The Diagnosis: Nonuremic Calciphylaxis

Histopathologic findings revealed ischemic necrosis and a subepidermal blister (Figure 1) with arteriosclerotic changes and fat necrosis. Foci of calcification were noted within the fat lobules. Arterioles within the deeper dermis and subcutis showed thickened hyalinized walls, narrowed lumina, and medial calcification (Figure 2). Multiple sections did not reveal any granulomatous inflammation. Periodic acid-Schiff and Gram stains were negative for fungal and bacterial elements, respectively. No dense neutrophilic infiltrate was seen. Multifocal calcific deposits within fat lobules and vessel walls (endothelium highlighted by the CD31 stain) suggested calciphylaxis.

Laboratory test results revealed a normal white blood cell count, international normalized ratio level of 4 (on warfarin), and an elevated sedimentation rate at 72 mm/h (reference range, 0-20 mm/h). Serum creatinine was 1.1 mg/dL (reference range, 0.6-1.2 mg/dL) and the calcium-phosphorous product was 40.8 mg²/dL (reference range, <55 mg²/dL). Hemoglobin A_1C (glycated hemoglobin) was 8.2% (reference range, 4%-7%). Wound cultures grew Proteus mirabilis sensitive to cefazolin. Acid-fast bacilli and fungal cultures were negative. Computed tomography of the left lower leg without contrast showed no evidence of osteomyelitis. Of note, the popliteal arteries and distal vessels showed moderate vascular calcification.

Histopathology findings as well as a clinical picture of painful ulceration on the distal extremities and uncontrolled diabetes with normal renal function favored a diagnosis of nonuremic calciphylaxis (NUC). The patient was treated with intravenous infusions of sodium thiosulfate 25 mg 3 times weekly and oral cefazolin for superadded bacterial infection. Local wound care included collagenase dressings with light compression. Warfarin was discontinued, as it can worsen calciphylaxis. Complete reepithelialization of the ulcer along with substantial reduction in pain was noted within 4 weeks.

Ulceration of the lower legs is a relatively common condition in the Western world, the prevalence of which increases up to 5% in patients older than 65 years.¹ Of the myriad of causes that lead to ulceration of the distal aspect of the leg, NUC is a rare but known phenomenon. The pathogenesis of NUC is complicated based on theories of derangement of receptor activator of nuclear factor κβ, receptor activator of nuclear factor κβ ligand, and osteoprotegerin, leading to calcium deposits in the media of the arteries.² This deposition precipitates vascular occlusion coupled with ischemic necrosis of the subcutaneous tissue and skin.³ Some of the more common causes of NUC are primary hyperparathyroidism, malignancy, and rheumatoid arthritis. Type 2 diabetes mellitus is a less common cause but often is found in association with NUC, as noted by Nigwekar et al.² According to their study, the laboratory parameters commonly found in NUC included a calcium-phosphorous product greater than 50 mg²/dL and serum creatinine of 1.2 mg/dL or less.²

Our patient displayed these laboratory findings. However, distinguishing NUC from other atypical lower extremity ulcers such as Martorell hypertensive ischemic ulcer, pyoderma gangrenosum, and warfarin necrosis can pose a challenge to the dermatologist. Martorell hypertensive ischemic ulcer is excruciatingly painful and occurs more frequently near the Achilles tendon, responding well to surgical debridement. Histopathologically, medial calcinosis and arteriosclerosis are seen.⁴

Pyoderma gangrenosum is a neutrophilic dermatosis wherein the classical ulcerative variant is painful. It occurs mostly on the pretibial area and worsens after debridement.⁵ Clinically and histopathologically, it is a diagnosis of exclusion in which a dense neutrophilic to mixed lymphocytic infiltrate is seen with necrosis of dermal vessels.⁶ 

Warfarin necrosis is extremely rare, affecting 0.01% to 0.1% of patients on warfarin-derived anticoagulant therapy.⁷ Necrosis occurs mostly on fat-bearing areas such as the breasts, abdomen, and thighs 3 to 5 days after initiating treatment. Histologically, fibrin deposits occlude dermal vessels without perivascular inflammation.⁸

Necrobiosis lipoidica is a rare cutaneous entity seen in 0.3% of diabetic patients.⁹ The exact pathogenesis is unknown; however, microangiopathy in collaboration with cross-linking of abnormal collagen fibers play a role. These lesions appear as erythematous plaques with a slightly depressed to atrophic center, ultimately taking on a waxy porcelain appearance. Although most of these lesions either resolve or become chronically persistent, approximately 15% undergo ulceration, which can be painful. Histologically, with hematoxylin and eosin staining, areas of necrobiosis are seen surrounded by an inflammatory infiltrate comprised mainly of histiocytes along with lymphocytes and plasma cells.⁹

Nonuremic calciphylaxis can mimic the aforementioned conditions to a greater extent in female patients with obesity, diabetes mellitus, and hypertension. However, microscopic calcium deposition in the media of dermal arterioles, extravascular calcification within fat lobules, and cutaneous necrosis, along with remarkable response to intravenous sodium thiosulfate, confirmed a diagnosis of NUC in our patient. Sodium thiosulfate scavenges reactive oxygen species and promotes nitric oxygen generation, thereby reducing endothelial damage.¹⁰ Although there are no randomized controlled trials to support its use, sodium thiosulfate has been successfully used to treat established cases of NUC.¹¹

The Diagnosis: Nonuremic Calciphylaxis

Histopathologic findings revealed ischemic necrosis and a subepidermal blister (Figure 1) with arteriosclerotic changes and fat necrosis. Foci of calcification were noted within the fat lobules. Arterioles within the deeper dermis and subcutis showed thickened hyalinized walls, narrowed lumina, and medial calcification (Figure 2). Multiple sections did not reveal any granulomatous inflammation. Periodic acid-Schiff and Gram stains were negative for fungal and bacterial elements, respectively. No dense neutrophilic infiltrate was seen. Multifocal calcific deposits within fat lobules and vessel walls (endothelium highlighted by the CD31 stain) suggested calciphylaxis.

Laboratory test results revealed a normal white blood cell count, international normalized ratio level of 4 (on warfarin), and an elevated sedimentation rate at 72 mm/h (reference range, 0-20 mm/h). Serum creatinine was 1.1 mg/dL (reference range, 0.6-1.2 mg/dL) and the calcium-phosphorous product was 40.8 mg²/dL (reference range, <55 mg²/dL). Hemoglobin A_1C (glycated hemoglobin) was 8.2% (reference range, 4%-7%). Wound cultures grew Proteus mirabilis sensitive to cefazolin. Acid-fast bacilli and fungal cultures were negative. Computed tomography of the left lower leg without contrast showed no evidence of osteomyelitis. Of note, the popliteal arteries and distal vessels showed moderate vascular calcification.

Histopathology findings as well as a clinical picture of painful ulceration on the distal extremities and uncontrolled diabetes with normal renal function favored a diagnosis of nonuremic calciphylaxis (NUC). The patient was treated with intravenous infusions of sodium thiosulfate 25 mg 3 times weekly and oral cefazolin for superadded bacterial infection. Local wound care included collagenase dressings with light compression. Warfarin was discontinued, as it can worsen calciphylaxis. Complete reepithelialization of the ulcer along with substantial reduction in pain was noted within 4 weeks.

Ulceration of the lower legs is a relatively common condition in the Western world, the prevalence of which increases up to 5% in patients older than 65 years.¹ Of the myriad of causes that lead to ulceration of the distal aspect of the leg, NUC is a rare but known phenomenon. The pathogenesis of NUC is complicated based on theories of derangement of receptor activator of nuclear factor κβ, receptor activator of nuclear factor κβ ligand, and osteoprotegerin, leading to calcium deposits in the media of the arteries.² This deposition precipitates vascular occlusion coupled with ischemic necrosis of the subcutaneous tissue and skin.³ Some of the more common causes of NUC are primary hyperparathyroidism, malignancy, and rheumatoid arthritis. Type 2 diabetes mellitus is a less common cause but often is found in association with NUC, as noted by Nigwekar et al.² According to their study, the laboratory parameters commonly found in NUC included a calcium-phosphorous product greater than 50 mg²/dL and serum creatinine of 1.2 mg/dL or less.²

Our patient displayed these laboratory findings. However, distinguishing NUC from other atypical lower extremity ulcers such as Martorell hypertensive ischemic ulcer, pyoderma gangrenosum, and warfarin necrosis can pose a challenge to the dermatologist. Martorell hypertensive ischemic ulcer is excruciatingly painful and occurs more frequently near the Achilles tendon, responding well to surgical debridement. Histopathologically, medial calcinosis and arteriosclerosis are seen.⁴

Pyoderma gangrenosum is a neutrophilic dermatosis wherein the classical ulcerative variant is painful. It occurs mostly on the pretibial area and worsens after debridement.⁵ Clinically and histopathologically, it is a diagnosis of exclusion in which a dense neutrophilic to mixed lymphocytic infiltrate is seen with necrosis of dermal vessels.⁶ 

Warfarin necrosis is extremely rare, affecting 0.01% to 0.1% of patients on warfarin-derived anticoagulant therapy.⁷ Necrosis occurs mostly on fat-bearing areas such as the breasts, abdomen, and thighs 3 to 5 days after initiating treatment. Histologically, fibrin deposits occlude dermal vessels without perivascular inflammation.⁸

Necrobiosis lipoidica is a rare cutaneous entity seen in 0.3% of diabetic patients.⁹ The exact pathogenesis is unknown; however, microangiopathy in collaboration with cross-linking of abnormal collagen fibers play a role. These lesions appear as erythematous plaques with a slightly depressed to atrophic center, ultimately taking on a waxy porcelain appearance. Although most of these lesions either resolve or become chronically persistent, approximately 15% undergo ulceration, which can be painful. Histologically, with hematoxylin and eosin staining, areas of necrobiosis are seen surrounded by an inflammatory infiltrate comprised mainly of histiocytes along with lymphocytes and plasma cells.⁹

Nonuremic calciphylaxis can mimic the aforementioned conditions to a greater extent in female patients with obesity, diabetes mellitus, and hypertension. However, microscopic calcium deposition in the media of dermal arterioles, extravascular calcification within fat lobules, and cutaneous necrosis, along with remarkable response to intravenous sodium thiosulfate, confirmed a diagnosis of NUC in our patient. Sodium thiosulfate scavenges reactive oxygen species and promotes nitric oxygen generation, thereby reducing endothelial damage.¹⁰ Although there are no randomized controlled trials to support its use, sodium thiosulfate has been successfully used to treat established cases of NUC.¹¹

The Diagnosis: Nonuremic Calciphylaxis

Histopathologic findings revealed ischemic necrosis and a subepidermal blister (Figure 1) with arteriosclerotic changes and fat necrosis. Foci of calcification were noted within the fat lobules. Arterioles within the deeper dermis and subcutis showed thickened hyalinized walls, narrowed lumina, and medial calcification (Figure 2). Multiple sections did not reveal any granulomatous inflammation. Periodic acid-Schiff and Gram stains were negative for fungal and bacterial elements, respectively. No dense neutrophilic infiltrate was seen. Multifocal calcific deposits within fat lobules and vessel walls (endothelium highlighted by the CD31 stain) suggested calciphylaxis.

Laboratory test results revealed a normal white blood cell count, international normalized ratio level of 4 (on warfarin), and an elevated sedimentation rate at 72 mm/h (reference range, 0-20 mm/h). Serum creatinine was 1.1 mg/dL (reference range, 0.6-1.2 mg/dL) and the calcium-phosphorous product was 40.8 mg²/dL (reference range, <55 mg²/dL). Hemoglobin A_1C (glycated hemoglobin) was 8.2% (reference range, 4%-7%). Wound cultures grew Proteus mirabilis sensitive to cefazolin. Acid-fast bacilli and fungal cultures were negative. Computed tomography of the left lower leg without contrast showed no evidence of osteomyelitis. Of note, the popliteal arteries and distal vessels showed moderate vascular calcification.

Histopathology findings as well as a clinical picture of painful ulceration on the distal extremities and uncontrolled diabetes with normal renal function favored a diagnosis of nonuremic calciphylaxis (NUC). The patient was treated with intravenous infusions of sodium thiosulfate 25 mg 3 times weekly and oral cefazolin for superadded bacterial infection. Local wound care included collagenase dressings with light compression. Warfarin was discontinued, as it can worsen calciphylaxis. Complete reepithelialization of the ulcer along with substantial reduction in pain was noted within 4 weeks.

Ulceration of the lower legs is a relatively common condition in the Western world, the prevalence of which increases up to 5% in patients older than 65 years.¹ Of the myriad of causes that lead to ulceration of the distal aspect of the leg, NUC is a rare but known phenomenon. The pathogenesis of NUC is complicated based on theories of derangement of receptor activator of nuclear factor κβ, receptor activator of nuclear factor κβ ligand, and osteoprotegerin, leading to calcium deposits in the media of the arteries.² This deposition precipitates vascular occlusion coupled with ischemic necrosis of the subcutaneous tissue and skin.³ Some of the more common causes of NUC are primary hyperparathyroidism, malignancy, and rheumatoid arthritis. Type 2 diabetes mellitus is a less common cause but often is found in association with NUC, as noted by Nigwekar et al.² According to their study, the laboratory parameters commonly found in NUC included a calcium-phosphorous product greater than 50 mg²/dL and serum creatinine of 1.2 mg/dL or less.²

Our patient displayed these laboratory findings. However, distinguishing NUC from other atypical lower extremity ulcers such as Martorell hypertensive ischemic ulcer, pyoderma gangrenosum, and warfarin necrosis can pose a challenge to the dermatologist. Martorell hypertensive ischemic ulcer is excruciatingly painful and occurs more frequently near the Achilles tendon, responding well to surgical debridement. Histopathologically, medial calcinosis and arteriosclerosis are seen.⁴

Pyoderma gangrenosum is a neutrophilic dermatosis wherein the classical ulcerative variant is painful. It occurs mostly on the pretibial area and worsens after debridement.⁵ Clinically and histopathologically, it is a diagnosis of exclusion in which a dense neutrophilic to mixed lymphocytic infiltrate is seen with necrosis of dermal vessels.⁶ 

Warfarin necrosis is extremely rare, affecting 0.01% to 0.1% of patients on warfarin-derived anticoagulant therapy.⁷ Necrosis occurs mostly on fat-bearing areas such as the breasts, abdomen, and thighs 3 to 5 days after initiating treatment. Histologically, fibrin deposits occlude dermal vessels without perivascular inflammation.⁸

Necrobiosis lipoidica is a rare cutaneous entity seen in 0.3% of diabetic patients.⁹ The exact pathogenesis is unknown; however, microangiopathy in collaboration with cross-linking of abnormal collagen fibers play a role. These lesions appear as erythematous plaques with a slightly depressed to atrophic center, ultimately taking on a waxy porcelain appearance. Although most of these lesions either resolve or become chronically persistent, approximately 15% undergo ulceration, which can be painful. Histologically, with hematoxylin and eosin staining, areas of necrobiosis are seen surrounded by an inflammatory infiltrate comprised mainly of histiocytes along with lymphocytes and plasma cells.⁹

Nonuremic calciphylaxis can mimic the aforementioned conditions to a greater extent in female patients with obesity, diabetes mellitus, and hypertension. However, microscopic calcium deposition in the media of dermal arterioles, extravascular calcification within fat lobules, and cutaneous necrosis, along with remarkable response to intravenous sodium thiosulfate, confirmed a diagnosis of NUC in our patient. Sodium thiosulfate scavenges reactive oxygen species and promotes nitric oxygen generation, thereby reducing endothelial damage.¹⁰ Although there are no randomized controlled trials to support its use, sodium thiosulfate has been successfully used to treat established cases of NUC.¹¹

Half of final-year residents surveyed this April had received 100 or more job solicitations during their training, according to physician-recruiting firm Merritt Hawkins.

Among the 935 survey responses the company received, 70% of physicians in their final year of residency had gotten more than 50 job offers: 20% received 51-100, and 50% received more than 100. The numbers were even higher for those in primary care: 76% had received at least 51 job solicitations, and 55% reported more than 100 offers, Merritt Hawkins said in its 2017 Survey of Final-Year Medical Residents.

[email protected]

Half of final-year residents surveyed this April had received 100 or more job solicitations during their training, according to physician-recruiting firm Merritt Hawkins.

Among the 935 survey responses the company received, 70% of physicians in their final year of residency had gotten more than 50 job offers: 20% received 51-100, and 50% received more than 100. The numbers were even higher for those in primary care: 76% had received at least 51 job solicitations, and 55% reported more than 100 offers, Merritt Hawkins said in its 2017 Survey of Final-Year Medical Residents.

[email protected]

Half of final-year residents surveyed this April had received 100 or more job solicitations during their training, according to physician-recruiting firm Merritt Hawkins.

Among the 935 survey responses the company received, 70% of physicians in their final year of residency had gotten more than 50 job offers: 20% received 51-100, and 50% received more than 100. The numbers were even higher for those in primary care: 76% had received at least 51 job solicitations, and 55% reported more than 100 offers, Merritt Hawkins said in its 2017 Survey of Final-Year Medical Residents.

[email protected]

It’s very unusual for hospitalists to achieve top quartile performance on the Physician Communication domain of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This is the story of a group that did just that for patients on one unit of a large hospital.

I’m not sure how reproducible this would be at other hospitals, or even on other units in the same hospital, and wonder whether performance will stay at this remarkably high level much longer than the current 5-month track record of success. Even so, five months of success suggests they’re on to something.

There is another hospitalist group at that hospital, but I’m discussing work done only by MedOne hospitalists, who together with hospital personnel, developed what they call the Comprehensive Medical Unit (CMU). Their goal was to involve multiple disciplines and use Lean principles to design a new approach to care on 5-Orange, a 20-bed unit in OhioHealth’s Riverside Methodist Hospital in Columbus. The CMU model went live in October 2016.

MedOne Hospital Physicians is a private hospitalist group of 35 physicians and 12 advanced practice clinicians, which comprise nurse practitioners (NPs) and physician assistants (PAs), constituting 46 full-time–equivalent clinical staffing. The group contracts with Riverside, which has approximately 710 staffed beds. MedOne also works in area skilled nursing facilities, helps a long-term acute care and rehabilitation hospital, and provides support to two other hospitals that are not part of OhioHealth.
 

Features of the model

At its core, this model is a variation of the increasingly common combination of geographically assigned hospitalists (who in this case don’t have patients elsewhere in the hospital) and multidisciplinary rounds (that is, the physician and NP hospitalists make bedside rounds with a nurse and pharmacist). But their model also incorporates a few less-common features.

Only 4 of the 35 MedOne hospitalists are eligible to provide care on the CMU, and each still spends a significant portion of time in the regular hospitalist rotation working in the rest of the hospital. These doctors weren’t selected as the highest performers or because they had the best patient satisfaction track record. Instead, five MedOne doctors volunteered to work on the unit, and four were chosen. A MedOne hospitalist NP also works on the unit, since any NP in the group is eligible to work there.

This is a hospitalist-only unit; no non–hospitalist patients are placed on the unit. There is no deliberate attempt to assign patients to the unit based on how sick they are or complicated their cases are. All are general medicine patients, including up to six intermediate care patients (e.g., “ICU step-down” patients requiring mask ventilation, etc.). While configured for 20 patients, the unit can flex to as many as 24 patients and has done so numerous times. The hospitalists (physician and NP combined) have averaged 18.9 daily encounters since the CMU opened.

Nurse staffing on the unit was reconfigured to comprise bedside nurses – known as Clinical Nurses (CNs) – and more experienced RNs – in the role of Comprehensive Charge Nurses (CCNs), who attend rounds and coordinate the patients’ hospitalizations rather than doing bedside care. 5-Orange has one more Charge Nurse than is typical for other units in the hospital, so total RN-to-patient staffing levels and nurse staffing costs are higher. But the CNs care for the same number of patients as do their counterparts in other hospital units.

In order to try to discharge patients early in the day, the NP sees only the patients who are being discharged, while the physician makes all other visits. When possible, I think it’s best to minimize the incidence of a provider’s first visit with a patient being a discharge visit; this may increase the risk of misunderstandings and errors. Instead, in this model, the physician working on the CMU will already know the patient from the preceding days and will be on the unit and readily accessible to the NP all day, which might mitigate some of these concerns.
 

Outcomes

I think the most notable outcome is the top quartile patient satisfaction scores from the 37 patients cared for on the unit who returned a survey, some of whom have asked to return to the CMU if they’re hospitalized again. Specifically, 86% of responses were “top box,” which places the hospitalists at the 84th percentile of performance for all hospitals. Physician Communication scores on the HCAHPS survey for hospitalists on other units at this hospital are in the bottom deciles, which is more typical for hospitalists.

Length of stay is half a day shorter than comparable units with similar readmission rates, and more patients are discharged earlier in the day. The four hospitalists who work on the unit report higher satisfaction, in part because they get an average of only 1 page a day – compared with the typical 15-40 pages their colleagues get working elsewhere in the hospital.
 

Cautions

I’m not sure why the MedOne model has yielded such impressive patient satisfaction and other results. While there are some relatively unique features of their model – only four hospitalists are eligible to work there and nursing roles have been reconfigured – I wouldn’t expect these to yield such remarkable results. So far, they have roughly 5 months of data and just 37 returned patient satisfaction surveys, so it’s possible that random variation and/or the Hawthorne effect are playing a meaningful role. It will be really informative to see their outcomes a year or 2 from now and to gauge how they fare if and when they implement the same model in other units of the hospital.

I suspect MedOne’s precise configuration for staffing and roles of nurses, NPs, and physicians is important, but I’m guessing the most valuable thing they implemented was the creation of a powerful sense of teamwork and shared purpose among those working on the unit. The interpersonal bonding and feeling of shared purpose that likely occurred as they worked to devise and go live with the model, as well as the tremendous satisfaction at seeing their early results, have probably led to terrific enthusiasm within their team.

That enthusiasm may be the key ingredient contributing to their early success.
 

Dr. Nelson has been working in clinical practice as a hospitalist since 1988. He is a cofounder and past president of Society of Hospital Medicine and a principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice-management courses. Contact him at [email protected]

It’s very unusual for hospitalists to achieve top quartile performance on the Physician Communication domain of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This is the story of a group that did just that for patients on one unit of a large hospital.

I’m not sure how reproducible this would be at other hospitals, or even on other units in the same hospital, and wonder whether performance will stay at this remarkably high level much longer than the current 5-month track record of success. Even so, five months of success suggests they’re on to something.

There is another hospitalist group at that hospital, but I’m discussing work done only by MedOne hospitalists, who together with hospital personnel, developed what they call the Comprehensive Medical Unit (CMU). Their goal was to involve multiple disciplines and use Lean principles to design a new approach to care on 5-Orange, a 20-bed unit in OhioHealth’s Riverside Methodist Hospital in Columbus. The CMU model went live in October 2016.

MedOne Hospital Physicians is a private hospitalist group of 35 physicians and 12 advanced practice clinicians, which comprise nurse practitioners (NPs) and physician assistants (PAs), constituting 46 full-time–equivalent clinical staffing. The group contracts with Riverside, which has approximately 710 staffed beds. MedOne also works in area skilled nursing facilities, helps a long-term acute care and rehabilitation hospital, and provides support to two other hospitals that are not part of OhioHealth.
 

Features of the model

At its core, this model is a variation of the increasingly common combination of geographically assigned hospitalists (who in this case don’t have patients elsewhere in the hospital) and multidisciplinary rounds (that is, the physician and NP hospitalists make bedside rounds with a nurse and pharmacist). But their model also incorporates a few less-common features.

Only 4 of the 35 MedOne hospitalists are eligible to provide care on the CMU, and each still spends a significant portion of time in the regular hospitalist rotation working in the rest of the hospital. These doctors weren’t selected as the highest performers or because they had the best patient satisfaction track record. Instead, five MedOne doctors volunteered to work on the unit, and four were chosen. A MedOne hospitalist NP also works on the unit, since any NP in the group is eligible to work there.

This is a hospitalist-only unit; no non–hospitalist patients are placed on the unit. There is no deliberate attempt to assign patients to the unit based on how sick they are or complicated their cases are. All are general medicine patients, including up to six intermediate care patients (e.g., “ICU step-down” patients requiring mask ventilation, etc.). While configured for 20 patients, the unit can flex to as many as 24 patients and has done so numerous times. The hospitalists (physician and NP combined) have averaged 18.9 daily encounters since the CMU opened.

Nurse staffing on the unit was reconfigured to comprise bedside nurses – known as Clinical Nurses (CNs) – and more experienced RNs – in the role of Comprehensive Charge Nurses (CCNs), who attend rounds and coordinate the patients’ hospitalizations rather than doing bedside care. 5-Orange has one more Charge Nurse than is typical for other units in the hospital, so total RN-to-patient staffing levels and nurse staffing costs are higher. But the CNs care for the same number of patients as do their counterparts in other hospital units.

In order to try to discharge patients early in the day, the NP sees only the patients who are being discharged, while the physician makes all other visits. When possible, I think it’s best to minimize the incidence of a provider’s first visit with a patient being a discharge visit; this may increase the risk of misunderstandings and errors. Instead, in this model, the physician working on the CMU will already know the patient from the preceding days and will be on the unit and readily accessible to the NP all day, which might mitigate some of these concerns.
 

Outcomes

I think the most notable outcome is the top quartile patient satisfaction scores from the 37 patients cared for on the unit who returned a survey, some of whom have asked to return to the CMU if they’re hospitalized again. Specifically, 86% of responses were “top box,” which places the hospitalists at the 84th percentile of performance for all hospitals. Physician Communication scores on the HCAHPS survey for hospitalists on other units at this hospital are in the bottom deciles, which is more typical for hospitalists.

Length of stay is half a day shorter than comparable units with similar readmission rates, and more patients are discharged earlier in the day. The four hospitalists who work on the unit report higher satisfaction, in part because they get an average of only 1 page a day – compared with the typical 15-40 pages their colleagues get working elsewhere in the hospital.
 

Cautions

I’m not sure why the MedOne model has yielded such impressive patient satisfaction and other results. While there are some relatively unique features of their model – only four hospitalists are eligible to work there and nursing roles have been reconfigured – I wouldn’t expect these to yield such remarkable results. So far, they have roughly 5 months of data and just 37 returned patient satisfaction surveys, so it’s possible that random variation and/or the Hawthorne effect are playing a meaningful role. It will be really informative to see their outcomes a year or 2 from now and to gauge how they fare if and when they implement the same model in other units of the hospital.

I suspect MedOne’s precise configuration for staffing and roles of nurses, NPs, and physicians is important, but I’m guessing the most valuable thing they implemented was the creation of a powerful sense of teamwork and shared purpose among those working on the unit. The interpersonal bonding and feeling of shared purpose that likely occurred as they worked to devise and go live with the model, as well as the tremendous satisfaction at seeing their early results, have probably led to terrific enthusiasm within their team.

That enthusiasm may be the key ingredient contributing to their early success.
 

Dr. Nelson has been working in clinical practice as a hospitalist since 1988. He is a cofounder and past president of Society of Hospital Medicine and a principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice-management courses. Contact him at [email protected]

It’s very unusual for hospitalists to achieve top quartile performance on the Physician Communication domain of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This is the story of a group that did just that for patients on one unit of a large hospital.

I’m not sure how reproducible this would be at other hospitals, or even on other units in the same hospital, and wonder whether performance will stay at this remarkably high level much longer than the current 5-month track record of success. Even so, five months of success suggests they’re on to something.

There is another hospitalist group at that hospital, but I’m discussing work done only by MedOne hospitalists, who together with hospital personnel, developed what they call the Comprehensive Medical Unit (CMU). Their goal was to involve multiple disciplines and use Lean principles to design a new approach to care on 5-Orange, a 20-bed unit in OhioHealth’s Riverside Methodist Hospital in Columbus. The CMU model went live in October 2016.

MedOne Hospital Physicians is a private hospitalist group of 35 physicians and 12 advanced practice clinicians, which comprise nurse practitioners (NPs) and physician assistants (PAs), constituting 46 full-time–equivalent clinical staffing. The group contracts with Riverside, which has approximately 710 staffed beds. MedOne also works in area skilled nursing facilities, helps a long-term acute care and rehabilitation hospital, and provides support to two other hospitals that are not part of OhioHealth.
 

Features of the model

At its core, this model is a variation of the increasingly common combination of geographically assigned hospitalists (who in this case don’t have patients elsewhere in the hospital) and multidisciplinary rounds (that is, the physician and NP hospitalists make bedside rounds with a nurse and pharmacist). But their model also incorporates a few less-common features.

Only 4 of the 35 MedOne hospitalists are eligible to provide care on the CMU, and each still spends a significant portion of time in the regular hospitalist rotation working in the rest of the hospital. These doctors weren’t selected as the highest performers or because they had the best patient satisfaction track record. Instead, five MedOne doctors volunteered to work on the unit, and four were chosen. A MedOne hospitalist NP also works on the unit, since any NP in the group is eligible to work there.

This is a hospitalist-only unit; no non–hospitalist patients are placed on the unit. There is no deliberate attempt to assign patients to the unit based on how sick they are or complicated their cases are. All are general medicine patients, including up to six intermediate care patients (e.g., “ICU step-down” patients requiring mask ventilation, etc.). While configured for 20 patients, the unit can flex to as many as 24 patients and has done so numerous times. The hospitalists (physician and NP combined) have averaged 18.9 daily encounters since the CMU opened.

Nurse staffing on the unit was reconfigured to comprise bedside nurses – known as Clinical Nurses (CNs) – and more experienced RNs – in the role of Comprehensive Charge Nurses (CCNs), who attend rounds and coordinate the patients’ hospitalizations rather than doing bedside care. 5-Orange has one more Charge Nurse than is typical for other units in the hospital, so total RN-to-patient staffing levels and nurse staffing costs are higher. But the CNs care for the same number of patients as do their counterparts in other hospital units.

In order to try to discharge patients early in the day, the NP sees only the patients who are being discharged, while the physician makes all other visits. When possible, I think it’s best to minimize the incidence of a provider’s first visit with a patient being a discharge visit; this may increase the risk of misunderstandings and errors. Instead, in this model, the physician working on the CMU will already know the patient from the preceding days and will be on the unit and readily accessible to the NP all day, which might mitigate some of these concerns.
 

Outcomes

I think the most notable outcome is the top quartile patient satisfaction scores from the 37 patients cared for on the unit who returned a survey, some of whom have asked to return to the CMU if they’re hospitalized again. Specifically, 86% of responses were “top box,” which places the hospitalists at the 84th percentile of performance for all hospitals. Physician Communication scores on the HCAHPS survey for hospitalists on other units at this hospital are in the bottom deciles, which is more typical for hospitalists.

Length of stay is half a day shorter than comparable units with similar readmission rates, and more patients are discharged earlier in the day. The four hospitalists who work on the unit report higher satisfaction, in part because they get an average of only 1 page a day – compared with the typical 15-40 pages their colleagues get working elsewhere in the hospital.
 

Cautions

I’m not sure why the MedOne model has yielded such impressive patient satisfaction and other results. While there are some relatively unique features of their model – only four hospitalists are eligible to work there and nursing roles have been reconfigured – I wouldn’t expect these to yield such remarkable results. So far, they have roughly 5 months of data and just 37 returned patient satisfaction surveys, so it’s possible that random variation and/or the Hawthorne effect are playing a meaningful role. It will be really informative to see their outcomes a year or 2 from now and to gauge how they fare if and when they implement the same model in other units of the hospital.

I suspect MedOne’s precise configuration for staffing and roles of nurses, NPs, and physicians is important, but I’m guessing the most valuable thing they implemented was the creation of a powerful sense of teamwork and shared purpose among those working on the unit. The interpersonal bonding and feeling of shared purpose that likely occurred as they worked to devise and go live with the model, as well as the tremendous satisfaction at seeing their early results, have probably led to terrific enthusiasm within their team.

That enthusiasm may be the key ingredient contributing to their early success.
 

Dr. Nelson has been working in clinical practice as a hospitalist since 1988. He is a cofounder and past president of Society of Hospital Medicine and a principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice-management courses. Contact him at [email protected]

The increasing demand for mental health care is having a positive effect on the popularity of psychiatry residents, according to physician-recruiting firm Merritt Hawkins.

In a survey conducted earlier this year, 78% of final-year psychiatry residents said that they had received more than 50 job solicitations during their training: 30% reported 51-100 offers, and 48% said they had gotten over 100, Merritt Hawkins said in its 2017 Survey of Final-Year Medical Residents.

[email protected]

The increasing demand for mental health care is having a positive effect on the popularity of psychiatry residents, according to physician-recruiting firm Merritt Hawkins.

In a survey conducted earlier this year, 78% of final-year psychiatry residents said that they had received more than 50 job solicitations during their training: 30% reported 51-100 offers, and 48% said they had gotten over 100, Merritt Hawkins said in its 2017 Survey of Final-Year Medical Residents.

[email protected]

The increasing demand for mental health care is having a positive effect on the popularity of psychiatry residents, according to physician-recruiting firm Merritt Hawkins.

In a survey conducted earlier this year, 78% of final-year psychiatry residents said that they had received more than 50 job solicitations during their training: 30% reported 51-100 offers, and 48% said they had gotten over 100, Merritt Hawkins said in its 2017 Survey of Final-Year Medical Residents.

[email protected]

CHICAGO – A study that compares babies who develop neonatal abstinence syndrome (NAS) with a control group of healthy newborns found largely what researchers expected to see – lower gestational ages, lower birth weights, and substance use in 100% of the mothers in the affected group. It’s when they looked at the control group of healthy newborns and their mothers that they got a surprise.

“Something that was very alarming in our study is [that] one in four of the control mothers was also positive for illicit drugs. That is something we definitely didn’t expect,” said Pallavi Karunakaran MD, a pediatric resident at Children’s Hospital of Michigan in Detroit.

Damian McNamara/Frontline Medical News

Dr. Karunakaran had no relevant financial disclosures.

CHICAGO – A study that compares babies who develop neonatal abstinence syndrome (NAS) with a control group of healthy newborns found largely what researchers expected to see – lower gestational ages, lower birth weights, and substance use in 100% of the mothers in the affected group. It’s when they looked at the control group of healthy newborns and their mothers that they got a surprise.

“Something that was very alarming in our study is [that] one in four of the control mothers was also positive for illicit drugs. That is something we definitely didn’t expect,” said Pallavi Karunakaran MD, a pediatric resident at Children’s Hospital of Michigan in Detroit.

Damian McNamara/Frontline Medical News

Dr. Karunakaran had no relevant financial disclosures.

CHICAGO – A study that compares babies who develop neonatal abstinence syndrome (NAS) with a control group of healthy newborns found largely what researchers expected to see – lower gestational ages, lower birth weights, and substance use in 100% of the mothers in the affected group. It’s when they looked at the control group of healthy newborns and their mothers that they got a surprise.

“Something that was very alarming in our study is [that] one in four of the control mothers was also positive for illicit drugs. That is something we definitely didn’t expect,” said Pallavi Karunakaran MD, a pediatric resident at Children’s Hospital of Michigan in Detroit.

Damian McNamara/Frontline Medical News

Dr. Karunakaran had no relevant financial disclosures.

Patients with severe obesity may have greater difficulty perceiving and grading pain than do average-weight patients. Those with severe obesity display hypoalgesia when exposed to random noxious stimuli, according to Bart Torensma and his associates.

In the study, 43 patients with severe obesity and 38 controls were enrolled, of whom 41 and 35 participated. Results found the penalty scores, a tool developed to assess perception and grading of pain, differed significantly with higher penalty scores in patients with obesity for both nociceptive assays (heat pain; P = .01, electrical pain; P = .03). “We observed that participants with severe obesity had higher electrical pain threshold and tolerance values, compared with control patients, an indication of lower sensitivity to electrical pain,” the investigators wrote.

In patients with obesity the penalty scores ranged from 1.5 to 13.5 (heat pain) and from 1.0 to 12.5 (electrical pain). But penalty score distribution differed significantly between study groups for electrical pain, with penalty scores greater than 3.5 in 47.3% in patients with obesity versus 22.9% of controls (P = .049). For heat pain, 46.2% of patients with obesity versus 28.6% of control participants had penalty scores greater than 3.5 (P = .15).

“Compared with patients without obesity, patients with obesity displayed hypoalgesia to noxious electrical stimuli together with difficulty in grading experimental noxious thermal and electrical stimuli in between pain threshold and tolerance,” researchers concluded. “We argue that the latter may have a significant effect on pain treatment and consequently needs to be taken into account when treating patients with obesity for acute or chronic pain.”

Read the full study in Surgery for Obesity and Related Diseases (doi: 10.1016/j.soard.2017.01.015).

[email protected]

Patients with severe obesity may have greater difficulty perceiving and grading pain than do average-weight patients. Those with severe obesity display hypoalgesia when exposed to random noxious stimuli, according to Bart Torensma and his associates.

In the study, 43 patients with severe obesity and 38 controls were enrolled, of whom 41 and 35 participated. Results found the penalty scores, a tool developed to assess perception and grading of pain, differed significantly with higher penalty scores in patients with obesity for both nociceptive assays (heat pain; P = .01, electrical pain; P = .03). “We observed that participants with severe obesity had higher electrical pain threshold and tolerance values, compared with control patients, an indication of lower sensitivity to electrical pain,” the investigators wrote.

In patients with obesity the penalty scores ranged from 1.5 to 13.5 (heat pain) and from 1.0 to 12.5 (electrical pain). But penalty score distribution differed significantly between study groups for electrical pain, with penalty scores greater than 3.5 in 47.3% in patients with obesity versus 22.9% of controls (P = .049). For heat pain, 46.2% of patients with obesity versus 28.6% of control participants had penalty scores greater than 3.5 (P = .15).

“Compared with patients without obesity, patients with obesity displayed hypoalgesia to noxious electrical stimuli together with difficulty in grading experimental noxious thermal and electrical stimuli in between pain threshold and tolerance,” researchers concluded. “We argue that the latter may have a significant effect on pain treatment and consequently needs to be taken into account when treating patients with obesity for acute or chronic pain.”

Read the full study in Surgery for Obesity and Related Diseases (doi: 10.1016/j.soard.2017.01.015).

[email protected]

Patients with severe obesity may have greater difficulty perceiving and grading pain than do average-weight patients. Those with severe obesity display hypoalgesia when exposed to random noxious stimuli, according to Bart Torensma and his associates.

In the study, 43 patients with severe obesity and 38 controls were enrolled, of whom 41 and 35 participated. Results found the penalty scores, a tool developed to assess perception and grading of pain, differed significantly with higher penalty scores in patients with obesity for both nociceptive assays (heat pain; P = .01, electrical pain; P = .03). “We observed that participants with severe obesity had higher electrical pain threshold and tolerance values, compared with control patients, an indication of lower sensitivity to electrical pain,” the investigators wrote.

In patients with obesity the penalty scores ranged from 1.5 to 13.5 (heat pain) and from 1.0 to 12.5 (electrical pain). But penalty score distribution differed significantly between study groups for electrical pain, with penalty scores greater than 3.5 in 47.3% in patients with obesity versus 22.9% of controls (P = .049). For heat pain, 46.2% of patients with obesity versus 28.6% of control participants had penalty scores greater than 3.5 (P = .15).

“Compared with patients without obesity, patients with obesity displayed hypoalgesia to noxious electrical stimuli together with difficulty in grading experimental noxious thermal and electrical stimuli in between pain threshold and tolerance,” researchers concluded. “We argue that the latter may have a significant effect on pain treatment and consequently needs to be taken into account when treating patients with obesity for acute or chronic pain.”

Read the full study in Surgery for Obesity and Related Diseases (doi: 10.1016/j.soard.2017.01.015).

[email protected]

DENVER – The anabolic agent teriparatide reduced the risk of clinical vertebral fractures in women with osteoporosis when compared with the antiresorptive agent risedronate, and the results held up across groups of women with varying fracture histories in a post hoc analysis of data from the VERO trial.

VERO, which pitted teriparatide (Forteo) against risedronate in women with at least two moderate or one severe vertebral fracture, as well as a bone mineral density (BMD) T-score of -1.5 or less, was the first study to compare an anabolic treatment to antiresorptive therapy using fractures as an endpoint, according to Astrid Fahrleitner-Pammer, MD, of the departments of internal medicine, endocrinology, and diabetology at Medical University of Graz (Austria), who presented the study at the annual meeting of the American Society for Bone and Mineral Research.

DENVER – The anabolic agent teriparatide reduced the risk of clinical vertebral fractures in women with osteoporosis when compared with the antiresorptive agent risedronate, and the results held up across groups of women with varying fracture histories in a post hoc analysis of data from the VERO trial.

VERO, which pitted teriparatide (Forteo) against risedronate in women with at least two moderate or one severe vertebral fracture, as well as a bone mineral density (BMD) T-score of -1.5 or less, was the first study to compare an anabolic treatment to antiresorptive therapy using fractures as an endpoint, according to Astrid Fahrleitner-Pammer, MD, of the departments of internal medicine, endocrinology, and diabetology at Medical University of Graz (Austria), who presented the study at the annual meeting of the American Society for Bone and Mineral Research.

DENVER – The anabolic agent teriparatide reduced the risk of clinical vertebral fractures in women with osteoporosis when compared with the antiresorptive agent risedronate, and the results held up across groups of women with varying fracture histories in a post hoc analysis of data from the VERO trial.

VERO, which pitted teriparatide (Forteo) against risedronate in women with at least two moderate or one severe vertebral fracture, as well as a bone mineral density (BMD) T-score of -1.5 or less, was the first study to compare an anabolic treatment to antiresorptive therapy using fractures as an endpoint, according to Astrid Fahrleitner-Pammer, MD, of the departments of internal medicine, endocrinology, and diabetology at Medical University of Graz (Austria), who presented the study at the annual meeting of the American Society for Bone and Mineral Research.

The American College of Surgeons (ACS) is pleased to announce that the Optimal Resources for Surgical Quality and Safety manual is now available for purchase. This manual is intended to serve as a trusted resource for surgical leaders seeking to improve patient care in their institutions, departments, and practices. It introduces key concepts in quality, safety, and reliability and explores the essential elements that all hospitals should have in place to ensure the delivery of patient-centered care.

Specific topics covered include the following: the domains and phases of surgical care, peer and case review, responsibilities of the surgical quality officer, institutional infrastructure, privileging and credentialing, high reliability, applications to the unique surgical disciplines, data analytics, clinical practice guidelines, quality collaboratives, and education and training. The manual also includes a look at some of the “soft skills” that influence quality and safety in health care, as well as the individual surgeon’s responsibility to patients, colleagues, and the next generation of surgeons.

Optimal Resources for Surgical Quality and Safety is available on the ACS website at facs.org/quality-programs/about/optimal-resources-manual for $44.95 (includes shipping) for single copies (up to a quantity of nine) or $39.95 (includes shipping) per copy for 10 copies or more.

The American College of Surgeons (ACS) is pleased to announce that the Optimal Resources for Surgical Quality and Safety manual is now available for purchase. This manual is intended to serve as a trusted resource for surgical leaders seeking to improve patient care in their institutions, departments, and practices. It introduces key concepts in quality, safety, and reliability and explores the essential elements that all hospitals should have in place to ensure the delivery of patient-centered care.

Specific topics covered include the following: the domains and phases of surgical care, peer and case review, responsibilities of the surgical quality officer, institutional infrastructure, privileging and credentialing, high reliability, applications to the unique surgical disciplines, data analytics, clinical practice guidelines, quality collaboratives, and education and training. The manual also includes a look at some of the “soft skills” that influence quality and safety in health care, as well as the individual surgeon’s responsibility to patients, colleagues, and the next generation of surgeons.

Optimal Resources for Surgical Quality and Safety is available on the ACS website at facs.org/quality-programs/about/optimal-resources-manual for $44.95 (includes shipping) for single copies (up to a quantity of nine) or $39.95 (includes shipping) per copy for 10 copies or more.

The American College of Surgeons (ACS) is pleased to announce that the Optimal Resources for Surgical Quality and Safety manual is now available for purchase. This manual is intended to serve as a trusted resource for surgical leaders seeking to improve patient care in their institutions, departments, and practices. It introduces key concepts in quality, safety, and reliability and explores the essential elements that all hospitals should have in place to ensure the delivery of patient-centered care.

Specific topics covered include the following: the domains and phases of surgical care, peer and case review, responsibilities of the surgical quality officer, institutional infrastructure, privileging and credentialing, high reliability, applications to the unique surgical disciplines, data analytics, clinical practice guidelines, quality collaboratives, and education and training. The manual also includes a look at some of the “soft skills” that influence quality and safety in health care, as well as the individual surgeon’s responsibility to patients, colleagues, and the next generation of surgeons.

Optimal Resources for Surgical Quality and Safety is available on the ACS website at facs.org/quality-programs/about/optimal-resources-manual for $44.95 (includes shipping) for single copies (up to a quantity of nine) or $39.95 (includes shipping) per copy for 10 copies or more.

The CURESZ Foundation was founded in 2016 to bring hope to people suffering from schizophrenia and those who love and care for them. CURESZ was established by Bethany Yeiser and her psychiatrist, Henry Nasrallah, MD, and was inspired by Bethany's complete recovery from schizophrenia after 4 years of delusions, hallucinations, homelessness, and disability. Bethany returned to her normal life and graduated from college with honors, thanks to clozapine, which cured her symptoms when several other medications did not work (for more of Bethany’s story, see From the Editor, Current Psychiatry. October 2014, p. 21,24-25).

One of the major initiatives of CURESZ is to promote the use of clozapine, which is vastly underused despite the fact that it is the only medication approved by the FDA for schizophrenia that fails to improve with other antipsychotics, and for schizophrenia patients with a history of suicidality. It is estimated that of the 2.5 million persons living with schizophrenia in the United States, about 500,000 have not had a chance to receive clozapine to possibly recover and overcome their vocational and social disability. To increase the chance that a patient suffering from treatment-resistant schizophrenia can receive a trial of clozapine, CURESZ is assembling a panel of clozapine experts around the United States to serve as a referral base.

This is a call for readers of Current Psychiatry who are prescribing clozapine to their patients and who practice in settings that can accommodate additional patients seeking clozapine treatment. We hope to get up to 100 experts to join this national panel, which we are calling CLOSZE (Clozapine Schizophrenia Experts). The mission is to “close” the door on disability among persons living with schizophrenia. Jonathan Meyer, MD, Deputy Editor of Current Psychiatry, a member of the Board of Trustees of the CURESZ Foundation, and a national clozapine expert, will serve as the Chair of the CLOSZE Panel.

If you would like to join CLOSZE, please go to https://curesz.org/closze-panel and enter your name, email, work address, and office phone number. We will later organize the list by state and city so that patients and families around the country can contact the nearest expert to get an evaluation for a possible clinical trial.

Thank you and we look forward to working with the Clozapine Experts who say “YESZ” to joining the CLOSZE Panel.

The CURESZ Foundation was founded in 2016 to bring hope to people suffering from schizophrenia and those who love and care for them. CURESZ was established by Bethany Yeiser and her psychiatrist, Henry Nasrallah, MD, and was inspired by Bethany's complete recovery from schizophrenia after 4 years of delusions, hallucinations, homelessness, and disability. Bethany returned to her normal life and graduated from college with honors, thanks to clozapine, which cured her symptoms when several other medications did not work (for more of Bethany’s story, see From the Editor, Current Psychiatry. October 2014, p. 21,24-25).

One of the major initiatives of CURESZ is to promote the use of clozapine, which is vastly underused despite the fact that it is the only medication approved by the FDA for schizophrenia that fails to improve with other antipsychotics, and for schizophrenia patients with a history of suicidality. It is estimated that of the 2.5 million persons living with schizophrenia in the United States, about 500,000 have not had a chance to receive clozapine to possibly recover and overcome their vocational and social disability. To increase the chance that a patient suffering from treatment-resistant schizophrenia can receive a trial of clozapine, CURESZ is assembling a panel of clozapine experts around the United States to serve as a referral base.

This is a call for readers of Current Psychiatry who are prescribing clozapine to their patients and who practice in settings that can accommodate additional patients seeking clozapine treatment. We hope to get up to 100 experts to join this national panel, which we are calling CLOSZE (Clozapine Schizophrenia Experts). The mission is to “close” the door on disability among persons living with schizophrenia. Jonathan Meyer, MD, Deputy Editor of Current Psychiatry, a member of the Board of Trustees of the CURESZ Foundation, and a national clozapine expert, will serve as the Chair of the CLOSZE Panel.

If you would like to join CLOSZE, please go to https://curesz.org/closze-panel and enter your name, email, work address, and office phone number. We will later organize the list by state and city so that patients and families around the country can contact the nearest expert to get an evaluation for a possible clinical trial.

Thank you and we look forward to working with the Clozapine Experts who say “YESZ” to joining the CLOSZE Panel.

The CURESZ Foundation was founded in 2016 to bring hope to people suffering from schizophrenia and those who love and care for them. CURESZ was established by Bethany Yeiser and her psychiatrist, Henry Nasrallah, MD, and was inspired by Bethany's complete recovery from schizophrenia after 4 years of delusions, hallucinations, homelessness, and disability. Bethany returned to her normal life and graduated from college with honors, thanks to clozapine, which cured her symptoms when several other medications did not work (for more of Bethany’s story, see From the Editor, Current Psychiatry. October 2014, p. 21,24-25).

One of the major initiatives of CURESZ is to promote the use of clozapine, which is vastly underused despite the fact that it is the only medication approved by the FDA for schizophrenia that fails to improve with other antipsychotics, and for schizophrenia patients with a history of suicidality. It is estimated that of the 2.5 million persons living with schizophrenia in the United States, about 500,000 have not had a chance to receive clozapine to possibly recover and overcome their vocational and social disability. To increase the chance that a patient suffering from treatment-resistant schizophrenia can receive a trial of clozapine, CURESZ is assembling a panel of clozapine experts around the United States to serve as a referral base.

This is a call for readers of Current Psychiatry who are prescribing clozapine to their patients and who practice in settings that can accommodate additional patients seeking clozapine treatment. We hope to get up to 100 experts to join this national panel, which we are calling CLOSZE (Clozapine Schizophrenia Experts). The mission is to “close” the door on disability among persons living with schizophrenia. Jonathan Meyer, MD, Deputy Editor of Current Psychiatry, a member of the Board of Trustees of the CURESZ Foundation, and a national clozapine expert, will serve as the Chair of the CLOSZE Panel.

If you would like to join CLOSZE, please go to https://curesz.org/closze-panel and enter your name, email, work address, and office phone number. We will later organize the list by state and city so that patients and families around the country can contact the nearest expert to get an evaluation for a possible clinical trial.

Thank you and we look forward to working with the Clozapine Experts who say “YESZ” to joining the CLOSZE Panel.

Take-Home Points

• CTA with loss of teres minor has been associated with worse clinical outcomes.
• Combined RSA and LDTT has been proposed and studied as a solution to this problem.
• LD tendon can be transferred to native teres minor insertion or lateral bicipital groove.
• Published studies have shown significant improvements in various subjective values, active forward elevation, external rotation, and abduction strength.
• Overall complication rates appear similar to RSA alone, however rates of neuropraxia may be higher.

Reverse shoulder arthroplasty (RSA) is a proven procedure that typically improves pain and function in patients with rotator cuff tear arthropathy.¹ Worse clinical outcomes are seen in patients with loss of teres minor function.^2,3 The teres minor is often the last important external rotator of the shoulder left in cuff tear arthropathy. When its function is lost, the ability to achieve active external rotation may become diminished. This phenomenon was termed combined loss of active elevation and external rotation (CLEER) by Boileau and colleagues.⁴ Patients with CLEER typically exhibit weakness with external rotation of the shoulder—most pronounced with the arm in an abducted position. Clinical examination may reveal a positive Hornblower test, and magnetic resonance imaging (MRI) of the shoulder often shows atrophy in the teres minor muscle.⁵

Patients with CLEER often do not exhibit the same degree of clinical improvement after RSA, largely because the external rotation strength deficit remains unchanged, causing persistent difficulty in completing activities of daily living (eg, combing hair, brushing teeth, eating).⁶ One option for treating patients with CLEER is to combine RSA with latissimus dorsi tendon transfer (LDTT) with or without teres major (TM)tendon transfer. In 1934, L’Episcopo⁷ was the first to describe performing LDTT with TM tendon transfer in an attempt to restore external rotation in patients with brachial plexus palsy. This procedure typically is used for irreparable posterior-superior rotator cuff tears in younger patients.⁸ Although the transfer was originally popularized with use of 2 incisions,⁹ Boileau and colleagues⁴ described a modified technique that allows the transfer to be performed through a single deltopectoral approach during RSA.

Although several authors have described the outcomes of RSA with LDTT, the expected clinical outcomes and complication rates remain elusive because of the relatively small number of patients in each case series. In a systematic review, we critically examined and synthesized the results of individual studies on RSA with LDTT. We had 3 questions: What are the demographics of patients treated with RSA-LDTT? What outcomes are associated with this combined procedure? What are the associated complications, and how often do they occur?

Methods

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. PubMed and Scopus computerized literature databases were searched through July 2015. Articles were identified with keyword searches (Figure). In our review, we included only studies that were reported in English, that included a minimum of 10 patients at baseline, and that had follow-up of at least 12 months; we excluded review papers, case reports, and technique papers without patient data. Mr. Sheth performed the initial search, and he and Dr. Namdari reviewed the qualifying abstracts. If one of the authors selected a paper, it was moved to the next phase of the review process. At the final phase (full-text review), there were no disagreements about which articles ultimately would be included (Figure).

We obtained 36 articles from PubMed and 12 from Scopus (Figure). Of these 48 articles, 15 were removed on the basis of their titles (reviews or editorials), and 8 for being duplicates. The remaining 25 articles underwent abstract review, which eliminated 17: reviews, case reports, technique articles, instructional articles, and reports on small case series (<10 patients) or studies lacking the minimum 12-month follow-up. The remaining 8 articles underwent full-text review. Inclusion/exclusion criteria removed 1 article, leaving 7 qualifying articles for analysis.

None of the studies compared outcomes with those of a control (nonoperative) group or an alternative surgical treatment. One study reported outcomes of RSA with and without LDTT; in this instance, we included only the data specific to the RSA-with-LDTT cases. Data from the individual studies were compiled to obtain demographic statistics. In cases in which outcomes data were consistently reported between studies, results were pooled for calculation of percentages and frequency-weighted (FW) means. FW means and grouped standard deviations were used to generate P values, using the number of “subjects” as the number of studies. As a result, comparative statistics for each variable were reported as means that 95% of the studies would report.

Results

Seven studies met the inclusion/exclusion criteria and were included in this systematic review. Five were retrospective,^10-14 and 2 were prospective.^5,6 All were published between 2007 and 2015. Table 1 lists the full study characteristics between groups.

Demographics

All 7 studies reported number of patients at baseline (Table 1); 133 patients (study range, 11-40) underwent RSA with LDTT.^5,6,10-14 All 7 studies reported patient ages; FW mean age was 69.5 years (range, 66-73 years).^5,6,10-14 Six studies reported sex at follow-up; there were 36 men (33.6%) and 71 women (66.4%).^5,6,10,12-14

Surgical Indications and Technique

All patients underwent RSA with LDTT with or without TM tendon transfer for the indications of cuff tear arthropathy and CLEER. All 7 studies assessed loss of elevation as active forward elevation of <80° or <90° and loss of external rotation as active external rotation of <0°, inability to maintain abducted arm at 0°, or external rotation lag sign of >30°. All surgeries were performed with the deltopectoral approach. Combined LD/TM tendons were transferred in 6 studies^5,6,10,12-14 and only the LD tendon in the seventh.¹¹ Of the 6 studies that indicated tendon transfer location, 4 reported attaching to the posterolateral aspect of the greater tuberosity at the level of the original teres minor insertion^5,6,11,12 and 2 reported attaching to the lateral aspect of the bicipital groove at the level of the LD insertion,10,14 . Six studies reported use of a sling or brace for 6 weeks after surgery.^5,6,10-12,14

Outcomes

The 7 studies reported outcomes data for 116 (87%) of their 133 baseline patients (Table 2). Patients were followed up an FW mean of 39.9 months (range, 18-65 months). Six studies reported postoperative Constant scores; FW mean Constant score was 28.7 before surgery and 64.4 afterward (P = .0001).^5,6,10-13

With regard to functional evaluation on physical examination, all 7 studies reported preoperative and postoperative active forward elevation and external rotation.5,6,10-14 Active forward elevation improved to an FW mean of 136°, from 71° (P < .0001), and external rotation improved to an FW mean of 25°, from –4° (P < .0001). Three studies reported preoperative and postoperative abduction; abduction improved to an FW mean of 137°, from 72° (P = .003).^6,10,13

Complications and Reoperations

The 7 studies reported 31 complications, for an overall complication rate of 22.8% (31/126).^5,6,10-14 There were 9 cases of neuropraxia (7.1%), 7 infections (6.0%), 4 dislocations or subluxations (3.4%), 2 cases of aseptic loosening (1.7%), 2 deltoid separations (1.7%), 2 periprosthetic fractures (1.7%), 1 acromion fracture (0.9%), 1 hematoma (0.9%), 1 LD/TM tendon rupture (0.9%), 1 intraoperative metaphyseal fracture (0.9%), and 1 painful baseplate screw (prominent where it penetrated the scapular spine)7 (0.9%).

The 7 studies also reported 19 reoperations, for an overall reoperation rate of 15.1% (19/126).^5,6,10-14 There were 4 wound revisions, 3 revision RSAs, 3 open reduction and internal fixations, 2 deltoid repairs, 2 irrigation and débridements, 1 revision to hemiarthroplasty, 1 acromioclavicular resection, 1 procedure for a shoulder dislocation, 1 cerclage wire fixation to correct an intraoperative metaphyseal fracture, and 1 procedure to burr down a protruding baseplate screw.

Discussion

RSA with LDTT improves postoperative function in patients with cuff tear arthropathy associated with profound external rotation weakness caused by loss of a functional teres minor muscle. That statement is consistent with the findings of our systematic review, as all 7 reviewed studies found functional improvements, particularly in active external rotation (~30° improvement). In addition, there were consistent reductions in pain and improvements in forward elevation.

Our review found a mean patient age of 69.5 years, similar to the 72.7 years reported in a recent population-based study on RSA utilization.¹⁵ Likewise, our percentage of women who underwent RSA with LDTT, 66.4%, is similar to the overall rate of 63.6%.15 It appears that the RSA-with-LDTT population and the traditional RSA population are not dramatically different.

The improvements we found in subjective outcome scores and range of motion can be compared with those found in RSA-only treatment of rotator cuff tear arthropathy. Wall and colleagues16 found an approximate 44-point Constant score improvement, to 65.1 from 21.7, which is similar to our 36-point improvement for RSA with LDTT. They also found an approximate 10-point increase in pain relief; ours was about 6 points. Regarding range of motion, they found 66° improvement in active forward elevation and 2° in active external rotation, and we found 65° and 29° improvement, respectively. Thus, the outcomes of RSA with LDTT and RSA alone appear to be comparable. Simovitch and colleagues17 evaluated RSA outcomes as a function of teres minor muscle atrophy and found that, compared with patients with stage 3 or 4 fatty infiltration, patients with stage 0, 1, or 2 infiltration had significantly better ultimate Constant scores, significantly better SSVs, and significantly more preoperative-to-postoperative improvement. On average, Constant scores and SSVs increased 32% and 25%, respectively, in patients with more extensive fatty atrophy, and these patients experienced an average net loss of 7° in external rotation. It appears that, whereas RSA-with-LDTT outcomes are similar to outcomes in a nonspecific group of cuff tear arthropathy patients treated with RSA alone, adding LDTT to RSA may substantially improve outcomes in cases in which the teres minor is of poor quality.

We found no differences in implant types. However, with the exception of the Arrow prosthesis, which had 8.5 mm of lateralization, all implants had a traditional Grammont design. Greiner and colleagues² recently found a trend toward improved external rotation in lateralized RSA designs, and a statistically significant improvement in external rotation in patients with an intact teres minor. The impact of LDTT with use of a lateralized design is unknown.

Our review found a relatively high rate of complications, 22.8%, and a reoperation rate of 15.1%. These are not dramatically different from the historical rates of complications (21%) and reoperations (13.4%).¹⁸ Although RSA with LDTT appears to have a higher rate of a specific complication, nerve-related injury, this is not necessarily surprising given the proximity of the axillary and radial nerves, the operative field, and the tendons transferred. This review’s rate of neuropraxia, 7.1%, is higher than the historical rate of 1.2% reported for RSA alone.¹⁸

This systematic review was limited by the quality of the studies available for inclusion. Although we followed PRISMA guidelines, none of the reviewed studies reported methods for controlling bias, confounding, and chance. In addition, the number of patients included and the relatively short follow-up period limit the impact of our findings. Finally, the individual studies used different outcome measures and did not report raw patient data, which limited our ability to perform more advanced statistical analysis.

Conclusion

This systematic review describes the demographics and outcomes of patients who underwent RSA with LDTT. Compiled data and FW means showed significant improvements in various subjective values, active forward elevation, external rotation, and abduction strength. For RSA with LDTT and RSA alone, complication rates appear comparable, but the rate of neuropraxia may be higher for the combined procedure. Although this review provides valuable information on RSA with LDTT, its lack of a control comparison group and its relatively short follow-up period limited our ability to draw meaningful conclusions about the efficacy of the combined procedure in treating rotator cuff tear arthropathy in the absence of a functional teres minor.

Take-Home Points

• CTA with loss of teres minor has been associated with worse clinical outcomes.
• Combined RSA and LDTT has been proposed and studied as a solution to this problem.
• LD tendon can be transferred to native teres minor insertion or lateral bicipital groove.
• Published studies have shown significant improvements in various subjective values, active forward elevation, external rotation, and abduction strength.
• Overall complication rates appear similar to RSA alone, however rates of neuropraxia may be higher.

Reverse shoulder arthroplasty (RSA) is a proven procedure that typically improves pain and function in patients with rotator cuff tear arthropathy.¹ Worse clinical outcomes are seen in patients with loss of teres minor function.^2,3 The teres minor is often the last important external rotator of the shoulder left in cuff tear arthropathy. When its function is lost, the ability to achieve active external rotation may become diminished. This phenomenon was termed combined loss of active elevation and external rotation (CLEER) by Boileau and colleagues.⁴ Patients with CLEER typically exhibit weakness with external rotation of the shoulder—most pronounced with the arm in an abducted position. Clinical examination may reveal a positive Hornblower test, and magnetic resonance imaging (MRI) of the shoulder often shows atrophy in the teres minor muscle.⁵

Patients with CLEER often do not exhibit the same degree of clinical improvement after RSA, largely because the external rotation strength deficit remains unchanged, causing persistent difficulty in completing activities of daily living (eg, combing hair, brushing teeth, eating).⁶ One option for treating patients with CLEER is to combine RSA with latissimus dorsi tendon transfer (LDTT) with or without teres major (TM)tendon transfer. In 1934, L’Episcopo⁷ was the first to describe performing LDTT with TM tendon transfer in an attempt to restore external rotation in patients with brachial plexus palsy. This procedure typically is used for irreparable posterior-superior rotator cuff tears in younger patients.⁸ Although the transfer was originally popularized with use of 2 incisions,⁹ Boileau and colleagues⁴ described a modified technique that allows the transfer to be performed through a single deltopectoral approach during RSA.

Although several authors have described the outcomes of RSA with LDTT, the expected clinical outcomes and complication rates remain elusive because of the relatively small number of patients in each case series. In a systematic review, we critically examined and synthesized the results of individual studies on RSA with LDTT. We had 3 questions: What are the demographics of patients treated with RSA-LDTT? What outcomes are associated with this combined procedure? What are the associated complications, and how often do they occur?

Methods

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. PubMed and Scopus computerized literature databases were searched through July 2015. Articles were identified with keyword searches (Figure). In our review, we included only studies that were reported in English, that included a minimum of 10 patients at baseline, and that had follow-up of at least 12 months; we excluded review papers, case reports, and technique papers without patient data. Mr. Sheth performed the initial search, and he and Dr. Namdari reviewed the qualifying abstracts. If one of the authors selected a paper, it was moved to the next phase of the review process. At the final phase (full-text review), there were no disagreements about which articles ultimately would be included (Figure).

We obtained 36 articles from PubMed and 12 from Scopus (Figure). Of these 48 articles, 15 were removed on the basis of their titles (reviews or editorials), and 8 for being duplicates. The remaining 25 articles underwent abstract review, which eliminated 17: reviews, case reports, technique articles, instructional articles, and reports on small case series (<10 patients) or studies lacking the minimum 12-month follow-up. The remaining 8 articles underwent full-text review. Inclusion/exclusion criteria removed 1 article, leaving 7 qualifying articles for analysis.

None of the studies compared outcomes with those of a control (nonoperative) group or an alternative surgical treatment. One study reported outcomes of RSA with and without LDTT; in this instance, we included only the data specific to the RSA-with-LDTT cases. Data from the individual studies were compiled to obtain demographic statistics. In cases in which outcomes data were consistently reported between studies, results were pooled for calculation of percentages and frequency-weighted (FW) means. FW means and grouped standard deviations were used to generate P values, using the number of “subjects” as the number of studies. As a result, comparative statistics for each variable were reported as means that 95% of the studies would report.

Results

Seven studies met the inclusion/exclusion criteria and were included in this systematic review. Five were retrospective,^10-14 and 2 were prospective.^5,6 All were published between 2007 and 2015. Table 1 lists the full study characteristics between groups.

Demographics

All 7 studies reported number of patients at baseline (Table 1); 133 patients (study range, 11-40) underwent RSA with LDTT.^5,6,10-14 All 7 studies reported patient ages; FW mean age was 69.5 years (range, 66-73 years).^5,6,10-14 Six studies reported sex at follow-up; there were 36 men (33.6%) and 71 women (66.4%).^5,6,10,12-14

Surgical Indications and Technique

All patients underwent RSA with LDTT with or without TM tendon transfer for the indications of cuff tear arthropathy and CLEER. All 7 studies assessed loss of elevation as active forward elevation of <80° or <90° and loss of external rotation as active external rotation of <0°, inability to maintain abducted arm at 0°, or external rotation lag sign of >30°. All surgeries were performed with the deltopectoral approach. Combined LD/TM tendons were transferred in 6 studies^5,6,10,12-14 and only the LD tendon in the seventh.¹¹ Of the 6 studies that indicated tendon transfer location, 4 reported attaching to the posterolateral aspect of the greater tuberosity at the level of the original teres minor insertion^5,6,11,12 and 2 reported attaching to the lateral aspect of the bicipital groove at the level of the LD insertion,10,14 . Six studies reported use of a sling or brace for 6 weeks after surgery.^5,6,10-12,14

Outcomes

The 7 studies reported outcomes data for 116 (87%) of their 133 baseline patients (Table 2). Patients were followed up an FW mean of 39.9 months (range, 18-65 months). Six studies reported postoperative Constant scores; FW mean Constant score was 28.7 before surgery and 64.4 afterward (P = .0001).^5,6,10-13

With regard to functional evaluation on physical examination, all 7 studies reported preoperative and postoperative active forward elevation and external rotation.5,6,10-14 Active forward elevation improved to an FW mean of 136°, from 71° (P < .0001), and external rotation improved to an FW mean of 25°, from –4° (P < .0001). Three studies reported preoperative and postoperative abduction; abduction improved to an FW mean of 137°, from 72° (P = .003).^6,10,13

Complications and Reoperations

The 7 studies reported 31 complications, for an overall complication rate of 22.8% (31/126).^5,6,10-14 There were 9 cases of neuropraxia (7.1%), 7 infections (6.0%), 4 dislocations or subluxations (3.4%), 2 cases of aseptic loosening (1.7%), 2 deltoid separations (1.7%), 2 periprosthetic fractures (1.7%), 1 acromion fracture (0.9%), 1 hematoma (0.9%), 1 LD/TM tendon rupture (0.9%), 1 intraoperative metaphyseal fracture (0.9%), and 1 painful baseplate screw (prominent where it penetrated the scapular spine)7 (0.9%).

The 7 studies also reported 19 reoperations, for an overall reoperation rate of 15.1% (19/126).^5,6,10-14 There were 4 wound revisions, 3 revision RSAs, 3 open reduction and internal fixations, 2 deltoid repairs, 2 irrigation and débridements, 1 revision to hemiarthroplasty, 1 acromioclavicular resection, 1 procedure for a shoulder dislocation, 1 cerclage wire fixation to correct an intraoperative metaphyseal fracture, and 1 procedure to burr down a protruding baseplate screw.

Discussion

RSA with LDTT improves postoperative function in patients with cuff tear arthropathy associated with profound external rotation weakness caused by loss of a functional teres minor muscle. That statement is consistent with the findings of our systematic review, as all 7 reviewed studies found functional improvements, particularly in active external rotation (~30° improvement). In addition, there were consistent reductions in pain and improvements in forward elevation.

Our review found a mean patient age of 69.5 years, similar to the 72.7 years reported in a recent population-based study on RSA utilization.¹⁵ Likewise, our percentage of women who underwent RSA with LDTT, 66.4%, is similar to the overall rate of 63.6%.15 It appears that the RSA-with-LDTT population and the traditional RSA population are not dramatically different.

The improvements we found in subjective outcome scores and range of motion can be compared with those found in RSA-only treatment of rotator cuff tear arthropathy. Wall and colleagues16 found an approximate 44-point Constant score improvement, to 65.1 from 21.7, which is similar to our 36-point improvement for RSA with LDTT. They also found an approximate 10-point increase in pain relief; ours was about 6 points. Regarding range of motion, they found 66° improvement in active forward elevation and 2° in active external rotation, and we found 65° and 29° improvement, respectively. Thus, the outcomes of RSA with LDTT and RSA alone appear to be comparable. Simovitch and colleagues17 evaluated RSA outcomes as a function of teres minor muscle atrophy and found that, compared with patients with stage 3 or 4 fatty infiltration, patients with stage 0, 1, or 2 infiltration had significantly better ultimate Constant scores, significantly better SSVs, and significantly more preoperative-to-postoperative improvement. On average, Constant scores and SSVs increased 32% and 25%, respectively, in patients with more extensive fatty atrophy, and these patients experienced an average net loss of 7° in external rotation. It appears that, whereas RSA-with-LDTT outcomes are similar to outcomes in a nonspecific group of cuff tear arthropathy patients treated with RSA alone, adding LDTT to RSA may substantially improve outcomes in cases in which the teres minor is of poor quality.

We found no differences in implant types. However, with the exception of the Arrow prosthesis, which had 8.5 mm of lateralization, all implants had a traditional Grammont design. Greiner and colleagues² recently found a trend toward improved external rotation in lateralized RSA designs, and a statistically significant improvement in external rotation in patients with an intact teres minor. The impact of LDTT with use of a lateralized design is unknown.

Our review found a relatively high rate of complications, 22.8%, and a reoperation rate of 15.1%. These are not dramatically different from the historical rates of complications (21%) and reoperations (13.4%).¹⁸ Although RSA with LDTT appears to have a higher rate of a specific complication, nerve-related injury, this is not necessarily surprising given the proximity of the axillary and radial nerves, the operative field, and the tendons transferred. This review’s rate of neuropraxia, 7.1%, is higher than the historical rate of 1.2% reported for RSA alone.¹⁸

This systematic review was limited by the quality of the studies available for inclusion. Although we followed PRISMA guidelines, none of the reviewed studies reported methods for controlling bias, confounding, and chance. In addition, the number of patients included and the relatively short follow-up period limit the impact of our findings. Finally, the individual studies used different outcome measures and did not report raw patient data, which limited our ability to perform more advanced statistical analysis.

Conclusion

This systematic review describes the demographics and outcomes of patients who underwent RSA with LDTT. Compiled data and FW means showed significant improvements in various subjective values, active forward elevation, external rotation, and abduction strength. For RSA with LDTT and RSA alone, complication rates appear comparable, but the rate of neuropraxia may be higher for the combined procedure. Although this review provides valuable information on RSA with LDTT, its lack of a control comparison group and its relatively short follow-up period limited our ability to draw meaningful conclusions about the efficacy of the combined procedure in treating rotator cuff tear arthropathy in the absence of a functional teres minor.

Take-Home Points

• CTA with loss of teres minor has been associated with worse clinical outcomes.
• Combined RSA and LDTT has been proposed and studied as a solution to this problem.
• LD tendon can be transferred to native teres minor insertion or lateral bicipital groove.
• Published studies have shown significant improvements in various subjective values, active forward elevation, external rotation, and abduction strength.
• Overall complication rates appear similar to RSA alone, however rates of neuropraxia may be higher.

Reverse shoulder arthroplasty (RSA) is a proven procedure that typically improves pain and function in patients with rotator cuff tear arthropathy.¹ Worse clinical outcomes are seen in patients with loss of teres minor function.^2,3 The teres minor is often the last important external rotator of the shoulder left in cuff tear arthropathy. When its function is lost, the ability to achieve active external rotation may become diminished. This phenomenon was termed combined loss of active elevation and external rotation (CLEER) by Boileau and colleagues.⁴ Patients with CLEER typically exhibit weakness with external rotation of the shoulder—most pronounced with the arm in an abducted position. Clinical examination may reveal a positive Hornblower test, and magnetic resonance imaging (MRI) of the shoulder often shows atrophy in the teres minor muscle.⁵

Patients with CLEER often do not exhibit the same degree of clinical improvement after RSA, largely because the external rotation strength deficit remains unchanged, causing persistent difficulty in completing activities of daily living (eg, combing hair, brushing teeth, eating).⁶ One option for treating patients with CLEER is to combine RSA with latissimus dorsi tendon transfer (LDTT) with or without teres major (TM)tendon transfer. In 1934, L’Episcopo⁷ was the first to describe performing LDTT with TM tendon transfer in an attempt to restore external rotation in patients with brachial plexus palsy. This procedure typically is used for irreparable posterior-superior rotator cuff tears in younger patients.⁸ Although the transfer was originally popularized with use of 2 incisions,⁹ Boileau and colleagues⁴ described a modified technique that allows the transfer to be performed through a single deltopectoral approach during RSA.

Although several authors have described the outcomes of RSA with LDTT, the expected clinical outcomes and complication rates remain elusive because of the relatively small number of patients in each case series. In a systematic review, we critically examined and synthesized the results of individual studies on RSA with LDTT. We had 3 questions: What are the demographics of patients treated with RSA-LDTT? What outcomes are associated with this combined procedure? What are the associated complications, and how often do they occur?

Methods

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. PubMed and Scopus computerized literature databases were searched through July 2015. Articles were identified with keyword searches (Figure). In our review, we included only studies that were reported in English, that included a minimum of 10 patients at baseline, and that had follow-up of at least 12 months; we excluded review papers, case reports, and technique papers without patient data. Mr. Sheth performed the initial search, and he and Dr. Namdari reviewed the qualifying abstracts. If one of the authors selected a paper, it was moved to the next phase of the review process. At the final phase (full-text review), there were no disagreements about which articles ultimately would be included (Figure).

We obtained 36 articles from PubMed and 12 from Scopus (Figure). Of these 48 articles, 15 were removed on the basis of their titles (reviews or editorials), and 8 for being duplicates. The remaining 25 articles underwent abstract review, which eliminated 17: reviews, case reports, technique articles, instructional articles, and reports on small case series (<10 patients) or studies lacking the minimum 12-month follow-up. The remaining 8 articles underwent full-text review. Inclusion/exclusion criteria removed 1 article, leaving 7 qualifying articles for analysis.

None of the studies compared outcomes with those of a control (nonoperative) group or an alternative surgical treatment. One study reported outcomes of RSA with and without LDTT; in this instance, we included only the data specific to the RSA-with-LDTT cases. Data from the individual studies were compiled to obtain demographic statistics. In cases in which outcomes data were consistently reported between studies, results were pooled for calculation of percentages and frequency-weighted (FW) means. FW means and grouped standard deviations were used to generate P values, using the number of “subjects” as the number of studies. As a result, comparative statistics for each variable were reported as means that 95% of the studies would report.

Results

Seven studies met the inclusion/exclusion criteria and were included in this systematic review. Five were retrospective,^10-14 and 2 were prospective.^5,6 All were published between 2007 and 2015. Table 1 lists the full study characteristics between groups.

Demographics

All 7 studies reported number of patients at baseline (Table 1); 133 patients (study range, 11-40) underwent RSA with LDTT.^5,6,10-14 All 7 studies reported patient ages; FW mean age was 69.5 years (range, 66-73 years).^5,6,10-14 Six studies reported sex at follow-up; there were 36 men (33.6%) and 71 women (66.4%).^5,6,10,12-14

Surgical Indications and Technique

All patients underwent RSA with LDTT with or without TM tendon transfer for the indications of cuff tear arthropathy and CLEER. All 7 studies assessed loss of elevation as active forward elevation of <80° or <90° and loss of external rotation as active external rotation of <0°, inability to maintain abducted arm at 0°, or external rotation lag sign of >30°. All surgeries were performed with the deltopectoral approach. Combined LD/TM tendons were transferred in 6 studies^5,6,10,12-14 and only the LD tendon in the seventh.¹¹ Of the 6 studies that indicated tendon transfer location, 4 reported attaching to the posterolateral aspect of the greater tuberosity at the level of the original teres minor insertion^5,6,11,12 and 2 reported attaching to the lateral aspect of the bicipital groove at the level of the LD insertion,10,14 . Six studies reported use of a sling or brace for 6 weeks after surgery.^5,6,10-12,14

Outcomes

The 7 studies reported outcomes data for 116 (87%) of their 133 baseline patients (Table 2). Patients were followed up an FW mean of 39.9 months (range, 18-65 months). Six studies reported postoperative Constant scores; FW mean Constant score was 28.7 before surgery and 64.4 afterward (P = .0001).^5,6,10-13

With regard to functional evaluation on physical examination, all 7 studies reported preoperative and postoperative active forward elevation and external rotation.5,6,10-14 Active forward elevation improved to an FW mean of 136°, from 71° (P < .0001), and external rotation improved to an FW mean of 25°, from –4° (P < .0001). Three studies reported preoperative and postoperative abduction; abduction improved to an FW mean of 137°, from 72° (P = .003).^6,10,13

Complications and Reoperations

The 7 studies reported 31 complications, for an overall complication rate of 22.8% (31/126).^5,6,10-14 There were 9 cases of neuropraxia (7.1%), 7 infections (6.0%), 4 dislocations or subluxations (3.4%), 2 cases of aseptic loosening (1.7%), 2 deltoid separations (1.7%), 2 periprosthetic fractures (1.7%), 1 acromion fracture (0.9%), 1 hematoma (0.9%), 1 LD/TM tendon rupture (0.9%), 1 intraoperative metaphyseal fracture (0.9%), and 1 painful baseplate screw (prominent where it penetrated the scapular spine)7 (0.9%).

The 7 studies also reported 19 reoperations, for an overall reoperation rate of 15.1% (19/126).^5,6,10-14 There were 4 wound revisions, 3 revision RSAs, 3 open reduction and internal fixations, 2 deltoid repairs, 2 irrigation and débridements, 1 revision to hemiarthroplasty, 1 acromioclavicular resection, 1 procedure for a shoulder dislocation, 1 cerclage wire fixation to correct an intraoperative metaphyseal fracture, and 1 procedure to burr down a protruding baseplate screw.

Discussion

RSA with LDTT improves postoperative function in patients with cuff tear arthropathy associated with profound external rotation weakness caused by loss of a functional teres minor muscle. That statement is consistent with the findings of our systematic review, as all 7 reviewed studies found functional improvements, particularly in active external rotation (~30° improvement). In addition, there were consistent reductions in pain and improvements in forward elevation.

Our review found a mean patient age of 69.5 years, similar to the 72.7 years reported in a recent population-based study on RSA utilization.¹⁵ Likewise, our percentage of women who underwent RSA with LDTT, 66.4%, is similar to the overall rate of 63.6%.15 It appears that the RSA-with-LDTT population and the traditional RSA population are not dramatically different.

The improvements we found in subjective outcome scores and range of motion can be compared with those found in RSA-only treatment of rotator cuff tear arthropathy. Wall and colleagues16 found an approximate 44-point Constant score improvement, to 65.1 from 21.7, which is similar to our 36-point improvement for RSA with LDTT. They also found an approximate 10-point increase in pain relief; ours was about 6 points. Regarding range of motion, they found 66° improvement in active forward elevation and 2° in active external rotation, and we found 65° and 29° improvement, respectively. Thus, the outcomes of RSA with LDTT and RSA alone appear to be comparable. Simovitch and colleagues17 evaluated RSA outcomes as a function of teres minor muscle atrophy and found that, compared with patients with stage 3 or 4 fatty infiltration, patients with stage 0, 1, or 2 infiltration had significantly better ultimate Constant scores, significantly better SSVs, and significantly more preoperative-to-postoperative improvement. On average, Constant scores and SSVs increased 32% and 25%, respectively, in patients with more extensive fatty atrophy, and these patients experienced an average net loss of 7° in external rotation. It appears that, whereas RSA-with-LDTT outcomes are similar to outcomes in a nonspecific group of cuff tear arthropathy patients treated with RSA alone, adding LDTT to RSA may substantially improve outcomes in cases in which the teres minor is of poor quality.

We found no differences in implant types. However, with the exception of the Arrow prosthesis, which had 8.5 mm of lateralization, all implants had a traditional Grammont design. Greiner and colleagues² recently found a trend toward improved external rotation in lateralized RSA designs, and a statistically significant improvement in external rotation in patients with an intact teres minor. The impact of LDTT with use of a lateralized design is unknown.

Our review found a relatively high rate of complications, 22.8%, and a reoperation rate of 15.1%. These are not dramatically different from the historical rates of complications (21%) and reoperations (13.4%).¹⁸ Although RSA with LDTT appears to have a higher rate of a specific complication, nerve-related injury, this is not necessarily surprising given the proximity of the axillary and radial nerves, the operative field, and the tendons transferred. This review’s rate of neuropraxia, 7.1%, is higher than the historical rate of 1.2% reported for RSA alone.¹⁸

This systematic review was limited by the quality of the studies available for inclusion. Although we followed PRISMA guidelines, none of the reviewed studies reported methods for controlling bias, confounding, and chance. In addition, the number of patients included and the relatively short follow-up period limit the impact of our findings. Finally, the individual studies used different outcome measures and did not report raw patient data, which limited our ability to perform more advanced statistical analysis.

Conclusion

This systematic review describes the demographics and outcomes of patients who underwent RSA with LDTT. Compiled data and FW means showed significant improvements in various subjective values, active forward elevation, external rotation, and abduction strength. For RSA with LDTT and RSA alone, complication rates appear comparable, but the rate of neuropraxia may be higher for the combined procedure. Although this review provides valuable information on RSA with LDTT, its lack of a control comparison group and its relatively short follow-up period limited our ability to draw meaningful conclusions about the efficacy of the combined procedure in treating rotator cuff tear arthropathy in the absence of a functional teres minor.