ORLANDO – The first study to directly compare plasma energy treatment of ovarian endometriomas to cystectomy demonstrates similar postintervention pregnancy rates, suggesting that plasma energy ablation may be a comparable treatment option.

Researchers evaluated 104 women seeking pregnancy after 1 year or more of infertility. Women presented with unilateral or bilateral ovarian endometriomas larger than 3 cm between January 2009 and June 2014. Clinicians treated 64 patients with plasma energy ablation and another 40 with cystectomy and followed them to compare pregnancy rates.

After at least 1 year of follow-up, pregnancy rates were 68% following plasma energy ablation, compared with 80% after cystectomy. Of the 76 pregnancies, 24 were due to spontaneous conception, including 40% of pregnancies in the plasma energy group and 18% in the cystectomy group. Even after adjustment for multiple factors, the type of intervention had no statistically significant impact on achieving a subsequent pregnancy.

“Ablation using plasma energy may be considered a valuable tool that allows a high pregnancy rate,” Basma Darwish, MD, an ob.gyn. at Rouen (France) University Hospital, said at the meeting, which was sponsored by AAGL.

These similar outcomes were observed despite a higher prevalence of risk predictors for infertility in the plasma energy group at baseline. For instance, women in this cohort were significantly older and had significantly higher revised American Fertility Society (rAFS) classification scores, as well as higher rates of pouch of Douglas obliteration, deep endometriosis, and colorectal localizations.

“Endometrial ablation using plasma energy allows good postoperative [pregnancy] rates, that is well known,” Dr. Darwish said, but the technique has not been directly compared with cystectomy outcomes.

Pregnancy rates remained similar in both groups at 24 and 36 months. The probability of pregnancy was 61% in the plasma energy group versus 69% in the cystectomy group at 24 months. At 36 months, these rates changed to 84% and 78%, respectively.

A unique property of plasma energy ablation is “very limited thermal spread, both in depth and laterally,” Dr. Darwish said.

A lack of randomization is a potential limitation of the study. “Each surgeon chose the technique he or she was best at, which may have explained our good outcomes.” Dr. Darwish said. Strengths of the study include a prospective design and follow-up to 5 years. In addition, the six centers involved in the study included both private and public hospitals, “so it’s a good reflection of what happens in real life.”

The investigators plan to conduct a randomized controlled trial to confirm these findings.

ORLANDO – The first study to directly compare plasma energy treatment of ovarian endometriomas to cystectomy demonstrates similar postintervention pregnancy rates, suggesting that plasma energy ablation may be a comparable treatment option.

Researchers evaluated 104 women seeking pregnancy after 1 year or more of infertility. Women presented with unilateral or bilateral ovarian endometriomas larger than 3 cm between January 2009 and June 2014. Clinicians treated 64 patients with plasma energy ablation and another 40 with cystectomy and followed them to compare pregnancy rates.

After at least 1 year of follow-up, pregnancy rates were 68% following plasma energy ablation, compared with 80% after cystectomy. Of the 76 pregnancies, 24 were due to spontaneous conception, including 40% of pregnancies in the plasma energy group and 18% in the cystectomy group. Even after adjustment for multiple factors, the type of intervention had no statistically significant impact on achieving a subsequent pregnancy.

“Ablation using plasma energy may be considered a valuable tool that allows a high pregnancy rate,” Basma Darwish, MD, an ob.gyn. at Rouen (France) University Hospital, said at the meeting, which was sponsored by AAGL.

These similar outcomes were observed despite a higher prevalence of risk predictors for infertility in the plasma energy group at baseline. For instance, women in this cohort were significantly older and had significantly higher revised American Fertility Society (rAFS) classification scores, as well as higher rates of pouch of Douglas obliteration, deep endometriosis, and colorectal localizations.

“Endometrial ablation using plasma energy allows good postoperative [pregnancy] rates, that is well known,” Dr. Darwish said, but the technique has not been directly compared with cystectomy outcomes.

Pregnancy rates remained similar in both groups at 24 and 36 months. The probability of pregnancy was 61% in the plasma energy group versus 69% in the cystectomy group at 24 months. At 36 months, these rates changed to 84% and 78%, respectively.

A unique property of plasma energy ablation is “very limited thermal spread, both in depth and laterally,” Dr. Darwish said.

A lack of randomization is a potential limitation of the study. “Each surgeon chose the technique he or she was best at, which may have explained our good outcomes.” Dr. Darwish said. Strengths of the study include a prospective design and follow-up to 5 years. In addition, the six centers involved in the study included both private and public hospitals, “so it’s a good reflection of what happens in real life.”

The investigators plan to conduct a randomized controlled trial to confirm these findings.

ORLANDO – The first study to directly compare plasma energy treatment of ovarian endometriomas to cystectomy demonstrates similar postintervention pregnancy rates, suggesting that plasma energy ablation may be a comparable treatment option.

Researchers evaluated 104 women seeking pregnancy after 1 year or more of infertility. Women presented with unilateral or bilateral ovarian endometriomas larger than 3 cm between January 2009 and June 2014. Clinicians treated 64 patients with plasma energy ablation and another 40 with cystectomy and followed them to compare pregnancy rates.

After at least 1 year of follow-up, pregnancy rates were 68% following plasma energy ablation, compared with 80% after cystectomy. Of the 76 pregnancies, 24 were due to spontaneous conception, including 40% of pregnancies in the plasma energy group and 18% in the cystectomy group. Even after adjustment for multiple factors, the type of intervention had no statistically significant impact on achieving a subsequent pregnancy.

“Ablation using plasma energy may be considered a valuable tool that allows a high pregnancy rate,” Basma Darwish, MD, an ob.gyn. at Rouen (France) University Hospital, said at the meeting, which was sponsored by AAGL.

These similar outcomes were observed despite a higher prevalence of risk predictors for infertility in the plasma energy group at baseline. For instance, women in this cohort were significantly older and had significantly higher revised American Fertility Society (rAFS) classification scores, as well as higher rates of pouch of Douglas obliteration, deep endometriosis, and colorectal localizations.

“Endometrial ablation using plasma energy allows good postoperative [pregnancy] rates, that is well known,” Dr. Darwish said, but the technique has not been directly compared with cystectomy outcomes.

Pregnancy rates remained similar in both groups at 24 and 36 months. The probability of pregnancy was 61% in the plasma energy group versus 69% in the cystectomy group at 24 months. At 36 months, these rates changed to 84% and 78%, respectively.

A unique property of plasma energy ablation is “very limited thermal spread, both in depth and laterally,” Dr. Darwish said.

A lack of randomization is a potential limitation of the study. “Each surgeon chose the technique he or she was best at, which may have explained our good outcomes.” Dr. Darwish said. Strengths of the study include a prospective design and follow-up to 5 years. In addition, the six centers involved in the study included both private and public hospitals, “so it’s a good reflection of what happens in real life.”

The investigators plan to conduct a randomized controlled trial to confirm these findings.

Acute ankle injuries are common problems treated by orthopedic surgeons. In the United States, nearly 2 million ankle sprains occur each year,¹ and ankle fractures account for 9% to 18% of all fractures treated in emergency departments.^2,3 Ankle injuries that involve the syndesmotic ligaments may result in instability and require specific treatment beyond fixation of the malleolar fractures.

The usual mechanism of syndesmotic injury is external rotation of the ankle with hyperdorsiflexion of a pronated or supinated foot.^4,5 Syndesmotic injuries are estimated to occur in up to 10% of ankle sprains⁶ and up to 23% of all ankle fractures.⁷ Overall US incidence of syndesmotic injury is estimated at 6445 injuries per year.⁸ Syndesmotic injury occurs in 39% to 45% of supination-external rotation IV ankle fractures.^9,10 Pronation-external rotation ankle fractures have the highest rate of syndesmotic injury. Syndesmotic injury may be less common in other types of malleolar fracture, but the exact incidence has not been reliably reported.

Traditionally, isolated nondisplaced syndesmotic injuries are treated nonoperatively, and syndesmotic injuries with concomitant malleolar fractures are treated surgically. Various options are available for syndesmotic fixation. The gold standard is syndesmotic screw placement from the lateral aspect of the fibula through the tibia. Fixation may be achieved with screws in a variety of configurations and formats. However, fixation with two 4.5-mm screws is stronger.^11,12 Functional outcomes are similar, regardless of screw material,^13-16 number of cortices,¹⁷ or number of screws.¹⁸ Disadvantages specific to screw fixation include altered ankle biomechanics,^19,20 potential for screw breakage,²¹ and need for implant removal.³Alternatively, suture button fixation is said to be equally as effective as screw fixation in achieving syndesmotic reduction, and their functional outcomes are similar.^22,23 The initial cost of suture button fixation is higher than that of screw fixation, but the difference may be offset by potential elimination of a second surgery for syndesmotic screw removal.²⁴ Soft-tissue irritation caused by the suture material and local osteolysis are reported complications of suture button fixation.^25-27

Regardless of fixation method used, achieving anatomical reduction of the syndesmosis is considered the most important factor in optimizing functional outcomes.^28-31 However, achieving and verifying anatomical reduction of the syndesmosis during surgery can be quite challenging.^30,32-34 Various methods of lowering the malreduction risk, including direct visualization of the tibiofibular joint during reduction^30,35 and intraoperative 3-dimensional imaging,^33,36 have been proposed.

In the study reported here, we used a US insurance database to determine the incidence and rate of syndesmotic stabilization within various ankle injuries and fracture patterns.

Materials and Methods

All data for this study were obtained from a publicly available for-fee healthcare database, the PearlDiver Patient Records Database, which includes procedural volumes and demographic information for patients with International Classification of Diseases, Ninth Revision (ICD-9) diagnoses and procedures or Current Procedural Terminology (CPT) codes. Data for the study were derived from 2 databases within PearlDiver: a private-payer database, which has its largest contribution (>30 million individual patient records for 2007-2011) from United HealthCare, and a Medicare database (>50 million patient records for 2007-2011). Access to the database was granted by PearlDiver Technologies for the purpose of academic research. The database was stored on a password-protected server maintained by PearlDiver.

We searched the database for cases of ankle fracture fixation, including fixation of isolated lateral malleolus (CPT 27792), bimalleolar (CPT 27814), and trimalleolar (CPTs 27822 and 27823) fractures. CPT 27829 was used to search for syndesmotic fixation, and CPT 20680 for implant removal. These codes were used individually and in combination.

Overall procedural volume data are reported as number of patients with the given CPT(s) in the database output and as incidence, calculated as number of patients with the CPT of interest normalized to total number of patients in the database for that particular subgroup. Results of age group and sex analyses are reported as number of patients reported in the database output and as percentage of patients who had the CPT procedure of interest that year. As United HealthCare is the largest contributor to the private-payer portion of the database and is represented most prominently in the southern region, data for the regional analysis are presented only as incidence. This incidence was calculated as number of patients in a particular region and year normalized to total number of patients in the database for that region or year. The regions were Midwest (IA, IL, IN, KS, MI, MN, MO, ND, NE, OH, SD, WI), Northeast (CT, MA, ME, NH, NJ, NY, PA, RI, VT), South (AL, AR, DC, DE, FL, GA, KY, LA, MD, MI, NC, OK, SC, TN, TX, VA, WV), and West (AK, AZ, CA, CO, HI, ID, MT, NM, NV, OR, UT, WA, WY).

Chi-square linear-by-linear association analysis was used to determine the statistical significance of time trends in procedural volume, sex, age group, and region. For all statistical comparisons, P < .05 was considered significant.

Results

Number of open reduction and internal fixation (ORIF) procedures increased for all ankle fracture types over the period 2007 to 2011 (Table 1).

ORIF was performed for an ankle injury in 54,767 patients during the period 2007 to 2011, resulting in a cumulative incidence of 64.2 per 1000 patients (Table 2).

Discussion

The present study found no significant change in number of lateral malleolus, bimalleolar, and trimalleolar ankle fracture ORIF procedures performed over the period 2007 to 2011. However, over the same period, incidence of syndesmosis fixation increased significantly in patients with isolated syndesmotic injuries and in patients with concomitant ankle fracture and syndesmotic injury. The largest percentage change was found in the bimalleolar ORIF group, which showed nearly a doubling of syndesmotic fixation over the 4-year study period, followed by a 38.1% increase in syndesmotic fixation in the trimalleolar ORIF group. Both groups had a syndesmotic fixation percentage change about twice that seen in the isolated lateral malleolus group.

There are several explanations for these trends. First, bimalleolar and trimalleolar fractures are more severe ankle fractures that tend to result from a more forceful mechanism, allowing for a higher rate of syndesmotic injury. Second, these trends likely do not reflect a true increase in the rate of syndesmosis injury but, rather, increased recognition of syndesmotic injury. Third, the data likely reflect a well-established approach to ankle fracture fixation and an increase in thinking that syndesmotic injuries should be stabilized in the setting of ankle fixation.

Incidence of syndesmotic injury as indicated by stabilization procedures can be compared with the data of Vosseller and colleagues,⁸ who reported an incidence of 6445 syndesmotic injuries per year in the United States. Our data showed fewer syndesmotic injuries, which may be related to use of CPT codes rather than ICD-9 codes for database searches, such that only operative syndesmotic injuries are represented in our data. Population differences between the 2 studies could also account for some of the differences in syndesmotic injury incidence.

We also found a significant change in the rate of hardware removal after syndesmosis ORIF. Across all treatment groups, incidence of screw removal decreased—a trend likely reflecting a change in attitude about the need for routine screw removal. Studies have shown that patients have favorable outcomes in the setting of syndesmotic screw loosening and screw breakage.³⁷ Some authors have suggested that screw breakage or removal could be advantageous, as it allows the syndesmosis to settle into a more anatomical position after imperfect reduction.³⁸ In addition, the trend of decreased syndesmotic screw removal could also have resulted from increased suture button fixation, which may less frequently require implant removal. Regardless, the overall trend is that routine syndesmotic implant removal has become less common.

This study had several limitations. First are the many limitations inherent to all studies that use large administrative databases, such as PearlDiver. The power of analysis depends on data quality; potential sources of error include accuracy of billing codes and physicians’ miscoding or noncoding. Although we tried to accurately represent a large population of interest through use of this database, we cannot be sure that the database represents a true cross-section of the United States. In addition, as we could not determine the method of syndesmotic fixation—the same CPT code is used for both suture button fixation and screw fixation—we could not establish trends for the rate of each method. More research is needed to establish these trends, and this research likely will require analysis of data from a large trauma center or from multiple centers.

Potential regional differences are another limitation. In the PearlDiver database, the South and Midwest are highly represented, the Northeast and West much less so. The South, Midwest, and West (but not the Northeast) had similar overall incidence and subgroup incidence of ankle ORIF. However, any regional differences in the rate of syndesmotic fixation could have skewed our data.

Ankle fractures and associated syndesmotic injuries remain a common problem. Although the prevalence of ankle fracture fixation has been relatively constant, the rate of syndesmosis stabilization has increased significantly. Young adults have the highest incidence of ankle fracture and associated syndesmotic fixation, but more ankle fractures occur in the large and growing elderly population. Increased awareness of syndesmotic injury likely has contributed to the recent rise in syndesmosis fixation seen in the present study. Given this trend, we recommend further analysis of outcome data and to establish treatment guidelines.

Am J Orthop. 2016;45(7):E472-E477. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

Acute ankle injuries are common problems treated by orthopedic surgeons. In the United States, nearly 2 million ankle sprains occur each year,¹ and ankle fractures account for 9% to 18% of all fractures treated in emergency departments.^2,3 Ankle injuries that involve the syndesmotic ligaments may result in instability and require specific treatment beyond fixation of the malleolar fractures.

The usual mechanism of syndesmotic injury is external rotation of the ankle with hyperdorsiflexion of a pronated or supinated foot.^4,5 Syndesmotic injuries are estimated to occur in up to 10% of ankle sprains⁶ and up to 23% of all ankle fractures.⁷ Overall US incidence of syndesmotic injury is estimated at 6445 injuries per year.⁸ Syndesmotic injury occurs in 39% to 45% of supination-external rotation IV ankle fractures.^9,10 Pronation-external rotation ankle fractures have the highest rate of syndesmotic injury. Syndesmotic injury may be less common in other types of malleolar fracture, but the exact incidence has not been reliably reported.

Traditionally, isolated nondisplaced syndesmotic injuries are treated nonoperatively, and syndesmotic injuries with concomitant malleolar fractures are treated surgically. Various options are available for syndesmotic fixation. The gold standard is syndesmotic screw placement from the lateral aspect of the fibula through the tibia. Fixation may be achieved with screws in a variety of configurations and formats. However, fixation with two 4.5-mm screws is stronger.^11,12 Functional outcomes are similar, regardless of screw material,^13-16 number of cortices,¹⁷ or number of screws.¹⁸ Disadvantages specific to screw fixation include altered ankle biomechanics,^19,20 potential for screw breakage,²¹ and need for implant removal.³Alternatively, suture button fixation is said to be equally as effective as screw fixation in achieving syndesmotic reduction, and their functional outcomes are similar.^22,23 The initial cost of suture button fixation is higher than that of screw fixation, but the difference may be offset by potential elimination of a second surgery for syndesmotic screw removal.²⁴ Soft-tissue irritation caused by the suture material and local osteolysis are reported complications of suture button fixation.^25-27

Regardless of fixation method used, achieving anatomical reduction of the syndesmosis is considered the most important factor in optimizing functional outcomes.^28-31 However, achieving and verifying anatomical reduction of the syndesmosis during surgery can be quite challenging.^30,32-34 Various methods of lowering the malreduction risk, including direct visualization of the tibiofibular joint during reduction^30,35 and intraoperative 3-dimensional imaging,^33,36 have been proposed.

In the study reported here, we used a US insurance database to determine the incidence and rate of syndesmotic stabilization within various ankle injuries and fracture patterns.

Materials and Methods

All data for this study were obtained from a publicly available for-fee healthcare database, the PearlDiver Patient Records Database, which includes procedural volumes and demographic information for patients with International Classification of Diseases, Ninth Revision (ICD-9) diagnoses and procedures or Current Procedural Terminology (CPT) codes. Data for the study were derived from 2 databases within PearlDiver: a private-payer database, which has its largest contribution (>30 million individual patient records for 2007-2011) from United HealthCare, and a Medicare database (>50 million patient records for 2007-2011). Access to the database was granted by PearlDiver Technologies for the purpose of academic research. The database was stored on a password-protected server maintained by PearlDiver.

We searched the database for cases of ankle fracture fixation, including fixation of isolated lateral malleolus (CPT 27792), bimalleolar (CPT 27814), and trimalleolar (CPTs 27822 and 27823) fractures. CPT 27829 was used to search for syndesmotic fixation, and CPT 20680 for implant removal. These codes were used individually and in combination.

Overall procedural volume data are reported as number of patients with the given CPT(s) in the database output and as incidence, calculated as number of patients with the CPT of interest normalized to total number of patients in the database for that particular subgroup. Results of age group and sex analyses are reported as number of patients reported in the database output and as percentage of patients who had the CPT procedure of interest that year. As United HealthCare is the largest contributor to the private-payer portion of the database and is represented most prominently in the southern region, data for the regional analysis are presented only as incidence. This incidence was calculated as number of patients in a particular region and year normalized to total number of patients in the database for that region or year. The regions were Midwest (IA, IL, IN, KS, MI, MN, MO, ND, NE, OH, SD, WI), Northeast (CT, MA, ME, NH, NJ, NY, PA, RI, VT), South (AL, AR, DC, DE, FL, GA, KY, LA, MD, MI, NC, OK, SC, TN, TX, VA, WV), and West (AK, AZ, CA, CO, HI, ID, MT, NM, NV, OR, UT, WA, WY).

Chi-square linear-by-linear association analysis was used to determine the statistical significance of time trends in procedural volume, sex, age group, and region. For all statistical comparisons, P < .05 was considered significant.

Results

Number of open reduction and internal fixation (ORIF) procedures increased for all ankle fracture types over the period 2007 to 2011 (Table 1).

ORIF was performed for an ankle injury in 54,767 patients during the period 2007 to 2011, resulting in a cumulative incidence of 64.2 per 1000 patients (Table 2).

Discussion

The present study found no significant change in number of lateral malleolus, bimalleolar, and trimalleolar ankle fracture ORIF procedures performed over the period 2007 to 2011. However, over the same period, incidence of syndesmosis fixation increased significantly in patients with isolated syndesmotic injuries and in patients with concomitant ankle fracture and syndesmotic injury. The largest percentage change was found in the bimalleolar ORIF group, which showed nearly a doubling of syndesmotic fixation over the 4-year study period, followed by a 38.1% increase in syndesmotic fixation in the trimalleolar ORIF group. Both groups had a syndesmotic fixation percentage change about twice that seen in the isolated lateral malleolus group.

There are several explanations for these trends. First, bimalleolar and trimalleolar fractures are more severe ankle fractures that tend to result from a more forceful mechanism, allowing for a higher rate of syndesmotic injury. Second, these trends likely do not reflect a true increase in the rate of syndesmosis injury but, rather, increased recognition of syndesmotic injury. Third, the data likely reflect a well-established approach to ankle fracture fixation and an increase in thinking that syndesmotic injuries should be stabilized in the setting of ankle fixation.

Incidence of syndesmotic injury as indicated by stabilization procedures can be compared with the data of Vosseller and colleagues,⁸ who reported an incidence of 6445 syndesmotic injuries per year in the United States. Our data showed fewer syndesmotic injuries, which may be related to use of CPT codes rather than ICD-9 codes for database searches, such that only operative syndesmotic injuries are represented in our data. Population differences between the 2 studies could also account for some of the differences in syndesmotic injury incidence.

We also found a significant change in the rate of hardware removal after syndesmosis ORIF. Across all treatment groups, incidence of screw removal decreased—a trend likely reflecting a change in attitude about the need for routine screw removal. Studies have shown that patients have favorable outcomes in the setting of syndesmotic screw loosening and screw breakage.³⁷ Some authors have suggested that screw breakage or removal could be advantageous, as it allows the syndesmosis to settle into a more anatomical position after imperfect reduction.³⁸ In addition, the trend of decreased syndesmotic screw removal could also have resulted from increased suture button fixation, which may less frequently require implant removal. Regardless, the overall trend is that routine syndesmotic implant removal has become less common.

This study had several limitations. First are the many limitations inherent to all studies that use large administrative databases, such as PearlDiver. The power of analysis depends on data quality; potential sources of error include accuracy of billing codes and physicians’ miscoding or noncoding. Although we tried to accurately represent a large population of interest through use of this database, we cannot be sure that the database represents a true cross-section of the United States. In addition, as we could not determine the method of syndesmotic fixation—the same CPT code is used for both suture button fixation and screw fixation—we could not establish trends for the rate of each method. More research is needed to establish these trends, and this research likely will require analysis of data from a large trauma center or from multiple centers.

Potential regional differences are another limitation. In the PearlDiver database, the South and Midwest are highly represented, the Northeast and West much less so. The South, Midwest, and West (but not the Northeast) had similar overall incidence and subgroup incidence of ankle ORIF. However, any regional differences in the rate of syndesmotic fixation could have skewed our data.

Ankle fractures and associated syndesmotic injuries remain a common problem. Although the prevalence of ankle fracture fixation has been relatively constant, the rate of syndesmosis stabilization has increased significantly. Young adults have the highest incidence of ankle fracture and associated syndesmotic fixation, but more ankle fractures occur in the large and growing elderly population. Increased awareness of syndesmotic injury likely has contributed to the recent rise in syndesmosis fixation seen in the present study. Given this trend, we recommend further analysis of outcome data and to establish treatment guidelines.

Am J Orthop. 2016;45(7):E472-E477. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

Acute ankle injuries are common problems treated by orthopedic surgeons. In the United States, nearly 2 million ankle sprains occur each year,¹ and ankle fractures account for 9% to 18% of all fractures treated in emergency departments.^2,3 Ankle injuries that involve the syndesmotic ligaments may result in instability and require specific treatment beyond fixation of the malleolar fractures.

The usual mechanism of syndesmotic injury is external rotation of the ankle with hyperdorsiflexion of a pronated or supinated foot.^4,5 Syndesmotic injuries are estimated to occur in up to 10% of ankle sprains⁶ and up to 23% of all ankle fractures.⁷ Overall US incidence of syndesmotic injury is estimated at 6445 injuries per year.⁸ Syndesmotic injury occurs in 39% to 45% of supination-external rotation IV ankle fractures.^9,10 Pronation-external rotation ankle fractures have the highest rate of syndesmotic injury. Syndesmotic injury may be less common in other types of malleolar fracture, but the exact incidence has not been reliably reported.

Traditionally, isolated nondisplaced syndesmotic injuries are treated nonoperatively, and syndesmotic injuries with concomitant malleolar fractures are treated surgically. Various options are available for syndesmotic fixation. The gold standard is syndesmotic screw placement from the lateral aspect of the fibula through the tibia. Fixation may be achieved with screws in a variety of configurations and formats. However, fixation with two 4.5-mm screws is stronger.^11,12 Functional outcomes are similar, regardless of screw material,^13-16 number of cortices,¹⁷ or number of screws.¹⁸ Disadvantages specific to screw fixation include altered ankle biomechanics,^19,20 potential for screw breakage,²¹ and need for implant removal.³Alternatively, suture button fixation is said to be equally as effective as screw fixation in achieving syndesmotic reduction, and their functional outcomes are similar.^22,23 The initial cost of suture button fixation is higher than that of screw fixation, but the difference may be offset by potential elimination of a second surgery for syndesmotic screw removal.²⁴ Soft-tissue irritation caused by the suture material and local osteolysis are reported complications of suture button fixation.^25-27

Regardless of fixation method used, achieving anatomical reduction of the syndesmosis is considered the most important factor in optimizing functional outcomes.^28-31 However, achieving and verifying anatomical reduction of the syndesmosis during surgery can be quite challenging.^30,32-34 Various methods of lowering the malreduction risk, including direct visualization of the tibiofibular joint during reduction^30,35 and intraoperative 3-dimensional imaging,^33,36 have been proposed.

In the study reported here, we used a US insurance database to determine the incidence and rate of syndesmotic stabilization within various ankle injuries and fracture patterns.

Materials and Methods

All data for this study were obtained from a publicly available for-fee healthcare database, the PearlDiver Patient Records Database, which includes procedural volumes and demographic information for patients with International Classification of Diseases, Ninth Revision (ICD-9) diagnoses and procedures or Current Procedural Terminology (CPT) codes. Data for the study were derived from 2 databases within PearlDiver: a private-payer database, which has its largest contribution (>30 million individual patient records for 2007-2011) from United HealthCare, and a Medicare database (>50 million patient records for 2007-2011). Access to the database was granted by PearlDiver Technologies for the purpose of academic research. The database was stored on a password-protected server maintained by PearlDiver.

We searched the database for cases of ankle fracture fixation, including fixation of isolated lateral malleolus (CPT 27792), bimalleolar (CPT 27814), and trimalleolar (CPTs 27822 and 27823) fractures. CPT 27829 was used to search for syndesmotic fixation, and CPT 20680 for implant removal. These codes were used individually and in combination.

Overall procedural volume data are reported as number of patients with the given CPT(s) in the database output and as incidence, calculated as number of patients with the CPT of interest normalized to total number of patients in the database for that particular subgroup. Results of age group and sex analyses are reported as number of patients reported in the database output and as percentage of patients who had the CPT procedure of interest that year. As United HealthCare is the largest contributor to the private-payer portion of the database and is represented most prominently in the southern region, data for the regional analysis are presented only as incidence. This incidence was calculated as number of patients in a particular region and year normalized to total number of patients in the database for that region or year. The regions were Midwest (IA, IL, IN, KS, MI, MN, MO, ND, NE, OH, SD, WI), Northeast (CT, MA, ME, NH, NJ, NY, PA, RI, VT), South (AL, AR, DC, DE, FL, GA, KY, LA, MD, MI, NC, OK, SC, TN, TX, VA, WV), and West (AK, AZ, CA, CO, HI, ID, MT, NM, NV, OR, UT, WA, WY).

Chi-square linear-by-linear association analysis was used to determine the statistical significance of time trends in procedural volume, sex, age group, and region. For all statistical comparisons, P < .05 was considered significant.

Results

Number of open reduction and internal fixation (ORIF) procedures increased for all ankle fracture types over the period 2007 to 2011 (Table 1).

ORIF was performed for an ankle injury in 54,767 patients during the period 2007 to 2011, resulting in a cumulative incidence of 64.2 per 1000 patients (Table 2).

Discussion

The present study found no significant change in number of lateral malleolus, bimalleolar, and trimalleolar ankle fracture ORIF procedures performed over the period 2007 to 2011. However, over the same period, incidence of syndesmosis fixation increased significantly in patients with isolated syndesmotic injuries and in patients with concomitant ankle fracture and syndesmotic injury. The largest percentage change was found in the bimalleolar ORIF group, which showed nearly a doubling of syndesmotic fixation over the 4-year study period, followed by a 38.1% increase in syndesmotic fixation in the trimalleolar ORIF group. Both groups had a syndesmotic fixation percentage change about twice that seen in the isolated lateral malleolus group.

There are several explanations for these trends. First, bimalleolar and trimalleolar fractures are more severe ankle fractures that tend to result from a more forceful mechanism, allowing for a higher rate of syndesmotic injury. Second, these trends likely do not reflect a true increase in the rate of syndesmosis injury but, rather, increased recognition of syndesmotic injury. Third, the data likely reflect a well-established approach to ankle fracture fixation and an increase in thinking that syndesmotic injuries should be stabilized in the setting of ankle fixation.

Incidence of syndesmotic injury as indicated by stabilization procedures can be compared with the data of Vosseller and colleagues,⁸ who reported an incidence of 6445 syndesmotic injuries per year in the United States. Our data showed fewer syndesmotic injuries, which may be related to use of CPT codes rather than ICD-9 codes for database searches, such that only operative syndesmotic injuries are represented in our data. Population differences between the 2 studies could also account for some of the differences in syndesmotic injury incidence.

We also found a significant change in the rate of hardware removal after syndesmosis ORIF. Across all treatment groups, incidence of screw removal decreased—a trend likely reflecting a change in attitude about the need for routine screw removal. Studies have shown that patients have favorable outcomes in the setting of syndesmotic screw loosening and screw breakage.³⁷ Some authors have suggested that screw breakage or removal could be advantageous, as it allows the syndesmosis to settle into a more anatomical position after imperfect reduction.³⁸ In addition, the trend of decreased syndesmotic screw removal could also have resulted from increased suture button fixation, which may less frequently require implant removal. Regardless, the overall trend is that routine syndesmotic implant removal has become less common.

This study had several limitations. First are the many limitations inherent to all studies that use large administrative databases, such as PearlDiver. The power of analysis depends on data quality; potential sources of error include accuracy of billing codes and physicians’ miscoding or noncoding. Although we tried to accurately represent a large population of interest through use of this database, we cannot be sure that the database represents a true cross-section of the United States. In addition, as we could not determine the method of syndesmotic fixation—the same CPT code is used for both suture button fixation and screw fixation—we could not establish trends for the rate of each method. More research is needed to establish these trends, and this research likely will require analysis of data from a large trauma center or from multiple centers.

Potential regional differences are another limitation. In the PearlDiver database, the South and Midwest are highly represented, the Northeast and West much less so. The South, Midwest, and West (but not the Northeast) had similar overall incidence and subgroup incidence of ankle ORIF. However, any regional differences in the rate of syndesmotic fixation could have skewed our data.

Ankle fractures and associated syndesmotic injuries remain a common problem. Although the prevalence of ankle fracture fixation has been relatively constant, the rate of syndesmosis stabilization has increased significantly. Young adults have the highest incidence of ankle fracture and associated syndesmotic fixation, but more ankle fractures occur in the large and growing elderly population. Increased awareness of syndesmotic injury likely has contributed to the recent rise in syndesmosis fixation seen in the present study. Given this trend, we recommend further analysis of outcome data and to establish treatment guidelines.

Am J Orthop. 2016;45(7):E472-E477. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

Malignant melanoma has continually shown a pattern of increased incidence and mortality over the last 50 years, especially in fair-skinned individuals. In fact, malignant melanoma has the highest mortality rate of all skin cancers in white individuals. Currently, wide local surgical excision is the mainstay of treatment of primary cutaneous melanomas.¹ The margins vary in size according to the Breslow thickness (or depth) of the involved tumor. As such, advancements in melanoma treatment continue to be studied. We present the case of a patient with invasive melanoma that was cleared with topical imiquimod.

Case Report

A 71-year-old man presented with biopsy-proven malignant melanoma on the right posterior scalp that was diagnosed a few weeks prior. The melanoma was invasive with a depth of 0.73 mm. The patient also had an approximately 8-cm, irregular, patchy area of hyperpigmentation involving almost the entire crown of the head (Figure 1A). The biopsy site used for melanoma diagnosis was on the right posterior aspect of the hyperpigmented area where a symptomatic pigmented papule was located. To determine if the rest of this macule represented an extension of the proven malignancy, surveillance biopsies were taken at the 12 o'clock (anterior aspect), 3 o'clock, 6 o'clock, and 9 o'clock positions on the head. All of the biopsies came back as lentigo simplex, which presented a clinical problem in that the boundaries of the invasive melanoma merged with the lentigo simplex and were not clinically apparent. Because an exact boundary could not be visualized, the entire area was treated with imiquimod cream 5% once nightly at bedtime for 4 weeks prior to excision of the original biopsy site. There was a notable decrease in hyperpigmentation in the treated area after 4 weeks of therapy (Figure 1B). The original biopsy site was then excised with a 0.6-cm margin and a complex linear repair was performed. Histologic examination of the excised specimen showed no residual melanoma.

Comment

Although surgical excision is the recommended treatment of cutaneous melanoma,¹ in some cases the defect following an excision can be quite large or even disfiguring. To minimize the size of the excision site, other treatment modalities should be studied. Imiquimod is an immunomodulating agent that exerts antitumor and antiviral effects. The US Food and Drug Administration has approved imiquimod for treatment of genital warts, actinic keratoses, and superficial basal cell carcinoma.² The most common side effects of topical imiquimod involve application-site reactions such as erythema, swelling, and crusting of the treated area. Ulceration of the skin also is possible. A small percentage of individuals have experienced systemic flulike symptoms after using topical imiquimod. Topical imiquimod has been used off label to treat noninvasive forms of melanoma. The topical therapy has been reported to clear melanoma in situ and lentigo maligna.^2,3 In addition, imiquimod has been used as a palliative therapy for cutaneous metastatic melanoma.^4,5 In another case of a primary melanoma that responded to topical imiquimod, clinical and histological clearance of a recurrent oral mucosa melanoma was obtained.⁶

Moon and Spencer⁷ reported a case of an invasive melanoma that was cleared with topical imiquimod. A 93-year-old woman presented with a central 2.75-mm thick invasive melanoma surrounded by a large area of melanoma in situ involving the left cheek and eyelid. The excised tissue was stained for CD31 and D2-40 to rule out intravascular and intralymphatic spread (Figure 2A). The standard-of-care treatment for this case would involve surgical excision with 2-cm margins and a sentinel lymph node biopsy, but given the morbidity involved with the surgery, an alternative treatment plan was made with the patient. The patient completed 5 weeks of topical imiquimod therapy and then underwent wide local excision with a 1-cm margin. Extensive histological examination of the excised specimen showed no residual melanoma; in fact, there was a near absence of junctional melanocytes that would normally have been seen. The specimen underwent immunoperoxidase staining for Melan-A (Figure 2B). The patient was followed for 14 months with no evidence of recurrence.⁷

Conclusion

We describe a patient who achieved complete histologic clearance of invasive melanoma following treatment with topical imiquimod. Four weeks of topical therapy completely cleared an invasive melanoma that was 0.73-mm thick. Follow-up was recommended for the patient because long-term outcomes of this therapy are unknown. More studies demonstrating reliability and reproducibility are needed to evaluate the role of topical imiquimod in melanoma treatment; however, our case shows the potential of this topical modality.

Malignant melanoma has continually shown a pattern of increased incidence and mortality over the last 50 years, especially in fair-skinned individuals. In fact, malignant melanoma has the highest mortality rate of all skin cancers in white individuals. Currently, wide local surgical excision is the mainstay of treatment of primary cutaneous melanomas.¹ The margins vary in size according to the Breslow thickness (or depth) of the involved tumor. As such, advancements in melanoma treatment continue to be studied. We present the case of a patient with invasive melanoma that was cleared with topical imiquimod.

Case Report

A 71-year-old man presented with biopsy-proven malignant melanoma on the right posterior scalp that was diagnosed a few weeks prior. The melanoma was invasive with a depth of 0.73 mm. The patient also had an approximately 8-cm, irregular, patchy area of hyperpigmentation involving almost the entire crown of the head (Figure 1A). The biopsy site used for melanoma diagnosis was on the right posterior aspect of the hyperpigmented area where a symptomatic pigmented papule was located. To determine if the rest of this macule represented an extension of the proven malignancy, surveillance biopsies were taken at the 12 o'clock (anterior aspect), 3 o'clock, 6 o'clock, and 9 o'clock positions on the head. All of the biopsies came back as lentigo simplex, which presented a clinical problem in that the boundaries of the invasive melanoma merged with the lentigo simplex and were not clinically apparent. Because an exact boundary could not be visualized, the entire area was treated with imiquimod cream 5% once nightly at bedtime for 4 weeks prior to excision of the original biopsy site. There was a notable decrease in hyperpigmentation in the treated area after 4 weeks of therapy (Figure 1B). The original biopsy site was then excised with a 0.6-cm margin and a complex linear repair was performed. Histologic examination of the excised specimen showed no residual melanoma.

Comment

Although surgical excision is the recommended treatment of cutaneous melanoma,¹ in some cases the defect following an excision can be quite large or even disfiguring. To minimize the size of the excision site, other treatment modalities should be studied. Imiquimod is an immunomodulating agent that exerts antitumor and antiviral effects. The US Food and Drug Administration has approved imiquimod for treatment of genital warts, actinic keratoses, and superficial basal cell carcinoma.² The most common side effects of topical imiquimod involve application-site reactions such as erythema, swelling, and crusting of the treated area. Ulceration of the skin also is possible. A small percentage of individuals have experienced systemic flulike symptoms after using topical imiquimod. Topical imiquimod has been used off label to treat noninvasive forms of melanoma. The topical therapy has been reported to clear melanoma in situ and lentigo maligna.^2,3 In addition, imiquimod has been used as a palliative therapy for cutaneous metastatic melanoma.^4,5 In another case of a primary melanoma that responded to topical imiquimod, clinical and histological clearance of a recurrent oral mucosa melanoma was obtained.⁶

Moon and Spencer⁷ reported a case of an invasive melanoma that was cleared with topical imiquimod. A 93-year-old woman presented with a central 2.75-mm thick invasive melanoma surrounded by a large area of melanoma in situ involving the left cheek and eyelid. The excised tissue was stained for CD31 and D2-40 to rule out intravascular and intralymphatic spread (Figure 2A). The standard-of-care treatment for this case would involve surgical excision with 2-cm margins and a sentinel lymph node biopsy, but given the morbidity involved with the surgery, an alternative treatment plan was made with the patient. The patient completed 5 weeks of topical imiquimod therapy and then underwent wide local excision with a 1-cm margin. Extensive histological examination of the excised specimen showed no residual melanoma; in fact, there was a near absence of junctional melanocytes that would normally have been seen. The specimen underwent immunoperoxidase staining for Melan-A (Figure 2B). The patient was followed for 14 months with no evidence of recurrence.⁷

Conclusion

We describe a patient who achieved complete histologic clearance of invasive melanoma following treatment with topical imiquimod. Four weeks of topical therapy completely cleared an invasive melanoma that was 0.73-mm thick. Follow-up was recommended for the patient because long-term outcomes of this therapy are unknown. More studies demonstrating reliability and reproducibility are needed to evaluate the role of topical imiquimod in melanoma treatment; however, our case shows the potential of this topical modality.

Malignant melanoma has continually shown a pattern of increased incidence and mortality over the last 50 years, especially in fair-skinned individuals. In fact, malignant melanoma has the highest mortality rate of all skin cancers in white individuals. Currently, wide local surgical excision is the mainstay of treatment of primary cutaneous melanomas.¹ The margins vary in size according to the Breslow thickness (or depth) of the involved tumor. As such, advancements in melanoma treatment continue to be studied. We present the case of a patient with invasive melanoma that was cleared with topical imiquimod.

Case Report

A 71-year-old man presented with biopsy-proven malignant melanoma on the right posterior scalp that was diagnosed a few weeks prior. The melanoma was invasive with a depth of 0.73 mm. The patient also had an approximately 8-cm, irregular, patchy area of hyperpigmentation involving almost the entire crown of the head (Figure 1A). The biopsy site used for melanoma diagnosis was on the right posterior aspect of the hyperpigmented area where a symptomatic pigmented papule was located. To determine if the rest of this macule represented an extension of the proven malignancy, surveillance biopsies were taken at the 12 o'clock (anterior aspect), 3 o'clock, 6 o'clock, and 9 o'clock positions on the head. All of the biopsies came back as lentigo simplex, which presented a clinical problem in that the boundaries of the invasive melanoma merged with the lentigo simplex and were not clinically apparent. Because an exact boundary could not be visualized, the entire area was treated with imiquimod cream 5% once nightly at bedtime for 4 weeks prior to excision of the original biopsy site. There was a notable decrease in hyperpigmentation in the treated area after 4 weeks of therapy (Figure 1B). The original biopsy site was then excised with a 0.6-cm margin and a complex linear repair was performed. Histologic examination of the excised specimen showed no residual melanoma.

Comment

Although surgical excision is the recommended treatment of cutaneous melanoma,¹ in some cases the defect following an excision can be quite large or even disfiguring. To minimize the size of the excision site, other treatment modalities should be studied. Imiquimod is an immunomodulating agent that exerts antitumor and antiviral effects. The US Food and Drug Administration has approved imiquimod for treatment of genital warts, actinic keratoses, and superficial basal cell carcinoma.² The most common side effects of topical imiquimod involve application-site reactions such as erythema, swelling, and crusting of the treated area. Ulceration of the skin also is possible. A small percentage of individuals have experienced systemic flulike symptoms after using topical imiquimod. Topical imiquimod has been used off label to treat noninvasive forms of melanoma. The topical therapy has been reported to clear melanoma in situ and lentigo maligna.^2,3 In addition, imiquimod has been used as a palliative therapy for cutaneous metastatic melanoma.^4,5 In another case of a primary melanoma that responded to topical imiquimod, clinical and histological clearance of a recurrent oral mucosa melanoma was obtained.⁶

Moon and Spencer⁷ reported a case of an invasive melanoma that was cleared with topical imiquimod. A 93-year-old woman presented with a central 2.75-mm thick invasive melanoma surrounded by a large area of melanoma in situ involving the left cheek and eyelid. The excised tissue was stained for CD31 and D2-40 to rule out intravascular and intralymphatic spread (Figure 2A). The standard-of-care treatment for this case would involve surgical excision with 2-cm margins and a sentinel lymph node biopsy, but given the morbidity involved with the surgery, an alternative treatment plan was made with the patient. The patient completed 5 weeks of topical imiquimod therapy and then underwent wide local excision with a 1-cm margin. Extensive histological examination of the excised specimen showed no residual melanoma; in fact, there was a near absence of junctional melanocytes that would normally have been seen. The specimen underwent immunoperoxidase staining for Melan-A (Figure 2B). The patient was followed for 14 months with no evidence of recurrence.⁷

Conclusion

We describe a patient who achieved complete histologic clearance of invasive melanoma following treatment with topical imiquimod. Four weeks of topical therapy completely cleared an invasive melanoma that was 0.73-mm thick. Follow-up was recommended for the patient because long-term outcomes of this therapy are unknown. More studies demonstrating reliability and reproducibility are needed to evaluate the role of topical imiquimod in melanoma treatment; however, our case shows the potential of this topical modality.

WASHINGTON – MRI can help to differentiate between neurosarcoidosis and primary angiitis of the central nervous system, according to a single-center study comparing the two conditions.

Patients with neurosarcoidosis were significantly more likely to display spinal cord, basal meningeal, and cranial nerve involvements than were patients with primary angiitis of the central nervous system (PACNS), making MRI an efficient tool in distinguishing between the two.

Deepak Chitnis/Frontline Medical News

[email protected]

WASHINGTON – MRI can help to differentiate between neurosarcoidosis and primary angiitis of the central nervous system, according to a single-center study comparing the two conditions.

Patients with neurosarcoidosis were significantly more likely to display spinal cord, basal meningeal, and cranial nerve involvements than were patients with primary angiitis of the central nervous system (PACNS), making MRI an efficient tool in distinguishing between the two.

Deepak Chitnis/Frontline Medical News

[email protected]

WASHINGTON – MRI can help to differentiate between neurosarcoidosis and primary angiitis of the central nervous system, according to a single-center study comparing the two conditions.

Patients with neurosarcoidosis were significantly more likely to display spinal cord, basal meningeal, and cranial nerve involvements than were patients with primary angiitis of the central nervous system (PACNS), making MRI an efficient tool in distinguishing between the two.

Deepak Chitnis/Frontline Medical News

[email protected]

An all-encompassing definition of “big data” in health care remains elusive, but most researchers and public health experts believe big data may be poised to revolutionize the field of infectious diseases research.

Big data could provide the means to finally achieve effective and timely surveillance systems, which form a “pillar of infectious disease control,” according to Shweta Bansal, PhD, of the department of biology, Georgetown University, Washington, and her associates (J Infect Dis. 2016 Nov;214[S4]:S375-9. doi: 10.1093/infdis/jiw400).

copyright Sebastian Duda/Thinkstock

[email protected]

On Twitter @jessnicolecraig

An all-encompassing definition of “big data” in health care remains elusive, but most researchers and public health experts believe big data may be poised to revolutionize the field of infectious diseases research.

Big data could provide the means to finally achieve effective and timely surveillance systems, which form a “pillar of infectious disease control,” according to Shweta Bansal, PhD, of the department of biology, Georgetown University, Washington, and her associates (J Infect Dis. 2016 Nov;214[S4]:S375-9. doi: 10.1093/infdis/jiw400).

copyright Sebastian Duda/Thinkstock

[email protected]

On Twitter @jessnicolecraig

An all-encompassing definition of “big data” in health care remains elusive, but most researchers and public health experts believe big data may be poised to revolutionize the field of infectious diseases research.

Big data could provide the means to finally achieve effective and timely surveillance systems, which form a “pillar of infectious disease control,” according to Shweta Bansal, PhD, of the department of biology, Georgetown University, Washington, and her associates (J Infect Dis. 2016 Nov;214[S4]:S375-9. doi: 10.1093/infdis/jiw400).

copyright Sebastian Duda/Thinkstock

[email protected]

On Twitter @jessnicolecraig

HOUSTON – Adults with epilepsy reported five of the six most common cardiovascular diseases more often than did adults without epilepsy, according to results from the 2013 National Health Interview Survey.

“Often, neurologists are busy treating the seizure, making sure the patient has proper treatment, but they often don’t have the time to look at these conditions that can cause deaths a lot more commonly than things like sudden unexpected death from epilepsy,” lead study author Matthew Zack, MD, said in an interview at the annual meeting of the American Epilepsy Society. “We’re not talking about mortality here, but it’s important for doctors to be aware of the fact that patients with epilepsy have increased risk for conditions like heart attacks, high blood pressure, and stroke.”

Doug Brunk/Frontline Medical News

[email protected]

HOUSTON – Adults with epilepsy reported five of the six most common cardiovascular diseases more often than did adults without epilepsy, according to results from the 2013 National Health Interview Survey.

“Often, neurologists are busy treating the seizure, making sure the patient has proper treatment, but they often don’t have the time to look at these conditions that can cause deaths a lot more commonly than things like sudden unexpected death from epilepsy,” lead study author Matthew Zack, MD, said in an interview at the annual meeting of the American Epilepsy Society. “We’re not talking about mortality here, but it’s important for doctors to be aware of the fact that patients with epilepsy have increased risk for conditions like heart attacks, high blood pressure, and stroke.”

Doug Brunk/Frontline Medical News

[email protected]

HOUSTON – Adults with epilepsy reported five of the six most common cardiovascular diseases more often than did adults without epilepsy, according to results from the 2013 National Health Interview Survey.

“Often, neurologists are busy treating the seizure, making sure the patient has proper treatment, but they often don’t have the time to look at these conditions that can cause deaths a lot more commonly than things like sudden unexpected death from epilepsy,” lead study author Matthew Zack, MD, said in an interview at the annual meeting of the American Epilepsy Society. “We’re not talking about mortality here, but it’s important for doctors to be aware of the fact that patients with epilepsy have increased risk for conditions like heart attacks, high blood pressure, and stroke.”

Doug Brunk/Frontline Medical News

[email protected]

So lets revisit this topic. We hate melasma. It is recalcitrant, resistant, and often recurs. But how many of us dermatologists look at melasma with a dermatoscope? A minority? And probably even fewer of us biopsy melasma. Are we missing the many, many cases of vascular or erythematotelangiectatic melasma and just treating melasma as a pigment problem instead of treating it as a vascular problem?

We know that melasma develops because of increased melanin production, not an increased number of melanocytes, but the underlying cause of increased melanogenesis is not fully understood. Several recent studies suggest that the increased vascularity in melasma skin is the underlying etiology. Understanding the way endogeneous and exogeneous stimuli such as sex hormones, oral contraceptives, ultraviolet irradiation, and visible light stimulate inflammation in the dermis, leading to the release of various mediators that stimulate angiogenesis and the activation of melanocytes, will help us improve the treatment of this relentless disease.

Courtesy Lily Talakoub, MD

References

J Dermatol Sci. 2007 May;46(2):111-6.

Exp Dermatol. 2005 Aug;14(8):625-33.

Clin Exp Dermatol. 2008;33(3):305-8.

J Eur Acad Dermatol Venereol. 2009 Nov;23(11):1254-62.

Ann Dermatol. 2010 Nov;22(4):373-8.

J Eur Acad Dermatol Venereol. 2013 Jan;27 Suppl 1:5-6.

Am J Clin Dermatol. 2013 Oct;14(5):359-76.

J Am Acad Dermatol. 2014 Feb;70(2):369-73.

Dr. Talakoub and Dr. Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected].

So lets revisit this topic. We hate melasma. It is recalcitrant, resistant, and often recurs. But how many of us dermatologists look at melasma with a dermatoscope? A minority? And probably even fewer of us biopsy melasma. Are we missing the many, many cases of vascular or erythematotelangiectatic melasma and just treating melasma as a pigment problem instead of treating it as a vascular problem?

We know that melasma develops because of increased melanin production, not an increased number of melanocytes, but the underlying cause of increased melanogenesis is not fully understood. Several recent studies suggest that the increased vascularity in melasma skin is the underlying etiology. Understanding the way endogeneous and exogeneous stimuli such as sex hormones, oral contraceptives, ultraviolet irradiation, and visible light stimulate inflammation in the dermis, leading to the release of various mediators that stimulate angiogenesis and the activation of melanocytes, will help us improve the treatment of this relentless disease.

Courtesy Lily Talakoub, MD

References

J Dermatol Sci. 2007 May;46(2):111-6.

Exp Dermatol. 2005 Aug;14(8):625-33.

Clin Exp Dermatol. 2008;33(3):305-8.

J Eur Acad Dermatol Venereol. 2009 Nov;23(11):1254-62.

Ann Dermatol. 2010 Nov;22(4):373-8.

J Eur Acad Dermatol Venereol. 2013 Jan;27 Suppl 1:5-6.

Am J Clin Dermatol. 2013 Oct;14(5):359-76.

J Am Acad Dermatol. 2014 Feb;70(2):369-73.

Dr. Talakoub and Dr. Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected].

So lets revisit this topic. We hate melasma. It is recalcitrant, resistant, and often recurs. But how many of us dermatologists look at melasma with a dermatoscope? A minority? And probably even fewer of us biopsy melasma. Are we missing the many, many cases of vascular or erythematotelangiectatic melasma and just treating melasma as a pigment problem instead of treating it as a vascular problem?

We know that melasma develops because of increased melanin production, not an increased number of melanocytes, but the underlying cause of increased melanogenesis is not fully understood. Several recent studies suggest that the increased vascularity in melasma skin is the underlying etiology. Understanding the way endogeneous and exogeneous stimuli such as sex hormones, oral contraceptives, ultraviolet irradiation, and visible light stimulate inflammation in the dermis, leading to the release of various mediators that stimulate angiogenesis and the activation of melanocytes, will help us improve the treatment of this relentless disease.

Courtesy Lily Talakoub, MD

References

J Dermatol Sci. 2007 May;46(2):111-6.

Exp Dermatol. 2005 Aug;14(8):625-33.

Clin Exp Dermatol. 2008;33(3):305-8.

J Eur Acad Dermatol Venereol. 2009 Nov;23(11):1254-62.

Ann Dermatol. 2010 Nov;22(4):373-8.

J Eur Acad Dermatol Venereol. 2013 Jan;27 Suppl 1:5-6.

Am J Clin Dermatol. 2013 Oct;14(5):359-76.

J Am Acad Dermatol. 2014 Feb;70(2):369-73.

Dr. Talakoub and Dr. Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected].

There were many books I read in 2016 that I found relevant and helpful for the practice of medicine as modern physicians. Here were some of my favorites:

”How to Have a Good Day” by Caroline Webb (Crown Business, 2016).

With media headlines screaming about the surge in physician burnout, now is a good time to read “How to Have a Good Day.” The author, Caroline Webb, an Oxford- and Cambridge-trained economist, management consultant, and executive coach, shows how little tweaks in behavior can garner big results in both your workday productivity and your overall well-being. Her science-based techniques are wonderfully practical. She teaches you how to be more effective at work by establishing smart habits, setting appropriate priorities, and pumping up your workplace enthusiasm. She also shows you a path to stronger workplace relationships by learning how to better manage conflict, build rapport, and get the most out of others. My copy is dog-eared. I hope yours will be too.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]. He has no disclosures related to this column.

There were many books I read in 2016 that I found relevant and helpful for the practice of medicine as modern physicians. Here were some of my favorites:

”How to Have a Good Day” by Caroline Webb (Crown Business, 2016).

With media headlines screaming about the surge in physician burnout, now is a good time to read “How to Have a Good Day.” The author, Caroline Webb, an Oxford- and Cambridge-trained economist, management consultant, and executive coach, shows how little tweaks in behavior can garner big results in both your workday productivity and your overall well-being. Her science-based techniques are wonderfully practical. She teaches you how to be more effective at work by establishing smart habits, setting appropriate priorities, and pumping up your workplace enthusiasm. She also shows you a path to stronger workplace relationships by learning how to better manage conflict, build rapport, and get the most out of others. My copy is dog-eared. I hope yours will be too.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]. He has no disclosures related to this column.

There were many books I read in 2016 that I found relevant and helpful for the practice of medicine as modern physicians. Here were some of my favorites:

”How to Have a Good Day” by Caroline Webb (Crown Business, 2016).

With media headlines screaming about the surge in physician burnout, now is a good time to read “How to Have a Good Day.” The author, Caroline Webb, an Oxford- and Cambridge-trained economist, management consultant, and executive coach, shows how little tweaks in behavior can garner big results in both your workday productivity and your overall well-being. Her science-based techniques are wonderfully practical. She teaches you how to be more effective at work by establishing smart habits, setting appropriate priorities, and pumping up your workplace enthusiasm. She also shows you a path to stronger workplace relationships by learning how to better manage conflict, build rapport, and get the most out of others. My copy is dog-eared. I hope yours will be too.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]. He has no disclosures related to this column.

VIENNA – Updated longer-term safety data for ixekizumab in patients with moderate to severe plaque psoriasis continue to show no new safety signals, Alexa B. Kimball, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.

The safety database now includes 4,213 psoriasis patients on ixekizumab (Taltz) for a total of 7,843 patient-years of regular ongoing follow-up in seven different phase I-III clinical trials. And with a large group of patients now having been on the novel humanized monoclonal antibody targeting interleukin-17A for 2 years and smaller numbers out to 5 years, there have been no surprises, according to Dr. Kimball, professor of dermatology at Harvard Medical School, Boston.

[email protected]

VIENNA – Updated longer-term safety data for ixekizumab in patients with moderate to severe plaque psoriasis continue to show no new safety signals, Alexa B. Kimball, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.

The safety database now includes 4,213 psoriasis patients on ixekizumab (Taltz) for a total of 7,843 patient-years of regular ongoing follow-up in seven different phase I-III clinical trials. And with a large group of patients now having been on the novel humanized monoclonal antibody targeting interleukin-17A for 2 years and smaller numbers out to 5 years, there have been no surprises, according to Dr. Kimball, professor of dermatology at Harvard Medical School, Boston.

[email protected]

VIENNA – Updated longer-term safety data for ixekizumab in patients with moderate to severe plaque psoriasis continue to show no new safety signals, Alexa B. Kimball, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.

The safety database now includes 4,213 psoriasis patients on ixekizumab (Taltz) for a total of 7,843 patient-years of regular ongoing follow-up in seven different phase I-III clinical trials. And with a large group of patients now having been on the novel humanized monoclonal antibody targeting interleukin-17A for 2 years and smaller numbers out to 5 years, there have been no surprises, according to Dr. Kimball, professor of dermatology at Harvard Medical School, Boston.

[email protected]

Physician pay has been flat for years, and my crystal ball doesn’t show that changing any time soon. But the American people just elected a regulatory wrecking ball, so let’s look at some changes we can hope the Trump administration will make.

Let’s start by eliminating the regulations that interfere with patient care and degrade the quality of care. Does the Medicare Access and CHIP Reauthorization Act (MACRA) and its Merit-based Incentive Payment System (MIPS) really have anything to do with the quality of care? No, the regulations that will implement the coming MACRA reforms were written contrary to congressional intent by the Department of Health & Human Services as a last-ditch attempt to impose the Affordable Care Act on American physicians. Let’s repeal it! At a minimum, let’s exempt physician practices of 9 or less, rather than 15, as the regulations call for. Where did 15 come from?

Dr. Coldiron is past president of the American Academy of Dermatology. He is currently 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. Write to him at [email protected].

Physician pay has been flat for years, and my crystal ball doesn’t show that changing any time soon. But the American people just elected a regulatory wrecking ball, so let’s look at some changes we can hope the Trump administration will make.

Let’s start by eliminating the regulations that interfere with patient care and degrade the quality of care. Does the Medicare Access and CHIP Reauthorization Act (MACRA) and its Merit-based Incentive Payment System (MIPS) really have anything to do with the quality of care? No, the regulations that will implement the coming MACRA reforms were written contrary to congressional intent by the Department of Health & Human Services as a last-ditch attempt to impose the Affordable Care Act on American physicians. Let’s repeal it! At a minimum, let’s exempt physician practices of 9 or less, rather than 15, as the regulations call for. Where did 15 come from?

Dr. Coldiron is past president of the American Academy of Dermatology. He is currently 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. Write to him at [email protected].

Physician pay has been flat for years, and my crystal ball doesn’t show that changing any time soon. But the American people just elected a regulatory wrecking ball, so let’s look at some changes we can hope the Trump administration will make.

Let’s start by eliminating the regulations that interfere with patient care and degrade the quality of care. Does the Medicare Access and CHIP Reauthorization Act (MACRA) and its Merit-based Incentive Payment System (MIPS) really have anything to do with the quality of care? No, the regulations that will implement the coming MACRA reforms were written contrary to congressional intent by the Department of Health & Human Services as a last-ditch attempt to impose the Affordable Care Act on American physicians. Let’s repeal it! At a minimum, let’s exempt physician practices of 9 or less, rather than 15, as the regulations call for. Where did 15 come from?

Dr. Coldiron is past president of the American Academy of Dermatology. He is currently 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. Write to him at [email protected].