Genomic stratification beyond Ras/B-Raf in colorectal liver metastasis patients treated with hepatic arterial infusion.

BACKGROUND: Resection of colorectal liver metastases (CLM) can cure disease, but many patients with extensive disease cannot be fully resected and others recur following surgery. Hepatic arterial infusion (HAI) chemotherapy can convert extensive liver disease to a resectable state or decrease recurrence risk, but response varies and no biomarkers currently exist to identify patients most likely to benefit. METHODS: We performed a retrospective cohort study of CLM patients receiving HAI chemotherapy whose tumors underwent MSK-IMPACT sequencing. The frequency of oncogenic alterations and their association with overall survival (OS) and objective response rate were analyzed at the individual gene and signaling pathway levels. RESULTS: Three hundred and seventy patients met inclusion criteria: 189 (51.1%) who underwent colorectal liver metastasectomy followed by HAI + systemic therapy (Adjuvant cohort), and 181 (48.9%) with unresectable CLM (Metastatic cohort) who received HAI + systemic therapy, consisting of 63 (34.8%) with extrahepatic disease and 118 (65.2%) with liver-restricted disease. Genomic alterations were similar in each cohort, and no individual gene or pathway was significantly associated with objective response. Patients in the adjuvant cohort with concurrent Ras/B-Raf alteration and SMAD4 inactivation had worse prognosis while in the metastatic cohort patients with co-alteration of Ras/B-Raf and TP53 had worse OS. Similar findings were observed in a validation cohort. CONCLUSIONS: Concurrently altered Ras/B-Raf and SMAD4 mutations were associated with worse survival in resectable patients, while concurrent Ras/B-Raf and TP53 alterations were associated with worse survival in unresectable patients. The mutual exclusivity of Ras/B-Raf, SMAD4, and TP53 may have prognostic value for CLM patients receiving HAI.

Long-term clinical outcome analysis of poly-methyl-methacrylate cranioplasty for large skull defects.

PURPOSE: The goal of secondary cranioplasty is permanent cerebral protection in an esthetically acceptable fashion. Reconstruction of cranial defects can be performed with several different materials. Alloplastic materials, such as preformed methyl-methacrylate (PMMA) cranioplasties, are an alternative frequently used at our institution. This retrospective analysis was designed to review the outcomes of PMMA cranioplasty for skull defect reconstruction. MATERIALS AND METHODS: Seventy consecutive patients who had 78 PMMA cranioplasties placed from 2003 through 2010 were identified. Mechanism of injury, location of cranioplasty, type of original repair, postoperative complications, and follow-up time were reviewed. RESULTS: Of the 70 patients, 6 patients had failure and removal of their original PMMA cranioplasty and reinsertion of another, and 2 patients had failure and removal of 2 cranioplasties with replacement of a third, creating a total of 78 PMMA cranioplasties placed. The predominant mechanism of injury was trauma (64%). The most frequent postoperative complication was infection (13%). With the exception of the 2 patients with implant exposure, no patients reported an unacceptable cosmetic result. An overall complication rate of 24% was seen. CONCLUSIONS: The results of previous studies have shown that infection and complication rates of cranioplasties accomplished with bone cement are substantially higher, that titanium-based implants may obscure follow-up imaging for tumor patients, and that the outcomes regarding hydroxyapatite-based ceramics, although similar to PMMA, are associated with a much higher cost. PMMA remains a cost-effective and proven method to repair cranial defects that fulfills the goals of cranial reconstruction for skull defects.

Cuboid subluxation: a case study and review of the literature.

Cuboid subluxation involves displacement of the cuboid, resulting in pain and problems with push off during dancing or running. Its incidence varies with the population being studied, being apparently highest in ballet dancers. Most cuboid subluxations are plantar and medial, with rare dorsal subluxations. Diagnosis rests on adequate clinical evaluation, and traditional imaging tends to be unhelpful. Ultrasound imaging may offer some insights, although much remains to be learned about this imaging modality in cuboid subluxation. Treatment focuses on conservative measures, including cuboid manipulation, bracing and taping, activity modification, and orthotics. Immobilization may be warranted in cases in which instability is noted, such as after acute traumatic injury. Most athletes and dancers with this disorder return to full participation after successful treatment. Adequate awareness and understanding of this condition will lead to improved diagnosis and outcomes.

Sports medicine practice economics part 1: coding basics.

Proper understanding of coding, billing, and other practice economics issues in sports medicine is vital for practice success. Lack of accuracy and understanding in these areas may lead to problems that range from lost income to practice audits and potentially steep fines. A basic understanding of current procedural terminology (CPT), awareness of international classification of diseases (ICD-9) and healthcare common procedure coding system (HCPCS) codes, and the knowledge of how to apply them benefit sports medicine physicians.

Sports medicine practice economics part 2: consultations, modifiers, and other codes.

Physicians face numerous challenges related to sports medicine practice economics, including coding and billing for consultations. Some of this difficulty stems from a lack of widespread recognition of sports medicine as a specialty. To further complicate matters, many insurance companies refuse to recognize dual credentials in both family medicine and sports medicine. Physicians can better position themselves for appropriate reimbursement from third-party payers by becoming familiar with modifiers and related codes for various sports medicine services, including fracture care, injections and arthrocentesis, and osteopathic mobilization.

Sports medicine practice economics part 3: billing, collecting, appeals, and related tasks.

Knowledge about proper coding in sports medicine will not benefit a physician or his or her practice if bills submitted to insurance companies are not regularly monitored and analyzed for trends. Physicians can help ensure successful collections by understanding the dynamics of reimbursement, enlisting the efforts of office colleagues, and facilitating patient involvement when appropriate. This is the third article in a three-part series about economics issues encountered in a sports medicine practice. The authors are not certified coding experts, and the articles are not meant to serve as a definitive guide to billing and coding in sports medicine, but rather to provide insight into this poorly understood and complex area of medicine that can make or break a practice. The first article, on coding basics, appeared in May, and the second, on advanced sports medicine coding, appeared in June.