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Context: The established relationship between lymph node metastasis and prognosis in colorectal cancer suggests that recurrence in 25% of patients with lymph nodes free of tumor cells by histopathology (pN0) reflects the presence of occult metastases. Guanylyl cyclase 2C (GUCY2C) is a marker expressed by colorectal tumors that could reveal occult metastases in lymph nodes and better estimate recurrence risk.Objective: To examine the association of occult lymph node metastases detected by quantifying GUCY2C messenger RNA, using the reverse transcriptase-polymerase chain reaction, with recurrence and survival in patients with colorectal cancer.Design, Setting, and Participants: Prospective study of 257 patients with pN0 colorectal cancer enrolled between March 2002 and June 2007 at 9 US and Canadian centers (7 academic medical centers and 2 community hospitals) provided 2570 fresh lymph nodes measuring 5 mm or larger for histopathology and GUCY2C messenger RNA analysis. Patients were followed up for a median of 24 months (range, 2-63 months) for disease recurrence or death.Main Outcome Measures: Time to recurrence (primary outcome) and disease-free survival (secondary outcome) relative to expression of GUCY2C in lymph nodes.Results: Thirty-two patients (12.5%) had lymph nodes negative for GUCY2C (pN0 [mol-]), and all but 2 remained free of disease during follow-up (recurrence rate, 6.3%; 95% confidence interval [CI], 0.8%-20.8%). Conversely, 225 patients (87.5%) had lymph nodes positive for GUCY2C (pN0 [mol+]), and 47 developed recurrent disease (20.9%; 95% CI, 15.8%-26.8%) (P = .006). Multivariate analyses revealed that GUCY2C in lymph nodes was an independent marker of prognosis. Patients who were pN0 (mol+) exhibited earlier time to recurrence (adjusted hazard ratio, 4.66; 95% CI, 1.11-19.57; P = .04) and reduced disease-free survival (adjusted hazard ratio, 3.27; 95% CI, 1.15-9.29; P = .03).Conclusion: Expression of GUCY2C in histologically negative lymph nodes appears to be independently associated with time to recurrence and disease-free survival in patients with pN0 colorectal cancer. [ABSTRACT FROM AUTHOR]

Objective: Colorectal cancer screening (CRCS) uptake in the US remains low. The purpose of this study was to use qualitative methods to characterize partner support and influence regarding CRCS decisions among couples who were both either adherent or non-adherent with CRCS.Methods: Eighteen couples were interviewed regarding their discussions about CRCS and support and influence strategies used. Analyses were guided by the Interdependence Model.Results: Direct and indirect partner effects were found. Direct partner effects were evidenced when the impact of one spouse on the CRCS decision of the other was clearly defined and intended. Three direct partner effect themes were leadership, persuasion, and partnership. Indirect partner effects were evidenced by one spouse considering the information, experience, or actions of the other in ways that informed CRCS decision-making, even if that influence was not intentional or specifically directed at CRCS. Three indirect partner effect themes were companionship, support, and peer socialization.Conclusion: Spouse influence plays a role in CRCS decisions. Individuals view CRCS as being important to the health and quality of their relationship.Practice Implications: With this increased understanding of the interpersonal context of CRCS, it may be possible to include close others in interventions to improve CRCS. [ABSTRACT FROM AUTHOR]

Atherosclerotic disease in the vessels that supply the cervical spine may lead to degenerative disease. In angina pectoris (AP), atherosclerotic disease leads to coronary vessel occlusion and resulting symptoms. This study aims to determine the relationship between AP and neck pain. Analysis was focused on respondents who had a history of cervical pain disorders, adjusting for demographic, education, and mental health confounders. A total of 30,461 participated in the survey. Of 1,049 respondents, 21% reported neck pain. Mean age of the respondents was 62.6 ± 16.1 years. Nonwhite race, current everyday smokers, lower family income, hypertension, and diabetes had higher prevalence of neck pain (p < 0.05). On multivariate analysis, AP was associated with increased odds of neck pain (odds ratio [OR] = 1.42 [95% confidence interval (CI) 1.04 to 1.92], p = 0.026). AP was independently associated with 42% increased odds of having neck pain. Further study into the association of cardiovascular disease with degenerative disc disease pain should be performed. (Journal of Surgical Orthopaedic Advances 33(2):093-096, 2024).

Study Design: Retrospective radiographic review., Objective: The objectives of the study were to determine the contributions to lumbar lordosis (LL) through both the vertebrae and the intervertebral disc (IVD), and to investigate the relationships between lumbar sagittal spine measurements and age and gender., Summary of Background Data: A small body of literature exists on the relative contributions of vertebral body and IVD morphology to LL, the effects of L4-S1 on overall LL, and the relationships/correlations between lumbar sagittal spine measurements., Methods: Patients who met the inclusion criteria were retrospectively evaluated. Measurements included LL, pelvic incidence (PI), and % contributions of vertebral body wedging/IVD wedging/L4-S1 to LL. Patients were separated into groups by age and sex, demographic data were collected, and statistical analysis was completed., Results: LL decreased with age, although PI remained similar. Females demonstrated increased LL and vertebral body wedging % than males. Males demonstrated increased L4-S1% than females. Despite a decrease in LL with age, patients maintained L4-S1% and IVD wedging %. There was a significant negative relationship between PI and IVD wedging, PI and L4-S1%, and LL and L4-S1%., Conclusions: During aging, the lumbar spine loses LL linearly. This occurs in the IVD and vertebral bodies. Females have increased LL compared with males, because of an increase in vertebral body wedging and IVD/vertebral wedging cranial to L4. In patients with high PI or LL, increased LL occurs from cranial to L4 and from vertebral body wedging., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Effective implementation of cancer screening programs can reduce disease-specific incidence and mortality. Screening is currently recommended for breast, cervical, colorectal and lung cancer. However, initial and repeat adherence to screening tests in accordance with current guidelines is sub-optimal, with the lowest rates observed in historically underserved groups. If used in concert with recommended cancer screening tests, new biospecimen-based multi-cancer early detection (MCED) tests could help to identify more cancers that may be amendable to effective treatment. Clinical trials designed to assess the safety and efficacy of MCED tests to assess their potential for reducing cancer mortality are needed and many are underway. In the conduct of MCED test trials, it is crucial that participant recruitment efforts successfully engage participants from diverse populations experiencing cancer disparities. Strategic partnerships involving health systems, clinical practices, and communities can increase the reach of MCED trial recruitment efforts among populations experiencing disparities. This goal can be achieved by developing health system-based learning communities that build understanding of and trust in biomedical research; and by applying innovative methods for identifying eligible trial patients, educating potential participants about research trials, and engaging eligible individuals in shared decision making (SDM) about trial participation. This article describes how a developing consortium of health systems has used this approach to encourage the uptake of cancer screening in a wide range of populations and how such a strategy can facilitate the enrollment of persons from diverse patient and community populations in MCED trials., Competing Interests: AB holds equity stake in MeTree and You, Inc. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Thompson, Buchanan, Myers and Weinberg.)

This case offers a safe and effective method for treating lumbopelvic dissociation in a pediatric patient with cauda equina syndrome using a triangular osteosynthesis construct. After a high-speed accident, an 11-year-old girl was admitted to the hospital with bowel and bladder incontinence and bilateral lower extremity weakness. The orthopaedic trauma and spine teams elected for surgical treatment with a triangular osteosynthesis construct, a procedure usually reserved for adults. The surgery was uncomplicated, and the patient experienced complete resolution of her preoperative symptoms. She is doing well over 1-year postoperatively, with full neurologic recovery, maintained reduction, bony healing, and subsequent implant removal. To our knowledge, this is the youngest reported case of lumbopelvic dissociation treated in this manner and represents a viable treatment option., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: While the influences of acetabular dysplasia and overcoverage on hip arthritis have been studied, the impact of femoral neck-shaft angle on hip arthritis is much more poorly understood. The purpose of this study is to determine if a relationship exists between neck shaft angle and the development of osteoarthritis, a better understanding of which would be useful to surgeons planning osteotomies about the hip., Methods: 533 cadaveric femora and acetabulae (1066 total) from the Hamann-Todd Osteological Collection (Cleveland, OH) were acquired. We measured true neck shaft angle using an AP photograph with the femoral neck parallel to the table. Femoral head volume to acetabular volume ratio, representing femoral head coverage, as well as femoral version were utilised. Correlation between neck shaft angle, femoral version, femoral head coverage and osteoarthritis were evaluated with multiple regression analysis., Results: The mean age and standard deviation was 56 ± 10 years. There were 64 females (12%) and 469 males. There were 380 Caucasians (71%) and 153 African-Americans. Mean femoral version was 11° ± 12° and mean true neck shaft angle was 127.7° ± 5.9° There was a strong correlation between age and arthritis (standardised beta 0.488, p  < 0.001). There was a significant correlation between increasing true neck shaft angle and decreasing hip arthritis (standardised beta -0.024, p  = 0.038). In the femoral head overcoverage subset, increasing true neck shaft angle was still significantly associated with decreasing hip arthritis (standardised beta -0.088, p  = 0.018), although this relationship was not significant with femoral head undercoverage subset., Conclusions: With sufficient acetabular coverage, a relative increase in femoral neck shaft angle within the physiologic range is associated with decreased hip osteoarthritis., Clinical Relevance: An understanding of the relationship between femoral neck shaft angle and hip osteoarthritis could be useful for surgeons planning pelvic or proximal femur osteotomies in children.

Background Context: Arthrodesis is important for the success of posterior cervical fusion (PCF), however, there exists limited data regarding the safety and efficacy of bone morphogenic protein (BMP) in PCF., Purpose: The primary objective was to evaluate early postoperative complications associated with BMP in PCF and determine whether BMP leads to adverse early clinical outcomes. A secondary objective was to determine the optimal location for BMP sponge placement, within the facet joint (IF) or elsewhere, and the optimal dosage/level., Design: Retrospective, consecutive case-control study., Patient Sample: Seven hundred sixty-five patients who underwent PCF OUTCOME MEASURES: Patient-reported outcomes (PROs), complications, arthrodesis, optimum dose/level of BMP METHODS: Surgical data, including preoperative diagnosis, levels fused, type of bone graft, BMP dose (when used), and fusion technique were recorded. Complications were assessed by reviewing the medical record encompassing the first 6-weeks postoperative. These included medical, neurological, and wound-related complications and reoperation. Neurological complications were defined as any new weakness, radicular pain, or numbness. PROs were collected, including SF36, VAS, EQ-5D, and NDI scores. To determine the optimal dosage and location for BMP placement, a sub-analysis was performed., Results: There were no significant differences between the BMP and no BMP group with regards to wound complications, neurological complications, or reoperation. There were no differences in PROs between BMP and no BMP. Placement of BMP for IF and at a dose of 0.87 mg/level minimized wound-related complications. The BMP group had a higher fusion rate compared to the no BMP group (96% vs. 91%, p=.02) when assessed 1 year post-operatively., Conclusion: BMP was not associated with a higher rate of early complications after PCF when the dose was minimized. Complications thought to be associated with BMP, such as compressive seroma, radiculitis, and wound-related complications were not seen at a higher rate. PROs at early follow-up were similar. Placement of BMP for IF and at lower doses than previously reported may minimize complications., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The etiology of patellofemoral disorders is multifactorial. Preoperative patellofemoral anatomy evaluation is of great importance in patients undergoing surgery for patellofemoral disorders. Although anatomical risk factors of patellofemoral disorders have been thoroughly investigated in clinical and radiological studies, there are sparse data regarding the association between trochlear dysplasia with other anatomical parameters. This study sought to explore those associations using a large osteological collection., Methods: Five-hundred and seventy-nine cadaveric skeletons were obtained from the Hamann-Todd osteological collection. Mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), femoral version, tibial torsion, lateral position of the tibial tubercle, and femoral length were modeled as predictors of medial and lateral flange height of the distal femur trochlea at various degrees of knee flexion., Results: The average age and standard deviation for the 1158 lower extremities analyzed was 55.9 ± 10.2 years. There were 500 males (86%) and 79 females. Increasing MPTA or tibial valgus predicted increasing lateral femoral flange height at 0, 30, and 50 degrees of knee flexion [(standardized beta 0.111, p = 0.01), (standardized beta 0.129, p < 0.001), and (standardized beta 0.186, p < 0.001), respectively]. Increasing internal tibial torsion predicted increased medial flange height at 30 and 50° [(standardized beta - 0.114, p = 0.006), (standardized beta - 0.108, p = 0.006), respectively]. Increased femoral retroversion predicted increasing lateral flange height at 0 and 30 degrees [(standardized beta - 0.105, p = 0.005), (standardized beta - 0.098, p = 0.004), respectively]., Conclusions: To maintain the equilibrium necessary for effective patellar tracking, the depth of trochlear groove appears to effectively compensate for some of the anatomical parameters of the proximal tibia associated with patellofemoral disorders, and appears to be less influenced by femoral alignment. The clinical relevance of these findings warrants further investigation, and emphasizes the importance of carefully assessing the lower limb alignment in the management of patellofemoral disorders., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Most safety and efficacy trials of the SARS-CoV-2 vaccines excluded patients with cancer, yet these patients are more likely than healthy individuals to contract SARS-CoV-2 and more likely to become seriously ill after infection. Our objective was to record short-term adverse reactions to the COVID-19 vaccine in patients with cancer, to compare the magnitude and duration of these reactions with those of patients without cancer, and to determine whether adverse reactions are related to active cancer therapy., Patients and Methods: A prospective, single-institution observational study was performed at an NCI-designated Comprehensive Cancer Center. All study participants received 2 doses of the Pfizer BNT162b2 vaccine separated by approximately 3 weeks. A report of adverse reactions to dose 1 of the vaccine was completed upon return to the clinic for dose 2. Participants completed an identical survey either online or by telephone 2 weeks after the second vaccine dose., Results: The cohort of 1,753 patients included 67.5% who had a history of cancer and 12.0% who were receiving active cancer treatment. Local pain at the injection site was the most frequently reported symptom for all respondents and did not distinguish patients with cancer from those without cancer after either dose 1 (39.3% vs 43.9%; P=.07) or dose 2 (42.5% vs 40.3%; P=.45). Among patients with cancer, those receiving active treatment were less likely to report pain at the injection site after dose 1 compared with those not receiving active treatment (30.0% vs 41.4%; P=.002). The onset and duration of adverse events was otherwise unrelated to active cancer treatment., Conclusions: When patients with cancer were compared with those without cancer, few differences in reported adverse events were noted. Active cancer treatment had little impact on adverse event profiles.

Previous studies have attempted to characterize patellar morphology and its relation to patellofemoral osteoarthritis but have utilized relatively small samples. We designed a large-scale cadaveric analysis to elucidate any potential relationship. Patellar morphology in 1,032 patellae was characterized using patellar facet concavity patterns initially developed by Wiberg and using the ratio of the lateral and medial facet lengths. Patellofemoral arthritis grading for specimens was previously completed based primarily on osteophytic burden. The average age at time of death was 56 ± 10 years. Wiberg's grading returned kappa values of 0.43 for intrarelator reliability and 0.27 for interrelator reliability. Using multiple regression analysis, Wiberg's type II was found to be correlated with patellofemoral arthritis ( p  = 0.003). Lateral to medial facet ratio measurements returned intraclass coefficients of 0.91 for intrarelator reliability and 0.85 for interrelator reliability. There was no association between lateral to medial facet ratio and osteoarthritis. Regression analysis between Wiberg's typing and lateral-to-medial ratio (L:M) resulted in a coefficient of determination of 0.14. To our knowledge, this is the largest study evaluating the relationship between patellar morphology and arthritis. Although there was a relationship between Wiberg's type II and patellofemoral arthritis, the Wiberg systems was not easily reproducible in our study and returned a correlation with arthritis different then anatomically expected. A more reproducible system of lateral to medial facet ratio was investigated but did not find an association with arthritic changes. Given these findings, we did not find a patella morphology grading system which is both reliable and valid in regard to association with patellofemoral arthritis., Competing Interests: None declared., (Thieme. All rights reserved.)

Objectives: The FACS, GILDA, and COLOFOL trials have cast doubt on the value of intensive extracolonic surveillance for resected nonmetastatic colorectal cancer and by extension metastasectomy. We reexamined this pessimistic interpretation. We evaluate an alternative explanation: insufficient power to detect a realistically sized survival benefit that may be clinically meaningful., Methods: A microsimulation model of postdiagnosis colorectal cancer was constructed assuming an empirically plausible efficacy for metastasectomy and thus surveillance. The model was used to predict the large-sample mortality reduction expected for each trial and the implied statistical power. A potential recurrence imbalance in the FACS trial was investigated. Goodness of fit between model predictions and trial results were evaluated. Downstream life expectancy was estimated and power calculations performed for future trials evaluating surveillance and metastasectomy., Results: For all 3 trials, the model predicted a mortality reduction of ≤5% and power of <10%. The FACS recurrence imbalance likely led to a large relative bias (>2.5) in the hazard ratio for overall survival favoring control. After adjustment, both COLOFOL and FACS results were consistent with model predictions (P>.5). A 2.6 (95% credible interval 0.5-5.1) and 3.6 (95% credible interval 0.8-7.0) month increase in life expectancy is predicted comparing intensive extracolonic surveillance-routine computed tomography scans and carcinoembryonic antigen assays-with 1 computed tomography scan at 12 months or no surveillance, respectively. An adequately sized surveillance trial is not feasible. A metastasectomy trial should randomize at least 200 to 300 patients., Conclusions: Recent trial results do not warrant de novo skepticism of metastasectomy nor targeted extracolonic surveillance. Given the potential for clinically meaningful life-expectancy gain and significant uncertainty, a trial of metastasectomy is needed., (Copyright © 2021 International Society for Pharmacoeconomics and Outcomes Research, Inc. Published by Elsevier Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To identify the patient, injury, and treatment factors associated with an acute infection during the treatment of open ankle fractures in a large multicenter retrospective review. To evaluate the effect of infectious complications on the rates of nonunion, malunion, and loss of reduction., Design: Multicenter retrospective review., Setting: Sixteen trauma centers., Patients: One thousand and 3 consecutive skeletally mature patients (514 men and 489 women) with open ankle fractures., Main Outcome Measures: Fracture-related infection (FRI) in open ankle fractures., Results: The charts of 1003 consecutive patients were reviewed, and 712 patients (357 women and 355 men) had at least 12 weeks of clinical follow-up. Their average age was 50 years (range 16-96), and average BMI was 31; they sustained OTA/AO types 44A (12%), 44B (58%), and 44C (30%) open ankle fractures. The rate FRI rate was 15%. A multivariable regression analysis identified male sex, diabetes, smoking, immunosuppressant use, time to wound closure, and wound location as independent risk factors for infection. There were 77 cases of malunion, nonunion, loss of reduction, and/or implant failure; FRI was associated with higher rates of these complications (P = 0.01)., Conclusions: Several patient, injury, and surgical factors were associated with FRI in the treatment of open ankle fractures., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Guanylyl cyclase C (GUCY2C) is a tumor-suppressing receptor silenced by loss of expression of the luminocrine hormones guanylin and uroguanylin early in colorectal carcinogenesis. This observation suggests oral replacement with a GUCY2C agonist may be an effective targeted chemoprevention agent. Previous studies revealed that linaclotide, an oral GUCY2C agonist formulated for gastric release, did not persist to activate guanylyl cyclase signaling in the distal rectum. Dolcanatide is an investigational oral uroguanylin analog, substituted with select D amino acids, for enhanced stability and extended persistence to activate GUCY2C in small and large intestine. However, the ability of oral dolcanatide to induce a pharmacodynamic (PD) response by activating GUCY2C in epithelial cells of the colorectum in humans remains undefined. Here, we demonstrate that administration of oral dolcanatide 27 mg daily for 7 d to healthy volunteers did not activate GUCY2C, quantified as accumulation of its product cyclic GMP, in epithelial cells of the distal rectum. These data reveal that the enhanced stability of dolcanatide, with persistence along the rostral-caudal axis of the small and large intestine, is inadequate to regulate GUCY2C across the colorectum to prevent tumorigenesis. These results highlight the importance of developing a GUCY2C agonist for cancer prevention formulated for release and activity targeted to the colorectum.

Background: Splinting is routinely performed in the emergency department (ED), and follow-up visits of improperly placed splints are commonplace in orthopaedic clinics. As open reduction and internal fixation (ORIF) of fractures has become the preferred treatment for many injuries, orthopaedic surgeons and emergency physicians have received less instruction on splinting technique. Limited literature exists regarding error/complication rates of splint application. The purpose of this study is to determine: (1) Is there a difference in splinting complication rates between orthopaedic and non-orthopaedic services, and low versus high volume emergency room and urgent care centers? (2) What are the most common technical errors and complications in splint application?, Methods: Patients presenting to orthopaedic clinic with any extremity splint were enrolled in this IRB approved prospective study. Splint characteristics collected included: type of provider placing the splint, duration of wear, type of splint, and material used (i.e. plaster or fiberglass). Errors included inappropriate length, circumferential placement, and direct contact between the ACE bandage and the skin; while complications included swelling, blistering, ulceration, heat injury, and other issues on a case-by-case basis., Results: 203 patients were enrolled in this study. 98 (48%) were splinted by the Orthopaedics service, 69 (34%) were splinted in the trauma hospital ED, and 36 (18%) were treated at an outside hospital. 123/203 (61%) had an error/ complication related to the splint. Error/complication rates for orthopaedics, the trauma hospital ED, and outside hospitals were 46% (45/98), 65% (45/69), and 92% (33/36) respectively. The most common errors were inappropriate length, present in 58/203 (29%) patients, and direct contact between the ACE bandage and skin, present in 50/203 (25%) patients., Conclusion: The appropriateness and complication rates of splints applied in the ED differ based on the type of provider and the institution. Outside hospitals were found to have the highest complication rates, while the lowest rates were associated with splints placed by Orthopaedics. These findings support the importance of education of proper splinting technique in non-trauma hospitals. Level of Evidence: III ., Competing Interests: Disclosures: The authors report no potential conflicts of interest related to this study., (Copyright © The Iowa Orthopaedic Journal 2021.)

Background: The long-term consequences of tibial torsion remain unclear. This study evaluated whether syndesmotic injuries are associated with tibial torsion., Methods: A collection of over 3000 cadaveric skeletons was screened for irregular bony prominence along the lateral distal tibia, consistent with previous syndesmosis injury. Tibial torsion was measured and compared to 1034 control cadaveric tibiae., Results: Mean torsion of 236 specimens with syndesmotic injury was 6.2±8.9 degrees, while that of control specimens was 7.9±8.8 degrees (P = 0.008). Multiple regression analysis showed a non-statistically significant trend toward internal torsion and syndesmotic injury (standardized beta=-0.051, P=0.059). Syndesmosis injury was present in 48/200 specimens (24.0%) with internal torsion and 31/199 specimens (15.6%) with external torsion (P=0.035)., Conclusion: This association between internal tibial torsion and syndesmotic injury suggests that internal tibial torsion might not be an entirely benign condition and merits further study., (Copyright © 2020 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: The optimal surveillance strategy for pancreatic cysts, which occur in up to 20% of the adult population, is ill defined. The risk of malignant degeneration of these cysts is low, however the morbidity and mortality associated with pancreatic cancer are high. Two clinical surveillance guidelines are in regular use. Both the Fukuoka and American Gastroenterological Association (AGA) guidelines rely on radiographic and endoscopic imaging. They differ primarily in their recommended frequencies of interval surveillance imaging. While evidence driven clinical guidelines should promote higher quality care, competing guidelines on the same topic may provide discordant recommendations and potential reduction in the quality and/or value of care., Objectives: The primary objective is to compare the clinical effectiveness of the two surveillance guidelines to identify patients most likely to benefit from pancreatic resection. Secondary objectives include comparison of resource utilization, patient reported outcomes, incidental findings are other clinical outcomes., Methods: 4606 asymptomatic patients with newly identified pancreatic cysts ≥1 cm in diameter will be randomized 1:1 to high intensity (Fukuoka) or low intensity (AGA) surveillance. All participants will be followed prospectively for 5 years., Conclusion: Differing guidelines confuse providers, patients and policymakers. This large, prospective, randomized trial will compare the clinical effectiveness and resource allocation requirements of two guidelines addressing a common clinical entity. CLINICALTRIALS., Gov Identifier: NCT04239573., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Surveillance following colorectal cancer (CRC) resection uses optical colonoscopy (OC) to detect intraluminal disease and CT to detect extracolonic recurrence. CT colonography (CTC) might be an efficient use of resources in this situation because it allows for intraluminal and extraluminal evaluations with one test., Design: We developed a simulation model to compare lifetime costs and benefits for a cohort of patients with resected CRC. Standard of care involved annual CT for 3 years and OC for years 1, 4 and every 5 years thereafter. For the CTC-based strategy, we replace CT+OC at year 1 with CTC. Patients with lesions greater than 6 mm detected by CTC underwent OC. Detection of an adenoma 10 mm or larger was followed by OC at 1 year, then every 3 years thereafter. Test characteristics and costs for CTC were derived from a clinical study. Medicare costs were used for cancer care costs as well as alternative test costs. We discounted costs and effects at 3% per year., Results: For persons with resected stage III CRC, the standard-of-care strategy was more costly (US$293) and effective (2.6 averted CRC cases and 1.1 averted cancer deaths per 1000) than the CTC-based strategy, with an incremental cost-effectiveness ratio of US$55 500 per quality-adjusted life-year gained. Our analysis was most sensitive to the sensitivity of CTC for detecting polyps 10 mm or larger and assumptions about disease progression., Conclusion: In a simulation model, we found that replacing the standard-of-care approach to postdiagnostic surveillance with a CTC-based strategy is not an efficient use of resources in most situations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To determine the impact of smoking on intensive care unit (ICU) outcomes in patients who underwent operative fixation for spine trauma., Design: Retrospective cohort study., Setting: Single academic level I trauma center., Patients: One hundred eighty-one consecutive surgical spine trauma patients from January 2010 to December 2014 requiring ICU stay., Intervention: Patients with smoking history compared to patients with no previous smoking history., Main Outcome Measurements: ICU length of stay, postoperative complications., Results: There were 297 spine trauma patients identified, of which 181 had an ICU stay (61%). There were 96 patients in the smoker cohort (53%) and 85 in the nonsmoker cohort (47%). On univariate analysis, the smoking cohort had a significantly longer ICU length of stay (11.0 ± 12.0 days vs. 8.01 ± 7.98 days, P = 0.046). Adjusting for confounders, smoking (beta: 3.99, P = 0.023), age ≥65 years (beta: 7.61, P = 0.001), body mass index ≥30 (beta: 4.47, P = 0.010), and American Spinal Injury Association Impairment Scale (beta: -1.39, P = 0.013) were independently associated with increased ICU length of stay. Smoking was not significantly associated with pneumonia (P = 0.238) or adult respiratory distress syndrome (P = 0.387) on multivariate analysis., Conclusions: A history of smoking, older age, obesity, and increasing American Spinal Injury Association Impairment Scale was independently associated with increased ICU length of stay in patients with surgical spine trauma. This study highlights the health care burden of smoking in the trauma population and may help physicians triage scarce ICU resources., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Readmission within 90 days following total joint arthroplasty has become a central quality measure of reimbursement initiatives; however, the validity of readmission rates as a measure of hospital care quality and the proportion of readmissions that are preventable are unknown. The purpose of this study is to determine if readmissions within 30 and 90 days after total knee arthroplasty (TKA) were related to orthopaedic or medical etiology and identify if these readmissions were preventable. We retrospectively reviewed 1,625 elective TKAs performed between 2011 and 2014 at our institution. Readmissions within 30 and 90 days were categorized into orthopaedic and medical etiologies and an expert research panel determined if readmissions were potentially preventable based on objective criteria from national or peer-reviewed consensus guidelines. Out of the 1,625 TKAs performed during the study period, there were a total of 79 (4.8%) readmissions within 90 days of surgery, of which 17 (22%) were of orthopaedic etiology and 62 (78%) were of medical etiology. Fifty-two (66%) of the 79 readmissions occurred within 30 days, with 11 (21%) of orthopaedic and 41 (80%) of medical etiology. Only 2 of 79 (3%) readmissions within 90 days were deemed potentially preventable, and neither of them were orthopaedic in nature. Hospital readmissions after total joint arthroplasty are inevitable; however, only a small percentage (3%) of readmissions to our health care system was potentially preventable. Orthopaedic readmissions constituted a minority of the proportion of readmissions at 30 or 90 days, and none were deemed preventable., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: This study provides a comprehensive, full-length assessment of radial and ulnar bowing in anteroposterior (AP) and sagittal planes., Methods: Radial and ulnar AP and lateral bowing were assessed using orthogonal digital photographs of 211 randomly selected cadaveric bilateral forearms (422 radius, 422 ulna bones) from a well-preserved osteologic collection., Results: In the radial AP plane, an apex-radial bow was present at a mean of 58% of bone length (slightly distal to midpoint), with a mean depth of 1.3 cm. In the radial lateral plane, an apex-dorsal bow occurred at a mean of 45% of bone length, with a mean depth of 0.8 cm. In the ulnar AP plane, apex-radial bow occurred at a mean of 32% of bone length with a mean depth of 1.0 cm. In the ulnar lateral plane, the majority of specimens (81%) had an apex-dorsal bow, whereas 19% had a reverse (apex-volar) bow. Lateral ulnar bow was located at a mean of 33% of bone length with a mean depth of 2.0 cm, with 36% of specimens possessing a lateral bow located at 35% or more distal along the ulna. Side-to-side differences for bow location and depth were less than 2% of bone length., Conclusions: Ulnar lateral bow was found to be more distal than in previously published works, which analyzed only the proximal ulna, and this study describes a reverse ulnar bow in 19% of specimens. This demonstrates lateral ulnar morphology to be more variable than previously defined with minimal side-to-side variability, which are important considerations for fracture fixation and elbow arthroplasty., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

To determine the diagnostic potential of prevertebral soft-tissue (PVST) swelling in cervical spine ligamentous injury (LI)., Background: PVST swelling in the cervical spine is a historical indicator of cervical spine injury; however, at present, there are no limited objective criteria to use PVST swelling to guide clinical decision-making regarding cervical spine LI. This study investigates PVST thickness as a screening measure for cervical spine LI with a potential to identify indications for advanced imaging., Methods: The registry at an urban level 1 trauma center was queried for cervical spine injuries between 2010 and 2016. Twenty-nine patients with LIs who had both CT and MRI available were included. Fifty-nine patients with bony injury (BI) were also included, and 99 patients undergoing CT of the cervical spine after blunt trauma without evidence of cervical spine injury were included as control patients., Results: PVST swelling >11.5 mm at C7 was 89.7% sensitive (72.7% to 97.8%) and 51.5% specific (41.3% to 61.7%) for LI. In men, a PVST thickness of 11.5 mm at C7 was 96% sensitive (79.7% to 99.9%) and 46.2% specific (32.2% to 60.5%) for LI. Patients with LI were more likely to be men (86.2% versus 52.5% control, P < 0.01). 86.2% of patients with LI (25 of 29) had associated BI. Patients who had LI and no associated BI (n = 4) were all men, and all had PVST thickness >11.5 mm at C7 (avg. PVST 17.7 mm ± 2.5)., Conclusion: C7 PVST thickness >11.5 mm was highly sensitive but poorly specific for cervical spine LI. This threshold may represent an appropriate PVST thickness to rule out LI because patients with PVST ≤11.5 mm are unlikely to have cervical spine LI and may not benefit from MRI., Competing Interests: None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Savakus, Dr. Weinberg, Dr. Moore, and Dr. Vallier., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Cervical laminoplasty is a non-fusion, decompression procedure for cervical spondylotic myelopathy (CSM). It is most commonly indicated for patients with multilevel stenosis who have preserved sagittal alignment and minimal to no axial neck pain related to spondylosis. Expansion of the laminar arch can allow for direct and indirect decompression of the spinal canal. Relative contraindications include those patients with significant preoperative neck pain, kyphotic alignment and substantial instability. Potential advantages over laminectomy and fusion include avoiding fusion-related complications, and the preservation of motion. Important technical considerations include meticulous extensor muscle management, with special attention being given to preserving the soft tissue attachments to C2. In the properly selected patient, outcomes are comparable, and in some studies superior, to other operations for CSM., Competing Interests: Conflicts of Interest: The series “Advanced Techniques in Complex Cervical Spine Surgery” was commissioned by the editorial office without any funding or sponsorship. JM Rhee: royalties from Biomet and Stryker; is a member of a speakers’ bureau or has made paid presentations on behalf of Biomet/Zimmer, Medtronic, and Depuy; serves as a paid consultant to Biomet, Synthes; has received research or institutional support from Depuy, Johnson & Johnson Company, Kineflex, and Medtronic; and serves as a board member of the Cervical Spine Research Society. Receives royalties from Wolters-Kluwer. Royalties for a laminoplasty plate. DS Weinberg has no conflicts of interest to declare., (2020 Journal of Spine Surgery. All rights reserved.)

Purpose: TGFβs are overexpressed in many advanced cancers and promote cancer progression through mechanisms that include suppression of immunosurveillance. Multiple strategies to antagonize the TGFβ pathway are in early-phase oncology trials. However, TGFβs also have tumor-suppressive activities early in tumorigenesis, and the extent to which these might be retained in advanced disease has not been fully explored., Experimental Design: A panel of 12 immunocompetent mouse allograft models of metastatic breast cancer was tested for the effect of neutralizing anti-TGFβ antibodies on lung metastatic burden. Extensive correlative biology analyses were performed to assess potential predictive biomarkers and probe underlying mechanisms., Results: Heterogeneous responses to anti-TGFβ treatment were observed, with 5 of 12 models (42%) showing suppression of metastasis, 4 of 12 (33%) showing no response, and 3 of 12 (25%) showing an undesirable stimulation (up to 9-fold) of metastasis. Inhibition of metastasis was immune-dependent, whereas stimulation of metastasis was immune-independent and targeted the tumor cell compartment, potentially affecting the cancer stem cell. Thus, the integrated outcome of TGFβ antagonism depends on a complex balance between enhancing effective antitumor immunity and disrupting persistent tumor-suppressive effects of TGFβ on the tumor cell. Applying transcriptomic signatures derived from treatment-naïve mouse primary tumors to human breast cancer datasets suggested that patients with breast cancer with high-grade, estrogen receptor-negative disease are most likely to benefit from anti-TGFβ therapy., Conclusions: Contrary to dogma, tumor-suppressive responses to TGFβ are retained in some advanced metastatic tumors. Safe deployment of TGFβ antagonists in the clinic will require good predictive biomarkers., (©2019 American Association for Cancer Research.)

Purpose: Post-operative surveillance strategies for colorectal cancer (CRC) include periodic optical colonoscopy (OC) and abdominal-pelvic CT scan. Adherence with these recommendations is limited. For CRC screening, CT colonography (CTC) identifies larger adenomas and cancers nearly as well as OC. Most screening studies demonstrate that patients prefer CTC. However, CTC has never been compared to OC in the post-operative surveillance setting., Methods: We hypothesized that CTC might represent an attractive substitute for the standard OC/CT scan combination. Here, 223 patients underwent CTC followed by same day OC 1 year after curative CRC resection., Results: Of the 144/223 (64.6%) participants with a preference, 65.9% (95/144) preferred OC. This preference was more pronounced in women and in patients with polyps detected. No additional patient level factors significantly altered this primary result., Conclusions: In contrast to CRC screening, this first study in CRC post-operative surveillance patients demonstrates a preference for OC. Assuming patient preference is an important determinant, introduction of CTC as a method to increase patient adherence with CRC surveillance is unlikely to be effective., Trial Registration: Clinical Trials.gov registration number: NCT02143115.

Study Design: This is a retrospective cohort study., Objective: The objective of this study was to verify the prevalence of lumbosacral transitional vertebrae (LSTV) in the general population and measure the resulting spinal arthritic changes., Summary of Background: LSTV are a morphologic variation within the lumbar spine that has potentially significant clinical implications. LSTV prevalence has been investigated using nonrandom volunteer samples and patient populations presenting with medical complaints such as abdominal or lumbar pain warranting computed tomography and magnetic resonance imaging scans. The examination of LSTV prevalence and variations using a true random population to our knowledge has yet to be conducted, and the relation between LSTV and spinal arthritis has not been rigorously examined., Materials and Methods: A total of 560 cadaveric skeletons were obtained from the Hamann-Todd osteological collection. The transverse processes of the terminal lumbar vertebrae were examined and measured, since the classification at times is based on examination and at times is based on measurement. The lumbar degenerative disease was graded on each specimen., Results: Our search revealed 489 (87.3%) nontransitional vertebrae and 71 (12.7%) transitional vertebrae, with the majority of these Castellvi type IA (N=28), type IB (N=19), and type IIA (N=11). Transitional vertebrae as a whole (standardized β=0.090, P=0.015), and in particular type Ia showed a correlation to osteoarthritis in the L4-L5 vertebral level (standardized β=0.089, P=0.015)., Conclusions: This cadaveric study aids in establishing the prevalence of LSTV (12.7%) in a random population and the frequency of the various Castellvi LSTV morphologies. An association was found between type Ia morphology and L4-L5 osteoarthritis which has not been reported in the past, suggesting that mild LSTV may carry more significance to lumbar pathology than previously considered.

Introduction: Posterior hip impingement is a recently-identified cause of hip pain. The purpose of this study is to characterise posterior femoroacetabular and ischiofemoral impingement and identify its predisposing morphologic traits., Methods: Two hundred and six cadaveric hips were randomly selected and taken through controlled motion in two pure axes associated with posterior hip impingement: external rotation (through the mechanical axis) and adduction (coronal plane). The range of motion and location of impingement was noted for each specimen. Morphologic traits including femoral/acetabular version, and true neck-shaft angle (TNSA) were also measured., Results: External rotation impingement occurred between the femoral neck and acetabulum in 83.0% of hips, and between the lesser trochanter and ischial tuberosity in 17.0%. Adduction impingement occurred between the lesser trochanter and ischial tuberosity in 78.6% of hips, and between the femoral neck and acetabulum in 21.4%. Multiple regression revealed that increased femoral/acetabular version predicted earlier external rotation and adduction impingement. Unstandardised betas ranging from -0.39 to -0.64 reflect that each degree of increased femoral/acetabular version individually accounts for a loss of external rotation or adduction of approximately half a degree before impingement ( p < 0.001 for each). Increased TNSA was associated with earlier adduction impingement only (unstandardised beta -0.35, p = 0.005)., Discussion: Relative femoral/acetabular anteversion was associated with earlier posterior hip impingement. Coxa valga was associated with earlier adduction impingement, but protective against external rotation impingement. These findings highlight the importance of monitoring correction during femoral/acetabular osteotomies, as overcorrection of retroversion may predispose to earlier posterior impingement.

Purpose. As part of a clinical trial comparing the utility of computed tomographic colonography (CTC) and optical colonoscopy (OC) for post colorectal cancer resection surveillance, we explored the diagnostic yield and costs of a strategy of CTC followed by OC if a polyp is observed (abbreviated CTC&#95;S), versus OC 1 year following curative bowel resection, using the detection of actionable polyps on OC as the criterion. Methods. Using data from 231 patients who underwent same-day CTC followed by OC, we created a decision tree that outlined the choices and outcomes at 1-year clinical follow-up. Colorectal polyp prevalence, sensitivity, and specificity of CTC were compared with five exemplary studies and meta-analyses. Detection criteria were derived for ≥6 mm or ≥10 mm polyps. OC was the gold standard. Costs were gleaned from cataloging components of the cases at the principal investigator's institution. Analyses included marginal cost of the OC strategy to detect additional actionable polyps and number of polyps missed per 10,000 patients. Results. At our prevalence of 0.156 for ≥6 mm (0.043 ≥10 mm), CTC&#95;S would miss 779 ≥6 mm actionable polyps per 10,000 patients (≥10 mm: 173 per 10,000). Cost to detect an additional ≥6 mm polyp in this cohort is $5,700 (≥10 mm: $28,000). Sensitivity analyses demonstrate that any improvement in performance characteristics would raise the cost of OC to detect more actionable polyps. Similar results were seen using Medicare costs, or when literature values were used for performance characteristics. Conclusion. At an action threshold of ≥6 mm, OC costs at least $5,700 per extra polyp detected relative to CTC&#95;S in patients undergoing surveillance after colorectal cancer surgery, on the order of incremental cost-effectiveness ratios found for other clinical problems involving short-term events., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2018.)

Guidelines recommend surveillance after resection of colorectal cancer (CRC), but rates of adherence to surveillance are variable and have not been studied at National Cancer Institute (NCI)-designated Comprehensive Cancer Centers. The aim of this study was to determine rates of adherence to standard postresection CRC surveillance recommendations including physician visits, carcinoembryonic antigen (CEA), computed tomography (CT), and colonoscopy after CRC resection at three NCI-designated centers. Data on patients with resected CRC from 2010 to 2017 were reviewed. Adherence to physician visits was defined as having at least two visits within 14 months after surgical resection. CEA adherence was defined as having at least four CEA levels drawn within 14 months. CT and colonoscopy adherence were defined as completing each between 10 and 14 months from surgical resection. Chi-square test and logistic regression analyses were performed for overall adherence and adherence to individual components. A total of 241 CRC patients were included. Overall adherence was 23%. While adherence to physician visits was over 98%, adherence to CEA levels, CT, and colonoscopy were each less than 50%. Center was an independent predictor of adherence to CEA, CT, and/or colonoscopy. Stage III disease predicted CT adherence, while distance traveled of 40 miles or less predicted colonoscopy adherence. Overall adherence to postresection CRC guideline-recommended care is low at NCI-designated centers. Adherence rates to surveillance vary by center, stage, and distance traveled for care. Understanding factors associated with adherence is critical to ensure CRC patients benefit from postresection surveillance., (© 2018 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Background: Although asymptomatic mild limb length discrepancy (LLD) in children is generally treated non-operatively, there is limited high quality follow up data to support this recommendation., Hypothesis: We hypothesized that there would be no association between LLD and arthritic changes with mild limb length discrepancy., Materials and Methods: We studied 576 well-preserved cadaveric skeletons ranging from 40 to 79 years of age. Limb length discrepancy was based on combined femoral and tibial lengths measured using digital calipers. Degenerative disease was hand graded in the spine, hips and knees using a previously described classification system. Power was set at 90%., Results: Average age was 56±10 years and average LLD was 4.8±4.0mm. Multiple regression analysis did not demonstrate any correlation between LLD and degenerative disease. After screening to find 26 additional specimens with LLD 10mm or greater, and assessing a potentially quadratic relationship, we still did not find any detrimental effects of LLD., Discussion: Our data support the general clinical recommendation of observation for mild asymptomatic LLD. These results do not apply to larger LLD nor LLD associated with other deformities or clinical symptoms., Level of Evidence: Not applicable, anatomic basic science study., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)