Search

Background: MetaMap is a valuable tool for processing biomedical texts to identify concepts. Although MetaMap is highly configurative, configuration decisions are not straightforward.Objective: To develop a systematic, data-driven methodology for configuring MetaMap for optimal performance.Methods: MetaMap, the word2vec model, and the phrase model were used to build a pipeline. For unsupervised training, the phrase and word2vec models used abstracts related to clinical decision support as input. During testing, MetaMap was configured with the default option, one behavior option, and two behavior options. For each configuration, cosine and soft cosine similarity scores between identified entities and gold-standard terms were computed for 40 annotated abstracts (422 sentences). The similarity scores were used to calculate and compare the overall percentages of exact matches, similar matches, and missing gold-standard terms among the abstracts for each configuration. The results were manually spot-checked. The precision, recall, and F-measure (β =1) were calculated.Results: The percentages of exact matches and missing gold-standard terms were 0.6–0.79 and 0.09–0.3 for one behavior option, and 0.56–0.8 and 0.09–0.3 for two behavior options, respectively. The percentages of exact matches and missing terms for soft cosine similarity scores exceeded those for cosine similarity scores. The average precision, recall, and F-measure were 0.59, 0.82, and 0.68 for exact matches, and 1.00, 0.53, and 0.69 for missing terms, respectively.Conclusion: We demonstrated a systematic approach that provides objective and accurate evidence guiding MetaMap configurations for optimizing performance. Combining objective evidence and the current practice of using principles, experience, and intuitions outperforms a single strategy in MetaMap configurations. Our methodology, reference codes, measurements, results, and workflow are valuable references for optimizing and configuring MetaMap.

Mitotic rate is an important prognostic predictor in invasive breast carcinoma. Current guidelines recommend counting mitoses from 10 contiguous high power fields (HPFs) in the core biopsy. We propose a method to score mitotic activity in 1 HPF at the most mitotically active area of the tumour edge, or the interface between invasive tumour and benign breast tissue. We propose a score of 1, 2, or 3, corresponding to ≤1, 2, or ≥3 mitoses in 1 HPF, respectively. A total of 141 breast core biopsies with corresponding surgical excisions were blindly examined. We counted the number of mitotic figures in 1 HPF and in 10 contiguous HPFs in the core biopsy and compared with the mitotic count from 10 contiguous HPFs in the excision which is considered the gold standard. Concordance rates and interobserver agreement rates were calculated. The concordance rate was 82.3%, 78.7% and 82.3% between 1 HPF versus 10 HPFs in the core biopsy, 1 HPF in the core biopsy versus 10 HPFs in the excision and 10 HPFs in the core biopsy vs 10 HPFs in the excision, respectively. In the core biopsy, all three investigators agreed in 73.8% and 83.7% of the cases using the 1 HPF method and the 10 HPFs method, respectively; in the excision specimen, agreement was reached in 82.3% of the cases. The 1 HPF method showed similar concordance rate and interobserver agreement compared to the conventional method in the prediction of the mitotic score in the excision in all score groups. When stratified by mitotic score, the 1 HPF method predicted superior correlation with excision in the score 1 group than the 10 HPFs method, but not in the score 2 or 3 groups. From these findings we conclude that the proposed 1 HPF method can be used in clinical practice to grade invasive breast carcinomas in core biopsies, with the possibility of being utilised in small biopsies with less than 10 HPFs of invasive carcinoma.

Interoperable clinical decision support system (CDSS) rules are a pathway to achieving interoperability which is a well-recognized challenge in health information technology. Building an ontology facilitates the creation of interoperable CDSS rules, which can be achieved by identifying the keyphrases (KP) from the existing literature. However, KP identification for labeling the data requires human expertise, consensus, and contextual understanding. This paper aims to present a semi-supervised framework for the CDSS using minimal labeled data based on hierarchical attention over the documents fused with domain adaptation approaches. Then, evaluate the effectiveness of KP identification with this framework. In the view of semi-supervised learning, our methodology toward building this framework outperforms the prior neural architectures by learning with document-level context, no explicit hand-crafted features, knowledge transfer from pre-trained models (on unlabeled corpus), and post-fine-tuning with smaller gold standard-labeled data. To the best of our knowledge, this is the first functional framework for the CDSS sub-domain to identify the KP, which is trained on limited labeled data. It contributes to the general natural language processing (NLP) architectures in areas such as clinical NLP, where manual data labeling is challenging.

Clinical decision support systems (CDSSs) are important for the quality and safety of healthcare delivery. Although CDSS rules guide CDSS behavior, they are not routinely shared and reused.Ontology has the potential to promote the reuse of CDSS rules. Therefore, we systematically screened literature to elaborate on the current status of ontology applied in CDSS rules, such as rule management (which uses captured CDSS rule usage data and user feedback data to tailor CDSS services to be more accurate) and maintenance (which updates CDSS rules). Through this systematic literature review, we aim to identify the frontiers of ontologies used in CDSS rules.The literature search was focused on the intersection of ontology, clinical decision support, and rules in PubMed, the Association for Computing Machinery (ACM) Digital Library, and the NursingAllied Health Database. Grounded theory and PRISMA 2020 guidelines were followed. One author initiated the screening and literature review, while the other two validated the processes and results independently. Inclusion and exclusion criteria were developed and refined iteratively.CDSSs were primarily used to manage chronic conditions, alerts for medication prescriptions, reminders for immunizations and preventive services, diagnoses, and treatment recommendations among the 81 included publications. The CDSS rules were presented in Semantic Web Rule Language, Jess, or Jena formats. Despite the fact that ontologies have been used to provide medical knowledge, CDSS rules, and terminologies, they have not been used in CDSS rule management or to facilitate the reuse of CDSS rules.Ontologies have been used to organize and represent medical knowledge, controlled vocabularies, and the content of CDSS rules. So far, there has been little reuse of CDSS rules. More work is needed to improve the CDSS rule reusability and interoperability. This paper identified and described the ontologies that, despite their limitations, enable Semantic Web technology and their applications in CDSS rules.

Interpretability, transparency, and auditability of machine learning (ML)-driven investment has become a key issue for investment managers as many look to enhance or replace traditional factor-based investing. The authors show that symbolic artificial intelligence (SAI) provides a solution to this conundrum, with superior return characteristics compared to traditional factor-based stock selection, while producing interpretable outcomes. Their SAI approach is a form of satisficing that systematically learns investment decision rules (symbols) for stock selection, using an a priori algorithm, avoiding the need for error-prone approaches for secondary explanations (known as XAI). The authors compare the empirical performance of an SAI approach with a traditional factor-based stock selection approach, in an emerging market equities universe. They show that SAI generates superior return characteristics and would provide a viable and interpretable alternative to factor-based stock selection. Their approach has significant implications for investment managers, providing an ML alternative to factor investing but with interpretable outcomes that could satisfy internal and external stakeholders. Key Findings ▪ Symbolic artificial intelligence (SAI) for stock selection, a form of satisficing, provides an alternative to factor investing and overcomes the interpretability issues of many machine learning (ML) approaches. ▪ An SAI that could be applied at scale is shown to produce superior return characteristics to traditional factor-based stock selection. ▪ SAI’s superior stock selection is examined using notional visualizations of its decision boundaries.

BACKGROUND Clinical decision support systems (CDSS) play a critical role in the quality and safety of healthcare delivery. Although CDSS rules direct CDSS behavior, CDSS rules have not been routinely shared and reused. OBJECTIVE Ontology has the potential to promote the reusing of CDSS rules. Therefore, we systematically screened literature to elaborate on the current status of ontology applied in CDSS rules, e.g., rule management (uses the captured CDSS rule usage data and users’ feedback data to customize CDSS services to be more accurate) and maintenance (updates CDSS rules). We aim to delineate the frontlines of ontologies applied in CDSS rules via this systematic literature review. METHODS The literature search was focused on ontology, clinical decision support, and rules in PubMed, the Association for Computing Machinery (ACM) Digital Library, and the Nursing & Allied Health Database. Grounded theory and PRISMA 2020 guidelines were followed. One author started the screening and literature analysis, and two validated the processes and results. Inclusion and exclusion criteria were developed and refined iteratively. RESULTS Among the 81 included publications, CDSS were mainly applied to managing chronic conditions, alerts for medication prescriptions, reminders for immunizations and preventive services, diagnoses, and treatment recommendations. The CDSS rules were presented in Semantic Web Rule Language, Jess, or Jena formats. Despite ontologies being used to supply medical knowledge, CDSS rules, and terminologies, ontologies have not been used in CDSS rule management or facilitate the reusing of CDSS rules. CONCLUSIONS Ontologies have been used to organize and represent medical knowledge and controlled vocabularies that contribute to CDSS and the content of CDSS rules. So far, there is a lack of reusing CDSS rules. More efforts are needed to improve the reusability and interoperability of CDSS rules. This paper delineated the ontologies, enabling Semantic Web technology, despite inadequate, and their applications in CDSS rules.

BackgroundSelf-rated health status, a subjective measure, is used broadly to describe an individual’s overall health status. Our long-term goal is to create a more objective, comprehensive, and accurate measure of individual health status. We selected 29 health indicators and prioritized them by conducting online surveys. Thirteen of these 29 indicators received relatively more consistent ratings across 3 samples.ObjectivesTo explore the main and interaction effects of 4 demographic factors as independent variables (age, gender, professional group, and educational level) in the importance ratings of the 13 health indicators.MethodsWe conducted a 4-way multivariate analysis of variance (MANOVA) with post-hoc testing to examine the effects of independent variables on all 13 dependent variables. Descriptive statistics and bivariate correlation analysis were also conducted.DesignCross-sectional study.SettingAn online survey (≥ 18 years).Participants791 participants in the USA.Results13 health indicators were significantly correlated with each other. Age correlated with most of the health indicators (8 of 13). The MANOVA modeling results indicated that gender, age, and education levels significantly affected the combination of the 13 health indicators. There was a significant interaction effect by age and professional group on 5 health indicators.ConclusionsAge is critical in rating the 13 health indicators. Among all the statistically significant main effects of demographic factors, the effect sizes descend regarding age, gender, educational level, and interaction between age and professional group. These results can provide a foundation for further studies to explore behavioral interventions for individual subgroups.Article SummaryStrengths and limitations of this studyThe work establishes the interactions and effects between demographic data (age, gender, education, and professional group) and the perceived importance of 13 health indicators via MANOVA analysisThe interactions and effects of demographic data on the importance ratings of the 13 health indicatorscan guide future study designs for behavioral interventionsDeep analysis of the demographic variables and their effects on and interactions with the rating results are helpful for thoroughly understanding the perspectivesThe study is an observational study despite with relatively large sample size and a robust analysisThe data are not racially representative

Bile acids (BAs), produced in the liver and further transformed in the gut, are cholesterol-derived molecules involved in essential physiological processes. Recent studies suggest that BAs regulate T helper 17 cell function, but the underlying mechanism of this action and their therapeutic value in disease models remains unclear. Using an IL-23 minicircle DNA-based murine model of psoriasiform dermatitis, we showed that oral administration of secondary BAs, including lithocholic acid (LCA), deoxycholic acid, and 3-oxoLCA, significantly improved psoriasiform dermatitis without inducing apparent hepatotoxicity. Of the BAs tested, LCA possessed the greatest potency in treating psoriasiform dermatitis. Intravenous administration of LCA at a much lower dosage (compared with oral treatment) showed a comparable antipsoriatic effect and markedly suppressed the IL-17A response. Exvivo experiments revealed that LCA reduced IL-17A production in IL-23-stimulated murine T cells in the absence of BA receptors TGR5 or FXR. Strikingly, BAs inhibited CCL20 expression in keratinocytes, which led to reduced migration of CCR6-expressing Jurkat cells cultured in the conditioned medium of stimulated keratinocytes. Thus, BAs improve psoriasiform dermatitis with minimal toxicity via direct inhibition of IL-17A production and blockade of CCL20-mediated trafficking, supporting the potential use of BAs in psoriasis.

BACKGROUND Disease status (eg, cancer stage) has been used in routine clinical practice to determine more accurate treatment plans. Health-related indicators, such as mortality, morbidity, and population group life expectancy, have also been used. However, few studies have specifically focused on the comprehensive and objective measures of individual health status. OBJECTIVE The aim of this study was to analyze the perspectives of the public toward 29 health indicators obtained from a literature review to provide evidence for further prioritization of the indicators. The difference between health status and disease status should be considered. METHODS This study used a cross-sectional design. Online surveys were administered through Ohio University, ResearchMatch, and Clemson University, resulting in three samples. Participants aged 18 years or older rated the importance of the 29 health indicators. The rating results were aggregated and analyzed as follows (in each case, the dependent variables were the individual survey responses): (1) to determine the agreement among the three samples regarding the importance of each indicator, where the independent variables (IVs) were the three samples; (2) to examine the mean differences between the retained indicators with agreement across the three samples, where the IVs were the identified indicators; and (3) to rank the groups of indicators into various levels after grouping the indicators with no mean differences, where the IVs were the groups of indicators. RESULTS In total, 1153 valid responses were analyzed. Descriptive statistics revealed that the top five–rated indicators were drug or substance abuse, smoking or tobacco use, alcohol abuse, major depression, and diet and nutrition. Among the 29 health indicators, the three samples agreed upon the importance of 13 indicators. Inferential statistical analysis indicated that some of the 13 indicators held equal importance. Therefore, the 13 indicators were categorized by rank into seven levels: level 1 included blood sugar level and immunization and vaccination; level 2 included LDL cholesterol; level 3 included HDL cholesterol, blood triglycerides, cancer screening detection, and total cholesterol; level 4 included health literacy rate; level 5 included personal care needs and air quality index greater than 100; level 6 included self-rated health status and HIV testing; and level 7 included the supply of dentists. Levels 1 to 3 were rated significantly higher than levels 4 to 7. CONCLUSIONS This study provides a baseline for prioritizing 29 health indicators, which can be used by electronic health record or personal health record system designers or developers to determine what can be included in the systems to capture an individual’s health status. Currently, self-rated health status is the predominantly used health indicator. Additionally, this study provides a foundation for tracking and measuring preventive health care services more accurately and for developing an individual health status index.

ObjectiveWe examined the perspectives of the general public on 29 health indicators to provide evidence for further prioritizing the indicators, which were obtained from the literature review. Health status is different from disease status, which can refer to different stages of cancer.DesignThis study uses a cross-sectional design.SettingAn online survey was administered through Ohio University, ResearchMatch, and Clemson University.ParticipantsParticipants included the general public who are 18 years or older. A total of 1153 valid responses were included in the analysis.Primary outcomes measuresParticipants rated the importance of the 29 health indicators. The data were aggregated, cleaned, and analyzed in three ways: (1) to determine the agreement among the three samples on the importance of each indicator (IV = the three samples, DV = individual survey responses); (2) to examine the mean differences between the retained indicators with agreement across the three samples (IV = the identified indicators, DV = individual survey responses); and (3) to rank the groups of indicators after grouping the indicators with no mean differences (IV = the groups of indicators, DV = individual survey responses).ResultsThe descriptive statistics indicate that the top-five rated indicators are drug or substance abuse, smoking or tobacco use, alcohol abuse, major depression, diet and nutrition. The importance of 13 of the 29 health indicators was agreed upon among the three samples. The 13 indicators were categorized into seven groups. Groups 1-3 were rated as significantly higher than Groups 4-7.ConclusionsThis study provides a baseline for prioritizing further the 29 health indicators, which can be used by electronic health records or personal health record system developers. Currently, self-rated health status is used predominantly. Our study provides a foundation to track and measure preventive services more accurately and to develop an individual health status index.Strengths and limitations of this studyThe work establishes the foundation to measure individual health status more comprehensively and objectivelyThe work reflects perspectives from three communities with a relatively large sample sizeThe work provides the foundation to prioritize the 29 health indicators furtherWith real-world longitudinal data, the public perspective data on individual health status measurement would be verified and validated further

Epstein-Barr virus (EBV) is associated with many neoplastic hematologic conditions, but scattered EBV-positive cells can be detected in lymph nodes of healthy individuals and they usually represent latently infected lymphocytes. The incidence of EBV detection in normal bone marrow samples has not been studied and is largely unknown. The lack of knowledge regarding the true incidence of encountering bystander latent EBV-positive cells in the bone marrow may potentially lead to a diagnostic dilemma when assessing a staging bone marrow for a patient with an EBV-positive B or T/NK-cell lymphoma. The aim of our study was to investigate the rate of detection of EBV expression in bone marrow samples and correlate any positive findings with various clinical parameters including patient's age, sex, clinical history, immune status, and any neoplastic transformation if follow-up data are available. We retrospectively studied 230 consecutive bone marrow biopsies performed in 2013 and found 5 cases (2.17%) with scattered EBV-positive cells by in situ hybridization. The observed scattered EBV-positive cells are largely small in size and likely represent bystander, latently infected cells. The rate of detection of EBV-positive cells in the bone marrow appears to be slightly higher in immunodeficient individuals (3%) than in immunocompetent patients (1%).

Background The Lapidus procedure has become a popular procedure in correcting hallux valgus deformities and has undergone several modifications in an effort to improve the efficacy of the procedure. The senior author modifies this procedure with the addition of an intermetatarsal and intercuneiform fusion. Our hypothesis is that this will improve the procedure outcomes and decrease deformity recurrence. Methods We reviewed patient charts who underwent the procedure between 2014 and 2017 performed by the senior author. This yielded 47 reviewable cases, with 34 meeting study criteria. The cases were analyzed for standard hallux valgus measurements (intermetatarsal angle [IMA], hallux valgus angle [HVA]) and fusion on X-ray. Results The results of the study showed partial intermetatarsal and intercuneiform fusion failure in seven (20%) cases, and one case where the great toe fell into varus. These cases were excluded. In the remaining cases, there was a statistically significant improvement in the HVA and IMA between the preoperative X-ray and first postoperative X-ray. Additionally, there was no significant difference between HVA and IMA between first and final postoperative radiographs. There was a significant increase in IMA for the fusion failure cases (p=0.001). Conclusion Clinically, our findings demonstrate that successful union is possible with low recurrence and complication rates when using this modification of the Lapidus procedure in patients with hallux valgus deformity.

We previously showed that exposure to a high-sugar and moderate-fat diet (i.e., Western diet [WD]) in mice induces appreciable skin inflammation and enhances the susceptibility to imiquimod-induced psoriasiform dermatitis, suggesting that dietary components may render the skin susceptible to psoriatic inflammation. In this study, utilizing an IL-23 minicircle-based model with features of both psoriasiform dermatitis and psoriatic arthritis, we showed that intake of WD for 10 weeks predisposed mice not only to skin but also to joint inflammation. Both WD-induced skin and joint injuries were associated with an expansion of IL-17A‒producing γδ T cells and increased expression of T helper type 17 cytokines. After IL-23 minicircle delivery, WD-fed mice had reduced microbial diversity and pronounced dysbiosis. Treatment with broad-spectrum antibiotics suppressed IL-23‒mediated skin and joint inflammation in the WD-fed mice. Strikingly, reduced skin and joint inflammation with a partial reversion of the gut microbiota were noted when mice switched from a WD to a standard diet after IL-23 minicircle delivery. These findings reveal that a short-term WD intake‒induced dysbiosis is accompanied by enhanced psoriasis-like skin and joint inflammation. Modifications toward a healthier dietary pattern should be considered in patients with psoriatic skin and/or joint disease.

OBJECTIVE To assess the involvement of the CCR6/CCL20 axis in psoriatic arthritis (PsA) and psoriasis (PsO) and to evaluate its potential as a therapeutic target. METHODS First, we quantified CCL20 levels in peripheral blood and synovial fluid from PsA patients and examined the presence of CCR6+ cells in synovial and tendon tissue. Utilizing an interleukin-23 minicircle DNA (IL-23 MC) mouse model exhibiting key features of both PsO and PsA, we investigated CCR6 and CCL20 expression as well as the preventive and therapeutic effect of CCL20 blockade. Healthy tendon stromal cells were stimulated in vitro with IL-1β to assess the production of CCL20 by quantitative polymerase chain reaction and enzyme-linked immunosorbent assay. The effect of conditioned media from stimulated tenocytes in inducing T cell migration was interrogated using a Transwell system. RESULTS We observed an up-regulation of both CCR6 and CCL20 in the enthesis of IL-23 MC-treated mice, which was confirmed in human biopsy specimens. Specific targeting of the CCR6/CCL20 axis with a CCL20 locked dimer (CCL20LD) blocked entheseal inflammation, leading to profound reductions in clinical and proinflammatory markers in the joints and skin of IL-23 MC-treated mice. The stromal compartment in the tendon was the main source of CCL20 in this model and, accordingly, in vitro activated human tendon cells were able to produce this chemokine and to induce CCR6+ T cell migration, the latter of which could be blocked by CCL20LD. CONCLUSION Our study highlights the pathogenic role of the CCR6/CCL20 axis in enthesitis and introduces the prospect of a novel therapeutic approach for treating patients with PsO and PsA.

Category: Other; Ankle; Ankle Arthritis; Bunion Introduction/Purpose: Foot and ankle surgeries are often be accompanied by a peripheral nerve block as a method of reducing post-operative pain. The major nerve targeted is the popliteal nerve. The nerve can be supplemented with a target of the adductor canal or saphenous nerve. Higher than expected complication rates with peripheral nerve blocks has led to increased concern among both surgeons as well as patients. To our knowledge, no study has been able to identify risk factors that may predispose a patient to one of these complications. Our goal was to attempt to identify those risk factors. Methods: We reviewed patient charts who underwent a foot and ankle procedure between 2014 and 2018 as performed by the senior author. The review yielded 992 procedures performed across four surgical locations. Of these, 137 procedures were removed because no regional block was used. The remaining cases were analyzed for nerve complications, defined as sensory (paresthesia, numbness, tingling, or burning pain) or motor (weakness or paralysis) deficits along the distribution of a peripheral nerve. The patients were divided into blocked patients with and without complications. The groups were evaluated for demographic differences. The categories consisted of age, sex, diabetic status, smoking, previous procedures, previously diagnosed neuropathies, surgical location, body mass index (BMI), race, and insurance provider. Statistical analysis was performed using SAS software. To determine significance of these different factors, Chi-square values were obtained for each data set. Additionally, a regression analysis was performed to identify odds ratio for individual factors. Results: The overall complication rate was 10.1% with a total of 855 blocks given. The significant factors associated with a complication were age (p=0.0061), BMI (p=0.0031), location (p=0.0016), and smoking status (p=0.0026). Factors that were not significantly associated with complications were sex, diabetes status, previous procedures requiring a block, previously diagnosed neuropathies, race, and insurance provider. A regression analysis was performed to determine odds ratio for individual factors. Those with significant higher odds ratio were age between 40-65 years, normal or underweight BMI, surgery occurring at an Outpatient Surgery Center, and current smoker. Conclusion: Current literature has reviewed operative variables such as tourniquet time and epinephrine use, while others have looked at diabetes and age as predictors of nerve block complications. Our study focuses more on epidemiological factors that can predict an increased risk. Our study helped to reinforce the findings previous literature has found in regards to age and diabetes status. This study has also introduced some new factors that can help the surgeon decide if a nerve block is necessary for each surgical patient. [Table: see text]

Introduction Isolated gastrocnemius equinus contracture has been associated with several foot and ankle pathologies within the literature. The Silfverskiold test is commonly used to identify isolated gastrocnemius contracture, however, the proper technique for performing the test has been scrutinized. The purpose of this study was to determine if there is a clinical significance in the ankle dorsiflexion that is obtained when the examination is performed incorrectly with a single hand versus the correct two-hand technique. Methods Thirty consecutive new patients with conditions associated with gastrocnemius equinus were included in the study. The Silfverskiold test was performed with a two-hand technique and a single-hand technique. The amount of dorsiflexion obtained with the knee in full extension was measured and recorded using an extendable goniometer for each technique, with the arms aligned with the fifth metatarsal and fibular head. Results The average amount of dorsiflexion that was obtained with the two-hand technique with the knee in full extension was 76.3°±4.2°. When the one-hand technique was utilized the average amount of dorsiflexion obtained with the knee in full extension was 88.4°±4.2°. This was found to be statistically significant (p

CCR6 is important for the trafficking of IL-17A–producing γδ T cells and required for the development of psoriasiform dermatitis in an IL-23 intradermal injection model. The role of CCR6, however, in IL-23–mediated joint inflammation is unclear. We herein hydrodynamically delivered IL-23 minicircle DNA into wild-type and CCR6-deficient (CCR6-knockout) mice to induce overexpression of IL-23 systemically. After IL-23 gene transfer, wild-type mice exhibited concurrent skin and joint changes that recapitulate some features found in human psoriatic skin and joints. CCR6-knockout mice were resistant to IL-23–induced skin inflammation but exhibited no changes in joint inflammation compared with wild-type mice. Depletion of neutrophils protected wild-type mice from skin and joint disease without suppressing T helper type 17 cytokine expression. In contrast, mice lacking γδ T cells showed a partial reduction in neutrophilic recruitment and a significant decrease in IL-17A expression in skin and paw tissue. Thus, in an IL-23–mediated model that allows concurrent assessment of both skin and joint disease, we showed that CCR6 is critical for inflammation in the skin but not in the joint. Furthermore, our data suggest that neutrophils and γδ T cells are key effector cells in IL-23–mediated skin and joint inflammation in mice.

Category: Bunion Introduction/Purpose: The Lapidus procedure is becoming more popular in the surgical correction of hallux valgus deformities. Bunion correction surgeries in general demonstrate good patient outcomes, however the recurrence rates are variable and are a concern for patient morbidity. The senior author of this study performs a modified Lapidus procedure where the first intermetatarsal, and first intercuneiform joints are fused along with the standard fusion of the first tarsometatarsal joint. We believe that this fusion will address the recurrence rate associated with the Lapidus procedure. Our theory is that recurrence occurs at the normally unfused intermetatarsal and intercuneiform joints, and when these joints are fused recurrence will be unable to occur. Methods: We reviewed the charts of patients who underwent the modified Lapidus procedure between 2014 and 2017 performed by the senior author. This review yielded 47 cases, of which 34 met the study criteria as a primary bunion repair with a preoperative X-ray, a postoperative X-ray at first surgical follow up, and a final postoperative X-ray =90 days postoperatively. Of the 13 charts that did not qualify, 11 had inadequate follow up data/radiographs, and 2 cases were revisions. The 34 remaining cases were then analyzed for IMA, HVA, and evidence of fusion on X-ray. Two patient subsets were created for additional analysis of the first and last postoperative X-rays with no patient overlap. 19 cases created subgroup A as they contained patients whose last postoperative X-rays were weight bearing. 6 cases were analyzed as subgroup B having final postoperative X-rays that were non-weight bearing. All first postoperative X-rays were non-weight bearing. Results: The average time of radiographic follow up was 10.5±8.9 months (range 3.1-41.5). There was evidence of fusion failure at the IMT joint in 7 cases (21%), and these patients were removed from group data analysis. Another case was excluded due to the great toe falling into varus. In the remaining 26 cases, the difference in IMA and HVA was significant between the last preoperative and first postoperative X-ray (pConclusion: Our study results suggest that the modified Lapidus procedure has good results in the short term, maintaining the operative reduction at a mean follow up time of 10 months. Our hypothesis that the intermetatarsal and intercuneiform joint fusion prevents bunion recurrence is supported by the fused cases showing no significant differences after at least 90 days postoperatively, while the unfused cases showed significant changes to their IMA angles after at least 90 days postoperatively. Although the study population is small, our data suggests that this procedure can maintain the correction achieved in surgery.

Category: Ankle, Sports Introduction/Purpose: Chronic lateral ankle instability (LAI) is a common cause of ankle pain. Surgical interventions have been shown to be highly effective in alleviating patient’s symptoms once conservative care has failed. Stress radiographs have not demonstrated a clear efficacy in diagnosing ankle instability. Currently, MRI is considered to be superior to stress radiographs in the available literature. Unfortunately, the literature comparing these methods is limited. The purpose of this study is to compare the results of an MRI and manual inversion stress radiographs, in order to assess the accuracy of each modality in assessing the lateral ankle ligament competence. We believe that stress radiographs may have more value in confirming chronic ankle instability than the more expensive MRI imaging. Methods: A retrospective chart review was performed between January 2016 - July 2018 for patients diagnosed with LAI. The review identified 318 cases, of which 57 met the study criteria of having both an AP manual inversion stress radiographs, assessed by the senior author, and MRI, interpreted by a musculoskeletal radiologist, occurring within 6 months of each other without an acute injury within 12 weeks of the first image. For the remaining 57 cases, the imaging was reviewed in the following manner. For the MRI studies, the report was read from the radiologist assessing the lateral ankle complex. A positive MRI was denoted as pathology being reported by the radiologist. For the manual inversion stress radiograph, measurements were made to assess the degree of talar tilt while being stressed. A positive stress radiograph was identified based on asymmetry of the ankle joint during the stress. Results: The average time between imaging studies was 7.2±7.4 weeks (range 0.5-24 weeks). Of the 57 cases that qualified for the study, 43 (75%) had a positive stress radiograph, and 21(37%) had a positive MRI. 24 cases (42%) demonstrated a positive stress radiograph with a negative MRI, while 2 cases (4%) demonstrated a negative stress radiograph with a positive MRI. In respect to talar tilt, those patients identified as having a positive stress radiograph also had a higher average talar tilt when compared to those who did not. The degree of talar tilt for each set of criteria is summarized in Table 1. Conclusion: Historically, lateral ankle instability has been a clinical diagnosis. When further imaging is needed, our data suggests stress radiographs may demonstrate a higher reliability than MRI when assessing the competence of the lateral ankle ligaments. Asymmetry in a joint during an inversion stress examination has been shown to be indicative of multi ligament involvement. Few studies have attempted to define a talar tilt consistent with instability and our data does not meet those numbers. However, with the addition of bundled care and rising health care costs, we believe this provides a potential alternative in confirming a diagnosis of ankle instability.

BackgroundA clinical decision support system (CDSS) covers a broad spectrum of applications, for example, screening reminders, can reduce malpractice, improve preventive services and enable better management of chronic conditions. CDSSs have traditionally been used successfully in large hospitals. The availability (ie, whether the function is provided by the software) and usage (ie, actual use) of a CDSS in office-based primary care settings, however, are less well studied.ObjectiveTo establish a benchmark of CDSS availability and usage in office-based primary care settings, particularly given the large volume of visits in such settings.MethodsWe used the 2015 Centers for Disease Control and Prevention’s National Ambulatory Medical Care Survey to conduct secondary data analysis. We selected preventive services reminders and drug interaction alerts, along with several other variables as examples of a CDSS.ResultsCDSS usage rates ranged from 68.5% to 100% among solo or non-solo primary care practices owned by physicians or physician groups that have electronic medical records (EMRs)/electronic health records (EHRs) and 44.7% to 96.1%, regardless of EMR/EHR status. According to proportion tests, solo practices had significantly lower CDSS usage and availability rates on several measures if the practice is entirely EMR/EHR based and significantly lower (16.3%–28.9%) CDSS usage rates than did non-solo practices on each measure, regardless of EMR/EHR status.ConclusionIn the USA, a CDSS, especially under the categories of basic preventive reminders and drug interaction alerts, is used routinely between 68% and 100% in primary care if a practice is entirely EMR/EHR based. More work is needed, however, to determine the reasons for large usage gaps between solo and non-solo practices and to reduce such gaps.

Category: Hindfoot Introduction/Purpose: Plantar fasciitis is a debilitating problem that can cause long-term pain. Multiple different studies with various modalities have been suggested to treat the inflammation of the plantar fascia. None of them have provided a cause for the inflammation. A few recent studies have shown gastrocnemius equinus to be a driving factor in foot pain, which includes plantar fasciitis. Our belief is that the inflammation is due to a stretch placed on the plantar fascia due to a gastrocnemius equinus contracture and the beginning of an arch collapse per the Grand Rapids arch collapse model. As such, we wanted to review our results with an isolated gastrocnemius recession for the treatment of plantar fasciitis. Methods: We retrospectively reviewed patient data collected by isolating ICD-9 and ICD-10 codes for plantar fasciitis. These patients presented to the senior author’s office with a complaint of plantar heel pain, were diagnosed with a gastrocnemius equinus contracture and plantar fasciitis, failed conservative treatment, and opted for an isolated gastrocnemius recession as a definitive treatment of the fasciitis. From the timeframe of 1/1/2015 to 6/12/17, there were 68 out of 97 patients who qualified for the study based on the necessary criteria: an initial consultation pain score, initial post-operative pain score at two weeks, and second post-operative pain score at eight weeks. These patients did not have coexisting surgeries at the time of the gastrocnemius recession or prior surgery to the area in discussion. Results: For the 68 patients (five of which underwent bilateral procedures at a minimum of six weeks apart), who elected to have a gastrocnemius recession for plantar fasciitis, the average initial presenting pain was a 7.4 on a scale of 0 to 10. The average initial post-operative pain score was 2.8 and the average second post-operative pain score was 3.3. The average number of days from initial to second post-operative appointment was 136 days. Of the 68 patients, 21 returned after their eight-week post-operative visit for evaluation. Only 3 returned with recurrent plantar heel pain, 4 more presented with new onset tarsal tunnel syndrome, three more with heel pain different from their pre operative pain and the remaining patients had new onset unrelated pain. Conclusion: We have demonstrated that an isolated gastrocnemius recession can decrease the pain score in patients with recalcitrant plantar fasciitis. Follow up care beyond eight weeks post operation is not routinely performed due to the limited nature of the procedure. The improvement demonstrated in the VAS scores of the patients included in this study show a definite improvement and as such, we believe that an isolated gastrocnemius recession should be considered as a definitive treatment of plantar fasciitis. Future prospective randomized studies will need to be completed to further evaluate the effectiveness of this procedure.