Geographic access to pediatric neurosurgeons in the USA: an analysis of sociodemographic factors.

PURPOSE: Geographic access to physicians has been shown to be unevenly distributed in the USA, with those in closer proximity having superior outcomes. The purpose of this study was to describe how geographic access to pediatric neurosurgeons varies across socioeconomic and demographic factors. METHODS: Actively practicing neurosurgeons were identified by matching several registries and membership logs. This data was used to find their primary practice locations and the distance the average person in a county must travel to visit a surgeon. Counties were categorized into "surgeon deserts" and "surgeon clusters," which were counties where providers were significantly further or closer to its residents, respectively, compared to the national average. These groups were also compared for differences in population characteristics using data obtained from the 2020 American Community Survey. RESULTS: A total of 439 pediatric neurosurgeons were identified. The average person in a surgeon desert and cluster was found to be 189.2 ± 78.1 miles and 39.7 ± 19.6 miles away from the nearest pediatric neurosurgeon, respectively. Multivariate analyses showed that higher Rural-Urban Continuum (RUC) codes (p < 0.001), and higher percentages of American Indian (p < 0.001) and Hispanic (p < 0.001) residents were independently associated with counties where the average person traveled significantly further to surgeons. CONCLUSION: Patients residing in counties with greater RUC codes and higher percentages of American Indian and Hispanic residents on average need to travel significantly greater distances to access pediatric neurosurgeons.

Neurogenic Thoracic Outlet Syndrome: A Primer for Hand and Peripheral Nerve Surgeons.

Neurogenic thoracic outlet syndrome is a complex condition and is commonly misunderstood. Historically, much of this confusion has been because of its grouping with other diagnoses that have little in common other than anatomic location. Modern understanding emphasizes the role of small unmyelinated C type pain and sympathetic fibers. Diagnosis is primarily clinical, after ruling out other common conditions. Hand therapy is usually the first-line treatment with variable success. Local anesthetic, botulinum toxins, or steroid injections can aid in diagnosis and offer short-term relief. Although surgery can yield reliable results, it is technically challenging, and the preferred surgical approach is a matter of debate. Despite limitations in diagnosis and treatment, recognition and successful treatment of this condition can be highly impactful for the patient.

Disparities in Access to Robotic Knee Arthroplasty: A Geospatial Analysis.

BACKGROUND: The utilization of robotic knee arthroplasty (RKA) continues to increase across the United States. The aim of this geospatial analysis was to elucidate if RKA is distributed uniformly across the United States or if disparities exist in patient access. METHODS: Publicly available provider-finding functions for 5 major manufacturers of RKA systems were used to obtain the practice locations of surgeons performing RKA along with their associated RKA system manufacturer. The average travel distance for each county to the nearest RKA surgeon was calculated and Moran's index clustering analysis was used to find hotspots and coldspots of RKA access. A logistic regression model was used to identify the predictive odds ratios between robotic hotspots and coldspots with county-level sociodemographic variables. Of the 34,216 currently practicing orthopedic surgeons in 2022, 2,571 have access to robotic assistance for knee arthroplasty. RESULTS: Hotspots of increased travel time were predominantly in West South Central and West North Central census regions. Hotspots were significantly more rural and consisted of predominantly White populations, with lower median income and health insurance coverage. CONCLUSIONS: The results of the current study align with existing literature, demonstrating absolute geographic access disparities for rural and economically disadvantaged populations. Additionally, relative access disparities persist for minority populations and individuals with high comorbidity burdens residing in urban areas.

Geographic Access to Pediatric Orthopedic Surgeons in the United States: An Analysis of Sociodemographic Factors.

BACKGROUND: It is unclear how pediatric orthopedic surgeons are geographically distributed relative to their patients. The purpose of this study was to evaluate the geographic distribution of pediatric orthopedic surgeons in the United States. MATERIALS AND METHODS: County-level data of actively practicing pediatric orthopedic surgeons were identified by matching several registries and membership logs. Data were used to calculate the distance between counties and nearest surgeon. Counties were categorized as "surgeon clusters" or "surgeon deserts" if the distance to the nearest surgeon was less than or greater than the national average and the average of all neighboring counties, respectively. Cohorts were then compared for differences in population characteristics using data obtained from the 2020 American Community Survey. RESULTS: A total of 1197 unique pediatric orthopedic surgeons were identified. The mean distance to the nearest pediatric orthopedic surgeon for a patient residing in a surgeon desert or a surgeon cluster was 141.9±53.8 miles and 30.9±16.0 miles, respectively. Surgeon deserts were found to have lower median household incomes (P<.001) and greater rates of children without health insurance (P<.001). Multivariate analyses showed that higher Rural-Urban Continuum codes (P<.001), Area Deprivation Index scores (P<.001), and percentage of patients without health insurance (P<.001) all independently required significantly greater travel distances to see a pediatric orthopedic surgeon. CONCLUSION: Pediatric orthopedic surgeons are not equally distributed in the United States, and many counties are not optimally served. Additional studies are needed to identify the relationship between travel distances and patient outcomes and how geographic inequalities can be minimized. [Orthopedics. 202x;4x(x):xx-xx.].

Total Intravenous Anesthesia with Propofol Reduces Discharge Times Compared with Inhaled General Anesthesia in Shoulder Arthroscopy: A Randomized Controlled Trial.

BACKGROUND: Shoulder arthroscopy is commonly performed at ambulatory surgical centers (ASCs) with use of an interscalene block and inhaled general anesthesia (IGA). However, an alternative option known as total intravenous anesthesia with propofol (TIVA-P) has shown promising results in reducing recovery time for other surgeries. The objective of this study was to assess whether there is a clinically meaningful difference in post-anesthesia care unit phase-I (PACU-I) time following shoulder arthroscopy between patients receiving an interscalene block with IGA and those receiving an interscalene block with TIVA-P. METHODS: Patients who underwent shoulder arthroscopy performed by a single surgeon at the ASC of our institution between 2020 and 2023 were enrolled. Enrollment was conducted in blocks, with up to 3 planned interim analyses. After 2 blocks, enrollment was halted because the study arms demonstrated a significant difference in the primary outcome measure, PACU-I time. A total of 96 patients were randomized into the TIVA-P and IGA groups; after patient withdrawals, the groups comprised 42 and 40 patients, respectively. Patients underwent shoulder arthroscopy with use of the anesthesia method corresponding to their assigned group. Pain, satisfaction, antiemetic use, perioperative interventions, surgical time, PACU-II time, postoperative care time, and total time until discharge were recorded and were analyzed with use of chi-square and Mann-Whitney U tests with a significance cutoff of 0.0167 to account for the interim analyses. RESULTS: Across groups, 81.7% of patients were non-Hispanic White and 58.5% were male. Significant differences were observed between the TIVA-P and IGA groups with respect to median PACU-I time (0.0 minutes [interquartile range (IQR), 0.0 to 6.0 minutes] versus 25.5 minutes [IQR, 20.5 to 32.5 minutes]; p < 0.001) and median total time until discharge (135.5 minutes [IQR, 118.5 to 156.8 minutes] versus 148.5 minutes [IQR, 133.8 to 168.8 minutes]; p = 0.0104). The TIVA-P group had a 9.1% quicker discharge time, primarily as a result of bypassing PACU-I (66.7% of patients) and spending 25.5 fewer minutes there overall. The TIVA-P group also had a lower rate of antiemetic use than the IGA group (59.5% versus 92.5% of patients; p = 0.0013). No significant differences were detected between the TIVA-P and IGA groups in terms of median pain improvement (1.0 [IQR, 0.0 to 2.0] versus 1.0 [IQR, 0.0 to 2.0]; p = 0.6734), perioperative interventions (78.6% versus 77.5% of patients, p = 1.0000), or median patient satisfaction (4.0 [IQR, 4.0 to 4.0] versus 4.0 [IQR, 3.8 to 4.0]; p = 0.4148). CONCLUSIONS: TIVA-P showed potential to improve both PACU-I time and the total time until discharge while reducing antiemetic use without impacting pain or satisfaction. TIVA-P thus warrants consideration by orthopaedic surgeons for use in shoulder arthroscopy performed at ASCs. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Provision of a Home-Based Video-Assisted Therapy Program Is Noninferior to In-Person Hand Therapy After Thumb Carpometacarpal Arthroplasty.

BACKGROUND: In-person hand therapy is commonly prescribed for rehabilitation after thumb carpometacarpal (CMC) arthroplasty but may be burdensome to patients because of the need to travel to appointments. Asynchronous, video-assisted home therapy is a method of care in which videos containing instructions and exercises are provided to the patient, without the need for in-person or telemedicine visits. The purpose of the present study was to evaluate the effectiveness of providing video-only therapy (VOT) as compared with scheduled in-person therapy (IPT) after thumb CMC arthroplasty. METHODS: We performed a single-site, prospective, randomized controlled trial of patients undergoing primary thumb CMC arthroplasty without an implant. The study included 50 women and 8 men, with a mean age of 61 years (range, 41 to 83 years). Of these, 96.6% were White, 3.4% were Black, and 13.8% were of Hispanic ethnicity. The primary outcome measure was the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) score. Subjects in the VOT group were provided with 3 videos of home exercises to perform. Subjects in the control group received standardized IPT with a hand therapist. Improvements in the PROMIS UE score from preoperatively to 12 weeks and 1 year postoperatively were compared. RESULTS: Fifty-eight subjects (29 control, 29 experimental) were included in the analysis at the 12-week time point, and 54 (27 control, 27 experimental) were included in the analysis at the 1-year time point. VOT was noninferior to IPT for the PROMIS UE score at 12 weeks and 1 year postoperatively, with a difference of mean improvement (VOT - IPT) of 1.5 (95% confidence interval [CI], -3.6 to 6.6) and 2.2 (95% CI, -3.0 to 7.3), respectively, both of which were below the minimal clinically important difference (4.1). Patients in the VOT group potentially saved on average 201.3 miles in travel. CONCLUSIONS: VOT was noninferior to IPT for upper extremity function after thumb CMC arthroplasty. Time saved in commutes was considerable for those who did not attend IPT. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Gastroesophageal Reflux Disease in a One-Week-Old Infant Presenting With Cyanosis and Respiratory Distress.

Gastroesophageal reflux (GER) is a common occurrence in infancy and early childhood. While GER is considered physiologic, gastroesophageal reflux disease (GERD) can result when extensive GER leads to troublesome symptoms such as choking, gagging, vomiting, refusal to feed, and poor weight gain. In extreme cases, GERD can cause severe respiratory complications such as apnea and aspiration pneumonia. We present the case of a one-week-old Amish female who had no prenatal care and presented with severe hypoxemia, tachypnea, and costal retractions. Further history from the family revealed persistent irregular breathing, sweating during feeds, and episodic perioral cyanosis. The patient required stabilization in the intensive care unit and received an extensive workup to rule out sepsis, cyanotic heart disease, other infectious etiologies, and other common causes of respiratory distress. The patient underwent a modified barium swallow study and was diagnosed with aspiration pneumonitis resulting from GERD and oropharyngeal dysphagia. Infantile cyanosis and respiratory distress can be manifestations of a variety of underlying illnesses. Once common causes of cyanosis have been excluded, GERD or disordered feeding should be considered as a potential etiology.

Pulmonary Artery Root Replacement for Leiomyosarcoma: A Viable Thoracic Oncovascular Operation.

Leiomyosarcoma of the pulmonary artery is a rare but potentially fatal disease. Due to its rarity, the treatment algorithm is not well-established. While there may be a role for both chemotherapy and radiotherapy, surgical management is the most definitive method. Unfortunately, when the disease process is advanced, surgery may not be curative. However, it may still be a palliative treatment option. In this case report, we present a patient who suffered from respiratory symptoms that were initially attributed to pulmonary embolism (PE). However, upon the diagnosis of pulmonary artery leiomyosarcoma (PAL), surgery intervention was undertaken and resulted in an improved quality of life for the patient.

Transcatheter Occlusion of a Patent Ductus Arteriosus for a Symptomatic Left-to-Right Shunt.

Congenital diaphragmatic hernias (CDH) can induce life-threatening pulmonary hypertension and right heart failure. The patent ductus arteriosus (PDA) is often maintained in CDH to allow for decompression into the systemic circulation. However, if the PDA becomes hemodynamically significant, PDA closure may be indicated. Traditional methods rely on pharmacological closure. In this report, we document a rare transcatheter closure of a hemodynamically significant PDA.

Mediastinal Liposarcoma With Anterior and Posterior Mediastinal Involvement: A Thoracic Oncovascular Case Report.

A 64-year-old patient presented with shortness of breath and chest pressure. The initial examination was unremarkable, and a chest X-ray revealed a large mediastinal mass. Computed tomography (CT) scan demonstrated a lobulated mediastinal mass involving the great vessels and mass effect on the trachea, esophagus, and heart. A CT-guided biopsy showed a monotonous, evenly spaced population of mature, normal-appearing adipocytes consistent with a well-differentiated lipoma-like liposarcoma/atypical lipomatous tumor. The patient underwent a median sternotomy with en bloc tumor resection without adjuvant chemoradiation. Three-year follow-up CT imaging shows no evidence of tumor recurrence.

Demographic and Geospatial Analysis of Buprenorphine and Methadone Prescription Rates.

Background The medical community continues to seek to understand both the causes and consequences of opioid use disorder (OUD). The recent 2019 public release of the Automation of Reports and Consolidated Orders System (ARCOS) database from the years 2006 to 2012 provides a unique opportunity to analyze a critical period of the opioid epidemic with unprecedented data granularity. Objectives This study aims to use the ARCOS dataset to (1) determine significant contributory variables to opioid overdose death rates, (2) determine significant contributory variables to the relative prescription of buprenorphine and methadone, and (3) evaluate the existence of statistically significant geospatial clusters in buprenorphine and methadone prescription rates. Methods This study utilizes multiple databases, including the Centers for Disease Control and Prevention (CDC) Wide-ranging Online Data for Epidemiologic Research (WONDER), the Drug Enforcement Administration (DEA) prescription drug data, and the United States (US) Census demographics, to examine the relationship between the different treatments of OUD. Linear regressions are used to determine significant contributory factors in overdose rate and the buprenorphine-to-methadone ratio. Geospatial analysis is used to identify geographic clusters in opioid overdoses and treatment patterns. Results Methadone prescriptions, racial demographics, and poverty were found to significantly correspond to opioid overdose death rates (p < 0.05). Buprenorphine prescriptions were not found to be significant (p = 0.20). Opioid overdoses, metro character, racial categorization, and education were found to significantly correspond to the ratio of buprenorphine to methadone prescribed (p < 0.05). Cluster analysis demonstrated different geospatial distributions in the prescriptions of buprenorphine and methadone (p < 0.05). Conclusion Historically, methadone prescriptions have been higher in areas with high overdose rates. Buprenorphine and methadone prescribing patterns have historically demonstrated different geographic trends.

Analysis of Rural Disparities in Ultrasound Access.

Purpose This work aims to conduct a geospatial analysis of recent ultrasound access and usage within the United States, with a particular focus on disparities between rural and urban areas. Methods/Materials Multiple public datasets were merged on a county level, including US Department of Agriculture economic metrics and Centers for Medicare Services data using the most recent years available (2015-2019). From these databases, 39 total variables encompassing the socioeconomic, health, and ultrasound characteristics of each county were obtained. Current Procedural Terminology (CPT) codes incorporated included ultrasound-guided procedures and diagnostic exams. Three thousand eleven counties were included. The combined dataset was then exported to GeoDa for network-based analysis and to produce map visualizations. To identify statistically significant (p < 0.05) hotspots and coldspots in point-of-care ultrasound (POCUS) prevalence, Moran's I was used. Choropleth maps were created for visualization. ANOVA was run across the four Moran's I groups for each of 39 variables of interest. Results A total of 30,135,085 ultrasound-related CPT codes were billed to Medicare over 2015-2019, with 26.55% of codes being ultrasound-guided procedures and 73.45% being diagnostic exams. 38.84% of rural counties had access to POC ultrasound compared to 88.56% of metropolitan counties and 74.19% of counties overall. Hotspots of POCUS were in Southern California and the Eastern US (average of 1,441 per 10,000 Medicare members per year). Coldspot areas were seen in the Great Plains and Midwest (average of 7.43 per 10k Medicare members per year). Hotspot clusters, when compared to coldspot clusters, were significantly (p < 0.001) more dense (703.6 to 14.9 people per square mile), more urbanized (3.5 to 7.1 Rural-Urban Continuum (RUC)), more college-educated (25.1% to 20.0%), more likely to have an Emergency Department (ED) visit (725.8 to 616.9 visits per 1,000 Medicare members), more likely to be obese (19.0% to 12.9%), less likely to be uninsured (10.1% to 13.0%), had more Black representation (8.5% to 3.4%), and less Hispanic representation (2.6% to 5.5%). Conclusions Ultrasound access and usage demonstrate significant geospatial trends across the United States. Hotspot and coldspot counties differ on several key sociodemographic and economic variables.

Adult-Onset IgA Vasculitis Presenting as an Unusual Rash and Pancolitis.

A 47-year-old female presented with complaints of abdominal pain and a history of new-onset maculopapular rash. A workup including laboratory and imaging studies, colonoscopy, and biopsy was performed that led to the diagnosis of adult-onset IgA vasculitis. The patient responded well to intravenous methylprednisolone and was followed up as an outpatient where she continued with oral methylprednisolone and azathioprine. This case is noteworthy for the unusual adult-onset presentation with primarily gastrointestinal symptoms and atypical rash pattern. Furthermore, while very effective in this patient, the use of corticosteroids is a treatment decision that has some controversy in the current literature.

Gender Representation in Orthopaedic Surgery: A Geospatial Analysis From 2015 to 2022.

Introduction The gender disparity in orthopaedic surgery is well-established. According to our analysis, only 7.4% of practicing orthopaedic surgeons in the US are female in 2022. While there are several theories attempting to explain this gender gap, our eight years of data show that limited female representation is a self-perpetuating cycle as areas without female representation almost never improve in that regard. It appears that existing female mentorship is critical to the growth of a female orthopaedic presence in an area. In the present work, we aim to describe how gender diversity in orthopaedic surgery differs across the country, how this diversity is changing over time, and how surgeon gender diversity may be affected by the sociodemographic characteristics making up the counties where orthopaedic surgery is practiced. Methods A retrospective study was conducted using publicly available National Provider Identifier (NPI) data from 2015 to 2022. Orthopaedic surgeons and their genders were identified using the Provider Type and Gender data elements associated with an individual NPI. Rural-urban and metro characters were defined using the USDA Economic Research Reserve's rural-urban continuum codes. Python was used for database building and data cleaning. GeoDa, a statistical map-based graphing software, was used to plot and assess demographic, geographic, and socioeconomic trends. Trends in gender diversity from 2015 to 2019 were analyzed for each individual year as well as the time period as an aggregate. Cluster analysis was performed to assess complex spatial patterns of variables that could not be condensed linearly or logarithmically. Moran's I was used to measure the similarity of a Federal Information Processing System (FIPS) area code to its neighbors. Within the clustering analysis, spatial clusters were broken down into four groups of spatial outliers (High-High, High-Low, Low-High, and Low-Low) referencing a given area's relationship with its neighbors. Factorial ANOVA between each of the four cluster types was performed using the variables provided in the article to identify significant demographic variables within the cluster analysis. Results There are relative hotspots of gender diversity in the Northwest, Northeast, and Southwest with relative coldspots in the Midwest and Southern US. In counties that are considered gender diversity hotspots, the total population of orthopaedic surgeons increases by 0.94 each year while the population of female orthopaedic surgeons increases by 0.2, suggesting that in areas with high gender diversity, 4.7 male orthopaedic surgeons are joining practices for every 1.0 female. In areas with low gender diversity, the population of orthopaedic surgeons increases by 0.11 surgeons each year while the slope for an increase in female orthopaedic surgeons is 0. Conclusions  Orthopaedic surgery lags behind other male-dominated surgical specialties in gender parity. Our analysis demonstrates that certain areas of the country including the Northwest, Northeast, and Arizona have improved gender diversity compared to the rest of the country. We also see that the rate of increase of female orthopaedic surgeons in the past seven years is highest in areas with more preexisting female orthopaedic surgeons, suggesting the importance of a "trailblazer" phenomenon in recruiting female surgeons.

Evaluation of Regional Geospatial Clusters in Inguinal Hernia Repair.

Introduction There is significant variation in how inguinal hernia repairs are conducted across the United States (US). This study seeks to utilize national public data on inguinal hernia repair to determine regional differences in the use of ambulatory surgical centers (ASC) and in the choice of laparoscopic or open technique. Methods Medicare provider billing and enrollee demographic data were merged with US census and economic data to create a county-level database for the years 2014-2019. Location, technique, and total count of all inguinal hernia repair billing were recorded for 1286 counties. Moran's I cluster analysis for inguinal hernia repairs, percent laparoscopic technique, and percent ACS were conducted. Subsequent hotspot and coldspot clusters identified in geospatial analysis were compared using ANOVA across 50 socioeconomic variables with a significance threshold of 0.001.  Results  There were 292,870 inguinal hernia repairs, of which 39.8% were conducted laparoscopically and 21.3% of which were in an ACS. Inguinal hernia repair coldspots were in the Mid-Atlantic and Northern Midwest, while hotspots were in Nebraska, Kansas, and Maryland (3.85 and 36.53 repairs per 1000 beneficiaries, respectively). Compared to coldspots, hotspot areas of repair were less obese, had less tobacco use, older, and less insured; there were no differences in gender, white population, or county urbanization (p<0.001). Laparoscopic technique coldspots were in the Mid-Atlantic, Michigan, and Great Plains, while hotspots were in the Rocky Mountains and contiguous states from Florida to Wisconsin (6.14% and 75.39%, respectively). ACS coldspots were diffusely scattered between Oklahoma and New Hampshire, while hotspots were in California, Colorado, Maryland, Tennessee, and Indiana (0.51% and 48.71%, respectively). Conclusions Inguinal hernia repair, the surgical setting, and the choice of technique demonstrated interesting geospatial trends in our population of interest that have not been previously characterized.

Evaluation of Access Disparities to Biologic Disease-Modifying Antirheumatic Drugs in Rural and Urban Communities.

The American College of Rheumatology guidelines provides a strong recommendation for the use of biologic disease-modifying antirheumatic drugs (bDMARDs) when conventional rheumatoid arthritis treatments fail to meet treatment targets. Although bDMARDs are an effective and important treatment component, access inequalities remain a challenge in many communities worldwide. The purpose of this analysis is to assess nationwide trends in bDMARD access in the United States, with a specific focus on rural and urban access gaps. This study combined multiple county-level databases to assess bDMARD prescriptions from 2015 to 2019. Using geospatial analysis and the Moran's I statistic, counties were classified according to prescription levels to assess for hotspots and coldspots. Analysis of variance (ANOVA) was used to compare significant counties across 49 socioeconomic variables of interest. The analysis identified statistically significant hotspot and coldspot prescription clusters within the United States. Coldspot (Low-Low) clusters with low access to bDMARDs are located predominantly in the rural west North Central region, extending down to Oklahoma and Arkansas. Hotspot (High-High) clusters are seen in urban and metro areas of Wisconsin, Minnesota, Pennsylvania, North Carolina, Georgia, Oregon, and the southern tip of Texas. Comparing coldspot to hotspot areas of bDMARD access revealed that the Medicare populations were older, more rural, less educated, less impoverished, and less likely to get their bDMARDs from a rheumatologist.