Citations

Introduction: Among those hospitalized with heart failure, diabetes (DM) is a common comorbid condition and the population characteristics and natural history of those with preserved EF (HFpEF) versus those with reduced EF (HFrEF) remain undefined. Hypothesis: To determine the epidemiologic profile and natural history among those hospitalized with acute heart failure (AHF) with DM and compare outcomes of those with reduced versus preserved EF. Methods: A retrospective chart analysis of adults hospitalized with primary ICD diagnosis of AHF from Olmsted County hospitalized from 2005 - 2008, with follow up until 2013. Demographic, clinical and lab data were collected. Results: Of 912 subjects hospitalized with AHF, 381 (42%) had DM. Among subjects with AHF and DM, those with HFrEF were similar in age to those with HFpEF (76.3±11.7 years vs 78.3±11.2 years, p=0.12), but were more likely to be male (58% vs 37%, p<0.001). Those with DM and HFrEF compared to HFpEF had less hypertension (95% vs 99%, p=0.046), but more coronary artery disease (89% vs 75%, p<0.001), prior myocardial infarction (65% vs 33%, p<0.001), and higher BNP values (1155±906 pg/mL vs 676±568 pg/mL, p<0.001). E/e’ ratio was similar in those with DM and HFrEF versus HFpEF (22.6±10.4 vs 21.7±10.9, p=0.49), suggesting both groups had increased filling pressures. There was no difference in mortality between the HFrEF and HFpEF groups up to 5 years in either the DM group (p=0.46) or the non-DM group (p=0.11). However, those hospitalized with AHF and DM demonstrated a higher rate in those with HFrEF versus HFpEF groups in all cause rehospitalization (p=0.019) and heart failure rehospitalization (p=0.008). This was different from the non-DM group, where there was no difference between HFrEF and HFpEF in all cause hospitalization (p=0.31) or heart failure rehospitalization (p=0.19). Conclusions: In patients hospitalized for AHF with DM, those with HFrEF had increased all cause and heart failure hospitalization as compared to HFpEF. In contrast, subjects without DM had no differences in rehospitalization between the HFrEF and HFpEF groups. Further studies are warranted to define pathophysiological mechanism for this observation.

Background: Unicompartmental knee arthroplasty (UKA) is a reliable procedure to treat medial compartment knee osteoarthritis (OA). The reported survivorship of UKA has varied in the literature 3–7 . In part, the higher failure rates of UKA seen in registries could be related to the caseload and experience of the reporting surgeon 8 . The introduction of techniques that make procedures more reliable, especially in the hands of inexperienced surgeons, can decrease the rate of failure. With the Oxford UKA implant (Zimmer Biomet), the recommended surgical technique involves cutting the tibia first, followed by the femoral preparation. However, a technique that allows for preparation of the femur first, as well as the use of the femoral component as a reference for the tibial cut, may reduce the common technical errors seen with the procedure. We have utilized the femur-first technique in cases of medial Oxford UKA. Description: The femur-first method outlined in the present article does not require any unique instruments beyond what is supplied by the manufacturer. Before beginning, the femoral positional guide needs to be decoupled from its base. To start, the intramedullary guide is introduced approximately 1 cm anterior and medial to the intercondylar notch. Once the femoral osteophytes are removed, the surgeon identifies the center of the femoral condyle and marks it. The posterior tibial cartilage is then removed with a saw to facilitate the placement of the appropriately sized femoral spherical guide. The size of the femoral component is determined by selecting the implant that aligns best with the width of the femoral condyle. The femoral drill guide is detached from its base because there is not enough space for the base, as the tibia has not yet been resected. The decoupled femoral guide is connected to the intramedullary rod, allowing the precise positioning of the femoral component in approximately 10° of flexion relative to the femoral sagittal plane and drilling of the 2 peg holes. The posterior condylar resection guide is impacted into position, and the osteotomy of the posterior condyle is made. The distal femur is then milled with use of a number-0 spigot, and the femoral component trial is positioned into place. The femoral condyle is “resurfaced” with the femoral component, which restores joint obliquity and the natural height, a critical element of the femur-first technique. Following this, the 1-mm (size-dependent) spherical gauge is placed around the femoral component trial. The tibial guide is secured with the G-clamp and a number-0 resection block, and is pinned into place. We recommend swapping the number-0 cutting guide for a +2 when making the cut in order to avoid over-resection. Recutting is advised if a minimum 3-mm feeler gauge does not adequately occupy the flexion space. The final step is to balance the flexion and extension gaps in the usual fashion. Alternatives: The alternative technique is a traditional tibia-first approach, in which tibial resection is performed prior to femoral resection. As described in the original manufacturer’s manual, the tibial cut is accomplished with use of a number-0 cutting guide, and the tibial rotation is based on the axis formed by the anterior superior iliac spine and knee center, irrespective of the femoral condyle. Rationale: The femur-first technique is advantageous in several ways. When performing the femoral cut first, the surgeon can better align the drill guide at the center of medial femoral condyle. This will result in the femoral component being positioned more in line with the coronal plane of the femoral condyle. Additionally, the tibial resection is made with the femoral trial in place; therefore, the depth of resection can be more accurate, potentially avoiding excessive bone resection. Finally, with the femoral trial in place, the surgeon can judge the rotation and medial-lateral position of the tibial component more precisely, hence lowering the possibility of bearing spin-out, impingement, and dislocation or unexplained pain. Expected Outcomes: The femur-first technique is a bone-preserving procedure that results in thinner bearings when compared with a tibia-first approach 1 . The femur-first approach also improves radiographic outcomes, including femoral coronal, femoral sagittal, and tibial sagittal alignments, while tibial coronal alignment does not differ. There is an early trend toward improved 5-year survivorship with the femur-first (98%) versus tibia-first (94%, p = 0.35) techniques. There has been no significant difference reported in Knee Society Scores between techniques. Important Tips: Perform a preliminary cut of the posterior tibial cartilage in order to allow insertion of the femoral drill guide under the femoral condyle. Make sure the femoral drill guide lies in the center of the marked medial femoral condyle. Align the tibial sagittal cut with the femoral component trial in order to avoid bearing impingement. Be conservative in the tibial cutting by utilizing a +2 cutting guide (since the coupling is performed with the intramedullary guide in place, which drives the tibial guide distally). Acronyms and Abbreviations: UKA = unicompartmental knee arthroplasty FF = femur-first M-L = medial-lateral AP = anteroposterior PA = posteroanterior ASA = acetylsalicylic acid (aspirin) BID = bis in die, twice a day PT = physical therapy TF = tibia-first FCA = femoral coronal angle FSA = femoral sagittal angle TSA = tibial sagittal angle IM = intramedullary OA = osteoarthritis

The NCCN Guidelines for Prostate Cancer include recommendations for staging and risk assessment after a prostate cancer diagnosis and for the care of patients with localized, regional, recurrent, and metastatic disease. These NCCN Guidelines Insights summarize the panel's discussions for the 2024 update to the guidelines with regard to initial risk stratification, initial management of very-low-risk disease, and the treatment of nonmetastatic recurrence.

ABSTRACT Introduction: Medical conferences are an integral aspect of medical education as they allow attendees to stay up to date with recent advancements in medicine, to develop presentation and communication skills, and to network and establish connections with professionals in their field of interest. But, when the coronavirus disease 2019 (COVID-19) pandemic was declared in March 2020, face-to-face medical conferences were suspended, and conference organizers began shifting their meetings to virtual platforms. These new virtual conferences afforded medical residents and fellows the unique opportunity to attend conferences from the comfort of their own home or workplace; however, the virtual meeting platforms did not provide attendees with the same networking experiences as in-person conferences. Since the end of the COVID-19 public health emergency, medical conferences are now faced with the question of whether they should remain virtual, shift back to in-person meetings, or develop a hybrid model of both options. Thus, the purpose of this study was to analyze medical resident and fellow sentiments and preferences by comparing virtual and in-person conference formats. Methods: A voluntary electronic survey was distributed to medical residents and fellows across the United States through their program coordinators and directors. Results: The main findings of this study suggest that medical residents and fellows largely prefer in-person conferences (85%) as compared to a virtual format because of the networking opportunities afforded to them along with the development of camaraderie with their peers. The findings in this study suggest that the largest benefit in attending a virtual conference is the flexibility to attend from any location (79% important or very important), which offered convenience, flexibility, and comfort to participants (n = 100). Conclusion: These results support our hypothesis that despite the convenience and portability afforded by attending conferences virtually, medical residents and fellows still ultimately prefer to attend conferences in person. Overall, the findings in this study are of relevance to conference organizers in understanding the driving forces behind attendance and should be considered in determining meeting format.

Summary Histiocytic neoplasms are diverse clonal haematopoietic disorders, and clinical disease is mediated by tumorous infiltration as well as uncontrolled systemic inflammation. Individual subtypes include Langerhans cell histiocytosis (LCH), Rosai–Dorfman–Destombes disease (RDD) and Erdheim–Chester disease (ECD), and these have been characterized with respect to clinical phenotypes, driver mutations and treatment paradigms. Less is known about patients with mixed histiocytic neoplasms (MXH), that is two or more coexisting disorders. This international collaboration examined patients with biopsy‐proven MXH with respect to component disease subtypes, oncogenic driver mutations and responses to conventional (chemotherapeutic or immunosuppressive) versus targeted (BRAF or MEK inhibitor) therapies. Twenty‐seven patients were studied with ECD/LCH (19/27), ECD/RDD (6/27), RDD/LCH (1/27) and ECD/RDD/LCH (1/27). Mutations previously undescribed in MXH were identified, including KRAS, MAP2K2, MAPK3, non‐V600‐BRAF, RAF1 and a BICD2‐BRAF fusion. A repeated‐measure generalized estimating equation demonstrated that targeted treatment was statistically significantly (1) more likely to result in a complete response (CR), partial response (PR) or stable disease (SD) (odds ratio [OR]: 17.34, 95% CI: 2.19–137.00, p = 0.007), and (2) less likely to result in progression (OR: 0.08, 95% CI: 0.03–0.23, p < 0.0001). Histiocytic neoplasms represent an entity with underappreciated clinical and molecular diversity, poor responsiveness to conventional therapy and exquisite sensitivity to targeted therapy.

AbstractObjectivesOnline educational platforms with open access have seen a growing adoption in the field of medical education. However, the extent of their global usage is still unclear. To fill this knowledge gap, our objective is to examine the usage patterns of two renowned open‐access resources in Otolaryngology. This includes identifying the most sought‐after topics and understanding the demographics of their users.MethodsRetrospective study of web analytics data between 2016 and 2021 extracted from the Headmirror.com and Mayo Clinic Otolaryngology YouTube channel platforms analyzing demographic and education topic trends via descriptive, geospatial, time‐series, t‐tests, and ANOVA analyses.ResultsViewership spanned 124 countries in 7 different geographic regions, with 72 countries comprising low‐ to middle‐income countries, mostly represented ages of 25–34 years old, came from high‐income countries rather than low‐income (p < .001), and used mobile phones followed by computers for device access. Video‐educational material comprised of subspecialty topics on Rhinology and Sinus Surgery (25%) at the highest end and Facial Trauma (1%) at the lowest. Controlling for the age of the video content, the most‐accessed videos comprised of subspecialty topics on Head and Neck Surgery at the highest end and Laryngology at the lowest with significant differentiation across topics of interest (p < .044).ConclusionsThis assessment of web‐analytics platforms from two widely used otolaryngology free, online‐access materials showed increasing global usage trends with significant differentiating factors along viewership demographics, as well as sought‐after subspecialty topics of interest. In turn, our results not only lay the groundwork for characterizing the global otolaryngology audience but also for future development of targeted educational materials and accessibility initiatives aimed at ameliorating global educational disparities in the field.

Background: Injury to the medial ulnar collateral ligament (MUCL) is a common setback experienced by many throwing athletes often requiring reconstruction with 12 to 18 months of rehabilitation. Current reconstructive techniques fail to anatomically restore the MUCL. This presentation demonstrates the “anatomic technique” for reconstruction of the MUCL supplemented by internal brace augmentation. Indications: Initial injuries of the MUCL can often be managed conservatively; however, many complete tears and those failing nonoperative management are frequently treated with MUCL reconstruction. Technique Description: After graft harvest, a 6-cm incision is created over the medial epicondyle to expose the sublime tubercle and medial epicondyle. Sutures are placed through the torn ligament which are used to formally repair the native ligament. A 4-mm socket is drilled in the MUCL origin of the medial epicondyle, and two 2-mm penetrating sockets are drilled toward the base of the 4-mm socket. The sutures in the native ligament are passed through the sockets and later tied over the bone bridge to complete the native ligament repair. A tight rope is shuttled through the medial epicondyle socket and assembled. The palmaris longus autograft and a suture tape are loaded onto the tightrope and reduced into the humeral socket. On the ulna, soft suture anchors are placed on either side of the sublime tubercle. The distal end of the graft is then sutured utilizing a FiberWire. The graft is secured to the sublime tubercle by tying down the previously placed suture anchors. The suture tapes and internal brace are loaded into a SwiveLock suture anchor, which is fixed distally along the sublime tubercle ridge creating an anatomic reconstruction. Then, the native ligament sutures and tight rope are re-tensioned and tied across the humeral bone bridge for final fixation. Results: In our cohort of 26 professional and amateur throwers, >90% returned to play at the same level at a mean of 9.9 months postoperatively. Discussion/Conclusion: Anatomic reconstruction of the MUCL with internal bracing is a viable option for MUCL injuries and may allow expedited return to sport for most athletes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.