Take-Home Points

• Prevalence of the medial oblique meniscomeniscal ligament is 1% to 4%.
• It is important to distinguish this ligament from a meniscus tear on MRI.
• The functional characteristics of this ligament are not well understood.
• What may appear to be a meniscal tear in a younger patient could be a medial oblique meniscomeniscal ligament.
• Dr. Flanigan recommends leaving the ligament intact unless resection is needed to provide better visualization.

We report a case of aberrant meniscus attachment in the setting of anterior cruciate ligament (ACL) injury. An anomalous cordlike attachment ran from the anterior horn of the medial meniscus to the posterior horn of the lateral meniscus through the intercondylar notch. This attachment was previously named the medial oblique meniscomeniscal ligament1 but has seldom been reported in the literature. Prevalence is 1% to 4%.^1,2 This case was treated at Ohio State University Wexner Medical Center in Columbus. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

An 18-year-old man presented with left knee pain after sustaining 2 injuries to the knee. The first injury occurred during a dodgeball game—when the knee buckled on landing from a jump. A “pop” was felt, and the knee swelled immediately. The second injury occurred about 3 months later, during soccer play. The patient was running when his foot slipped and caused the knee to buckle. Again, a “pop” was felt, and there was swelling. Mechanical symptoms of clicking then started. The patient reported no instability episodes. His medical history and family history were otherwise unremarkable. The patient was healthy and had a body mass index of 23.05 kg/m2.

Physical examination revealed no effusion, erythema, or warmth in the left knee. Range of motion was 0° to 135° in the left knee and 0° to 140° in the right knee. There was no pain on hyperextension of the knee or medial or lateral joint-line tenderness, but there was pain on hyperflexion, and the McMurray test was positive. Ligament examination was negative except for positive anterior drawer, Lachman, and pivot-shift tests.

Radiographs taken the day of the first clinic visit showed no acute osseous abnormality. Magnetic resonance imaging (MRI) showed complete disruption of the proximal fibers of the ACL (Figures 1, 2). 

Also observed was a small oblique tear of the body of the lateral meniscus with slight blunting of the anterior horn of the medial meniscus, which may have been related to a small tear. A pivot-shift contusion pattern with impaction fracture of the lateral femoral condyle was also appreciated. There were no definite cartilage defects identified.

Discussion

The medial and lateral menisci typically are separate fibrocartilaginous structures acting as a cushion for the knee, but normal variant connections between the structures have been described. These connections include the anterior transverse meniscal ligament, the posterior transverse meniscal ligament, and the medial and lateral oblique meniscomeniscal ligaments.³ In the present case, a medial oblique meniscomeniscal ligament was identified. Its path between menisci was traceable on coronal and axial views. Video taken during arthroscopy also clearly showed its path and its relationship to other structures in the knee. To Dr. Flanigan’s knowledge, this ligament was not previously described with video. It is important to distinguish this ligament from a horizontal tear of the meniscus, given the potential for misinterpretation on MRI. A horizontal tear is a degenerative change that often occurs in older patients. Our patient was 18 years old at time of injury. In addition, the surface of his lower meniscus was smooth, whereas in a tear the edge is irregular and discontinuous. Dr. Flanigan prefers to leave this ligament intact unless resection would provide better visualization during arthroscopy. His reasoning is that the functional characteristics of the ligament are not well understood.

There are few reports on the medial oblique meniscomeniscal ligament.¹ Sanders and colleagues¹ found 3 cases of this normal variant. In the first, the ligament was interpreted as a flap tear on MRI; in the other 2 cases, the ligament was correctly identified. Kim and Laor² and Dervin and Paterson⁴ also described this variant in case reports.

There are many abnormalities of the meniscus. In our literature review, we found reports on various anomalies, including discoid meniscus,⁵ ring-shape meniscus,^6,7 accessory meniscus,⁸ double-layer meniscus,^9-12 abnormal band formation,^13,14 hypoplasia,¹⁵ Wrisberg meniscus,⁶ and congenital absence of meniscus.¹⁶ These variations have multifactorial causes, including congenital and developmental influences.

In a recent case report, Giordano and Goldblatt¹⁴ described an abnormal band of lateral meniscus extending from the posterior horn to the anterior-mid portion of the same meniscus. Lee and Min¹³ described the same band earlier, in a 2-patient case report.¹³ One patient presented symptomatically, nontraumatically, and the other with a posterior cruciate ligament tear. Each case was deemed congenital given the characteristic appearance and bilaterality of the anomaly.

In an 11-patient case series in Finland, Rainio and colleagues¹⁷ described an attachment from the anterior horn of the medial meniscus inserting into the ACL—a crescent band from the upper surface of the anterior horn that attached along the upper two thirds of the ACL.

At 2-year follow-up, our patient was doing well with rehabilitation and experienced only minimal symptoms. Radiologists and surgeons should be able to identify such variants. Knowing the common and rare variants, radiologists can help surgeons by identifying normal anatomy from pathology and providing a more clinically relevant report. Surgeons should be aware of the anatomical variability in the knee in order to provide the best care for their patients. 

Take-Home Points

• Prevalence of the medial oblique meniscomeniscal ligament is 1% to 4%.
• It is important to distinguish this ligament from a meniscus tear on MRI.
• The functional characteristics of this ligament are not well understood.
• What may appear to be a meniscal tear in a younger patient could be a medial oblique meniscomeniscal ligament.
• Dr. Flanigan recommends leaving the ligament intact unless resection is needed to provide better visualization.

We report a case of aberrant meniscus attachment in the setting of anterior cruciate ligament (ACL) injury. An anomalous cordlike attachment ran from the anterior horn of the medial meniscus to the posterior horn of the lateral meniscus through the intercondylar notch. This attachment was previously named the medial oblique meniscomeniscal ligament1 but has seldom been reported in the literature. Prevalence is 1% to 4%.^1,2 This case was treated at Ohio State University Wexner Medical Center in Columbus. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

An 18-year-old man presented with left knee pain after sustaining 2 injuries to the knee. The first injury occurred during a dodgeball game—when the knee buckled on landing from a jump. A “pop” was felt, and the knee swelled immediately. The second injury occurred about 3 months later, during soccer play. The patient was running when his foot slipped and caused the knee to buckle. Again, a “pop” was felt, and there was swelling. Mechanical symptoms of clicking then started. The patient reported no instability episodes. His medical history and family history were otherwise unremarkable. The patient was healthy and had a body mass index of 23.05 kg/m2.

Physical examination revealed no effusion, erythema, or warmth in the left knee. Range of motion was 0° to 135° in the left knee and 0° to 140° in the right knee. There was no pain on hyperextension of the knee or medial or lateral joint-line tenderness, but there was pain on hyperflexion, and the McMurray test was positive. Ligament examination was negative except for positive anterior drawer, Lachman, and pivot-shift tests.

Radiographs taken the day of the first clinic visit showed no acute osseous abnormality. Magnetic resonance imaging (MRI) showed complete disruption of the proximal fibers of the ACL (Figures 1, 2). 

Also observed was a small oblique tear of the body of the lateral meniscus with slight blunting of the anterior horn of the medial meniscus, which may have been related to a small tear. A pivot-shift contusion pattern with impaction fracture of the lateral femoral condyle was also appreciated. There were no definite cartilage defects identified.

Discussion

The medial and lateral menisci typically are separate fibrocartilaginous structures acting as a cushion for the knee, but normal variant connections between the structures have been described. These connections include the anterior transverse meniscal ligament, the posterior transverse meniscal ligament, and the medial and lateral oblique meniscomeniscal ligaments.³ In the present case, a medial oblique meniscomeniscal ligament was identified. Its path between menisci was traceable on coronal and axial views. Video taken during arthroscopy also clearly showed its path and its relationship to other structures in the knee. To Dr. Flanigan’s knowledge, this ligament was not previously described with video. It is important to distinguish this ligament from a horizontal tear of the meniscus, given the potential for misinterpretation on MRI. A horizontal tear is a degenerative change that often occurs in older patients. Our patient was 18 years old at time of injury. In addition, the surface of his lower meniscus was smooth, whereas in a tear the edge is irregular and discontinuous. Dr. Flanigan prefers to leave this ligament intact unless resection would provide better visualization during arthroscopy. His reasoning is that the functional characteristics of the ligament are not well understood.

There are few reports on the medial oblique meniscomeniscal ligament.¹ Sanders and colleagues¹ found 3 cases of this normal variant. In the first, the ligament was interpreted as a flap tear on MRI; in the other 2 cases, the ligament was correctly identified. Kim and Laor² and Dervin and Paterson⁴ also described this variant in case reports.

There are many abnormalities of the meniscus. In our literature review, we found reports on various anomalies, including discoid meniscus,⁵ ring-shape meniscus,^6,7 accessory meniscus,⁸ double-layer meniscus,^9-12 abnormal band formation,^13,14 hypoplasia,¹⁵ Wrisberg meniscus,⁶ and congenital absence of meniscus.¹⁶ These variations have multifactorial causes, including congenital and developmental influences.

In a recent case report, Giordano and Goldblatt¹⁴ described an abnormal band of lateral meniscus extending from the posterior horn to the anterior-mid portion of the same meniscus. Lee and Min¹³ described the same band earlier, in a 2-patient case report.¹³ One patient presented symptomatically, nontraumatically, and the other with a posterior cruciate ligament tear. Each case was deemed congenital given the characteristic appearance and bilaterality of the anomaly.

In an 11-patient case series in Finland, Rainio and colleagues¹⁷ described an attachment from the anterior horn of the medial meniscus inserting into the ACL—a crescent band from the upper surface of the anterior horn that attached along the upper two thirds of the ACL.

At 2-year follow-up, our patient was doing well with rehabilitation and experienced only minimal symptoms. Radiologists and surgeons should be able to identify such variants. Knowing the common and rare variants, radiologists can help surgeons by identifying normal anatomy from pathology and providing a more clinically relevant report. Surgeons should be aware of the anatomical variability in the knee in order to provide the best care for their patients. 

Take-Home Points

• Prevalence of the medial oblique meniscomeniscal ligament is 1% to 4%.
• It is important to distinguish this ligament from a meniscus tear on MRI.
• The functional characteristics of this ligament are not well understood.
• What may appear to be a meniscal tear in a younger patient could be a medial oblique meniscomeniscal ligament.
• Dr. Flanigan recommends leaving the ligament intact unless resection is needed to provide better visualization.

We report a case of aberrant meniscus attachment in the setting of anterior cruciate ligament (ACL) injury. An anomalous cordlike attachment ran from the anterior horn of the medial meniscus to the posterior horn of the lateral meniscus through the intercondylar notch. This attachment was previously named the medial oblique meniscomeniscal ligament1 but has seldom been reported in the literature. Prevalence is 1% to 4%.^1,2 This case was treated at Ohio State University Wexner Medical Center in Columbus. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

An 18-year-old man presented with left knee pain after sustaining 2 injuries to the knee. The first injury occurred during a dodgeball game—when the knee buckled on landing from a jump. A “pop” was felt, and the knee swelled immediately. The second injury occurred about 3 months later, during soccer play. The patient was running when his foot slipped and caused the knee to buckle. Again, a “pop” was felt, and there was swelling. Mechanical symptoms of clicking then started. The patient reported no instability episodes. His medical history and family history were otherwise unremarkable. The patient was healthy and had a body mass index of 23.05 kg/m2.

Physical examination revealed no effusion, erythema, or warmth in the left knee. Range of motion was 0° to 135° in the left knee and 0° to 140° in the right knee. There was no pain on hyperextension of the knee or medial or lateral joint-line tenderness, but there was pain on hyperflexion, and the McMurray test was positive. Ligament examination was negative except for positive anterior drawer, Lachman, and pivot-shift tests.

Radiographs taken the day of the first clinic visit showed no acute osseous abnormality. Magnetic resonance imaging (MRI) showed complete disruption of the proximal fibers of the ACL (Figures 1, 2). 

Also observed was a small oblique tear of the body of the lateral meniscus with slight blunting of the anterior horn of the medial meniscus, which may have been related to a small tear. A pivot-shift contusion pattern with impaction fracture of the lateral femoral condyle was also appreciated. There were no definite cartilage defects identified.

Discussion

The medial and lateral menisci typically are separate fibrocartilaginous structures acting as a cushion for the knee, but normal variant connections between the structures have been described. These connections include the anterior transverse meniscal ligament, the posterior transverse meniscal ligament, and the medial and lateral oblique meniscomeniscal ligaments.³ In the present case, a medial oblique meniscomeniscal ligament was identified. Its path between menisci was traceable on coronal and axial views. Video taken during arthroscopy also clearly showed its path and its relationship to other structures in the knee. To Dr. Flanigan’s knowledge, this ligament was not previously described with video. It is important to distinguish this ligament from a horizontal tear of the meniscus, given the potential for misinterpretation on MRI. A horizontal tear is a degenerative change that often occurs in older patients. Our patient was 18 years old at time of injury. In addition, the surface of his lower meniscus was smooth, whereas in a tear the edge is irregular and discontinuous. Dr. Flanigan prefers to leave this ligament intact unless resection would provide better visualization during arthroscopy. His reasoning is that the functional characteristics of the ligament are not well understood.

There are few reports on the medial oblique meniscomeniscal ligament.¹ Sanders and colleagues¹ found 3 cases of this normal variant. In the first, the ligament was interpreted as a flap tear on MRI; in the other 2 cases, the ligament was correctly identified. Kim and Laor² and Dervin and Paterson⁴ also described this variant in case reports.

There are many abnormalities of the meniscus. In our literature review, we found reports on various anomalies, including discoid meniscus,⁵ ring-shape meniscus,^6,7 accessory meniscus,⁸ double-layer meniscus,^9-12 abnormal band formation,^13,14 hypoplasia,¹⁵ Wrisberg meniscus,⁶ and congenital absence of meniscus.¹⁶ These variations have multifactorial causes, including congenital and developmental influences.

In a recent case report, Giordano and Goldblatt¹⁴ described an abnormal band of lateral meniscus extending from the posterior horn to the anterior-mid portion of the same meniscus. Lee and Min¹³ described the same band earlier, in a 2-patient case report.¹³ One patient presented symptomatically, nontraumatically, and the other with a posterior cruciate ligament tear. Each case was deemed congenital given the characteristic appearance and bilaterality of the anomaly.

In an 11-patient case series in Finland, Rainio and colleagues¹⁷ described an attachment from the anterior horn of the medial meniscus inserting into the ACL—a crescent band from the upper surface of the anterior horn that attached along the upper two thirds of the ACL.

At 2-year follow-up, our patient was doing well with rehabilitation and experienced only minimal symptoms. Radiologists and surgeons should be able to identify such variants. Knowing the common and rare variants, radiologists can help surgeons by identifying normal anatomy from pathology and providing a more clinically relevant report. Surgeons should be aware of the anatomical variability in the knee in order to provide the best care for their patients. 

Take-Home Points

• Guidelines regarding glenoid component size selection for primary TSA are lacking.
• Intraoperative in situ glenoid sizing may not be ideal.
• 3-D digital models may be utilized for preoperative templating of glenoid component size in primary TSA.
• 3-D templating that allows for superior-inferior, anterior-posterior, and rotational translation can lead to consistent and reproducible templating of glenoid component size.
• 3-D templating may reduce the risks of implant overhang, peg penetration, and decreased stability ratio.

In 1974, Neer¹ introduced the shoulder prosthesis. In 1982, Neer and colleagues² found significant improvement in shoulder pain and function in patients with glenohumeral osteoarthritis treated with the Neer prosthesis. Since then, use of total shoulder arthroplasty (TSA) has increased. Between 1993 and 2007, TSA use increased 319% in the United States.³ Long-term outcomes studies have found implant survivorship ranging from 87% to 93% at 10 to 15 years.⁴

Although TSA is a successful procedure, glenoid component failure is the most common complication.^5-10 Outcomes of revision surgery for glenoid instability are inferior to those of primary TSA.¹¹ Recent research findings highlight the effect of glenoid size on TSA complications.¹² A larger glenoid component increases the stability ratio (peak subluxation force divided by compression load).¹² However, insufficient glenoid bone stock, small glenoid diameter, and inability to fit a properly sized reamer owing to soft-tissue constraints may lead surgeons to choose a smaller glenoid component in order to avoid peg penetration, overhang, and soft-tissue damage, respectively. Therefore, preoperative templating of glenoid size is a potential strategy for minimizing complications.

Templating is performed for proximal humeral components, but glenoid sizing typically is deferred to intraoperative in situ sizing with implant-specific targeting guides. This glenoid sizing practice arose out of a lack of standard digital glenoid templates and difficulty in selecting glenoid size based on plain radiographs and/or 2-dimensional (2-D) computed tomography (CT) scans. However, targeting devices are sporadically used during surgery, and intraoperative glenoid vault dimension estimates derived from visualization and palpation are often inaccurate. Often, rather than directly assess glenoid morphology, surgeons infer glenoid size from the size and sex of patients.¹³

Three-dimensional (3-D) CT can be used to accurately assess glenoid version, bone loss, and implant fit.^14-19 We conducted a study to determine if 3-D digital imaging can be consistently and reproducibly used for preoperative templating of glenoid component size and to determine if glenoid sizes derived from templating correlate with the sizes of subsequently implanted glenoids.

Materials and Methods

This retrospective study was conducted at the Center for Shoulder, Elbow, and Sports Medicine at Columbia University Medical Center in New York City and was approved by our Institutional Review Board. Included in the study were all patients who underwent primary TSA for primary glenohumeral osteoarthritis over a 12-month period. Patients were required to have preoperative CT performed according to our study protocol. The CT protocol consisted of 0.5-mm axial cuts of the entire scapula and 3-D reconstruction of the scapula, glenoid, glenohumeral articulation, and proximal humerus. Patients were excluded from the study for primary TSA for a secondary cause of glenohumeral osteoarthritis, inflammatory arthritis, connective tissue disease, prior contralateral TSA, and prior ipsilateral scapula, glenoid, and proximal humerus surgery. Ultimately, 24 patients were included in the study.

CT data were formatted for preoperative templating. The CT images of each patient’s scapula were uploaded into Materialise Interactive Medical Image Control System (Mimics) software. Mimics allows 3-D image rendering and editing from various imaging modalities and formats. The software was used to create the 3-D scapula models for templating. Prior studies have validated the anatomical precision of 3-D models created with Mimics.²⁰

Mimics was also used to digitize in 3-D the glenoid components from the Bigliani-Flatow Shoulder System (Zimmer Biomet). Glenoid components of 3 different sizes (40 mm, 46 mm, 52 mm) were used. (The Bigliani glenoid component was digitized, as this implant system was used for primary TSA in all 24 patients.) Each glenoid component was traced in 3-D with a Gage 2000 coordinate-measuring machine (Brown & Sharpe) and was processed with custom software. The custom software, cited in previous work by our group,¹⁷ created the same coordinate system for each scapula based on anatomical reference points. These digitized 3-D images of glenoid components were uploaded with the digitized 3-D scapulae derived from patients’ CT scans to the Magics software. Magics allows for manipulation and interaction of multiple 3-D models by creating electronic stereolithography files that provide 3-D surface geometry.

Three fellowship-trained shoulder surgeons and 4 shoulder fellows templated the most appropriately sized glenoid component for each of the 24 patients. At the time of templating, the surgeon was blinded to the size of the glenoid implant used in the surgery. In Magics, each scapula was positioned in 3-D similar to how it would appear with the patient in the beach-chair position during surgery. In both study arms, surgeons selected the largest component that maximized the area of contact while avoiding peg penetration of the glenoid vault or component overhang. In addition, surgeons were instructed to correct glenoid version to as near neutral as possible with component positioning but were not permitted to remove glenoid bone stock to correct deformity. All surgeons based placement of the glenoid component on the patient’s actual bone stock and not on osteophytes, which are readily appreciable on 3-D CT.

In study arm 1, the 3-D view of the glenoid was restricted to the initial view in the beach-chair position. The surgeon then manipulated the 3-D glenoid component template across a single 2-D plane, either the superior-inferior plane or the anterior-posterior plane, over the surface of the 3-D glenoid (Figure 1).

In study arm 2, surgeons were permitted to rotate the 3-D glenoid template and scapula in any manner (Figure 2).

Interobserver agreement was determined by comparing prosthetic glenoid component size selection among all study surgeons, and intraobserver agreement was determined by comparing glenoid size selection during 2 sessions separated by at least 3 weeks.

After each trial, the order of patients’ scapula images was randomly rearranged to reduce recall bias. Kappa (κ) coefficients were calculated for interobserver and intraobserver agreement. Kappas ranged from −1.0 (least agreement) to +1.0 (complete agreement). A κ of 0 indicated an observer selection was equivalent to random chance. The level of agreement was categorized according to κ using a system described by Landis and Koch²¹ (Table 1).

Results

The group of 24 patients consisted of 15 men and 9 women. Mean age was 70.3 years (range, 56-88 years). Primary TSA was performed in 14 right shoulders and 10 left shoulders. Of the 24 patients, 20 (83%) had a 46-mm glenoid component implanted, 3 male patients had a 52-mm glenoid component implanted, and 1 female patient had a 40-mm glenoid component implanted.

Study Arm 1: Glenoid Templating Based on 2 df 

In study arm 1, overall intraobserver agreement was substantial, as defined in the statistical literature.²¹ Among all surgeons who participated, intraobserver agreeement was 0.76 (substantial), 0.60 (substantial), and 0.58 (moderate) for the 40-mm, 46-mm, and 52-mm glenoid components, respectively (overall κ = 0.67, substantial agreement). Trial 1 interobserver agreement was 0.56 (moderate) (P < .001), 0.25 (fair) (P < .001), and 0.21 (fair) (P < .001) for the 40-mm, 46-mm, and 52-mm glenoid components, respectively (overall κ = 0.36, fair agreement) (P < .001), and trial 2 interobserver agreement was 0.58 (moderate) (P < .001), 0.18 (poor) (P = .003), and 0.24 (fair) (P <.001) for the 40-mm, 46-mm, and 52-mm glenoid components, respectively (overall κ = 0.32, fair agreement) (P < .001). In study arm 1, therefore, trials 1 and 2 both showed fair interobserver agreement.

Study Arm 2: Glenoid Templating Based on 6 df

In study arm 2, a mean correlation of 0.42 (moderate agreement) was found between glenoid component size in 3-D templating and the glenoid component size ultimately selected during surgery (Table 3).

In study arm 2, overall intraobserver agreement was moderate. Among all surgeons who participated, intraobserver agreement was 0.80 (excellent), 0.43 (moderate), and 0.47 (moderate) for the 40-mm, 46-mm, and 52-mm glenoid components, respectively (overall κ = 0.58, moderate agreement). Trial 1 interobserver agreement was 0.75 (substantial) (P < .001), 0.39 (fair) (P < .001), and 0.50 (moderate) (P < .001) for the 40-mm, 46-mm, and 52-mm glenoid components, respectively (overall κ = 0.54, moderate agreement) (P < .001), and trial 2 interobserver agreement was 0.66 (substantial) (P < .001), 0.28 (fair) (P = .003), and 0.40 (moderate) (P < .001) for the 40-mm, 46-mm, and 52-mm glenoid components, respectively (overall κ = 0.43, moderate agreement) (P < .001). 

Discussion

Our results showed that 3-D glenoid templating had reproducible intraobserver and interobserver agreement. Overall intraobserver agreement was substantial (κ = 0.67) for study arm 1 and moderate (κ = 0.58) for study arm 2. Interobserver agreement was fair for trials 1 and 2 (κ = 0.36 and 0.32) in arm 1 and moderate for trials 1 and 2 (κ = 0.54 and 0.43) in arm 2.

Intraobserver and interobserver agreement values, particularly in study arm 2, which incorporated rotation (6 df), are consistent with values in commonly used classification systems, such as the Neer system for proximal humerus fractures, the Frykman system for distal radius fractures, and the King system for adolescent idiopathic scoliosis.^22-30 Sidor and colleagues²⁷ found overall interobserver agreement of 0.50 and overall intraobserver agreement of 0.66 for the Neer system, and Illarramendi and colleagues²⁴ found overall interobserver agreement of 0.43 and overall intraobserver agreement of 0.61 for the Frykman system.

In study arm 2, overall interobserver and intraobserver agreement was moderate. A higher level of surgeon agreement is unlikely given the lack of well-defined parameters for determining glenoid component size. Therefore, glenoid size selection is largely a matter of surgeon preference. More research is needed to establish concrete guidelines for glenoid component size selection. Once guidelines are adopted, interobserver agreement in templating may increase.

In both study arms, the component that surgeons selected during templating tended to be smaller than the component they selected during surgery. In study arm 1, 32% of patients had a smaller component selected based on computer modeling, and 7% had a larger component selected. In study arm 2, the difference was narrower: 27% of patients had a smaller component selected during templating, and 16% had a larger component selected. A statistically significant difference (P < .001) in templated and implanted component sizes was found between men and women: Templated glenoid components were smaller than implanted components in 53% of women and larger than implanted components in 33% of men. Differences between templated and implanted components may be attributable to visualization differences. During templating, the entire glenoid can be visualized and the slightest peg penetration or component overhang detected; in contrast, during surgery, anatomical constraints preclude such a comprehensive assessment.

Differences in agreement between templated and implanted glenoid components suggest that the size of implanted components may not be ideal. In this study, the distribution of the templated glenoid sizes was much wider than that of the implanted glenoid sizes. During templating, each glenoid component can be definitively visualized and assessed for possible peg penetration and overhang. Visualization allows surgeons to base glenoid size selection solely on glenoid morphology, as opposed to factors such as patient sex and height. In addition, interobserver and intraobserver agreement values for the 40-mm glenoid component were considerably higher than those for components of other sizes, indicating that the 40-mm component was consistently and reproducibly selected for the same patients. Hence, templating may particularly help prevent peg penetration and component overhang for patients with a smaller diameter glenoid.

More research on 3-D templating is warranted given the results of this study and other studies.^12,17,31 Scalise and colleagues³¹ found that, in TSA planning, surgeons’ use of 2-D (vs 3-D) imaging led them to overestimate glenoid component sizes (P = .006). In our study, the glenoid size selected during 3-D templating was, in many cases, smaller than the size selected during surgery. In order to avoid peg penetration and glenoid overhang, anecdotal guidelines commonly used in glenoid size selection, likely was the driving force in selecting smaller glenoid components during templating. Although anterior, superior, and inferior glenoid overhang typically can be assessed during surgery, posterior overhang is more difficult to evaluate. Three-dimensional modeling allows surgeons to determine optimal glenoid component size and position. In addition, intraoperative evaluation of glenoid component peg penetration is challenging, and peg penetration becomes evident only after it has occurred. During templating, however, surgeons were able to easily assess for peg penetration, and smaller glenoid components were selected.

A limitation of this study is that intraoperative glenoid version correction or peg containment was not quantified. More research is needed on the relationship between glenoid size selection and component overhang and peg penetration. Another limitation was use of only 1 TSA system (with 3 glenoid sizes, all with inline pegs); reliability of 3-D templating was not evaluated across different component designs. Last, given the absence of guidelines for glenoid component size selection, there was surgeon bias in preoperative templating and in intraoperative selection of glenoid size. Surgeons had differing opinions on the importance of maximizing the contact area of the component and correcting glenoid deformity and version.

Our study results showed that preoperative 3-D templating that allows for superior-inferior, anterior-posterior, and rotational translation was consistent and reproducible in determining glenoid component size, and use of this templating may reduce the risks of implant overhang, peg penetration, and decreased stability ratio. These results highlight the possibility that glenoid component sizes selected during surgery may not be ideal. More research is needed to determine if intraoperative glenoid size selection leads to adequate version correction and peg containment. The present study supports use of 3-D templating in primary TSA planning.

Take-Home Points

• Guidelines regarding glenoid component size selection for primary TSA are lacking.
• Intraoperative in situ glenoid sizing may not be ideal.
• 3-D digital models may be utilized for preoperative templating of glenoid component size in primary TSA.
• 3-D templating that allows for superior-inferior, anterior-posterior, and rotational translation can lead to consistent and reproducible templating of glenoid component size.
• 3-D templating may reduce the risks of implant overhang, peg penetration, and decreased stability ratio.

In 1974, Neer¹ introduced the shoulder prosthesis. In 1982, Neer and colleagues² found significant improvement in shoulder pain and function in patients with glenohumeral osteoarthritis treated with the Neer prosthesis. Since then, use of total shoulder arthroplasty (TSA) has increased. Between 1993 and 2007, TSA use increased 319% in the United States.³ Long-term outcomes studies have found implant survivorship ranging from 87% to 93% at 10 to 15 years.⁴

Although TSA is a successful procedure, glenoid component failure is the most common complication.^5-10 Outcomes of revision surgery for glenoid instability are inferior to those of primary TSA.¹¹ Recent research findings highlight the effect of glenoid size on TSA complications.¹² A larger glenoid component increases the stability ratio (peak subluxation force divided by compression load).¹² However, insufficient glenoid bone stock, small glenoid diameter, and inability to fit a properly sized reamer owing to soft-tissue constraints may lead surgeons to choose a smaller glenoid component in order to avoid peg penetration, overhang, and soft-tissue damage, respectively. Therefore, preoperative templating of glenoid size is a potential strategy for minimizing complications.

Templating is performed for proximal humeral components, but glenoid sizing typically is deferred to intraoperative in situ sizing with implant-specific targeting guides. This glenoid sizing practice arose out of a lack of standard digital glenoid templates and difficulty in selecting glenoid size based on plain radiographs and/or 2-dimensional (2-D) computed tomography (CT) scans. However, targeting devices are sporadically used during surgery, and intraoperative glenoid vault dimension estimates derived from visualization and palpation are often inaccurate. Often, rather than directly assess glenoid morphology, surgeons infer glenoid size from the size and sex of patients.¹³

Three-dimensional (3-D) CT can be used to accurately assess glenoid version, bone loss, and implant fit.^14-19 We conducted a study to determine if 3-D digital imaging can be consistently and reproducibly used for preoperative templating of glenoid component size and to determine if glenoid sizes derived from templating correlate with the sizes of subsequently implanted glenoids.

Materials and Methods

This retrospective study was conducted at the Center for Shoulder, Elbow, and Sports Medicine at Columbia University Medical Center in New York City and was approved by our Institutional Review Board. Included in the study were all patients who underwent primary TSA for primary glenohumeral osteoarthritis over a 12-month period. Patients were required to have preoperative CT performed according to our study protocol. The CT protocol consisted of 0.5-mm axial cuts of the entire scapula and 3-D reconstruction of the scapula, glenoid, glenohumeral articulation, and proximal humerus. Patients were excluded from the study for primary TSA for a secondary cause of glenohumeral osteoarthritis, inflammatory arthritis, connective tissue disease, prior contralateral TSA, and prior ipsilateral scapula, glenoid, and proximal humerus surgery. Ultimately, 24 patients were included in the study.

CT data were formatted for preoperative templating. The CT images of each patient’s scapula were uploaded into Materialise Interactive Medical Image Control System (Mimics) software. Mimics allows 3-D image rendering and editing from various imaging modalities and formats. The software was used to create the 3-D scapula models for templating. Prior studies have validated the anatomical precision of 3-D models created with Mimics.²⁰

Mimics was also used to digitize in 3-D the glenoid components from the Bigliani-Flatow Shoulder System (Zimmer Biomet). Glenoid components of 3 different sizes (40 mm, 46 mm, 52 mm) were used. (The Bigliani glenoid component was digitized, as this implant system was used for primary TSA in all 24 patients.) Each glenoid component was traced in 3-D with a Gage 2000 coordinate-measuring machine (Brown & Sharpe) and was processed with custom software. The custom software, cited in previous work by our group,¹⁷ created the same coordinate system for each scapula based on anatomical reference points. These digitized 3-D images of glenoid components were uploaded with the digitized 3-D scapulae derived from patients’ CT scans to the Magics software. Magics allows for manipulation and interaction of multiple 3-D models by creating electronic stereolithography files that provide 3-D surface geometry.

Three fellowship-trained shoulder surgeons and 4 shoulder fellows templated the most appropriately sized glenoid component for each of the 24 patients. At the time of templating, the surgeon was blinded to the size of the glenoid implant used in the surgery. In Magics, each scapula was positioned in 3-D similar to how it would appear with the patient in the beach-chair position during surgery. In both study arms, surgeons selected the largest component that maximized the area of contact while avoiding peg penetration of the glenoid vault or component overhang. In addition, surgeons were instructed to correct glenoid version to as near neutral as possible with component positioning but were not permitted to remove glenoid bone stock to correct deformity. All surgeons based placement of the glenoid component on the patient’s actual bone stock and not on osteophytes, which are readily appreciable on 3-D CT.

In study arm 1, the 3-D view of the glenoid was restricted to the initial view in the beach-chair position. The surgeon then manipulated the 3-D glenoid component template across a single 2-D plane, either the superior-inferior plane or the anterior-posterior plane, over the surface of the 3-D glenoid (Figure 1).

In study arm 2, surgeons were permitted to rotate the 3-D glenoid template and scapula in any manner (Figure 2).

Interobserver agreement was determined by comparing prosthetic glenoid component size selection among all study surgeons, and intraobserver agreement was determined by comparing glenoid size selection during 2 sessions separated by at least 3 weeks.

After each trial, the order of patients’ scapula images was randomly rearranged to reduce recall bias. Kappa (κ) coefficients were calculated for interobserver and intraobserver agreement. Kappas ranged from −1.0 (least agreement) to +1.0 (complete agreement). A κ of 0 indicated an observer selection was equivalent to random chance. The level of agreement was categorized according to κ using a system described by Landis and Koch²¹ (Table 1).

Results

The group of 24 patients consisted of 15 men and 9 women. Mean age was 70.3 years (range, 56-88 years). Primary TSA was performed in 14 right shoulders and 10 left shoulders. Of the 24 patients, 20 (83%) had a 46-mm glenoid component implanted, 3 male patients had a 52-mm glenoid component implanted, and 1 female patient had a 40-mm glenoid component implanted.

Study Arm 1: Glenoid Templating Based on 2 df 

In study arm 1, overall intraobserver agreement was substantial, as defined in the statistical literature.²¹ Among all surgeons who participated, intraobserver agreeement was 0.76 (substantial), 0.60 (substantial), and 0.58 (moderate) for the 40-mm, 46-mm, and 52-mm glenoid components, respectively (overall κ = 0.67, substantial agreement). Trial 1 interobserver agreement was 0.56 (moderate) (P < .001), 0.25 (fair) (P < .001), and 0.21 (fair) (P < .001) for the 40-mm, 46-mm, and 52-mm glenoid components, respectively (overall κ = 0.36, fair agreement) (P < .001), and trial 2 interobserver agreement was 0.58 (moderate) (P < .001), 0.18 (poor) (P = .003), and 0.24 (fair) (P <.001) for the 40-mm, 46-mm, and 52-mm glenoid components, respectively (overall κ = 0.32, fair agreement) (P < .001). In study arm 1, therefore, trials 1 and 2 both showed fair interobserver agreement.

Study Arm 2: Glenoid Templating Based on 6 df

In study arm 2, a mean correlation of 0.42 (moderate agreement) was found between glenoid component size in 3-D templating and the glenoid component size ultimately selected during surgery (Table 3).

In study arm 2, overall intraobserver agreement was moderate. Among all surgeons who participated, intraobserver agreement was 0.80 (excellent), 0.43 (moderate), and 0.47 (moderate) for the 40-mm, 46-mm, and 52-mm glenoid components, respectively (overall κ = 0.58, moderate agreement). Trial 1 interobserver agreement was 0.75 (substantial) (P < .001), 0.39 (fair) (P < .001), and 0.50 (moderate) (P < .001) for the 40-mm, 46-mm, and 52-mm glenoid components, respectively (overall κ = 0.54, moderate agreement) (P < .001), and trial 2 interobserver agreement was 0.66 (substantial) (P < .001), 0.28 (fair) (P = .003), and 0.40 (moderate) (P < .001) for the 40-mm, 46-mm, and 52-mm glenoid components, respectively (overall κ = 0.43, moderate agreement) (P < .001). 

Discussion

Our results showed that 3-D glenoid templating had reproducible intraobserver and interobserver agreement. Overall intraobserver agreement was substantial (κ = 0.67) for study arm 1 and moderate (κ = 0.58) for study arm 2. Interobserver agreement was fair for trials 1 and 2 (κ = 0.36 and 0.32) in arm 1 and moderate for trials 1 and 2 (κ = 0.54 and 0.43) in arm 2.

Intraobserver and interobserver agreement values, particularly in study arm 2, which incorporated rotation (6 df), are consistent with values in commonly used classification systems, such as the Neer system for proximal humerus fractures, the Frykman system for distal radius fractures, and the King system for adolescent idiopathic scoliosis.^22-30 Sidor and colleagues²⁷ found overall interobserver agreement of 0.50 and overall intraobserver agreement of 0.66 for the Neer system, and Illarramendi and colleagues²⁴ found overall interobserver agreement of 0.43 and overall intraobserver agreement of 0.61 for the Frykman system.

In study arm 2, overall interobserver and intraobserver agreement was moderate. A higher level of surgeon agreement is unlikely given the lack of well-defined parameters for determining glenoid component size. Therefore, glenoid size selection is largely a matter of surgeon preference. More research is needed to establish concrete guidelines for glenoid component size selection. Once guidelines are adopted, interobserver agreement in templating may increase.

In both study arms, the component that surgeons selected during templating tended to be smaller than the component they selected during surgery. In study arm 1, 32% of patients had a smaller component selected based on computer modeling, and 7% had a larger component selected. In study arm 2, the difference was narrower: 27% of patients had a smaller component selected during templating, and 16% had a larger component selected. A statistically significant difference (P < .001) in templated and implanted component sizes was found between men and women: Templated glenoid components were smaller than implanted components in 53% of women and larger than implanted components in 33% of men. Differences between templated and implanted components may be attributable to visualization differences. During templating, the entire glenoid can be visualized and the slightest peg penetration or component overhang detected; in contrast, during surgery, anatomical constraints preclude such a comprehensive assessment.

Differences in agreement between templated and implanted glenoid components suggest that the size of implanted components may not be ideal. In this study, the distribution of the templated glenoid sizes was much wider than that of the implanted glenoid sizes. During templating, each glenoid component can be definitively visualized and assessed for possible peg penetration and overhang. Visualization allows surgeons to base glenoid size selection solely on glenoid morphology, as opposed to factors such as patient sex and height. In addition, interobserver and intraobserver agreement values for the 40-mm glenoid component were considerably higher than those for components of other sizes, indicating that the 40-mm component was consistently and reproducibly selected for the same patients. Hence, templating may particularly help prevent peg penetration and component overhang for patients with a smaller diameter glenoid.

More research on 3-D templating is warranted given the results of this study and other studies.^12,17,31 Scalise and colleagues³¹ found that, in TSA planning, surgeons’ use of 2-D (vs 3-D) imaging led them to overestimate glenoid component sizes (P = .006). In our study, the glenoid size selected during 3-D templating was, in many cases, smaller than the size selected during surgery. In order to avoid peg penetration and glenoid overhang, anecdotal guidelines commonly used in glenoid size selection, likely was the driving force in selecting smaller glenoid components during templating. Although anterior, superior, and inferior glenoid overhang typically can be assessed during surgery, posterior overhang is more difficult to evaluate. Three-dimensional modeling allows surgeons to determine optimal glenoid component size and position. In addition, intraoperative evaluation of glenoid component peg penetration is challenging, and peg penetration becomes evident only after it has occurred. During templating, however, surgeons were able to easily assess for peg penetration, and smaller glenoid components were selected.

A limitation of this study is that intraoperative glenoid version correction or peg containment was not quantified. More research is needed on the relationship between glenoid size selection and component overhang and peg penetration. Another limitation was use of only 1 TSA system (with 3 glenoid sizes, all with inline pegs); reliability of 3-D templating was not evaluated across different component designs. Last, given the absence of guidelines for glenoid component size selection, there was surgeon bias in preoperative templating and in intraoperative selection of glenoid size. Surgeons had differing opinions on the importance of maximizing the contact area of the component and correcting glenoid deformity and version.

Our study results showed that preoperative 3-D templating that allows for superior-inferior, anterior-posterior, and rotational translation was consistent and reproducible in determining glenoid component size, and use of this templating may reduce the risks of implant overhang, peg penetration, and decreased stability ratio. These results highlight the possibility that glenoid component sizes selected during surgery may not be ideal. More research is needed to determine if intraoperative glenoid size selection leads to adequate version correction and peg containment. The present study supports use of 3-D templating in primary TSA planning.

Take-Home Points

• Guidelines regarding glenoid component size selection for primary TSA are lacking.
• Intraoperative in situ glenoid sizing may not be ideal.
• 3-D digital models may be utilized for preoperative templating of glenoid component size in primary TSA.
• 3-D templating that allows for superior-inferior, anterior-posterior, and rotational translation can lead to consistent and reproducible templating of glenoid component size.
• 3-D templating may reduce the risks of implant overhang, peg penetration, and decreased stability ratio.

In 1974, Neer¹ introduced the shoulder prosthesis. In 1982, Neer and colleagues² found significant improvement in shoulder pain and function in patients with glenohumeral osteoarthritis treated with the Neer prosthesis. Since then, use of total shoulder arthroplasty (TSA) has increased. Between 1993 and 2007, TSA use increased 319% in the United States.³ Long-term outcomes studies have found implant survivorship ranging from 87% to 93% at 10 to 15 years.⁴

Although TSA is a successful procedure, glenoid component failure is the most common complication.^5-10 Outcomes of revision surgery for glenoid instability are inferior to those of primary TSA.¹¹ Recent research findings highlight the effect of glenoid size on TSA complications.¹² A larger glenoid component increases the stability ratio (peak subluxation force divided by compression load).¹² However, insufficient glenoid bone stock, small glenoid diameter, and inability to fit a properly sized reamer owing to soft-tissue constraints may lead surgeons to choose a smaller glenoid component in order to avoid peg penetration, overhang, and soft-tissue damage, respectively. Therefore, preoperative templating of glenoid size is a potential strategy for minimizing complications.

Templating is performed for proximal humeral components, but glenoid sizing typically is deferred to intraoperative in situ sizing with implant-specific targeting guides. This glenoid sizing practice arose out of a lack of standard digital glenoid templates and difficulty in selecting glenoid size based on plain radiographs and/or 2-dimensional (2-D) computed tomography (CT) scans. However, targeting devices are sporadically used during surgery, and intraoperative glenoid vault dimension estimates derived from visualization and palpation are often inaccurate. Often, rather than directly assess glenoid morphology, surgeons infer glenoid size from the size and sex of patients.¹³

Three-dimensional (3-D) CT can be used to accurately assess glenoid version, bone loss, and implant fit.^14-19 We conducted a study to determine if 3-D digital imaging can be consistently and reproducibly used for preoperative templating of glenoid component size and to determine if glenoid sizes derived from templating correlate with the sizes of subsequently implanted glenoids.

Materials and Methods

This retrospective study was conducted at the Center for Shoulder, Elbow, and Sports Medicine at Columbia University Medical Center in New York City and was approved by our Institutional Review Board. Included in the study were all patients who underwent primary TSA for primary glenohumeral osteoarthritis over a 12-month period. Patients were required to have preoperative CT performed according to our study protocol. The CT protocol consisted of 0.5-mm axial cuts of the entire scapula and 3-D reconstruction of the scapula, glenoid, glenohumeral articulation, and proximal humerus. Patients were excluded from the study for primary TSA for a secondary cause of glenohumeral osteoarthritis, inflammatory arthritis, connective tissue disease, prior contralateral TSA, and prior ipsilateral scapula, glenoid, and proximal humerus surgery. Ultimately, 24 patients were included in the study.

CT data were formatted for preoperative templating. The CT images of each patient’s scapula were uploaded into Materialise Interactive Medical Image Control System (Mimics) software. Mimics allows 3-D image rendering and editing from various imaging modalities and formats. The software was used to create the 3-D scapula models for templating. Prior studies have validated the anatomical precision of 3-D models created with Mimics.²⁰

Mimics was also used to digitize in 3-D the glenoid components from the Bigliani-Flatow Shoulder System (Zimmer Biomet). Glenoid components of 3 different sizes (40 mm, 46 mm, 52 mm) were used. (The Bigliani glenoid component was digitized, as this implant system was used for primary TSA in all 24 patients.) Each glenoid component was traced in 3-D with a Gage 2000 coordinate-measuring machine (Brown & Sharpe) and was processed with custom software. The custom software, cited in previous work by our group,¹⁷ created the same coordinate system for each scapula based on anatomical reference points. These digitized 3-D images of glenoid components were uploaded with the digitized 3-D scapulae derived from patients’ CT scans to the Magics software. Magics allows for manipulation and interaction of multiple 3-D models by creating electronic stereolithography files that provide 3-D surface geometry.

Three fellowship-trained shoulder surgeons and 4 shoulder fellows templated the most appropriately sized glenoid component for each of the 24 patients. At the time of templating, the surgeon was blinded to the size of the glenoid implant used in the surgery. In Magics, each scapula was positioned in 3-D similar to how it would appear with the patient in the beach-chair position during surgery. In both study arms, surgeons selected the largest component that maximized the area of contact while avoiding peg penetration of the glenoid vault or component overhang. In addition, surgeons were instructed to correct glenoid version to as near neutral as possible with component positioning but were not permitted to remove glenoid bone stock to correct deformity. All surgeons based placement of the glenoid component on the patient’s actual bone stock and not on osteophytes, which are readily appreciable on 3-D CT.

In study arm 1, the 3-D view of the glenoid was restricted to the initial view in the beach-chair position. The surgeon then manipulated the 3-D glenoid component template across a single 2-D plane, either the superior-inferior plane or the anterior-posterior plane, over the surface of the 3-D glenoid (Figure 1).

In study arm 2, surgeons were permitted to rotate the 3-D glenoid template and scapula in any manner (Figure 2).

Interobserver agreement was determined by comparing prosthetic glenoid component size selection among all study surgeons, and intraobserver agreement was determined by comparing glenoid size selection during 2 sessions separated by at least 3 weeks.

After each trial, the order of patients’ scapula images was randomly rearranged to reduce recall bias. Kappa (κ) coefficients were calculated for interobserver and intraobserver agreement. Kappas ranged from −1.0 (least agreement) to +1.0 (complete agreement). A κ of 0 indicated an observer selection was equivalent to random chance. The level of agreement was categorized according to κ using a system described by Landis and Koch²¹ (Table 1).

Results

The group of 24 patients consisted of 15 men and 9 women. Mean age was 70.3 years (range, 56-88 years). Primary TSA was performed in 14 right shoulders and 10 left shoulders. Of the 24 patients, 20 (83%) had a 46-mm glenoid component implanted, 3 male patients had a 52-mm glenoid component implanted, and 1 female patient had a 40-mm glenoid component implanted.

Study Arm 1: Glenoid Templating Based on 2 df 

In study arm 1, overall intraobserver agreement was substantial, as defined in the statistical literature.²¹ Among all surgeons who participated, intraobserver agreeement was 0.76 (substantial), 0.60 (substantial), and 0.58 (moderate) for the 40-mm, 46-mm, and 52-mm glenoid components, respectively (overall κ = 0.67, substantial agreement). Trial 1 interobserver agreement was 0.56 (moderate) (P < .001), 0.25 (fair) (P < .001), and 0.21 (fair) (P < .001) for the 40-mm, 46-mm, and 52-mm glenoid components, respectively (overall κ = 0.36, fair agreement) (P < .001), and trial 2 interobserver agreement was 0.58 (moderate) (P < .001), 0.18 (poor) (P = .003), and 0.24 (fair) (P <.001) for the 40-mm, 46-mm, and 52-mm glenoid components, respectively (overall κ = 0.32, fair agreement) (P < .001). In study arm 1, therefore, trials 1 and 2 both showed fair interobserver agreement.

Study Arm 2: Glenoid Templating Based on 6 df

In study arm 2, a mean correlation of 0.42 (moderate agreement) was found between glenoid component size in 3-D templating and the glenoid component size ultimately selected during surgery (Table 3).

In study arm 2, overall intraobserver agreement was moderate. Among all surgeons who participated, intraobserver agreement was 0.80 (excellent), 0.43 (moderate), and 0.47 (moderate) for the 40-mm, 46-mm, and 52-mm glenoid components, respectively (overall κ = 0.58, moderate agreement). Trial 1 interobserver agreement was 0.75 (substantial) (P < .001), 0.39 (fair) (P < .001), and 0.50 (moderate) (P < .001) for the 40-mm, 46-mm, and 52-mm glenoid components, respectively (overall κ = 0.54, moderate agreement) (P < .001), and trial 2 interobserver agreement was 0.66 (substantial) (P < .001), 0.28 (fair) (P = .003), and 0.40 (moderate) (P < .001) for the 40-mm, 46-mm, and 52-mm glenoid components, respectively (overall κ = 0.43, moderate agreement) (P < .001). 

Discussion

Our results showed that 3-D glenoid templating had reproducible intraobserver and interobserver agreement. Overall intraobserver agreement was substantial (κ = 0.67) for study arm 1 and moderate (κ = 0.58) for study arm 2. Interobserver agreement was fair for trials 1 and 2 (κ = 0.36 and 0.32) in arm 1 and moderate for trials 1 and 2 (κ = 0.54 and 0.43) in arm 2.

Intraobserver and interobserver agreement values, particularly in study arm 2, which incorporated rotation (6 df), are consistent with values in commonly used classification systems, such as the Neer system for proximal humerus fractures, the Frykman system for distal radius fractures, and the King system for adolescent idiopathic scoliosis.^22-30 Sidor and colleagues²⁷ found overall interobserver agreement of 0.50 and overall intraobserver agreement of 0.66 for the Neer system, and Illarramendi and colleagues²⁴ found overall interobserver agreement of 0.43 and overall intraobserver agreement of 0.61 for the Frykman system.

In study arm 2, overall interobserver and intraobserver agreement was moderate. A higher level of surgeon agreement is unlikely given the lack of well-defined parameters for determining glenoid component size. Therefore, glenoid size selection is largely a matter of surgeon preference. More research is needed to establish concrete guidelines for glenoid component size selection. Once guidelines are adopted, interobserver agreement in templating may increase.

In both study arms, the component that surgeons selected during templating tended to be smaller than the component they selected during surgery. In study arm 1, 32% of patients had a smaller component selected based on computer modeling, and 7% had a larger component selected. In study arm 2, the difference was narrower: 27% of patients had a smaller component selected during templating, and 16% had a larger component selected. A statistically significant difference (P < .001) in templated and implanted component sizes was found between men and women: Templated glenoid components were smaller than implanted components in 53% of women and larger than implanted components in 33% of men. Differences between templated and implanted components may be attributable to visualization differences. During templating, the entire glenoid can be visualized and the slightest peg penetration or component overhang detected; in contrast, during surgery, anatomical constraints preclude such a comprehensive assessment.

Differences in agreement between templated and implanted glenoid components suggest that the size of implanted components may not be ideal. In this study, the distribution of the templated glenoid sizes was much wider than that of the implanted glenoid sizes. During templating, each glenoid component can be definitively visualized and assessed for possible peg penetration and overhang. Visualization allows surgeons to base glenoid size selection solely on glenoid morphology, as opposed to factors such as patient sex and height. In addition, interobserver and intraobserver agreement values for the 40-mm glenoid component were considerably higher than those for components of other sizes, indicating that the 40-mm component was consistently and reproducibly selected for the same patients. Hence, templating may particularly help prevent peg penetration and component overhang for patients with a smaller diameter glenoid.

More research on 3-D templating is warranted given the results of this study and other studies.^12,17,31 Scalise and colleagues³¹ found that, in TSA planning, surgeons’ use of 2-D (vs 3-D) imaging led them to overestimate glenoid component sizes (P = .006). In our study, the glenoid size selected during 3-D templating was, in many cases, smaller than the size selected during surgery. In order to avoid peg penetration and glenoid overhang, anecdotal guidelines commonly used in glenoid size selection, likely was the driving force in selecting smaller glenoid components during templating. Although anterior, superior, and inferior glenoid overhang typically can be assessed during surgery, posterior overhang is more difficult to evaluate. Three-dimensional modeling allows surgeons to determine optimal glenoid component size and position. In addition, intraoperative evaluation of glenoid component peg penetration is challenging, and peg penetration becomes evident only after it has occurred. During templating, however, surgeons were able to easily assess for peg penetration, and smaller glenoid components were selected.

A limitation of this study is that intraoperative glenoid version correction or peg containment was not quantified. More research is needed on the relationship between glenoid size selection and component overhang and peg penetration. Another limitation was use of only 1 TSA system (with 3 glenoid sizes, all with inline pegs); reliability of 3-D templating was not evaluated across different component designs. Last, given the absence of guidelines for glenoid component size selection, there was surgeon bias in preoperative templating and in intraoperative selection of glenoid size. Surgeons had differing opinions on the importance of maximizing the contact area of the component and correcting glenoid deformity and version.

Our study results showed that preoperative 3-D templating that allows for superior-inferior, anterior-posterior, and rotational translation was consistent and reproducible in determining glenoid component size, and use of this templating may reduce the risks of implant overhang, peg penetration, and decreased stability ratio. These results highlight the possibility that glenoid component sizes selected during surgery may not be ideal. More research is needed to determine if intraoperative glenoid size selection leads to adequate version correction and peg containment. The present study supports use of 3-D templating in primary TSA planning.

DALLAS – U.S. hospitals have recently shown a consistent and disturbing disconnect between reductions in their heart failure hospital readmission rates and heart failure mortality. Readmissions have dropped while mortality has risen.

“Despite reductions in 30-day heart failure readmissions in 89% of U.S. hospitals” during 2009-2016, “30-day heart failure mortality rates increased at 73%* of these ‘successful’ hospitals” during the same period,” Ahmad A. Abdul-Aziz, MD, said at the annual scientific meeting of the Heart Failure Society of America.

Mitchel L. Zoler/Frontline Medical News

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

*This article was updated October 5, 2017

DALLAS – U.S. hospitals have recently shown a consistent and disturbing disconnect between reductions in their heart failure hospital readmission rates and heart failure mortality. Readmissions have dropped while mortality has risen.

“Despite reductions in 30-day heart failure readmissions in 89% of U.S. hospitals” during 2009-2016, “30-day heart failure mortality rates increased at 73%* of these ‘successful’ hospitals” during the same period,” Ahmad A. Abdul-Aziz, MD, said at the annual scientific meeting of the Heart Failure Society of America.

Mitchel L. Zoler/Frontline Medical News

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

*This article was updated October 5, 2017

DALLAS – U.S. hospitals have recently shown a consistent and disturbing disconnect between reductions in their heart failure hospital readmission rates and heart failure mortality. Readmissions have dropped while mortality has risen.

“Despite reductions in 30-day heart failure readmissions in 89% of U.S. hospitals” during 2009-2016, “30-day heart failure mortality rates increased at 73%* of these ‘successful’ hospitals” during the same period,” Ahmad A. Abdul-Aziz, MD, said at the annual scientific meeting of the Heart Failure Society of America.

Mitchel L. Zoler/Frontline Medical News

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

*This article was updated October 5, 2017

There are about 16 existing dermatology groups, with about 700 dermatologists employed, backed by private equity money, that are eager to buy dermatology practices. They figure the market is highly fragmented, and they can bring efficiency and savings to make a profit. This is a highly complex topic, so bear with me; this may take a few columns. Entrepreneurial dermatologists initially set these groups up for practical reasons, such as bargaining power and cost efficiencies. Now, with low-cost money (look at interest rates) flooding the equity markets, large firms are looking to make a better, safe return on their money by buying these groups, and commoditizing them.

So who may this be a good deal for? Older physicians, say 5 years from retirement, may be able to capitalize on the value – usually calculated by EBITDA (a company’s earnings before interest, tax, depreciation, and amortization) – and sell their practices over time. EBITDA is a rough estimate of a practice’s profitability. Recall that a few years ago, some dermatologists were simply begging to find a buyer to get out or shuttering their offices and walking away into retirement.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

There are about 16 existing dermatology groups, with about 700 dermatologists employed, backed by private equity money, that are eager to buy dermatology practices. They figure the market is highly fragmented, and they can bring efficiency and savings to make a profit. This is a highly complex topic, so bear with me; this may take a few columns. Entrepreneurial dermatologists initially set these groups up for practical reasons, such as bargaining power and cost efficiencies. Now, with low-cost money (look at interest rates) flooding the equity markets, large firms are looking to make a better, safe return on their money by buying these groups, and commoditizing them.

So who may this be a good deal for? Older physicians, say 5 years from retirement, may be able to capitalize on the value – usually calculated by EBITDA (a company’s earnings before interest, tax, depreciation, and amortization) – and sell their practices over time. EBITDA is a rough estimate of a practice’s profitability. Recall that a few years ago, some dermatologists were simply begging to find a buyer to get out or shuttering their offices and walking away into retirement.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

There are about 16 existing dermatology groups, with about 700 dermatologists employed, backed by private equity money, that are eager to buy dermatology practices. They figure the market is highly fragmented, and they can bring efficiency and savings to make a profit. This is a highly complex topic, so bear with me; this may take a few columns. Entrepreneurial dermatologists initially set these groups up for practical reasons, such as bargaining power and cost efficiencies. Now, with low-cost money (look at interest rates) flooding the equity markets, large firms are looking to make a better, safe return on their money by buying these groups, and commoditizing them.

So who may this be a good deal for? Older physicians, say 5 years from retirement, may be able to capitalize on the value – usually calculated by EBITDA (a company’s earnings before interest, tax, depreciation, and amortization) – and sell their practices over time. EBITDA is a rough estimate of a practice’s profitability. Recall that a few years ago, some dermatologists were simply begging to find a buyer to get out or shuttering their offices and walking away into retirement.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

CHICAGO – Tocilizumab may be a therapeutic option for steroid-refractory immune-related adverse events that are secondary to PD-1 blockade, according to findings from a review of patients treated with nivolumab for various malignancies.

Of 87 patients who were treated with the PD-1 inhibitor between April 2015 and October 2016, 34 received tocilizumab for high-grade immune-related adverse events (irAEs) that were refractory to corticosteroids. Of those, 27 experienced clinical improvement, which was defined as documentation of symptom resolution or hospital discharge within 7 days, Aparna Hegde, MD, of East Carolina University, Greenville, N.C., reported at the Chicago Multidisciplinary Symposium in Thoracic Oncology.

The median time to discharge was 4 days, and no adverse effect on median overall survival was seen between those who received tocilizumab and those who did not (6.1 vs, 6.7 months, respectively), Dr. Hegde said.

There was, however, a trend toward inferior overall survival in patients who required more than one dose of tocilizumab, but the difference was not statistically significant (hazard ratio, 1.72), she noted.

“Immune checkpoint inhibitors are associated with an unprecedented clinical benefit in patients with lung cancer. However, they are also associated with a unique spectrum of immune-mediated adverse events. While the standard of care for initial management of these adverse events is corticosteroids, the management of steroid-refractory events is poorly defined,” she said, adding that data from randomized trials on which consensus guidelines could be based are lacking.

At East Carolina University, a significant proportion of patients treated with PD-1 inhibitors were presenting with systemic inflammatory response syndrome (SIRS)-like symptoms and immune-related organ toxicities similar to what has been described in cytokine release syndrome, Dr. Hegde said.

Such symptoms have also been reported with other types of immune therapy, such as CAR T-cell therapy and bispecific T-cell receptor–engaging antibodies in hematologic malignancies, she noted.

“In our experience, when we treated these patients with tocilizumab, which is an [anti-interleukin-6] receptor monoclonal antibody, we saw dramatic and rapid responses, not only in the SIRS symptoms, but also in other immune-related organ toxicities. Therefore, we adopted the use of tocilizumab as our standard treatment for high-grade immune-related adverse events,” she said, explaining that it has been well documented that interleukin (IL)-6 levels increase during cytokine release syndrome and are mediators of inflammation, suggesting that blocking IL-6 may treat irAEs without compromising the efficacy of immune therapy.

The current study was undertaken to look more closely at the responses to tocilizumab and to assess overall survival in those who received tocilizumab.

Study participants were being prospectively followed as part of another ongoing study looking at the relationship between systemic inflammation and cancer-related symptom burden. Most (77) were being treated for lung cancer and 10 had other types of malignancy. They received nivolumab at a dose of 3 mg/kg (or a flat dose of 240 mg after September 2016) every 2 weeks, and received tocilizumab at a dose of 4 mg/kg given over 1 hour. Those with grade 3 or 4 irAEs also received supportive care and corticosteroids. Median follow-up was 10.6 months.

C-reactive protein (CRP), a reliable surrogate marker of IL-6, was drawn at the first nivolumab infusion and before each subsequent infusion as part of the study in which the patients were enrolled, and for the current analysis was measured in relation to irAEs.

Significant reductions were seen in CRP levels after tocilizumab treatment; similar responses have been described in cytokine release syndrome, Dr. Hegde noted.

“Tocilizumab is a therapeutic option for management of immune-related adverse events in patients who are already on corticosteroids. CRP may be of clinical utility in detecting immune-related adverse events as well as monitoring the response to tocilizumab,” she said, adding that the current analysis is limited by the small patient number, single-center setting, use of tocilizumab outside of a clinical trial setting, and short follow-up.

Therefore, the findings require confirmation in multicenter randomized trials to determine “the definitive utility of tocilizumab, as well as CRP as an accompanying biomarker in the management of high-grade steroid refractory immune-related adverse events.”

Heather Wakelee, MD, an invited discussant at the symposium, commended Dr. Hegde and her colleagues for “coming up with a novel idea about how to treat [irAEs],” but also stressed the need for further study.

“This is a novel agent that has the potential ability to manage toxicity, and that’s important, because when you get beyond the steroids that we use as a first-line approach ... there’s not a whole lot else. We definitely have a clear unmet need,” said Dr. Wakelee of Stanford (Calif.) University.

However, she stressed that the approach must be evaluated in multicenter randomized trials “before we can be widely discussing this as a good thing to be doing.”

Dr. Hegde reported having no disclosures. Dr. Wakelee has been the institutional principal investigator for studies of nivolumab, tocilizumab, and other agents. She has consulted for Peregrine, ACEA, Pfizer, Helsinn, Genentech/Roche, Clovis, and Lilly, and received research/grant support from Clovis, Exelixis, AstraZeneca/Medimmune, Genentech/Roche, BMS, Gilead, Novartis, Xcovery, Pfizer, Celgene, Gilead, Pharmacyclics, and Lilly.

[email protected]

CHICAGO – Tocilizumab may be a therapeutic option for steroid-refractory immune-related adverse events that are secondary to PD-1 blockade, according to findings from a review of patients treated with nivolumab for various malignancies.

Of 87 patients who were treated with the PD-1 inhibitor between April 2015 and October 2016, 34 received tocilizumab for high-grade immune-related adverse events (irAEs) that were refractory to corticosteroids. Of those, 27 experienced clinical improvement, which was defined as documentation of symptom resolution or hospital discharge within 7 days, Aparna Hegde, MD, of East Carolina University, Greenville, N.C., reported at the Chicago Multidisciplinary Symposium in Thoracic Oncology.

The median time to discharge was 4 days, and no adverse effect on median overall survival was seen between those who received tocilizumab and those who did not (6.1 vs, 6.7 months, respectively), Dr. Hegde said.

There was, however, a trend toward inferior overall survival in patients who required more than one dose of tocilizumab, but the difference was not statistically significant (hazard ratio, 1.72), she noted.

“Immune checkpoint inhibitors are associated with an unprecedented clinical benefit in patients with lung cancer. However, they are also associated with a unique spectrum of immune-mediated adverse events. While the standard of care for initial management of these adverse events is corticosteroids, the management of steroid-refractory events is poorly defined,” she said, adding that data from randomized trials on which consensus guidelines could be based are lacking.

At East Carolina University, a significant proportion of patients treated with PD-1 inhibitors were presenting with systemic inflammatory response syndrome (SIRS)-like symptoms and immune-related organ toxicities similar to what has been described in cytokine release syndrome, Dr. Hegde said.

Such symptoms have also been reported with other types of immune therapy, such as CAR T-cell therapy and bispecific T-cell receptor–engaging antibodies in hematologic malignancies, she noted.

“In our experience, when we treated these patients with tocilizumab, which is an [anti-interleukin-6] receptor monoclonal antibody, we saw dramatic and rapid responses, not only in the SIRS symptoms, but also in other immune-related organ toxicities. Therefore, we adopted the use of tocilizumab as our standard treatment for high-grade immune-related adverse events,” she said, explaining that it has been well documented that interleukin (IL)-6 levels increase during cytokine release syndrome and are mediators of inflammation, suggesting that blocking IL-6 may treat irAEs without compromising the efficacy of immune therapy.

The current study was undertaken to look more closely at the responses to tocilizumab and to assess overall survival in those who received tocilizumab.

Study participants were being prospectively followed as part of another ongoing study looking at the relationship between systemic inflammation and cancer-related symptom burden. Most (77) were being treated for lung cancer and 10 had other types of malignancy. They received nivolumab at a dose of 3 mg/kg (or a flat dose of 240 mg after September 2016) every 2 weeks, and received tocilizumab at a dose of 4 mg/kg given over 1 hour. Those with grade 3 or 4 irAEs also received supportive care and corticosteroids. Median follow-up was 10.6 months.

C-reactive protein (CRP), a reliable surrogate marker of IL-6, was drawn at the first nivolumab infusion and before each subsequent infusion as part of the study in which the patients were enrolled, and for the current analysis was measured in relation to irAEs.

Significant reductions were seen in CRP levels after tocilizumab treatment; similar responses have been described in cytokine release syndrome, Dr. Hegde noted.

“Tocilizumab is a therapeutic option for management of immune-related adverse events in patients who are already on corticosteroids. CRP may be of clinical utility in detecting immune-related adverse events as well as monitoring the response to tocilizumab,” she said, adding that the current analysis is limited by the small patient number, single-center setting, use of tocilizumab outside of a clinical trial setting, and short follow-up.

Therefore, the findings require confirmation in multicenter randomized trials to determine “the definitive utility of tocilizumab, as well as CRP as an accompanying biomarker in the management of high-grade steroid refractory immune-related adverse events.”

Heather Wakelee, MD, an invited discussant at the symposium, commended Dr. Hegde and her colleagues for “coming up with a novel idea about how to treat [irAEs],” but also stressed the need for further study.

“This is a novel agent that has the potential ability to manage toxicity, and that’s important, because when you get beyond the steroids that we use as a first-line approach ... there’s not a whole lot else. We definitely have a clear unmet need,” said Dr. Wakelee of Stanford (Calif.) University.

However, she stressed that the approach must be evaluated in multicenter randomized trials “before we can be widely discussing this as a good thing to be doing.”

Dr. Hegde reported having no disclosures. Dr. Wakelee has been the institutional principal investigator for studies of nivolumab, tocilizumab, and other agents. She has consulted for Peregrine, ACEA, Pfizer, Helsinn, Genentech/Roche, Clovis, and Lilly, and received research/grant support from Clovis, Exelixis, AstraZeneca/Medimmune, Genentech/Roche, BMS, Gilead, Novartis, Xcovery, Pfizer, Celgene, Gilead, Pharmacyclics, and Lilly.

[email protected]

CHICAGO – Tocilizumab may be a therapeutic option for steroid-refractory immune-related adverse events that are secondary to PD-1 blockade, according to findings from a review of patients treated with nivolumab for various malignancies.

Of 87 patients who were treated with the PD-1 inhibitor between April 2015 and October 2016, 34 received tocilizumab for high-grade immune-related adverse events (irAEs) that were refractory to corticosteroids. Of those, 27 experienced clinical improvement, which was defined as documentation of symptom resolution or hospital discharge within 7 days, Aparna Hegde, MD, of East Carolina University, Greenville, N.C., reported at the Chicago Multidisciplinary Symposium in Thoracic Oncology.

The median time to discharge was 4 days, and no adverse effect on median overall survival was seen between those who received tocilizumab and those who did not (6.1 vs, 6.7 months, respectively), Dr. Hegde said.

There was, however, a trend toward inferior overall survival in patients who required more than one dose of tocilizumab, but the difference was not statistically significant (hazard ratio, 1.72), she noted.

“Immune checkpoint inhibitors are associated with an unprecedented clinical benefit in patients with lung cancer. However, they are also associated with a unique spectrum of immune-mediated adverse events. While the standard of care for initial management of these adverse events is corticosteroids, the management of steroid-refractory events is poorly defined,” she said, adding that data from randomized trials on which consensus guidelines could be based are lacking.

At East Carolina University, a significant proportion of patients treated with PD-1 inhibitors were presenting with systemic inflammatory response syndrome (SIRS)-like symptoms and immune-related organ toxicities similar to what has been described in cytokine release syndrome, Dr. Hegde said.

Such symptoms have also been reported with other types of immune therapy, such as CAR T-cell therapy and bispecific T-cell receptor–engaging antibodies in hematologic malignancies, she noted.

“In our experience, when we treated these patients with tocilizumab, which is an [anti-interleukin-6] receptor monoclonal antibody, we saw dramatic and rapid responses, not only in the SIRS symptoms, but also in other immune-related organ toxicities. Therefore, we adopted the use of tocilizumab as our standard treatment for high-grade immune-related adverse events,” she said, explaining that it has been well documented that interleukin (IL)-6 levels increase during cytokine release syndrome and are mediators of inflammation, suggesting that blocking IL-6 may treat irAEs without compromising the efficacy of immune therapy.

The current study was undertaken to look more closely at the responses to tocilizumab and to assess overall survival in those who received tocilizumab.

Study participants were being prospectively followed as part of another ongoing study looking at the relationship between systemic inflammation and cancer-related symptom burden. Most (77) were being treated for lung cancer and 10 had other types of malignancy. They received nivolumab at a dose of 3 mg/kg (or a flat dose of 240 mg after September 2016) every 2 weeks, and received tocilizumab at a dose of 4 mg/kg given over 1 hour. Those with grade 3 or 4 irAEs also received supportive care and corticosteroids. Median follow-up was 10.6 months.

C-reactive protein (CRP), a reliable surrogate marker of IL-6, was drawn at the first nivolumab infusion and before each subsequent infusion as part of the study in which the patients were enrolled, and for the current analysis was measured in relation to irAEs.

Significant reductions were seen in CRP levels after tocilizumab treatment; similar responses have been described in cytokine release syndrome, Dr. Hegde noted.

“Tocilizumab is a therapeutic option for management of immune-related adverse events in patients who are already on corticosteroids. CRP may be of clinical utility in detecting immune-related adverse events as well as monitoring the response to tocilizumab,” she said, adding that the current analysis is limited by the small patient number, single-center setting, use of tocilizumab outside of a clinical trial setting, and short follow-up.

Therefore, the findings require confirmation in multicenter randomized trials to determine “the definitive utility of tocilizumab, as well as CRP as an accompanying biomarker in the management of high-grade steroid refractory immune-related adverse events.”

Heather Wakelee, MD, an invited discussant at the symposium, commended Dr. Hegde and her colleagues for “coming up with a novel idea about how to treat [irAEs],” but also stressed the need for further study.

“This is a novel agent that has the potential ability to manage toxicity, and that’s important, because when you get beyond the steroids that we use as a first-line approach ... there’s not a whole lot else. We definitely have a clear unmet need,” said Dr. Wakelee of Stanford (Calif.) University.

However, she stressed that the approach must be evaluated in multicenter randomized trials “before we can be widely discussing this as a good thing to be doing.”

Dr. Hegde reported having no disclosures. Dr. Wakelee has been the institutional principal investigator for studies of nivolumab, tocilizumab, and other agents. She has consulted for Peregrine, ACEA, Pfizer, Helsinn, Genentech/Roche, Clovis, and Lilly, and received research/grant support from Clovis, Exelixis, AstraZeneca/Medimmune, Genentech/Roche, BMS, Gilead, Novartis, Xcovery, Pfizer, Celgene, Gilead, Pharmacyclics, and Lilly.

[email protected]

Who watches the watchers?

In a world where the majority of practices depend on electronic health record systems to care for patients, we also depend on the companies that make them. After all, the main (if not only) reason most practices jumped to them was to qualify for meaningful use payments.

In buying them, we’re trusting that the manufacturer is doing its best to keep them updated, operational, and compliant, right? Beyond people’s health, there’s also a lot of money at stake here.

Right? Right.

kokouu/iStockphoto

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Who watches the watchers?

In a world where the majority of practices depend on electronic health record systems to care for patients, we also depend on the companies that make them. After all, the main (if not only) reason most practices jumped to them was to qualify for meaningful use payments.

In buying them, we’re trusting that the manufacturer is doing its best to keep them updated, operational, and compliant, right? Beyond people’s health, there’s also a lot of money at stake here.

Right? Right.

kokouu/iStockphoto

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Who watches the watchers?

In a world where the majority of practices depend on electronic health record systems to care for patients, we also depend on the companies that make them. After all, the main (if not only) reason most practices jumped to them was to qualify for meaningful use payments.

In buying them, we’re trusting that the manufacturer is doing its best to keep them updated, operational, and compliant, right? Beyond people’s health, there’s also a lot of money at stake here.

Right? Right.

kokouu/iStockphoto

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Imipramine is a tricyclic medication uncommonly used to treat depression, anxiety, and other psychiatric illnesses. Although relatively rare, it has been associated with hyperpigmentation of the skin including slate gray discoloration of sun-exposed areas.

We present the case of a 63-year-old woman who had been taking imipramine for more than 20 years when she developed bluish gray discoloration on the face and neck. Histopathology of biopsy specimens showed numerous perivascular and interstitial brown globules in the dermis that were composed of melanin only, as evidenced by positive Fontana-Masson staining and negative Perls Prussian blue staining. A diagnosis of imipramine-induced hyperpigmentation was made based on histopathology and clinical history.

In addition to the case presentation, we provide a review of drugs that commonly cause hyperpigmentation as well as their associated histopathologic staining characteristics.

Case Report

A 63-year-old woman presented with blue-gray discoloration on the face and neck. She first noted the discoloration on the left side of the forehead 3 years prior; it then spread to the right side of the forehead, cheeks, and neck. She denied pruritus, pain, redness, and scaling of the involved areas; any recent changes in medications; or the use of any topical products on the affected areas. Her medical history was remarkable for hypertension, which was inconsistently controlled with lisinopril and hydrochlorothiazide, and depression, which had been managed with oral imipramine.

Physical examination disclosed blue-gray hyperpigmented patches with irregular borders on the bilateral forehead, temples, and periorbital skin (Figure 1). Reticulated brown patches were noted on the bilateral cheeks, and the neck displayed diffuse muddy brown patches with sparing of the submental areas.

Punch biopsies obtained from the lateral forehead showed an unremarkable epidermis with deposition of numerous golden brown granules in the upper and mid dermis and in perivascular macrophages (Figure 2). The pigmented granules showed positive staining with Fontana-Masson (Figure 3), and a Perls Prussian blue stain for hemosiderin was negative. Based on the clinical history, a diagnosis of imipramine-induced hyperpigmentation was made.

The patient revealed that she had taken imipramine for more than 20 years for depression as prescribed by her mental health professional. She had tried several other antidepressants but none were as effective as imipramine. Therefore, she was not willing to discontinue it despite the likelihood that the hyperpigmentation would persist and could worsen with continued use of the medication. Diligent photoprotection was advised. Additionally, she started taking lisinopril some time after the appearance of the hyperpigmentation presented and had not taken hydrochlorothiazide consistently for several years. Although these drugs are known to cause various cutaneous reactions, it was not considered likely in this case.

Comment

Drug-induced hyperpigmentation accounts for 10% to 20% of all cases of acquired hyperpigmentation.¹ Common causative drugs include amiodarone, antimalarials, minocycline, and rarely psychotropics including phenothiazines and tricyclic antidepressants such as imipramine.^1-4 Although amiodarone-induced hyperpigmentation is associated with lipofuscin in addition to melanin, most other medications, including imipramine, induce cutaneous effects through deposition of melanin and/or hemosiderin. A review of the histopathologic staining characteristics in pigment anomalies caused by these drugs is summarized in the Table.

Imipramine-induced hyperpigmentation presents as slate gray discrete macules and patches on sun-exposed skin that may appear anywhere from 2 to 22 years after initiating the medication.^1-4 Affected areas include the malar cheeks, temples, periorbital areas, hands, forearms, and seldom the iris and sclera.^2-4 Although the blue to slate gray coloring is classic, other colors have been described including brown, golden brown, and purple.²

Histopathology of imipramine-induced hyperpigmentation shows golden brown, round to oval granules in the superficial dermis and within dermal macrophages.^1,3 Generally, Fontana-Masson staining is positive for melanin and Perls Prussian blue staining is negative for iron.^1,2,4

Imipramine-induced hyperpigmentation likely results from photoexcitation of imipramine or one of its metabolites. These compounds activate tyrosinase, increasing melanogenesis and leading to formation of melanin-imipramine or melanin-metabolite complexes.^1-3 Complexes are deposited in the dermis and basal layer or are engulfed by dermal macrophages and darkened on sun exposure due to their high melanin content.¹ Other possible mechanisms of hyperpigmentation include nonspecific inflammation caused by the drug in the skin, hemosiderin deposition from vessel damage and subsequent erythrocyte extravasation, or deposition of newly formed pigments related to the drug.¹

Most patients report satisfactory resolution of imipramine-induced discoloration within 1 year of stopping imipramine or switching to a different antidepressant.^1,4 Patients who are unwilling to discontinue imipramine may achieve resolution with alexandrite or Q-switched ruby laser therapy.^1,4 Strict sun protective measures are necessary, both to prevent new deposition of melanin and to prevent darkening of existing pigment.

Despite the advent of new psychotropic medications, imipramine remains the antidepressant of choice for many patients. Although rare, it is important to be able to recognize imipramine-induced hyperpigmentation and to encourage patient-psychiatrist communication to determine an antidepressant regimen that avoids unnecessary cutaneous side effects.

Imipramine is a tricyclic medication uncommonly used to treat depression, anxiety, and other psychiatric illnesses. Although relatively rare, it has been associated with hyperpigmentation of the skin including slate gray discoloration of sun-exposed areas.

We present the case of a 63-year-old woman who had been taking imipramine for more than 20 years when she developed bluish gray discoloration on the face and neck. Histopathology of biopsy specimens showed numerous perivascular and interstitial brown globules in the dermis that were composed of melanin only, as evidenced by positive Fontana-Masson staining and negative Perls Prussian blue staining. A diagnosis of imipramine-induced hyperpigmentation was made based on histopathology and clinical history.

In addition to the case presentation, we provide a review of drugs that commonly cause hyperpigmentation as well as their associated histopathologic staining characteristics.

Case Report

A 63-year-old woman presented with blue-gray discoloration on the face and neck. She first noted the discoloration on the left side of the forehead 3 years prior; it then spread to the right side of the forehead, cheeks, and neck. She denied pruritus, pain, redness, and scaling of the involved areas; any recent changes in medications; or the use of any topical products on the affected areas. Her medical history was remarkable for hypertension, which was inconsistently controlled with lisinopril and hydrochlorothiazide, and depression, which had been managed with oral imipramine.

Physical examination disclosed blue-gray hyperpigmented patches with irregular borders on the bilateral forehead, temples, and periorbital skin (Figure 1). Reticulated brown patches were noted on the bilateral cheeks, and the neck displayed diffuse muddy brown patches with sparing of the submental areas.

Punch biopsies obtained from the lateral forehead showed an unremarkable epidermis with deposition of numerous golden brown granules in the upper and mid dermis and in perivascular macrophages (Figure 2). The pigmented granules showed positive staining with Fontana-Masson (Figure 3), and a Perls Prussian blue stain for hemosiderin was negative. Based on the clinical history, a diagnosis of imipramine-induced hyperpigmentation was made.

The patient revealed that she had taken imipramine for more than 20 years for depression as prescribed by her mental health professional. She had tried several other antidepressants but none were as effective as imipramine. Therefore, she was not willing to discontinue it despite the likelihood that the hyperpigmentation would persist and could worsen with continued use of the medication. Diligent photoprotection was advised. Additionally, she started taking lisinopril some time after the appearance of the hyperpigmentation presented and had not taken hydrochlorothiazide consistently for several years. Although these drugs are known to cause various cutaneous reactions, it was not considered likely in this case.

Comment

Drug-induced hyperpigmentation accounts for 10% to 20% of all cases of acquired hyperpigmentation.¹ Common causative drugs include amiodarone, antimalarials, minocycline, and rarely psychotropics including phenothiazines and tricyclic antidepressants such as imipramine.^1-4 Although amiodarone-induced hyperpigmentation is associated with lipofuscin in addition to melanin, most other medications, including imipramine, induce cutaneous effects through deposition of melanin and/or hemosiderin. A review of the histopathologic staining characteristics in pigment anomalies caused by these drugs is summarized in the Table.

Imipramine-induced hyperpigmentation presents as slate gray discrete macules and patches on sun-exposed skin that may appear anywhere from 2 to 22 years after initiating the medication.^1-4 Affected areas include the malar cheeks, temples, periorbital areas, hands, forearms, and seldom the iris and sclera.^2-4 Although the blue to slate gray coloring is classic, other colors have been described including brown, golden brown, and purple.²

Histopathology of imipramine-induced hyperpigmentation shows golden brown, round to oval granules in the superficial dermis and within dermal macrophages.^1,3 Generally, Fontana-Masson staining is positive for melanin and Perls Prussian blue staining is negative for iron.^1,2,4

Imipramine-induced hyperpigmentation likely results from photoexcitation of imipramine or one of its metabolites. These compounds activate tyrosinase, increasing melanogenesis and leading to formation of melanin-imipramine or melanin-metabolite complexes.^1-3 Complexes are deposited in the dermis and basal layer or are engulfed by dermal macrophages and darkened on sun exposure due to their high melanin content.¹ Other possible mechanisms of hyperpigmentation include nonspecific inflammation caused by the drug in the skin, hemosiderin deposition from vessel damage and subsequent erythrocyte extravasation, or deposition of newly formed pigments related to the drug.¹

Most patients report satisfactory resolution of imipramine-induced discoloration within 1 year of stopping imipramine or switching to a different antidepressant.^1,4 Patients who are unwilling to discontinue imipramine may achieve resolution with alexandrite or Q-switched ruby laser therapy.^1,4 Strict sun protective measures are necessary, both to prevent new deposition of melanin and to prevent darkening of existing pigment.

Despite the advent of new psychotropic medications, imipramine remains the antidepressant of choice for many patients. Although rare, it is important to be able to recognize imipramine-induced hyperpigmentation and to encourage patient-psychiatrist communication to determine an antidepressant regimen that avoids unnecessary cutaneous side effects.

Imipramine is a tricyclic medication uncommonly used to treat depression, anxiety, and other psychiatric illnesses. Although relatively rare, it has been associated with hyperpigmentation of the skin including slate gray discoloration of sun-exposed areas.

We present the case of a 63-year-old woman who had been taking imipramine for more than 20 years when she developed bluish gray discoloration on the face and neck. Histopathology of biopsy specimens showed numerous perivascular and interstitial brown globules in the dermis that were composed of melanin only, as evidenced by positive Fontana-Masson staining and negative Perls Prussian blue staining. A diagnosis of imipramine-induced hyperpigmentation was made based on histopathology and clinical history.

In addition to the case presentation, we provide a review of drugs that commonly cause hyperpigmentation as well as their associated histopathologic staining characteristics.

Case Report

A 63-year-old woman presented with blue-gray discoloration on the face and neck. She first noted the discoloration on the left side of the forehead 3 years prior; it then spread to the right side of the forehead, cheeks, and neck. She denied pruritus, pain, redness, and scaling of the involved areas; any recent changes in medications; or the use of any topical products on the affected areas. Her medical history was remarkable for hypertension, which was inconsistently controlled with lisinopril and hydrochlorothiazide, and depression, which had been managed with oral imipramine.

Physical examination disclosed blue-gray hyperpigmented patches with irregular borders on the bilateral forehead, temples, and periorbital skin (Figure 1). Reticulated brown patches were noted on the bilateral cheeks, and the neck displayed diffuse muddy brown patches with sparing of the submental areas.

Punch biopsies obtained from the lateral forehead showed an unremarkable epidermis with deposition of numerous golden brown granules in the upper and mid dermis and in perivascular macrophages (Figure 2). The pigmented granules showed positive staining with Fontana-Masson (Figure 3), and a Perls Prussian blue stain for hemosiderin was negative. Based on the clinical history, a diagnosis of imipramine-induced hyperpigmentation was made.

The patient revealed that she had taken imipramine for more than 20 years for depression as prescribed by her mental health professional. She had tried several other antidepressants but none were as effective as imipramine. Therefore, she was not willing to discontinue it despite the likelihood that the hyperpigmentation would persist and could worsen with continued use of the medication. Diligent photoprotection was advised. Additionally, she started taking lisinopril some time after the appearance of the hyperpigmentation presented and had not taken hydrochlorothiazide consistently for several years. Although these drugs are known to cause various cutaneous reactions, it was not considered likely in this case.

Comment

Drug-induced hyperpigmentation accounts for 10% to 20% of all cases of acquired hyperpigmentation.¹ Common causative drugs include amiodarone, antimalarials, minocycline, and rarely psychotropics including phenothiazines and tricyclic antidepressants such as imipramine.^1-4 Although amiodarone-induced hyperpigmentation is associated with lipofuscin in addition to melanin, most other medications, including imipramine, induce cutaneous effects through deposition of melanin and/or hemosiderin. A review of the histopathologic staining characteristics in pigment anomalies caused by these drugs is summarized in the Table.

Imipramine-induced hyperpigmentation presents as slate gray discrete macules and patches on sun-exposed skin that may appear anywhere from 2 to 22 years after initiating the medication.^1-4 Affected areas include the malar cheeks, temples, periorbital areas, hands, forearms, and seldom the iris and sclera.^2-4 Although the blue to slate gray coloring is classic, other colors have been described including brown, golden brown, and purple.²

Histopathology of imipramine-induced hyperpigmentation shows golden brown, round to oval granules in the superficial dermis and within dermal macrophages.^1,3 Generally, Fontana-Masson staining is positive for melanin and Perls Prussian blue staining is negative for iron.^1,2,4

Imipramine-induced hyperpigmentation likely results from photoexcitation of imipramine or one of its metabolites. These compounds activate tyrosinase, increasing melanogenesis and leading to formation of melanin-imipramine or melanin-metabolite complexes.^1-3 Complexes are deposited in the dermis and basal layer or are engulfed by dermal macrophages and darkened on sun exposure due to their high melanin content.¹ Other possible mechanisms of hyperpigmentation include nonspecific inflammation caused by the drug in the skin, hemosiderin deposition from vessel damage and subsequent erythrocyte extravasation, or deposition of newly formed pigments related to the drug.¹

Most patients report satisfactory resolution of imipramine-induced discoloration within 1 year of stopping imipramine or switching to a different antidepressant.^1,4 Patients who are unwilling to discontinue imipramine may achieve resolution with alexandrite or Q-switched ruby laser therapy.^1,4 Strict sun protective measures are necessary, both to prevent new deposition of melanin and to prevent darkening of existing pigment.

Despite the advent of new psychotropic medications, imipramine remains the antidepressant of choice for many patients. Although rare, it is important to be able to recognize imipramine-induced hyperpigmentation and to encourage patient-psychiatrist communication to determine an antidepressant regimen that avoids unnecessary cutaneous side effects.

MADRID – Patients with refractory/relapsed multiple myeloma had similar rates of progression-free survival (PFS) whether they were younger than age 65 or 65 years and older, based on the results of eight recent phase 3 trials in an analysis presented at the European Society for Medical Oncology Congress.

“The PFS benefit was significant in both younger and older patients with relapsed and refractory multiple myeloma with a cut off at 75 years,” reported Thierry Landre, PharmD, of the department of geriatric oncology, University of Paris 13, France. “Age, by itself, should not be a contraindication to the new myeloma drugs.”

In this meta-analysis, 5,421 patients were evaluated from the CASTOR and POLLUX trials, which evaluated daratumumab; the ELOQUENT-2 trial, which evaluated elotuzumab; the ASPIRE and ENDEAVOR trials, which evaluated carfilzomib; the TOURMALINE-MM trial, which evaluated ixazomib; the PANORAMA trial, which evaluated panobinostat; and the VANTAGE trial, which evaluated vorinostat.

For the analysis, patients were stratified by age younger than 65 years and age 65 years and older. Hazard ratios for benefit were calculated for the experimental and comparator arm for these two age groups. Though the number of patients over age 75 was small, hazard ratios were determined on an exploratory basis for that age group.

For the experimental arm relative to the comparator arm, all hazard ratios were statistically significant for patients less than age 65 with the exception of patients receiving elotuzumab in ELOQUENT-2. In that trial, the hazard ratio slightly exceeded the upward bound of the 95% confidence interval (95% CI, 0.55-1.02).

When the data were combined for the eight trials, the hazard ratio for PFS was 0.62 for newer agents relative to the comparator arms.

Similar results were seen for individual trial and aggregated trial data when the same calculations were done in patients aged 65-75. When the data for the eight trials were combined, the hazard ratio for PFS was 0.67 for newer agents relative to comparators.

The calculations for patients over age 75 were more limited because of the small numbers of trial participants in that age group. Of the hazard ratio estimates that were done, however, they were again of the same general magnitude seen in younger patients.

When PFS was broken down by type of therapy, the hazard ratios for patients younger than age 65 and those aged 65-75 were 0.57 and 0.52, respectively, for monoclonal antibodies. For combined data with the histone deacetylase inhibitors panobinostat and vorinostat, the respective hazard ratios were 0.67 and 0.78, respectively. For the second generation proteasome inhibitors carfilzomib and ixazomib, the respective hazard ratios were 0.61 and 0.70.

The ESMO-invited discussant for this presentation, Evangelos Terpos, MD, PhD, of the University of Athens, called the results reassuring. These data support treating relatively fit elderly patients with the newer agents.

“The data with the monoclonal antibodies suggest that these drugs actually provide their best results in elderly patients,” noted Dr. Terpos, pointing to the numerical advantage for the hazard ratio in older versus younger patients. The efficacy of monoclonal antibodies in older patients was further reinforced by the narrow confidence interval (95% CI, 0.42-0.61).

“There are many new drugs in the refractory setting [of multiple myeloma],” Dr. Terpos remarked. “It is helpful to have some data to show that these are also beneficial in the age group where this disease is most common.”

Dr. Landre agreed, noting that the median age at diagnosis of multiple myeloma is 69. This analysis helps to address the gap of “data available for evaluating efficacy in those older than 65 years and older than 75 years of age.”

MADRID – Patients with refractory/relapsed multiple myeloma had similar rates of progression-free survival (PFS) whether they were younger than age 65 or 65 years and older, based on the results of eight recent phase 3 trials in an analysis presented at the European Society for Medical Oncology Congress.

“The PFS benefit was significant in both younger and older patients with relapsed and refractory multiple myeloma with a cut off at 75 years,” reported Thierry Landre, PharmD, of the department of geriatric oncology, University of Paris 13, France. “Age, by itself, should not be a contraindication to the new myeloma drugs.”

In this meta-analysis, 5,421 patients were evaluated from the CASTOR and POLLUX trials, which evaluated daratumumab; the ELOQUENT-2 trial, which evaluated elotuzumab; the ASPIRE and ENDEAVOR trials, which evaluated carfilzomib; the TOURMALINE-MM trial, which evaluated ixazomib; the PANORAMA trial, which evaluated panobinostat; and the VANTAGE trial, which evaluated vorinostat.

For the analysis, patients were stratified by age younger than 65 years and age 65 years and older. Hazard ratios for benefit were calculated for the experimental and comparator arm for these two age groups. Though the number of patients over age 75 was small, hazard ratios were determined on an exploratory basis for that age group.

For the experimental arm relative to the comparator arm, all hazard ratios were statistically significant for patients less than age 65 with the exception of patients receiving elotuzumab in ELOQUENT-2. In that trial, the hazard ratio slightly exceeded the upward bound of the 95% confidence interval (95% CI, 0.55-1.02).

When the data were combined for the eight trials, the hazard ratio for PFS was 0.62 for newer agents relative to the comparator arms.

Similar results were seen for individual trial and aggregated trial data when the same calculations were done in patients aged 65-75. When the data for the eight trials were combined, the hazard ratio for PFS was 0.67 for newer agents relative to comparators.

The calculations for patients over age 75 were more limited because of the small numbers of trial participants in that age group. Of the hazard ratio estimates that were done, however, they were again of the same general magnitude seen in younger patients.

When PFS was broken down by type of therapy, the hazard ratios for patients younger than age 65 and those aged 65-75 were 0.57 and 0.52, respectively, for monoclonal antibodies. For combined data with the histone deacetylase inhibitors panobinostat and vorinostat, the respective hazard ratios were 0.67 and 0.78, respectively. For the second generation proteasome inhibitors carfilzomib and ixazomib, the respective hazard ratios were 0.61 and 0.70.

The ESMO-invited discussant for this presentation, Evangelos Terpos, MD, PhD, of the University of Athens, called the results reassuring. These data support treating relatively fit elderly patients with the newer agents.

“The data with the monoclonal antibodies suggest that these drugs actually provide their best results in elderly patients,” noted Dr. Terpos, pointing to the numerical advantage for the hazard ratio in older versus younger patients. The efficacy of monoclonal antibodies in older patients was further reinforced by the narrow confidence interval (95% CI, 0.42-0.61).

“There are many new drugs in the refractory setting [of multiple myeloma],” Dr. Terpos remarked. “It is helpful to have some data to show that these are also beneficial in the age group where this disease is most common.”

Dr. Landre agreed, noting that the median age at diagnosis of multiple myeloma is 69. This analysis helps to address the gap of “data available for evaluating efficacy in those older than 65 years and older than 75 years of age.”

MADRID – Patients with refractory/relapsed multiple myeloma had similar rates of progression-free survival (PFS) whether they were younger than age 65 or 65 years and older, based on the results of eight recent phase 3 trials in an analysis presented at the European Society for Medical Oncology Congress.

“The PFS benefit was significant in both younger and older patients with relapsed and refractory multiple myeloma with a cut off at 75 years,” reported Thierry Landre, PharmD, of the department of geriatric oncology, University of Paris 13, France. “Age, by itself, should not be a contraindication to the new myeloma drugs.”

In this meta-analysis, 5,421 patients were evaluated from the CASTOR and POLLUX trials, which evaluated daratumumab; the ELOQUENT-2 trial, which evaluated elotuzumab; the ASPIRE and ENDEAVOR trials, which evaluated carfilzomib; the TOURMALINE-MM trial, which evaluated ixazomib; the PANORAMA trial, which evaluated panobinostat; and the VANTAGE trial, which evaluated vorinostat.

For the analysis, patients were stratified by age younger than 65 years and age 65 years and older. Hazard ratios for benefit were calculated for the experimental and comparator arm for these two age groups. Though the number of patients over age 75 was small, hazard ratios were determined on an exploratory basis for that age group.

For the experimental arm relative to the comparator arm, all hazard ratios were statistically significant for patients less than age 65 with the exception of patients receiving elotuzumab in ELOQUENT-2. In that trial, the hazard ratio slightly exceeded the upward bound of the 95% confidence interval (95% CI, 0.55-1.02).

When the data were combined for the eight trials, the hazard ratio for PFS was 0.62 for newer agents relative to the comparator arms.

Similar results were seen for individual trial and aggregated trial data when the same calculations were done in patients aged 65-75. When the data for the eight trials were combined, the hazard ratio for PFS was 0.67 for newer agents relative to comparators.

The calculations for patients over age 75 were more limited because of the small numbers of trial participants in that age group. Of the hazard ratio estimates that were done, however, they were again of the same general magnitude seen in younger patients.

When PFS was broken down by type of therapy, the hazard ratios for patients younger than age 65 and those aged 65-75 were 0.57 and 0.52, respectively, for monoclonal antibodies. For combined data with the histone deacetylase inhibitors panobinostat and vorinostat, the respective hazard ratios were 0.67 and 0.78, respectively. For the second generation proteasome inhibitors carfilzomib and ixazomib, the respective hazard ratios were 0.61 and 0.70.

The ESMO-invited discussant for this presentation, Evangelos Terpos, MD, PhD, of the University of Athens, called the results reassuring. These data support treating relatively fit elderly patients with the newer agents.

“The data with the monoclonal antibodies suggest that these drugs actually provide their best results in elderly patients,” noted Dr. Terpos, pointing to the numerical advantage for the hazard ratio in older versus younger patients. The efficacy of monoclonal antibodies in older patients was further reinforced by the narrow confidence interval (95% CI, 0.42-0.61).

“There are many new drugs in the refractory setting [of multiple myeloma],” Dr. Terpos remarked. “It is helpful to have some data to show that these are also beneficial in the age group where this disease is most common.”

Dr. Landre agreed, noting that the median age at diagnosis of multiple myeloma is 69. This analysis helps to address the gap of “data available for evaluating efficacy in those older than 65 years and older than 75 years of age.”

Doctors who did not adequately meet Physician Quality Reporting System (PQRS) requirements in 2016 will soon be receiving notification letters alerting them that their Medicare Part B physician fee schedule payments will be reduced by 2%.

Officials from the Centers for Medicare & Medicaid Services said in a statement that “the majority” of eligible professionals “successfully reported to PQRS and avoided the downward payment adjustment,” but did not state how many doctors are expected to receive letters.

TheaDesign/Thinkstock

[email protected]

Doctors who did not adequately meet Physician Quality Reporting System (PQRS) requirements in 2016 will soon be receiving notification letters alerting them that their Medicare Part B physician fee schedule payments will be reduced by 2%.

Officials from the Centers for Medicare & Medicaid Services said in a statement that “the majority” of eligible professionals “successfully reported to PQRS and avoided the downward payment adjustment,” but did not state how many doctors are expected to receive letters.

TheaDesign/Thinkstock

[email protected]

Doctors who did not adequately meet Physician Quality Reporting System (PQRS) requirements in 2016 will soon be receiving notification letters alerting them that their Medicare Part B physician fee schedule payments will be reduced by 2%.

Officials from the Centers for Medicare & Medicaid Services said in a statement that “the majority” of eligible professionals “successfully reported to PQRS and avoided the downward payment adjustment,” but did not state how many doctors are expected to receive letters.

TheaDesign/Thinkstock

[email protected]

BACKGROUND: Patient preferences regarding cardiopulmonary resuscitation (CPR) are important, especially during hospitalization when a patient’s health is changing, yet many patients are not adequately informed or involved in the decision-making process.

OBJECTIVES: We examined the effect of an informational video about CPR on hospitalized patients’ code status choices.

DESIGN: This was a prospective, randomized trial conducted at the Veteran’s Affairs Hospital in Minneapolis.

PARTICIPANTS: We enrolled 119 patients who were hospitalized on the general medicine service and at least 65 years old. The majority were men (97%) with a mean age of 75.

INTERVENTION: A video described code status choices: full code (CPR and intubation if required), do not resuscitate (DNR), and do not resuscitate/do not intubate (DNR/DNI). Participants were randomized to watch the video (n = 59) or usual care (n = 60).

MEASUREMENTS: The primary outcome was participants’ code status preferences. Secondary outcomes included a questionnaire designed to evaluate participants’ trust in their health care team and their knowledge and perceptions about CPR.

RESULTS: Participants who viewed the video were less likely to choose full code (37%), compared with participants in the usual-care group (71%), and were more likely to choose DNR/DNI (56% in the video group vs. 17% in the control group) (P < .00001). We did not see a difference in trust in their health care team or knowledge and perceptions about CPR as assessed by our questionnaire.

CONCLUSIONS: Hospitalized patients who watched a video about CPR and code status choices were less likely to choose full code and more likely to choose DNR/DNI.
 

Also in JHM this month

Influenza season hospitalization trends in Israel: A multi-year comparative analysis 2005/2006 through 2012/2013

AUTHORS: Aharona Glatman-Freedman, MD, MPH, Zalman Kaufman, MS, Yaniv Stein, BS, Hanna Sefty, MS, Hila Zadka, PhD, Barak Gordon, MD, MHA, Jill Meron, BSc, Ethel-Sherry Gordon, PhD, Rita Dichtiar, BSc, Ziona Haklai, MSc, Arnon Afek, MD, Tamy Shohat, MD, MPH



Appropriate reconciliation of cardiovascular medications after elective surgery and postdischarge acute hospital and ambulatory visits

AUTHORS: Jonathan S. Lee, MD, Ralph Gonzales, MD, MSPH, Eric Vittinghoff, PhD, Kitty K. Corbett, PhD, MPH, Kirsten E. Fleischmann, MD, Neil Sehgal, MD, MPH, Andrew D. Auerbach, MD, MPH



Patterns and appropriateness of thrombophilia testing in an academic medical center

AUTHORS: Nicholas Cox, PharmD, Stacy A. Johnson, MD, Sara Vazquez, PharmD, Ryan P. Fleming, PharmD, BCPS, Matthew T. Rondina, MD, David Kaplan, MD, Stephanie Chauv, PharmD, Gabriel V. Fontaine, PharmD, Scott M. Stevens, MD, Scott Woller, MD, Daniel M. Witt, PharmD, BCPS, FCCP



National trends (2007-2013) of Clostridium difficile infection in patients with septic shock: Impact on outcome

AUTHORS: Kshitij Chatterjee, MD, Abhinav Goyal, MD, Aditya Chada, MD, Krishna Siva Sai Kakkera, MD, Howard L Corwin, MD



Blood products provided to patients receiving inappropriate critical care

AUTHORS: Thanh H. Neville, MD, MSHS, Alyssa Ziman, MD, Neil S. Wenger, MD, MPH

BACKGROUND: Patient preferences regarding cardiopulmonary resuscitation (CPR) are important, especially during hospitalization when a patient’s health is changing, yet many patients are not adequately informed or involved in the decision-making process.

OBJECTIVES: We examined the effect of an informational video about CPR on hospitalized patients’ code status choices.

DESIGN: This was a prospective, randomized trial conducted at the Veteran’s Affairs Hospital in Minneapolis.

PARTICIPANTS: We enrolled 119 patients who were hospitalized on the general medicine service and at least 65 years old. The majority were men (97%) with a mean age of 75.

INTERVENTION: A video described code status choices: full code (CPR and intubation if required), do not resuscitate (DNR), and do not resuscitate/do not intubate (DNR/DNI). Participants were randomized to watch the video (n = 59) or usual care (n = 60).

MEASUREMENTS: The primary outcome was participants’ code status preferences. Secondary outcomes included a questionnaire designed to evaluate participants’ trust in their health care team and their knowledge and perceptions about CPR.

RESULTS: Participants who viewed the video were less likely to choose full code (37%), compared with participants in the usual-care group (71%), and were more likely to choose DNR/DNI (56% in the video group vs. 17% in the control group) (P < .00001). We did not see a difference in trust in their health care team or knowledge and perceptions about CPR as assessed by our questionnaire.

CONCLUSIONS: Hospitalized patients who watched a video about CPR and code status choices were less likely to choose full code and more likely to choose DNR/DNI.
 

Also in JHM this month

Influenza season hospitalization trends in Israel: A multi-year comparative analysis 2005/2006 through 2012/2013

AUTHORS: Aharona Glatman-Freedman, MD, MPH, Zalman Kaufman, MS, Yaniv Stein, BS, Hanna Sefty, MS, Hila Zadka, PhD, Barak Gordon, MD, MHA, Jill Meron, BSc, Ethel-Sherry Gordon, PhD, Rita Dichtiar, BSc, Ziona Haklai, MSc, Arnon Afek, MD, Tamy Shohat, MD, MPH



Appropriate reconciliation of cardiovascular medications after elective surgery and postdischarge acute hospital and ambulatory visits

AUTHORS: Jonathan S. Lee, MD, Ralph Gonzales, MD, MSPH, Eric Vittinghoff, PhD, Kitty K. Corbett, PhD, MPH, Kirsten E. Fleischmann, MD, Neil Sehgal, MD, MPH, Andrew D. Auerbach, MD, MPH



Patterns and appropriateness of thrombophilia testing in an academic medical center

AUTHORS: Nicholas Cox, PharmD, Stacy A. Johnson, MD, Sara Vazquez, PharmD, Ryan P. Fleming, PharmD, BCPS, Matthew T. Rondina, MD, David Kaplan, MD, Stephanie Chauv, PharmD, Gabriel V. Fontaine, PharmD, Scott M. Stevens, MD, Scott Woller, MD, Daniel M. Witt, PharmD, BCPS, FCCP



National trends (2007-2013) of Clostridium difficile infection in patients with septic shock: Impact on outcome

AUTHORS: Kshitij Chatterjee, MD, Abhinav Goyal, MD, Aditya Chada, MD, Krishna Siva Sai Kakkera, MD, Howard L Corwin, MD



Blood products provided to patients receiving inappropriate critical care

AUTHORS: Thanh H. Neville, MD, MSHS, Alyssa Ziman, MD, Neil S. Wenger, MD, MPH

BACKGROUND: Patient preferences regarding cardiopulmonary resuscitation (CPR) are important, especially during hospitalization when a patient’s health is changing, yet many patients are not adequately informed or involved in the decision-making process.

OBJECTIVES: We examined the effect of an informational video about CPR on hospitalized patients’ code status choices.

DESIGN: This was a prospective, randomized trial conducted at the Veteran’s Affairs Hospital in Minneapolis.

PARTICIPANTS: We enrolled 119 patients who were hospitalized on the general medicine service and at least 65 years old. The majority were men (97%) with a mean age of 75.

INTERVENTION: A video described code status choices: full code (CPR and intubation if required), do not resuscitate (DNR), and do not resuscitate/do not intubate (DNR/DNI). Participants were randomized to watch the video (n = 59) or usual care (n = 60).

MEASUREMENTS: The primary outcome was participants’ code status preferences. Secondary outcomes included a questionnaire designed to evaluate participants’ trust in their health care team and their knowledge and perceptions about CPR.

RESULTS: Participants who viewed the video were less likely to choose full code (37%), compared with participants in the usual-care group (71%), and were more likely to choose DNR/DNI (56% in the video group vs. 17% in the control group) (P < .00001). We did not see a difference in trust in their health care team or knowledge and perceptions about CPR as assessed by our questionnaire.

CONCLUSIONS: Hospitalized patients who watched a video about CPR and code status choices were less likely to choose full code and more likely to choose DNR/DNI.
 

Also in JHM this month

Influenza season hospitalization trends in Israel: A multi-year comparative analysis 2005/2006 through 2012/2013

AUTHORS: Aharona Glatman-Freedman, MD, MPH, Zalman Kaufman, MS, Yaniv Stein, BS, Hanna Sefty, MS, Hila Zadka, PhD, Barak Gordon, MD, MHA, Jill Meron, BSc, Ethel-Sherry Gordon, PhD, Rita Dichtiar, BSc, Ziona Haklai, MSc, Arnon Afek, MD, Tamy Shohat, MD, MPH



Appropriate reconciliation of cardiovascular medications after elective surgery and postdischarge acute hospital and ambulatory visits

AUTHORS: Jonathan S. Lee, MD, Ralph Gonzales, MD, MSPH, Eric Vittinghoff, PhD, Kitty K. Corbett, PhD, MPH, Kirsten E. Fleischmann, MD, Neil Sehgal, MD, MPH, Andrew D. Auerbach, MD, MPH



Patterns and appropriateness of thrombophilia testing in an academic medical center

AUTHORS: Nicholas Cox, PharmD, Stacy A. Johnson, MD, Sara Vazquez, PharmD, Ryan P. Fleming, PharmD, BCPS, Matthew T. Rondina, MD, David Kaplan, MD, Stephanie Chauv, PharmD, Gabriel V. Fontaine, PharmD, Scott M. Stevens, MD, Scott Woller, MD, Daniel M. Witt, PharmD, BCPS, FCCP



National trends (2007-2013) of Clostridium difficile infection in patients with septic shock: Impact on outcome

AUTHORS: Kshitij Chatterjee, MD, Abhinav Goyal, MD, Aditya Chada, MD, Krishna Siva Sai Kakkera, MD, Howard L Corwin, MD



Blood products provided to patients receiving inappropriate critical care

AUTHORS: Thanh H. Neville, MD, MSHS, Alyssa Ziman, MD, Neil S. Wenger, MD, MPH