Residual Gap Research Articles

Abdominal Wall Expanding System. Intraoperative Abdominal Wall Expansion as a Technique to Repair Giant Incisional Hernia and Laparostoma. New and Long-Term Results From a Three-Center Feasibility Study.

The abdominal wall expanding system (AWEX) was first applied in 2012 and published in 2017. This novel technique was developed to reconstruct complex incisional hernias and residual skin-grafted laparostoma after treatment of an open abdomen, when primary midline closure was impossible. The main aim was the anatomical reconstruction of the abdominal wall and the avoidance of dissecting techniques (component separation). Between 2012 and 2019, 33 patients underwent AWEX hernia repair in three certified hernia centers. The retracted abdominal wall was stretched with the AWEX system intraoperatively for approximately 30min. Hernia size was measured preoperatively, on CT, and intraoperatively. The gain in length on the lateral abdominal wall (decrease in width of the defect) after stretching and any residual midline gap were determined in the OR. 33 patients underwent AWEX procedures. Six cases were evaluated separately because of additional procedures (TAR, four cases) and preoperative application of botulinum toxin (two cases). The median (95% confidence interval) measured width of hernia defects was 13 (12-16) cm, the median gain in length on the lateral abdominal wall was 12 (10-15) cm. After median follow-up of 29 (12-54) months, one recurrence from the broken mesh was observed. No method-related complications occurred. Based on the 2017 and current results, the AWEX system represents an alternative or supplemental procedure to current techniques for complex abdominal wall reconstruction. The system proved again to be time-saving, safe, effective, and easy to learn. Further studies with enhanced technology are in progress.

The accuracy of gap and step-off measurements in acetabular fracture treatment

The assessment of gaps and steps in acetabular fractures is challenging. Data from various imaging techniques to enable accurate quantification of acetabular fracture displacement are limited. The aim of this study was to assess the accuracy of pelvic radiographs, intraoperative fluoroscopy, and computed tomography (CT) in detecting gaps and step-offs in acetabular fractures. Sixty patients, surgically treated for acetabular fractures, were included. Five observers (5400 measurements) measured the gaps and step-offs on radiographs and CT scans. Intraoperative fluoroscopy images were reassessed for the presence of gaps and/or step-offs. Preoperatively, 25% of the gaps and 40% of the step-offs were undetected on radiographs compared to CT. Postoperatively, 52% of the gaps and 80% of the step-offs were missed on radiographs compared to CT. Radiograph analysis led to a significantly smaller gap and step-off compared to the CT measurements, an underestimation by a factor of two. Approximately 70% of the residual gaps and step-offs was not detected using intraoperative fluoroscopy. Gaps and step-offs that exceed the critical cut-off indicating worse prognosis often remained undetected on radiographs compared to CT scans. Less-experienced observers tend to overestimate gaps and step-offs compared to the more-experienced observers. In acetabular fracture treatment, gaps and step-offs were often undetected and underestimated on radiographs and intraoperative fluoroscopy in comparison with CT scans. This means that CT is superior to radiographs in detecting acetabular fracture displacement, which is clinically relevant for patient counselling regarding treatment decisions and prognosis.

Sexism, household decisions, and the gender wage gap

We develop an index of local sexism for the United States using publicly available Google Trends data. We shed light on the correlates of local sexism and find that the most important factors that predict it are the economic outcomes of men. Finally, we show that online sexism is associated with higher levels of the residual gender wage gap, the wage gap after controlling for education, occupation, industry, and age. We find evidence for a direct association of sexism with the wage gap, consistent with labor market discrimination and an indirect association that works through household decisions which themselves are associated with wages.

Mechanics, modeling and seismic behavior of a dual-core self-centering brace in series with a frictional gusset connection

An all-steel dual-core self-centering brace (DC-SCB) has been developed to provide a self-centering and energy-dissipative response, which can reduce residual deformations of buildings in a large earthquake. The self-centering property of the brace is provided by elastic tensioning elements, but the surpassing yield strain of the tensioning elements under loading may decrease the elastic restoring force and increase the residual displacement of the brace. A high-performance DC-SCB that has a DC-SCB in series with a frictional gusset connection (FGC) is proposed to prevent the initial force of tensioning elements from decreasing by the FGC movement. The mechanics and the hysteretic response of the high-performance DC-SCB are first presented. The DC-SCBs with and without the FGC are modeled by a finite element program to verify the cyclic performance and the advantage of using the FGC. Then, a 5275 mm-long high-performance DC-SCB is tested for the verification; a full-scale one-story frame with a high-performance DC-SCB is also cyclically tested. Test results show that the local buckling of the beam occurred at 1.5% drift; the FGC activation and the beam lateral-torsional buckling (LTB) occurred at 2.3% drift. Moreover, three ten-story frames with and without the high-performance DC-SCB are analyzed to (1) validate the modeling scheme of the DC-SCB in series with the FGC, and (2) evaluate the seismic responses in earthquake motions. The high-performance DC-SCB is demonstrated to prevent the PT elements from exceeding the elastic deformation limit by using the additional FGC device in series at the brace end. However, an unexpected residual gap at the brace end after the FGC activation causes un-symmetric brace response in subsequent loading.

Pedicle subtraction osteotomy with patient-specific instruments

BackgroundAlthough the utility of patient-specific instruments (PSI) has been well established for complex osteotomies in orthopedic surgery, it is yet to be comparatively analyzed for complex spinal deformity correction, such as pedicle subtraction osteotomy (PSO). MethodsSix thoracolumbar human cadavers were used to perform nine PSOs using the free-hand (FH) technique and nine with PSI (in total 18 PSOs). Osteotomy planes were planned on the basis of preoperative computed tomography (CT). A closing-wedge angle of 30° was targeted for each PSO. Postoperative CT scans were obtained to measure segmental lordosis correction and the deviation from the planned 30° correction as well as the osseous gap of posterior elements. ResultsThe time required to perform a PSO was 18:22 (range 10:22–26:38) min and 14:14 (range 10:13–22:16) min in the PSI and FH groups, respectively (p = 0.489). The PSI group had a significantly higher lordosis gain (29°, range 23–31° vs. 21°, range 13–34°; p = 0.015). The lordosis gain was significantly more accurate with PSI (deviation angle: 1°; range 0–7°) than with the FH technique (9°; range 4–17°; p = 0.003). PSI achieved a significantly smaller residual osseous gap of the posterior elements (5 mm; range 0–9 mm) than the FH group (11 mm; range 3–27 mm; p = 0.043).With PSI, an angular difference of 3° (range 1–12°), a translational offset of 1 (range 0–6) mm at the level of the lamina, and a vertebral body entry point deviation of 1 (range 0–4) mm was achieved in the osteotomies. ConclusionsPSI-guided PSO can be a more feasible and accurate approach in achieving a planned lordosis angle than the traditional FH technique in a cadaver model. This approach further reduced osseous gaps, potentially promoting higher fusion rates in vivo.

Rediseño institucional para el cierre de brecha residual de telecomunicaciones en Perú: Una tercera vía de intervención para la emergencia de redes comunitarias sostenibles

The problem of the lack of connectivity in a large part of the world has been further exposed due to the pandemic COVID-19; particularly in Latin America and the Caribbean, including in Peru. We have witnessed the lack of Internet access limits the conditions of development and widens the social and economic gaps among the people connected in urban areas and those who are not connected in rural areas. This problem has a multidimensional nature and arises from several underlying and structural causes that have been widely diagnosed so far. In this regard, this paper is focused on Peru, but it is potentially applicable to Latin America and the Caribbean. The new contribution is the definition of the residual gap of rural telecommunications (“residual gap”), understood as the group of localities that are not either prioritized or to be prioritized by the private sector or the traditional public interventions in the short and medium term. Likewise, we have analyzed the effectiveness of the current institutional design to deal with the connectivity gap and have proposed the incorporation of a third channel for the whole “residual gap”: a model of bottom-up governance for the emergency of sustainable community networks. According to its characteristics, this third channel demands the reconfiguration of the roles in the different social classes and enables the inclusion of territoriality and interculturality approaches in a wide range of geographical spaces. Finally, even though the localities that are part of the residual gap are characterized by a range of adverse conditions for the provision of traditional telecommunication services or others, for the rural Peruvian case, a great residual gap has a huge community network, beyond telecommunications (e.g. rural communities, indigenous populations, water and irrigation associations, etc.). This previous condition is a great advantage for the successful application of the model of community networks proposed in the institutional redesign. Its identification of opportunities is the third contribution of this paper.

Intra-articular fibromembranous septum after intra-articular distal radial fracture: Arthroscopic excision and factors associated with formation of the septum

BackgroundIntra-articular fibromembranous septum in the radiocarpal joint can cause wrist contracture after distal radial fracture, but the mechanism underlying the formation of the septum is unknown. This study examined the clinical outcomes in patients treated with arthroscopic excision of the septum and the factors associated with formation of the septum in patients with and without a septum. MethodsFifty-three patients (22 with septum and 31 without septum) treated for intra-articular distal radial fracture with arthroscopy using a volar locking plate and secondary removal of the plate were included. Clinical outcomes and radiological assessments were analyzed. ResultsIn patients with a septum, the range of wrist flexion and total wrist arc before the second operation were significantly more limited than in those without a septum (p < 0.01 and p = 0.03, respectively). The improvement rate (improvement in wrist arc divided by the wrist arc of the healthy side) after arthroscopic excision of the septum and plate removal was greater in patients with a septum than in those without a septum (6.1% vs. 2.0%, p = 0.08). The significant factors affecting formation of the septum were the residual articular gap and the height of the midradial ridge on computed tomography images. ConclusionsIntra-articular fibromembranous septum after surgically treated intra-articular distal radial fracture affects limited range of motion and secondary arthroscopic excision of the septum improves the wrist range of motion. Anatomical reduction and maintenance of the articular fragment, as well as anatomical characteristics might be causes of septum formation.

Correlation between functional outcome and the SAMEO-ATO framework.

PurposeTo evaluate the recently proposed SAMEO-ATO framework for middle ear and mastoid surgery, by correlating it with the functional outcome in a large cohort of patients operated for middle ear and mastoid cholesteatoma in a tertiary referral center.MethodsWe retrospectively included all surgeries for middle ear and mastoid cholesteatoma undergone in our Department between January 2009 and December 2014, by excluding revision surgeries, congenital and petrous bone cholesteatoma. All surgeries were classified according to the SAMEO-ATO framework. The post-operative air bone gap (ABG) was calculated and chosen as benchmark parameter for the correlation analysis.Results282 consecutive surgeries for middle ear and mastoid cholesteatoma were released in the study period on a total of 273 patients, with a mean age of 41.2 years. All patients were followed for an average period of 55.3 months. 54% of patients underwent M2c mastoidectomy (Canal Wall Down, CWD), while the remaining underwent Canal Wall Up (CWU) procedures, being M1b2a mastoidectomy the most common one (33%). Mean pre-operative and post-operative ABGs were 29.2 and 23.5 dB, with a significant improvement (p < 0.0001). ‘Mastoidectomy’ and ‘Ossicular reconstruction’ parameters of SAMEO-ATO showed significant association with postoperative ABG, with smaller residual gaps for the classes Mx and On, and worse hearing results for M3a and Ox.ConclusionOur results show the utility of SAMEO-ATO framework, and in particular of ‘M’ (Mastoidectomy) and ‘O’ (Ossicular reconstruction) parameters, in predicting the hearing outcome.

Prevalence, characteristics, and predictors of endocardial and nonendocardial conduction gaps during local impedance-guided extensive pulmonary vein isolation of atrial fibrillation with high-resolution mapping.

Local impedance (LI) drops during radiofrequency ablation can predict lesion formation. Some conduction gaps during pulmonary vein isolation (PVI) can be associated with nonendocardial connections. This study aimed to investigate the incidence, characteristics, and predictors of endocardial and nonendocardial conduction gaps during an LI-guided PVI. We prospectively enrolled 157 consecutive patients undergoing an initial LI-guided extensive PVI of atrial fibrillation (AF). After the first-pass encirclement, the residual conduction gaps and reconnected gaps were mapped using Rhythmia (Boston Scientific) and a mini-basket catheter. Right and left PV (RPV/LPV) gaps were observed in 22.3% and 18.5% of the patients, respectively: 27 endocardial and 49 nonendocardial gaps. The carina regions were common sites for the gaps (51 carina-related vs. 25 noncarina-related). The carina-related gaps consisted of more nonendocardial gaps than endocardial gaps (RPVs: 90.0% vs. 10.0%, p = .001; LPVs: 76.2% vs. 23.8%, p < .001). A univariate analysis revealed that paroxysmal AF and the left atrial (LA) volume index for RPV endocardial gaps (odds ratio [OR]: 8.640 and 0.946; p = .043 and 0.009), minor right inferior PV diameter for RPV nonendocardial gaps (OR: 1.165; p = .028), and major left inferior PV diameter for LPV endocardial gaps (OR: 1.233; p = .028) were significant predictors. During the LI-guided PVI, approximately two-thirds of the conduction gaps were nonendocardial. The carina regions had more conduction gaps than noncarina regions, which was due to the presence of nonendocardial connections. Paroxysmal AF, a lower LA volume index, and larger inferior PV diameters may increase the risk of conduction gaps.

Evaluation of different ablation strategies verifying the optimal overlap ratio in point-by-point laser balloon ablation for patients with atrial fibrillation.

BackgroundOptimal overlap ratio remains unclear in point-by-point laser balloon (LB) ablation.ObjectiveThis study sought to determine the optimal overlap strategy with target energies on the acute and chronic outcomes in LB pulmonary vein (PV) isolation (PVI).MethodsConsecutive 38 patients (148 PVs) with atrial fibrillation underwent the first-generation LB PVI with the following protocols based on the overlap ratios for each PV anterior/posterior wall: 50%/50% (13 patients [49 PVs], group A), 50%/25% (15 patients [60 PVs], group B), and 25%/25% (10 patients [39 PVs], group C). High energies (240–255 J: 12 W / 20 seconds, 8.5 W / 30 seconds), moderate energies (200–210 J: 10 W / 20 seconds, 7 W / 30 seconds), and low-to-moderate energies (low, 165–170 J: 5.5 W / 30 seconds, 8.5 W / 20 seconds) were targeted for left PV anterior walls, right PV anterior walls, and bilateral PV posterior walls, respectively. First-pass PVI, the other procedure-related data, and atrial tachyarrhythmia recurrences were analyzed.ResultsFirst-pass PVI rate per PV was higher in group A (94%) than in group B (88%) and group C (62%) (P < .001). All PVs were finally isolated. First-pass time, total LB PVI time, complications, and atrial tachyarrhythmia recurrences during a mean follow-up of 11 ± 5 months did not differ between the groups. A few residual gaps after first-pass LB ablations were found for PV anterior walls even in group A and group B.ConclusionSufficiently overlapped LB ablation promises a high rate of first-pass PVI without adverse outcomes. High energy could be required for PV anterior walls.

Three dimensional changes of alveolar bone after flapless immediate implant placement

Objectives The aim of this study was to evaluate clinically and radiographically alveolar Bone dimensional Changes after flapless immediate implant placement. Material and methods: Thirty-two Patients were divided into two groups; Group A (control group): received flapped immediate implants combined with xeno graft. Group B (Test group): received flapless immediate implants combined by xeno-graft. Evaluation includes Presence of infection.Wound dehiscence. Implant exposure. Graft exposure or loss. Soft tissue dehiscence. Implant stability. Buccal bone height and lingual bone height of the extracted socket. Ridge width. Results: buccal bone height, flapless group showed a significant lower (0.09 mm)Change than flap (1.13 mm).Ridge width, at 2, 4, 6 mm, flapless group showed a significant lower Change than flap. Flapless group showed significant higher implant stability than flap. Conclusion:the flapless group has shown a lower reduction in height and width after placing immediate implants and filling the residual gap with an organic bovine bone. More ridge reduction was observed for the flapless group.

Atrial trigeminy induced at a specific pacing cycle length in a patient with residual pulmonary vein conduction gap

We report a case of atrial trigeminy induced only at a specific pacing cycle length in a patient with residual pulmonary vein conduction gap.

Incidence and location of residual gaps identified by a high-density grid-style catheter after PVI is confirmed by pacing the ablation lines

Abstract Funding Acknowledgements Type of funding sources: None. Background The continual pursuit of more durable pulmonary vein isolation (PVI) has led ablationists to evaluate many different techniques for confirming isolation. One such technique involves using the ablation catheter to pace along the ablation lines, ensuring loss of pace capture. Initial observations from a small cohort of patients suggested that a high-density, grid style mapping catheter (HD Grid) enabling simultaneous recording of adjacent bipolar EGMs in two directions (HD Wave) may identify residual gaps that are missed when using the technique of pacing the ablation line in isolation. The true incidence of these residual gaps as identified in a large patient population has not been previously reported. Purpose To quantify in a large cohort of AF ablation patients, the presence of residual gaps identified by HD Grid which are missed by a technique of pacing along the ablation lines with the ablation catheter. Methods Self-reported data was prospectively collected in AF radiofrequency ablation procedures in which PVI was first confirmed by pacing along the ablation line followed by assessment using the HD Grid. Procedural characteristics and acute outcomes, including the incidence and location of gaps post-ablation, were analyzed. Results Data was collected in 111 AF ablation procedures performed in 18 centers across the United States and Europe. Paroxysmal (PAF), persistent (PersAF), and longstanding persistent AF (LsPersAF) accounted for 60.4%, 33.3%, and 6.3% of cases, respectively. Overall, 64.0% of ablations were de novo procedures. Following ablation, PVI was confirmed in all cases by pacing the ablation line with an average output of 9.1 ± 2.6mA and pulse width of 2.1 ± 0.5ms. Adenosine was administered in 3.6% of cases, isoproterenol in 3.6%, and a combination in 0.9%. PVI was then reassessed with HD Grid using a variety of techniques including exit block (91.0%), voltage mapping (82.0%), loss of pace capture along the ablation lines (47.7%), and entrance block (27.0%); note: total exceeds 100% as more than one technique may be used in a single case. A second dose of adenosine was administered in 2.7% of cases; isoproterenol in 2.7%. The HD Wave configuration was used in 96.4% of cases. HD Grid identified a total of 130 gaps in 65 (58.6%) patients, which were missed by pacing the ablation line (Figure 1). Conclusions In over half of the patients evaluated, the HD Grid identified residual PVI gaps that were missed when isolation was confirmed by using the ablation catheter to pace the ablation lines. These results suggest that the pacing technique, used in isolation, is not sufficient for complete gap detection. One limitation of this analysis was the use of a workflow which consistently assessed PVI with the HD Grid following confirmation of isolation by pacing the ablation lines. Despite this limitation, the rate at which residual gaps were identified is noteworthy and likely warrants additional study. Abstract Figure.

Incidence of residual gaps identified by a high-density grid-style catheter post-cryoballoon ablation for atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Despite advances in cardiac ablation technologies and the introduction of single-shot ablation devices such as the cryoballoon, the ability to consistently achieve complete and durable PVI remains elusive. While this is often attributed to PV reconnections that develop after the index procedure, recent data has suggested that traditional diagnostic techniques and technologies may in fact fail to identify gaps that remain upon completion of the index ablation. Initial observations in a small cohort of patients suggested that these residual gaps could be detected by a high-density, grid-style mapping catheter (HD Grid) post-cryoballoon ablation (CBA). The true incidence of these residual gaps as identified in a large patient population has not been previously reported. Purpose To quantify in a large cohort of CBA procedures, the presence of residual gaps identified by HD Grid which are missed by standard techniques of PVI confirmation using a 3.3F circular mapping catheter (CMC). Methods Self-reported data was prospectively collected in CBA procedures in which PVI was first confirmed using CMC followed by assessment using the HD Grid. Procedural characteristics and acute outcomes, including the incidence and location of residual gaps were analyzed. Results Data was collected in 150 CBA procedures performed in 24 centers across the US, Europe and Japan. De novo and repeat ablations represented 78.7% and 12.0% of cases, respectively (9.3% NR). A left common PV was present and ablated in 5.3%; right common in 0.7%. The CMC was used to confirm isolation in all cases using a variety of techniques including voltage mapping (73.3%), exit block (54.7%), and entrance block (29.3%); note: total exceeds 100% as &amp;gt;1 technique may be used in a single case. PVI was then reassessed with HD Grid, enabling a direct comparison of the two technologies. The HD Wave configuration, measuring simultaneous orthogonal bipoles, was used in 94.0% of cases. HD Grid identified a total of 119 gaps in 41 (27.3%) patients, which were missed by the CMC (Figure 1). Conclusions Assessment of PVI using the HD Grid identified residual PV conduction gaps that were missed by the CMC and standard diagnostic techniques in over a quarter of the patients evaluated. One limitation of this analysis is that the technique(s) used for confirmation of PVI were left to the discretion of the operator. Additionally, this analysis includes only workflows in which PVI was confirmed with HD Grid after confirmation using the CMC. Considering the prevalence of residual gaps observed, it is reasonable to interpret that new diagnostic catheter technologies could be critical in the pursuit of more complete and durable PVI, potentially impacting long-term clinical outcomes. Further study on other high-density mapping catheter configurations would be warranted before extrapolating these results to different technologies. Abstract Figure.

Efficacy and safety of a high power short duration ablation-index guided protocol for pulmonary vein isolation using a single catheter

Abstract Funding Acknowledgements Type of funding sources: None. Background Catheter ablation for atrial fibrillation (AF) is the most common performed electrophysiological procedure. The cost of this procedure remains high. Purpose To improve health care utilization, we aimed to compare the efficacy and safety of a minimalistic, streamlined single radiofrequency catheter ablation approach using high power short duration ablation-index guided protocol (HPSD) vs. a standard single catheter protocol. Methods A circular mapping catheter free PVI with a single transseptal puncture was performed in 91 patients. A CARTO fast anatomical map was performed with the ablation catheter. Pacing maneuvers were used to confirm exit block. Procedural characteristics and success rates were compared using HPSD- vs. a standard ablation-protocol. Freedom from recurrence was defined as a 1-year absence of AF episodes &amp;gt; 30 s, beyond the 3-month-blanking-period. Results Using the HPSD-protocol the median procedure, map and RF ablation time were significantly shorter in the HPSD group compared to the standard group, 84 (IQR 76-100) vs. 118 minutes (IQR 104-141), 12 (IQR 10-16) vs. 18 minutes (IQR 15-21) and 1036 (898-1184) vs. 1949 seconds (IQR 1693-2261), respectively, P &amp;lt; .001 for all. First-pass-PVI was achieved using the HPSD-protocol in 23 patients (74%) and the standard-protocol in 30 patients (53%), p = 0.08. Localization of conduction gaps are illustrated for the HPSD-protocol and the standard-protocol in Figure 1. The residual gap was identified using the ablation catheter only in all patients. No procedural complication were observed. At 12 months follow-up, 60 (89.6%) patients remained free from AF with no differences between groups. Conclusions A minimalistic, CMC-free HPSD-guided PVI approach is very efficient, safe, likely cost-saving, and associated with excellent clinical outcomes at 1 year. Abstract Figure 1

Determination of the permittivity of materials in a volume resonator with allowance for the surface roughness

The accuracy of determining the permittivity of the material depends on the thickness of the intermediate layer with variable dielectric characteristics formed on the surface of the sample upon manufacturing. We present the results of studying the influence of the surface roughness of the test sample on the accuracy of determining the permittivity using the resonator method. An algorithm for calculating the permittivity in a volumetric cylindrical resonator is proposed, taking into account the roughness value and the residual gap. Using the matrix method for calculating the wave transmitted through the plate, a model for determination of the dielectric permittivity of a multilayer sample using a measuring resonator is developed. The results obtained can be used to improve the accuracy of the permittivity determination in a volume resonator when testing the samples with a roughness exceeding the required standard.

Reduction of olecranon fractures with no or minimal dorsal cortex comminution based on the contour of the posterior ulnar cortex: does it restore the greater sigmoid notch?

When treating olecranon fractures surgically, surgeons rely on the contour of the posterior cortex of the proximal ulna. However, it is unclear whether the greater sigmoid notch (GSN) is restored anatomically by this method. We analyzed whether reduction of fractures based on the posterior ulnar cortex contour is reliable for restoration of the GSN contour in displaced olecranon fractures with no or minimal dorsal cortex comminution. We performed a retrospective review of 23 patients with Mayo type 2 olecranon fractures with no or minimal dorsal cortex comminution who were treated surgically. We analyzed pre- and postoperative elbow CT images and measured the interfragmentary distance (IFD), articular step-off, articular gap, contour defect and GSN angle to evaluate the restoration of the GSN contour. The mean preoperative IFD and contour defect were 16.5 mm (range 4.3-35.6 mm) and 4.3 mm (range 0.7-13.3 mm), respectively. Postoperatively, there was no residual IFD, and the mean contour defect decreased significantly to 1.4 mm (range 0-3.7 mm). The residual articular step-off and gap were 0.2 mm (range 0-3.8 mm) and 1.0 mm (range 0-5.9 mm), respectively. Acceptable GSN restoration was achieved in 14 of 23 patients (60.9%). Sixteen patients had > 2 mm of preoperative contour defect, and 7 (43.8%) achieved acceptable GSN restoration; the remaining 7 patients (100%) who had < 2 mm of the contour defect achieved acceptable GSN restoration. Patients whose preoperative contour defect was > 2 mm had a higher risk of unacceptable GSN restoration, with an odds ratio of 2.29 (p = 0.019). In displaced olecranon fractures without significant dorsal cortex comminution, reduction based on the posterior ulnar cortex could be reliable for fractures with under 2 mm of preoperative contour defect, but not for those with > 2 mm of contour defect. IV.

Oncologist management of NTRK fusion-positive NSCLC improves after virtual patient simulation participation.

e23008 Background: Although relatively rare, neurotrophic receptor tyrosine kinase (NTRK) fusions, represent a clinically relevant subgroup of NSCLC that can derive benefit from targeted therapies. Relatively quick and durable responses have been achieved with these targeted therapies in advanced NSCLC and intracranial activity has also been observed. The objective of this study was to determine if an online, virtual patient simulation (VPS)-based continuing medical education (CME) intervention improved performance of oncologists in using appropriate strategies to diagnose and manage patients with NTRK fusion-positive advanced NSCLC. Methods: The CME intervention consisted of two patient cases presented in a VPS platform that allowed learners to order lab tests, diagnoses and treatments in a manner matching the scope and depth of actual practice. Clinical decisions made by the learners using open field entries within an EHR interface were analyzed and, after each decision, tailored clinical guidance (CG) was provided based on current evidence and expert recommendation. Learner decisions were collected post-CG and compared with each user’s baseline (pre-CG) data using a McNemar’s test to determine P values. Results were then aggregated for the two cases based on clinical decisions and stratified by practice setting. The activity posted July 31, 2020; data were collected through December 1, 2020. Results: Overall significant improvements were seen after CG in clinical decisions made by oncologists in both the community and academic settings [reported as % absolute improvement (% correct pre-CG vs % correct post-CG); P value]. Conclusions: This analysis demonstrated that VPS that immerses and engages oncologists in an authentic and practical learning experience can significantly improve evidence-based clinical decisions related to the diagnosis and management of patients with NTRK fusion-positive advanced NSCLC. Despite the improvements, additional educational activities are needed to address any residual gaps and further increase oncologists’ ability in this clinical setting.[Table: see text]

CME curriculum improves clinician knowledge, competence, and confidence in managing patients with NF1-related tumors.

e23009 Background: Neurofibromatosis type 1 (NF1) is an uncommon complex autosomal dominant disorder caused by germline mutations in the NF1 tumor suppressor gene. Therapeutic options have historically been limited with surgical debulking being the preferred treatment modality. However, recent clinical data have shown improved outcomes with the use of MEK inhibitors. The objective of this study was to assess the educational impact of a series of continuing medical education (CME) activities on the knowledge, competence, and confidence of physician learners with respect to the treatment of NF1-related tumors. Methods: The educational series consisted of four online, CME-certified activities. For each activity, educational effect was assessed with a repeated pairs pre-/post-assessment study including a 3-item, multiple choice, knowledge/competence questionnaire and one confidence assessment question, with each participant serving as his/her own control. To assess changes in knowledge, competence, and confidence data from all clinicians who completed both pre- and post-questions were aggregated across activities, stratified by learning theme, and evaluated by target specialty. A repeated pairs pre-/post-assessment study design was used and McNemar’s test or paired samples t-test (P &lt; .05) assessed educational effect. The first activity in the series launched Dec. 2019 and the last launched June 2020; data were collected until Dec. 2020. Results: Overall significant improvements were seen after education for oncologists (N = 258, P &lt; .001), neurologists (N = 474, P &lt; .001), surgeons (N = 427, P &lt; .001), neurosurgeons (N = 93, P &lt; .05), and pediatricians (N = 56, P &lt; .001), regardless of practice setting. A sub-analysis of community specialists also showed significant improvements after education: oncologists (N = 117, P &lt; .01), neurologists (N = 188, P &lt; .001), and surgeons (N = 206, P &lt; .001). Outcomes assessed by learning themes and specialty showed relative percent increases, with the majority being statistically significant. Conclusions: This analysis demonstrates that oncologists’ and other specialists’ knowledge, competence, and confidence regarding the treatment of NF1-related tumors improved after education, as measured through a comprehensive analysis of CME outcomes data from a variety of activities designed to achieve these ends. These results have the ability to translate to improvements in clinical care. Despite the improvements, additional educational activities are needed to address residual gaps and further increase clinicians’ ability in this clinical setting.

Characterizing clinical outcomes and factors associated with conduction gaps in VISITAG SURPOINT-guided catheter ablation for atrial fibrillation.

PurposeAlthough usefulness of VISITAG SURPOINT (VS) on pulmonary vein isolation (PVI) in catheter ablation of atrial fibrillation has been reported, optimal VS thresholds can depend on the inter‐tag distance (ITD) and vice versa. We validated the efficacy of PVI with lower target ITDs and VS values than in previous studies.MethodsRetrospective review of consecutive patients (N = 100) with paroxysmal (n = 32) or persistent AF (n = 68) undergoing VS‐guided ablation between 09/2018 and 08/2019 was conducted. All procedures were performed by two operators. Target VS values were 425 (anterior), 375 (posterior), and 325 (near the esophagus). Target ITD was 4 mm.ResultsAcute PVI was achieved in all cases, however, 13 residual gaps in 12 patients were observed after initial encirclement (first pass isolation: 88%). Ten gaps due to spontaneous PV reconnections (PVR) were found in nine patients (9%). These 23 gaps had similar median VS (gap‐related vs non‐gap: 429 vs 410, P = .4545) and power (36 vs 36W, P = .4843), higher contact force (13.8 vs 11.0g, P = .0061), and larger ITD (5.3 vs 3.7mm, P < .001) when compared to the remaining tags. Only ITDs were independently associated with gap formation in multivariate analysis. One‐year Kaplan‐Meier freedom from any atrial arrhythmia was 87.2%. Eight patients received repeat ablation (8.1%) and of these, 6 (75%) were free from PVR.ConclusionFavorable rates of first pass isolation, acute PVR, and long‐term procedure success were achieved using lower VS values than in previous reports. With a target VS value of 375‐425, ITDs of 4 mm was sufficient for durable PVI.