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High offset liners help to restore soft tissue tension after primary total hip arthroplasty (THA). However, prior research has reported increased rates of aseptic loosening when using offset components. The purpose of this study was to examine the postoperative complication and revision rates of neutral vs offset acetabular liners at our institution. Two hundred eight primary THAs in 206 patients performed between 2016 and 2018 using neutral or offset liners were reviewed. All patients had a minimum 2-year clinical follow-up (mean, 3.3 years; range, 2.0-5.7 years). Postoperative complications and revision surgeries were reviewed. All offset liners were 4 mm in thickness. Twelve (10.0%) complications occurred in the neutral liner group, and 13 (14.8%) complications occurred in the offset liner group. Two cases of aseptic loosening occurred in the neutral liner group, with no cases reported in the offset liner group. Nine cases (7.5%) in the neutral group required revision surgery, whereas 3 cases in the offset group required revision surgery. Chi-square analysis found no difference between the groups in the rate of postoperative complications, χ 2 (1, N=208)=1.09 ( P >.05), or the rate of revision, χ 2 (1, N=208)=1.56 ( P >.05). We found no significant differences between the neutral and offset groups regarding the rates of postoperative complications, aseptic loosening, or revision surgery. Our findings suggest that contemporary high offset liners, up to 4 mm, are safe and effective when attempting to restore native hip mechanics after THA. [ Orthopedics . 202x;4x(x):xx–xx.]

The aim of this study was to evaluate the radiographic and clinical outcomes of a recently introduced metaphyseal cone system for revision TKA.73 revision TKAs in 72 patients were retrospectively reviewed. All patients had a minimum of 2-year clinical follow-up (mean 34.1 months; range 24.0 to 50.3 months). 114 Metaphyseal cones (64 tibial and 50 femoral) of a single manufacturer were implanted. The most common indications for revision were aseptic loosening (56.9%), second stage reimplantation for periprosthetic joint infection (PJI; 26.4%), and instability (12.5%). All femoral and tibial stems were press-fit cementless stems.Ten of 72 patients underwent re-revision: six for infection (8.3%), two for instability (2.8%), one (1.4%) for patellar tendon rupture and one (1.4%) for femoral component loosening (a cone was not utilized at index revision). Two patients had loose cones (one with an isolated tibial cone and one with both femoral and tibial cones) associated with loose implants but declined re-revision. Aseptic survivorship of our patient cohort free from any re-revision surgery was 95.9% at 2 years (95% CI 87.4-98.7%) and 96.5% of cones demonstrated radiographic evidence of osseointegration. At 2-years, the Knee Society Score (KSS) improved from a mean of 17.2 points preoperatively to 57.8 points (p .0001).Porous-coated metaphyseal cones from this manufacturer demonstrate excellent aseptic survivorship and radiographic evidence of osseointegration similar to prior designs when used with cementless stems.

Revision total hip arthroplasties (THA) are time-consuming, expensive, and technically challenging. Today's Current Procedural Terminology (CPT) codes and relative value units (RVU) may in fact disincentivize surgeons to perform revision THAs. Our study reviewed labor and time investments for each component-specific revision THA and analyzed the gap between procedural value billed and final reimbursement.A retrospective review of 165 primary and revision THAs were validated using operative notes and billing records. We stratified revision THAs by standard CPT coding (with modifiers) as single acetabular component, single femoral component, femoral head plus polyethylene liner (head/liner) exchange, all-components, and spacer placement for infection. Operative time, RVUs, total charges, deductions, and final reimbursement data was collected. Mann-Whitney U tests studied final reimbursement per minute vs per RVU in revision and primary THAs.Our cohort consisted of 27 primary THAs, 26 acetabular component revisions, 32 head/liner exchanges, 26 femoral component revisions, 27 all-component revisions, and 27 spacer placements. Compared to primary THAs, every revision subgroup except for head/liner exchanges were found to reimburse less per minute and all revision subgroups reimbursed less per RVU (P.05).Physicians face less reimbursement per minute and per RVU for revision THAs. With cuts in reimbursement set forth by Centers for Medicare and Medicaid Services (CMS) and insurers, revisions may be financially unfavorable. This ultimately will lead to an impending access to care problem in the future. Our study supports the need to re-examine the RVU allocation amongst revision THAs and evaluate changes to the Current Procedural Terminology (CPT) coding system.

Revision total knee arthroplasties (TKA) are costly, time-intensive, and technically demanding procedures. There are concerns regarding the valuation of Current Procedural Terminology (CPT) codes and the assigned relative value units (RVU) as a potential disincentive to perform revision TKAs. This study evaluated the labor and time investment for each component-specific revision and assessed the disparities between procedural value billed and reimbursement.A retrospective review of 154 primary and revision TKA cases were thoroughly vetted using operative notes and internal billing data. Revision TKAs were stratified by single femoral component, single tibial component, polyethylene liner only, all-component, and spacer placement for prosthetic infection. Operative time, RVUs billed, total charges, deductions, and reimbursements were recorded. Mann-Whitney U tests compared final reimbursement per minute and per RVU between revision and primary TKAs.There were 28 primary TKAs, 11 femoral component revisions, 25 tibial component revisions, 25 liner exchanges, 37 all-component revisions, and 28 spacer placements. Revisions involving the tibial component, all-components, and placement of spacers were reimbursed less dollars per minute than primary TKAs (P.05). Controlling for RVUs, liner exchanges and all-component revisions had fewer dollars per RVU than primary TKAs (P.05).As revision complexity increases, physicians face less reimbursement per minute and per RVU. With reductions set by CMS and private insurers, revisions may be financially unfavorable and lead to restrictions and access to care problems. Our data supports the need for reevaluating RVU allocation amongst revision procedures with potential updates to the CPT coding system.

PURPOSE: Delivering care for immunocompromised, high-risk patients with cancer during a pandemic has proven challenging. Patients with cancer on chemotherapy have a high risk of mortality if contracted COVID-19. If a patient goes directly to the emergency room, multiple contact points with other individuals can lead to unnecessary exposures from any airborne virus, such as COVID-19. Our cancer center has implemented an isolated clinic with personal protective equipment and direct access to a COVID-19 rule-out floor to manage those with febrile neutropenia (FN). METHODS: We implemented an outpatient, isolated, extended-hour clinic with access to personal protective equipment, laboratories, and antibiotics for patients with FN as a pilot project from April 1 to December 31, 2020, with the aim to decrease emergency department (ED) visits for FN by 50%. RESULTS: Since the implementation of our clinic, we have screened 74 unique patients during 102 visits, of which 76 led to a discharge and 26 led to a direct admit, thus avoiding the ED. Thirty-nine of these visits were for patients with recent travel or a known COVID-19 exposure. Bringing these patients to our isolated clinic ensured safety of the approximately 200 patients undergoing active treatment in our infusion center daily. CONCLUSION: Implementing this clinic has thus far successfully decreased the social footprint of our highest-risk patients with cancer in the ED considerably. Our efforts and hopes of decreasing the possible exposure of our immunocompromised patients to COVID-19 as well as the unnecessary exposure of the infusion center patients and personnel have thus far been effective.

Background & aims Burnout among transplant hepatologists has not been well-characterized. The goal of this study was to describe the prevalence and predictors of burnout among practicing transplant hepatologists in the United States. Methods We designed a 69-item survey, including the Maslach Burnout Inventory - Human Services Survey (MBI-HSS) and questions on provider demographics, practice characteristics, and psychological factors. The survey was administered to practicing U.S. transplant hepatologists between October and December 2019. We described burnout using MBI subscales [emotional exhaustion (EE), depersonalization (DP), personal accomplishment (PA)] and determined significant predictors of burnout, which we defined as high EE, using univariate and multivariate analyses. Results A total of 185 transplant hepatologists completed the survey (response rate= 25% of 738 practicing transplant hepatologists in the US). Forty percent reported high EE, while 17% and 16% reported high DP and low PA, respectively. On multivariate analysis, respondents with more than five colleagues (odds ratio [OR], 95% confidence interval [CI]: 0.44 (0.23-0.84)), reporting adequate time for outpatient visits (OR 0.42 [0.22-0.80]), reporting greater comfort with their clinical caseload (OR 0.58 [0.37-0.91]) and reporting higher confidence in their prior training (OR 0.59 [0.29-0.86]) had a lower likelihood of high EE. Working six or more hours from home outside of work per week (OR 2.04, [1.07-3.89]) predicted a higher likelihood of burnout. Compensation, age, gender, career phase, caregiver status, and transplant center volume did not predict burnout. Conclusion Forty percent of transplant hepatologists experienced burnout, predicted mostly by factors related to work-time distribution, peer support, and affect. These findings should prompt development of system-level initiatives.

Background In 2020, the United States Preventive Services Taskforce recommended one-time Hepatitis C virus (HCV) screening for all adults aged 18-79. As the largest provider of HCV treatment in the US the Veterans Health Administration (VA) is committed to implementing these recommendations; thus, understanding perspectives of primary care teams towards this is critical. Methods We disseminated a 24-item online survey to PCPs at the VA Greater Los Angeles Healthcare System (VAGLAHCS), serving 1.5 million Veterans within an area that spans five counties. Our sample included physicians, pharmacists, nurse practitioners, and physician assistants on primary care teams. Our survey contained questions on demographics, provider knowledge of HCV testing, practice patterns and beliefs, and preferences for new screening tools. Descriptive statistics were completed and we compared item responses across demographics. Hypothesis testing was performed using Wilcoxon rank sum test for continuous variables and Fisher’s exact or Chi-square tests for categorical variables. Results In total, 107 PCPs responded to the survey (107/385=28% response rate), with 100 complete responses. Most respondents were women (63%) with median age of 42 years, physicians (53%), Internal Medicine-trained (47%), and of Asian descent (45%). A majority (59%) were aware of new screening recommendations. Most PCPs reported confidence (71%), intent (77%), and commitment towards (82%) HCV screening. Only 38% reported remembering to screen Veterans regularly. Physicians were most aware of new recommendations (73%), compared to pharmacists (55%) and nurse practitioners (42%). The most strongly preferred strategies to enhance screening included automatic test orders during physician visits (71%), automatic electronic-consults (68%), clinician reminders for HCV screening (57%), and opt-out phlebotomy (48%). Conclusion In a sample of providers within a large and diverse VA, 3 in 5 PCPs were aware of new universal HCV screening recommendations. There is high motivation among PCPs to perform screening, but forgetting to screen is still common. Several strategies to augment universal HCV screening were acceptable towards PCPs. Disclosures Debika Bhattacharya, MD, MSc, Gilead: Grant/Research Support|Regeneron: Grant/Research Support.

Background Although universal Hepatitis C Virus (HCV) Screening in the US was recommended in 2020, the optimal implementation method is unknown. We characterized the efficacy of an automated letter HCV screening program at the Veteran’s Affairs (VA) Greater Los Angeles Healthcare System (VAGLAHS) and evaluated associations with linkage to care. Methods From January 2017 to May 2020, 14,804 Veterans born between 1945-1965 who did not have an HCV antibody (Ab) test result within the last 10 years and who were within the VAGLAHS catchment area were identified. Veterans were mailed a letter recommending HCV screening via a centralized process. Veterans then used the letter to present to a VA laboratory for HCV Ab testing, which included reflex HCV viral load. Those who were HCV viremic were referred to Hepatology/Infectious Diseases clinics for initiation of HCV treatment. Baseline characteristics of those with subsequent HCV viremia were collected. To determine associations with the first HCV visit (linkage to care), we performed independent chi-squared tests. Flowchart of Automated Letter HCV Screening for Veterans Results A total of 12,875 Veterans were identified, 4,011 (31%) Veterans presented for HCV Ab testing, 167/4011 were HCV Ab + (4.2%), and 69/167 (41.3%) had HCV viremia. Of those viremic, 94 % were male, 26% were African-American, 62% had stable housing, 24% lived >90 miles from the nearest VA clinic, and 17% had cirrhosis. Fifty-five Veterans (80%) were evaluated in a viral hepatitis clinic and 84 % (46/55) initiated HCV treatment (Figure 1). Patients’ housing status (p = 0.02), cirrhosis (p< 0.0001), and distance to clinic (p=0.063) were associated with non-linkage to an initial HCV appointment. Conclusion One third of Veterans approached via mail participated in HCV Ab testing. Overall HCV Ab positivity rates were 4% and nearly half had HCV viremia. The majority of Veterans were linked to care but housing status, cirrhosis, and distance to clinic were associated with non-linkage to care. Automated letter screening is a promising approach to HCV screening, including universal screening. Future research should include investigations of telehealth and e-consults for linkage to care, especially for those who have marginalized housing status and live far from clinic. Disclosures Debika Bhattacharya, MD, MSc, Gilead: Grant/Research Support|Regeneron: Grant/Research Support.

BACKGROUND : Spur cell hemolytic anemia (SCHA) is a rare, acquired, non-immune hemolytic anemia of decompensated cirrhosis resulting from abnormal lipid composition of the red cell membrane. Treatment is limited to red cell transfusion. Data describing prognostic impact, outcomes of liver transplant, and clinical hematologic characteristics of SCHA are absent or limited; published data on SCHA are limited to single-patient case reports and small single-center case series. The independent prognostic impact of SCHA on patients with cirrhosis remains unclear, and it is not known if hemolytic anemia severity has a significant impact on survival of these patients. As a result, SCHA is not formally considered during liver transplant evaluation, and patients do not receive MELD exception points for this diagnosis. METHODS : We performed a multicenter, 24-year observational cohort study of patients with SCHA, retrospectively analyzing hepatic and hematologic parameters, independent predictors of mortality, and long-term outcomes of liver transplant. Strict diagnostic criteria for SCHA were applied, requiring all of the following: (1) decompensated cirrhosis; (2) anemia; (3) objective laboratory evidence of hemolysis; (4) no alternate contributing cause of hemolysis or acanthocytosis; and (5) chart documentation of a confirmed diagnosis of SCHA incorporating peripheral blood film examination. The primary outcome was mortality at 3 months after date of SCHA diagnosis. The impact of hemolytic parameters on 3-month mortality was evaluated utilizing multivariable logistic models. Observed mortality vs. expected mortality (per MELD-Na score and Child-Turcotte-Pugh class) was compared using standardized mortality ratios. Given the limited survival of this population, red cell transfusion dependence was defined as 4 or more units of red cells transfused during the 60-day peri-diagnostic period. RESULTS : Patients: 69 patients with SCHA were included (FIGURE 1). The median (interquartile range) age was 53 (42-59) years; 46.4% were female, and 11 (15.9%) received liver transplant. Alcohol contributed to the etiology of cirrhosis in 53 patients (76.8%). The median (IQR) survival from SCHA diagnosis of patients not receiving liver transplant was 58 (23-113) days. 39 patients (56.5%) were red cell transfusion-dependent. Hematologic parameters are described in TABLE 1. Outcomes of Liver Transplant: All 11 patients undergoing transplant had rapid and complete resolution of SCHA, with an improvement in median hematocrit from 22.1% to 34.6% post-transplant (P=0.001) (TABLE 2) and excellent post-transplant outcomes, with 9 patients still alive after 6.1 years median follow-up. Independent Predictors of Mortality in SCHA: In multivariable logistic models adjusting for age, sex, etiology of cirrhosis, active/recent variceal bleeding, and Child-Turcotte-Pugh score, transfusion dependence had an OR for 90-day mortality of 9.14 (95% CI, 2.46-34.00) and reduced pre-transfusion hematocrit had an OR of 4.73 (95% CI, 1.42-15.82) per 6% decrease; increased red cell transfusion requirement, reduced hemoglobin, increased lactate dehydrogenase, and increased indirect bilirubin were also independently predictive of higher 90-day mortality (FIGURE 2). Performance of MELD-Na and Child-Turcotte-Pugh Scores in Estimating 90-Day Mortality: MELD-Na and Child-Turcotte-Pugh scores consistently significantly underestimated 90-day mortality, with standardized mortality ratios (SMRs) >1 across all scores/classes [MELD-Na 20-29, SMR 2.42 (1.18-4.44); Child-Turcotte-Pugh class B, SMR 4.46 (1.64-9.90)], FIGURE 3. CONCLUSIONS : In this largest study of SCHA to date, SCHA was associated with substantial excess mortality than was predicted by MELD-Na or Child-Turcotte-Pugh scores. Several clinical and laboratory parameters of hemolytic anemia severity, including transfusion burden, hemoglobin, and markers of hemolysis were each independent predictors of 90-day mortality in SCHA. Despite its unique morbidity as a complication of decompensated cirrhosis, outcomes of liver transplant were excellent in all 11 patients undergoing this intervention, with total resolution of SCHA and no evidence of recurrence. These findings should promote greater awareness of SCHA as a clinical entity and broader consideration of MELD exception points for afflicted patients when transplant-eligible. Figure 1 Figure 1. Disclosures Al-Samkari: Novartis: Consultancy; Amgen: Research Funding; Argenx: Consultancy; Rigel: Consultancy; Dova/Sobi: Consultancy, Research Funding; Agios: Consultancy, Research Funding; Moderna: Consultancy.

Individuals with advanced liver disease (AdvLD), such as decompensated cirrhosis (DC) and hepatocellular carcinoma (HCC), have significant palliative needs. However, little research is available to guide health care providers on how to improve key domains related to palliative care (PC). We sought to identify priority areas for future research in PC by performing a comprehensive literature review and conducting iterative expert panel discussions. We conducted a literature review using search terms related to AdvLD and key PC domains. Individual reviews of these domains were performed, followed by iterative discussions by a panel consisting of experts from multiple disciplines, including hepatology, specialty PC, and nursing. Based on these discussions, priority areas for research were identified. We identified critical gaps in the available research related to PC and AdvLD. We developed and shared five key priority questions incorporating domains related to PC. Conclusion: Future research endeavors focused on improving PC in AdvLD should consider addressing the five key priorities areas identified from literature reviews and expert panel discussions., The FIB‐4 index, a simple tool of routine clinical data, was found to independently be associated with need for mechanical ventilation in patients with COVID‐19.

There is a strong association between obstructive sleep apnea (OSA) and cognitive dysfunction. Executive function, attention, verbal/visual long-term memory, visuospatial/constructional ability, and information processing are more likely to be affected, whereas language, psychomotor function, and short-term memory are less likely to be affected. Increased accumulation of As2-amyloid in the brain, episodic hypoxemia, oxidative stress, vascular inflammation, and systemic comorbidities may contribute to the pathogenesis. Patients with OSA should have cognitive screening or formal testing, and patients with cognitive decline should have testing for OSA. Treatment with continuous positive airway pressure may improve cognitive symptoms in the patient with OSA.

Anticipation of patient-specific component sizes prior to total knee arthroplasty (TKA) is essential to avoid excessive cost associated with additional surgical trays and morbidity associated with imperfect sizing. Current methods of size prediction, including templating, are inconsistent and time-consuming. Machine learning (ML) algorithms may allow for accurate TKA component size prediction with the ability to make predictions in real-time. Consecutive patients receiving primary TKA between 2012 and 2020 from two large tertiary academic and six community hospitals were identified. The primary outcomes were the final femoral and tibial component sizes extracted from automated inventory systems. Five ML algorithms were trained with routinely corrected demographic variables (age, height, weight, body mass index, and sex) using 80% of the study population and internally validated on an independent set of the remaining 20% of patients. Algorithm performance was evaluated through accuracy, mean absolute error (MAE), and root mean-squared error (RMSE). A total of 17,283 patients that received one of 9 TKA implants from independent manufacturers were included. The SGB model accuracy for predicting ± 4-mm of the true femoral anteroposterior diameter was 83.6% and for ± 1 size of the true femoral component size was 95.0%. The SGB model accuracy for predicting ± 4-mm of the true tibial medial/lateral diameter was 83.0% and for ± 1 size of the true tibial component size was 97.8%. Patient sex was the most influential feature in terms of informing the SGB model predictions for both femoral and tibial component sizing. A TKA implant sizing application was subsequently created. Novel machine learning algorithms demonstrated good to excellent performance for predicting TKA component size. Patient sex appears to contribute an important role in predicting TKA size. A web-based real-time prediction application was created capable of integrating patient specific data to predict TKA size, which will require external validation prior to clinical use.

Syringomyelia and syringobulbia continue to remain a diagnosis without widely accepted treatment paradigms. Furthermore, the currently available treatment options can be complicated by delayed symptom recurrence and the need for revision surgery. Revision intradural surgery is challenging, and currently, there is a paucity of literature describing safe techniques for revision syringotomy and shunt placement. In this technical report, we present a surgical video describing the technique of revision syringo-subarachnoid shunt placement in a 61-year-old female with a history of multiple intradural surgeries who presented with progressively symptomatic ascending syringobulbia.

BACKGROUND AND AIMS We assessed the burden of nonalcoholic fatty liver disease (NAFLD)-related acute on chronic liver failure (ACLF) among transplant candidates in the United States, along with waitlist outcomes for this population. APPROACH AND RESULTS We analyzed the United Network for Organ Sharing registry from 2005 to 2017. Patients with ACLF were identified using the European Association for the Study of the Liver/Chronic Liver Failure criteria and categorized into NAFLD, alcohol-associated liver disease (ALD), and hepatitis C virus (HCV) infection. We used linear regression and Chow's test to determine significance in trends and evaluated waitlist outcomes using Fine and Gray's competing risks regression and Cox proportional hazards regression. Between 2005 and 2017, waitlist registrants for NAFLD-ACLF rose by 331.6% from 134 to 574 candidates (P

Pancreatic ductal adenocarcinoma (PDA) is characterized by an immune-suppressive tumor microenvironment that renders it largely refractory to immunotherapy. We implemented a multimodal analysis approach to elucidate the immune landscape in PDA. Using a combination of CyTOF, single-cell RNA sequencing and multiplex immunohistochemistry on patient tumors, matched blood and non-malignant samples, we uncovered a complex network of immune-suppressive cellular interactions. These experiments revealed heterogeneous expression of immune checkpoint receptors in individual patients’ T cells and increased markers of CD8+ T cell dysfunction in the advanced disease stage. Tumor-infiltrating CD8+ T cells had an increased proportion of cells expressing an exhausted expression profile that included upregulation of the immune checkpoint TIGIT, a finding that we validated at the protein level. Our findings point to a profound alteration of the immune landscape of tumors, and to patient-specific immune changes that should be taken into account as combination immunotherapy becomes available for pancreatic cancer. Using single-cell RNA sequencing, CyTOF and multiplex immunohistochemistry, Steele et al. survey the immune landscape in pancreatic cancers, adjacent tissue and blood, observing heterogeneous immune checkpoint receptor expression within patients.

Background Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) is an alternative to enteroscopy- and laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Although short-term results are promising, the long-term outcomes are not known. The aims of this study were: (1) to determine the rates of long-term adverse events after EDGE, with a focus on rates of persistent gastrogastric or jejunogastric fistula; (2) to identify predictors of persistent fistula; (3) to assess the outcomes of endoscopic closure when persistent fistula is encountered. Methods This was a multicenter retrospective study involving 13 centers between February 2015 and March 2019. Adverse events were defined according to the ASGE lexicon. Persistent fistula was defined as an upper gastrointestinal series or esophagogastroduodenoscopy showing evidence of fistula. Results 178 patients (mean age 58 years, 79 % women) underwent EDGE. Technical success was achieved in 98 % of cases (175/178), with a mean procedure time of 92 minutes. Periprocedural adverse events occurred in 28 patients (15.7 %; mild 10.1 %, moderate 3.4 %, severe 2.2 %). The four severe adverse events were managed laparoscopically. Persistent fistula was diagnosed in 10 % of those sent for objective testing (9/90). Following identification of a fistula, 5 /9 patients underwent endoscopic closure procedures, which were successful in all cases. Conclusions The EDGE procedure is associated with high clinical success rates and an acceptable risk profile. Persistent fistulas after lumen-apposing stent removal are uncommon, but objective testing is recommended to identify their presence. When persistent fistulas are identified, endoscopic treatment is warranted, and should be successful in closing the fistula.

Head and neck squamous cell carcinomas (HNSCC) are a heterogeneous group of malignancies which make up approximately 5% of all cancers worldwide. Molecular profiling of HNSCC tumors has identified ...

Background: The COVID pandemic has impacted almost every aspect of human interaction, causing global changes in financial, health care, and social environments for the foreseeable future. More than 1.3 million of the 4 million cases of COVID-19 confirmed globally as of May 2020 have been identified in the United States, testing the capacity and resilience of our hospitals and health care workers. The impacts of the ongoing pandemic, caused by a novel strain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have far-reaching implications for the future of our health care system and how we deliver routine care to patients. The adoption of social distancing during this pandemic has demonstrated efficacy in controlling the spread of this virus and has been the only proven means of infection control thus far. Social distancing has prompted hospital closures and the reduction of all non-COVID clinical visits, causing widespread financial despair to many outpatient centers. However, the need to treat patients for non-COVID problems remains important despite this pandemic, as care must continue to be delivered to patients despite their ability or desire to report to outpatient centers for their general care. Our national health care system has realized this need and has incentivized providers to adopt distance-based care in the form of telemedicine and video medicine visits. Many institutions have since incorporated these into their practices without financial penalty because of Medicare’s 1135 waiver, which currently reimburses telemedicine at the same rate as evaluation and management codes (E/M Codes). Although the financial burden has been alleviated by this policy, the practitioner remains accountable for providing proper assessment with this new modality of health care delivery. This is a challenge for most physicians, so our team of national experts has created a reference guide for musculoskeletal and neurologic examination selection to retrofit into the telemedicine experience. Objectives: To describe and illustrate musculoskeletal and neurologic examination techniques that can be used effectively in telemedicine. Study Design: Consensus-based multispecialty guidelines. Setting: Tertiary care center. Methods: Literature review of the neck, shoulder, elbow, wrist, hand, lumbar, hip, and knee physical examinations were performed. A multidisciplinary team comprised of physical medicine and rehabilitation, orthopedics, rheumatology, neurology, and anesthesia experts evaluated each examination and provided consensus opinion to select the examinations most appropriate for telemedicine evaluation. The team also provided consensus opinion on how to modify some examinations to incorporate into a nonhealth care office setting. Results: Sixty-nine examinations were selected by the consensus team. Household objects were identified that modified standard and validated examinations, which could facilitate the examinations.The consensus review team did not believe that the modified tests altered the validity of the standardized tests.Limitations: Examinations selected are not validated for telemedicine. Qualitative and quantitative analyses were not performed. Conclusions: The physical examination is an essential component for sound clinical judgment and patient care planning. The physical examinations described in this manuscript provide a comprehensive framework for the musculoskeletal and neurologic examination, which has been vetted by a committee of national experts for incorporation into the telemedicine evaluation. Key words: COVID, pain, telemedicine, physical examination, spine, shoulder, elbow, hand, hip, knee

Background Despite significant morbidity and mortality among patients with decompensated cirrhosis, reported rates of advance directive (AD) completion and goals of care discussions (GCDs) between patients and providers are very low. We aimed to improve these rates by implementing a hepatologist-led advance care planning (ACP) intervention. Measures Rates of AD and GCD completion, as well as self-reported barriers to ACP. Intervention Provider-led ACP in patients with decompensated cirrhosis without a prior documented AD. Outcomes Sixty-two patients were seen over 115 clinic visits. After the intervention, AD completion rates increased from 8% to 31% and GCD completion rates rose from 0% to 51%. Women (P = 0.048) and nonmarried adults (P = 0.01) had greater changes in AD completion compared to men and married adults, respectively. Needing more time during visits was seen as the major barrier to ACP among providers. Conclusions/Lessons Learned Addressing provider and system-specific barriers dramatically improved documentation rates of ACP.

Background and Aims Reimbursement often presents a significant barrier to widespread adoption of innovative endoscopic devices. We aimed to determine the value (defined as cost savings to a payer) of endoscopic suturing devices in preventing the migration of esophageal stents placed for benign esophageal diseases. Methods A decision-analytic model was constructed from a payer perspective evaluating fully covered metal stent placement for benign esophageal diseases (fistula, leak, perforation, or stricture) in a hospital outpatient setting. The model compared 2 strategies: endoscopic suturing to anchor the stent or no suture. Health care outcomes and costs were derived from published systematic reviews and national databases (U.S. Food and Drug Administration Manufacturer and User Facility Device Experience [MAUDE] for safety data; 2018 Medicare Physician Fee Schedule and Provider Utilization and Payment Data databases for reimbursement data). Results From a payer perspective, reimbursement for care increased by US$1487.98 without endoscopic suturing per patient, compared with US$621.06 with endoscopic suturing, to cover the risk of stent migration in addition to usual professional and facility reimbursement for stent placement. Thus, an average cost saving of US$866.92 per patient was achieved with endoscopic suturing to reduce stent migration risks. Cost savings associated with suturing ranged from US$147.48 to US$1586.36 per patient, based on the indication for the procedure in sensitivity analysis. Cost savings increased with higher rates of technical success in suture placement. Conclusions Creating a defined reimbursement pathway for endoscopic suture fixation of a stent for the treatment of benign esophageal diseases appears to be justified from a payer perspective.