耶鲁大学医学院

Purpose Medicare reimbursement for hand surgery procedures has declined in real terms over the past two decades. The purpose of this study was to characterize trends in procedural and cognitive reimbursement in hand surgery over a 17-year period spanning the 2021 revaluation of office Evaluation and Management (E&M) codes, implemented under statutory budget-neutrality. We hypothesized that inflation-adjusted procedural and cognitive reimbursement would diverge in the years following the 2021 revaluation and that this divergence would widen through 2026. Methods Annual Medicare Physician Fee Schedule reimbursement was extracted for 25 high-volume hand and upper-extremity Current Procedural Terminology (CPT) codes and nine office E&M codes (99202–99205, 99211–99215) between 2010 and 2026. Conversion factors were obtained from Centers for Medicare & Medicaid Services final rules and verified against the American Medical Association historical record. Reimbursement was adjusted for inflation using both the Consumer Price Index for All Urban Consumers and the Medicare Economic Index, the latter capturing practice cost inflation specifically. Compound annual growth rates were computed for the full study period and for the segments before (2010–2020) and after (2021–2026) the E&M revaluation. A segmented linear regression with a 2021 breakpoint tested whether the slope and level of inflation-adjusted reimbursement differed significantly across eras. Results From 2010 to 2026, inflation-adjusted (Consumer Price Index for All Urban Consumers) Medicare reimbursement for hand surgery procedures fell 33.9% (compound annual growth rate, −2.55%), while E&M reimbursement fell 10.1% (−0.66%). When adjusted using the Medicare Economic Index, hand surgery reimbursement fell 24.3%, whereas E&M reimbursement increased 2.9%. Segmented regression demonstrated significant level shifts at 2021 of −5.7 index points for hand surgery (P = .002) and +6.5 index points for E&M (P = .021). Slope acceleration in the post-2021 segment was significant for both baskets. The E&M-to-hand reimbursement ratio increased from 100 (2010 baseline) to 120 in 2021, rising to 136 by 2026, coinciding with the 2026 efficiency adjustment applied selectively to procedural codes and other 2026 valuation changes. Conclusions The 2021 E&M revaluation was temporally associated with a structural divergence between procedural and cognitive reimbursement in hand surgery that has compounded under continued conversion factor cuts and the 2026 efficiency adjustment. Clinical relevance These findings have implications for hand surgery workforce sustainability, practice site selection, and ongoing advocacy for inflationary updates indexed to the Medicare Economic Index. Type of study/level of evidence Economic/Decision Analysis III.

Background Endoleaks after thoracoabdominal fenestrated/branched endovascular aneurysm repair (TA-F/BEVAR) may require multimodal treatment, including sac access and cavity filling. Shape memory polymer (SMP) is a self-expanding porous scaffold that promotes organized thrombus, is radiolucent, exerts low radial force, and biodegrades. We evaluated SMP embolization to fill endoleak cavities after TA-F/BEVAR. Methods Retrospective review of all patients treated at a single center with IMPEDE-FX Embolization Plugs for endoleak after TA-F/BEVAR (July 2024–June 2026). Outcomes were endoleak resolution, change in sac diameter and volume, complications, and endoleak-related reintervention. Results Ten patients (8 male; median age 70) underwent 12 procedures. The median preoperative endoleak volume was 25 mL (range, 3–148 mL); 6 had prior endoleak-directed reintervention. A median 114 plugs were implanted per procedure (range, 29–297). No procedural complications occurred. At a median of 34 days, 5 patients (50%) had complete resolution, 3 (30%) near-complete resolution (residual 1.3–2.0 mL), and 2 (20%) partial resolution (residual 25–32 mL); both of the latter underwent a second SMP procedure achieving near-complete resolution. At last follow-up (median 155 days; range, 30–761 days) no new endoleaks were identified. Sacs regressed in 6 patients and were stable in 4; none expanded. Conclusion SMP embolization was safe and effective for significant endoleak after TA-F/BEVAR, despite large endoleak volumes and frequent prior failed intervention. All patients achieved substantial endoleak reduction or resolution; most sacs regressed and none expanded. Longer follow-up is needed to establish durability.

Within cells, across diverse organisms, macromolecular condensation enables spatial and temporal organization of biochemical reactions by organizing proteins and nucleic acids into compositionally distinct membraneless biomolecular condensates. In the gut bacterium Bacteroides thetaiotaomicron, condensate formation by the transcription termination factor Rho (BtRho) increases its termination activity and promotes B. thetaiotaomicron fitness in the mammalian gut. Here, we elucidate the molecular mechanism governing carbon starvation-induced BtRho phase separation. We establish that short, specific amino acid sequences within BtRho's intrinsically disordered region (IDR) control BtRho condensation via complex coacervation. The identified sequences participate in RNA and intra-IDR regulatory interactions that drive condensate formation in vitro and in vivo. We also report that the signaling molecule ppGpp is essential for BtRho phase separation in vivo, binds to purified BtRho in an IDR-dependent manner, and promotes RNA-dependent BtRho condensation in vitro. Our findings demonstrate how specific short sequences within an IDR dictate phase separation in response to nutritional cues.

Cocaine use disorder (CUD) remains a major public health problem, particularly among individuals receiving medications for opioid use disorder (mOUD), where ongoing cocaine use is associated with poorer treatment outcomes and elevated overdose risk. N-acetylcysteine (NAC) is a promising adjunctive candidate that reduces cocaine-seeking in preclinical models and shows mixed efficacy in humans, but its functional neural mechanisms in individuals with CUD—especially within mOUD settings—remain poorly understood. The present study uses functional magnetic resonance imaging (fMRI) to determine whether short-term NAC administration modulates brain activity in regions associated with inhibitory control and affective processing in people with CUD receiving medications for opioid use disorder (mOUD). In this double-blind, placebo-controlled, crossover study, 21 individuals with CUD enrolled in an mOUD program were randomized to receive NAC or placebo for 7 days and participated in fMRI scanning on the 7th day of this period. Following a fourteen-day washout period, participants were crossed over to receive the other condition for another 7-day period. Participants received a second fMRI scan on the 7th day of this period. Participants completed a go/no-go (GNG) and emotion-regulation task (ERT) during each scan. Compared to placebo, active NAC did not significantly affect brain activity during either the GNG task or the ERT. Overall, short-term NAC did not robustly modulate neural circuits supporting inhibitory control or emotion regulation in individuals with comorbid CUD and OUD receiving mOUD, consistent with prior trials reporting limited efficacy of NAC for CUD. These findings underscore the value of incorporating neuroimaging into early-phase treatment trials to evaluate target engagement in humans. ClinicalTrials.gov identifier: NCT02994875, registered 2016–12-16.