Citations

Background: This study aimed to evaluate and compare the outcomes of proximal row carpectomy (PRC) with interposition arthroplasty using dorsal wrist capsule interposition, lateral meniscus allograft, or dermal allograft in patients with lunate facet/capitate degeneration. Methods: Patients who underwent PRC with interposition arthroplasty between 2010 and 2022 at a single institution were identified. Preoperative and postoperative visual analog scale (VAS) pain, functional outcomes, and complications were recorded. Results: Twenty-one patients (11 dorsal capsule, 6 meniscus, 4 dermal matrix) were identified with a mean follow-up of 65.8 months. Postoperative pain and functional outcome scores significantly improved. The mean postoperative Quick Disabilities of the Arm, Shoulder, and Hand score was 20.3. In total, 89.5% of patients returned to work, including 75% of manual laborers. Conclusions: No significant differences were found between dorsal capsular flap versus allograft groups. Proximal row carpectomy with interposition arthroplasty is an effective motion-sparing procedure for patients with proximal capitate and/or lunate fossa arthritis, improving pain and function.

ObjectiveNot much is known regarding musculoskeletal ultrasound (MSUS) practices of rheumatologists in the United States. We sought to determine the current use of MSUS among past participants of the Ultrasound School of North American Rheumatologists (USSONAR) training program and, by extension, MSUS‐practicing rheumatologists and to understand barriers to its MSUS use.MethodsAn online survey was sent to 374 participants in the eight‐month USSONAR blended course (Fundamentals in Musculoskeletal Ultrasound and Train the Trainer) between 2009 and 2020. Each respondent had a unique identifier linked to their total number of submitted practice scans and examination scores during training.ResultsThe survey response rate was 28.1% (105 of 374), comprising 82% adult and 18% pediatric rheumatologists. Of the respondents, 71% were MSUS certified: 86.7% performed and/or interpreted diagnostic MSUS, 81.0% performed/interpreted procedural MSUS, 59.8% billed for at least 50% of diagnostic studies, and 78.8% billed for at least 50% of procedural studies. The top reasons for not doing diagnostic and procedural ultrasonography were lack of administrative support and limited time, respectively. For 25% of diagnostic ultrasonography and 12.9% of procedural ultrasonography, billing was done <50% of the time. Of the respondents, 78.0% reported that USSONAR training made them better rheumatologists.ConclusionMost USSONAR‐trained rheumatologists are certified, practicing both diagnostic and procedural MSUS and billing for most of their work. However, a substantial number of studies are not being billed due to time constraints, limited administrative support, and legal liability. Participants agreed that USSONAR training made them better rheumatologists.

Abstract Thromboembolic complication is common in severe coronavirus disease 2019 (COVID-19), leading to an investigation into the presence of prothrombotic antibodies akin to those found in heparin-induced thrombocytopenia (HIT). In a study of samples from 130 hospitalized patients, collected 3.6 days after COVID-19 diagnosis, 80% had immunoglobulin G (IgG) antibodies recognizing complexes of heparin and platelet factor 4 (PF4; PF4/H), and 41% had antibodies inducing PF4-dependent P-selectin expression in CpG oligodeoxynucleotide–treated normal platelets. Unlike HIT, both PF4/H-reactive and platelet-activating antibodies were found in patients with COVID-19 regardless of recent heparin exposure. Notably, PF4/H-reactive IgG antibodies correlated with those targeting the receptor-binding domain (RBD) of the severe acute respiratory syndrome coronavirus 2 spike protein. Moreover, introducing exogenous RBD to or removing RBD-reactive IgG from COVID-19 plasma or IgG purified from COVID-19 plasma significantly reduced their ability to activate platelets. RBD-specific antibodies capable of platelet activation were cloned from peripheral blood B cells of patients with COVID-19. These antibodies possessed sequence motifs in the heavy-chain complementarity-determining region 3 (HCDR3), resembling those identified in pathogenic HIT antibodies. Furthermore, IgG+ B cells having these HCDR3 signatures were markedly expanded in patients with severe COVID-19. Importantly, platelet-activating antibodies present in patients with COVID-19 were associated with a specific elevation of platelet α-granule proteins in the plasma and showed a positive correlation with markers for inflammation and tissue damage, suggesting a functionality of these antibodies in patients. The demonstration of functional and structural similarities between certain RBD-specific antibodies in patients with COVID-19 and pathogenic antibodies typical of HIT suggests a novel mechanism by which RBD-specific antibodies might contribute to thrombosis in COVID-19.

Purpose of review Persistent air leaks, defined as an air leak extending beyond 5 days, pose a significant challenge for cardiothoracic surgeons and pulmonologists. Although current guidelines advocate for surgical intervention as the primary treatment, many patients may not suitable candidates for immediate return to the operating room. Alternatively, conservative management, which involves watchful waiting for pleural healing, often results in prolonged hospital stays and increased morbidity. Recent findings Although current guidelines advocate for surgical intervention as the primary treatment, many patients may not suitable candidates for immediate return to the operating room. Alternatively, conservative management, which involves watchful waiting for pleural healing, often results in prolonged hospital stays and increased morbidity. For patients who are not surgical candidates, use of autologous blood patch, pleurodesis or endobronchial valves may offer a viable alternative to conservatively manage air leak. Summary This review evaluates the various noninvasive therapies that have been explored, including sealants, Heimlich valves, chemical and autologous blood patch pleurodesis, and endo and intrabronchial valves. Although these alternatives show promise, further research is needed to compare these treatments before they can be recommended in new guidelines.

Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) have become increasingly utilized in patients undergoing percutaneous coronary intervention (PCI). Despite these purported advantages, prior reports regarding the use of IVUS and OCT have indicated that contemporary use of intravascular imaging remains low with significant regional variation. Here, we present the findings of an updated contemporary analysis regarding the use of IVUS/OCT-guided PCI versus angiography-guided PCI in the United States. We also evaluated in-hospital mortality and clinical outcomes between IVUS/OCT-guided PCI versus angiography-guided PCI-only over million patients in the United States. There has been a significant decrease in the number of PCIs performed, while there has been increasing in the trend of IVUS/OCT-guided PCI over this period. Most importantly, we found that IVUS/OCT-guided PCI was associated with better clinical outcomes in terms of in-hospital mortality, compared with angiography-guided PCI.

PURPOSE BRAF and MEK inhibitors are standard treatments in histiocytic disorders, such as Erdheim-Chester disease (ECD). Some patients lack MAPK-pathway alterations, making these treatments less effective. METHODS We describe three patients with histiocytic disorders who have novel non-MAPK pathway alterations. These alterations were studied through genomic and in silico analyses when applicable, then treated with off-label medications rationally selected on the basis of genomic alterations. RESULTS Patient 1 had rapidly progressive ECD involving the CNS. A CSF1R in-frame deletion (p.S560_P566del) was identified, and in silico modeling predicted a gain-of-function mutation. This alteration was targeted with pexidartinib, which led to a clinical complete response (CR) within 2 months, and a partial response (PR) on imaging after 3 months. After 15 months, the disease became resistant to pexidartinib and transformed to histiocytic sarcoma. Patient 2 has skin-only involvement of a xanthogranuloma disorder. A KIF5B-FGFR1 fusion was identified on RNA sequencing and targeted with pemigatinib. At 24 months of follow-up, she remains in a clinical PR. Patient 3 has ECD involving the bone marrow, gastrointestinal tract, and subcutaneous tissues. A MEF2C-FLT3 fusion was identified and targeted with sorafenib. He achieved a clinical CR and radiographic PR within 3 months, which has continued for 30 months. CONCLUSION We report three patients with histiocytic disorders harboring novel alterations who had sustained responses to off-label kinase inhibitors specific to their histiocytic disorder. Pathogenic variants outside of the MAPK pathway, including variants of unknown significant, may be targeted with readily available small molecules.

A 40 year old woman who underwent combined heart-lung transplant for familial severe pulmonary hypertension experienced episodes of nonsustained ventricular tachycardia followed by sudden ventricular fibrillation arrest 8 days after transplant. Postarrest investigations revealed left lower lobe herniation into the right lower hemithorax, prompting emergent reoperation, and hernia reduction. Arrhythmias resolved following reduction of the herniated lung and facilitated rapid weaning from vasopressor and ventilatory support. To our knowledge, this is the first reported case of cardiac arrest due to lung herniation after combined heart-lung transplantation. Herein, we describe this rare presentation and offer insights and management strategies for the cardiac intensivist.

Purpose To compare Medicaid and Medicare rates for the 20 most commonly billed orthopaedic sports medicine procedures. Methods Medicaid reimbursement rates were obtained from state‐specific fee schedules. Medicare rates were collected from the Centers for Medicare & Medicaid Services Physician Fee Schedule, along with relative value units for each procedure. State rates were compared using averages and dollar differences. Reimbursement rates were adjusted for cost of living using the Medicare Wage Index. Variability between states and between procedures was assessed using coefficients of variation. Results Mean Medicaid reimbursement was lower than that of Medicare for 19 of the 20 procedures. In total, Medicaid reimbursed surgeons 14.9% less when data were unadjusted and 26.0% less when data were adjusted for cost of living. Variation in Medicare rates between states was constant, with a coefficient of variation of 0.06. For Medicaid, the coefficients of variation ranged from 0.27 to 0.70 for unadjusted data and from 0.35 to 0.69 for adjusted data. Conclusions On average, Medicaid reimburses orthopaedic sports medicine specialists less than does Medicare, with substantial variability between states. Adjustment for cost of living increases the percentage difference and the variability between states’ Medicaid reimbursement rates. Level of Evidence Level IV, economic analysis.