Robin Kamal

All Publications

• Team Approach: Management of Scapholunate Instability. JBJS reviews Kamal, R. N., Moore, W., Kakar, S. 2019

  View details for PubMedID 30724763

• Orthopaedic Trauma Quality Measures for Value Based Healthcare Delivery: A Systematic Review. Journal of orthopaedic trauma DeBaun, M. R., Chen, M. J., Bishop, J. A., Gardner, M. J., Kamal, R. N. 2019

  Abstract

  OBJECTIVES: To assess the current portfolio of quality measures and candidate quality measures that address orthopaedic trauma surgery.DATA SOURCES: We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Quality Payment Program for quality measures relevant to fracture surgery. We also searched MEDLINE/PubMed, Embase/Scopus, and Cochrane libraries.DATA EXTRACTION: Clinical practice guidelines were included as candidate quality measures if their development was in accordance with the Institute of Medicine criteria for development of clinical practice guidelines, were based on consistent clinical evidence including at least one Level I study, and carried the strongest possible recommendation by the developing body. We categorized the measures as structure, process, or outcome domains according to the framework described by Donabedian.DATA SYNTHESIS: From the 3809 articles initially identified and screened, a total of 189 combined quality or candidate quality measures were extracted from our review. With regard to the Donabedian framework, there were a total of 7% (13/189) structure, 52% process (99/189), and 41% (77/189) outcome measures identified.CONCLUSIONS: As quality measures progressively inform reimbursement in value based healthcare models, quality measures evaluating the care of patients sustaining a fracture will become increasingly relevant to orthopaedic trauma surgeons.

  View details for PubMedID 30624346

• Variation in Nonsurgical Services for Carpal Tunnel Syndrome Across a Large Integrated Health Care System. The Journal of hand surgery Sears, E. D., Meerwijk, E. L., Schmidt, E. M., Kerr, E. A., Chung, K. C., Kamal, R. N., Harris, A. H. 2018

  Abstract

  PURPOSE: To evaluate facility-level variation in the use of services for patients with carpal tunnel syndrome (CTS) receiving care in the Veterans Health Administration (VHA).METHODS: A national cohort of VHA patients diagnosed with CTS during fiscal year 2013 was divided into nonsurgical and operative treatment groups for comparison. We assessed the use of 5 types of CTS-related services (electrodiagnostic studies [EDS], imaging, steroid injection, oral steroids, and therapeutic modalities) in the prediagnosis and postdiagnosis periods before any operative intervention at the patient and facility levels.RESULTS: Among 72,599 patients newly diagnosed with CTS, 5,666 (7.8%) received carpal tunnel release within 12 months. The remaining 66,933 (92.2%) were in the nonsurgical group. Therapeutic modalities and EDS were the most commonly employed services after the index diagnosis and had large facility-level variation in use. At the facility level, the use of therapeutic modalities ranged from 0% to 93% in the operative group (mean, 32%) compared with 1% to 67% (mean, 30%) in the nonsurgical group. The use of EDS in the postdiagnosis period ranged from 0% to 100% (mean, 59%) in the operative treatment group and 0% to 55% (mean, 26%) in the nonsurgical group at the facility level.CONCLUSIONS: There is wide facility variation in the use of services for CTS among patients receiving operative and nonsurgical treatment. Care delivered by facilities with the highest and lowest rates of service use may suggest overuse and underuse, respectively, of nonsurgical CTS services and a lack of consideration of individual patient factors in making health care decisions regarding use.CLINICAL RELEVANCE: Surgeons must understand the degree of treatment variability for CTS, comprehend the ramifications of large variation in reimbursement and waste in the health care system, and become involved in devising strategies to optimize hand care across all phases of care.

  View details for PubMedID 30579690

• Variations in Utilization of Carpal Tunnel Release Among Medicaid Beneficiaries. The Journal of hand surgery Zhuang, T., Eppler, S. L., Kamal, R. N. 2018

  Abstract

  PURPOSE: To evaluate the null hypothesis that Medicaid patients receive carpal tunnel release (CTR) at the same time interval from diagnosis as do patients with Medicare Advantage or private insurance.METHODS: We conducted a retrospective review using a database containing claims records from 2007 to 2016. The cohort consisted of patient records with a diagnosis code of carpal tunnel syndrome (CTS) and a procedural code for CTR within 3 years of diagnosis. We stratified patients into 3 groups by insurance type (Medicaid managed care, Medicare Advantage, and private) for an analysis of the time from diagnosis until surgery and use of preoperative electrodiagnostic testing.RESULTS: Of all patients who received CTR within 3 years of diagnosis, Medicaid patients experienced longer intervals from CTS diagnosis to CTR compared with Medicare Advantage and privately insured patients (median, 99 days vs 65 and 62 days, respectively). The Medicaid cohort was significantly less likely to receive CTR within 1 year of diagnosis compared with the Medicare Advantage cohort (adjusted odds ratio [OR]= 0.54) or within 6 months of diagnosis compared with the privately insured cohort (adjusted OR= 0.61). Those in the Medicaid cohort were less likely to receive electromyography and nerve conduction studies within 9 months before surgery compared with their Medicare Advantage (adjusted OR= 0.43) and privately insured (adjusted OR= 0.41) counterparts. These effects were statistically significant after accounting for age, sex, region, and Charlson comorbidity index.CONCLUSIONS: Medicaid managed care patients experience longer times from diagnosis to surgery compared with Medicare Advantage or privately insured patients in this large administrative claims database. Similar variation exists in the use of electrodiagnostic testing based on insurance type.CLINICAL RELEVANCE: Medicaid patients may experience barriers to CTS care, such as delays from diagnosis to surgery and reduced use of electrodiagnostic testing.

  View details for PubMedID 30579689

• Clinical Care Redesign to Improve Value in Carpal Tunnel Syndrome: A Before-and-After Implementation Study. The Journal of hand surgery Kamal, R. N., Behal, R. 2018

  Abstract

  PURPOSE: Carpal tunnel surgery is one of the most common procedures completed on the upper limb in the United States. There is currently no evidence-based high-value clinical care pathway to inform the management of carpal tunnel syndrome (CTS). We created an evidence-based care pathway and implemented a quality improvement initiative to evaluate its effect on patient time, quality, and cost in a tertiary care ambulatory surgery center.METHODS: We developed a high-value clinical care pathway for CTS and implemented the intraoperative phase of the pathway. This included (1) implementing an evidence-based protocol for wide-awake local anesthesia, (2) removing non-value-added processes of care, and (3) implementing educational sessions with surgery staff regarding the initiative. We prospectively collected data on patient time, visual analog scale pain scores (quality), and percent change in total direct costs of the intraoperative phase of care (cost).RESULTS: A total of 50 patients were included in this implementation study: 30 prior to implementation of the intervention and 20 after. There was a significant decrease in average patient wheels in to surgery time, postanesthesia care unit to discharge time, and total patient time (lead time). There was no difference in preoperative or postoperative pain before and after the intervention. There was a 31% reduction in total direct costs.CONCLUSIONS: Implementing the intraoperative phase of this clinical care pathway with wide-awake surgery can reduce patient lead time, maintain quality, and reduce total direct costs in an ambulatory surgery center.CLINICAL RELEVANCE: Quality improvement interventions, such as the implementation of an evidence-based clinical care pathway for the treatment for CTS, may improve value to health systems.

  View details for PubMedID 30502930

• The Role of Patient Research in Patient Trust in Their Physician. The Journal of hand surgery Lu, L. Y., Sheikholeslami, N., Alokozai, A., Eppler, S. L., Kamal, R. N. 2018

  Abstract

  PURPOSE: Trust is foundational to the patient-physician relationship. However, there is limited information on the patient characteristics and behaviors that are related to patient trust. We investigated whether the time patients spend researching their physician and/or symptoms before a clinic visit was correlated with patient trust in their hand surgeon.METHODS: We conducted a prospective study of new patients (n= 134) who presented to a hand surgery clinic. We tested the null hypothesis that time spent researching the physician or symptom does not correlate with physician trust. Secondarily, we tested the association of a maximizing personality (a decision-making personality type defined as one who exhaustively searches for the "best option" as opposed to a "satisficer" who settles for the "good enough" decision) with time spent researching the hand surgeon and patient symptoms, general self-efficacy (one's ability tomanage adversity), and patient trust. Patients completed a questionnaire assessing demographics, patient researching behavior, general self-efficacy (GSE-6), maximizing personality(Maximization Short Form), and physician trust (Trust in Physician Form).RESULTS: The average age of our cohort was 50 ± 17 years, and men and women were equally represented. Patients spent more time researching their symptoms (median, 60 min; range, 5-1,201 min) than they did researching their physician (median, 20 min; range, 1-1,201 min). There was no correlation between time spent by patients seeking information on their hand surgeon and/or symptoms with patient trust in their physician. However, female patients were significantly more trusting of their physician than male patients.CONCLUSIONS: Most patients research their symptoms before clinic, whereas about half research their physicians before meeting them. Time spent seeking information before clinic was not correlated with patient trust in their physician. However, in our study, female patients were more likely to trust their hand surgeon than male patients. Thus, modifying physician behavior rather than patient characteristics may be a stronger driver of patient trust.TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

  View details for PubMedID 30366736

• Quality Measures in Foot and Ankle Care. The Journal of the American Academy of Orthopaedic Surgeons Xiong, G., Bennett, C. G., Chou, L., Kamal, R. N. 2018

  Abstract

  BACKGROUND: Quality measures may be operationalized in payment models or quality reporting programs to assess foot and ankle surgeons, but if existing measures allow accurate representation of a foot and ankle surgeon's practice is unclear.METHODS: National quality measures databases, clinical guidelines, and MEDLINE/PubMed were systematically reviewed for quality measures relevant to foot and ankle care. Measures meeting internal criteria were categorized by clinical diagnosis, National Quality Strategy priority, and Donabedian domain.RESULTS: Of 12 quality measures and 16 candidate measures, National Quality Strategy priorities most commonly addressed "Effective Clinical Care" (n = 19) and "Communication and Coordination of Care" (n = 6). Donabedian classifications addressed were process (n = 25) and outcome (n = 3). Diabetic foot care was most commonly addressed (n = 18).CONCLUSIONS: Available foot and ankle quality measures are limited in number and scope, which may hinder appropriate assessment of care, analysis of trends, and quality improvement. Additional measures are needed to support the transition to a value-based system.LEVEL OF EVIDENCE: Level I.

  View details for DOI 10.5435/JAAOS-D-17-00733

  View details for PubMedID 30325881

• Quality Measures in Total Hip and Total Knee Arthroplasty. The Journal of the American Academy of Orthopaedic Surgeons Amanatullah, D. F., McQuillan, T., Kamal, R. N. 2018

  Abstract

  INTRODUCTION: Total joint arthroplasty represents the largest expense for a single condition among Medicare beneficiaries. Payment models exist, such as bundled payments, where physicians and hospitals are reimbursed based on providing cost-efficient, high-quality care. There is a need to explicitly define "quality" relevant to hip and knee arthroplasty. Based on prior quality measure research, we hypothesized that less than 20% of developed quality measures are outcome measures.METHODS: This study systematically reviewed current and candidate quality measures relevant to total hip and knee arthroplasty using several quality measure databases and an Internet library search.RESULTS: We found a total of 35 quality measures and 81 candidate measures, most of which were process measures (N = 21, 60%), and represented the National Quality Strategy priorities of patient- and caregiver-centered experience and outcomes (31%), effective clinical care (28%), or patient safety (19%).CONCLUSION: Various stakeholders have developed quality measures in total joint arthroplasty, with increasing focus on developing outcome measures. The results of this review inform orthopaedic surgeons on quality measures that payers could use value-based payment models like the Merit-based Incentive Payment System and Comprehensive Care for Joint Replacement.LEVEL OF EVIDENCE: Level I, systematic review of level I evidence.

  View details for PubMedID 30303844

• Low Value Preoperative Testing for Carpal Tunnel Release in the Veterans Health Administration Sox-Harris, A., Meerwijk, E. L., Kamal, R. N., Sears, E., Finlay, A. K., Hawn, M. T., Eisenberg, D., Mudumbai, S. ELSEVIER SCIENCE INC. 2018: E32

  View details for DOI 10.1016/j.jamcollsurg.2018.08.084

  View details for Web of Science ID 000447772500070

• Defining Quality in Hand Surgery From the Patient'sPerspective: A Qualitative Analysis. The Journal of hand surgery Eppler, S. L., Kakar, S., Sheikholeslami, N., Sun, B., Pennell, H., Kamal, R. N. 2018

  Abstract

  PURPOSE: Quality measures are used to evaluate health care delivery. They are traditionally developed from the physician and health system viewpoint. This approach can lead to quality measures that promote care that may be misaligned with patient values and preferences. We completed an exploratory, qualitative study to identify how patients with hand problems define high-quality care. Our purpose was to develop a better understanding of the surgery and recovery experience of hand surgery patients, specifically focusing on knowledge gaps, experience, and the surgical process.METHODS: A steering committee (n= 10) of patients who had previously undergone hand surgery reviewed and revised an open-ended survey. Ninety-nine patients who had undergone hand surgery at 2 tertiary care institutions completed the open-ended, structured questionnaire during their 6- to 8-week postoperative clinic visit. Two reviewers completed a thematic analysis to generate subcodes and codes to identify themes in high-quality care from the patient's perspective.RESULTS: We identified 4 themes of high-quality care: (1) Being prepared and informed for the process of surgery, (2) Regaining hand function without pain or complication, (3) Patients and caregivers negotiating the physical and psychological challenges of recovery, and (4) Financial and logistical burdens of undergoing hand surgery.CONCLUSIONS: Multiple areas that patients identify as representing high-quality care are not reflected in current quality measures for hand surgery. The patient-derived themes of high-quality care can inform future patient-centered quality measure development.CLINICAL RELEVANCE: Efforts to improve health care delivery may have the greatest impact by addressing areas of care that are most valued by patients. Such areas include patient education, system navigation, the recovery process, and cost.

  View details for PubMedID 30031599

• Financial Distress and Discussing the Cost of Total Joint Arthroplasty. The Journal of arthroplasty Amanatullah, D. F., Murasko, M. J., Chona, D. V., Crijns, T. J., Ring, D., Kamal, R. N. 2018

  Abstract

  BACKGROUND: Total joint arthroplasty is expensive. Out-of-pocket cost to patients undergoing elective total joint arthroplasty varies considerably depending on their insurance coverage but can range into the tens of thousands of dollars. The goal of this study is to evaluate the association between patient financial stress and interest in discussing costs associated with surgery.METHODS: One hundred forty-one patients undergoing elective total hip and knee arthroplasty at a suburban academic medical center were enrolled and completed questionnaires about cost prior to surgery. Questions regarding if and when doctors should discuss the cost of healthcare with patients, evaluating if patients were affected by the cost of healthcare and to what extent, and financial security scores to assess current financial situation were included. The primary outcome was the answer to the question of whether a doctor should discuss cost with patients.RESULTS: Financial stress was found to be associated with patient experience of hardship due to cost of care [P= .004], likelihood to turn down a test or treatment due to copayment [P= .029], to decline a test or treatment due to other costs [P= .003], to experience difficulty affording basic necessities [P= .008], and to have used up all or most of their savings to pay for surgery [P= .011]. In total, 84% of patients reported that they wanted to discuss surgical costs with their doctors, but 90% did not want to do so at every visit.CONCLUSION: Total joint arthroplasty creates considerable out-of-pocket costs that may affect patient decisions. These findings help elucidate important patient concerns that orthopedic surgeons should account for when discussing elective arthroplasty with patients.

  View details for PubMedID 30057266

• Patient Perceptions Correlate Weakly With Observed Patient Involvement in Decision-making in Orthopaedic Surgery. Clinical orthopaedics and related research Mertz, K., Eppler, S., Yao, J., Amanatullah, D. F., Chou, L., Wood, K. B., Safran, M., Steffner, R., Gardner, M., Kamal, R. 2018

  Abstract

  BACKGROUND: Shared decision-making between patients and physicians involves educating the patient, providing options, eliciting patient preferences, and reaching agreement on a decision. There are different ways to measure shared decision-making, including patient involvement, but there is no consensus on the best approach. In other fields, there have been varying relationships between patient-perceived involvement and observed patient involvement in shared decision-making. The relationship between observed and patient-perceived patient involvement in decision-making has not been studied in orthopaedic surgery.QUESTIONS/PURPOSES: (1) Does patient-perceived involvement correlate with observed measurements of patient involvement in decision-making in orthopaedic surgery? (2) Are patient demographics associated with perceived and observed measurements of patient involvement in decision-making?METHODS: We performed a prospective, observational study to compare observed and perceived patient involvement in new patient consultations for eight orthopaedic surgeons in subspecialties including hand/upper extremity, total joint arthroplasty, spine, sports, trauma, foot and ankle, and tumor. We enrolled 117 English-literate patients 18 years or older over an enrollment period of 2 months. A member of the research team assessed observed patient involvement during a consultation with the Observing Patient Involvement in Decision-Making (OPTION) instrument (scaled 1-100 with higher scores representing greater involvement). After the consultation, we asked patients to complete a questionnaire with demographic information including age, sex, race, education, income, marital status, employment status, and injury type. Patients also completed the Perceived Involvement in Care Scale (PICS), which measures patient-perceived involvement (scaled 1-13 with higher scores representing greater involvement). Both instruments are validated in multiple studies in various specialties and the physicians were blinded to the instruments used. We assessed the correlation between observed and patient-perceived involvement as well as tested the association between patient demographics and patient involvement scores.RESULTS: There was weak correlation between observed involvement (OPTION) and patient-perceived involvement (PICS) (r = 0.37, p < 0.01) in decision-making (mean OPTION, 28.7, SD 7.7; mean PICS, 8.43, SD 2.3). We found a low degree of observed patient involvement despite a moderate to high degree of perceived involvement. No patient demographic factor had a significant association with patient involvement.CONCLUSIONS: Further work is needed to identify the best method for evaluating patient involvement in decision-making in the setting of discordance between observed and patient-perceived measurements. Knowing whether it is necessary for (1) actual observable patient involvement to occur; or (2) a patient to simply believe they are involved in their care can inform physicians on the best way to improve shared decision-making in their practice.LEVEL OF EVIDENCE: Level II, therapeutic study.

  View details for PubMedID 29965894

• Complication rates by surgeon type after open treatment of distal radius fractures. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Truntzer, J., Mertz, K., Eppler, S., Li, K., Gardner, M., Kamal, R. 2018

  Abstract

  BACKGROUND: In distal radius fracture repair, complications often lead to reoperation and increased cost. We examined the trends and complications in open reduction internal fixation of distal radius fractures across hand specialist and non-hand specialist surgeons.METHODS: We examined claims data from the Humana administrative claims database between 2007 and 2016. International Classification of Disease, 9th Edition and Current Procedural Terminology codes were searched related to distal radius fractures repaired by open reduction internal fixation. Patients were filtered based on initial treatment by a hand specialty or non-hand specialty surgeon. Complications were reported within 1year of surgical treatment in the following distinct categories: non-union, malunion, extensor/flexor tendon repair, CRPS, infection. Descriptive statistics were reported.RESULTS: Hand specialists accounted for 182 procedures compared with 7708 procedures by non-hand specialty orthopaedic or general surgeons. There was an increase in the total number of procedures performed by hand specialists across the years of study, with a higher percentage of intra-articular cases completed by hand specialists (80.7%) compared to non-hand specialists (70.1%). Overall, the complication rates of hand specialists (6.5%) were higher than that of non-specialists (4.7%).CONCLUSIONS: The results of this study demonstrate a small difference in overall complications for open reduction internal fixation of distal radius fractures by hand specialists in comparison to non-specialists despite treating a higher percentage of intra-articular fractures. Future work controlling for factors unaccounted for in claims-based analyses, such as fracture complexity, patient comorbidities, and surgeon factors are needed.TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

  View details for PubMedID 29922979

• Patients Should Define Value in Health Care: A Conceptual Framework. The Journal of hand surgery Kamal, R. N., Lindsay, S. E., Eppler, S. L. 2018

  Abstract

  The main tenet of value-based health care is delivering high-quality care that is centered on the patient, improving health, and minimizing cost. Collaborative decision-making frameworks have been developed to help facilitate delivering care based on patient preferences (patient-centered care). The current value-based health care model, however, focuses on improving population health and overlooks the individuality of patients and their preferences for care. We highlight the importance of eliciting patient preferences in collaborative decision making and describe a conceptual framework that incorporates individual patients' preferences when defining value.

  View details for PubMedID 29754755

• The Affordable Care Act Decreased the Proportion of Uninsured Patients in a Safety Net Orthopaedic Clinic CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Gil, J. A., Goodman, A. D., Kleiner, J., Kamal, R. N., Baker, L. C., Akelman, E. 2018; 476 (5): 925–31

  Abstract

  The Patient Protection and Affordable Care Act (ACA) was approved in 2010, substantially altering the economics of providing and receiving healthcare services in the United States. One of the primary goals of this legislation was to expand insurance coverage for under- and uninsured residents. Our objective was to examine the effect of the ACA on the insurance status of patients at a safety net clinic. Our institution houses a safety net clinic that provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, our study allows us to accurately examine the magnitude of the effect on insurance status in safety net orthopaedic clinics.(1) Did the ACA result in a decrease in the number of uninsured patients at a safety net orthopaedic clinic that provides the dominant majority of orthopaedic care for the uninsured in the state? (2) Did the proportion of patients insured after passage of the ACA differ across age or demographic groups in one state?We retrospectively examined our longitudinally maintained adult orthopaedic surgery clinic database from January 2009 to March 2015 and collected visit and demographic data, including zip code income quartile. Based on the data published by the Rhode Island Department of Health, our clinic provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, examination of the changes in the proportion of insurance status in our clinic allows us to assess the effect of the ACA on the state level. Univariate and multivariable logistic regression analyses were used to determine the relationship between demographic variables and insurance status. Adjusted odds ratios and 95% CIs were calculated for the proportion of uninsured visits. The proportion of uninsured visits before and after implementation of the ACA was evaluated with an interrupted time-series analysis. The reduction in the proportion of patients without insurance between demographic groups (ie, race, gender, language spoken, and income level) also was compared using an interrupted time-series design.There was a 36% absolute reduction (95% CI, 35%-38%; p < 0.001) in uninsured visits (73% relative reduction; 95% CI, 71%-75%; p < 0.001). There was an immediate 28% absolute reduction (95% CI, 21%-34%; p < 0.001) at the time of ACA implementation, which continued to decline thereafter. After controlling for potential confounding variables such as gender, race, age, and income level, we found that patients who were white, men, younger than 65 years, and seen after January 2014 were more likely to have insurance than patients of other races, women, older patients, and patients treated before January 2014.After the ACA was implemented, the proportion of patients with health insurance at our safety net adult orthopaedic surgery clinic increased substantially. The reduction in uninsured patients was not equal across genders, races, ages, and incomes. Future studies may benefit from identifying barriers to insurance acquisition in these subpopulations. The results of this study could affect orthopaedic practices in the United States by guiding policy decisions regarding health care.Level III, therapeutic study.

  View details for PubMedID 29672327

• The Sigmoid Notch View for Distal Radius Fractures. The Journal of hand surgery Kamal, R. N., Leversedge, F., Ruch, D. S., Mithani, S. K., Cotterell, I. H., Richard, M. J. 2018

  Abstract

  PURPOSE: This study defines the sigmoid notch view of the distal radius. Specifically, we tested the null hypothesis that there is no relationship between the subchondral stripe of bone seen on a sigmoid notch view of the distal radius and the articular surface of the sigmoid notch.METHODS: We used 44 wrist specimens for anatomic and fluoroscopic analysis. We measured the articular depth of the sigmoid notch from its deepest point and classified the shape of the sigmoid notch. We then placed a radiopaque marker at the nadir of the articular surface and quantified the fluoroscopic depth of the sigmoid notch. A sigmoid notch view, which was a tangential fluoroscopic view of the volar and dorsal lips of the sigmoid notch, was obtained. The relationship of the articular surface to the stripe of subchondral bone seen on this view, called the sigmoid stripe, was determined.RESULTS: Anatomic analysis revealed sigmoid notch types with proportions similar to those in previous descriptions. The marker for the articular surface was superimposed or just ulnar to the sigmoid stripe in all specimens. In flat face and ski slope notches, this was coincident with the volar and dorsal lips of the sigmoid notch. In C- and S-type notches, there was a measurable distance from the articular surface marker to the edges of the bone of the volar and dorsal lips of the sigmoid.CONCLUSIONS: The articular surface marker at the nadir of the sigmoid notch is always coincident or ulnar to the sigmoid stripe in the sigmoid notch view.CLINICAL RELEVANCE: Surgeons can use the sigmoid notch view as a reliable method to (1) evaluate the integrity of the articular surface, (2) ensure hardware is not placed in the distal radioulnar joint, and (3) guide placement of volar locking plates in the coronal plane.

  View details for PubMedID 29680335

• What Is the State of Quality Measurement in Spine Surgery? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Bennett, C., Xiong, G., Hu, S., Wood, K., Kamal, R. N. 2018; 476 (4): 725–31

  Abstract

  Value-based healthcare models rely on quality measures to evaluate the efficacy of healthcare delivery and to identify areas for improvement. Quality measure research in other areas of health care has generally shown that there is a limited number of available quality measures and that those that exist disproportionately focus on processes as opposed to outcomes. The purpose of this study was to assess the current state of quality measures and candidate quality measures in spine surgery.(1) How many quality measures and candidate quality measures are currently available? (2) According to Donabedian domains and National Quality Strategy (NQS) priorities, what aspects or domains of care do the present quality measures and candidate quality measures represent?We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Physician Quality Reporting System for quality measures relevant to spine surgery. A systematic search for candidate quality measures was also performed using MEDLINE/PubMed and Embase as well as publications from the American Academy of Orthopaedic Surgeons, Congress of Neurological Surgeons, and the North American Spine Society. Clinical practice guidelines were included as candidate quality measures if their development was in accordance with Institute of Medicine criteria for the development of clinical practice guidelines, they were based on consistent clinical evidence including at least one Level I study, and they carried the strongest possible recommendation by the developing body. Quality measures and candidate quality measures were then pooled for analysis and categorized by clinical focus, NQS priority, and Donabedian domain. Our initial search yielded a total of 3940 articles, clinical practice guidelines, and quality measures, 74 of which met criteria for inclusion in this study.Of the 74 measures studied, 29 (39%) were quality measures and 45 (61%) were candidate quality measures. Fifty of 74 (68%) were specific to the care of the spine, and 24 of 74 (32%) were related to the general care of spine patients. The majority of the spine-specific measures were process measures (45 [90%]) and focused on the NQS priority of "Effective Clinical Care" (44 [88%]). The majority of the general care measures were also process measures (14 [58%]), the highest portion of which focused on the NQS priority of "Patient Safety" (10 [42%]).Given the large number of pathologies treated by spine surgeons, the limited number of available quality measures and candidate quality measures in spine surgery is inadequate to support the transition to a value-based care model. Additionally, current measures disproportionately focus on certain aspects or domains of care, which may hinder the ability to appropriately judge an episode of care, extract usable data, and improve quality. Physicians can steward the creation of meaningful quality measures by participating in clinical practice guideline development, assisting with the creation and submission of formal quality measures, and conducting the high-quality research on which effective guidelines and quality measures depend.

  View details for PubMedID 29480884

• Does Wrist Laxity Influence Three-Dimensional Carpal Bone Motion? JOURNAL OF BIOMECHANICAL ENGINEERING-TRANSACTIONS OF THE ASME Best, G. M., Zec, M. L., Pichora, D. R., Kamal, R. N., Rainbow, M. J. 2018; 140 (4)

  View details for DOI 10.1115/1.4038897

  View details for Web of Science ID 000426560800007

• Tensile and Torsional Structural Properties of the Native Scapholunate Ligament. The Journal of hand surgery Pang, E. Q., Douglass, N., Behn, A., Winterton, M., Rainbow, M. J., Kamal, R. N. 2018

  Abstract

  PURPOSE: The ideal material for reconstruction of the scapholunate interosseous ligament (SLIL) should replicate the mechanical properties of the native SLIL to recreate normal kinematics and prevent posttraumatic arthritis. The purpose of our study was to evaluate the cyclic torsional and tensile properties of the native SLIL and load to failure tensile properties of the dorsal SLIL.METHODS: The SLIL bone complex was resected from 10 fresh-frozen cadavers. The scaphoid and lunate were secured in polymethylmethacrylate and mounted on a test machine that incorporated an x-y stage and universal joint, which permitted translations perpendicular to the rotation/pull axis as well as nonaxial angulations. After a 1 N preload, specimens underwent cyclic torsional testing (±0.45 N m flexion/extension at 0.5 Hz) and tensile testing (1-50 N at 1 Hz) for 500 cycles. Lastly, the dorsal 10 mm of the SLIL was isolated and displaced at 10 mm/min until failure.RESULTS: During intact SLIL cyclic torsional testing, the neutral zone was 29.7° ± 6.6° and the range of rotation 46.6° ± 7.1°. Stiffness in flexion and extension were 0.11 ± 0.02 and 0.12 ± 0.02 N m/deg, respectively. During cyclic tensile testing, the engagement length was 0.2 ± 0.1 mm, the mean stiffness was 276 ± 67 N/mm, and the range of displacement was 0.4 ± 0.1 mm. The dorsal SLIL displayed a 0.3 ± 0.2 mm engagement length, 240 ± 65 N/mm stiffness, peak load of 270 ± 91 N, and displacement at peak load of 1.8 ± 0.3 mm.CONCLUSIONS: We report the torsional properties of the SLIL. Our novel test setup allows for free rotation and translation, which reduces out-of-plane force application. This may explain our observation of greater dorsal SLIL load to failure than previous reports.CLINICAL RELEVANCE: By matching the natural ligament with respect to its tensile and torsional properties, we believe that reconstructions will better restore the natural kinematics of the wrist and lead to improved outcomes. Future clinical studies should aim to investigate this further.

  View details for PubMedID 29459171

• Effectiveness of Preoperative Antibiotics in Preventing Surgical Site Infection After Common Soft Tissue Procedures of the Hand. Clinical orthopaedics and related research Li, K., Sambare, T. D., Jiang, S. Y., Shearer, E. J., Douglass, N. P., Kamal, R. N. 2018

  Abstract

  Antibiotic prophylaxis is a common but controversial practice for clean soft tissue procedures of the hand, such as carpal tunnel release or trigger finger release. Previous studies report no substantial reduction in the risk of surgical site infection (SSI) after antibiotic prophylaxis, yet are limited in power by low sample sizes and low overall rates of postoperative infection.Is there evidence that antibiotic prophylaxis decreases the risk of SSI after soft tissue hand surgery when using propensity score matching to control for potential confounding variables such as demographics, procedure type, medication use, existing comorbidities, and postoperative events?This retrospective analysis used the Truven Health MarketScan databases, large, multistate commercial insurance claims databases corresponding to inpatient and outpatient services and outpatient drug claims made between January 2007 and December 2014. The database includes records for patients enrolled in health insurance plans from self-insured employers and other private payers. Current Procedural Terminology codes were used to identify patients who underwent carpal tunnel release, trigger finger release, ganglion and retinacular cyst excision, de Quervain's release, or soft tissue mass excision, and to assign patients to one of two cohorts based on whether they had received preoperative antibiotic prophylaxis. We identified 943,741 patients, of whom 426,755 (45%) were excluded after meeting one or more exclusion criteria: 357,500 (38%) did not have 12 months of consecutive insurance enrollment before surgery or 1 month of enrollment after surgery; 60,693 (6%) had concomitant bony, implant, or incision and drainage or débridement procedures; and 94,141 (10%) did not have complete data. In all, our initial cohort consisted of 516,986 patients, among whom 58,201 (11%) received antibiotic prophylaxis. Propensity scores were calculated and used to create cohorts matched on potential risk factors for SSI, including age, procedure type, recent use of steroids and immunosuppressive agents, diabetes, HIV/AIDs, tobacco use, obesity, rheumatoid arthritis, alcohol abuse, malnutrition, history of prior SSI, and local procedure volume. Multivariable logistic regression before and after propensity score matching was used to test whether antibiotic prophylaxis was associated with a decrease in the risk of SSI within 30 days after surgery.After controlling for patient demographics, hand procedure type, medication use, existing comorbidities (eg, diabetes, HIV/AIDs, tobacco use, obesity), and postoperative events through propensity score matching, we found that the risk of postoperative SSI was no different between patients who had received antibiotic prophylaxis and those who had not (odds ratio, 1.03; 95% CI, 0.93-1.13; p = 0.585).Antibiotic prophylaxis for common soft tissue procedures of the hand is not associated with reduction in postoperative infection risk. While our analysis cannot account for factors that are not captured in the billing process, this study nevertheless provides strong evidence against unnecessary use of antibiotics before these procedures, especially given the difficulty of conducting a randomized prospective study with a sample size large enough to detect the effect of prophylaxis on the low baseline risk of infection.Level III, therapeutic study.

  View details for PubMedID 29432267

• Volar Capsular Release After Distal RadiusFractures. The Journal of hand surgery Kamal, R. N., Ruch, D. S. 2017

  Abstract

  PURPOSE: Loss of full wrist range of motion is common after treatment of distal radius fractures. Loss of wrist extension limiting functional activities, although uncommon, can occur after volar plating of distal radius fractures. Unlike other joints in which capsular release is a common form of treatment for stiffness, this has been approached with caution in the wrist owing to concerns for carpal instability. We tested the null hypothesis that hardware removal and open volar capsular release would not lead to improved upper extremity-specific patient-reported outcome (Disabilities of the Arm, Shoulder, and Hand [DASH] questionnaire).METHODS: We conducted a retrospective chart review of patients who underwent a tenolysis of the flexor carpi radialis tendon, removal of hardware, and subperiosteal release of the volar capsule (extrinsic ligaments). The primary outcome measure was patient-reported outcome on the DASH. Secondary outcomes included wrist flexion, extension, pronation, and supination, visual analog scale for pain, and radiographs/fluoroscopy for ulnocarpal translocation.RESULTS: Eleven patients were treated with a mean follow-up of 4.5 years. Mean DASH scores improved after surgery. Mean wrist flexion, wrist extension, pronation, and supination improved after surgery. Mean visual analog scale scores did not change. The radiocarpal relationship on radiographs/fluoroscopy was normal.CONCLUSIONS: Open volar capsular release to regain wrist extension after treatment of distal radius fractures with volar locking plates is safe and effective. Patients regain wrist extension in addition to improved DASH scores. There were no radiographic/fluoroscopic or clinical signs of ulnocarpal translocation after release of the volar extrinsic ligaments.TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

  View details for PubMedID 28917548

• Cost Minimization Analysis of Ganglion Cyst Excision. The Journal of hand surgery Pang, E. Q., Zhang, S., Harris, A. H., Kamal, R. N. 2017; 42 (9)

  Abstract

  PURPOSE: Cost minimization analysis can be employed to determine the least costly option when multiple treatments lead to equivalent outcomes. We present a cost minimization analysis from the payers' perspective, of the direct per patient cost of arthroscopic versus open ganglion cyst excision. We tested the null hypothesis that there is no difference in cost between the 2 procedures from the payer perspective.METHODS: We utilized data from a private payer administrative claims database comprising 16 million individuals from 2007 to 2015. Using Current Procedural Terminology codes to identify open and arthroscopic ganglion excisions, we extracted demographic data and fees paid to providers and facilities for the procedure.RESULTS: We identified 5,119 patients undergoing open ganglion cyst excision and 20 patients undergoing arthroscopic ganglion excision. The average cost of an open excision was significantly lower than an arthroscopic excision ($1,821 vs $3,668).CONCLUSIONS: Surgical costs from arthroscopic ganglion excision are significantly more thanopen excision. This data can inform health systems participating in value-based models.TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analysis IV.

  View details for PubMedID 28606435

• Cost-minimization Analysis of the Management of Acute Achilles Tendon Rupture. journal of the American Academy of Orthopaedic Surgeons Truntzer, J. N., Triana, B., Harris, A. H., Baker, L., Chou, L., Kamal, R. N. 2017; 25 (6): 449-457

  Abstract

  Outcomes of nonsurgical management of acute Achilles tendon rupture have been demonstrated to be noninferior to those of surgical management. We performed a cost-minimization analysis of surgical and nonsurgical management of acute Achilles tendon rupture.We used a claims database to identify patients who underwent surgical (n = 1,979) and nonsurgical (n = 3,065) management of acute Achilles tendon rupture and compared overall costs of treatment (surgical procedure, follow-up care, physical therapy, and management of complications). Complication rates were also calculated. Patients were followed for 1 year after injury.Average treatment costs in the year after initial diagnosis were higher for patients who underwent initial surgical treatment than for patients who underwent nonsurgical treatment ($4,292 for surgical treatment versus $2,432 for nonsurgical treatment; P < 0.001). However, surgical treatment required fewer office visits (4.52 versus 10.98; P < 0.001) and less spending on physical therapy ($595 versus $928; P < 0.001). Rates of rerupture requiring subsequent treatment (2.1% versus 2.4%; P = 0.34) and additional costs ($2,950 versus $2,515; P = 0.34) were not significantly different regardless whether initial treatment was surgical or nonsurgical. In both cohorts, management of complications contributed to approximately 5% of the total cost.From the payer's perspective, the overall costs of nonsurgical management of acute Achilles tendon rupture were significantly lower than the overall costs of surgical management.III, Economic Decision Analysis.

  View details for DOI 10.5435/JAAOS-D-16-00553

  View details for PubMedID 28459710

• Quality Measures in Breast Reconstruction: A Systematic Review. Annals of plastic surgery Nazerali, R. N., Finnegan, M. A., Divi, V., Lee, G. K., Kamal, R. N. 2017

  Abstract

  The importance of providing quality care over quantity of care, and its positive effects on health care expenditure and health, has motivated a transition toward value-based payments. The Centers for Medicare and Medicaid Services and private payers are establishing programs linking financial incentives and penalties to adherence to quality measures. As payment models based on quality measures are transitioned into practice, it is beneficial to identify current quality measures that address breast reconstruction surgery as well as understand gaps to inform future quality measure development.We performed a systematic review of quality measures for breast reconstruction surgery by searching quality measure databases, professional society clinical practice guidelines, and the literature. Measures were categorized as structure, process, or outcome according to the Donabedian domains of quality.We identified a total of 27 measures applicable to breast reconstruction: 5 candidate quality measures specifically for breast reconstruction surgery and 22 quality measures that relate broadly to surgery. Of the breast reconstruction candidate measures, 3 addressed processes and 2 addressed outcomes. Seventeen of the general quality measures were process measures and 5 were outcome measures. We did not identify any structural measures.Currently, an overrepresentation of process measures exists, which addresses breast reconstruction surgery. There is a limited number of candidate measures that specifically address breast reconstruction. Quality measure development efforts on underrepresented domains, such as structure and outcome, and stewarding the measure development process for candidate quality measures can ensure breast reconstruction surgery is appropriately evaluated in value-based payment models.

  View details for DOI 10.1097/SAP.0000000000001088

  View details for PubMedID 28570449

• Association of Lunate Morphology With Carpal Instability in Scapholunate Ligament Injury. Hand (New York, N.Y.) Pang, E. Q., Douglass, N., Kamal, R. N. 2017: 1558944717709073-?

  Abstract

  We examined the relationship between lunate morphology (type 1 without a medial facet; type II with a medial facet) and dorsal intercalated segmental instability (DISI) in patients with scapholunate ligament injuries. We tested the primary null hypothesis that there is no relationship between lunate morphology and development of DISI. Secondary analysis compared the agreement of classifying lunate morphology based on the presence of a medial lunate facet, capitate-to-triquetrum (CT) distance, and magnetic resonance imaging (MRI).We performed a retrospective chart review of patients with known scapholunate ligament injuries from 2001 to 2016. Posterior-anterior radiographs and MRI, when available, were evaluated. CT distances were measured as a secondary classification method. DISI and scapholunate instability were determined as radiolunate angle >15° and scapholunate angle >60°, respectively. Differences between groups were determined using chi-square analysis with significance set at P < .05. Agreement between plain radiographs, MRI, and CT distance was calculated using the kappa statistic.Our search found 58 of 417 patients who met inclusion criteria; 41 of 58 had type II and 17 of 58 had type I lunates. There was no significant difference between groups in regard to DISI or scapholunate instability. Subanalysis using MRI alone or correcting any discrepancy between plain film and MRI classification, using MRI as the standard, found no difference between groups in regard to DISI or scapholunate instability.In patients with scapholunate ligament injuries, there are no differences in the development of DISI or scapholunate instability between patients with type I and type II lunates.

  View details for DOI 10.1177/1558944717709073

  View details for PubMedID 28525962

• Impact of Health Literacy on Time Spent Seeking Hand Care. Hand (New York, N.Y.) Alokozai, A., Bernstein, D. N., Sheikholeslami, N., Uhler, L., Ring, D., Kamal, R. N. 2017: 1558944717708027-?

  Abstract

  Patients with limited health literacy may have less knowledge and fewer resources for efficient access and navigation of the health care system. We tested the null hypothesis that there is no correlation between health literacy and total time spent seeking hand surgery care.New patients visiting a hand surgery clinic at a suburban academic medical center were asked to complete a questionnaire to determine demographics, total time spent seeking hand surgery care, and outcomes. A total of 112 patients were included in this study.We found health literacy levels did not correlate with total time seeking hand surgery care or from booking an appointment to being evaluated in clinic.In this suburban academic medical center, patients with low health literacy do not spend more time seeking hand surgery care and do have longer delays between seeking and receiving care. The finding that-at least in this setting-health literacy does not impact patient time seeking hand care suggests that resources to improve health disparities can be focused elsewhere in the care continuum.

  View details for DOI 10.1177/1558944717708027

  View details for PubMedID 28513193

• Simple Assessment of Global Bone Density and Osteoporosis Screening Using Standard Radiographs of the Hand. journal of hand surgery Schreiber, J. J., Kamal, R. N., Yao, J. 2017

  Abstract

  Osteoporosis and fragility fractures have consequences both at the individual level and to the overall health care system. Although dual-energy x-ray absorptiometry (DXA) is the reference standard for assessing bone mineral density (BMD), other, simpler tools may be able to screen bone quality provisionally and signal the need for intervention. We hypothesized that the second metacarpal cortical percentage (2MCP) calculated from standard radiographs of the hand or wrist would correlate with hip BMD derived from DXA and could provide a simple screening tool for osteoporosis.Two hundred patients who had hand or wrist radiographs and hip DXA scans within 1 year of each other were included in this series. Mid-diaphyseal 2MCP was calculated as the ratio of the cortical diameter to the total diameter. We assessed the correlation between 2MCP and total hip BMD. Subjects were stratified into normal, osteopenic, and osteoporotic cohorts based on hip t scores, and thresholds were identified to optimize screening sensitivity and specificity.Second metacarpal cortical percentage correlated significantly with BMD and t scores from the hip. A 2MCP threshold of less than 60% optimized sensitivity (88%) and specificity (60%) for discerning osteopenic subjects from normal subjects, whereas a threshold of less than 50% optimized sensitivity (100%) and specificity (91%) for differentiating osteoporotic from normal subjects.By demonstrating that global BMD may be assessed from 2MCP, these data suggest that radiographs of the hand and wrist may have a role in accurately screening for osteopenia and osteoporosis. This simple investigation, which is already used ubiquitously for patients with hand or wrist problems, may identify patients at risk for fragility fractures and allow for appropriate referral or treatment.Diagnostic II.

  View details for DOI 10.1016/j.jhsa.2017.01.012

  View details for PubMedID 28242242

• Cost-Minimization Analysis of Open and Endoscopic Carpal Tunnel Release. journal of bone and joint surgery. American volume Zhang, S., Vora, M., Harris, A. H., Baker, L., Curtin, C., Kamal, R. N. 2016; 98 (23): 1970-1977

  Abstract

  Carpal tunnel release is the most common upper-limb surgical procedure performed annually in the U.S. There are 2 surgical methods of carpal tunnel release: open or endoscopic. Currently, there is no clear clinical or economic evidence supporting the use of one procedure over the other. We completed a cost-minimization analysis of open and endoscopic carpal tunnel release, testing the null hypothesis that there is no difference between the procedures in terms of cost.We conducted a retrospective review using a private-payer and Medicare Advantage database composed of 16 million patient records from 2007 to 2014. The cohort consisted of records with an ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis of carpal tunnel syndrome and a CPT (Current Procedural Terminology) code for carpal tunnel release. Payer fees were used to define cost. We also assessed other associated costs of care, including those of electrodiagnostic studies and occupational therapy. Bivariate comparisons were performed using the chi-square test and the Student t test.Data showed that 86% of the patients underwent open carpal tunnel release. Reimbursement fees for endoscopic release were significantly higher than for open release. Facility fees were responsible for most of the difference between the procedures in reimbursement: facility fees averaged $1,884 for endoscopic release compared with $1,080 for open release (p < 0.0001). Endoscopic release also demonstrated significantly higher physician fees than open release (an average of $555 compared with $428; p < 0.0001). Occupational therapy fees associated with endoscopic release were less than those associated with open release (an average of $237 per session compared with $272; p = 0.07). The total average annual reimbursement per patient for endoscopic release (facility, surgeon, and occupational therapy fees) was significantly higher than for open release ($2,602 compared with $1,751; p < 0.0001).Our data showed that the total average fees per patient for endoscopic release were significantly higher than those for open release, although there currently is no strong evidence supporting better clinical outcomes of either technique.Value-based health-care models that favor delivering high-quality care and improving patient health, while also minimizing costs, may favor open carpal tunnel release.

  View details for PubMedID 27926678

• Quality Measures That Address the Upper Limb JOURNAL OF HAND SURGERY-AMERICAN VOLUME Kamal, R. N., Ring, D., Akelman, E., Ruch, D. S., Richard, M. J., Ladd, A., Got, C., Blazar, P., Yao, J., Kakar, S. 2016; 41 (11): 1041-1048

  Abstract

  Physicians, health care systems, and payers use quality measures to judge performance and monitor the outcomes of interventions. Practicing upper-limb surgeons desire quality measures that are important to patients and feasible to use, and for which it is fair to hold them accountable.Nine academic upper-limb surgeons completed a RAND/University of California-Los Angeles Delphi Appropriateness process to evaluate the importance, feasibility, and accountability of 134 quality measures identified from systematic review. Panelists rated measures on an ordinal scale between 1 (definitely not valid) and 9 (definitely valid) in 2 rounds (preliminary round and final round) with an intervening face-to-face discussion. Ratings from 1 to 3 were considered not valid, 4 to 6 were equivocal or uncertain, and 7 to 9 were valid. If no more than 2 of the 9 ratings were outside the 3-point range that included the median (1-3, 4-6, or 7-9), panelists were considered to be in agreement. If 3 or more ratings of a measure were within the 1 to 3 range whereas 3 or more ratings were in the 7 to 9 range, panelists were considered to be in disagreement.There was agreement that 58 of the measures are important (43%), 74 are feasible (55%), and surgeons can be held accountable for 39 (29%). All 3 thresholds were met for 33 measures (25%). A total of 36 reached agreement for being unimportant (48%) and 57 were not suited for surgeon accountability (43%).A minority of upper-limb quality measures were rated as important for care, feasible to complete, and suitable for upper-limb surgeon accountability.Before health systems and payers implement quality measures, we recommend ensuring their importance and feasibility to safeguard against measures that may not improve care and might misappropriate attention and resources.

  View details for DOI 10.1016/j.jhsa.2016.07.107

  View details for Web of Science ID 000387632600001

  View details for PubMedID 27577525

• Carpal Kinematics and Kinetics JOURNAL OF HAND SURGERY-AMERICAN VOLUME Kamal, R. N., Starr, A., Akelman, E. 2016; 41 (10): 1011-1018

  Abstract

  The complex interaction of the carpal bones, their intrinsic and extrinsic ligaments, and the forces in the normal wrist continue to be studied. Factors that influence kinematics, such as carpal bone morphology and clinical laxity, continue to be identified. As imaging technology improves, so does our ability to better understand and identify these factors. In this review, we describe advances in our understanding of carpal kinematics and kinetics. We use scapholunate ligament tears as an example of the disconnect that exists between our knowledge of carpal instability and limitations in current reconstruction techniques.

  View details for DOI 10.1016/j.jhsa.2016.07.105

  View details for Web of Science ID 000385340300008

  View details for PubMedID 27569785

• Quality and Value in an Evolving Health Care Landscape. journal of hand surgery Kamal, R. N. 2016; 41 (7): 794-799

  Abstract

  Demonstrating and improving value of care continues to be increasingly important in hand surgery. To prepare for emerging models that transition payment from volume to value, hand surgeons will benefit from a clear understanding of quality, cost, and value. National organizations and both public and private payers increasingly advocate for patient-reported outcome measures for pay for reporting and pay for performance initiatives. These are intended to incentivize providers and health systems to improve patient-centered care while minimizing costs. Appreciating the limitations to using patient-reported outcomes in hand surgery can ensure hand surgery is appropriately assessed in novel payment models.

  View details for DOI 10.1016/j.jhsa.2016.05.016

  View details for PubMedID 27374791

• High Disparity Between Orthopedic Resident Interest and Participation in International Health Electives ORTHOPEDICS Zhang, S., Shultz, P., Daniels, A., Akelman, E., Kamal, R. N. 2016; 39 (4): E680-E686

  Abstract

  Few orthopedic surgical residency programs offer international health electives (IHEs). Efforts to expand these programs have been increasing across medical disciplines. Whether orthopedic residents will participate remains unknown. This study quantified and characterized orthopedic resident interest and barriers to IHEs in US residency programs. A web-based survey was administered to residents from 154 US orthopedic residency programs accredited by the Accreditation Council for Graduate Medical Education 2014 to 2015. Questions assessed demographics and program background, previous medical experience abroad, barriers to participation, and level of interest in participating in an international health elective during their training and beyond. Twenty-seven (17.5%) residency programs responded. Chi-square analysis showed that residents who expressed interest in participating were significantly more likely to have experience abroad compared with those who expressed no interest (P<.004). Analysis using Mann-Whitney U test suggested that those who expressed interest were more likely to believe IHEs are important to resident training (P<.0011; mean Likert scale score of 3.7 vs 2.6), provide valuable experience (P<.001; mean Likert scale score of 4.2 vs 3.2), and should be required for orthopedic residencies (P<.001; mean Likert scale score of 2.8 vs 1.9). Residents are strongly interested in participating in IHEs during their training, and many may integrate global health into future practices. Residents perceive lack of funding and scheduling flexibility as barriers preventing them from participating. Prior experience abroad influences level of interest, and international clinical experience may enhance future perception of its value. [Orthopedics. 2016; 39(4):e680-e686.].

  View details for DOI 10.3928/01477447-20160419-02

  View details for Web of Science ID 000393105500014

  View details for PubMedID 27111074

• Quality Measurement: A Primer for Hand Surgeons JOURNAL OF HAND SURGERY-AMERICAN VOLUME Kamal, R. N., Kakar, S., Ruch, D., Richard, M. J., Akelman, E., Got, C., Blazar, P., Ladd, A., Yao, J., Ring, D. 2016; 41 (5): 645-651

  Abstract

  As the government and payers place increasing emphasis on measuring and reporting quality and meeting-specific benchmarks, physicians and health care systems will continue to adapt to meet regulatory requirements. Hand surgeons' involvement in quality measure development will help ensure that our services are appropriately assessed. Moreover, by embracing a culture of quality assessment and improvement, we will improve patient care while demonstrating the importance of our services in a health care system that is transitioning from a fee-for-service model to a fee-for-value model. Understanding quality and the tools for its measurement, and the application of quality assessment and improvement methods can help hand surgeons continue to deliver high-quality care that aligns with national priorities.

  View details for DOI 10.1016/j.jhsa.2015.10.002

  View details for PubMedID 26576831

• Orthopaedic Surgeon Burnout: Diagnosis, Treatment, and Prevention JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Daniels, A. H., Depasse, J. M., Kamal, R. N. 2016; 24 (4): 213-219

  Abstract

  Burnout is a syndrome marked by emotional exhaustion, depersonalization, and low job satisfaction. Rates of burnout in orthopaedic surgeons are higher than those in the general population and many other medical subspecialties. Half of all orthopaedic surgeons show symptoms of burnout, with the highest rates reported in residents and orthopaedic department chairpersons. This syndrome is associated with poor outcomes for surgeons, institutions, and patients. Validated instruments exist to objectively diagnose burnout, although family members and colleagues should be aware of early warning signs and risk factors, such as irritability, withdrawal, and failing relationships at work and home. Emerging evidence indicates that mindfulness-based interventions or educational programs combined with meditation may be effective treatment options. Orthopaedic residency programs, departments, and practices should focus on identifying the signs of burnout and implementing prevention and treatment programs that have been shown to mitigate symptoms.

  View details for DOI 10.5435/JAAOS-D-15-00148

  View details for Web of Science ID 000372851200001

  View details for PubMedID 26885712

• Quality Measures in Upper Limb Surgery. journal of bone and joint surgery. American volume Kamal, R. N., Ring, D., Akelman, E., Yao, J., Ruch, D. S., Richard, M., Ladd, A., Got, C., Blazar, P., Kakar, S. 2016; 98 (6): 505-510

  Abstract

  Quality measures are now commonplace and are increasingly tied to financial incentives. We reviewed the existing quality measures that address the upper limb and tested the null hypothesis that structure (capacity to deliver care), process (appropriate care), and outcome (the result of care) measures are equally represented.We systematically reviewed MEDLINE/PubMed, Embase, Google Scholar, the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines, the National Quality Forum, the Agency for Healthcare Research and Quality, and the Physician Quality Reporting System for quality measures addressing upper limb surgery. Measures were characterized as structure, process, or outcome measures and were categorized according to their developer and their National Strategy for Quality Improvement in Health Care (National Quality Strategy) priority as articulated by the U.S. Department of Health & Human Services.We identified 134 quality measures addressing the upper limb: 131 (98%) process and three (2%) outcome measures. The majority of the process measures address the National Quality Strategy priority of effective clinical care (90%), with the remainder addressing communication and care coordination (5%), person and caregiver-centered experience and outcomes (4%), and community/population health (1%).Our review identified opportunities to develop more measures in the structure and outcome domains as well as measures addressing patient and family engagement, public health, safety, care coordination, and efficient use of resources. The most common existing measures-process measures addressing care-might not be the best measures of upper limb surgery quality given the relative lack of evidence for their use in care improvement.

  View details for DOI 10.2106/JBJS.15.00651

  View details for PubMedID 26984919

• Subject-Specific Carpal Ligament Elongation in Extreme Positions, Grip, and the Dart Thrower's Motion JOURNAL OF BIOMECHANICAL ENGINEERING-TRANSACTIONS OF THE ASME Rainbow, M. J., Kamal, R. N., Moore, D. C., Akelman, E., Wolfe, S. W., Crisco, J. J. 2015; 137 (11)

  View details for DOI 10.1115/1.4031580

  View details for Web of Science ID 000362842900006

  View details for PubMedID 26367853

• Management of Intercarpal Ligament Injuries Associated with Distal Radius Fractures. Hand clinics Desai, M. J., Kamal, R. N., Richard, M. J. 2015; 31 (3): 409-416

  Abstract

  The prevalence of ligamentous injury associated with fractures of the distal radius is reported to be as high as 69% with injury to the scapholunate interosseous ligament and lunotriquetral interosseous ligament occurring in 16% to 40% and 8.5% to 15%, respectively. There is a lack of consensus on which patients should undergo advanced imaging, arthroscopy, and treatment and whether this changes their natural history. Overall, patients with high-grade intercarpal ligament injuries are shown to have longer-term disability and sequelae compared with those with lower-grade injuries. This article reviews the diagnosis and treatment options for these injuries.

  View details for DOI 10.1016/j.hcl.2015.04.009

  View details for PubMedID 26205702

• Management of Intercarpal Ligament Injuries Associated with Distal Radius Fractures. Hand clinics Desai, M. J., Kamal, R. N., Richard, M. J. 2015; 31 (3): 409-416

  View details for DOI 10.1016/j.hcl.2015.04.009

  View details for PubMedID 26205702

• Ulnar shortening osteotomy for distal radius malunion. Journal of wrist surgery Kamal, R. N., Leversedge, F. J. 2014; 3 (3): 181-186

  Abstract

  Background Malunion is a common complication of distal radius fractures. Ulnar shortening osteotomy (USO) may be an effective treatment for distal radius malunion when appropriate indications are observed. Methods The use of USO for treatment of distal radius fracture malunion is described for older patients (typically patients >50 years) with dorsal or volar tilt less than 20 degrees and no carpal malalignment or intercarpal or distal radioulnar joint (DRUJ) arthritis. Description of Technique Preoperative radiographs are examined to ensure there are no contraindications to ulnar shortening osteotomy. The neutral posteroanterior (PA) radiograph is used to measure ulnar variance and to estimate the amount of ulnar shortening required. An ulnar, mid-sagittal incision is used and the dorsal sensory branch of the ulnar nerve is preserved. An USO-specific plating system with cutting jig is used to create parallel oblique osteotomies to facilitate shortening. Intraoperative fluoroscopy and clinical range of motion are checked to ensure adequate shortening and congruous reduction of the ulnar head within the sigmoid notch. Results Previous outcomes evaluation of USO has demonstrated improvement in functional activities, including average flexion-extension and pronosupination motions, and patient reported outcomes. Conclusion The concept and technique of USO are reviewed for the treatment of distal radius malunion when specific indications are observed. Careful attention to detail related to surgical indications and to surgical technique typically will improve range of motion, pain scores, and patient-reported outcomes and will reduce the inherent risks of the procedure, such as ulnar nonunion or the symptoms related to unrecognized joint arthritis. Level IV.

  View details for DOI 10.1055/s-0034-1384747

  View details for PubMedID 25097811

• Salvage of Distal Radius Nonunion With a Dorsal Spanning Distraction Plate JOURNAL OF HAND SURGERY-AMERICAN VOLUME Mithani, S. K., Srinivasan, R. C., Kamal, R., Richard, M. J., Leversedge, F. J., Ruch, D. S. 2014; 39 (5): 981-984

  Abstract

  Treatment of nonunion after previous instrumentation of distal radius fractures represents a reconstructive challenge. Resultant osteopenia provides a poor substrate for fixation, often necessitating wrist fusion for salvage. A spanning dorsal distraction plate (bridge plate) can be a useful adjunct to neutralize forces across the wrist, alone or in combination with nonspanning plates to achieve union, salvage wrist function, and avoid wrist arthrodesis in distal radius nonunion.

  View details for DOI 10.1016/j.jhsa.2014.02.006

  View details for Web of Science ID 000335422200025

  View details for PubMedID 24679491

• Post-traumatic Raynaud's phenomenon following volar plate injury. Rhode Island medical journal (2013) Chodakiewitz, Y. G., Daniels, A. H., Kamal, R. N., Weiss, A. C. 2014; 97 (4): 24-26

  Abstract

  Post-traumatic Raynaud's phenomenon following non-penetrating or non-repetitive injury is rare. We report a case of Raynaud's phenomenon occurring in a single digit 3 months following volar plate avulsion injury. Daily episodes of painless pallor of the digit occurred for 1 month upon any exposure to cold, resolving with warm water therapy. Symptoms resolved after the initiation of hand therapy, splinting, and range-of- motion exercises.

  View details for PubMedID 24660212

• Quality of internet health information on thumb carpometacarpal joint arthritis. Rhode Island medical journal (2013) Kamal, R. N., Paci, G. M., Daniels, A. H., Gosselin, M., Rainbow, M. J., Weiss, A. C. 2014; 97 (4): 31-35

  Abstract

  The Internet has become a heavily used source of health information. No data currently exists on the quality and characteristics of Internet information regarding carpometacarpal (CMC) arthritis.The search terms "cmc arthritis," "basal joint arthritis," and "thumb arthritis" were searched using Google and Bing. Search results were evaluated independently by four reviewers. Classification and content specific review was performed utilizing a weighted 100-point information quality scale.Of the 60 websites reviewed, 27 were unique pages with 6 categorized as academic and 21 as non- academic. Average score on content specific review of academic websites was 56.8 and for non-academic was 42.7 (p=0.054). Average Flesch-Kincaid Grade Level for academic websites was 12.4, and for non-academic was 9.9 (p=0.015).Internet health information regarding thumb CMC arthritis is primarily non-academic in nature, of generally poor quality, and at a reading level far above the U.S. average reading level of 6th grade. Higher-quality websites with more complete content and appropriate readability are needed.The quality of Internet health information regarding thumb CMC arthritis is suboptimal.

  View details for PubMedID 24660214

• Extensive Subcutaneous Emphysema Resembling Necrotizing Fasciitis ORTHOPEDICS Kamal, R. N., Paci, G. M., Born, C. T. 2013; 36 (5): 671-675

  Abstract

  Necrotizing fasciitis is an aggressive, invasive soft tissue infection. Because it can rapidly progress to patient instability, prompt diagnosis followed by urgent debridement is critical to decreasing mortality. Despite the importance of early diagnosis, necrotizing fasciitis remains a clinical diagnosis, with little evidence in the literature regarding the effectiveness of diagnostic tools or criteria. Common clinical findings are nonspecific, including pain, blistering, crepitus, and swelling with or without fever and a known infection source.This article describes a patient who was transferred to the authors' institution from another hospital, where she had been taken following seizure activity and was treated with antibiotics for suspected cellulitis at the intravenous catheter placement site on her left dorsal hand. On admission to the current authors' institution, she presented with pain and swelling in the setting of significant left upper-extremity emphysema. She had undergone a left shoulder arthroscopy 4 weeks previously. Vital signs were within normal limits, and a preoperative chest radiograph was read as normal. The patient underwent an emergent fasciotomy, irrigation and debridement of the left upper extremity, and intravenous antibiotics for suspected necrotizing fasciitis. Intraoperative findings indicative of infection were absent, and a left apical pneumothorax was later found on postoperative chest imaging.In a stable patient with a normal chest radiograph on presentation who demonstrates upper-extremity crepitus suspicious for necrotizing fasciitis, a chest computed tomography scan may be indicated to rule out an intrathoracic source.

  View details for DOI 10.3928/01477447-20130426-34

  View details for Web of Science ID 000319811900037

  View details for PubMedID 23672900

• Nerve compression syndromes of the upper extremity: diagnosis, treatment, and rehabilitation. Rhode Island medical journal (2013) Mansuripur, P. K., Deren, M. E., Kamal, R. 2013; 96 (5): 37-39

  Abstract

  Nerve compression syndromes of the upper extremity, including carpal tunnel syndrome, cubital tunnel syndrome, posterior interosseous syndrome and radial tunnel syndrome, are common in the general population. Diagnosis is made based on patient complaint and history as well as specific exam and study findings. Treatment options include various operative and nonoperative modalities, both of which include aspects of hand therapy and rehabilitation.

  View details for PubMedID 23641462

• Total Wrist Arthroplasty JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Weiss, A. C., Kamal, R. N., Shultz, P. 2013; 21 (3): 140-148

  Abstract

  Over the past 40 years, total wrist arthroplasty (TWA) has emerged as a cost-effective treatment option for wrist arthritis. First-generation implant designs have changed tremendously; current devices are designed to enhance wrist stability, provide greater implant longevity, and minimize surgical and postoperative complications. Although arthrodesis remains the standard for surgical management, TWA outcomes demonstrate that the procedure has excellent clinical promise. Additional prospective studies are needed to compare outcomes of wrist arthrodesis with those of TWA with current implants.

  View details for DOI 10.5435/JAAOS-21-03-140

  View details for Web of Science ID 000317444900003

  View details for PubMedID 23457064

• In vivo kinematics of the scaphoid, lunate, capitate, and third metacarpal in extreme wrist flexion and extension. journal of hand surgery Rainbow, M. J., Kamal, R. N., Leventhal, E., Akelman, E., Moore, D. C., Wolfe, S. W., Crisco, J. J. 2013; 38 (2): 278-288

  Abstract

  Insights into the complexity of active in vivo carpal motion have recently been gained using 3-dimensional imaging; however, kinematics during extremes of motion has not been elucidated. The purpose of this study was to determine motion of the carpus during extremes of wrist flexion and extension.We obtained computed tomography scans of 12 healthy wrists in neutral grip, extreme loaded flexion, and extreme loaded extension. We obtained 3-dimensional bone surfaces and 6-degree-of-freedom kinematics for the radius and carpals. The flexion and extension rotation from neutral grip to extreme flexion and extreme extension of the scaphoid and lunate was expressed as a percentage of capitate flexion and extension and then compared with previous studies of active wrist flexion and extension. We also tested the hypothesis that the capitate and third metacarpal function as a single rigid body. Finally, we used joint space metrics at the radiocarpal and midcarpal joints to describe arthrokinematics.In extreme flexion, the scaphoid and lunate flexed 70% and 46% of the amount the capitate flexed, respectively. In extreme extension, the scaphoid extended 74% and the lunate extended 42% of the amount the capitates extended, respectively. The third metacarpal extended 4° farther than the capitate in extreme extension. The joint contact area decreased at the radiocarpal joint during extreme flexion. The radioscaphoid joint contact center moved onto the radial styloid and volar ridge of the radius in extreme flexion from a more proximal and ulnar location in neutral.The contributions of the scaphoid and lunate to capitate rotation were approximately 25% less in extreme extension compared with wrist motion through an active range of motion. More than half the motion of the carpus when the wrist was loaded in extension occurred at the midcarpal joint.These findings highlight the difference in kinematics of the carpus at the extremes of wrist motion, which occur during activities and injuries, and give insight into the possible etiologies of the scaphoid fractures, interosseous ligament injuries, and carpometacarpal bossing.

  View details for DOI 10.1016/j.jhsa.2012.10.035

  View details for PubMedID 23266007

• The effect of the dorsal intercarpal ligament on lunate extension after distal scaphoid excision. journal of hand surgery Kamal, R. N., Chehata, A., Rainbow, M. J., Llusá, M., Garcia-Elias, M. 2012; 37 (11): 2240-2245

  Abstract

  After a distal scaphoid excision, most wrists develop a mild form of carpal instability-nondissociative with dorsal intercalated segment instability. Substantial dysfunctional malalignment is only occasionally seen. We hypothesized that distal scaphoid excision would lead to carpal instability-nondissociative with dorsal intercalated segment instability in cadavers and that the dorsal intercarpal (DIC) ligament plays a role in preventing such complications.We used 10 cadaver upper extremities in this experiment. A customized jig was used to load the wrist with 98 N. Motion of the capitate and lunate was monitored using the Fastrak motion tracking system. Five specimens had a distal scaphoid excision first, followed by excision of the DIC ligament, whereas the other 5 specimens first had excision of the DIC ligament and then had a distal scaphoid excision. Rotation of the lunate and capitate was calculated as a sum of the relative motions between each intervention and was compared with its original location before intervention (control) for statistical analysis.Distal scaphoid excision and subsequent DIC ligament excision both led to significant lunate extension. DIC ligament excision alone resulted in lunate flexion that was not statistically significant. After DIC ligament excision, distal scaphoid excision led to significant lunate extension. Capitate rotation was minimal in both groups, verifying that the overall wrist position did not change with loading.Distal scaphoid excision leads to significant lunate extension through an imbalance in the force couple between the scaphotrapeziotrapezoidal joint and the triquetrum-hamate joint. The DIC ligament may serve as a secondary stabilizer to the lunocapitate joint and prevent further lunate extension with the wrist in neutral position.The development of a clinically symptomatic carpal instability-nondissociative with dorsal intercalated segment instability with lunocapitate subluxation after distal scaphoid excision may be due to an incompetent DIC ligament.

  View details for DOI 10.1016/j.jhsa.2012.07.029

  View details for PubMedID 23044477

• Elongation of the dorsal carpal ligaments: a computational study of in vivo carpal kinematics. journal of hand surgery Rainbow, M. J., Crisco, J. J., Moore, D. C., Kamal, R. N., Laidlaw, D. H., Akelman, E., Wolfe, S. W. 2012; 37 (7): 1393-1399

  Abstract

  The dorsal radiocarpal (DRC) and dorsal intercarpal (DIC) ligaments play an important role in scapholunate and lunotriquetral stability. The purpose of this study was to compute changes in ligament elongation as a function of wrist position for the DRC and the scaphoid and trapezoidal insertions of the DIC.We developed a computational model that incorporated a digital dataset of ligament origin and insertions, bone surface models, and in vivo 3-dimensional kinematics (n = 28 wrists), as well as an algorithm for computing ligament fiber path.The differences between the maximum length and minimum length of the DRC, DIC scaphoid component, and DIC trapezoidal component over the entire range of motion were 5.1 ± 1.5 mm, 2.7 ± 1.5 mm, and 5.9 ± 2.5 mm, respectively. The DRC elongated as the wrist moved from ulnar extension to radial flexion, and the DIC elongated as the wrist moved from radial deviation to ulnar deviation.The DRC and DIC lengthened in opposing directions during wrist ulnar and radial deviation. Despite complex carpal bone anatomy and kinematics, computed fiber elongations were found to vary linearly with wrist position. Errors between computed values and model predictions were less than 2.0 mm across all subjects and positions.The relationships between ligament elongation and wrist position should further our understanding of ligament function, provide insight into the potential effects of dorsal wrist incisions on specific wrist ranges of motion, and serve as a basis for modeling of the wrist.

  View details for DOI 10.1016/j.jhsa.2012.04.025

  View details for PubMedID 22633233

• Updates on Disaster Preparedness and Progress in Disaster Relief JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Pollak, A. N., Born, C. T., Kamal, R. N., Adashi, E. Y. 2012; 20: S54-S58

  Abstract

  Immediately after the January 2010 earthquake in Haiti, many private citizens, governmental and nongovernmental organizations, and medical associations struggled to mount an effective humanitarian aid response. The experiences of these groups have led to changes at their institutions regarding disaster preparedness and response to future events. One of the main challenges in a humanitarian medical response to a disaster is determining when to end response efforts and return responsibility for delivery of medical care back to the host nation. For such a transition to occur, the host nation must have the capacity to deliver medical care. In Haiti, minimal capacity to deliver such care existed before the earthquake, making subsequent transition difficult. If successful, several initiatives proposed to improve disaster response and increase surgical capacity in Haiti could be deployed to other low- and middle-income countries.

  View details for DOI 10.5435/JAAOS-20-08-S54

  View details for Web of Science ID 000307199000013

  View details for PubMedID 22865138

• In Vivo Triquetrum-Hamate Kinematics through a Simulated Hammering Wrist Motion J Bone Joint Surg Am Kamal, R., et al 2012
• The Use of Near-Infrared Spectrometry for the Diagnosis of Lower-extremity Compartment Syndrome ORTHOPEDICS Bariteau, J. T., Beutel, B. G., Kamal, R., Hayda, R., Born, C. 2011; 34 (3)

  View details for DOI 10.3928/01477447-20110124-12

  View details for Web of Science ID 000209016700010

• Total Wrist Athroplasty in the Non-Rheumatoid Patient J Hand Surg Am. Kamal, R. 2011
• Arthroscopic Treatment of Radiocarpal Dislocation: A Case Report Journal of Bone and Joint Surgery Kamal, R., et al 2011
• Effects on cytokines and histology by treatment with the ace inhibitor captopril and the antioxidant retinoic acid in the monocrotaline model of experimentally induced lung fibrosis CURRENT PHARMACEUTICAL DESIGN Baybutt, R. C., Herndon, B. L., Umbehr, J., Mein, J., Xue, Y., Reppert, S., Van Dillen, C., Kamal, R., Halder, A., Moteni, A. 2007; 13 (13): 1327-1333

  Abstract

  Monocrotaline (MCT), a pyrrolizidine alkaloid extracted from the shrub Crotalaria spectabilis, induces in the lungs of many mammalian species severe hypertension and fibrosis. Previous work with MCT-induced lung disease in rats has shown that some of the steps to progressive fibrosis can be interrupted or decreased by intervention with retinoic acid (RA) or with the angiotensin converting enzyme inhibitor, captopril. This report emphasizes the pathology and cytokines present in lungs of rats in the MCT model of hypertension and fibrosis in 8 treatment groups, six per group: (1) controls, not treated; (2) captopril; (3) RA; (4) combined captopril and RA. Groups 5-8 replicated groups 1-4 and also received MCT subcutaneously. Tissues were harvested at 28 days for histopathology and measurement of cytokines TGFbeta, TNFalpha, interleukin 6, and IFN_. TGFbeta was depressed at 28 days by MCT, an effect reversed by a combination of captopril and RA. RA influences production of an important Th1 cytokine, IFN_, and demonstrated the greatest limitation of MCT-induced TNFalpha. The MCT-induced lung pathology of vasculitis, interstitial pneumonia and fibrosis was limited by captopril. Smooth muscle actin was overexpressed in MCT treated animals receiving RA, an effect reduced with captopril. Overall, the study confirmed the existence of a protective effect for both captopril and RA from MCT-induced lung damage at 30 days. No synergistic or antagonistic activity was observed when the two drugs were administered together. Each of the drugs exerts different and particular effects on serum and tissue levels of various cytokines, suggesting that each drug is efficient at different points of attack in the control of lung fibrosis.

  View details for Web of Science ID 000247013200005

  View details for PubMedID 17506718

• Retinoic Acid-High Diet controls M1/M2 Activation Phenotypes in Macrophages and Protects from Monocrotaline-Induced Pulmonary Fibrosis Nutrition Research Kamal, R., et al 2004