Search

Background The ACGME mandates that residency programs provide training related to high value care (HVC). The purpose of this study was to explore HVC education in general surgery residency programs. Methods An electronic survey was distributed to general surgery residents in geographically diverse programs. Results The response rate was 29% (181/619). Residents reported various HVC components in their curricula. Less than half felt HVC is very important for their future practice (44%) and only 15% felt confident they could lead a QI initiative in practice. Only 20% of residents reported participating in a root cause analysis and less than one-third of residents (30%) were frequently exposed to cost considerations. Conclusion Few residents feel prepared to lead quality improvement initiatives, have participated in patient safety processes, or are aware of patients’ costs of care. This underscores the need for improved scope and quality of HVC education and establishment of formal curricula.

Background Challenging emerging entities with distinctive molecular signatures may benefit from algorithms for diagnostic work-up. Methods Fusion sarcomas (2020–2021, during pandemic) were diagnosed by clinicoradiology, morphology, phenotype, and next-generation sequencing (NGS). Results Six fusion sarcomas in two males and four females involved the chest-wall, neck, or extremities; ages ranged 2-73, median 18 years. Sizes ranged 5.3-25.0, median 9.1 cm. These include high grade 1) TPR-NTRK1 of proximal femur with a larger rounded soft tissue mass, previously considered osteosarcoma yet without convincing tumor matrix. A pathologic fracture necessitated emergency hemipelvectomy (NED) and 2) novel KANK1-NTRK2 sarcoma of bone and soft tissue with spindled pleomorphic to epithelioid features (AWD metastases). 3) Novel ERC1-ALK unaligned fusion, a low grade infiltrative deep soft tissue hand sarcoma with prominent-vascularity, myopericytoid/lipofibromatosis-like ovoid cells, and collagenized stroma, was successfully treated with ALK-inhibitor (Crizotinib), avoiding amputation. These NTRK and ALK tumors variably express S100 and CD34 and were negative for SOX10. 4) and 5) CIC-DUX4 round cell tumors (rapid metastases/demise), one with COVID superinfection, were previously treated as Ewing sarcoma. These demonstrated mild pleomorphism and necrosis, variable myxoid change and CD99 reactivity, and a distinctive dot-like-Golgi WT1 immunostaining pattern. 6) A chest wall/thoracic round cell sarcoma, focal CD34/ keratins/CK7, revealed nuclear-STAT6, STAT6-NAB2 by NGS, confirming malignant solitary fibrous tumor, intermediate-risk-stratification (AWD metastases). Conclusions Recent fusion sarcomas include new KANK1-NTRK2 and ERC1-ALK, the latter successfully treated by targeted-therapy. ALK/NTRK fusion partners TPR and KANK1 suggest unusual high-grade morphology/behavior. Clinicoradiologic, morphologic, and phenotypic algorithms can prompt molecular-targeted immunostains or NGS for final classification and promising inhibitor therapy.

Category: Basic Sciences/Biologics; Ankle; Diabetes; Midfoot/Forefoot Introduction/Purpose: Charcot neuropathic arthropathy (CNA) is a debilitating, rapidly destructive degenerative joint disease that occurs in diabetic, neuropathic midfoot. Clinicoradiologic assessment for CNA previously relied on Eichenholtz Stage. There is limited data on CNA histopathology. The goal of this study was to independently develop a histopathologic scoring system for Charcot neuropathic arthropathy. Methods: Retrieval of surgical pathology specimens from neuroarthropathic CNA patients (2012-2019) were analyzed to evaluate joint soft tissue and bone. Considering progression from large to small periarticular bone fragments to resolution, we devised and applied a CNA FEMASK-score (named after coauthors): 0= intraneural arteriolosclerosis; 1= large bone fragments without host histiocytic response; 2= mixed bone fragments with host histiocytic response; 3= small minute bone spicules resorption to fibrosis. Clinical modified Eichenholtz staging and outcome were then compared the CNA FEMASK-score to assess for associations between these three elements. Results: Forty-eight cases of CNA included 34 males and 14 females, mean age 60.3 and age range 28-83 years, with clinical diabetes mellitus (predominantly Type II) and longstanding neuropathy. Elevated HbA1C, Eichenholtz stage, American Society of Anesthesia score, and Charlson comorbidity index were predictive of amputation. Pathologic specimens varied from fixation tissue to amputation. In addition to neurotraumatic, neurovascular and inflammatory findings, a distinctive intraneural hyalinized arteriolosclerosis was observed. FEMASK-scores:1 = 10%, 2= 58%, and 3=32%. FEMASK-score comparisons were 98% accurate compared with the modified Eichenholtz criteria scores of each patient and 98% reproducible among pathologists. FEMASK 2 and 3 correlates strongly with amputation. Conclusion: Our novel CNA FEMASK-score classification, derived from the largest cohort of diabetic neuropathic specimens, is reproducible, explains pathophysiology, correlates with Eichenholtz, and predicts amputation. The unique intraneural vasculopathy observed contributes to CNA etiology.

Objective: Split-thickness skin graft (STSG) donor site dressings can play an integral role in reducing donor site morbidity. This study tested a novel, chitosan-based wound dressing, Opticell Ag, as an STSG donor site dressing for wounds Method: Between January and December 2016, the chitosan-based dressing was placed on participating patients' donor sites immediately following graft harvest and covered with a transparent occlusive dressing. Pain was evaluated on postoperative day one, before dressing change between days 5–7, and before and after dressing removal between days 10–14 using the Visual Analog Scale (VAS). The extent of re-epithelialisation was determined between day 10–14 and at one month, and healing quality was also evaluated at one month post-operatively using the Vancouver Scar Scale (VSS). Results: A total of 19 patients were recruited, of which 16 completed the study. Patients experienced mild-to-moderate pain in their donor sites when the chitosan-based dressing was used. Pain decreased significantly between postoperative day one and days 10–14, as well as between days 5–7 and 10–14. The mean percentage of re-epithelialisation on days 10–14 was 92% and by one month was 99%. The mean VSS at one month was 3.2±1.4. There were no statistically significant differences between patients' re-epithelialisation rates or VSS scores. There were unplanned dressing changes in four patients. No donor site infections or other adverse events were identified. Conclusion: The chitosan-based dressing tested in this study is safe, effective, and associated with reasonable pain control and acceptable healing quality. The results suggest that it is a promising STSG donor site dressing.

Charcot neuropathic arthropathy is a debilitating, rapidly destructive degenerative joint disease that occurs in diabetic, neuropathic midfoot. Clinicoradiologic assessment for Charcot neuropathic arthropathy previously relied on Eichenholtz stage. There is limited histopathologic data on this entity. We wanted to independently develop a histopathologic scoring system for Charcot neuropathic arthropathy.Retrieval of surgical pathology midfoot specimens from Charcot patients (2012-2019) were analyzed to evaluate joint soft tissue and bone. Considering progression from large (≥half 40× hpf) to small (half 40× hpf) periarticular bone fragments to resolution, we devised and applied a Charcot neuropathic arthropathy novel FEMASK-score (named after coauthors: Fanburg-Smith, Frauenhoffer, Flemming, Fritsche, Elfar, Murie, Aynardi, Stauch, Smith, King, and Klein): 0 (initial) = the observed intraneural arteriolosclerosis in all diabetic neuropathic patient specimens (not observed in other diabetic nerves); and finally scored with the most destruction observed: 1 = large bone fragments without host histiocytic response; 2 = mixed bone fragments with host histiocytic response; 3 = small minute bone spicules resorption to fibrosis. Eichenholtz stage and outcome were then compared.Forty-eight cases of Charcot neuropathic arthropathy included 34 males and 14 females, mean age 60.3 and age range 28-83 years, with clinical diabetes mellitus (predominantly Type II) and longstanding neuropathy. Elevated HbA1C, Eichenholtz stage, American Society of Anesthesia score, and Charlson comorbidity index indicated initial clinical amputation. Pathologic specimens varied from fixation tissue to amputation. In addition to neurotraumatic, neurovascular and inflammatory findings, a distinctive intraneural hyalinized arteriolosclerosis was observed. FEMASK-scores: 1 = 10%, 2 = 58%, and 3 = 32%. Score comparisons were 98% accurate compared with Eichenholtz and 98% reproducible among pathologists. FEMASK 2 and 3 correlate with clinical need for amputation.Our novel Charcot neuropathic arthropathy FEMASK-score classification, derived from the largest cohort of diabetic neuropathic specimens, is reproducible, explains pathophysiologic progression of destructive phase of Charcot, correlates with Eichenholtz, and predicts progression to or clinical need for amputation. The unique intraneural vasculopathy observed contributes to Charcot neuropathic arthropathy etiology.

Negative-pressure wound therapy (NPWT) has become a widely used and well-described treatment for acute and chronic wounds. The authors discuss advantages of XL-NPWT for large burns, infection prevention, promoting re-epithelialization, and fluid management. The techniques are described such as the “total body wrap” or “sandwich” technique, in which affected areas are sandwiched between large polyurethane dressings and silver-impregnated nonadherent foam that is applied to both recipient and donor sites, as well as over any intervening intact skin or burn wound. Although relatively new, XL-NPWT has proven to be safe and effective in treating burns ≥15% TBSA.

Introduction: Worksites are promising venues for promoting health, given considerable time spent at work and opportunities for environmental change. Yet, the impact of worksite wellness programs (WWPs) on diet and adiposity, as well as the most relevant WWP components, are not established. Methods: Following MOOSE and PRISMA guidelines, we conducted a systematic review and meta-analysis of the impact of multi-component WWP trials (RCT or quasi-experimental) on diet and adiposity. Data were extracted in duplicate and pooled using inverse variance random effects meta-analysis. Pre-specified sources of heterogeneity (study design, world region, worksite type, duration, WWP components) were analyzed by meta-regression and subgroup analysis. Funnel plots, Begg’s, and Egger’s tests evaluated potential publication bias. Results: From 6612 abstracts, we identified 48 studies assessing WWPs and diet or adiposity. Most were in the US (54%) or Europe (23%), with diet (64%) and exercise/weight loss (20%) as main targets. Intervention components were variable (Figure). Most common outcomes were intakes of fruits and vegetables (F&V) (19 studies), total fat or fat subtypes (18), and dietary fiber (4); and BMI (35) and waist circumference (WC) (10). Median duration was 12 months (range: 1-48 mo). In pooled analyses, WWP increased intake of F&V, especially fruits (Figure). Significant effects were not identified for dietary fiber, total fat, or fat subtypes. WWP also reduced BMI (Figure) and WC (-2.03 cm, 95% CI:-3.88,-0.20). Trial duration significantly modified effects on BMI (2 ; 12+ mo: -0.16 kg/m 2 ; P-interaction=0.046); but not WC or F&V intake. Additional findings for heterogeneity, including WWP components, and publication bias will be presented. Conclusions: These novel findings support effectiveness of WWP for increasing F&V and reducing BMI and WC.

Background: Because long-term weight gain typically occurs insidiously (~1 lb/y) it is very difficult to study in RCTs and prospective cohorts provide crucial evidence on its key contributors. Most prior studies have evaluated how baseline diet, rather than change in diet that may be more physiologically relevant, relates to future weight gain. Aim: To evaluate and compare different methodological approaches for investigating how diet relates to long-term weight gain. Methods: Participants from 3 separate cohorts, the Nurses Health Study (NHS, n=50,422), Nurses Health Study II (NHS II, n=47,898), and the Health Professionals Follow-up Study (HPFS, n=22,557), free of obesity and chronic diseases at baseline, were included and followed for up to 20 y. Lifestyle, health status, and weight were assessed by questionnaires every 2 y, and diet by validated FFQ every 4 y. We assessed 3 different analytic approaches, including relations of 1) baseline diet at the start of each 4 y with weight change in the next 4 y; 2) 4-y change in diet with weight change in the same 4 y; and 3) 4-y change in diet with lagged weight change in the next 4 y. We compared these approaches evaluating consistency across cohorts, magnitudes of associations, and biological plausibility of findings. Results: Across the three methods, consistent, robust, and biologically plausible associations were only seen between changes in diet and changes in weight in the same 4 y (Figure). Findings evaluating baseline diet and lagged dietary change were less consistent across cohorts, far smaller in magnitude, and often not biologically plausible, suggesting presence of both bias and misclassification of the true relevant dietary metric. Conclusions: The methods used to analyze dietary habits and long-term weight gain are crucial. The most robust, biologically relevant, and consistent findings are seen when evaluating dietary change and weight change in discrete periods.

Poor diet is the leading cause of cardiovascular disease in the USA and globally. Evidence-based policies are crucial to improve diet and population health. We reviewed the effectiveness for a range of policy levers to alter diet and diet-related risk factors. We identified evidence to support benefits of focused mass media campaigns (especially for fruits, vegetables, salt), food pricing strategies (both subsidies and taxation, with stronger effects at lower income levels), school procurement policies (for increasing healthful or reducing unhealthful choices), and worksite wellness programs (especially when comprehensive and multicomponent). Evidence was inconclusive for food and menu labeling (for consumer or industry behavior) and changes in local built environment (e.g., availability or accessibility of supermarkets, fast food outlets). We found little empiric evidence evaluating marketing restrictions, although broad principles and large resources spent on marketing suggest utility. Widespread implementation and evaluation of evidence-based policy strategies, with further research on other strategies with mixed/limited evidence, are essential "population medicine" to reduce health and economic burdens and inequities of diet-related illness worldwide.