Cost-Benefit Analysis of Robotic vs. Laparoscopic Hepatectomy: A Propensity-Matched Retrospective Cohort Study of American College of Surgeons National Surgical Quality Improvement Program Database.

BACKGROUND: Robotic and laparoscopic hepatectomies having increased utilization as minimally invasive techniques are explored for hepatobiliary malignancies. Although the data on outcomes from these 2 approaches are emerging, the cost-benefit analysis of these approaches remains sparse. This study compares the costs associated with robotic vs. laparoscopic liver resections, taking into account 30-day complications. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, a propensity-matched cohort of patients with laparoscopic or robotic liver resections between 2014 and 2017 was identified. Costs were assigned to perioperative variables, including operating room (OR) time, length of stay, blood transfusions, and 30-day complications. Cost estimates were obtained from the Centers for Medicare and Medicaid Services billing data (2017), American Hospital Association data (2017), relevant literature, and local institutional cost data. RESULTS: In our matched cohort of 454 patients (227 per group), total costs associated with laparoscopic liver resections were estimated at $5.5 M ($24 K per patient) vs. $6.8 M ($29.8 K per patient) for robotic liver resections (21.3% difference, P < .001). The higher cost associated with robotic hepatectomies was related to blood transfusions ($22.0 K vs. $12.1 K, P = .02), length of stay ($2.05 M vs. $1.76 M, P = .046), and OR time ($4.01 M vs. $3.24 M, P < .0001). DISCUSSION: Robotic hepatectomies were associated with higher costs compared to laparoscopic hepatectomies. The 2 major contributors to the cost disparity were increased OR time and increased length of stay. Future studies are warranted to analyze high-volume Minimally Invasive Surgery surgeons' impact in specialty centers on potentially mitigating this current cost disparity.

The Delivery of Orthopaedic Care midst COVID-19 and Social Distancing.

In this paper we present the findings of a literature review covering articles published in the last three decades describing the application of telemedicine in orthopaedics. A review of the PubMed Central and Medline provided 75 articles studying the role of telemedicine, the majority directly examining the application of telemedicine in orthopaedic patients. We report the summarized findings of these studies, the financial and HIPAA considerations of using telemedicine, and provide an example of our single urban level-1 trauma center's strategy for incorporating telemedicine into the clinical practice of orthopaedic surgeons during the COVID-19 pandemic.

Simple Versus Radical Resection for Duodenal Adenocarcinoma: A Propensity Score Matched Analysis of National Cancer Database.

BACKGROUND: Duodenal adenocarcinoma treatment consists of either simple or radical surgical resection. Existing evidence suggests similar survival outcomes between the two but is limited by small numbers and single-institution analysis. We aim to compare survival after partial versus radical resection for duodenal adenocarcinoma using the National Cancer Database (NCDB). METHODS: Using NCDB results from 2004 to 2014, we compared patients with duodenal adenocarcinoma undergoing partial resection (n = 1247) and radical resection (n = 1240) by age, sex, facility type, facility location, cancer stage, cancer grade, lymph node sampling, node status, tumor size, margin status, neoadjuvant therapy, and adjuvant therapy using chi-square analysis. Survival was compared using propensity matching. RESULTS: Patients undergoing partial resection had overall earlier cancer stage, more favorable tumor grade, and were less likely to undergo lymph node sampling and neoadjuvant therapy. When overall survival was compared between the 2 propensity-matched groups, the median survival was 46.7 months after partial resection and 43.2 months after radical resection (P = .329), and overall survival was similar between the 2 groups (P = .894). The use of adjuvant therapy demonstrated improved survival over either surgery alone (P < .0001, P = .0037). CONCLUSION: Partial resection did not demonstrate worse survival outcomes than radical resection for duodenal adenocarcinoma. The use of adjuvant therapy in addition to surgery demonstrated improved survival regardless of surgery type and played a larger role in survival than the type of surgery. Our findings provide evidence to support the continued use of both partial and radical surgical resections to treat duodenal malignancy.

Implications for Telemedicine for Surgery Patients After COVID-19: Survey of Patient and Provider Experiences.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has expanded the utilization of telemedicine in clinical practice to minimize potential risks to both patients and providers. We aim to describe the perception of telemedicine by both surgical patients and providers to understand the preferences for future incorporation in future surgical practice. METHODS: An anonymous survey was administered to providers that transitioned clinic visits to telemedicine encounters since the start of the COVID-19 pandemic. In the second part of the study, patients who underwent video telemedicine appointments answered survey questions via telephone. RESULTS: Twenty-six out of 36 (72.7%) providers responded. Over 75% reported that they could effectively communicate with patients over telemedicine. Six (23.1%) reported that they could adequately assess surgical sites. Of 361 patients, 187 consented to the study (consent rate 51.8%). Among patients, the most common result to choose a telemedicine appointment was to avoid the risk of COVID-19 transmission (84, 44.9%), though the minority reported that they would choose telemedicine after the pandemic (64, 34.2%). Those patients who would choose an in-person visit were more likely to have a higher Charlson Comorbidity Score, body mass index, and use friends or family for transportation. In open-ended feedback, patients suggested that telemedicine would be better suited for long-term follow-up rather than the immediate postoperative setting. CONCLUSIONS: Patients and providers reported a high degree of satisfaction using telemedicine during the COVID-19 pandemic but noted concern with limited physical examinations. Telemedicine may be suited for preoperative evaluation and medium-term and long-term postoperative follow-up for surgical patients.

Assessing alveolar rhabdomyosarcoma cell lines as tumor models by comparison of mRNA expression profiles.

Numerous cell lines for human alveolar rhabdomyosarcoma (ARMS) have been developed and are widely used to study biological processes of this myogenic cancer. The present study investigated the resemblance of commonly used ARMS cell lines to primary tumors in regards to gene expression. RNA-sequencing data was retrieved from published datasets for 4 commonly used ARMS cell lines and 35 ARMS primary tumors. The genes with most variable expression across primary tumors were used to calculate rank-based Spearman's correlation. The observed median correlations ranged from 0.36 to 0.61. RH-41 showed the highest median correlation while KYM-1 was the least correlated cell line. A significant number of genes dysregulated between tumors and non-tumors also exhibited similar expression patterns between tumors and cell lines, including The findings suggest that ARMS cell lines exhibit changes in gene expression compared to primary tumors and may not be completely representative of the disease process.

What Is the Effect on Kinesio Taping on Pain and Gait in Patients With Patellofemoral Pain Syndrome?

Introduction Patellofemoral pain syndrome (PFPS) is one of the leading causes of anterior knee pain treated by orthopedists and physical therapists. This syndrome predominantly affects young, active individuals, and remains a challenging syndrome to manage due to the lack of quantitative diagnostic criteria to monitor during treatment. The etiology of this syndrome is believed to be multifactorial, with the gait and movement patterns of a patient potentially contributing to pain due to increased stress on the knee. In this study, we investigated the gait of participants with PFPS using the GaitRite system (CIR Systems Inc., Clifton, NJ) before and after the application of Kinesio Tape in order to assess the impact of Kinesio Tape on cadence, stance time, and pain. Methods A convenience sample of 10 participants were recruited for this study, with five participants without PFPS serving as controls, and five with PFPS in the Kinesio Tape group. Participants in the Kinesio Tape groups served as their own internal control, ambulating both before and after taping. All participants ambulated across the GaitRite carpet three times and completed a visual analogue scale pain score for each trip. Results The results of our study found there to be no significant difference in the cadence for gait between the participants without PFPS and participants with PFPS (105.2 seconds vs. 105.1 seconds, p = 0.272), or in the stance time between the control and PFPS group (1.43 seconds vs. 1.44, p = 0.907). Similarly, no significant difference was found in participants with PFPS before and after Kinesio Taping in the cadence and stance times (105.1 seconds vs. 107.4 seconds, p =0.288, and 1.44 vs. 1.40, p = 0.272). There was a significant difference in pain in PFPS participants before and after taping, with a 112.5% reduction in pain reported after taping (3.4 vs. 1.6, p < 0.05). Discussion and conclusion This study is one of the first studies to utilize the GaitRite system in order to analyze the impact of Kinesio Tape on gait in participants with PFPS. While our study failed to demonstrate a significant difference in the gait of participants with PFPS in comparison to those without PFPS, we did demonstrate a significant reduction in pain after the application of Kinesio Tape. These results suggest other variables addressed by the Kinesio Tape may be causing the pain associated with PFPS.

Where on the Differential Is Eisenmenger Syndrome in a Patient Without Prior Cardiopulmonary Disease?

Pulmonary hypertension (PH) can occur in patients with undiagnosed congenital heart disease, like atrial septal defects (ASDs), causing chronic left-to-right shunting. This may ultimately result in Eisenmenger physiology or syndrome (ES), a reversal of left-to-right shunting, resulting in a right-to-left shunt, thereby causing deoxygenated blood to enter systemic circulation as it bypasses the lungs. Development of PH due to an ASD is uncommon, and the occurrence of ES is <1% as most ASDs are corrected early in life. We present a 28-year-old female presenting with new-onset dyspnea found to have an undiagnosed ASD with ES. A 28-year-old female without past medical history presented to the emergency department after a chest x-ray performed by her primary care physician (PCP) showed dilation of the pulmonary artery concerning PH. The patient reported a three-month history of progressively worsening intermittent palpitations and dyspnea, now unable to walk more than one block without becoming dyspneic. Further imaging studies revealed a 1.4 centimeters (cm) secundum ASD, 4.4 cm dilatation of the PA, a mean pulmonary artery pressure (PAPm) of 132 millimeters (mm) mercury (Hg), and Eisenmenger physiology. She was placed on pulmonary vasodilators and iron supplementation to address an underlying iron-deficiency anemia. The patient is stable on her current regimen and is undergoing evaluation for possible heart-lung transplantation at an outside hospital. Dyspnea is one of the top 10 most common indications for emergency room visits annually. The differential diagnosis for dyspnea is vast, with ES, affecting only 0.8 in 1 million, far down on the list of possibilities, thus requiring high clinical suspicion to prompt further evaluation. Ultimately, the condition is preventable with early identification of underlying structural abnormalities for which definitive treatment options exist and are readily available, dramatically improving the prognosis if implemented before ES develops.

Inguinal Lymph Node Dissection Does Not Improve Overall Survival in Anal Cancer Nodal Disease.

BACKGROUND: Anal SCC is a rare disease mainly treated with chemoradiation. Abdominoperineal resection (APR), once the mainstay of treatment for anal cancer, now serves a role as salvage therapy for persistent or recurrent disease after chemoradiation. In addition, clinically positive nodes are currently treated by extending the radiation field to the groin. The role of inguinal lymph node dissection in recurrent or persistent anal SCC is unclear. The aim of the study is to determine the role of inguinal lymph node dissection in the management of inguinal lymph node metastasis for anal squamous cell carcinoma (SCC). METHODS: Retrospective analysis of patients with anal SCC in the National Cancer Database with positive inguinal nodes undergoing salvage APR between 2004 and 2014 was performed. A comparison of overall survival between patients who underwent APR with lymph node dissection versus APR only was analyzed using Kaplan-Meier plot. RESULTS: A total of 3424 patients underwent salvage APR, with 274 (8%) having clinically positive nodes. Within the subgroup that had clinically positive nodes, 195 (71%) underwent APR, whereas 79 (29%) underwent both APR and node dissection. Kaplan-Meier analysis demonstrates no difference in overall survival in the two groups (P = 0.99). Five-year survival for both groups was similar (36% versus 42%; P = 0.987). No significant difference was found when adjusted for age, gender, and Tumor Node Metastasis staging. CONCLUSIONS: Inguinal lymph node dissection does not appear to improve overall survival in patients with advanced-stage anal cancer requiring salvage APR. Proper patient selection for node dissection is essential to spare patients from additional morbid procedures.

Induction of Myogenic Differentiation Improves Chemosensitivity of Chemoresistant Cells in Soft-Tissue Sarcoma Cell Lines.

Rhabdomyosarcoma (RMS) and rhabdoid tumors (RT) are rare soft-tissue malignancies with the highest incidence in infants, children, and adolescents. Advanced, recurrent, and/or metastatic RMS and RT exhibit poor response to treatment. One of the main mechanisms behind resistance to treatment is believed to be intratumoral heterogeneity. In this study, we investigated the myogenic determination factor 1 (MYOD1) and Noggin (NOG) markers in an embryonal RMS (ERMS) cell line and an RT cell line and the differential response of the MYOD1 and NOG expressing subpopulations to chemotherapy. Importantly, we found that these markers together identify a subpopulation of cells (MYOD1+ NOG+ cells) with primary resistance to Vincristine and Doxorubicin, two commonly used chemotherapies for ERMS and RT. The chemoresistant MYOD1+ NOG+ cells express markers of undifferentiated cells such as myogenin and ID1. Combination of Vincristine with TPA/GSK126, a drug combination shown to induce differentiation of RMS cell lines, is able to partially overcome MYOD1/NOG cells chemoresistance.

Saliva enhances infection of gingival fibroblasts by herpes simplex virus 1.

Oral herpes is a highly prevalent infection caused by herpes simplex virus 1 (HSV-1). After an initial infection of the oral cavity, HSV-1 remains latent in sensory neurons of the trigeminal ganglia. Episodic reactivation of the virus leads to the formation of mucocutaneous lesions (cold sores), but asymptomatic reactivation accompanied by viral shedding is more frequent and allows virus spread to new hosts. HSV-1 DNA has been detected in many oral tissues. In particular, HSV-1 can be found in periodontal lesions and several studies associated its presence with more severe periodontitis pathologies. Since gingival fibroblasts may become exposed to salivary components in periodontitis lesions, we analyzed the effect of saliva on HSV-1 and -2 infection of these cells. We observed that human gingival fibroblasts can be infected by HSV-1. However, pre-treatment of these cells with saliva extracts from some but not all individuals led to an increased susceptibility to infection. Furthermore, the active saliva could expand HSV-1 tropism to cells that are normally resistant to infection due to the absence of HSV entry receptors. The active factor in saliva was partially purified and comprised high molecular weight complexes of glycoproteins that included secretory Immunoglobulin A. Interestingly, we observed a broad variation in the activity of saliva between donors suggesting that this activity is selectively present in the population. The active saliva factor, has not been isolated, but may lead to the identification of a relevant biomarker for susceptibility to oral herpes. The presence of a salivary factor that enhances HSV-1 infection may influence the risk of oral herpes and/or the severity of associated oral pathologies.