Collagenase Clostridium Histolyticum Injection for Dupuytren Contracture: 2-Year Follow-up

Suresh K. Nayar,Dennis Pfisterer,John V. Ingari 대한정형외과학회 2019 Clinics in Orthopedic Surgery Vol.11 No.3

Background: Dupuytren disease is characterized by the development of palmar fibrous tissue that can lead to fixed flexion contracture (FFC) and contribute to functional loss of the involved digits. Our goal was to investigate rates of contracture resolution and recurrence in patients who underwent enzymatic fasciotomy for Dupuytren contracture consisting of collagenase clostridium histolyticum (CCH) injection followed by passive manipulation combined with splinting and home-based therapy. Methods: We prospectively enrolled 34 patients (44 metacarpophalangeal [MCP] and 33 proximal interphalangeal [PIP] joints) treated by one orthopaedic hand surgeon between November 2010 and November 2014. On day 1, CCH was injected into a palpable fibrous cord of the involved fingers. The next day, the finger was passively extended to its maximal corrective position. FFC was measured for each joint before injection and immediately after manipulation. Patients were instructed to wear an extension splint at night and perform stretching exercises at home and were re-evaluated at 6 weeks, 4 months, 1 year, and 2 years. Resolution was defined as improvement of contracture to ≤ 5° of neutral. Recurrence was defined as an increase in FCC of ≥ 20° after treatment. Results: Immediate contracture resolution occurred in 42 of 44 MCP joints (p < 0.001), improving from 50° to 1.5°, and in 14 of 33 PIP joints (p = 0.182), improving from 44° to 16°. Four joints had recurrence within 6 weeks. Of the 48 joints with minimum 4-month follow-up (mean, 26 months), 12 had recurrence at 2-year follow-up (MCP, 6; PIP, 6). At 2-year follow-up, MCP and PIP contractures measured 17° and 35.5°, respectively. Older age and multiple digit involvement were associated with higher recurrence rates. Conclusions: CCH offers a safe, nonoperative option to correct FCC in Dupuytren disease with greater success for MCP joints compared to PIP joints. There is a tendency of reoccurrence within 2 years of treatment. Further investigation is needed to determine optimal timing of repeat CCH injection to improve upon or extend the period of contracture resolution.

Reassessment of Relative Value in Shoulder and Elbow Surgery: Do Payment and Relative Value Units Reflect Reality?

Suresh K Nayar,Richard L. Skolasky,Dawn M LaPorte,Ryan M Zimmerman,Aviram M Giladi,Umasuthan Srikumaran 대한정형외과학회 2021 Clinics in Orthopedic Surgery Vol.13 No.1

Background: Many U.S. health care institutions have adopted compensation models based on work relative value units (wRVUs) to standardize payments and incentivize providers. A major determinant of payment and wRVU assignments is operative time. We sought to determine whether differences in estimated operative times between the Centers for Medicare & Medicaid Services (CMS) and the National Surgical Quality Improvement Program (NSQIP) contribute to payment and wRVU misvaluation for the most common shoulder/elbow procedures. Methods: We collected data on wRVUs, payments, and operative times from CMS for 29 types of isolated arthroscopic and open shoulder/elbow procedures. Using regression analysis, we compared relationships between these variables, in addition to median operative times reported by NSQIP (2013–2016). We then determined the relative valuation of each procedure based on operative time. Results: Seventy-nine percent of CMS operative time were longer than NSQIP time (R2 = 0.58), including, but not limited to, shoulder arthroplasty and arthroscopic shoulder surgery. The correlation between payments and operative times was stronger between CMS data (R2 = 0.61) than NSQIP data (R2 = 0.43). Similarly, the correlation between wRVUs and operative times was stronger when using CMS data (R2 = 0.87) than NSQIP data (R2 = 0.69). Nearly all arthroscopic shoulder procedures (aside from synovectomy, debridement, and decompression) were highly valued according to both datasets. Per NSQIP, compensation for revision total shoulder arthroplasty ($10.14/min; 0.26 wRVU/min) was higher than that for primary cases ($9.85, 0.23 wRVU/min) and nearly twice the CMS rate for revision cases ($5.84/min; 0.13 wRVU/min). Conclusions: CMS may overestimate operative times compared to actual operative times as recorded by NSQIP. Shorter operative times may render certain procedures more highly valued than others. Case examples show that this can potentially affect patient care and incentivize higher compensating procedures per operative time when less-involved, shorter operations have similar patient-reported outcomes.

Racial Disparity in Time to Surgery and Complications for Hip Fracture Patients

Suresh K. Nayar,Majd Marrache,Iman Ali,Jarred Bressner,Micheal Raad,Babar Shafiq,Uma Srikumaran 대한정형외과학회 2020 Clinics in Orthopedic Surgery Vol.12 No.4

Background: Racial and ethnic disparities in orthopedic surgery may be associated with worse perioperative complications. For patients with hip fractures, studies have shown that early surgery, typically within 24 to 48 hours of admission, may decrease postoperative morbidity and mortality. Our objective was to determine whether race is associated with longer time to surgery from hospital presentation and increased postoperative complications. Methods: We queried the National Surgical Quality Improvement Program database from 2011 to 2017 for patients (> 65 years) with hip fractures who underwent surgical fixation. Patients were identified using Current Procedural Terminology codes (27235, 27236, 27244, and 27245). Delayed surgery was defined as time to surgery from hospital admission that was greater than 48 hours. Time to surgery was compared between races using analysis of variance. A multivariate logistic regression analysis adjusting for comorbidities, age, sex, and surgery was performed to determine the likelihood of delayed surgery and rate of postoperative complications. Results: A total of 58,456 patients who underwent surgery for a hip fracture were included in this study. Seventy-two percent were female patients and the median age was 87 years. The median time to surgery across all patients was 24 hours. African Americans had the longest time to surgery (30.4 ± 27.6 hours) compared to Asians (26.5 ± 24.6 hours), whites (25.8 ± 23.4 hours), and other races (22.7 ± 22.0 hours) (p < 0.001). After adjusting for comorbidities, age, sex, and surgery, there was a 43% increase in the odds of delayed surgery among American Africans compared to whites (odds ratio, 1.43; 95% confidence interval, 1.29–1.58; p < 0.001). Despite higher odds of reintubation, pulmonary embolism, renal insufficiency or failure, and cardiac arrest in African Americans, mortality was significantly lower compared to white patients (4.41% vs. 6.02%, p < 0.001). Asian Americans had the lowest mortality rate (3.84%). Conclusions: A significant disparity in time to surgery and perioperative complications was seen amongst different races with only African Americans having a longer time to surgery than whites. Further study is needed to determine the etiology of this disparity and highlights the need for targeted strategies to help at-risk patient populations.

A Cost Effective Energy Saving of Fluorescent Lighting in Commercial Buildings

Lee, Seong-Ryong,Nayar, Chemmangot V. The Korean Institute of Power Electronics 2012 JOURNAL OF POWER ELECTRONICS Vol.12 No.1

Lighting represents a significant component of commercial buildings, particularly office buildings. Fluorescent lighting is invariably used in all commercial, industrial and residential areas. A significant amount of lighting energy is wasted every day by leaving the lights on and not utilizing daylight energy. However, if daylight illuminance can be harnessed, this will reduce the electricity consumption of fluorescent lamps and save energy. This paper explains possible significant savings in lighting energy consumption and hence in costs, without reducing the performance and visual satisfaction in office or industrial buildings. It is proposed to obtain energy saving by reducing the supply voltage without degradation in lighting performance. Experimental results confirm that as much as 20% of electrical energy can be saved by reducing about 9% of the supply voltage, without noticeably affecting light output while complying with lighting standard limits.

Mother-to-Child Transmission of HIV in China and the USA: A Comparative Analysis

Susanna Arcella,Usha S. Nayar 한국사회복지학회 2010 Asian Social Work and Policy Review Vol.4 No.3

This paper analyzes and compares the existing policies and programs for the prevention of motherto-child transmission of HIV existing in China and in the USA. The implementation of these is stillimperfect and there needs to be improvements in the education (the spreading of information) andin the general health care system of China. Particular attention will be drawn to the existing barriersto the effective implementation of prevention of mother-to-child-transmission. The recommendationsaim to solve similar barriers in both countries and some specifically dealing with problemsin China. Since HIV infection in children is caused almost entirely by prenatal transmission, it isimportant that the governments, in partnership with civic society organizations, make all the necessaryefforts to save the lives of their newborn citizens.

Iatrogenic iliac arteriovenous fistula with aortic pseudoaneurysm formation post lumbar (L4-L5) laminectomy and pedicular screw fixation

Viraj M Shah,Reena Nayar 대한마취통증의학회 2016 Korean Journal of Anesthesiology Vol.69 No.3

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A Cost Effective Energy Saving of Fluorescent Lighting in Commercial Buildings

Seong-Ryong Lee,Chemmangot V. Nayar 전력전자학회 2012 JOURNAL OF POWER ELECTRONICS Vol.12 No.1

Lighting represents a significant component of commercial buildings, particularly office buildings. Fluorescent lighting is invariably used in all commercial, industrial and residential areas. A significant amount of lighting energy is wasted every day by leaving the lights on and not utilizing daylight energy. However, if daylight illuminance can be harnessed, this will reduce the electricity consumption of fluorescent lamps and save energy. This paper explains possible significant savings in lighting energy consumption and hence in costs, without reducing the performance and visual satisfaction in office or industrial buildings. It is proposed to obtain energy saving by reducing the supply voltage without degradation in lighting performance. Experimental results confirm that as much as 20% of electrical energy can be saved by reducing about 9% of the supply voltage, without noticeably affecting light output while complying with lighting standard limits.

A Grid Current-Controlling Shunt Active Power Filter

Tumbelaka, Hanny H.,Borle, Lawrence J.,Nayar, Chemmangot V.,Lee, Seong-Ryong The Korean Institute of Power Electronics 2009 JOURNAL OF POWER ELECTRONICS Vol.9 No.3

In this paper, the implementation of a three-phase shunt active power filter is presented. The filter is essentially three independent single-phase current-controlled voltage source inverters (CC-VSI) with a common DC bus. The CC- VSI is operated to directly control the AC grid current to be sinusoidal and in phase with the grid voltage without detecting the load currents. The APF consists of a current control loop, which shapes the grid currents to be sinusoidal and a voltage control loop, which regulates the active power balance of the system. The experimental results indicate that the active filter is able to handle predominantly the harmonics, as well as the unbalance and reactive power, so that the grid currents are sinusoidal, in phase with the grid voltages and symmetrical.

Nonlinear earthquake capacity of slender old masonry structures prestressed with steel, FRP and NiTi SMA tendons

Adolfo Preciado,Alejandro Ramírez-Gaytan,Nayar Gutierrez,David Vargas,Jose Manuel Falcon,Gil Ochoa 국제구조공학회 2018 Steel and Composite Structures, An International J Vol.26 No.2

This paper focuses on the seismic protection of slender old masonry structures by the implementation of prestressing devices at key locations. The devices are vertically and externally located inside the towers in order to be reversible and calibrated. An extensive parametric study on a selected slender tower is carried out based on more than 100 nonlinear static simulations aimed at investigating the impact of different parameters on the seismic performance: (i) different prestressing levels; (ii) shape memory alloy superelasticity and (iii) changes in prestressing-forces in all the stages of the analysis until failure and masonry toe crushing. The tendon materials under analysis are conventional prestressing steel, fiber-reinforced polymers of different fibers and shape memory alloys. The parametric study serves to select the most suitable prestressing device and optimal prestressing level able to dissipate more earthquake energy. The seismic energy dissipation is evaluated by comparing the structural capacity curves in original state and retrofitted.

Algorithmic approach to the lymphatic leak after vascular reconstruction: a systematic review

Nicksic, Peter John,Condit, Kevin Michael,Nayar, Harry Siva,Michelotti, Brett Foster Korean Society of Plastic and Reconstructive Surge 2021 Archives of Plastic Surgery Vol.48 No.4

Background To date, there are no consensus guidelines for management of lymphatic leak in groin vascular reconstruction patients. The goal of this study is to review the relevant literature to determine alternatives for treatment and to design an evidence-based algorithm to minimize cost and morbidity and maximize efficacy. Methods A systematic review of the literature was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Two independent reviewers applied agreed-upon inclusion and exclusion criteria to eligible records. Studies that included patients who underwent groin dissection for oncologic diagnoses and level 5 data were excluded. Interventions were then categorized by efficacy using predetermined criteria. Results Our search yielded 333 records, of which eight studies were included. In four studies, the success of lymphatic ligation ranged from 75% to 100%, with average days to resolution ranging from 0 to 9. Conservative management in the form of elevation, compression, and bedrest may prolong time to resolution of lymphatic leak (14-24 days) and therefore cost. Conclusions The majority of patients should be offered early operative intervention in the form of lymphatic ligation with or without a primary muscle flap. If the patient is not an operative candidate, a trial of conservative management should be attempted before other nonsurgical interventions.