Unified Airway Disease: Examining Prevalence and Treatment of Upper Airway Eosinophilic Disease with Comorbid Asthma.

The "unified airway" describes the concept that inflammation affects upper and lower airways by similar mechanisms; this often manifests as rhinitis, rhinosinusitis, and/or nasal polyposis in the upper airway with associated asthma or bronchial inflammation in the lower airways. The relationships between eosinophilic diseases of the upper and lower airways are highlighted by examining their prevalence and treatment regimens along with the synergistic effects of treatment on upper and lower airway symptoms. It is important to recognize the interrelatedness of upper and lower airway eosinophilic disease to assess and manage patients accurately and holistically.

Biologic Augmentation of Tibiotalocalcaneal Arthrodesis With Allogeneic Bone Block Is Associated With High Rates of Fusion.

BACKGROUND: The orthopaedic conditions and systemic comorbidities that occur in patients who require bone block tibiotalocalcaneal (TTC) arthrodesis have made this procedure associated with a higher-than-normal risk of nonunion, graft collapse, hardware failure, and amputation. Here, we present a novel approach to bone block TTC arthrodesis using adjunctive osteoinductive agents and a prolonged course of protected weightbearing to assess if we could improve on historical outcomes. We also evaluated the efficacy of a vascularized medial femoral condyle (MFC) free flap to augment TTC arthrodesis. METHODS: Fourteen adult patients underwent bone block TTC arthrodesis biologically augmented with fresh-frozen femoral head allograft, bone marrow aspirate concentrate, and demineralized bone matrix cortical fibers. Three patients with soft tissue defects underwent vascularized reconstruction with an MFC free flap. Radiographic union, the Foot Function Index (FFI), and PROMIS pain interference (PI), and physical function (PF) scores were assessed at follow-up. RESULTS: TTC fusion was documented on plain radiograph in 13 of 14 patients (92.9%) and CT in 10 of 11 patients (90.9%). Mean time to fusion was 183.2 ± 83.2 days. One patient (7.1%) experienced nonunion and persistent infection requiring amputation. Patients who underwent vascularized bone grafting had significantly shorter time to fusion (112.3 ± 31.7 days vs 204.4 ± 82.7 days, P = .05). Patient-reported outcomes revealed mild to moderate pain and dysfunction after 1 year (mean FFI = 41.0% ± 23.1%, PROMIS PI = 58.3 ± 1.8, PROMIS PF = 39.0 ± 2.2). CONCLUSION: In this relatively small series, the biologic augmentation of bone block TTC arthrodesis with osteoinductive agents and protective weightbearing resulted in excellent rates of fusion, modest pain, and preserved function of the lower extremity in almost all those treated. Osseous healing appears to be enhanced and accelerated with application of an MFC flap. We believe that this approach offers a viable salvage option for these challenging clinical problems. LEVEL OF EVIDENCE: Level IV, case series.

Radiographic disease severity in chronic rhinosinusitis patients and health care utilization.

OBJECTIVES: Chronic rhinosinusitis (CRS) affects approximately 12% of the population and leads to increased health care utilization and indirect costs exceeding $20 billion annually in the United States. The Lund-Mackay score (LMS) measures radiographic disease severity for CRS but poorly correlates with symptom scores. The association between LMS and health care utilization in CRS patients has not yet been investigated. The study aimed to assess the association between health care utilization and CRS radiographic severity using LMS. METHODS: CRS patients enrolled in a clinical registry were evaluated. Nasal endoscopy findings and LMS were recorded for patients with sinus CT imaging. Patient symptom scores, demographic characteristics, and health care utilization measures were collected. The relationship between these factors and LMS was examined. RESULTS: A total of 556 patients met inclusion criteria. Mean age was 45.3 years, 53.4% were male, and 41.7% had nasal polyps. There was no difference in sex, smoking history, 22-item Sino-nasal Outcome Test scores, or past medical history factors between patients with high (≥8, n = 410) and low (<8, n = 146) LMS. Among high LMS patients, 73.7% underwent endoscopic sinus surgery (ESS) compared to 55.5% with low LMS (P < .01), and a greater percentage of patients had nasal polyps (49.3% vs 20.5%, P < .01). On multivariable logistic regression, high LMS patients used fewer antibiotic courses (OR: 0.68 [0.51-0.91]), but were more likely to be managed with ESS (OR: 2.28 [1.41-3.73]), and have nasal polyps (OR: 2.11 [1.16-3.93]) compared to low LMS patients. There was no significant difference in the number of steroid courses, over the counter pill use, provider visits, work/school days missed, or symptom duration between the two LMS groups. CONCLUSION: CRS patients with severe radiographic disease are more likely to have nasal polyps, undergo ESS, and take fewer antibiotic courses. However, there is no association between radiographic disease severity and other measures of health care utilization. LEVEL OF EVIDENCE: 2b, individual retrospective cohort study.

Evaluating dysphagia and xerostomia outcomes following transoral robotic surgery for patients with oropharyngeal cancer.

BACKGROUND: We assessed long-term patient-reported dysphagia and xerostomia outcomes following definitive surgical management with transoral robotic surgery (TORS) in patients with oropharyngeal cancer (OPC) via a cross-sectional survey study. METHODS: Patients with OPC managed with primary oropharyngeal surgery as definitive treatment at least 1 year ago between 2015 and 2019 were identified. The M. D. Anderson Dysphagia Inventory (MDADI) and Xerostomia Inventory (XI) scores were compared across treatment types (i.e., no adjuvant therapy [TORS-A] vs. adjuvant radiotherapy [TORS+RT] vs. adjuvant chemoradiotherapy [TORS+CT/RT]). RESULTS: The sample had 62 patients (10 TORS-A, 30 TORS+RT, 22 TORS+CT/RT). TORS-A had clinically and statistically significantly better MDADI scores than TORS+RT (p = 0.03) and TORS+CT/RT (p = 0.02), but TORS+RT and TORS+CT/RT were not significantly different. TORS-A had clinically and statistically significantly less XI than TORS+RT (p < 0.01) and TORS+CT/RT (p < 0.01). CONCLUSIONS: Patients with OPC who have undergone TORS+RT or TORS+CT/RT following surgery face clinically worse dysphagia and xerostomia outcomes relative to patients who undergo TORS-A.

A qualitative assessment of return to sport following Achilles tendon repair.

Studies have demonstrated successful return to sport rates following Achilles tendon rupture and repair. The purpose of this study is to understand the subjective intrinsic and extrinsic motivational factors influencing an athlete's return to pre-injury level of sport following Achilles tendon repair. Qualitative, semi-structured interviews of 23 athletes who had undergone Achilles tendon repair were conducted and analyzed to derive codes, categories, and themes. Three major themes affecting return to sport were elucidated from the interviews: personal motivation, shift in focus, and confidence in healthcare team. These findings can direct healthcare teams on how to better guide patients post-operatively.

Evaluating Prospective Patient-Reported Pain and Function Outcomes After Ankle and Hindfoot Arthrodesis.

BACKGROUND: Hindfoot and ankle fusions are mechanically limiting procedures for patients. However, patient-reported outcomes of these procedures have not been well studied. This study assessed outcomes of hindfoot and ankle fusions by using Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) Computer Adaptive Tests (CATs). METHODS: Between 2014 and 2018, 102 patients were prospectively enrolled after presenting to a tertiary care facility for ankle and hindfoot fusions, including tibiotalar, tibiotalocalcaneal, subtalar, and triple arthrodeses. Study participants completed preoperative and 12-month postoperative PF and PI CATs. The differences between mean 12-month postoperative and preoperative PROMIS PF and PI T scores were analyzed with paired t tests. The relationship between the 12-month PF and PI differences for the overall sample and patient factors was examined using multiple regression modeling. RESULTS: The sample had mean age of 57.69 years; 48% were male, and 55% were obese. Patients who underwent ankle and hindfoot arthrodesis had statistically significant improvements from preoperative to 12 months postoperative in mean PF (36.26±7.85 vs 39.38±6.46, P = .03) and PI (61.07±7.75 vs 56.62±9.81, P = .02). Triple arthrodesis saw the greatest increases in physical function (▵PF = 7.22±7.31, P = .01) and reductions in pain (▵PI = -9.17±8.31, P = .01), achieving minimal clinically important difference (MCID). Patients who underwent tibiotalar fusion had significant improvement in physical function (▵PF = 4.18±5.68, P = .04) and pain reduction that approached statistical significance (▵PI = -6.24±8.50, P = .09), achieving MCID. Older age (≥60 years ) was associated with greater improvements in PF (ß = 0.20, P = .07) and PI (ß = -0.29, P = .04). Preoperative PF and PI T scores were significantly associated with the 12-month change in PF and PI T scores, respectively (ß = -0.74, P < .01; ß = -0.61, P < .01). CONCLUSION: Hindfoot and ankle fusions are procedures with favorable patient outcomes leading to increased physical function and decreased pain at 12 months postoperation relative to preoperation. LEVEL OF EVIDENCE: Level II, prospective comparative study.

The case of a 30-year-old man with subacute gait instability, weakness, and muscle spasms.

A 30-year-old healthy man presents after a fall with diffuse weakness and pain and recent onset left eye ptosis in the setting of three weeks of progressive bilateral leg weakness, gait instability, and difficulty washing his hair due to upper extremity weakness. He had also developed stiffness in his neck and shoulders and uncontrollable muscle spasms. Exam was notable for ptosis, fatiguing weakness in extremities, increased tone, hyperreflexia with clonus, and spastic gait. A mediastinal mass was found on chest CT (Fig. 1), and biopsy confirmed an invasive thymoma with positive nodes. Serum testing was positive for antibodies to acetylcholine receptors as well as glutamic acid decarboxylase.

Improving Use of a Hospital Transitional Care Clinic.

BACKGROUND: In response to Medicare readmission penalties, some hospitals have introduced transitional care clinics (TCCs) to meet the care needs of patients recently discharged from the emergency room or inpatient setting. This study was undertaken to increase the proportion of low-income, medically complex patients using a TCC at a large academic medical center, Northwestern Medical Group Transitional Care Clinic (NMG-TC). METHODS: This quality improvement study combined interviews and quantitative data analysis to determine how to increase use of NMG-TC. Physicians and patients were interviewed and surveyed to identify opportunities to expand clinic use. Logistic regression analysis of electronic health record (EHR) data was used to identify sociodemographic and clinical conditions influencing the TCC appointment show rate. RESULTS: Provider surveys and interviews suggested that referrals would likely increase via automation of referral guidelines and enhanced transitional care education. Patient interviews indicated that better communication of NMG-TC purpose, emphasizing nonmedical offerings, and warm handoffs could increase engagement. EHR analyses revealed that patients least likely to attend appointments were male, uninsured, non-Hispanic black, or homeless; had documented substance use; or lived > 50 miles from the clinic. Conversely, patients with heart failure, anxiety, or malignancy were more likely to attend appointments. CONCLUSION: TCC show rates could be improved with better communication of NMG-TC benefits to both patients and referring providers, as well as warm appointment handoffs, particularly for patients least likely to attend scheduled visits.

A qualitative assessment of return to sport following ulnar collateral ligament reconstruction in baseball players.

BACKGROUND: The rate of ulnar collateral ligament (UCL) reconstruction has been increasing at all levels of play. With excellent outcomes, primary UCL reconstruction has allowed many overhead athletes to return to their pre-injury sport. However, the subjective factors influencing this decision to return to sport have yet to be studied. The aim of this study is to understand the factors influencing an athlete's decision to return to pre-injury level of sport after primary UCL reconstruction. METHODS: An experienced interviewer conducted qualitative, semi-structured interviews of patients aged 18-35 years who had undergone primary UCL reconstruction by one fellowship-trained, Major League Baseball (MLB) team orthopaedic surgeon. All subjects were throwing athletes prior to injury and had a minimum two-year follow-up without revisions. Qualitative analysis was then performed to derive codes, categories, and themes. Patients were surveyed to assess familiarity with UCL reconstruction as well as to obtain Kerlan-Jobe Orthopaedic Clinic (KJOC) Overhead Athlete Shoulder and Elbow score, American Shoulder and Elbow Surgeons Shoulder (ASES) score, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) highlighting current activity and function levels along with sport participation. RESULTS: Twenty-two athletes were interviewed to elucidate four predominant themes influencing their return to sport: trust in surgeon and care team, innate drive and optimism, misconceptions regarding post-operative athletic ability, and life priorities. A significant difference was noted between patients that returned and those that did not in the KJOC survey and for the statement that UCL reconstruction surgery would improve throwing ability relative to patients' peak performance three years prior to the surgery. Athletes who did not return to sport cited lifestyle changes and age as limiting factors. CONCLUSION: Patients' decision to return to their pre-injury level of sport after primary UCL reconstruction was based on trust in their care team's reputation, intrinsic personality traits, anecdotal evidence about post-operative outcomes, and lifestyle. This study emphasizes the importance for health care providers to educate patients toward realistic expectations upon return to sport. On a larger scale, this study illustrates the effects the media and anecdotal experiences of a growing population of players undergoing UCL reconstruction have had on the game of baseball and players' decisions to return to sport. LEVEL OF EVIDENCE: Level IV.