Faculty Bibliography

The cost of healthcare spending in foot and ankle surgery continues to rise. Several recent studies about cost effectiveness have been published. These may be difficult to understand and analyze without a background in business and healthcare economics. The goal of this narrative review is to provide the fundamentals for understanding and interpreting healthcare economic studies by defining key terminology and providing examples in the field of foot and ankle surgery. Foot and ankle surgeons should be familiar with the elements that comprise cost-effectiveness for providers, clinicians, researchers, and economists in caring for patients and making healthcare-related decisions.

Traumatic diaphragmatic hernia (TDH) occurs when abdominal contents herniate into the thoracic cavity, as the diaphragm is particularly susceptible to blunt or penetrating trauma. Currently, the standard treatments for TDH include minimally invasive surgical repair (MISR) and open surgical repair (OSR). MISR offers advantages such as reduced mortality, shorter hospital stays, and decreased postoperative pain and complications. In contrast, OSR is preferred for complex cases requiring better visualization, such as large defect repairs and comprehensive abdominal exploration. This study compares the clinical outcomes of MISR and OSR for TDH in adults, analyzing variables such as hospital stay, complications, recurrence rates, and postoperative pain. Following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses or PRISMA guidelines, this systematic review was conducted across six online databases (PubMed, Embase, Scopus, Cochrane, Web of Science, and Google Scholar), screening 1,894 studies. Six comparative studies were included in the final analysis, comprising 8,990 patients (7,735 MISR; 1,255 OSR). Postoperative pain was measured using the visual analog scale (0-10), while hospital stays and recurrence rates were extrapolated from patient charts and reported as percentages. The results indicate that MISR offers potential benefits, including shorter hospital stays and fewer complications. Additionally, reduction in respiratory failure and postoperative pneumonia suggests improved hospital course with the minimally invasive approach. Comparable recurrence rates between techniques demonstrate that MISR achieves technical success similar to OSR when appropriately selected, with fewer complications and shorter hospital stays. In conclusion, MISR for TDH resulted in shorter hospital stays with fewer complications and had recurrence rates similar to OSR. However, variability in outcome reporting limits the clinical applicability of these conclusions and calls for further standardized studies.

BACKGROUND:Near-infrared autofluorescence (NIRAF) spectroscopy is an emerging adjunct for intraoperative parathyroid identification. However, its ability to differentiate between normocellular, hyperplastic, or adenomatous parathyroids remains unexplored. We hypothesize that parathyroid adenomas have lower NIRAF ratios than normocellular parathyroids since the likely fluorophore is the calcium-sensing receptor (CaSR), which is downregulated in adenomas. METHODS:In vivo NIRAF ratios for each identified parathyroid gland were recorded for patients undergoing thyroidectomy or parathyroidectomy from 08/2023 to 12/2023 at a single institution. Parathyroids were categorized as normocellular by visual inspection and hyperplastic or adenomatous by final histology. RESULTS:Of the 44 patients included (66% underwent parathyroidectomy and 34% underwent thyroidectomy), 137 parathyroids were identified intraoperatively with 66 resected and analyzed histologically. A total of 71 (52%) parathyroids were normocellular, 45 (33%) were hyperplastic, and 21 (15%) were adenomatous. Among the resected parathyroids, there was moderate agreement (81%) between visual categorization and final histology for hyperplasia versus adenoma (κ = 0.6). Parathyroid adenomas had lower median NIRAF ratios than normocellular parathyroids (p = 0.0005). Median NIRAF ratios were not significantly different between normocellular and hyperplastic parathyroids (p = 0.35) nor between hyperplastic parathyroids and adenomas (p = 0.04). The performance of NIRAF spectroscopy in differentiating parathyroid pathology is poor based on receiver operator characteristics analysis. CONCLUSION:Parathyroid adenomas have lower NIRAF ratios than normocellular parathyroids. However, the performance of using NIRAF ratios to differentiate between parathyroid pathology is poor. Therefore, the differences in NIRAF ratios are unlikely to be sufficient at point-of-care use to distinguish between various parathyroid pathologies. As NIRAF ratios are highest in normocellular parathyroid glands, NIRAF appears to be most useful in detecting normal parathyroid glands.

OBJECTIVE/UNASSIGNED:Early detection and removal of suspicious polyps during routine colonoscopies play an important role in reducing the risk of colorectal cancer. Patient management and follow-up are determined by the type of polyps removed and the degree of dysplasia present on histological evaluation. Whereas discerning between a benign polyp and a dysplastic one is a trivial task, distinguishing between tubular adenomas with low-grade dysplasia (LGD) and high-grade dysplasia (HGD) is a challenging task. In this study, we trained a deep learning model to distinguish between colorectal adenomas with LGD and HGD. DESIGN/UNASSIGNED:We retrieved 259 slides of adenomatous polyps taken between January 2011 and October 2024. Slides with HGD were reviewed by a subspecialty-trained GI pathologist. After excluding discordant and duplicate cases, 200 slides remained: 71 (35.5%) with HGD and 129 (64.5%) with LGD. The slides were divided into training (160 slides, 80%) and test (40 slides, 20%) sets. After patch generation and stain normalization, a ResNet34 model (pre-trained on ImageNet) was trained using 5-fold cross-validation. Slide classification was determined by aggregating patch-level predictions. RESULTS/UNASSIGNED:The model's slide-level prediction accuracy was 95.0%, correctly classifying all but 2 out of 40 slides. The model achieved an area under the receiver operating characteristic curve score of 0.981 and an F1 score of 0.923. CONCLUSIONS/UNASSIGNED:This study demonstrates that deep learning models can accurately distinguish between colonic adenomas with LGD and HGD. Training on a larger dataset could increase the accuracy and generalizability of the model and should be a focus of further studies.

OBJECTIVE:Recent guidelines suggest that non-invasive prenatal screening (NIPS) should be offered to all patients with singleton and twin pregnancies. Accurate determination of fetal fraction in cell-free DNA (cfDNA) is vital for reliable NIPS outcomes. We propose a methylation-based approach using droplet digital PCR (ddPCR) and methylation-sensitive restriction enzyme (MSRE) digestion for fetal fraction quantification as an affordable and fast solution. METHOD/METHODS:Following biomarker discovery using early pregnancy placental genomic DNA (gDNA) and cfDNA from non-pregnant female individuals, we designed assays targeting MSRE-compatible regions based on contrasting methylation patterns between maternal and fetal cfDNA. We established a proof-of-concept ddPCR workflow on the Bio-Rad Droplet Digital PCR QX600 instrument. RESULTS:Testing the fetal fraction assay multiplex on 137 prospective clinical samples demonstrated high concordance with NGS results for both female and male pregnancies as well as with chromosome Y-based calculations for samples with a male fetus. Reproducibility analysis indicated lower variability compared to previously reported NGS performance. CONCLUSION/CONCLUSIONS:This study showcases the potential of this novel, 6-color, high-multiplex methylation ddPCR panel for accurate measurement of fetal fraction in cfDNA samples. It presents opportunities to integrate such methodology as a standalone measurement to assess the quality of samples undergoing NIPS.

BACKGROUND & AIMS/OBJECTIVE:There is significant variability in the immediate post-operative and long-term management of patients undergoing per-oral endoscopic myotomy (POEM), largely stemming from the lack of high-quality evidence. We aimed to establish a consensus on several important questions on the after care of post-POEM patients through a modified Delphi process. METHODS:A steering committee developed an initial questionnaire consisting of 5 domains (33 statements): post-POEM admission/discharge, indication for immediate post-POEM esophagram, peri-procedural medications and diet resumption, clinic follow-up recommendations, and post-POEM reflux surveillance and management. A total of 34 experts participated in the 2 rounds of the Delphi process, with quantitative and qualitative data analyzed for each round to achieve consensus. RESULTS:A total of 23 statements achieved a high degree of consensus. Overall, the expert panel agreed on the following: (1) same-day discharge after POEM can be considered in select patients; (2) a single dose of prophylactic antibiotics may be as effective as a short course; (3) a modified diet can be advanced as tolerated; and (4) all patients should be followed in clinic and undergo objective testing for surveillance and management of reflux. Consensus could not be achieved on the indication of post-POEM esophagram to evaluate for leak. CONCLUSIONS:The results of this Delphi process established expert agreement on several important issues and provides practical guidance on key aspects in the care of patients following POEM.

BACKGROUND/UNASSIGNED:The increasing number of organ transplant recipients has led to a rise in cancer diagnoses in this population. Kidney transplant recipients, in particular, have a two-to-four-fold higher risk of developing cancer due to immunosuppressive therapy. The management of gynecologic cancers in this subset of patients presents unique challenges due to anatomical considerations, immunosuppression, and the nephrotoxicity of oncologic treatments.Case Presentation.A 44-year-old woman with a history of polycystic kidney disease underwent a bilateral nephrectomy followed by a living-related intraperitoneal renal transplant. She presented with pelvic pain and was found to have high-grade ovarian adenocarcinoma, possibly arising from endometriosis. Surgical staging included total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and right pelvic lymph node dissection. The patient underwent six cycles of carboplatin and paclitaxel chemotherapy while maintaining stable renal function with close monitoring of immunosuppressive drug levels. Surveillance imaging detected recurrence in the right pelvic lymph nodes, leading to secondary tumor debulking and whole pelvic radiation therapy. Despite a slight increase in creatinine, kidney function remained stable, and the patient has remained disease-free on subsequent follow-ups. CONCLUSION/UNASSIGNED:The management of ovarian cancer in kidney transplant recipients requires a multidisciplinary approach to balance oncologic control with graft preservation. Close monitoring of renal function, careful surgical planning, and tailored chemotherapy and radiation strategies are critical. More research is needed to establish standardized guidelines for managing gynecologic malignancies in transplant patients.

OBJECTIVES/UNASSIGNED:Outside of the association of SS-A antibody with congenital heart block, little is known about adverse maternal and neonatal outcomes, in patients with Sjogren's disease (SjD). Our study involved collaboration with maternal-fetal medicine (MFM). METHODS/UNASSIGNED:-test and Fisher's exact test. RESULTS/UNASSIGNED:48 patients were included: 12 SjD patients and 36 controls. APO was significantly increased in SjD with one preterm birth, one fetal growth restriction, and one limb anomaly; non-SjD had one cardiac anomaly. There were no cases of CHB. SjD patients were more likely to be delivered by cesarean delivery. CONCLUSION/UNASSIGNED:There was an increased risk of APO in SjD patients compared with controls. No significant difference in neonatal outcomes was found. We speculate that placental pathology may play a role in pathophysiology and future studies should be performed. KEY POINTS/UNASSIGNED:There was an increased risk of APO in SjD patients compared with controls.No significant difference in neonatal outcomes was found.We speculate that placental pathology may play a role in pathophysiology, prompting future studies.