Risk of Treatment Escalation in Recipients vs Nonrecipients of Spinal Manipulation for Musculoskeletal Cervical Spine Disorders: An Analysis of Insurance Claims.

OBJECTIVE: The purpose of this study was to evaluate the relationship between treatment escalation and spinal manipulation in a retrospective cohort of people diagnosed with musculoskeletal disorders of the cervical spine. METHODS: We used retrospective analysis of insurance claims data (2012-2018) from a single Fortune 500 company. After isolating the first episode of care, we categorized 58 147 claims into 7951 unique patient episodes. Treatment escalation included claims where imaging, injection, emergency room, or surgery was present. Modified Poisson regression was used to determine the relative risk of treatment escalation comparing recipients vs nonrecipients of spinal manipulation, adjusted for age, sex, episode duration, and risk scores. RESULTS: The sample was 55% women, with a mean age of 44 years (range, 18-103). Treatment escalation was present in 42% of episodes overall: 2448 (46%) associated with other care and 876 (26%) associated with spinal manipulation. The estimated risk of any treatment escalation was 2.38 times higher in those who received other care than in those who received spinal manipulation (95% confidence interval, 2.22-2.55, P = .001). CONCLUSION: Among episodes of care associated with neck pain diagnoses, those associated with other care had twice the risk of any treatment escalation compared with those associated with spinal manipulation. In the United States, over 90% of spinal manipulation is provided by doctors of chiropractic; therefore, these findings are relevant and should be considered in addressing solutions for neck pain. Additional research investigating the factors influencing treatment escalation is necessary to moderate the use of high-cost and guideline-incongruent procedures in people with neck pain.

PortFindr: A Novel, More Accurate, and Precise Device for Locating Tissue Expander Ports.

Two-stage breast reconstruction is the most common method of reconstructive modality following mastectomy and requires serial saline infusions into temporary tissue expanders through subcutaneous ports. Historically, these ports were located using a small magnet attached to a string or support structure. Magnetic force decreases exponentially as tissue thickness or fluid accumulation creates more distance between the TE port and skin. We developed a prototype handheld electronic device, the PortFindr, which more accurately and precisely locates the centre of subcutaneous ports. This device may lead to more confident localization of ports, less inadvertent puncture of tissue expanders, and thus less complications during infusions.

La reconstruction mammaire en deux étapes est la principale intervention reconstructive utilisée après une mastectomie. Elle exige plusieurs perfusions de soluté physiologique dans des expanseurs tissulaires temporaires par l'entremise de chambres sous-cutanées. Par le passé, ces chambres étaient localisées à l'aide d'un petit aimant fixé à une cordelette ou une structure de soutien. La force magnétique diminuait exponentiellement à mesure que l'épaisseur du tissu ou l'accumulation de liquide accroissait la distance entre la chambre et la peau. Les chercheurs ont créé un prototype électronique manuel, le PortFindr, qui situe le centre de la chambre sous-cutanée avec plus d'exactitude et de précision. Ce dispositif pourrait permettre de localiser les chambres de manière plus objective, de réduire les perforations accidentelles des expanseurs tissulaires et donc de limiter les complications pendant les perfusions.

Three-Dimensionally-Printed Hand Surgical Simulator for Resident Training.

Reduced work hours and funding have fueled an increase in simulation-based training for plastic and orthopedic surgery residency programs. Unfortunately, certain simulation training can fail to enhance surgical skills because of availability, cost, or low fidelity. There is a growing interest among training programs for a cost-effective surgical simulator to improve basic skills and muscle memory of residents. The authors developed a three-dimensionally-printed, malleable, and anatomically accurate hand surgery simulator from a computed tomographic scan of an adult male subject. The bone matrix was specifically designed to provide proprioceptive feedback to hone drilling skills used in fracture repair and arthrodesis. The silicone soft-tissue covering provides excellent malleability to dissect and perform fracture-reducing maneuvers. Three-dimensional printing of "fracture bridges" allows the design of on-demand polyfracture models so the trainee can practice multiple types and locations of repairs as skills progress. To summarize, the authors' hand simulator is an anatomical, low-cost, multiprocedure tool that can be used to improve the muscle memory and basic surgery skills of residents in training.

The cost impact of a quality-assured mechanical assessment in primary low back pain care.

Objectives: The escalating cost of low back pain (LBP) care has not improved outcomes. Our purpose: to compare costs between LBP care guided by a quality-assured mechanical assessment (MC) and usual community care (CC).Study Design: Administrative claims data analysis.Methods: Employees and dependents of a large self-insured manufacturer seeking care for LBP in 2013 chose between the company's primary care clinic (where MC was delivered) and community care.The claims of 5,036 were analyzed for one year following subjects' initial evaluation excluding only those with diagnostic codes for fractures, dislocations, or infections. MC included an advanced form of Mechanical Diagnosis & Therapy (MDT). CC varied based on each subjects' selection of providers. Primary outcome measure: one-year cost of each subject's care. Secondary: number of MRIs, spinal injections, and lumbar surgeries undertaken. The payer's proprietary risk-adjustment algorithm was utilized.Results: After risk adjustment, the average cost per MC subject was 51.48% lower than the CC average cost (p < .0279). The utilization of MRIs, injections, and surgeries was lower with MC by 49.75%, 39.44%, 78.38% with relative risks of 1.99, 1.64, and 4.73, respectively.Conclusions: This 51.5% cost-savings reflects the substantial reduction in downstream care-seeking with MC, including lower utilization of MRIs, injections, surgeries, and downstream care after six months from the initial visit. It is well documented that the MDT clinical examination typically elicit patterns of pain response that in turn identify how most can rapidly recover with self-care with no need for other intervention.Level of Evidence: 1b.

Acquires Anterior Thoracic Lung Herniation and Repair: A Rare Case and Discussion.

We report a case of acquired anterior thoracic lung herniation in a 63-yeal-old female. This painful herniation developed four years after uncomplicated video-assisted thoracic surgery for lung cancer resection and adjuvant radiation for concomitant breast cancer. The herniation site was remote from all prior incisions, and demonstrated intercostal muscle denervation and radiation fibrosis. The 8 cm x 10 cm chest wall defect was reconstructed with inlay PROCEED mesh and reinforced with a pedicled latissimus dorsi flap. Five months postoperatively the patient had complete resolution of symptoms, no evidence of herniation, and a stable wound.

IV 3000 Dressing for Fingertip Injury: Management and Discussion.

An active, right hand dominant. 86-year-old male presented with transverse amputation of the right ring finger just distal to the DIP joint. Conservative management was recommended in order to preserve digit length, mobility, and the DIP joint. The IV3000 semipermeable dressing was utilized as the primary treatment. The clear adhesive dressing has a high moisture vapor transmission rate that facilitates creation of a suitable wound microenvironment. The digit showed significant epithelialization and mobility at two weeks post-injury and was healed with full range of motion at both the DIP and PIP joints by week six. There were no complications from use of the IV3000 dressing, and both healing time and pain during dressing change are improved over alternative dressings like gauze.

Unilateral Forehead Paralysis Following Operative Repair of Facial Trauma: A Case Study and Review of the Literature.

The temporal branch of the facial nerve is a commonly injured nerve during facial trauma due to its superficial course over the zygomatic arch, and is a commonly damaged nerve during facial surgery. We report a case of trauma to the left temporal fossa, and subsequent unilateral forehead paralysis. Early exploration revealed external suture compression as the origin of his paralysis. Removal of the suture led to complete resolution of the neurological deficit. The differential diagnosis did not include the possibility of the compression of the nerve by a suture, however the decision for early exploration led to a full recovery.

Biomechanical analysis of the FlatWire Figure 8 sternal fixation device.

OBJECTIVE: To determine whether the FlatWire Figure 8 sternal fixation device (Penn United, USA) is mechanically superior to the current standard in sternotomy closure. DESCRIPTION: Unstable sternal closure using traditional steel-wire cerclage can increase postoperative pain, bony cut-through and wound dehiscence. The authors present the Figure 8 sternal fixation device to minimize these complications. Biomechanical properties of the device were compared with conventional steel wire sternal repair. EVALUATION: Using two constructs of both FlatWire and steel wire, pull-to-failure, Hertzian contact and cut-through were compared. Samples were tested to 500,000 cycles or failure. Cyclic comparisons were performed using log-rank t tests and Student's t tests for cut-through analysis. FlatWires were found to have superior biomechanical properties in all categories tested. CONCLUSION: The FlatWire provides superior biomechanical properties compared with conventional steel wire, which may lead to reduced sternal wound complications.

OBJECTIF: Déterminer si le dispositif de fixation du sternum FlatWire Figure 8 (Penn United, États-Unis) est mécaniquement supérieur à la norme actuelle pour la fermeture des sternotomies. DESCRIPTION: La fermeture du sternum au moyen du cerclage classique en fil d'acier peut accroître la douleur postopératoire, l'insertion osseuse et la déhiscence de la plaie. Les auteurs présentent le dispositif de fixation du sternum Figure 8 pour réduire ces complications au minimum. Les auteurs ont comparé les propriétés biomécaniques du dispositif à la réparation sternale classique à l'aide d'un fil d'acier. ÉVALUATION: Les auteurs ont comparé le test de tension, le contact hertzien et l'insertion du modèle FlatWire à celui du fil d'acier. Ils ont comparé les échantillons jusqu'à 500 000 cycles ou jusqu'à l'échec. Les comparaisons cycliques ont été effectuées au moyen de tests t de Mantel-Haenzel et de tests t pour l'analyse de tension. Le modèle FlatWire avait des propriétés biomécaniques supérieures dans toutes les catégories mises à l'essai. CONCLUSION: Le FlatWire a des propriétés biomécaniques supérieures à celles du fil d'acier classique, lesquelles peuvent réduire les complications de la plaie du sternum.

The lazy lateral incision: an innovative approach to the skin-sparing mastectomy.

The skin-sparing mastectomy has many advantages over a simple mastectomy, including preservation of the native breast skin, inframammary fold, and improved aesthetics for immediate reconstruction. The traditional transverse elliptical access incision is anterior on the breast mound, requires a second incision for previous biopsy sites, and provides restricted access to the axilla. We describe a novel mastectomy incision that improves scar appearance, improves access to the axillary contents, and reduces skin flap retraction. This incision starts at the nipple-areolar complex and extends laterally in a curvilinear fashion toward the axilla incorporating the biopsy scar along the way. This simple sinusoidal design results in an aesthetically superior alternative to the traditional linear mastectomy incision.

Reducing pathogen transmission in a hospital setting. Handshake versus fist bump: a pilot study.

Handshaking is a known vector for bacterial transmission between individuals. Handwashing has become a major initiative throughout healthcare systems to reduce transmission rates, but as many as 80% of individuals retain some disease-causing bacteria after washing. The fist bump is an alternative to the handshake that has become popular. We have determined that implementing the fist bump in the healthcare setting may further reduce bacterial transmission between healthcare providers by reducing contact time and total surface area exposed when compared with the standard handshake.

Eyelid reconstruction.

Reconstruction of the eyelids after excision of skin cancer can be challenging. Knowledge of surgical eyelid anatomy and appropriate preoperative planning are critical in order to perform eyelid reconstruction and minimize complications and the need for reoperation. The fundamental principle for full-thickness eyelid reconstruction is based on reconstructing the subunits of the eyelid, including the anterior and posterior lamellae as well as the tarsoligamentous sling.

Racial and ethnic differences in pediatric access to preemptive kidney transplantation in the United States.

Preemptive kidney transplantation is the optimal treatment for pediatric end stage renal disease patients to avoid increased morbidity and mortality associated with dialysis. It is unknown how race/ethnicity and poverty influence preemptive transplant access in pediatric. We examined the incidence of living donor or deceased donor preemptive transplantation among all black, white, and Hispanic children (<18 years) in the United States Renal Data System from 2000 to 2009. Adjusted risk ratios for preemptive transplant were calculated using multivariable-adjusted models and examined across health insurance and neighborhood poverty levels. Among 8,053 patients, 1117 (13.9%) received a preemptive transplant (66.9% from LD, 33.1% from DD). In multivariable analyses, there were significant racial/ethnic disparities in access to LD preemptive transplant where blacks were 66% (RR = 0.34; 95% CI: 0.28-0.43) and Hispanics 52% (RR = 0.48; 95% CI: 0.35-0.67) less likely to receive a LD preemptive transplant versus whites. Blacks were 22% less likely to receive a DD preemptive transplant versus whites (RR = 0.78, 95% CI: 0.57-1.05), although results were not statistically significant. Future efforts to promote equity in preemptive transplant should address the critical issues of improving access to pre-ESRD nephrology care and overcoming barriers in living donation, including obstacles partially driven by poverty.

Availability, utilization and outcomes of deceased diabetic donor kidneys; analysis based on the UNOS registry.

The number of kidneys obtained from deceased diabetic donors available for transplantation has increased >eightfold increase in the past 15 years. We assessed allograft outcomes associated with deceased diabetic donors and compared them with that of standard and extended criteria donors (ECD) in the UNOS data registry. We identified 1982 recipients of diabetic standard criteria donors over a 10-year period from 1995 through 2004. Both overall and death-censored survival of organs from diabetic standard criteria donors was significantly better than that of organs obtained from nondiabetic ECD while inferior to that from nondiabetic standard criteria donors. Compared with ECD donors, diabetic donors had lower serum creatinine, less cold ischemia and these kidneys were less likely to be pump-perfused. Recipients of diabetic kidneys were younger and less likely to experience delayed graft function compared with recipient of ECD kidneys. More recently, many diabetic donor kidneys have been given to diabetic recipients with early graft survival being similar to that among nondiabetic recipients. These findings demonstrate the potential to expand and to improve utilization of this resource without compromising outcomes for recipients. Improved, evidence-based evaluation and allocation of deceased diabetic donor kidneys is needed to optimize their use.

Schwannoma of the ulnar nerve: a case report and review of the literature.

We report a case of a large ulnar nerve schwannoma, a rare type of soft tissue neoplasm. Diagnostic pearls are described to facilitate a more accurate and timely diagnosis. These characteristics include mobility, Tinel's sign, MRI target sign, S100 histological staining, Antoni patterns, and others. With a correct diagnosis, the tumor can be extirpated with preservation of nerve function and a low risk of recurrence.

Racial disparities in pediatric access to kidney transplantation: does socioeconomic status play a role?

Racial disparities persist in access to renal transplantation in the United States, but the degree to which patient and neighborhood socioeconomic status (SES) impacts racial disparities in deceased donor renal transplantation access has not been examined in the pediatric and adolescent end-stage renal disease (ESRD) population. We examined the interplay of race and SES in a population-based cohort of all incident pediatric ESRD patients <21 years from the United States Renal Data System from 2000 to 2008, followed through September 2009. Of 8452 patients included, 30.8% were black, 27.6% white-Hispanic, 44.3% female and 28.0% lived in poor neighborhoods. A total of 63.4% of the study population was placed on the waiting list and 32.5% received a deceased donor transplant. Racial disparities persisted in transplant even after adjustment for SES, where minorities were less likely to receive a transplant compared to whites, and this disparity was more pronounced among patients 18-20 years. Disparities in access to the waiting list were mitigated in Hispanic patients with private health insurance. Our study suggests that racial disparities in transplant access worsen as pediatric patients transition into young adulthood, and that SES does not explain all of the racial differences in access to kidney transplantation.

The role of race and poverty on steps to kidney transplantation in the Southeastern United States.

Racial disparities in access to renal transplantation exist, but the effects of race and socioeconomic status (SES) on early steps of renal transplantation have not been well explored. Adult patients referred for renal transplant evaluation at a single transplant center in the Southeastern United States from 2005 to 2007, followed through May 2010, were examined. Demographic and clinical data were obtained from patient's medical records and then linked with United States Renal Data System and American Community Survey Census data. Cox models examined the effect of race on referral, evaluation, waitlisting and organ receipt. Of 2291 patients, 64.9% were black, the mean age was 49.4 years and 33.6% lived in poor neighborhoods. Racial disparities were observed in access to referral, transplant evaluation, waitlisting and organ receipt. SES explained almost one-third of the lower rate of transplant among black versus white patients, but even after adjustment for demographic, clinical and SES factors, blacks had a 59% lower rate of transplant than whites (hazard ratio = 0.41; 95% confidence interval: 0.28-0.58). Results suggest that improving access to healthcare may reduce some, but not all, of the racial disparities in access to kidney transplantation.

Forehead reconstruction using a modified dual-plane A to T flap.

Forehead defects often present myriad challenges for the reconstructive surgeon. Many options exist for forehead reconstruction, from primary closure to free flaps. To optimally match colour, contour and texture, the best approach replaces 'like with like'. When primary closure is not possible due to size limitations, and colour or depth is not suitable for grafts, then locoregional flaps become the mainstay of repair. The authors present three cases in which a dual-plane modified A to T flap is used to reconstruct central and lateral forehead defects up to 8 cm in size with excellent aesthetic results. This technique applies principles of the periglabellar flap, with modifications designed to encompass larger defects as well as defects of the lateral forehead.

Les anomalies du front comportent de multiples défis pour le plasticien. Il existe de nombreuses possibilités pour reconstruire le front, de la fermeture primaire aux lambeaux libres. Pour optimiser l'agencement de couleur, de contour et de texture, la meilleure démarche consiste à utiliser des structures similaires. Lorsqu'il est impossible de procéder à une fermeture primaire en raison des dimensions, et que la couleur ou la profondeur ne se prêtent pas à une greffe, les lambeaux locorégionaux deviennent le pilier de la reconstruction. Les auteurs présentent trois cas dans lesquels un lambeau en A modifié en lambeau en T en deux plans est utilisé pour reconstruire les anomalies centrales et latérales du front d'une dimension pouvant atteindre 8 cm et ainsi obtenir d'excellents résultats esthétiques. Cette technique met en application les principes du lambeau périglabellaire, et les modifications sont conçues pour englober des anomalies plus importantes et les anomalies de la partie latérale du front.