Citations

Abstract Introduction Ki-67 is often used as a proliferation index to evaluate how aggressive a tumor is and its likelihood of recurrence. Vestibular schwannomas (VS) are a unique benign pathology that lends itself well to evaluation with Ki-67 as a potential marker for disease recurrence or progression following surgical resection. Methods All English language studies of VSs and Ki-67 indices were screened. Studies were considered eligible for inclusion if they reported series of VSs undergoing primary resection without prior irradiation, with outcomes including both recurrence/progression and Ki-67 for individual patients. For published studies reporting pooled Ki-67 index data without detailed by-patient values, we contacted the authors to request data sharing for the current meta-analysis. Studies reporting a relationship between Ki-67 index and clinical outcomes in VS for which detailed patients' outcomes or Ki-67 indices could not be obtained were incorporated into the descriptive analysis, but excluded from the formal (i.e., quantitative) meta-analysis. Results A systematic review identified 104 candidate citations of which 12 met inclusion criteria. Six of these studies had accessible patient-specific data. Individual patient data were collected from these studies for calculation of discrete study effect sizes, pooling via random-effects modeling with restricted maximum likelihood, and meta-analysis. The standardized mean difference in Ki-67 indices between those with and without recurrence was calculated as 0.79% (95% confidence interval [CI]: 0.28–1.30; p = 0.0026). Conclusion Ki-67 index may be higher in VSs that demonstrate recurrence/progression following surgical resection. This may represent a promising means of evaluating tumor recurrence and potential need for early adjuvant therapy for VSs.

343 Background: Esophageal adenocarcinoma (EAC) continues to have extremely poor prognosis despite advances in surgical and oncological regimens. Targeted and immune therapy hold promise to improve outcomes in solid tumors including EAC. At present HER-2 and anti-PD-L1 therapies are approved by the FDA for EAC. Additionally, off-label use of EGFR directed therapy has been reported. The aim of this study is to measure expression of 80+ oncoproteins in EAC using multiplexed mass spectrometry to elucidate expression of currently approved-drug targets and explore promising new targets for drug development. Methods: After Institutional Review Board approval (Mayo Clinic and KUMC), EAC patients whose tumors were resected via esophagectomy before chemotherapy and/or radiation were identified. Normal esophageal mucosa samples with no history of EAC were also retrieved for analysis. Tissue sections were microdissected to exclude stroma from adenocarcinoma cells. Isolated EAC cells were solubilized for mass spectrometry-based quantitation of more than 80 clinically relevant tumor markers. Results: 55 EAC tissues were analyzed. HER2, PD-L1 and EGFR were overexpressed only in 16.3%, 0%, and 0% of patients, respectively. New oncoproteins #2 and #6 were noted to have high (7,634.0 and 27,222.6 attomoles/ug) and consistent (98.1% and 94.5%) overexpression in EAC samples. Expression of HER2, oncoproteins #2 and #6 were significantly higher in EAC compared to normal esophageal mucosa. There was no statistical difference in the expression of PD-L1 and EGFR between EAC and normal samples. Conclusions: Mass spectrometry revealed a very low prevalence of target oncoproteins in EAC for currently used drugs. Our study potentially reveals alternate markers which are near universally present at high levels and should be further explored for targeted treatment.[Table: see text]

Background: Chronic tendon retraction subsequent to distal biceps tendon rupture significantly increases repair difficulty and potential for tendon grafting. Biceps tendons that appear short or absent with magnetic resonance imaging (MRI) or that cannot be readily identified at surgery may erroneously be classified as irreparable. These apparent “absent” biceps tendons may actually be retracted and curled up inside the muscle, visually resembling the head-neck of a turtle retracted inside its shell (the “turtle neck sign”). When located, these tendons could be unfolded and repaired primarily. This type of tendon retraction seems to be associated with high-degree ruptures and larcertus fibrosus tears. Purpose: To test the hypothesis that tendon retractions with a turtle neck sign on MRI are more associated with high-degree ruptures and larcertus fibrosus tears versus tendon tears with simple linear retraction. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Retracted distal biceps tendon ruptures on sagittal MRI were categorized as linear retraction or curled-up (turtle neck) retraction. Retraction length, injury severity, and lacertus fibrosus tears were analyzed. Results: The authors retrospectively analyzed the patient records of 85 consecutive traumatic distal biceps tendon ruptures from 2003 to 2019; the final study cohort was 37 patients. Injury-to-surgery timing was as follows: <3 weeks, 43% (16 cases); 3 weeks to 3 months, 32% (12 cases); and >3 months, 24% (9 cases). Overall, 19 patients had linear retraction <7 cm (mean, 3.3 ± 1.9 cm) and 18 patients had a turtle neck retraction ≥7 cm (mean, 9.1 ± 1.6 cm). The injury-to-surgery time (median [± interquartile range]) was 27 days (±90 days) in the linear retraction group and 23 days (±65 days) in the turtle neck retraction group. The turtle neck retraction group had a significantly higher occurrence of abnormal hook test findings, complete distal biceps tendon rupture, and lacertus fibrosus tears compared with the linear retraction group (100% vs 58%, 100% vs 68%, and 100% vs 37%, respectively; P ≤ .02). However, significant repairability differences were not found. Conclusion: Highly retracted distal biceps turtle neck sign tendon ruptures occur frequently in association with high-degree ruptures and lacertus fibrosus tears. The presence of a turtle neck retraction did not affect reparability. Surgeons should be aware of this curled-up retraction to avoid mistaking it for an absent tendon or a muscle-tendon disruption.

AbstractBackgroundThere is a need to better understand the overall state of sub‐specialization in physical medicine and rehabilitation (PM&R).ObjectiveTo examine the status and trends in subspecialty certification for each of the seven subspecialties approved for American Board of Physical Medicine and Rehabilitation (ABPMR) diplomates.Design/SettingRetrospective analysis of deidentified information from the ABPMR database.ParticipantsPhysicians certified by ABPMR through 2019.InterventionsNot applicable.Main Outcome MeasuresFor each subspecialty, we examined: (1) the number of certificates issued to ABPMR diplomates; (2) the recertification rate; (3) the yearly trends for total active, new, and expired certificates; and (4) for ABPMR‐administered subspecialties, recertification rates for those entering the subspecialty through fellowship completion versus a “grandfathered” practice pathway.ResultsOf 11,421 ABPMR diplomates in the United States in 2019, a total of 3560 (31.2%) had 3985 active subspecialty certificates. Pain Medicine (PM) was the most common subspecialty certification (15.5% of all ABPMR diplomates) followed by Sports Medicine (SM, 6.6%), Brain Injury Medicine (BIM, 4.8%), Spinal Cord Injury Medicine (SCIM, 4.2%), Pediatric Rehabilitation Medicine (PRM, 2.5%), Neuromuscular Medicine (NMM, 0.7%), and Hospice and Palliative Medicine (HPM, 0.5%). For diplomates with more than one subspecialty certification, PM and SM was the most frequent combination. Both the recertification rate and the end of practice track eligibility influenced certification trends differently for individual subspecialties. The average number of new certificates added annually for every subspecialty was higher before than after the temporary practice track‐based eligibility ended; the difference was statistically significant (p < .05) for SCIM, PM, SM, and NMM. The recertification rate for all subspecialties combined was 73.4%. For the subspecialties (SCIM, PRM) for which these data were available, fellowship candidates had higher recertification rates than those grandfathered through a practice track.ConclusionThis report informs stakeholders about the state and evolution of subspecialty certification in PM&R over time.

AbstractObjectiveDescribe the presentation and management strategy for patients with symptomatic foramen of Huschke (FH).PatientsAdults with persistent FH confirmed on imaging.InterventionsDiagnosis and management of symptomatic persistent FH.Main outcome measureResolution of otologic symptoms.ResultsA total of four patients with symptomatic, radiographically‐confirmed persistent FH were included. The majority of patients endorsed otalgia (n = 4) and otorrhea (n = 3), and only one patient was noted to have a conductive hearing loss. All patients were noted to have dynamic movement of an external auditory canal mass with mandible manipulation on examination, and all patients had an identifiable fistula on imaging. Patients underwent surgical intervention, including both preauricular (n = 2) and transcanal (n = 2) approaches, and all endorsed symptomatic resolution after convalescence.ConclusionsPersistent FH remains an uncommon and potentially underrecognized cause of otologic symptoms. Diagnosis requires a high index of suspicion, and one must rely on both key examination findings and imaging to confirm this diagnosis. In appropriately selected patients, surgical intervention can provide durable symptomatic resolution.Level of evidenceIV

Objectives: Compare speech perception performance growth and benchmark score achievement among adult cochlear implant (CI) recipients with single-sided deafness (SSD) versus bilateral moderate to profound hearing loss. Study Design: Retrospective matched cohort analysis. Setting: Tertiary referral center. Patients: Adults with SSD or bilateral moderate to profound hearing sensorineural hearing loss who underwent cochlear implantation from 2014 to 2019. Interventions: Cochlear implantation. Main outcome measures: Time-to-benchmark speech perception score (CNC, AzBio in quiet) and speech performance within first postoperative year. Results: Thirty-three SSD patients were matched to 66 bilateral hearing loss patients (referent cohort) for duration of deafness and preoperative ipsilateral CNC scores. Although SSD patients were more likely to achieve benchmark CNC scores more quickly compared with matched referents, this difference did not reach statistical significance (HR 1.72; 95% CI 0.78–3.82; p = 0.18). AzBio scores showed similar trends (HR 1.40; 95% CI 0.66–2.98; p = 0.38). At last follow-up, the SSD cohort had lower CNC (median 54% vs. 62%; p = 0.019) and AzBio scores (median 72% vs. 84%; p = 0.029) compared to the referent cohort. Conclusions: No significant difference in speech perception performance growth (i.e., time-to-benchmark speech perception score) was identified between SSD and bilateral hearing loss CI recipients, although patients with bilateral hearing loss achieved higher scores in the implanted ear within the first year of follow-up.

Background: The management of severe radiocapitellar joint pathologies in young patients is challenging. Radial head arthroplasty (RHA) is a treatment option in the adult population, but most surgeons avoid implementing it in younger patients, and there are no published results for patients younger than 16 years. Methods: Our retrospective cohort describes 5 patients (4 male 1 female) who underwent cementless modular RHA at an average age of 14 years (range: 13 to 15). The preoperative diagnoses were post-traumatic radiocapitellar incongruity and arthrosis because of previous Salter-Harris type 3 or 4 fractures of the radial head in 3 cases; and axial instability of the forearm following failed radial head excision in 2 cases. Because of the complexity of the elbow pathology in these cases, all underwent concomitant procedures including: contracture release (5 cases), corrective ulnar osteotomy (2 cases), distal ulnar shortening osteotomy, excision of radioulnar synostosis, microfracture of the capitellum, and partial excision of the medial triceps (1 case each). Collected data included patient-reported outcomes, visual analog scale pain score at rest and during physical activity and radiographic assessment of arthritis and prosthesis loosening. Results: Average clinical follow-up was 8 years (range: 3 to 13). All 5 patients were pain-free at rest, and 3 reported moderate elbow pain (visual analog scale: 5 to 6) with physical activity. At an average radiographic follow-up of 3 years (range: 0.5 to 5), 3 patients showed mild progression of elbow arthrosis, but there were no signs of progressive capitellar erosion or implant loosening. Only 1 complication was noted—development of heterotopic ossification in 1 patient, which required open heterotopic ossification excision and contracture release 2 years following the RHA. None of the patients required prosthesis revision or removal. Conclusion: RHA was successful in improving pain and axial forearm stability in this very small series of adolescent patients. Concerns regarding long-term longevity and complications still exist. Considering the lack of other reliable treatment options, RHA may be indicated in this challenging patient population. Level of Evidence: Level IV: therapeutic study—case series.

Objectives/Hypothesis To review hearing preservation after microsurgical resection of sporadic vestibular schwannomas according to tumor size. Study Design Retrospective cohort. Methods Baseline, intraoperative, and postoperative patient and tumor characteristics were retrospectively collected for a cohort who underwent hearing preservation microsurgery. Serviceable hearing was defined by a pure tone average ≤50 dB and word recognition score ≥50%. Results A total of 243 patients had serviceable hearing preoperatively. Fifty (21%) tumors were confined to the internal auditory canal, and the median tumor size was 16.2 mm (interquartile range [IQR] 11.3–23.2) for tumors with cerebellopontine angle extension. Serviceable hearing was maintained in 64% of patients with tumors confined to the internal auditory canal, 28% with cerebellopontine angle extension <15 mm, and 9% with cerebellopontine angle extension ≥15 mm. On multivariable analysis, the odds ratios of acquiring nonserviceable hearing postoperatively for tumors extending <15 mm and ≥15 mm into the cerebellopontine angle were 5.75 (95% confidence interval [CI] 2.13–15.53; P < .001) and 22.11 (95% CI 7.04–69.42; P < .001), respectively, compared with intracanalicular tumors. Conclusions The strongest predictor of hearing preservation with microsurgery after multivariable adjustment is tumor size. Approximately 10% of patients with tumors ≥15 mm of cerebellopontine angle extension will retain serviceable hearing after microsurgery. Furthermore, hearing preservation techniques offer cochlear nerve preservation and cochlear patency allowing for possible future cochlear implantation. An attempt at hearing preservation, including avoiding surgical approaches that necessarily sacrifice hearing, is worthwhile even in larger tumors if serviceable hearing is present preoperatively. Level of Evidence 4 Laryngoscope , 132:1657–1664, 2022