The effect of Medicaid expansion on rates of carpal tunnel release: an interrupted time series analysis.

BACKGROUND: Medicaid expansion through the Affordable Care Act (ACA) has been associated with greater access and utilization of surgical services in underserved populations. However, its impact on use of hand surgical care is less understood. The purpose of this study was to evaluate the association between New York State adoption of the ACA and carpal tunnel release (CTR) procedural volume in Medicaid beneficiaries. METHODS: We conducted a pooled cross-sectional analysis of patients who underwent CTR using the Healthcare Cost and Utilization Project New York State all-payer database (2010-2018). An interrupted time series (ITS) analysis using an autoregressive integrated moving average model estimated the immediate and long-term impact of Medicaid expansion in January 2014 on CTR procedural volume in Medicaid beneficiaries and uninsured individuals. RESULTS: A total of 112,569 patients were included in the sample. After expansion, we observed an absolute increase of 6% in the share of CTR procedures provided to Medicaid beneficiaries. Policy implementation was associated with an immediate 1.81% increase (95% CI=0.0085, 0.0277; p<0.001) in the probability of Medicaid as the primary payer and an annual increase of 1.68% (95% CI=0.0134, 0.0202; p<0.001) after reform. ITS analysis found this resulted in 4,190 additional CTR procedures in Medicaid beneficiaries than predicted without expansion. CONCLUSIONS: Study results suggest New York's adoption of the ACA was associated with an immediate and steady increase in use of outpatient CTR in Medicaid beneficiaries. Most of this increase represented newly treated patients rather than those who were previously uninsured.

Medicare Eligibility and Racial and Ethnic Disparities in Operative Fixation for Distal Radius Fracture.

Importance: Medicare provides near-universal health insurance to US residents aged 65 years or older. How eligibility for Medicare coverage affects racial and ethnic disparities in operative management after orthopedic trauma is poorly understood. Objective: To assess the association of Medicare eligibility with racial and ethnic disparities in open reduction and internal fixation (ORIF) after distal radius fracture (DRF). Design, Setting, and Participants: This retrospective cohort study with a regression discontinuity design obtained data from the Healthcare Cost and Utilization Project all-payer statewide databases for Florida, Maryland, and New York. These databases contain encounter-level data and unique patient identifiers for longitudinal follow-up across emergency departments, outpatient surgical centers, and hospitals. The cohort included patients aged 57 to 72 years who sustained DRFs between January 1, 2016, and November 30, 2019. Data analysis was performed between March 1 and October 15, 2023. Exposure: Eligibility for Medicare coverage at age 65 years. Main Outcomes and Measures: Type of management for DRF (closed treatment, external fixation, percutaneous pinning, and ORIF). Time to surgery was ascertained in patients undergoing ORIF. Multivariable logistic regression and regression discontinuity design were used to compare racial and ethnic disparities in patients who underwent ORIF before or after age 65 years. Results: A total of 26 874 patients with DRF were included (mean [SD] age, 64.6 [4.6] years; 22 359 were females [83.2%]). Of these patients, 2805 were Hispanic or Latino (10.4%; hereafter, Hispanic), 1492 were non-Hispanic Black (5.6%; hereafter, Black), and 20 548 were non-Hispanic White (76.5%; hereafter, White) and 2029 (7.6%) were individuals of other races and ethnicities (including Asian or Pacific Islander, Native American, and other races). Overall, 32.6% of patients received ORIF but significantly lower use was observed in Black (20.2% vs 35.4%; P < .001) and Hispanic (25.8% vs 35.4%; P < .001) patients compared with White individuals. After adjusting for potential confounders, multivariable logistic regression analysis confirmed the disparity in ORIF use in Black (odds ratio [OR], 0.60; 95% CI, 0.50-0.72) and Hispanic patients (OR, 0.82; 95% CI, 0.72-0.94) compared with White patients. No significant difference in ORIF use was found among racial and ethnic groups at age 65 years. The expected disparity in ORIF use between White and Black patients at age 65 years without Medicare coverage was 12.6 percentage points; however, the actual disparity was 22.0 percentage points, 9.4 percentage points (95% CI, 0.3-18.4 percentage points) greater than expected, a 75% increase (P = .04). In the absence of Medicare coverage, the expected disparity in ORIF use between White and Hispanic patients was 8.3 percentage points, and this result persisted without significant change in the presence of Medicare coverage. Conclusions and Relevance: Results of this study showed that surgical management for DRF was popular in adults aged 57 to 72 years, but there was lower ORIF use in racial or ethnic minority patients. Medicare eligibility at age 65 years did not attenuate race and ethnicity-based disparities in surgical management of DRFs.

Does Academic Productivity Correlate With Industry Payments in Hand Surgery Fellowship Programs in the United States?

BACKGROUND: Hand surgeons and the industry share a common goal to improve the care of patients. However, industry support remains controversial, and the current relationship with fellowship programs remains unclear. This study explores the relationship between industry support and research productivity among hand surgeons in the academic setting. METHODS: The Open Payments database, created by the Centers for Medicare and Medicaid Services (CMS) as a result of the Sunshine Act, was used to identify supplemental income paid to physicians of hand surgery fellowships in the United States. Both lifetime individual physician and aggregated fellowship Sunshine Act supplemental income (2015-2021) were collected for review. Supplemental income only reflects royalties, consulting fees, or food and does not include direct research funding. H-index was collected through the Scopus website as a proxy for academic productivity. RESULTS: Six hundred and thirty-four faculty physicians (90.8%) from 94 hand surgery fellowships (100%) were included in the study. The mean individual physician lifetime supplemental income was $67,272 (median $341,861), whereas the mean individual physician H-index was 12.5 (median 9.0). There was a significant and weak positive correlation between individual physician H-index and lifetime income (p<0.001). Similarly, there was a significant and moderately positive correlation between the combined fellowship H-index and total lifetime income (p<0.001). CONCLUSION: Research productivity of an orthopedic hand fellowship group and individual academic hand surgeon correlate with overall industry support from indirect research funding. Further work is required to better understand the advantages and disadvantages of industry support of academically productive hand surgeons at hand surgery fellowships.

BMI is Not Associated with Chest-Specific Body Image, Complications or Revisions in Gender-Affirming Mastectomy: A Single-Center Cross-Sectional Study.

OBJECTIVE: To analyze the impact of Body Mass Index (BMI) on clinical and patient-reported outcomes following gender-affirming mastectomy (GM). BACKGROUND: BMI is a barrier for obese patients seeking GM despite increasing evidence that it is safe in this population. Currently little is known about the impact of BMI on chest-specific body image and satisfaction following GM. METHODS: This single-center, cross-sectional study included individuals 18 years and older who underwent GM between 1990-2020 and were at least 2 years post-operative. Patient-reported chest-specific body image was measured using the BODY-Q and Gender Congruence and Life Satisfaction (GCLS) chest subscales. Satisfaction was measured using the Holmes-Rovner Satisfaction with Decision (SWD) scale. Clinical and demographic variables were identified from chart review. Bivariate analysis was performed to determine if BMI was associated with chest-specific body image, satisfaction, complications within 30 days or revisions in GM. RESULTS: Two hundred twenty-seven individuals meeting eligibility criteria were contacted to participate and one hundred thirty-seven responded (60.4% response rate). The mean age was 29.1 (SD=9.0) and mean BMI was 30.9 (SD=8.0), with 26.4% (N=60) of the cohort having a BMI>35. Chest-specific body image, and satisfaction with decision did not vary by BMI or breast resection weight. Complications and revisions were not associated with BMI. CONCLUSION: Individuals undergoing GM reported high rates of satisfaction following GM regardless of BMI. Complication and revision rates did not vary significantly by BMI or breast resection weight. Surgeons should re-evaluate the role BMI plays in patient selection and counseling for GM.

Long-Term Regret and Satisfaction With Decision Following Gender-Affirming Mastectomy.

Importance: There has been increasing legislative interest in regulating gender-affirming surgery, in part due to the concern about decisional regret. The regret rate following gender-affirming surgery is thought to be approximately 1%; however, previous studies relied heavily on ad hoc instruments. Objective: To evaluate long-term decisional regret and satisfaction with decision using validated instruments following gender-affirming mastectomy. Design, Setting, and Participants: For this cross-sectional study, a survey of patient-reported outcomes was sent between February 1 and July 31, 2022, to patients who had undergone gender-affirming mastectomy at a US tertiary referral center between January 1, 1990, and February 29, 2020. Exposure: Decisional regret and satisfaction with decision to undergo gender-affirming mastectomy. Main Outcomes and Measures: Long-term patient-reported outcomes, including the Holmes-Rovner Satisfaction With Decision scale, the Decision Regret Scale, and demographic characteristics, were collected. Additional information was collected via medical record review. Descriptive statistics and univariable analysis using Fisher exact and Wilcoxon rank sum tests were performed to compare responders and nonresponders. Results: A total of 235 patients were deemed eligible for the study, and 139 responded (59.1% response rate). Median age at the time of surgery was 27.1 (IQR, 23.0-33.4) years for responders and 26.4 (IQR, 23.1-32.7) years for nonresponders. Nonresponders (n = 96) had a longer postoperative follow-up period than responders (median follow-up, 4.6 [IQR, 3.1-8.6] vs 3.6 [IQR, 2.7-5.3] years, respectively; P = .002). Nonresponders vs responders also had lower rates of depression (42 [44%] vs 94 [68%]; P < .001) and anxiety (42 [44%] vs 97 [70%]; P < .001). No responders or nonresponders requested or underwent a reversal procedure. The median Satisfaction With Decision Scale score was 5.0 (IQR, 5.0-5.0) on a 5-point scale, with higher scores noting higher satisfaction. The median Decision Regret Scale score was 0.0 (IQR, 0.0-0.0) on a 100-point scale, with lower scores noting lower levels of regret. A univariable regression analysis could not be performed to identify characteristics associated with low satisfaction with decision or high decisional regret due to the lack of variation in these responses. Conclusions and Relevance: In this cross-sectional survey study, the results of validated survey instruments indicated low rates of decisional regret and high levels of satisfaction with decision following gender-affirming mastectomy. The lack of dissatisfaction and regret impeded the ability to perform a more complex statistical analysis, highlighting the need for condition-specific instruments to assess decisional regret and satisfaction with decision following gender-affirming surgery.

The Current State of Fat Grafting in the Hand: A Systematic Review for Hand Diseases.

Autologous fat grafting (AFG) has traditionally been used for facial rejuvenation and soft tissue augmentation, but in recent years, its use has expanded to treat diseases of the hand. Autologous fat grafting is ideal for use in the hand because it is minimally invasive, can restore volume, and has regenerative capabilities. This review summarizes the emerging evidence regarding the safety and efficacy of AFG to the hand in several conditions, including systemic sclerosis, Dupuytren disease, osteoarthritis, burns, and traumatic fingertip injuries. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant literature search on the use of AFG in hand pathologies was performed on October 8, 2020, in Ovid MEDLINE, Elsevier Embase, Clarivate Web of Science, and Wiley Cochrane Central Register of Controlled Trials. The retrieved hits were screened and reviewed by 2 independent reviewers and a third reviewer adjudicated when required. Reviewers identified 919 unique hits. Screening of the abstracts identified 22 manuscripts which described the use of AFG to treat an identified hand condition. Studies suggest AFG in the hands is a safe, noninvasive option for the management of systemic sclerosis, Dupuytren contracture, osteoarthritis, burns, and traumatic fingertip injuries. While AFG is a promising therapeutic option for autoimmune, inflammatory, and fibrotic disease manifestations in the hand, further studies are warranted to understand its efficacy and to establish more robust clinical guidelines. Studies to date show the regenerative, immunomodulatory, and volume-filling properties of AFG that facilitate wound healing and restoration of hand function with limited complications.

Managing Resident Mental Health: Prevention is Better than Cure.

OBJECTIVE: There is a high prevalance of burnout and mental health illness among trainees. Through structured meetings, Program Directors (PDs) have an opportunity to screen and aid residents that may be affected by mental health concerns. However, barriers to this process exist. This study sought to evaluate the perspectives of PDs regarding mental health screening for trainees. DESIGN: A 13-item survey-based study. SETTING: Electronic distribution of the survey was performed via three individualized requests sent via e-mail to PDs. PARTICIPANTS: PDs of 5 ACGME specialties, including Internal Medicine, Pediatrics, Emergency Medicine, General Surgery, and Psychiatry were invited to participate. RESULTS: In total, 595 PDs responded to the survey (response rate = 40.0%) In general, PDs expressed dissatisfaction with the management of burnout and mental health. Most PDs supported periodic screening of residents for burnout (87.0%) and mental health (73.9%). For a resident that could screen positive for mental illness, most PDs were concerned about the possibility of harm to a patient (70.7%) and implications for future licensing (65.7%). Only 30.2% of PDs currently use some form of standardized screening to identify residents struggling with mental health and burnout concerns. CONCLUSION: The majority of PDs across 5 ACGME specialties support the use of periodic screening of residents for burnout and mental health. However, concerns exist regarding such screening such as the implications for future licensing. Additional work needs to be done to address PD concerns and destigmatizate mental health wellbeing and care among trainees.

Current Concepts in Gender-Affirming Surgery Postgraduate Training.

Background Recent advocacy efforts and expanded insurance coverage has increased health care utilization among transgender patients. Therefore, it is pivotal that surgical residents are properly trained to care for transgender patients in both clinical and surgical settings. Yet, no formal curriculum or training requirements exist for surgical residents. The aim of this systematic review is to understand the surgical trainee's postgraduate education and training with respect to transgender health and gender-affirming surgeries (GAS). Methods A Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)-compliant literature search was performed on December 04, 2020 in PubMed, Elsevier Embase, and Wiley Cochrane Central Register of Controlled Trials. The retrieved hits were screened and reviewed by two independent reviewers. Results Our literature search identified 186 unique publications, of which 14 surveys and one interventional study from various surgical specialties including plastic surgery, urology, otolaryngology, oral and maxillofacial surgery (OMS), dermatology, and obstetrics and gynecology (OBGYN) were included in this study. The majority of residents and program directors in surgical specialties believe education related to transgender health is important, and the current exposure in surgical training does not sufficiently prepare surgical residents to care for this marginalized population. Conclusion Current postgraduate surgical training in gender-affirming surgery is nonuniform across surgical specialty, geographical region, and individual program. Incorporating training modules and hands-on experiences into surgical trainee education will better prepare residents for the numerous clinical and surgical interactions with transgender patients. Further research is required to better understand how to best incorporate these experiences into existing surgical curriculums.

Sensory nerve regeneration and reinnervation in muscle following peripheral nerve injury.

Sensory afferent fibers are an important component of motor nerves and compose the majority of axons in many nerves traditionally thought of as "pure" motor nerves. These sensory afferent fibers innervate special sensory end organs in muscle, including muscle spindles that respond to changes in muscle length and Golgi tendons that detect muscle tension. Both play a major role in proprioception, sensorimotor extremity control feedback, and force regulation. After peripheral nerve injury, there is histological and electrophysiological evidence that sensory afferents can reinnervate muscle, including muscle that was not the nerve's original target. Reinnervation can occur after different nerve injury and muscle models, including muscle graft, crush, and transection injuries, and occurs in a nonspecific manner, allowing for cross-innervation to occur. Evidence of cross-innervation includes the following: muscle spindle and Golgi tendon afferent-receptor mismatch, vagal sensory fiber reinnervation of muscle, and cutaneous afferent reinnervation of muscle spindle or Golgi tendons. There are several notable clinical applications of sensory reinnervation and cross-reinnervation of muscle, including restoration of optimal motor control after peripheral nerve repair, flap sensation, sensory protection of denervated muscle, neuroma treatment and prevention, and facilitation of prosthetic sensorimotor control. This review focuses on sensory nerve regeneration and reinnervation in muscle, and the clinical applications of this phenomena. Understanding the physiology and limitations of sensory nerve regeneration and reinnervation in muscle may ultimately facilitate improvement of its clinical applications.

The Role of Autologous Flap Reconstruction in Patients with Crohn's Disease Undergoing Abdominoperineal Resection.

BACKGROUND: Patients with symptomatic Crohn's disease who undergo abdominoperineal resection can experience impaired postoperative wound healing. This results in significant morbidity, burdensome dressing changes, and increased postoperative pain. When abdominoperineal resection is performed for oncological reasons, autologous flap reconstruction is occasionally performed to optimize wound healing and reconstruction outcomes. However, the role of flap reconstruction after abdominoperineal resection for Crohn's disease has not been established. OBJECTIVE: This study examines the utility of flap reconstruction in patients with symptomatic Crohn's disease undergoing abdominoperineal resection. We hypothesize that patients with immediate flap reconstruction after abdominoperineal resection will demonstrate improved wound healing. DESIGN: This study is a retrospective chart review. SETTINGS: Eligible patients at our institution were identified from 2010 to 2018 by using a combination of Current Procedural Terminology, International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision codes. PATIENTS: Of 40 adult patients diagnosed with Crohn's disease, 20 underwent abdominoperineal resection only and 20 underwent abdominoperineal resection with flap reconstruction. INTERVENTIONS: Immediate autologous flap reconstruction was performed after abdominoperineal resection. MAIN OUTCOME MEASURES: The primary outcomes measured were the presence of postoperative perineal wounds and postoperative wound care burden. RESULTS: Patients in the abdominoperineal resection with flap reconstruction group demonstrated significantly worse preoperative disease traits, including fistula burden, than patients in the abdominoperineal resection only group. A lower number of patients tended to be associated with a persistent perineal wound in the flap group at 30 days (abdominoperineal resection with flap reconstruction = 55% vs abdominoperineal resection only = 70%; p = 0.327) and at 6 months (abdominoperineal resection with flap reconstruction = 25% vs abdominoperineal resection only = 40%; p = 0.311) postoperatively. There was also a trend toward a lower incidence of complications in the flap group. Patients in the abdominoperineal resection with flap reconstruction group tended to experience lower postoperative pain than patients in the abdominoperineal resection only group. LIMITATIONS: This retrospective cohort study was limited by its reliance on data in electronic medical records, and by its small sample size and the fact that it was a single-institution study. CONCLUSIONS: In select patients who have severe perianal fistulizing Crohn's disease, there may be a benefit to immediate flap reconstruction after abdominoperineal resection to lower postoperative wound care burden without significant intraoperative or postoperative risk. In addition, flap reconstruction may lead to lower postoperative pain. See Video Abstract at http://links.lww.com/DCR/B416. EL ROL DE LA RECONSTRUCCIN CON COLGAJO AUTLOGO EN PACIENTES CON ENFERMEDAD DE CROHN SOMETIDOS A RESECCIN ABDOMINOPERINEAL: ANTECEDENTES:Los pacientes con enfermedad de Crohn sintomática que se someten a una resección abdominoperineal pueden experimentar una curación posoperatoria deficiente de la herida. Esto da como resultado una morbilidad significativa, cambios de apósito molestos y un aumento del dolor posoperatorio. Cuando se realiza una resección abdominoperineal por razones oncológicas, ocasionalmente se realiza una reconstrucción con colgajo autólogo para optimizar los resultados de la curación y reconstrucción de la herida. Sin embargo, no se ha establecido la función de la reconstrucción con colgajo después de la resección abdominoperineal para la enfermedad de Crohn.OBJETIVO:Este estudio examina la utilidad de la reconstrucción con colgajo en pacientes con enfermedad de Crohn sintomática sometidos a resección abdominoperineal. Presumimos que los pacientes con reconstrucción inmediata con colgajo después de la resección abdominoperineal demostrarán una mejor curación de la herida.DISEÑO:Revisión retrospectiva de expedientes.MARCO:Los pacientes elegibles en nuestra institución se identificaron entre 2010 y 2018 mediante una combinación de los códigos de Terminología actual de procedimientos, Clasificación internacional de enfermedades 9 y Clasificación internacional de enfermedades 10.PACIENTES:Cuarenta pacientes adultos diagnosticados con enfermedad de Crohn que se someten a resección abdominoperineal solamente (APR-solo = 20) y resección abdominoperineal con reconstrucción con colgajo (APR-colgajo = 20).INTERVENCIÓN (ES):Reconstrucción inmediata con colgajo autólogo después de la resección abdominoperineal.MEDIDAS DE RESULTADOS PRINCIPALES:Presencia de herida perineal posoperatoria y carga de cuidado de la herida posoperatoria.RESULTADOS:Los pacientes del grupo APR-colgajo demostraron rasgos de enfermedad preoperatoria significativamente peores, incluida la carga de la fístula, en comparación con los pacientes del grupo APR-solo. Un número menor de pacientes tendió a asociarse con una herida perineal persistente en el grupo de colgajo a los 30 días (APR-colgajo = 55% vs APR-solo = 70%; p = 0.327) y 6 meses (APR-colgajo = 25% vs APR-solo = 40%; p = 0.311) postoperatoriamente. También hubo una tendencia hacia una menor incidencia de complicaciones en el grupo APR-colgajo. Los pacientes del grupo APR-colgajo tendieron a experimentar menos dolor posoperatorio en comparación con el grupo APR-solo.LIMITACIONES:Estudio de cohorte retrospectivo basado en datos de historias clínicas electrónicas. Tamaño de muestra pequeño y estudio de una sola institución.CONCLUSIONES:En pacientes seleccionados que tienen enfermedad de Crohn fistulizante perianal grave, la reconstrucción inmediata del colgajo después de la resección abdominoperineal puede beneficiar a reducir la carga posoperatoria del cuidado de la herida sin riesgo intraoperatorio o posoperatorio significativo. Además, la reconstrucción con colgajo puede resultar un dolor posoperatorio menor. Consulte Video Resumen en http://links.lww.com/DCR/B416.

IDO1 and Kynurenine Pathway Metabolites Activate PI3K-Akt Signaling in the Neoplastic Colon Epithelium to Promote Cancer Cell Proliferation and Inhibit Apoptosis.

The tryptophan-metabolizing enzyme indoleamine 2,3 dioxygenase 1 (IDO1) is frequently overexpressed in epithelial-derived malignancies, where it plays a recognized role in promoting tumor immune tolerance. We previously demonstrated that the IDO1-kynurenine pathway (KP) also directly supports colorectal cancer growth by promoting activation of ß-catenin and driving neoplastic growth in mice lacking intact adaptive immunity. In this study, we sought to delineate the specific role of epithelial IDO1 in colon tumorigenesis and define how IDO1 and KP metabolites interact with pivotal neoplastic signaling pathways of the colon epithelium. We generated a novel intestinal epithelial-specific IDO1 knockout mouse and utilized established colorectal cancer cell lines containing ß-catenin-stabilizing mutations, human colorectal cancer samples, and human-derived epithelial organoids (colonoids and tumoroids). Mice with intestinal epithelial-specific knockout of IDO1 developed fewer and smaller tumors than wild-type littermates in a model of inflammation-driven colon tumorigenesis. Moreover, their tumors exhibited reduced nuclear ß-catenin and neoplastic proliferation but increased apoptosis. Mechanistically, KP metabolites (except kynurenic acid) rapidly activated PI3K-Akt signaling in the neoplastic epithelium to promote nuclear translocation of ß-catenin, cellular proliferation, and resistance to apoptosis. Together, these data define a novel cell-autonomous function and mechanism by which IDO1 activity promotes colorectal cancer progression. These findings may have implications for the rational design of new clinical trials that exploit a synergy of IDO1 inhibitors with conventional cancer therapies for which Akt activation provides resistance such as radiation.Significance: This study identifies a new mechanistic link between IDO1 activity and PI3K/AKT signaling, both of which are important pathways involved in cancer growth and resistance to cancer therapy.