BACKGROUND:Quantitative coronary CT angiography plaque analysis (QCCTA) is a novel tool for atherosclerosis detection. OBJECTIVES:The authors examined utilization of a health plan offering of QCCTA to diabetic members and the impact of utilization on health plan costs. METHODS:Diabetic health plan members ≥40 years without prior myocardial infarction were offered QCCTA as a pilot benefit. Benefit utilizers were compared to eligible nonutilizers for incident cardiovascular episodes of care post-notification of eligibility. RESULTS:Over 14 months, 2,064 of 38,079 health plan members were identified as eligible. Utilizers (19.1%) were predominantly White (76.4%) and female (72.6%) residing in communities with high census median household income ($54,321 [$54,321-$71,159]). Utilizers' glycemic control was better (glycated hemoglobin 6.5% [6.0%-7.3%] vs 7.0% [6.4%-7.7%], P = 0.05), and 10-year atherosclerotic cardiovascular disease risk was lower (8.5% [4.2%-15.8%] vs 10.8% [5.7%-20.3%], P = 0.07). Detailed claims data from a matched cohort of 169 utilizers and 169 nonutilizers after a median of 19 months' follow-up showed more incident cardiovascular episodes of care in utilizers (1 [1-3] vs 1 [1-1], P < 0.0001) and higher incremental per-member per-month health plan expenditure for cardiovascular episodes of care ($19.04/month [4.65-85.11] vs $0/month [0-0], P < 0.0001). Per-member per-month was similar after adjusting for baseline glycated hemoglobin and atherosclerotic cardiovascular disease risk score (P = 0.78). CONCLUSIONS:Utilization of QCCTA offered to an employed population with diabetes varies by demographics while increasing near-term health plan expenditure for cardiovascular care. Longer-term studies are warranted to evaluate QCCTA's impact in value-based care models on diabetic members' health outcomes and total health plan spend.

A 78-year-old woman with severe bioprosthetic mitral valve degeneration underwent successful transcatheter mitral valve replacement with a valve-in-valve procedure. This case postprocedure was complicated by cardiogenic shock from left ventricular perforation and underscores the importance of the accurate assessment and treatment of patients following transcatheter valvular procedures.

IGF1R-related disorders are associated with intrauterine growth restriction (IUGR), postnatal growth failure, short stature, microcephaly, developmental delay, and dysmorphic facial features. We report a patient who presented to medical genetics at 7 mo of age with a history of IUGR, poor feeding, mild developmental delays, microcephaly, and dysmorphic facial features. Whole-exome sequencing revealed a novel c.1464T > G p.(Cys488Trp) variant in the IGF1R gene, initially classified as a variation of uncertain significance (VUS). We enrolled the patient in the URDC (Undiagnosed Rare Disease Clinic) and performed additional studies including deep phenotyping and familial segregation analysis, which demonstrated that the patient's IGF1R VUS was present in phenotypically similar family members. Furthermore, biochemical testing revealed an elevated serum IGF-1 level consistent with abnormal IGF-1 receptor function. Workup resulted in the patient's variant being upgraded from a VUS to likely pathogenic. Our report expands the variant and phenotypic spectrum of IGF1R-related disorders and illustrates benefits and feasibility of reassessing a VUS beyond the initial molecular diagnosis by deep phenotyping, 3D modeling, additional biochemical testing, and familial segregation studies through the URDC, a multidisciplinary clinical program whose major goal is to end the diagnostic odyssey in patients with rare diseases.

PURPOSE:To consolidate the evidence from the available literature and undertake a meta-analysis to provide a reference for physicians to make evidence-based recommendations to their patients regarding the return to driving after hip or knee arthroscopic procedures. METHODS:A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The OVID, Embase, and Cochrane databases were searched through June 2020 for articles containing keywords and/or MeSH (Medical Subject Headings) terms "hip arthroscopy" and "knee arthroscopy" in conjunction with "total brake response time" or "reaction time" in the context of automobile driving. A title review and full article review were performed to assess quality and select relevant articles. A meta-analysis of qualifying articles was undertaken. RESULTS:Eight studies met the inclusion criteria for meta-analysis of brake reaction time (BRT). Meta-analysis of all knee BRTs showed times slower than or equal to baseline BRTs through 5 weeks, with a trend of improving BRTs from 6 to 10 weeks (weeks 8 and 10 were significant, P < .05). Among all hip BRTs, week 2 showed times slower than baseline BRTs, but after week 4, a trend toward faster BRTs was observed through week 8 (week 8 was significant, P < .05). CONCLUSIONS:BRTs met baseline or control values and continued to improve after 6 weeks after knee arthroscopy and after 4 weeks after hip arthroscopy. On the basis of these results, it would be safe to recommend a return to driving at 6 weeks after knee arthroscopic procedures and 4 weeks after hip arthroscopic procedures. CLINICAL RELEVANCE:These results can be used by surgeons to base their recommendations on to provide guidance for their patients on the resumption of driving. Although BRT is an important aspect of driving ability, there are additional factors that need to be taken into consideration when making these recommendations, including cessation of opioid analgesics, strength of the surgical limb, and range of motion.

Background/Objective: Advice given to patients on driving resumption after total hip arthroplasty (THA) is inconsistent. Due to a lack of clear guidelines, surgeons’ recommendations range between 4–8 weeks after surgery to resume driving. Delays in driving return can have detrimental social and economic impact. However, it is important to ensure patients only resume driving once safe. This study presents a systematic review and meta-analysis of driving simulation studies after THA to establish when patients can safely return to driving postoperatively. Methods: A systematic review and meta-analysis using PRISMA guidelines was undertaken. Titles and abstracts were screened for inclusion, data was extracted, and studies assessed for bias risk. Review Manager, was used for statistical analysis. Values for brake reaction time (BRT) were included for meta-analysis. Results: 14 articles met the inclusion criteria. Of these, 7 measured BRT and were included in the meta-analysis. Pooled means of both right and left THA showed BRT around or above preoperative baseline at 1 week, 2 weeks and 3 weeks, and below baseline at 6 weeks, 12 weeks, 32 weeks and 52 weeks. Of these, the pooled means at 6, 32, and 52 weeks were significant ( p < 0.05). Studies not meeting meta-analysis inclusion criteria were included in a qualitative analysis, examining self-reported postoperative driving return times which ranged from 6 days to over a year or in rare cases, never. Majority of patients ( n = 960) self-reported driving return within approximately 6 weeks (pooling of mean values 32.9 days). Conclusions: The mean return to driving time recommended in the literature was 4.5 weeks. Based upon BRT meta-analysis, a return to baseline braking performance was noted at 6 weeks postoperatively. However, driving is a complex skill, and patient recommendation should be individualised based on factors such as vehicle transmission type, THA technique, surgical side, medication and comorbidities.

Background: Hip and knee arthroscopies are common orthopaedic procedures. As patients are looking to return to their regular schedules and regain their independence post-surgery, physicians often encounter the question of, “when can I drive again?” While safety of the patient is of the utmost importance when making these recommendations, it is equally important to consider the possibility of harm to others and potential legal ramifications. The purpose of this study is to consolidate evidence from available literature and undertake a systematic review and meta-analysis to determine when it is safe for patients to return to driving after hip and knee arthroscopic procedures. Methods: A systematic review was conducted using PRISMA guidelines. OVID, EMBASE, and COCHRANE databases were searched through June 2020 for articles containing keywords and/or MeSH terms “Hip arthroscopy” and “knee arthroscopy” in conjunction with “total brake response time” or “reaction time” in the context of automobile driving. Title review and full article review were done to assess quality and select relevant articles. Review Manager Version 5.4 was utilized for statistical analysis. Results: 8 papers were included in the meta-analysis of Brake Reaction Time (BRT). Meta-analysis of all Knee BRTs showed times slower-than or equal-to-baseline BRTs through 5 weeks, with a trend of improving BRT from 6 to 10 weeks (only weeks 8 and 10 were significant P < 0.05). Of all Hip BRTs, week 2 showed slower-than-baseline BRTs, but after week 4 demonstrated a trend toward faster BRTs through week 8 (only week 8 was significant P < 0.05). Conclusion: BRTs met baseline/control values and continued to improve after 6 weeks following knee arthroscopy and after 4 weeks following hip arthroscopy. Based on these results it would be safe to recommend return to driving at 6 weeks after knee arthroscopy and 4 weeks after hip arthroscopic procedures.

Background/Objective: The advice given to patients on resumption of driving after total hip arthroplasty (THA) is inconsistent. Due to a lack of clear guidelines, surgeons make recommendations in the range of waiting 4 to 8 weeks after surgery to resume driving. Driving is a crucial part of daily life thus, withholding driving longer than necessary can have a detrimental social and economic impact on the patient. However, it is equally important to ensure that patients only resume driving once safe. This study presents a systematic review of the literature and a meta-analysis of simulation studies to establish when it is safe for patients to return to driving after hip arthroplasty. Methods: The review was performed according to the PRISMA guidelines. Medline, EMBASE, and CENTRAL databases were searched to June 2020 for studies examining ‘return to driving’ or ‘brake reaction time’ after ‘total hip arthroplasty’. Titles and abstracts were screened for inclusion, data was extracted, and studies were assessed for risk of bias. Review Manager, Version 5.4 was used for statistical analysis. Results: A total of 14 articles met the inclusion criteria. Of these, 7 measured brake reaction time and were included in the meta-analysis. The pooled means of both right and left THA show a brake reaction time (BRT) around or just above baseline at 1 week, 2 weeks and 3 weeks, and below baseline at 6 weeks, 12 weeks, 32 weeks and 52 weeks. Of these, the pooled means at 6, 32, and 52 weeks were significant (p < 0.05). Conclusion: The mean recommended return to driving time was 4.5 weeks. Based upon the meta-analysis of BRT, it appears that it is safe to return to driving at 6 weeks post operatively. Orthopedic surgeons should use these results as a guideline when advising patients on when to resume driving.