Faculty Bibliography

PURPOSE/OBJECTIVE:To evaluate the utilization and charges related to physical therapy (PT) after rotator cuff repair in privately insured and Medicare patients and between arthroscopic and open/mini-open repair techniques. METHODS:The PearlDiver insurance database was queried for patients receiving postoperative PT using Current Procedural Terminology codes. Data were available from 2007 to 2011 for United Healthcare and from 2005 to 2011 for Medicare patients. Patients undergoing arthroscopic (CPT 29827) or open/mini-open approaches (CPT 23410, 23412, 23420) were identified in both populations. Utilization was determined by both the percentage of patients with at least one postoperative PT-related code and the average number of encounters per patient. Per-patient average charge was determined by dividing total charges within the billing period by the patient total. RESULTS:A total of 365,891 patients undergoing rotator cuff repair were identified. There was an increase in the number of arthroscopic repairs (+29.1%, P = .027, United Healthcare; +78.9%, P < .001, Medicare) and a decrease in the number of open/mini-open repairs (-18.2%, P = .038, United Healthcare; -18.2%, P < .001, Medicare) across the study period. At 6 months postoperatively, PT utilization was greater in the United Healthcare groups (82.9% arthroscopic, 81.0% open/mini-open) than in the Medicare groups (41.8% arthroscopic, 43.2% open/mini-open). Utilization-weighted per-patient average charge was comparable among all 4 groups, with slightly higher charges in the United Healthcare groups ($3,376 arthroscopic, $3,251 open/mini-open) compared with the Medicare groups ($2,940 arthroscopic, $2,807 open/mini-open). The United Healthcare groups had a greater number of utilization-weighted billed encounters (36.1 for open/mini-open, 9.5 for arthroscopic) than their Medicare counterparts (12.8 open/mini-open, 16.7 arthroscopic). CONCLUSIONS:Utilization of PT after rotator cuff repair is substantially higher in privately insured than in Medicare patients. Utilization rates appear to be comparable between surgical approaches. Per-patient costs were comparable irrespective of surgical approach and insurance modality. LEVEL OF EVIDENCE/METHODS:Level IV, economic.

OBJECTIVES/OBJECTIVE:To determine the epidemiology and prognostic indicators in patients with malignant peripheral nerve sheath tumors (MPNST) of the head and neck. MATERIALS AND METHODS/METHODS:The surveillance, epidemiology, and end results registry was reviewed for patients with head and neck MPNST from 1973 to 2011. Study variables included age, sex, race, tumor size, stage at presentation, and treatment modality. RESULTS:There were 374 cases of head and neck MPNST identified. Mean age at diagnosis was 50.7 y ears; 60.2% of patients were male and 82.6% were white. After diagnosis, 38.8% of patients underwent surgery and radiation therapy and 48.1% underwent surgery alone. Kaplan-Meier analysis demonstrated overall (OS) and disease-specific survival (DSS) of 51% and 67% at 5 years. Multivariate Cox regression analysis showed that age (p=0.030), stage (p=0.002), surgery (p=0.037), and size (p<0.001) were predictors of OS, while stage (p<0.001) and size (p<0.001) were predictors of DSS. For stage I/II cancers, surgery (p=0.011) and size (p=0.010) were predictors of OS, and size (p=0.001) predicted DSS. For stage III/IV cancers, both radiotherapy (p=0.024, p=0.009) and size (p=0.001, p=0.001) predicted OS and DSS. For tumors ⩽5 cm, stage (p=0.031) predicted DSS. For tumors >5 cm, male gender (p=0.005), stage (p=0.001), surgery (p=0.003), and radiotherapy (p=0.050) were determinants of OS, and male gender (p=0.022), stage (p<0.001), and radiotherapy (p=0.002) were determinants of DSS. CONCLUSION/CONCLUSIONS:Surgical resection confers survival benefit in patients with early stage MPNST, while radiotherapy improves survival in cases with metastatic disease. Surgery and radiotherapy are prognostically important in patients with tumors >5 cm.

Cells suspended in bodily fluids are routinely analyzed by cytopathologists as a means of diagnosing malignancies and other diseases. The physical and morphological properties of these suspended cells are evaluated in making diagnostic decisions, which often requires manual concentration, staining, and washing procedures to extract information about intracellular architecture. The need to manually prepare slides for analysis by a cytopathologist is a labor-intensive process, which is ripe for additional automation to reduce costs but also to potentially provide more repeatable and improved accuracy in diagnoses. We have developed a microfluidic system to perform several steps in the preparation of samples for cytopathology that (i) automates colorimetric staining on-chip, and (ii) images cells in flow, as well as provides (iii) additional quantitative analyses of captured images to aid cytopathologists. A flow-through approach provides benefits by allowing staining and imaging to be performed in a continuous, integrated manner, which also overcomes previous challenges with in-suspension colorimetric staining. We envision such a tool may reduce costs and aid cytopathologists in identifying rare or characteristic cells of interest by providing isolated images along with quantitative metrics on single cells from various rotational angles, allowing efficient determination of disease etiology.

BACKGROUND:An acute infection after arthroscopic shoulder surgery is a rare but serious complication. Previous studies estimating the incidence of infections after arthroscopic surgery have been conducted, but the majority of these had either relatively small study groups or were not specific to shoulder arthroscopic surgery. PURPOSE/OBJECTIVE:To investigate the incidence of acute infections after arthroscopic shoulder surgery and compare infection rates by age group, sex, geographic region, and specific procedures. STUDY DESIGN/METHODS:Case series; Level of evidence, 4. METHODS:A retrospective review of a large insurance company database was performed for all shoulder arthroscopic surgeries performed in the United States between 2004 and 2009 that required additional surgery for infections within 30 days. The data were stratified by sex, age group, and region. Data were also stratified for specific procedures (capsulorrhaphy, treatment for superior labrum anterior-posterior tears, claviculectomy, decompression, and rotator cuff repair) and used to assess the variation in the incidence of infections across different arthroscopic shoulder procedures. Linear regression was used to determine the significance of differences in the data from year to year. χ(2) analysis was used to assess the statistical significance of variations among all groups. Poisson regression analysis with exposure was used to determine significant differences in a pairwise comparison between 2 groups. RESULTS:The total number of arthroscopic shoulder surgeries performed was 165,820, and the number of infections requiring additional surgery was 450, resulting in an overall infection rate of 0.27%. The incidence of infections varied significantly across age groups (P < .001); the infection rate was highest in the ≥60-year age group (0.36%) and lowest in the 10- to 39-year age group (0.18%). The incidence of infections also varied by region (P < .001); the incidence was highest in the South (0.37%) and lowest in the Midwest (0.11%). The incidence of infection treatments was also significantly different between different arthroscopic procedures (P < .01) and was highest for rotator cuff repair (0.29%) and lowest for capsulorrhaphy (0.16%). The incidence did not significantly vary by year or sex. CONCLUSION/CONCLUSIONS:The overall infection rate for all arthroscopic shoulder procedures was 0.27%. The incidence was highest in elderly patients, in the South, and for rotator cuff repair. The incidence was lowest in young patients, in the Midwest, and for capsulorrhaphy. In general, shoulder arthroscopic surgery in this study population had a low rate of reoperation in the acute period.

In the absence of an imaging technique that provides imagery of diseased tissue with high diagnostic accuracy and contrast, surgeons must often excise excess healthy tissue surrounding neoplasms to ensure complete removal of malignant tissues. Additional approaches that are commonly used in the detection of tumor regions include palpation and conventional ultrasound to locate the affected area. However, these techniques suffer from limitations such as minimal specificity and lack of depth penetration. Lack of specificity results in the production of unclear diseased tissue regions, and therefore fails to offer surgeons a reliable and accurate image guidance tool. The proposed work provides an alternative diagnostic modality termed ultrasound-stimulated vibro-acoustography (USVA) that aims to generate detailed images characterized by viscoelastic properties of tissues. We demonstrate selective imaging using phantom tissue samples of polyvinyl alcohol (PVA) that are altered and arranged into unique geometries of varying elastic topology. Determining the precision and sensitivity of the USVA imaging system in identifying boundary regions as well as intensity ranges associated with tissue phantom targets will provide additional important information to allow for a non-invasive tool to distinguish diseased tissues from normal tissues in an in vivo setting.

IMPORTANCE/OBJECTIVE:There is a need for larger studies characterizing the effect of tumor grade on survival for patients with esthesioneuroblastoma. OBJECTIVE:To investigate prognostic factors for survival in patients diagnosed with esthesioneuroblastoma, including emphasis on tumor grade. DESIGN, SETTING, AND PARTICIPANTS/METHODS:Retrospective, population-based cohort study of patients in the Surveillance, Epidemiology, and End Results (SEER) tumor registry who were diagnosed with esthesioneuroblastoma from January 1, 1973, to January 1, 2010. The last date of survival follow-up was 2013. MAIN OUTCOMES AND MEASURES/METHODS:Overall and disease-specific survival. RESULTS:The cohort included 281 patients with a mean age of 52 years. There were 154 males (54.8%) and 127 females (45.2%). Kaplan-Meier analysis demonstrated an overall and disease-specific survival rate of 61% and 70% at 5 years and 50% and 64% at 10 years, respectively. Multivariable Cox regression analysis showed that advanced tumor grade and modified Kadish stage (hazard ratio, 4.930; 95% CI, 2.635-9.223; P = .001) portended worse disease-specific survival, and radiation therapy (hazard ratio, 0.499; 95% CI, 0.272-0.916; P = .03) improved disease-specific survival. Patients with low-grade tumors (grades I and II) demonstrated an overall and disease-specific survival rate of 84% and 92% at 5 years and 67% and 87% at 10 years, respectively. Multivariable analysis of low-grade tumors only revealed receiving surgery (P = .004) as an independent positive predictor of disease-specific survival. High-grade tumors (grades III and IV) demonstrated overall and disease-specific survival of 40% and 50% at 5 years and 34% and 43% at 10 years, respectively. Multivariable analysis of high-grade tumors showed modified Kadish stage (hazard ratio, 2.025; 95% CI, 1.430-2.866; P < .001) predicted worse disease-specific survival, and radiation therapy (hazard ratio, 0.433; 95% CI, 0.228-0.864; P = .02) independently predicted improved disease-specific survival. CONCLUSIONS AND RELEVANCE/CONCLUSIONS:Here, to our knowledge, we report the largest study investigating prognostic factors for survival, with the inclusion of tumor grade, in patients diagnosed with esthesioneuroblastoma. Patients with high-grade tumors had substantially worse survival rates than patients with low-grade tumors. Multivariable analysis revealed only receiving surgery as an independent predictor of disease-specific survival for patients with low-grade tumors, while modified Kadish stage and postoperative radiation therapy were significant factors in predicting disease-specific survival in patients with high-grade tumors. This study highlights the growing evidence that tumor grade should be a key factor in predicting survival in patients with esthesioneuroblastoma, and that adjuvant radiation therapy improves survival rates among patients with high-grade, but not low-grade, tumors.

IMPORTANCE/OBJECTIVE:Primary tumors of the lacrimal gland are rare and are associated with substantial morbidity and mortality. The literature regarding these tumors is limited to case series and case reports. OBJECTIVE:To examine the incidence, treatment, and overall survival (OS) and disease-specific survival (DSS) of patients with cancer of the lacrimal gland. DESIGN, SETTING, AND PARTICIPANTS/METHODS:Population-based cohort analysis using the Surveillance, Epidemiology, and End Results (SEER) database to identify patients with primary tumors of the lacrimal gland from 1973 to 2010. MAIN OUTCOMES AND MEASURES/METHODS:Overall survival and DSS. RESULTS:A total of 321 patients with nonlymphoid tumors of the lacrimal gland were identified. The most common histological subtypes were adenoid cystic carcinoma (ACC) (32.1%) and squamous cell carcinoma (SCC) (29.9%). Survival analysis revealed a 5-year OS and DSS for all lacrimal gland tumors of 60% and 75%, respectively. On univariate analysis, low tumor grade (P = .04) and surgical treatment (P < .001) were associated with significantly better OS. For ACC tumors, surgery (P = .009), but not radiotherapy (P = .44), was found to significantly improve OS. For SCC tumors, surgical treatment significantly improved both OS (P < .001) and DSS (P = .004); radiation therapy also significantly improved OS (P = .03). Using a multivariable analysis model, age (hazard ratio [HR], 1.03 [95% CI, 1.01-1.04]; P < .001), surgery (HR, 0.43 [95% CI, 0.25-0.75]; P = .003), and T stage at presentation (HR, 1.18 [95% CI, 1.01-1.37]; P = .03) were found to be independent predictors of OS. For ACC alone, age (HR, 1.04 [95% CI, 1.02-1.06]; P < .001) and surgery (HR, 0.35 [95% CI, 0.13-0.91]; P = .03) were independent predictors of OS. For SCC, age (HR, 1.05 [95% CI, 1.02-1.09]; P = .005), surgical resection (HR, 0.31 [95% CI, 0.12-0.83]; P = .02), and radiation therapy (HR, 0.33 [95% CI, 0.14-0.80]; P = .01) were independent predictors of OS. CONCLUSIONS AND RELEVANCE/CONCLUSIONS:Our study demonstrates that ACC is the most common malignant epithelial neoplasm of the lacrimal gland. Determinants of survival for tumors of the lacrimal gland include age at diagnosis and surgical therapy. Radiation therapy is associated with improved DSS in SCC but not in ACC.

Haematopoietic cells arise from spatiotemporally restricted domains in the developing embryo. Although studies of non-mammalian animal and in vitro embryonic stem cell models suggest a close relationship among cardiac, endocardial and haematopoietic lineages, it remains unknown whether the mammalian heart tube serves as a haemogenic organ akin to the dorsal aorta. Here we examine the haemogenic activity of the developing endocardium. Mouse heart explants generate myeloid and erythroid colonies in the absence of circulation. Haemogenic activity arises from a subset of endocardial cells in the outflow cushion and atria earlier than in the aorta-gonad-mesonephros region, and is transient and definitive in nature. Interestingly, key cardiac transcription factors, Nkx2-5 and Isl1, are expressed in and required for the haemogenic population of the endocardium. Together, these data suggest that a subset of endocardial/endothelial cells serve as a de novo source for transient definitive haematopoietic progenitors.

While adult heart muscle is the least regenerative of tissues, embryonic cardiomyocytes are proliferative, with embryonic stem (ES) cells providing an endless reservoir. In addition to secreted factors and cell-cell interactions, the extracellular microenvironment has been shown to play an important role in stem cell lineage specification, and understanding how scaffold elasticity influences cardiac differentiation is crucial to cardiac tissue engineering. Though previous studies have analyzed the role of the matrix elasticity on the function of differentiated cardiomyocytes, whether it affects the induction of cardiomyocytes from pluripotent stem cells is poorly understood. Here, we examined the role of matrix rigidity on the cardiac differentiation using mouse and human ES cells. Culture on polydimethylsiloxane (PDMS) substrates of varied monomer-to-crosslinker ratios revealed that rigid extracellular matrices promote a higher yield of de novo cardiomyocytes from undifferentiated ES cells. Using an genetically modified ES system that allows us to purify differentiated cardiomyocytes by drug selection, we demonstrate that rigid environments induce higher cardiac troponin T expression, beating rate of foci, and expression ratio of adult α- to fetal β- myosin heavy chain in a purified cardiac population. M-mode and mechanical interferometry image analyses demonstrate that these ES-derived cardiomyocytes display functional maturity and synchronization of beating when co-cultured with neonatal cardiomyocytes harvested from a developing embryo. Together, these data identify matrix stiffness as an independent factor that instructs not only the maturation of the already differentiated cardiomyocytes but also the induction and proliferation of cardiomyocytes from undifferentiated progenitors. Manipulation of the stiffness will help direct the production of functional cardiomyocytes en masse from stem cells for regenerative medicine purposes.