analysis; multiple imputation (MI) was used in a sensitivity analysis. RESULTS: Locoregional disease (LRD) was found in 373 (85%) of patients. In univariate analysis with LRD, surgery correlated with superior OS [HR = 0.27; 95% confidence interval (CI), 0.16-0.47]; chemotherapy and radiotherapy associated with inferior OS (HR = 1.90; 95% CI, 1.11-3.27 and HR = 1.45; 95% CI, 1.03-2.06, respectively). No treatment modality associated with OS in the adjusted, complete case model. In the adjusted sensitivity analysis, surgery associated with superior outcomes (HR = 0.36; 95% CI, 0.19-0.69). There was no OS difference by primary tumor site. 10-year OS with distant disease was 10% (95% CI, 2%-25%). CONCLUSIONS: Surgery in LRD associated with improved OS in univariate analysis and adjusted models correcting for missing data. There was no OS benefit with chemotherapy or radiotherapy. IMPACT: This represents the largest report of EMCS with long-term follow-up. Despite the reputedly indolent nature of EMCS, outcomes with metastatic disease are poor. We provide OS benchmarks and guidance for stratification in future prospective trials.

Catastrophic failure of an acetabular total hip arthroplasty component mimicking a posterior dislocation.

In our case study, we examine a case of catastrophic failure of a total hip arthroplasty acetabular component leading to complete central wear by the ceramic femoral head, requiring revision total hip arthroplasty. Despite subtle clinical findings, initial orthopaedic evaluation and treatment yielded a diagnosis of total hip arthroplasty dislocation. While a much more common phenomenon, the diagnosis led to futile initial attempts at closed reduction. Our index of suspicion must remain high to pick up on subtle, less common diagnoses we will encounter.

Residents as Mentors: The Development of Resident Mentorship Milestones.

BACKGROUND: Mentorship of residents by more senior colleagues has been identified as important for stress management and creating an ideal learning environment. OBJECTIVE: We set out to define the attributes of an ideal resident mentor and explore ways to develop these attributes during residency training. METHODS: A 28-member, multi-specialty counsel of residents and fellows used 2 phases of a small group exercise. In the first phase, the group developed desirable attributes of resident mentors and explored means of developing these attributes. In the second phase, the group identified trends in the results, and in a second small group exercise with participants at a major national conference, refined these trends into Resident Mentorship Milestones. RESULTS: The exercises identified 3 common themes: availability, competence, and support of the mentee. We defined milestones for mentorship in each of these areas. CONCLUSIONS: The Resident Mentorship Milestones, developed by a national panel of residents, describe 3 key dimensions of mentorship: availability, defined as making time for mentorship; competence for and success in mentoring; and support of the mentee. These milestones may serve as a novel tool to develop and assess successful resident mentorship models.

Patient-Centered Care and Population Health: Establishing Their Role in the Orthopaedic Practice.

As health care increasingly emphasizes high value, the terms "population health" and "patient-centered care" have become common, but their application is less clear. Patient-centered care encourages using data to optimize care for an individual. Population health offers a framework to consider how to efficiently and effectively manage a condition for a population, how prevention affects large groups, and the specific distribution of a given disorder. Integrating both concepts into practice can facilitate required outcome-measure reporting and potentially improve patient outcomes. Clinical practice guidelines and appropriate use criteria are examples of reconciliation of these topics. By embracing attempts to decrease variation in treating musculoskeletal disorders while personalizing delivery to individual patients, surgeons may benefit from the improvement of both efficiency and patient experience.

Consensus on Graduate Medical Education Financing: An Analysis of Stakeholder Responses to the House Energy and Commerce Committee's Open Letter.

BACKGROUND: In December 2014, the Energy and Commerce Committee of the US House of Representatives sent an open letter requesting interested parties to respond to 7 questions on graduate medical education (GME). More than 100 organizations and individuals responded. METHODS: An online search for responses yielded 27 organizations that had published their responses to the committee's open letter. Responses included answers to the 7 questions and additional recommendations. The 27 respondents proposed a total of 80 unique interventions. Each intervention was screened for concordance with those from other organizations, and then categorized as supportive, in opposition, or making no mention. Data were entered into a spreadsheet and rank ordered on the frequency of support. RESULTS: At the top of the rankings were several interventions with significant support from many respondents. CONCLUSIONS: Given the broader GME constituency represented by the 27 stakeholders in this analysis, the 80 proposed interventions represent a comprehensive inventory of the extant ideas regarding the financing, governance, and oversight of GME. This objective analysis could help both spur productive discussions and form the foundation for a larger public policy deliberation of GME financing.

Targeted Chemotherapy in Bone and Soft-Tissue Sarcoma.

Historically surgical intervention has been the mainstay of therapy for bone and soft-tissue sarcomas, augmented with adjuvant radiation for local control. Although cytotoxic chemotherapy revolutionized the treatment of many sarcomas, classic treatment regimens are fraught with side effects while outcomes have plateaued. However, since the approval of imatinib in 2002, research into targeted chemotherapy has increased exponentially. With targeted therapies comes the potential for decreased side effects and more potent, personalized treatment options. This article reviews the evolution of medical knowledge regarding sarcoma, the basic science of sarcomatogenesis, and the major targets and pathways now being studied.

Promotion of Wellness and Mental Health Awareness Among Physicians in Training: Perspective of a National, Multispecialty Panel of Residents and Fellows.

BACKGROUND: Physicians in training are at high risk for depression, and physicians in practice have a substantially elevated risk of suicide compared to the general population. The graduate medical education community is currently mobilizing efforts to improve resident wellness. OBJECTIVE: We sought to provide a trainee perspective on current resources to support resident wellness and resources that need to be developed to ensure an optimal learning environment. METHODS: The ACGME Council of Review Committee Residents, a 29-member multispecialty group of residents and fellows, conducted an appreciative inquiry exercise to (1) identify existing resources to address resident wellness; (2) envision the ideal learning environment to promote wellness; and (3) determine how the existing infrastructure could be modified to approach the ideal. The information was aggregated to identify consensus themes from group discussion. RESULTS: National policy on resident wellness should (1) increase awareness of the stress of residency and destigmatize depression in trainees; (2) develop systems to identify and treat depression in trainees in a confidential way to reduce barriers to accessing help; (3) enhance mentoring by senior peers and faculty; (4) promote a supportive culture; and (5) encourage additional study of the problem to deepen our understanding of the issue. CONCLUSIONS: A multispecialty, national panel of trainees identified actionable goals to broaden efforts in programs and sponsoring institutions to promote resident wellness and mental health awareness. Engagement of all stakeholders within the graduate medical education community will be critical to developing a comprehensive solution to this important issue.

Two aircraft carriers' perspectives: a comparative of control measures in shipboard H1N1 outbreaks.

BACKGROUND: The USS George Washington (GW) and the USS Ronald Reagan (RR), 2 US Navy aircraft carriers, experienced almost simultaneous outbreaks of novel H1N1 influenza A in the summer of 2009. We compared the respective epidemic control measures taken and subsequent lessons learned. METHODS: Data were collated from both outbreaks to assess various elements including attack rate, isolation/quarantine protocols, and treatment methods. The respective duration of each outbreak was compared with survival curve analysis. The number of personnel affected in each outbreak was compared using χ2 analysis. RESULTS: Differences were found in the protocols used on the 2 ships. The GW treated about two-thirds of the patients with oseltamivir through day 14 and quarantined all patients meeting case definition throughout the outbreak. Face masks were used throughout. The RR used oseltamivir and quarantined many fewer patients (through days 5 and 3, respectively). No face masks were used after day 5. The outbreaks were similar in duration (GW = 25 days, RR = 27 days, P = .38), but the RR had significantly more cases (n = 253 vs 142, P < .0001). A portion of each group had samples that were confirmed H1N1 by polymerase chain reaction. CONCLUSIONS: GW's protocol, including aggressive oseltamivir treatment of two-thirds of the cases and quarantine throughout the duration decreased the overall number of personnel affected, likely reducing the overall control reproduction number. Both outbreaks were similar in duration. Even though the GW expended significantly more resources than the RR, if the 2009 pandemic H1N1 strain had been as clinically severe as the 1918 pandemic, a more stringent treatment protocol may have been the only way to prevent significant operational impact.

The attack rate of H1N1 in various berthing configurations on board an aircraft carrier.

OBJECTIVE: We compared attack rates for novel H1N1 influenza A (H1N1) among various groups aboard an aircraft carrier as influenced by characteristics of their living arrangements. METHODS: During an outbreak of H1N1 on board the USS George Washington (GW), group affiliation (department or squadron membership) data were obtained on all patients who were placed in respiratory isolation based on their diagnosis with presumptive H1N1. Because berthing spaces are assigned by department and various characteristics of each department's berthing spaces are known, analysis of attack rates in comparison to these characteristics was possible. Attack rates were compared with the square feet of living space per sailor, occupancy rate of the berthing areas, and size of the berthing areas. These results were further correlated with the mission of the various departments or squadrons. RESULTS: The average attack rate was 3%, with the highest rates occurring in departments or squadrons whose mission required ongoing contact with civilian populations ashore. The attack rate among officers was 2.04 versus 3.19 among enlisted personnel; this difference was not significant (P = .21). The attack rate for women was 1.90 versus 3.09 for men, which was significant (P = .05). Although attack rates varied considerably based on organizational mission, no correlation was found between attack rate and square feet of living space per person or occupancy rate or size of berthing spaces. CONCLUSIONS: The attack rate of the outbreak overall was limited to 3%. Smaller and more crowded berthing configurations did not contribute to higher attack rates, suggesting that transmission occurs most frequently elsewhere while engaged in other activities such as working, eating, or relaxing. Further studies are necessary to filter out potential correlations or variables not identified in this study, such as the difference between the number of men and women isolated.