NEW ORLEANS – The latest revision of U.S. guidelines for diagnosing and managing lower-extremity peripheral artery disease is seen by several experts as primarily a renewed call to action by American physicians to more diligently identify at-risk people in their practices, diagnose the disease with ankle-brachial index measurement, and appropriately treat patients who have the disease.

The new lower-extremity peripheral artery disease (PAD) guidelines “give us a platform to get something done,” said Heather L. Gornik, MD, vice chair of the guidelines panel and medical director of the noninvasive vascular lab at the Cleveland Clinic. Improved PAD identification and care “starts with the fundamentals of recognizing who is at risk for PAD and then doing some clinical investigation to find it, because it’s there. You just need to ask patients if they have leg symptoms, have them take off their socks and examine their feet,” Dr. Gornik said in an interview following a program devoted to the revised guidelines at the American Heart Association scientific sessions.

The new guidelines are “a clarion call to action,” commented Alan T. Hirsch, MD, professor of medicine, epidemiology, and community health and director of the vascular medicine program at the University of Minnesota in Minneapolis. PAD “is the single most morbid and fatal of all cardiovascular diseases, so why in 2016 are we challenged to have every cardiologist trained in basic PAD competency?” asked Dr. Hirsch, who chaired the 2005 guidelines panel.

Mitchel L. Zoler/Frontline Medical News

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

NEW ORLEANS – The latest revision of U.S. guidelines for diagnosing and managing lower-extremity peripheral artery disease is seen by several experts as primarily a renewed call to action by American physicians to more diligently identify at-risk people in their practices, diagnose the disease with ankle-brachial index measurement, and appropriately treat patients who have the disease.

The new lower-extremity peripheral artery disease (PAD) guidelines “give us a platform to get something done,” said Heather L. Gornik, MD, vice chair of the guidelines panel and medical director of the noninvasive vascular lab at the Cleveland Clinic. Improved PAD identification and care “starts with the fundamentals of recognizing who is at risk for PAD and then doing some clinical investigation to find it, because it’s there. You just need to ask patients if they have leg symptoms, have them take off their socks and examine their feet,” Dr. Gornik said in an interview following a program devoted to the revised guidelines at the American Heart Association scientific sessions.

The new guidelines are “a clarion call to action,” commented Alan T. Hirsch, MD, professor of medicine, epidemiology, and community health and director of the vascular medicine program at the University of Minnesota in Minneapolis. PAD “is the single most morbid and fatal of all cardiovascular diseases, so why in 2016 are we challenged to have every cardiologist trained in basic PAD competency?” asked Dr. Hirsch, who chaired the 2005 guidelines panel.

Mitchel L. Zoler/Frontline Medical News

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

NEW ORLEANS – The latest revision of U.S. guidelines for diagnosing and managing lower-extremity peripheral artery disease is seen by several experts as primarily a renewed call to action by American physicians to more diligently identify at-risk people in their practices, diagnose the disease with ankle-brachial index measurement, and appropriately treat patients who have the disease.

The new lower-extremity peripheral artery disease (PAD) guidelines “give us a platform to get something done,” said Heather L. Gornik, MD, vice chair of the guidelines panel and medical director of the noninvasive vascular lab at the Cleveland Clinic. Improved PAD identification and care “starts with the fundamentals of recognizing who is at risk for PAD and then doing some clinical investigation to find it, because it’s there. You just need to ask patients if they have leg symptoms, have them take off their socks and examine their feet,” Dr. Gornik said in an interview following a program devoted to the revised guidelines at the American Heart Association scientific sessions.

The new guidelines are “a clarion call to action,” commented Alan T. Hirsch, MD, professor of medicine, epidemiology, and community health and director of the vascular medicine program at the University of Minnesota in Minneapolis. PAD “is the single most morbid and fatal of all cardiovascular diseases, so why in 2016 are we challenged to have every cardiologist trained in basic PAD competency?” asked Dr. Hirsch, who chaired the 2005 guidelines panel.

Mitchel L. Zoler/Frontline Medical News

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

A newly devised risk score may help identify which patients with acute venous thromboembolism (VTE) are most likely to have occult cancer and where they are likely to have it, according to a report published online in CHEST.

Although VTE is known to occur before an occult cancer becomes symptomatic in a minority of patients, clinicians don’t agree on which patients with VTE should be screened for occult cancer or on how extensive that screening should be. Some favor a basic screening with only a clinical history, physical exam, simple lab tests, and a chest X-ray, while others advocate a more thorough work-up to improve the patient’s chance for a cure. “The potential benefits and harms of such screening are controversial, partly because there is little evidence” concerning which patients are at highest risk and which cancer types/sites should be assessed, said Luis Jara-Palomares, MD, PhD, of the medical surgical unit of respiratory diseases, Virgen del Rocio Hospital, Seville, Spain, and his associates.

Dr. Jara-Palomares and his associates devised a prognostic score by assigning points to the variables they found to be most significantly associated with occult cancer. For example, male sex was accorded 1 point, chronic lung disease or a high platelet count was accorded 1 point, age over 70 years or anemia was accorded 2 points, and postoperative or prior VTE was accorded negative 2 points. The incidence of occult cancer was significantly lower among patients whose total score was 2 points or less (5.8%) than among those whose total score was 3 points or higher (12%).

The mean age of these study participants was 63 years, and approximately half were women. A total of 444 (7.6%) were diagnosed as having cancer at 1-24 months after presenting with VTE. Most of these cancers were discovered within 6 months of the VTE.

Patients who had occult cancer were significantly more likely than those who did not to be male and older than 70 years of age; to have chronic lung disease, an elevated platelet count, and/or anemia; and to have a history of recent surgery and/or prior VTE.

The percentage of VTE patients who had occult cancer increased with advancing age, from 2%-3% in the youngest age group (younger than 50 years) to 8%-12% in the oldest age group (older than 70 years). Among men with occult cancer, the most frequently affected sites were the lung (26%), prostate (17%), and colon/rectum (10%). Among women, the most frequent types of cancer were colorectal (19%), breast (12%), uterine (9.1%), hematologic (8.6%), pancreatic (7.6%), and stomach (6.6%).

Overall, more than half of the men who had occult cancer had cancer affecting the lung, prostate, or colon/rectum, while two-thirds of the women who had occult cancer had cancer affecting the colon/rectum, breast, or abdomen. “This is important because [cancer] screening is not necessary in all VTE patients, but any information suggesting [which] patients are at increased risk and [which] sites are more common may be of help to decide the most appropriate work-up for each patient,” the investigators noted.

To determine which patients are most likely to have occult cancer and which cancer types are most likely to develop, the investigators analyzed data from RIETE (the Computerized Registry of Patients With Venous Thromboembolism), an international registry of more than 50,000 consecutive patients with confirmed acute VTE. They focused on 5,863 patients who presented with pulmonary embolism (34%), deep vein thrombosis (48%), or both disorders (18%) and were followed for at least 2 years for the development of cancer.

The accuracy of this risk scoring system must be tested further in a large validation cohort before it can be widely adopted. If it proves to be accurate, then patients with low total risk scores could forgo the expense, discomfort, and psychological stress of extensive cancer screening, Dr. Jara-Palomares and his associates said.

Men whose total score is 3 points or more could benefit from a rectal exam and fecal occult blood test to rule out colorectal cancer, a rectal exam and prostate-specific antigen test to rule out prostate cancer, and a chest CT to rule out lung cancer. Women whose total score is 3 points or higher could benefit from a fecal occult blood test to rule out colorectal cancer, a mammogram to rule out breast cancer, and abdominopelvic CT to rule out uterine, pancreatic, and stomach cancer, they noted.

The RIETE Registry is supported by an unrestricted educational grant from Sanofi Spain and by Bayer Pharma AG. Dr. Jara-Palomares reported having no relevant financial disclosures; his associates reported ties to Sanofi, Bayer, and LEO Pharma.

A newly devised risk score may help identify which patients with acute venous thromboembolism (VTE) are most likely to have occult cancer and where they are likely to have it, according to a report published online in CHEST.

Although VTE is known to occur before an occult cancer becomes symptomatic in a minority of patients, clinicians don’t agree on which patients with VTE should be screened for occult cancer or on how extensive that screening should be. Some favor a basic screening with only a clinical history, physical exam, simple lab tests, and a chest X-ray, while others advocate a more thorough work-up to improve the patient’s chance for a cure. “The potential benefits and harms of such screening are controversial, partly because there is little evidence” concerning which patients are at highest risk and which cancer types/sites should be assessed, said Luis Jara-Palomares, MD, PhD, of the medical surgical unit of respiratory diseases, Virgen del Rocio Hospital, Seville, Spain, and his associates.

Dr. Jara-Palomares and his associates devised a prognostic score by assigning points to the variables they found to be most significantly associated with occult cancer. For example, male sex was accorded 1 point, chronic lung disease or a high platelet count was accorded 1 point, age over 70 years or anemia was accorded 2 points, and postoperative or prior VTE was accorded negative 2 points. The incidence of occult cancer was significantly lower among patients whose total score was 2 points or less (5.8%) than among those whose total score was 3 points or higher (12%).

The mean age of these study participants was 63 years, and approximately half were women. A total of 444 (7.6%) were diagnosed as having cancer at 1-24 months after presenting with VTE. Most of these cancers were discovered within 6 months of the VTE.

Patients who had occult cancer were significantly more likely than those who did not to be male and older than 70 years of age; to have chronic lung disease, an elevated platelet count, and/or anemia; and to have a history of recent surgery and/or prior VTE.

The percentage of VTE patients who had occult cancer increased with advancing age, from 2%-3% in the youngest age group (younger than 50 years) to 8%-12% in the oldest age group (older than 70 years). Among men with occult cancer, the most frequently affected sites were the lung (26%), prostate (17%), and colon/rectum (10%). Among women, the most frequent types of cancer were colorectal (19%), breast (12%), uterine (9.1%), hematologic (8.6%), pancreatic (7.6%), and stomach (6.6%).

Overall, more than half of the men who had occult cancer had cancer affecting the lung, prostate, or colon/rectum, while two-thirds of the women who had occult cancer had cancer affecting the colon/rectum, breast, or abdomen. “This is important because [cancer] screening is not necessary in all VTE patients, but any information suggesting [which] patients are at increased risk and [which] sites are more common may be of help to decide the most appropriate work-up for each patient,” the investigators noted.

To determine which patients are most likely to have occult cancer and which cancer types are most likely to develop, the investigators analyzed data from RIETE (the Computerized Registry of Patients With Venous Thromboembolism), an international registry of more than 50,000 consecutive patients with confirmed acute VTE. They focused on 5,863 patients who presented with pulmonary embolism (34%), deep vein thrombosis (48%), or both disorders (18%) and were followed for at least 2 years for the development of cancer.

The accuracy of this risk scoring system must be tested further in a large validation cohort before it can be widely adopted. If it proves to be accurate, then patients with low total risk scores could forgo the expense, discomfort, and psychological stress of extensive cancer screening, Dr. Jara-Palomares and his associates said.

Men whose total score is 3 points or more could benefit from a rectal exam and fecal occult blood test to rule out colorectal cancer, a rectal exam and prostate-specific antigen test to rule out prostate cancer, and a chest CT to rule out lung cancer. Women whose total score is 3 points or higher could benefit from a fecal occult blood test to rule out colorectal cancer, a mammogram to rule out breast cancer, and abdominopelvic CT to rule out uterine, pancreatic, and stomach cancer, they noted.

The RIETE Registry is supported by an unrestricted educational grant from Sanofi Spain and by Bayer Pharma AG. Dr. Jara-Palomares reported having no relevant financial disclosures; his associates reported ties to Sanofi, Bayer, and LEO Pharma.

A newly devised risk score may help identify which patients with acute venous thromboembolism (VTE) are most likely to have occult cancer and where they are likely to have it, according to a report published online in CHEST.

Although VTE is known to occur before an occult cancer becomes symptomatic in a minority of patients, clinicians don’t agree on which patients with VTE should be screened for occult cancer or on how extensive that screening should be. Some favor a basic screening with only a clinical history, physical exam, simple lab tests, and a chest X-ray, while others advocate a more thorough work-up to improve the patient’s chance for a cure. “The potential benefits and harms of such screening are controversial, partly because there is little evidence” concerning which patients are at highest risk and which cancer types/sites should be assessed, said Luis Jara-Palomares, MD, PhD, of the medical surgical unit of respiratory diseases, Virgen del Rocio Hospital, Seville, Spain, and his associates.

Dr. Jara-Palomares and his associates devised a prognostic score by assigning points to the variables they found to be most significantly associated with occult cancer. For example, male sex was accorded 1 point, chronic lung disease or a high platelet count was accorded 1 point, age over 70 years or anemia was accorded 2 points, and postoperative or prior VTE was accorded negative 2 points. The incidence of occult cancer was significantly lower among patients whose total score was 2 points or less (5.8%) than among those whose total score was 3 points or higher (12%).

The mean age of these study participants was 63 years, and approximately half were women. A total of 444 (7.6%) were diagnosed as having cancer at 1-24 months after presenting with VTE. Most of these cancers were discovered within 6 months of the VTE.

Patients who had occult cancer were significantly more likely than those who did not to be male and older than 70 years of age; to have chronic lung disease, an elevated platelet count, and/or anemia; and to have a history of recent surgery and/or prior VTE.

The percentage of VTE patients who had occult cancer increased with advancing age, from 2%-3% in the youngest age group (younger than 50 years) to 8%-12% in the oldest age group (older than 70 years). Among men with occult cancer, the most frequently affected sites were the lung (26%), prostate (17%), and colon/rectum (10%). Among women, the most frequent types of cancer were colorectal (19%), breast (12%), uterine (9.1%), hematologic (8.6%), pancreatic (7.6%), and stomach (6.6%).

Overall, more than half of the men who had occult cancer had cancer affecting the lung, prostate, or colon/rectum, while two-thirds of the women who had occult cancer had cancer affecting the colon/rectum, breast, or abdomen. “This is important because [cancer] screening is not necessary in all VTE patients, but any information suggesting [which] patients are at increased risk and [which] sites are more common may be of help to decide the most appropriate work-up for each patient,” the investigators noted.

To determine which patients are most likely to have occult cancer and which cancer types are most likely to develop, the investigators analyzed data from RIETE (the Computerized Registry of Patients With Venous Thromboembolism), an international registry of more than 50,000 consecutive patients with confirmed acute VTE. They focused on 5,863 patients who presented with pulmonary embolism (34%), deep vein thrombosis (48%), or both disorders (18%) and were followed for at least 2 years for the development of cancer.

The accuracy of this risk scoring system must be tested further in a large validation cohort before it can be widely adopted. If it proves to be accurate, then patients with low total risk scores could forgo the expense, discomfort, and psychological stress of extensive cancer screening, Dr. Jara-Palomares and his associates said.

Men whose total score is 3 points or more could benefit from a rectal exam and fecal occult blood test to rule out colorectal cancer, a rectal exam and prostate-specific antigen test to rule out prostate cancer, and a chest CT to rule out lung cancer. Women whose total score is 3 points or higher could benefit from a fecal occult blood test to rule out colorectal cancer, a mammogram to rule out breast cancer, and abdominopelvic CT to rule out uterine, pancreatic, and stomach cancer, they noted.

The RIETE Registry is supported by an unrestricted educational grant from Sanofi Spain and by Bayer Pharma AG. Dr. Jara-Palomares reported having no relevant financial disclosures; his associates reported ties to Sanofi, Bayer, and LEO Pharma.

A trastuzumab biosimilar drug has shown an equivalent response, compared with trastuzumab, in the treatment of ERBB2 (HER2)-positive metastatic breast cancer, according to the results of a randomized double-blind controlled trial.

The anti-ERBB2 humanized monoclonal antibody trastuzumab in combination with chemotherapy has been found in numerous trials to significantly improve progression-free survival and overall survival in women with ERBB2-positive metastatic breast, compared with chemotherapy alone.

A trastuzumab biosimilar drug has shown an equivalent response, compared with trastuzumab, in the treatment of ERBB2 (HER2)-positive metastatic breast cancer, according to the results of a randomized double-blind controlled trial.

The anti-ERBB2 humanized monoclonal antibody trastuzumab in combination with chemotherapy has been found in numerous trials to significantly improve progression-free survival and overall survival in women with ERBB2-positive metastatic breast, compared with chemotherapy alone.

A trastuzumab biosimilar drug has shown an equivalent response, compared with trastuzumab, in the treatment of ERBB2 (HER2)-positive metastatic breast cancer, according to the results of a randomized double-blind controlled trial.

The anti-ERBB2 humanized monoclonal antibody trastuzumab in combination with chemotherapy has been found in numerous trials to significantly improve progression-free survival and overall survival in women with ERBB2-positive metastatic breast, compared with chemotherapy alone.

CHICAGO – Ferric citrate was safe and effective for treatment of iron-deficiency anemia in patients who had non–dialysis-dependent chronic kidney disease (NDD-CKD), based on data from a phase III, randomized, double-blind study.

The responses were durable, and none of the patients received erythropoiesis-stimulating agents (ESAs), presenter Pablo Pergola, MD, PhD, of Renal Associates, San Antonio, said in an interview at a meeting sponsored by the American Society of Nephrology.

Brian Hoyle/Frontline Medical News

CHICAGO – Ferric citrate was safe and effective for treatment of iron-deficiency anemia in patients who had non–dialysis-dependent chronic kidney disease (NDD-CKD), based on data from a phase III, randomized, double-blind study.

The responses were durable, and none of the patients received erythropoiesis-stimulating agents (ESAs), presenter Pablo Pergola, MD, PhD, of Renal Associates, San Antonio, said in an interview at a meeting sponsored by the American Society of Nephrology.

Brian Hoyle/Frontline Medical News

CHICAGO – Ferric citrate was safe and effective for treatment of iron-deficiency anemia in patients who had non–dialysis-dependent chronic kidney disease (NDD-CKD), based on data from a phase III, randomized, double-blind study.

The responses were durable, and none of the patients received erythropoiesis-stimulating agents (ESAs), presenter Pablo Pergola, MD, PhD, of Renal Associates, San Antonio, said in an interview at a meeting sponsored by the American Society of Nephrology.

Brian Hoyle/Frontline Medical News

Papular Mucinosis/Scleromyxedema

Papular mucinosis/scleromyxedema, also known as generalized lichen myxedematosus, is a rare dermal mucinosis characterized by a papular eruption that can have an associated IgG λ paraproteinemia. The clinical presentation is gradual with the development of firm, flesh-colored, 2- to 3-mm papules often involving the hands, face, and neck that can progress to plaques that cover the entire body. Skin stiffening also can be seen.¹ Extracutaneous symptoms are common and include dysphagia, arthralgia, myopathy, and cardiac dysfunction.² Occasionally, central nervous system involvement can lead to the often fatal dermato-neuro syndrome.^3,4

Histologically, papular mucinosis/scleromyxedema demonstrates increased, irregularly arranged fibroblasts in the reticular dermis with increased dermal mucin deposition (quiz image and Figure 1). The epidermis is normal or slightly thinned due to pressure from dermal changes. There may be a mild superficial perivascular lymphocytic infiltrate and atrophy of hair follicles.5 In this case, the clinical and histologic findings best supported a diagnosis of papular mucinosis/scleromyxedema.

Infundibulofolliculitis is a pruritic follicular papular eruption typically involving the neck, trunk, and proximal upper arms and shoulders. It is most common in black men who reside in hot and humid climates. Although infundibulofolliculitis would be included in the clinical differential diagnosis for the current patient, the histopathologic findings were quite distinct for the correct diagnosis of papular mucinosis/scleromyxedema. Infundibulofolliculitis shows widening of the upper part of the hair follicle (infundibulum) and infundibular inflammatory infiltrate with follicular spongiosis (Figure 2). Neither mucin deposition nor fibroblast proliferation is appreciated in infundibulofolliculitis.^6,7 

Granuloma annulare (GA) often can be distinguished clinically from papular mucinosis/scleromyxedema due to the annular appearance of papules and plaques in GA and the lack of stiffness of underlying skin. Interstitial granuloma annulare is a histologic variant of GA that can be included in the histologic differential diagnosis of papular mucinosis/scleromyxedema. Histologically, there is an interstitial infiltrate of cytologically bland histiocytes dissecting between collagen bundles in interstitial GA (Figure 3). Necrobiosis and collections of mucin often are inconspicuous. Occasionally, the presence of eosinophils can be a helpful clue.⁸ A fibroblast proliferation is not a feature of GA.

Reticular erythematous mucinosis also is a type of cutaneous mucinosis but with a classic clinical appearance of a reticulated erythematous plaque on the chest or back, making it clinically distinct from papular mucinosis/scleromyxedema and the presentation described in the current patient. Reticular erythematous mucinosis can be histologically distinguished from papular mucinosis/scleromyxedema by the presence of a superficial and deep perivascular lymphocytic infiltrate with increased dermal mucin deposition (Figure 4). It often shows a positive IgM deposition on the basement membrane on direct immunofluorescence.⁹

Similar to papular mucinosis/scleromyxedema, scleredema shows thickening of the skin with decreased movement of involved areas. Scleredema often involves the upper back, shoulders, and neck where affected areas often have a peau d'orange appearance. Scleredema is classified into 3 clinical forms based on clinical associations. Type 1 often is preceded by an infection, classically Streptococcus pyogenes. Type 2 is associated with a hematologic dyscrasia such as multiple myeloma, or it can have an associated paraproteinemia that is typically of the IgA κ type, which is distinct from papular mucinosis/scleromyxedema where IgG λ paraproteinemia typically is seen. Type 3 is associated with diabetes mellitus. Histologically, scleredema also is distinct from papular mucinosis/scleromyxedema. Although increased mucin is seen in the dermis, the mucin is classically more prominent in the deep reticular dermis as compared with papular mucinosis/scleromyxedema (Figure 5). Additionally, collagen bundles are thickened with clear separation between them. Hyperplasia of fibroblasts in the dermis that is a characteristic feature of papular mucinosis/scleromyxedema is not observed in scleredema.¹⁰

Papular Mucinosis/Scleromyxedema

Papular mucinosis/scleromyxedema, also known as generalized lichen myxedematosus, is a rare dermal mucinosis characterized by a papular eruption that can have an associated IgG λ paraproteinemia. The clinical presentation is gradual with the development of firm, flesh-colored, 2- to 3-mm papules often involving the hands, face, and neck that can progress to plaques that cover the entire body. Skin stiffening also can be seen.¹ Extracutaneous symptoms are common and include dysphagia, arthralgia, myopathy, and cardiac dysfunction.² Occasionally, central nervous system involvement can lead to the often fatal dermato-neuro syndrome.^3,4

Histologically, papular mucinosis/scleromyxedema demonstrates increased, irregularly arranged fibroblasts in the reticular dermis with increased dermal mucin deposition (quiz image and Figure 1). The epidermis is normal or slightly thinned due to pressure from dermal changes. There may be a mild superficial perivascular lymphocytic infiltrate and atrophy of hair follicles.5 In this case, the clinical and histologic findings best supported a diagnosis of papular mucinosis/scleromyxedema.

Infundibulofolliculitis is a pruritic follicular papular eruption typically involving the neck, trunk, and proximal upper arms and shoulders. It is most common in black men who reside in hot and humid climates. Although infundibulofolliculitis would be included in the clinical differential diagnosis for the current patient, the histopathologic findings were quite distinct for the correct diagnosis of papular mucinosis/scleromyxedema. Infundibulofolliculitis shows widening of the upper part of the hair follicle (infundibulum) and infundibular inflammatory infiltrate with follicular spongiosis (Figure 2). Neither mucin deposition nor fibroblast proliferation is appreciated in infundibulofolliculitis.^6,7 

Granuloma annulare (GA) often can be distinguished clinically from papular mucinosis/scleromyxedema due to the annular appearance of papules and plaques in GA and the lack of stiffness of underlying skin. Interstitial granuloma annulare is a histologic variant of GA that can be included in the histologic differential diagnosis of papular mucinosis/scleromyxedema. Histologically, there is an interstitial infiltrate of cytologically bland histiocytes dissecting between collagen bundles in interstitial GA (Figure 3). Necrobiosis and collections of mucin often are inconspicuous. Occasionally, the presence of eosinophils can be a helpful clue.⁸ A fibroblast proliferation is not a feature of GA.

Reticular erythematous mucinosis also is a type of cutaneous mucinosis but with a classic clinical appearance of a reticulated erythematous plaque on the chest or back, making it clinically distinct from papular mucinosis/scleromyxedema and the presentation described in the current patient. Reticular erythematous mucinosis can be histologically distinguished from papular mucinosis/scleromyxedema by the presence of a superficial and deep perivascular lymphocytic infiltrate with increased dermal mucin deposition (Figure 4). It often shows a positive IgM deposition on the basement membrane on direct immunofluorescence.⁹

Similar to papular mucinosis/scleromyxedema, scleredema shows thickening of the skin with decreased movement of involved areas. Scleredema often involves the upper back, shoulders, and neck where affected areas often have a peau d'orange appearance. Scleredema is classified into 3 clinical forms based on clinical associations. Type 1 often is preceded by an infection, classically Streptococcus pyogenes. Type 2 is associated with a hematologic dyscrasia such as multiple myeloma, or it can have an associated paraproteinemia that is typically of the IgA κ type, which is distinct from papular mucinosis/scleromyxedema where IgG λ paraproteinemia typically is seen. Type 3 is associated with diabetes mellitus. Histologically, scleredema also is distinct from papular mucinosis/scleromyxedema. Although increased mucin is seen in the dermis, the mucin is classically more prominent in the deep reticular dermis as compared with papular mucinosis/scleromyxedema (Figure 5). Additionally, collagen bundles are thickened with clear separation between them. Hyperplasia of fibroblasts in the dermis that is a characteristic feature of papular mucinosis/scleromyxedema is not observed in scleredema.¹⁰

Papular Mucinosis/Scleromyxedema

Papular mucinosis/scleromyxedema, also known as generalized lichen myxedematosus, is a rare dermal mucinosis characterized by a papular eruption that can have an associated IgG λ paraproteinemia. The clinical presentation is gradual with the development of firm, flesh-colored, 2- to 3-mm papules often involving the hands, face, and neck that can progress to plaques that cover the entire body. Skin stiffening also can be seen.¹ Extracutaneous symptoms are common and include dysphagia, arthralgia, myopathy, and cardiac dysfunction.² Occasionally, central nervous system involvement can lead to the often fatal dermato-neuro syndrome.^3,4

Histologically, papular mucinosis/scleromyxedema demonstrates increased, irregularly arranged fibroblasts in the reticular dermis with increased dermal mucin deposition (quiz image and Figure 1). The epidermis is normal or slightly thinned due to pressure from dermal changes. There may be a mild superficial perivascular lymphocytic infiltrate and atrophy of hair follicles.5 In this case, the clinical and histologic findings best supported a diagnosis of papular mucinosis/scleromyxedema.

Infundibulofolliculitis is a pruritic follicular papular eruption typically involving the neck, trunk, and proximal upper arms and shoulders. It is most common in black men who reside in hot and humid climates. Although infundibulofolliculitis would be included in the clinical differential diagnosis for the current patient, the histopathologic findings were quite distinct for the correct diagnosis of papular mucinosis/scleromyxedema. Infundibulofolliculitis shows widening of the upper part of the hair follicle (infundibulum) and infundibular inflammatory infiltrate with follicular spongiosis (Figure 2). Neither mucin deposition nor fibroblast proliferation is appreciated in infundibulofolliculitis.^6,7 

Granuloma annulare (GA) often can be distinguished clinically from papular mucinosis/scleromyxedema due to the annular appearance of papules and plaques in GA and the lack of stiffness of underlying skin. Interstitial granuloma annulare is a histologic variant of GA that can be included in the histologic differential diagnosis of papular mucinosis/scleromyxedema. Histologically, there is an interstitial infiltrate of cytologically bland histiocytes dissecting between collagen bundles in interstitial GA (Figure 3). Necrobiosis and collections of mucin often are inconspicuous. Occasionally, the presence of eosinophils can be a helpful clue.⁸ A fibroblast proliferation is not a feature of GA.

Reticular erythematous mucinosis also is a type of cutaneous mucinosis but with a classic clinical appearance of a reticulated erythematous plaque on the chest or back, making it clinically distinct from papular mucinosis/scleromyxedema and the presentation described in the current patient. Reticular erythematous mucinosis can be histologically distinguished from papular mucinosis/scleromyxedema by the presence of a superficial and deep perivascular lymphocytic infiltrate with increased dermal mucin deposition (Figure 4). It often shows a positive IgM deposition on the basement membrane on direct immunofluorescence.⁹

Similar to papular mucinosis/scleromyxedema, scleredema shows thickening of the skin with decreased movement of involved areas. Scleredema often involves the upper back, shoulders, and neck where affected areas often have a peau d'orange appearance. Scleredema is classified into 3 clinical forms based on clinical associations. Type 1 often is preceded by an infection, classically Streptococcus pyogenes. Type 2 is associated with a hematologic dyscrasia such as multiple myeloma, or it can have an associated paraproteinemia that is typically of the IgA κ type, which is distinct from papular mucinosis/scleromyxedema where IgG λ paraproteinemia typically is seen. Type 3 is associated with diabetes mellitus. Histologically, scleredema also is distinct from papular mucinosis/scleromyxedema. Although increased mucin is seen in the dermis, the mucin is classically more prominent in the deep reticular dermis as compared with papular mucinosis/scleromyxedema (Figure 5). Additionally, collagen bundles are thickened with clear separation between them. Hyperplasia of fibroblasts in the dermis that is a characteristic feature of papular mucinosis/scleromyxedema is not observed in scleredema.¹⁰

SAN FRANCISCO – More than two-thirds of parents worry about their children’s privacy online and/or that photos of their children might be reshared on the wider Web, according to a survey conducted by C.S. Mott Children’s Hospital.

Those fears are not baseless, and they need to be considered more often by parents themselves in posting about their children online, presenters agreed at a symposium on the media at the annual meeting of the American Academy of Pediatrics.

“The first children of social media are just now entering adulthood, entering the job market,” said Stacey Steinberg, JD, a legal skills professor at the University of Florida Levin College of Law, Gainesville. She is also with the law school’s center on children and families.

She and Bahareh Keith, DO, a pediatrician at the University of Florida, discussed the challenges and risks of “sharenting” – parents’ sharing information and photos of their children online – and pediatricians’ role in advising parents and looking out for children’s best interests.

“The dearth of discussion on this topic leaves even the most well-intentioned parents without enough information to thoroughly analyze this,” Ms. Steinberg said. “We’re not sitting here saying we know what the answers are. But we’re saying this is an important issue that affects families, and these children require a voice in this discussion.”

The way social media and blogging have changed the landscape for children coming of age today means that they often have a digital footprint shaped by their parents long before they create their own first account. This reality means it’s necessary to consider how to balance children’s right to privacy with parents’ right to free speech and expression.

The 2015 C.S. Mott survey asked 569 parents of children aged 4 years and younger about how they use social media as parents, and reported that more than half of mothers (56%) and a third of fathers (34%) discuss parenting and child health topics on Facebook, Twitter, blogs, online forums, and other online platforms.

The risks of this sharenting can range from embarrassment of the child to significantly more sinister repercussions. Just over half of the parents (52%) in the Mott survey reported that they are concerned their child might feel embarrassed when they grow older and discover what their parents shared online. But that embarrassment also can lead to bullying or determent of psychosocial development, Ms. Steinberg and Dr. Keith explained.

More serious, if less common, risks include the possibility that data brokers could access and use information about the children or that online child pornographers could repurpose the photos inappropriately. One worst case scenario of the former is digital kidnapping, a disturbing practice in which a stranger uses baby photos and information that is not their own to pass off the child as their own or to invite others to “invent” identities for the child. The Children’s Online Privacy Protection Rule of the Federal Trade Commission addresses only online use by those under age 13 years, not others’ use of those images.

Regarding the latter, Ms. Steinberg and Dr. Keith showed an example of a bare-bottomed baby standing in front of a bathtub that had been reshared hundreds of times, but other images that have been shared on child pornography sites depict children in everyday situations such as playing on a playground, running at the beach, or doing gymnastics.

“These are images that many of us would think are innocent, but pornographers would categorize these into folders,” Dr. Keith said. “It’s not even naked or half-naked pictures.”

A study conducted by an e-safety commission in Australia, for example, found that half of the thousands of photos shared on a sample of child pornography sites had originated from parental sharing.

But Ms. Steinberg and Dr. Keith pointed out that benefits of parents’ online sharing exist as well, as the Mott survey found. In that survey, 72% of parents who discuss parenting and/or their children on social media reported that doing so helps them feel less alone. Similarly, 70% said they learn what not to do through those experiences, 67% said they receive advice from more experienced parents, and 62% said they consequently worry less. Common topics they discussed included sleep, nutrition, discipline, day care, and behavior management.

Other benefits, Ms. Steinberg pointed out, are that families geographically spread apart can stay connected, and communities can grow stronger with shared communal experiences of parents meeting others online.

“For some parents, it gives them an opportunity for advocacy work and raises awareness for important social issues,” Ms. Steinberg said, although she added, “If you’re going to share your children’s behavioral problems, consider sharing anonymously.”

Neither Ms. Steinberg and Dr. Keith said they had simple solutions to these challenges. Rather, they recommended using the public health model of raising awareness and encouraging open dialogue among pediatricians, parents, and their children to look for ways to balance competing interests.

“Social media offers many positive benefits, and we don’t want to silence the many voices of parents who take part in online sharing,” Ms. Steinberg explained. But she and Ms. Keith said it’s also worth considering children’s potential interest in controlling what their digital footprint is as they become adults.

For example, one study they cited found that, among 249 pairs of parents and their children, three times more children than parents wanted the parents to have and follow rules regarding what they could share on social media about their children.

Although guidance for parents on monitoring children’s social media use is a part of the AAP policy statement on media, only one recommendation obliquely addresses how parents should or shouldn’t use social media by advising them to model appropriate use for their children.

“It’s just like any medical decision: What is the benefit, and what is the risk, and does the benefit outweigh the risk?” said Wendy Sue Swanson, MD, executive director of digital health at Seattle Children’s Hospital. She recommended that parents ask their child for permission before posting a story or photo if their kids are aged 6 or older.

Ms. Steinberg and Dr. Keith recommended that pediatricians broach this subject with parents to help them think about risks they simply might not have considered before.

“When we looked at what sorts of best practices could be encouraged or doctors could talk to parents about – the tangible harms, such as whether data brokers or people interested in child pornography could access the information – we didn’t want to create any unnecessary panic,” Ms. Steinberg said. “But we did find some concerns that were troublesome, and we thought that parents or at least physicians [should] be aware of those potential risks.”

Ms. Steinberg and Dr. Keith reported that they had no relevant financial disclosures.

SAN FRANCISCO – More than two-thirds of parents worry about their children’s privacy online and/or that photos of their children might be reshared on the wider Web, according to a survey conducted by C.S. Mott Children’s Hospital.

Those fears are not baseless, and they need to be considered more often by parents themselves in posting about their children online, presenters agreed at a symposium on the media at the annual meeting of the American Academy of Pediatrics.

“The first children of social media are just now entering adulthood, entering the job market,” said Stacey Steinberg, JD, a legal skills professor at the University of Florida Levin College of Law, Gainesville. She is also with the law school’s center on children and families.

She and Bahareh Keith, DO, a pediatrician at the University of Florida, discussed the challenges and risks of “sharenting” – parents’ sharing information and photos of their children online – and pediatricians’ role in advising parents and looking out for children’s best interests.

“The dearth of discussion on this topic leaves even the most well-intentioned parents without enough information to thoroughly analyze this,” Ms. Steinberg said. “We’re not sitting here saying we know what the answers are. But we’re saying this is an important issue that affects families, and these children require a voice in this discussion.”

The way social media and blogging have changed the landscape for children coming of age today means that they often have a digital footprint shaped by their parents long before they create their own first account. This reality means it’s necessary to consider how to balance children’s right to privacy with parents’ right to free speech and expression.

The 2015 C.S. Mott survey asked 569 parents of children aged 4 years and younger about how they use social media as parents, and reported that more than half of mothers (56%) and a third of fathers (34%) discuss parenting and child health topics on Facebook, Twitter, blogs, online forums, and other online platforms.

The risks of this sharenting can range from embarrassment of the child to significantly more sinister repercussions. Just over half of the parents (52%) in the Mott survey reported that they are concerned their child might feel embarrassed when they grow older and discover what their parents shared online. But that embarrassment also can lead to bullying or determent of psychosocial development, Ms. Steinberg and Dr. Keith explained.

More serious, if less common, risks include the possibility that data brokers could access and use information about the children or that online child pornographers could repurpose the photos inappropriately. One worst case scenario of the former is digital kidnapping, a disturbing practice in which a stranger uses baby photos and information that is not their own to pass off the child as their own or to invite others to “invent” identities for the child. The Children’s Online Privacy Protection Rule of the Federal Trade Commission addresses only online use by those under age 13 years, not others’ use of those images.

Regarding the latter, Ms. Steinberg and Dr. Keith showed an example of a bare-bottomed baby standing in front of a bathtub that had been reshared hundreds of times, but other images that have been shared on child pornography sites depict children in everyday situations such as playing on a playground, running at the beach, or doing gymnastics.

“These are images that many of us would think are innocent, but pornographers would categorize these into folders,” Dr. Keith said. “It’s not even naked or half-naked pictures.”

A study conducted by an e-safety commission in Australia, for example, found that half of the thousands of photos shared on a sample of child pornography sites had originated from parental sharing.

But Ms. Steinberg and Dr. Keith pointed out that benefits of parents’ online sharing exist as well, as the Mott survey found. In that survey, 72% of parents who discuss parenting and/or their children on social media reported that doing so helps them feel less alone. Similarly, 70% said they learn what not to do through those experiences, 67% said they receive advice from more experienced parents, and 62% said they consequently worry less. Common topics they discussed included sleep, nutrition, discipline, day care, and behavior management.

Other benefits, Ms. Steinberg pointed out, are that families geographically spread apart can stay connected, and communities can grow stronger with shared communal experiences of parents meeting others online.

“For some parents, it gives them an opportunity for advocacy work and raises awareness for important social issues,” Ms. Steinberg said, although she added, “If you’re going to share your children’s behavioral problems, consider sharing anonymously.”

Neither Ms. Steinberg and Dr. Keith said they had simple solutions to these challenges. Rather, they recommended using the public health model of raising awareness and encouraging open dialogue among pediatricians, parents, and their children to look for ways to balance competing interests.

“Social media offers many positive benefits, and we don’t want to silence the many voices of parents who take part in online sharing,” Ms. Steinberg explained. But she and Ms. Keith said it’s also worth considering children’s potential interest in controlling what their digital footprint is as they become adults.

For example, one study they cited found that, among 249 pairs of parents and their children, three times more children than parents wanted the parents to have and follow rules regarding what they could share on social media about their children.

Although guidance for parents on monitoring children’s social media use is a part of the AAP policy statement on media, only one recommendation obliquely addresses how parents should or shouldn’t use social media by advising them to model appropriate use for their children.

“It’s just like any medical decision: What is the benefit, and what is the risk, and does the benefit outweigh the risk?” said Wendy Sue Swanson, MD, executive director of digital health at Seattle Children’s Hospital. She recommended that parents ask their child for permission before posting a story or photo if their kids are aged 6 or older.

Ms. Steinberg and Dr. Keith recommended that pediatricians broach this subject with parents to help them think about risks they simply might not have considered before.

“When we looked at what sorts of best practices could be encouraged or doctors could talk to parents about – the tangible harms, such as whether data brokers or people interested in child pornography could access the information – we didn’t want to create any unnecessary panic,” Ms. Steinberg said. “But we did find some concerns that were troublesome, and we thought that parents or at least physicians [should] be aware of those potential risks.”

Ms. Steinberg and Dr. Keith reported that they had no relevant financial disclosures.

SAN FRANCISCO – More than two-thirds of parents worry about their children’s privacy online and/or that photos of their children might be reshared on the wider Web, according to a survey conducted by C.S. Mott Children’s Hospital.

Those fears are not baseless, and they need to be considered more often by parents themselves in posting about their children online, presenters agreed at a symposium on the media at the annual meeting of the American Academy of Pediatrics.

“The first children of social media are just now entering adulthood, entering the job market,” said Stacey Steinberg, JD, a legal skills professor at the University of Florida Levin College of Law, Gainesville. She is also with the law school’s center on children and families.

She and Bahareh Keith, DO, a pediatrician at the University of Florida, discussed the challenges and risks of “sharenting” – parents’ sharing information and photos of their children online – and pediatricians’ role in advising parents and looking out for children’s best interests.

“The dearth of discussion on this topic leaves even the most well-intentioned parents without enough information to thoroughly analyze this,” Ms. Steinberg said. “We’re not sitting here saying we know what the answers are. But we’re saying this is an important issue that affects families, and these children require a voice in this discussion.”

The way social media and blogging have changed the landscape for children coming of age today means that they often have a digital footprint shaped by their parents long before they create their own first account. This reality means it’s necessary to consider how to balance children’s right to privacy with parents’ right to free speech and expression.

The 2015 C.S. Mott survey asked 569 parents of children aged 4 years and younger about how they use social media as parents, and reported that more than half of mothers (56%) and a third of fathers (34%) discuss parenting and child health topics on Facebook, Twitter, blogs, online forums, and other online platforms.

The risks of this sharenting can range from embarrassment of the child to significantly more sinister repercussions. Just over half of the parents (52%) in the Mott survey reported that they are concerned their child might feel embarrassed when they grow older and discover what their parents shared online. But that embarrassment also can lead to bullying or determent of psychosocial development, Ms. Steinberg and Dr. Keith explained.

More serious, if less common, risks include the possibility that data brokers could access and use information about the children or that online child pornographers could repurpose the photos inappropriately. One worst case scenario of the former is digital kidnapping, a disturbing practice in which a stranger uses baby photos and information that is not their own to pass off the child as their own or to invite others to “invent” identities for the child. The Children’s Online Privacy Protection Rule of the Federal Trade Commission addresses only online use by those under age 13 years, not others’ use of those images.

Regarding the latter, Ms. Steinberg and Dr. Keith showed an example of a bare-bottomed baby standing in front of a bathtub that had been reshared hundreds of times, but other images that have been shared on child pornography sites depict children in everyday situations such as playing on a playground, running at the beach, or doing gymnastics.

“These are images that many of us would think are innocent, but pornographers would categorize these into folders,” Dr. Keith said. “It’s not even naked or half-naked pictures.”

A study conducted by an e-safety commission in Australia, for example, found that half of the thousands of photos shared on a sample of child pornography sites had originated from parental sharing.

But Ms. Steinberg and Dr. Keith pointed out that benefits of parents’ online sharing exist as well, as the Mott survey found. In that survey, 72% of parents who discuss parenting and/or their children on social media reported that doing so helps them feel less alone. Similarly, 70% said they learn what not to do through those experiences, 67% said they receive advice from more experienced parents, and 62% said they consequently worry less. Common topics they discussed included sleep, nutrition, discipline, day care, and behavior management.

Other benefits, Ms. Steinberg pointed out, are that families geographically spread apart can stay connected, and communities can grow stronger with shared communal experiences of parents meeting others online.

“For some parents, it gives them an opportunity for advocacy work and raises awareness for important social issues,” Ms. Steinberg said, although she added, “If you’re going to share your children’s behavioral problems, consider sharing anonymously.”

Neither Ms. Steinberg and Dr. Keith said they had simple solutions to these challenges. Rather, they recommended using the public health model of raising awareness and encouraging open dialogue among pediatricians, parents, and their children to look for ways to balance competing interests.

“Social media offers many positive benefits, and we don’t want to silence the many voices of parents who take part in online sharing,” Ms. Steinberg explained. But she and Ms. Keith said it’s also worth considering children’s potential interest in controlling what their digital footprint is as they become adults.

For example, one study they cited found that, among 249 pairs of parents and their children, three times more children than parents wanted the parents to have and follow rules regarding what they could share on social media about their children.

Although guidance for parents on monitoring children’s social media use is a part of the AAP policy statement on media, only one recommendation obliquely addresses how parents should or shouldn’t use social media by advising them to model appropriate use for their children.

“It’s just like any medical decision: What is the benefit, and what is the risk, and does the benefit outweigh the risk?” said Wendy Sue Swanson, MD, executive director of digital health at Seattle Children’s Hospital. She recommended that parents ask their child for permission before posting a story or photo if their kids are aged 6 or older.

Ms. Steinberg and Dr. Keith recommended that pediatricians broach this subject with parents to help them think about risks they simply might not have considered before.

“When we looked at what sorts of best practices could be encouraged or doctors could talk to parents about – the tangible harms, such as whether data brokers or people interested in child pornography could access the information – we didn’t want to create any unnecessary panic,” Ms. Steinberg said. “But we did find some concerns that were troublesome, and we thought that parents or at least physicians [should] be aware of those potential risks.”

Ms. Steinberg and Dr. Keith reported that they had no relevant financial disclosures.

Oncology Practice associate editors Dr. Hope S. Rugo and Dr. William J. Gradishar reveal several anticipated studies from the 39th annual San Antonio Breast Cancer Symposium, set to begin on Wednesday, Dec. 7:

• S1-02. PrECOG 0102. A randomized, double-blind, phase II trial of fulvestrant plus everolimus or placebo in postmenopausal women with hormone receptor (HR)–positive, human epidermal growth factor receptor 2 (HER2)–negative metastatic breast cancer resistant to aromatase inhibitor therapy

• S1-03. First results from the multicenter phase III DATA study comparing 3 vs. 6 years of anastrozole after 2-3 years of tamoxifen in postmenopausal women with HR–positive early breast cancer.

• S1-04. Optimal duration of extended letrozole treatment after 5 years of adjuvant endocrine therapy; results of the randomized phase III IDEAL trial (BOOG 2006-05).

• S1-05. A randomized, double-blind, placebo-controlled clinical trial to evaluate extended adjuvant endocrine therapy (5 years of letrozole) in postmenopausal women with HR–positive breast cancer who have completed previous adjuvant endocrine therapy: initial results of NRG oncology/NSABP B-42.

• S1-08. Prognostic associations of tumor-infiltrating lymphocytes in metastatic HER2-positive breast cancer treated with trastuzumab and pertuzumab: a secondary analysis of the CLEOPATRA study.

• S3-01.

Dr. Rugo is professor of medicine, University of California, San Francisco, and director, breast oncology and clinical trials education, UCSF Helen Diller Family Comprehensive Cancer Center. Dr. Gradishar is the Betsy Bramsen Professor of Breast Oncology, professor of medicine, and deputy chief in the division of hematology/oncology, Feinberg School of Medicine, Chicago; and deputy director for the Clinical Network and director of the Maggie Daley Center for Women’s Cancer Care, Robert H. Lurie Comprehensive Cancer Center Network of Northwestern University, Chicago.

Oncology Practice associate editors Dr. Hope S. Rugo and Dr. William J. Gradishar reveal several anticipated studies from the 39th annual San Antonio Breast Cancer Symposium, set to begin on Wednesday, Dec. 7:

• S1-02. PrECOG 0102. A randomized, double-blind, phase II trial of fulvestrant plus everolimus or placebo in postmenopausal women with hormone receptor (HR)–positive, human epidermal growth factor receptor 2 (HER2)–negative metastatic breast cancer resistant to aromatase inhibitor therapy

• S1-03. First results from the multicenter phase III DATA study comparing 3 vs. 6 years of anastrozole after 2-3 years of tamoxifen in postmenopausal women with HR–positive early breast cancer.

• S1-04. Optimal duration of extended letrozole treatment after 5 years of adjuvant endocrine therapy; results of the randomized phase III IDEAL trial (BOOG 2006-05).

• S1-05. A randomized, double-blind, placebo-controlled clinical trial to evaluate extended adjuvant endocrine therapy (5 years of letrozole) in postmenopausal women with HR–positive breast cancer who have completed previous adjuvant endocrine therapy: initial results of NRG oncology/NSABP B-42.

• S1-08. Prognostic associations of tumor-infiltrating lymphocytes in metastatic HER2-positive breast cancer treated with trastuzumab and pertuzumab: a secondary analysis of the CLEOPATRA study.

• S3-01.

Dr. Rugo is professor of medicine, University of California, San Francisco, and director, breast oncology and clinical trials education, UCSF Helen Diller Family Comprehensive Cancer Center. Dr. Gradishar is the Betsy Bramsen Professor of Breast Oncology, professor of medicine, and deputy chief in the division of hematology/oncology, Feinberg School of Medicine, Chicago; and deputy director for the Clinical Network and director of the Maggie Daley Center for Women’s Cancer Care, Robert H. Lurie Comprehensive Cancer Center Network of Northwestern University, Chicago.

Oncology Practice associate editors Dr. Hope S. Rugo and Dr. William J. Gradishar reveal several anticipated studies from the 39th annual San Antonio Breast Cancer Symposium, set to begin on Wednesday, Dec. 7:

• S1-02. PrECOG 0102. A randomized, double-blind, phase II trial of fulvestrant plus everolimus or placebo in postmenopausal women with hormone receptor (HR)–positive, human epidermal growth factor receptor 2 (HER2)–negative metastatic breast cancer resistant to aromatase inhibitor therapy

• S1-03. First results from the multicenter phase III DATA study comparing 3 vs. 6 years of anastrozole after 2-3 years of tamoxifen in postmenopausal women with HR–positive early breast cancer.

• S1-04. Optimal duration of extended letrozole treatment after 5 years of adjuvant endocrine therapy; results of the randomized phase III IDEAL trial (BOOG 2006-05).

• S1-05. A randomized, double-blind, placebo-controlled clinical trial to evaluate extended adjuvant endocrine therapy (5 years of letrozole) in postmenopausal women with HR–positive breast cancer who have completed previous adjuvant endocrine therapy: initial results of NRG oncology/NSABP B-42.

• S1-08. Prognostic associations of tumor-infiltrating lymphocytes in metastatic HER2-positive breast cancer treated with trastuzumab and pertuzumab: a secondary analysis of the CLEOPATRA study.

• S3-01.

Dr. Rugo is professor of medicine, University of California, San Francisco, and director, breast oncology and clinical trials education, UCSF Helen Diller Family Comprehensive Cancer Center. Dr. Gradishar is the Betsy Bramsen Professor of Breast Oncology, professor of medicine, and deputy chief in the division of hematology/oncology, Feinberg School of Medicine, Chicago; and deputy director for the Clinical Network and director of the Maggie Daley Center for Women’s Cancer Care, Robert H. Lurie Comprehensive Cancer Center Network of Northwestern University, Chicago.

The diagnosis

To clarify the diagnosis, endoscopic resection of the smaller lesion was performed and deeper biopsies of the other lesions were taken. Histology revealed lymphoid, centroblast, and centrocyte-like cell proliferation with follicular pattern (Figure D). Immunohistochemically, the follicles stained for bcl-6, CD20, and bcl-2 (Figure E), but not CD3, CD5, CD10, or cyclin D1.

Malignant lymphomas of the colon represent about 0.2% of all colonic neoplasms and most frequently are diffuse large B-cell, mucosa-associated lymphoid tissue, and mantle cell lymphomas.2 This phenotypic presentation, as multiple lymphomatous polyposis, has been reported in colon follicular lymphomas but is more typical of mantle cell lymphoma.3 Treatment usually consists of chemotherapy containing rituximab (anti-CD20) and should be decided on a case-by-case basis owing to possible relapse and the often indolent course.1

References

1. Damaj, G., Verkarre, V., Delmer, A. et al. Primary follicular lymphoma of the gastrointestinal tract: A study of 25 cases and a literature review. Ann Oncol. 2003;14:623-9.

2. Muller-Hermelink, H.K., Chott, A., Gascoyne, R.D. et al. B-cell lymphoma of the colon and rectum. In: S.R. Hamilton, L.A. Asltonen, eds. WHO Classification of Tumours. Lyon, France: IARC Press;2001:139-41.

3. Hiraide, T., Shoji, T., Higashi, Y. et al. Extranodal multiple polypoid follicular lymphoma of the sigmoid colon. Gastrointest Endosc. 2011;73(1):182-4.

The diagnosis

To clarify the diagnosis, endoscopic resection of the smaller lesion was performed and deeper biopsies of the other lesions were taken. Histology revealed lymphoid, centroblast, and centrocyte-like cell proliferation with follicular pattern (Figure D). Immunohistochemically, the follicles stained for bcl-6, CD20, and bcl-2 (Figure E), but not CD3, CD5, CD10, or cyclin D1.

Malignant lymphomas of the colon represent about 0.2% of all colonic neoplasms and most frequently are diffuse large B-cell, mucosa-associated lymphoid tissue, and mantle cell lymphomas.2 This phenotypic presentation, as multiple lymphomatous polyposis, has been reported in colon follicular lymphomas but is more typical of mantle cell lymphoma.3 Treatment usually consists of chemotherapy containing rituximab (anti-CD20) and should be decided on a case-by-case basis owing to possible relapse and the often indolent course.1

References

1. Damaj, G., Verkarre, V., Delmer, A. et al. Primary follicular lymphoma of the gastrointestinal tract: A study of 25 cases and a literature review. Ann Oncol. 2003;14:623-9.

2. Muller-Hermelink, H.K., Chott, A., Gascoyne, R.D. et al. B-cell lymphoma of the colon and rectum. In: S.R. Hamilton, L.A. Asltonen, eds. WHO Classification of Tumours. Lyon, France: IARC Press;2001:139-41.

3. Hiraide, T., Shoji, T., Higashi, Y. et al. Extranodal multiple polypoid follicular lymphoma of the sigmoid colon. Gastrointest Endosc. 2011;73(1):182-4.

The diagnosis

To clarify the diagnosis, endoscopic resection of the smaller lesion was performed and deeper biopsies of the other lesions were taken. Histology revealed lymphoid, centroblast, and centrocyte-like cell proliferation with follicular pattern (Figure D). Immunohistochemically, the follicles stained for bcl-6, CD20, and bcl-2 (Figure E), but not CD3, CD5, CD10, or cyclin D1.

Malignant lymphomas of the colon represent about 0.2% of all colonic neoplasms and most frequently are diffuse large B-cell, mucosa-associated lymphoid tissue, and mantle cell lymphomas.2 This phenotypic presentation, as multiple lymphomatous polyposis, has been reported in colon follicular lymphomas but is more typical of mantle cell lymphoma.3 Treatment usually consists of chemotherapy containing rituximab (anti-CD20) and should be decided on a case-by-case basis owing to possible relapse and the often indolent course.1

References

1. Damaj, G., Verkarre, V., Delmer, A. et al. Primary follicular lymphoma of the gastrointestinal tract: A study of 25 cases and a literature review. Ann Oncol. 2003;14:623-9.

2. Muller-Hermelink, H.K., Chott, A., Gascoyne, R.D. et al. B-cell lymphoma of the colon and rectum. In: S.R. Hamilton, L.A. Asltonen, eds. WHO Classification of Tumours. Lyon, France: IARC Press;2001:139-41.

3. Hiraide, T., Shoji, T., Higashi, Y. et al. Extranodal multiple polypoid follicular lymphoma of the sigmoid colon. Gastrointest Endosc. 2011;73(1):182-4.

Total knee arthroplasty (TKA) is an efficacious procedure for end-stage knee arthritis. Although TKA is cost-effective and has a high rate of success,^1-6 TKAs fail and may require revision surgery. Failure mechanisms include periprosthetic fracture, aseptic loosening, wear, osteolysis, instability, and infection.^7-9 In these cases, revision arthroplasty may be needed in order to restore function.

There has been a steady increase in the number of primary and revision TKAs performed in the United States.^8,10,11 Revision rates are 4% at 5 years after index TKA and 8.9% at 9 years.¹² However, surgical techniques and improved implants have led to improved outcomes after primary TKA, as evidenced by the reduction in revisions performed for polyethylene wear and osteolysis.¹³ Given the continuing need for revision TKAs (despite technical improvements¹³), evidence-based standard protocols that improve outcomes after revision TKA are necessary.

The Total Joint Replacement Perioperative Surgical Home (TJR-PSH) implemented and used by surgeons and anesthesiologists at our institution has shown that an evidence-based perioperative protocol can provide consistent and improved outcomes in primary TKA.^14-16

Materials and Methods

In this study, which received Institutional Review Board approval, we performed a prospective cross-sectional analysis comparing the perioperative outcomes of patients who underwent primary TKA with those of patients who underwent revision TKA. Medical records and our institution’s data registry were queried for LOS, discharge disposition, readmission rates, and reoperation rates.

The study included all primary and revision TKAs performed at our institution since the inception of TJA-PSH. Unicompartmental knee arthroplasties and exchanges of a single component (patella, tibia, or femur) were excluded. We identified a total of 285 consecutive primary or revision TKAs, all performed by a single surgeon. Three cases lacked complete data and were excluded, leaving 282 cases: 235 primary and 50 revision TKAs (no simultaneous bilateral TKAs). The demographic data we collected included age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, calculated Charlson Comorbidity Index (CCI), LOS, and discharge disposition.

The same established perioperative surgical home clinical pathway was used to care for all patients, whether they underwent primary or revision TKA. The primary outcomes studied were LOS, discharge disposition (subacute nursing facility or home), 30-day orthopedic readmission, and return to operating room. All reoperations on the same knee were analyzed.

Statistical Analysis

Primary and revision TKAs were compared on LOS (with an independent-sample t test) and discharge disposition, 30-day readmissions, and reoperations (χ² Fisher exact test). Multivariate regression analysis was performed with each primary outcome, using age, sex, BMI, ASA score, and CCI as covariates. Statistical significance was set at P ≤ .05. All analyses were performed with SPSS Version 16.0 (SPSS Inc.) and Microsoft Excel 2011 (Microsoft).

Results

Mean (SD) age was 66 (13.2) years for primary TKA patients and 62 (12.8) years for revision TKA patients. The cohort had more women (62.5%) than men (37.5%). There was no statistical difference in patient demographics with respect to age (P = .169) or BMI (P = .701) between the 2 groups. There was an even age distribution within each group and between the groups (Table).

There was no statistically significant difference in LOS between the groups. Mean (SD) LOS was 2.55 (1.25) days for primary TKA and 2.92 (1.24) days for revision TKA (P = .061; 95% confidence interval [CI], 0.017-0.749). Regression analysis showed a correlation between ASA score and LOS for primary TKAs but not revision TKAs. For every unit increase in ASA score, there was a 0.39-day increase in LOS for primary TKA (P = .46; 95% CI, 0.006-0.781). There was no correlation between ASA score and LOS for revision TKA when controlling for covariates (P = .124). Eighty (34%) of the 235 primary TKA patients and 21 (41%) of the 50 revision TKA patients were discharged to a subacute nursing facility; the difference was not significant (P = .123). No patient was discharged to an acute inpatient rehabilitation unit. In addition, there was no significant difference in 30-day readmission rates between primary and revision TKA (P = .081). One primary TKA patient (0.4%) and 2 revision TKA patients (4%) were readmitted within 30 days after surgery (P = .081). The primary TKA readmission was for severe spasticity and a history of cerebral palsy leading to a quadriceps avulsion fracture from the superior pole of the patella. One revision TKA readmission was for acute periprosthetic joint infection, and the other for periprosthetic fracture around a press-fit distal femoral replacement stem. There was no significant difference in number of 30-day reoperations between the groups (P = .993). None of the primary TKAs and 2 (4%) of the revision TKAs underwent reoperation. Of the revision TKA patients who returned to the operating room within 30 days after surgery, one was treated for an acute periprosthetic joint infection, the other for a femoral periprosthetic fracture.

Discussion

Advances in multidisciplinary co-management of TKA patients and their clinical effects are highlighted in the TJR-PSH.¹⁴ TJR-PSH allows the health team and the patient to prepare for surgery with an understanding of probable outcomes and to optimize the patient’s medical and educational standing to better meet expectations and increase satisfaction.

Previous studies have focused on the etiologies of revision TKA^7,8 and on understanding the factors that may predict increased risk for a poor outcome after primary TKA and indicate a possible need for revision.^8,12 The present study focused on practical clinical processes that could potentially constitute a standardized perioperative protocol for revision TKA. An organized TJR-PSH may allow the health team to educate patients that LOS, rehabilitation and acute recovery, risk of acute (30-day) complications, and risk of readmission and return to the operating room within the first 30 days after surgery are similar for revision and primary TKAs, as long as proper preoperative optimization and education occur within the TJR-PSH.

Studies have found correlations between revision TKA and significantly increased LOS and postoperative complications.^20,21 In contrast, we found no significant difference in LOS between our primary and revision TKA groups. LOS was 2.6 days for primary TKA and 2.9 days for revision TKA—a significant improvement in care and cost for revision TKA patients. That the reduced mean LOS for revision TKA is similar to the mean LOS for primary TKA also implies a reduction in the higher cost of care in revision TKA.²⁰ In addition to obtaining similar LOS for primary and revision TKA, TJR-PSH achieved an overall reduction in LOS.^17,22Our results also showed no difference in discharge disposition between primary and revision TKA in our protocol. Discharge disposition also did not correlate with age, sex, BMI, ASA score, or CCI. In TJR-PSH, discharge planning starts before admission and is patient-oriented for optimal recovery. About 66% of primary TKA patients and 58% of revision TKA patients in our cohort were discharged home—implying we are able to send a majority of our postoperative patients home after a shorter hospital stay, while obtaining the same good outcomes. Discharging fewer revision TKA patients to extended-care facilities also indicates a possible reduction in the cost of postoperative care, bringing it in line with the cost in primary TKA. Early individualized discharge planning in TJA-PSH accounts for the similar outcomes in primary and revision TKAs.

There was no significant difference in 30-day readmission rates between our primary and revision TKA patients. An important component of the TJR-PSH pathway is the individualized postdischarge recovery plan, which helps with optimal recovery and reduces readmission rates. Our cohort’s 30-day readmission rate was 0.4% for primary TKA and 4% for revision TKA (P = .081). Thirty-day readmission is a good indicator of postoperative complications and recovery from surgery. We have previously reported on primary TKA outcomes.^{14,15,,18,22,23} In a study using an NSQIP (National Surgical Quality Improvement Program) database, 11,814 primary TKAs had a 30-day readmission rate of 4.2%.¹⁸ In an outcomes study of 17,994 patients who underwent primary TKA in a single fiscal year, the 30-day readmission rate was 5.9%.⁹ In addition, in a single-institution cohort study of 1032 primary TKA patients, Schairer and colleagues²³ found a 30-day unplanned readmission rate of 3.4%. Compared with primary TKA, revision TKA traditionally has had a higher postoperative complication rate.^20,21 There is also concern that shorter hospital stays may indicate that significant complications of revision TKAs are being missed. In this study, however, we established that the equal outcomes obtained in the perioperative period carry over to the 30-day postoperative period in our revision TKA group. Good postoperative follow-up and planning are important factors in readmission reduction. Readmissions also have significant overall cost implications.²⁴There was no statistical difference in 30-day reoperation rates between our primary and revision TKA patients. The primary TKA patients had no 30-day reoperations. Previous studies have found reoperation rates ranging from 1.8% to 4.7%.^25,26 Revision TKA patients are up to 6 times more likely than primary TKA patients to require reoperation.²⁰ Our study found no significant difference in outcomes between primary and revision TKAs.

Comparison of the outcomes of primary TKA and revision TKA in TJR-PSH showed no difference in acute recovery from surgery. LOS and discharge disposition, 30-day readmission rate, and 30-day return to the operating room were the same for primary and revision TKAs. The morbidity gap between primary and revision TKA patients has been closed in our research cohort. This outcome is important, as indications for primary TKA continue to expand and more primary TKAs are performed in younger patients.^18,23 The implication is that, in the future, more knees will need to be revised as patients outlive their prostheses.

Our study had some limitations. First, it involved a small sample of patients, operated on by a single surgeon in a well-organized TJR-PSH at a large academic center. This population might not represent the US patient population, but that should not have adversely affected data analysis, because patients were compared with a similar population. Second, the data might be incomplete because some patients with complications might have sought care at other medical facilities, and we might not have been aware of these cases. Third, we focused on objective clinical outcomes in order to measure the success of TKAs. We did not include any subjective, patient-reported data, such as rehabilitation advances and functioning levels. Fourth, multiple parameters can be used to address complication outcomes, but we used LOS, discharge disposition, 30-day readmission rate, and 30-day reoperation rate because current payers and institutions often consider these variables when assessing quality of care. These parameters can be influenced by factors such as inpatient physical therapy goals, facility discharge practices, individual social support structure, and hospital pay-for-performance model. The implication is that different facilities have different outcomes in terms of LOS, discharge disposition, readmissions, and reoperations. However, we expect proportionate similarities in these parameters as patient perioperative outcomes become more complicated. Nevertheless, a multicenter study would be able to answer questions raised by this limitation. Fifth, our statistical analysis might have been affected by decreased power of some of the outcome variables.

TJR-PSH has succeeded in closing the perioperative morbidity and outcomes gap between primary and revision TKAs. Outcome parameters used to measure the success of TJR-PSH are standard measures of the immediate postoperative recovery and short-term outcomes of TKA patients. These measures are linked to complication rates and overall outcomes in many TKA studies.^14,15,17,19 Also important is that hospital costs can be drastically cut by reducing LOS, readmissions, and reoperations. Presence of any complication of primary or revision TKA raises the cost up to 34%. This increase can go as high as 64% in the 90 days after surgery.²⁷

Conclusion

The major challenge of the changing medical landscape is to integrate quality care and a continually improving healthcare system with the goal of cost-effective delivery of healthcare. Surgical care costs can be significantly increased by evitable hospital stays, complications that lead to readmissions, and unplanned returns to the operating room after index surgery. The new perioperative surgical home created for TJA has helped drastically reduce LOS, discharge disposition, 30-day readmission rate, and 30-day reoperation rate in revision TKA. This study demonstrates similar outcomes in our revision TKA patients relative to their primary TKA counterparts.

Am J Orthop. 2016;45(7):E458-E464. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

Total knee arthroplasty (TKA) is an efficacious procedure for end-stage knee arthritis. Although TKA is cost-effective and has a high rate of success,^1-6 TKAs fail and may require revision surgery. Failure mechanisms include periprosthetic fracture, aseptic loosening, wear, osteolysis, instability, and infection.^7-9 In these cases, revision arthroplasty may be needed in order to restore function.

There has been a steady increase in the number of primary and revision TKAs performed in the United States.^8,10,11 Revision rates are 4% at 5 years after index TKA and 8.9% at 9 years.¹² However, surgical techniques and improved implants have led to improved outcomes after primary TKA, as evidenced by the reduction in revisions performed for polyethylene wear and osteolysis.¹³ Given the continuing need for revision TKAs (despite technical improvements¹³), evidence-based standard protocols that improve outcomes after revision TKA are necessary.

The Total Joint Replacement Perioperative Surgical Home (TJR-PSH) implemented and used by surgeons and anesthesiologists at our institution has shown that an evidence-based perioperative protocol can provide consistent and improved outcomes in primary TKA.^14-16

Materials and Methods

In this study, which received Institutional Review Board approval, we performed a prospective cross-sectional analysis comparing the perioperative outcomes of patients who underwent primary TKA with those of patients who underwent revision TKA. Medical records and our institution’s data registry were queried for LOS, discharge disposition, readmission rates, and reoperation rates.

The study included all primary and revision TKAs performed at our institution since the inception of TJA-PSH. Unicompartmental knee arthroplasties and exchanges of a single component (patella, tibia, or femur) were excluded. We identified a total of 285 consecutive primary or revision TKAs, all performed by a single surgeon. Three cases lacked complete data and were excluded, leaving 282 cases: 235 primary and 50 revision TKAs (no simultaneous bilateral TKAs). The demographic data we collected included age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, calculated Charlson Comorbidity Index (CCI), LOS, and discharge disposition.

The same established perioperative surgical home clinical pathway was used to care for all patients, whether they underwent primary or revision TKA. The primary outcomes studied were LOS, discharge disposition (subacute nursing facility or home), 30-day orthopedic readmission, and return to operating room. All reoperations on the same knee were analyzed.

Statistical Analysis

Primary and revision TKAs were compared on LOS (with an independent-sample t test) and discharge disposition, 30-day readmissions, and reoperations (χ² Fisher exact test). Multivariate regression analysis was performed with each primary outcome, using age, sex, BMI, ASA score, and CCI as covariates. Statistical significance was set at P ≤ .05. All analyses were performed with SPSS Version 16.0 (SPSS Inc.) and Microsoft Excel 2011 (Microsoft).

Results

Mean (SD) age was 66 (13.2) years for primary TKA patients and 62 (12.8) years for revision TKA patients. The cohort had more women (62.5%) than men (37.5%). There was no statistical difference in patient demographics with respect to age (P = .169) or BMI (P = .701) between the 2 groups. There was an even age distribution within each group and between the groups (Table).

There was no statistically significant difference in LOS between the groups. Mean (SD) LOS was 2.55 (1.25) days for primary TKA and 2.92 (1.24) days for revision TKA (P = .061; 95% confidence interval [CI], 0.017-0.749). Regression analysis showed a correlation between ASA score and LOS for primary TKAs but not revision TKAs. For every unit increase in ASA score, there was a 0.39-day increase in LOS for primary TKA (P = .46; 95% CI, 0.006-0.781). There was no correlation between ASA score and LOS for revision TKA when controlling for covariates (P = .124). Eighty (34%) of the 235 primary TKA patients and 21 (41%) of the 50 revision TKA patients were discharged to a subacute nursing facility; the difference was not significant (P = .123). No patient was discharged to an acute inpatient rehabilitation unit. In addition, there was no significant difference in 30-day readmission rates between primary and revision TKA (P = .081). One primary TKA patient (0.4%) and 2 revision TKA patients (4%) were readmitted within 30 days after surgery (P = .081). The primary TKA readmission was for severe spasticity and a history of cerebral palsy leading to a quadriceps avulsion fracture from the superior pole of the patella. One revision TKA readmission was for acute periprosthetic joint infection, and the other for periprosthetic fracture around a press-fit distal femoral replacement stem. There was no significant difference in number of 30-day reoperations between the groups (P = .993). None of the primary TKAs and 2 (4%) of the revision TKAs underwent reoperation. Of the revision TKA patients who returned to the operating room within 30 days after surgery, one was treated for an acute periprosthetic joint infection, the other for a femoral periprosthetic fracture.

Discussion

Advances in multidisciplinary co-management of TKA patients and their clinical effects are highlighted in the TJR-PSH.¹⁴ TJR-PSH allows the health team and the patient to prepare for surgery with an understanding of probable outcomes and to optimize the patient’s medical and educational standing to better meet expectations and increase satisfaction.

Previous studies have focused on the etiologies of revision TKA^7,8 and on understanding the factors that may predict increased risk for a poor outcome after primary TKA and indicate a possible need for revision.^8,12 The present study focused on practical clinical processes that could potentially constitute a standardized perioperative protocol for revision TKA. An organized TJR-PSH may allow the health team to educate patients that LOS, rehabilitation and acute recovery, risk of acute (30-day) complications, and risk of readmission and return to the operating room within the first 30 days after surgery are similar for revision and primary TKAs, as long as proper preoperative optimization and education occur within the TJR-PSH.

Studies have found correlations between revision TKA and significantly increased LOS and postoperative complications.^20,21 In contrast, we found no significant difference in LOS between our primary and revision TKA groups. LOS was 2.6 days for primary TKA and 2.9 days for revision TKA—a significant improvement in care and cost for revision TKA patients. That the reduced mean LOS for revision TKA is similar to the mean LOS for primary TKA also implies a reduction in the higher cost of care in revision TKA.²⁰ In addition to obtaining similar LOS for primary and revision TKA, TJR-PSH achieved an overall reduction in LOS.^17,22Our results also showed no difference in discharge disposition between primary and revision TKA in our protocol. Discharge disposition also did not correlate with age, sex, BMI, ASA score, or CCI. In TJR-PSH, discharge planning starts before admission and is patient-oriented for optimal recovery. About 66% of primary TKA patients and 58% of revision TKA patients in our cohort were discharged home—implying we are able to send a majority of our postoperative patients home after a shorter hospital stay, while obtaining the same good outcomes. Discharging fewer revision TKA patients to extended-care facilities also indicates a possible reduction in the cost of postoperative care, bringing it in line with the cost in primary TKA. Early individualized discharge planning in TJA-PSH accounts for the similar outcomes in primary and revision TKAs.

There was no significant difference in 30-day readmission rates between our primary and revision TKA patients. An important component of the TJR-PSH pathway is the individualized postdischarge recovery plan, which helps with optimal recovery and reduces readmission rates. Our cohort’s 30-day readmission rate was 0.4% for primary TKA and 4% for revision TKA (P = .081). Thirty-day readmission is a good indicator of postoperative complications and recovery from surgery. We have previously reported on primary TKA outcomes.^{14,15,,18,22,23} In a study using an NSQIP (National Surgical Quality Improvement Program) database, 11,814 primary TKAs had a 30-day readmission rate of 4.2%.¹⁸ In an outcomes study of 17,994 patients who underwent primary TKA in a single fiscal year, the 30-day readmission rate was 5.9%.⁹ In addition, in a single-institution cohort study of 1032 primary TKA patients, Schairer and colleagues²³ found a 30-day unplanned readmission rate of 3.4%. Compared with primary TKA, revision TKA traditionally has had a higher postoperative complication rate.^20,21 There is also concern that shorter hospital stays may indicate that significant complications of revision TKAs are being missed. In this study, however, we established that the equal outcomes obtained in the perioperative period carry over to the 30-day postoperative period in our revision TKA group. Good postoperative follow-up and planning are important factors in readmission reduction. Readmissions also have significant overall cost implications.²⁴There was no statistical difference in 30-day reoperation rates between our primary and revision TKA patients. The primary TKA patients had no 30-day reoperations. Previous studies have found reoperation rates ranging from 1.8% to 4.7%.^25,26 Revision TKA patients are up to 6 times more likely than primary TKA patients to require reoperation.²⁰ Our study found no significant difference in outcomes between primary and revision TKAs.

Comparison of the outcomes of primary TKA and revision TKA in TJR-PSH showed no difference in acute recovery from surgery. LOS and discharge disposition, 30-day readmission rate, and 30-day return to the operating room were the same for primary and revision TKAs. The morbidity gap between primary and revision TKA patients has been closed in our research cohort. This outcome is important, as indications for primary TKA continue to expand and more primary TKAs are performed in younger patients.^18,23 The implication is that, in the future, more knees will need to be revised as patients outlive their prostheses.

Our study had some limitations. First, it involved a small sample of patients, operated on by a single surgeon in a well-organized TJR-PSH at a large academic center. This population might not represent the US patient population, but that should not have adversely affected data analysis, because patients were compared with a similar population. Second, the data might be incomplete because some patients with complications might have sought care at other medical facilities, and we might not have been aware of these cases. Third, we focused on objective clinical outcomes in order to measure the success of TKAs. We did not include any subjective, patient-reported data, such as rehabilitation advances and functioning levels. Fourth, multiple parameters can be used to address complication outcomes, but we used LOS, discharge disposition, 30-day readmission rate, and 30-day reoperation rate because current payers and institutions often consider these variables when assessing quality of care. These parameters can be influenced by factors such as inpatient physical therapy goals, facility discharge practices, individual social support structure, and hospital pay-for-performance model. The implication is that different facilities have different outcomes in terms of LOS, discharge disposition, readmissions, and reoperations. However, we expect proportionate similarities in these parameters as patient perioperative outcomes become more complicated. Nevertheless, a multicenter study would be able to answer questions raised by this limitation. Fifth, our statistical analysis might have been affected by decreased power of some of the outcome variables.

TJR-PSH has succeeded in closing the perioperative morbidity and outcomes gap between primary and revision TKAs. Outcome parameters used to measure the success of TJR-PSH are standard measures of the immediate postoperative recovery and short-term outcomes of TKA patients. These measures are linked to complication rates and overall outcomes in many TKA studies.^14,15,17,19 Also important is that hospital costs can be drastically cut by reducing LOS, readmissions, and reoperations. Presence of any complication of primary or revision TKA raises the cost up to 34%. This increase can go as high as 64% in the 90 days after surgery.²⁷

Conclusion

The major challenge of the changing medical landscape is to integrate quality care and a continually improving healthcare system with the goal of cost-effective delivery of healthcare. Surgical care costs can be significantly increased by evitable hospital stays, complications that lead to readmissions, and unplanned returns to the operating room after index surgery. The new perioperative surgical home created for TJA has helped drastically reduce LOS, discharge disposition, 30-day readmission rate, and 30-day reoperation rate in revision TKA. This study demonstrates similar outcomes in our revision TKA patients relative to their primary TKA counterparts.

Am J Orthop. 2016;45(7):E458-E464. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

Total knee arthroplasty (TKA) is an efficacious procedure for end-stage knee arthritis. Although TKA is cost-effective and has a high rate of success,^1-6 TKAs fail and may require revision surgery. Failure mechanisms include periprosthetic fracture, aseptic loosening, wear, osteolysis, instability, and infection.^7-9 In these cases, revision arthroplasty may be needed in order to restore function.

There has been a steady increase in the number of primary and revision TKAs performed in the United States.^8,10,11 Revision rates are 4% at 5 years after index TKA and 8.9% at 9 years.¹² However, surgical techniques and improved implants have led to improved outcomes after primary TKA, as evidenced by the reduction in revisions performed for polyethylene wear and osteolysis.¹³ Given the continuing need for revision TKAs (despite technical improvements¹³), evidence-based standard protocols that improve outcomes after revision TKA are necessary.

The Total Joint Replacement Perioperative Surgical Home (TJR-PSH) implemented and used by surgeons and anesthesiologists at our institution has shown that an evidence-based perioperative protocol can provide consistent and improved outcomes in primary TKA.^14-16

Materials and Methods

In this study, which received Institutional Review Board approval, we performed a prospective cross-sectional analysis comparing the perioperative outcomes of patients who underwent primary TKA with those of patients who underwent revision TKA. Medical records and our institution’s data registry were queried for LOS, discharge disposition, readmission rates, and reoperation rates.

The study included all primary and revision TKAs performed at our institution since the inception of TJA-PSH. Unicompartmental knee arthroplasties and exchanges of a single component (patella, tibia, or femur) were excluded. We identified a total of 285 consecutive primary or revision TKAs, all performed by a single surgeon. Three cases lacked complete data and were excluded, leaving 282 cases: 235 primary and 50 revision TKAs (no simultaneous bilateral TKAs). The demographic data we collected included age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, calculated Charlson Comorbidity Index (CCI), LOS, and discharge disposition.

The same established perioperative surgical home clinical pathway was used to care for all patients, whether they underwent primary or revision TKA. The primary outcomes studied were LOS, discharge disposition (subacute nursing facility or home), 30-day orthopedic readmission, and return to operating room. All reoperations on the same knee were analyzed.

Statistical Analysis

Primary and revision TKAs were compared on LOS (with an independent-sample t test) and discharge disposition, 30-day readmissions, and reoperations (χ² Fisher exact test). Multivariate regression analysis was performed with each primary outcome, using age, sex, BMI, ASA score, and CCI as covariates. Statistical significance was set at P ≤ .05. All analyses were performed with SPSS Version 16.0 (SPSS Inc.) and Microsoft Excel 2011 (Microsoft).

Results

Mean (SD) age was 66 (13.2) years for primary TKA patients and 62 (12.8) years for revision TKA patients. The cohort had more women (62.5%) than men (37.5%). There was no statistical difference in patient demographics with respect to age (P = .169) or BMI (P = .701) between the 2 groups. There was an even age distribution within each group and between the groups (Table).

There was no statistically significant difference in LOS between the groups. Mean (SD) LOS was 2.55 (1.25) days for primary TKA and 2.92 (1.24) days for revision TKA (P = .061; 95% confidence interval [CI], 0.017-0.749). Regression analysis showed a correlation between ASA score and LOS for primary TKAs but not revision TKAs. For every unit increase in ASA score, there was a 0.39-day increase in LOS for primary TKA (P = .46; 95% CI, 0.006-0.781). There was no correlation between ASA score and LOS for revision TKA when controlling for covariates (P = .124). Eighty (34%) of the 235 primary TKA patients and 21 (41%) of the 50 revision TKA patients were discharged to a subacute nursing facility; the difference was not significant (P = .123). No patient was discharged to an acute inpatient rehabilitation unit. In addition, there was no significant difference in 30-day readmission rates between primary and revision TKA (P = .081). One primary TKA patient (0.4%) and 2 revision TKA patients (4%) were readmitted within 30 days after surgery (P = .081). The primary TKA readmission was for severe spasticity and a history of cerebral palsy leading to a quadriceps avulsion fracture from the superior pole of the patella. One revision TKA readmission was for acute periprosthetic joint infection, and the other for periprosthetic fracture around a press-fit distal femoral replacement stem. There was no significant difference in number of 30-day reoperations between the groups (P = .993). None of the primary TKAs and 2 (4%) of the revision TKAs underwent reoperation. Of the revision TKA patients who returned to the operating room within 30 days after surgery, one was treated for an acute periprosthetic joint infection, the other for a femoral periprosthetic fracture.

Discussion

Advances in multidisciplinary co-management of TKA patients and their clinical effects are highlighted in the TJR-PSH.¹⁴ TJR-PSH allows the health team and the patient to prepare for surgery with an understanding of probable outcomes and to optimize the patient’s medical and educational standing to better meet expectations and increase satisfaction.

Previous studies have focused on the etiologies of revision TKA^7,8 and on understanding the factors that may predict increased risk for a poor outcome after primary TKA and indicate a possible need for revision.^8,12 The present study focused on practical clinical processes that could potentially constitute a standardized perioperative protocol for revision TKA. An organized TJR-PSH may allow the health team to educate patients that LOS, rehabilitation and acute recovery, risk of acute (30-day) complications, and risk of readmission and return to the operating room within the first 30 days after surgery are similar for revision and primary TKAs, as long as proper preoperative optimization and education occur within the TJR-PSH.

Studies have found correlations between revision TKA and significantly increased LOS and postoperative complications.^20,21 In contrast, we found no significant difference in LOS between our primary and revision TKA groups. LOS was 2.6 days for primary TKA and 2.9 days for revision TKA—a significant improvement in care and cost for revision TKA patients. That the reduced mean LOS for revision TKA is similar to the mean LOS for primary TKA also implies a reduction in the higher cost of care in revision TKA.²⁰ In addition to obtaining similar LOS for primary and revision TKA, TJR-PSH achieved an overall reduction in LOS.^17,22Our results also showed no difference in discharge disposition between primary and revision TKA in our protocol. Discharge disposition also did not correlate with age, sex, BMI, ASA score, or CCI. In TJR-PSH, discharge planning starts before admission and is patient-oriented for optimal recovery. About 66% of primary TKA patients and 58% of revision TKA patients in our cohort were discharged home—implying we are able to send a majority of our postoperative patients home after a shorter hospital stay, while obtaining the same good outcomes. Discharging fewer revision TKA patients to extended-care facilities also indicates a possible reduction in the cost of postoperative care, bringing it in line with the cost in primary TKA. Early individualized discharge planning in TJA-PSH accounts for the similar outcomes in primary and revision TKAs.

There was no significant difference in 30-day readmission rates between our primary and revision TKA patients. An important component of the TJR-PSH pathway is the individualized postdischarge recovery plan, which helps with optimal recovery and reduces readmission rates. Our cohort’s 30-day readmission rate was 0.4% for primary TKA and 4% for revision TKA (P = .081). Thirty-day readmission is a good indicator of postoperative complications and recovery from surgery. We have previously reported on primary TKA outcomes.^{14,15,,18,22,23} In a study using an NSQIP (National Surgical Quality Improvement Program) database, 11,814 primary TKAs had a 30-day readmission rate of 4.2%.¹⁸ In an outcomes study of 17,994 patients who underwent primary TKA in a single fiscal year, the 30-day readmission rate was 5.9%.⁹ In addition, in a single-institution cohort study of 1032 primary TKA patients, Schairer and colleagues²³ found a 30-day unplanned readmission rate of 3.4%. Compared with primary TKA, revision TKA traditionally has had a higher postoperative complication rate.^20,21 There is also concern that shorter hospital stays may indicate that significant complications of revision TKAs are being missed. In this study, however, we established that the equal outcomes obtained in the perioperative period carry over to the 30-day postoperative period in our revision TKA group. Good postoperative follow-up and planning are important factors in readmission reduction. Readmissions also have significant overall cost implications.²⁴There was no statistical difference in 30-day reoperation rates between our primary and revision TKA patients. The primary TKA patients had no 30-day reoperations. Previous studies have found reoperation rates ranging from 1.8% to 4.7%.^25,26 Revision TKA patients are up to 6 times more likely than primary TKA patients to require reoperation.²⁰ Our study found no significant difference in outcomes between primary and revision TKAs.

Comparison of the outcomes of primary TKA and revision TKA in TJR-PSH showed no difference in acute recovery from surgery. LOS and discharge disposition, 30-day readmission rate, and 30-day return to the operating room were the same for primary and revision TKAs. The morbidity gap between primary and revision TKA patients has been closed in our research cohort. This outcome is important, as indications for primary TKA continue to expand and more primary TKAs are performed in younger patients.^18,23 The implication is that, in the future, more knees will need to be revised as patients outlive their prostheses.

Our study had some limitations. First, it involved a small sample of patients, operated on by a single surgeon in a well-organized TJR-PSH at a large academic center. This population might not represent the US patient population, but that should not have adversely affected data analysis, because patients were compared with a similar population. Second, the data might be incomplete because some patients with complications might have sought care at other medical facilities, and we might not have been aware of these cases. Third, we focused on objective clinical outcomes in order to measure the success of TKAs. We did not include any subjective, patient-reported data, such as rehabilitation advances and functioning levels. Fourth, multiple parameters can be used to address complication outcomes, but we used LOS, discharge disposition, 30-day readmission rate, and 30-day reoperation rate because current payers and institutions often consider these variables when assessing quality of care. These parameters can be influenced by factors such as inpatient physical therapy goals, facility discharge practices, individual social support structure, and hospital pay-for-performance model. The implication is that different facilities have different outcomes in terms of LOS, discharge disposition, readmissions, and reoperations. However, we expect proportionate similarities in these parameters as patient perioperative outcomes become more complicated. Nevertheless, a multicenter study would be able to answer questions raised by this limitation. Fifth, our statistical analysis might have been affected by decreased power of some of the outcome variables.

TJR-PSH has succeeded in closing the perioperative morbidity and outcomes gap between primary and revision TKAs. Outcome parameters used to measure the success of TJR-PSH are standard measures of the immediate postoperative recovery and short-term outcomes of TKA patients. These measures are linked to complication rates and overall outcomes in many TKA studies.^14,15,17,19 Also important is that hospital costs can be drastically cut by reducing LOS, readmissions, and reoperations. Presence of any complication of primary or revision TKA raises the cost up to 34%. This increase can go as high as 64% in the 90 days after surgery.²⁷

Conclusion

The major challenge of the changing medical landscape is to integrate quality care and a continually improving healthcare system with the goal of cost-effective delivery of healthcare. Surgical care costs can be significantly increased by evitable hospital stays, complications that lead to readmissions, and unplanned returns to the operating room after index surgery. The new perioperative surgical home created for TJA has helped drastically reduce LOS, discharge disposition, 30-day readmission rate, and 30-day reoperation rate in revision TKA. This study demonstrates similar outcomes in our revision TKA patients relative to their primary TKA counterparts.

Am J Orthop. 2016;45(7):E458-E464. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

Internet-delivered cognitive-behavioral therapy is effective at overcoming chronic insomnia, a randomized controlled trial of 303 adults showed.

In the trial, patients who were randomized to receive cognitive-behavioral therapy for insomnia (CBT-I) used a Web-based program called Sleep Healthy Using the Internet (SHUTi), which “incorporates the primary tenets of face-to-face CBT-I, including sleep restriction, stimulus control, cognitive restructuring, sleep hygiene, and relapse prevention,” wrote Lee M. Ritterband, PhD, and his associates. Meanwhile, patients in the control group received online, nonspecific patient education.

©Karen Winton/iStockphoto

lfranki@frontlinemedcom.com

Internet-delivered cognitive-behavioral therapy is effective at overcoming chronic insomnia, a randomized controlled trial of 303 adults showed.

In the trial, patients who were randomized to receive cognitive-behavioral therapy for insomnia (CBT-I) used a Web-based program called Sleep Healthy Using the Internet (SHUTi), which “incorporates the primary tenets of face-to-face CBT-I, including sleep restriction, stimulus control, cognitive restructuring, sleep hygiene, and relapse prevention,” wrote Lee M. Ritterband, PhD, and his associates. Meanwhile, patients in the control group received online, nonspecific patient education.

©Karen Winton/iStockphoto

lfranki@frontlinemedcom.com

Internet-delivered cognitive-behavioral therapy is effective at overcoming chronic insomnia, a randomized controlled trial of 303 adults showed.

In the trial, patients who were randomized to receive cognitive-behavioral therapy for insomnia (CBT-I) used a Web-based program called Sleep Healthy Using the Internet (SHUTi), which “incorporates the primary tenets of face-to-face CBT-I, including sleep restriction, stimulus control, cognitive restructuring, sleep hygiene, and relapse prevention,” wrote Lee M. Ritterband, PhD, and his associates. Meanwhile, patients in the control group received online, nonspecific patient education.

©Karen Winton/iStockphoto

lfranki@frontlinemedcom.com