Presenter: Matthew Grossman, MD, FAAP

Summary: Treating Neonatal Abstinence Syndrome (NAS) traditionally has followed a standardized approach using the Finnegan Scoring System in which if there were three consecutive scores > 8 or two scores > 12, medications would be started. Common medications included tincture of opium or morphine. Medication doses would be adjusted or weaned, typically every other day, by Finnegan scoring.

A better approach is indicated with the 2012 AAP guidelines that indicate the first-line approach to NAS should be nonpharmacological. The approach should be that used for any crying baby, i.e., holding, swaddling, on-demand feeding, and parents rooming in with the infant. NAS infants without significant other medical problems are best cared for in a regular nursery or hospital unit rather than a NICU. With these simple interventions, some NAS infants may not need medications, and if they do, may be weaned sooner.

Additionally, medication management can be more successful if using combinations of a narcotic plus an additional agent such as clonidine or phenobarbital. Medications may be safely weaned more quickly than every other day. Using such a combined approach, the Yale New Haven Hospital has significantly reduced NAS infant LOS, total narcotic dose, and cost while increasing rates of breast feeding.

Key Takeaways

1. Treat NAS first by providing high quality nursing care with infants out of an ICU, swaddled, fed and held when first exhibiting withdrawal symptoms.
2. Use combination narcotic and other medication if pharmacologic treatment is needed.
3. Wean aggressively by symptoms. TH

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Presenter: Matthew Grossman, MD, FAAP

Summary: Treating Neonatal Abstinence Syndrome (NAS) traditionally has followed a standardized approach using the Finnegan Scoring System in which if there were three consecutive scores > 8 or two scores > 12, medications would be started. Common medications included tincture of opium or morphine. Medication doses would be adjusted or weaned, typically every other day, by Finnegan scoring.

A better approach is indicated with the 2012 AAP guidelines that indicate the first-line approach to NAS should be nonpharmacological. The approach should be that used for any crying baby, i.e., holding, swaddling, on-demand feeding, and parents rooming in with the infant. NAS infants without significant other medical problems are best cared for in a regular nursery or hospital unit rather than a NICU. With these simple interventions, some NAS infants may not need medications, and if they do, may be weaned sooner.

Additionally, medication management can be more successful if using combinations of a narcotic plus an additional agent such as clonidine or phenobarbital. Medications may be safely weaned more quickly than every other day. Using such a combined approach, the Yale New Haven Hospital has significantly reduced NAS infant LOS, total narcotic dose, and cost while increasing rates of breast feeding.

Key Takeaways

1. Treat NAS first by providing high quality nursing care with infants out of an ICU, swaddled, fed and held when first exhibiting withdrawal symptoms.
2. Use combination narcotic and other medication if pharmacologic treatment is needed.
3. Wean aggressively by symptoms. TH

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Presenter: Matthew Grossman, MD, FAAP

Summary: Treating Neonatal Abstinence Syndrome (NAS) traditionally has followed a standardized approach using the Finnegan Scoring System in which if there were three consecutive scores > 8 or two scores > 12, medications would be started. Common medications included tincture of opium or morphine. Medication doses would be adjusted or weaned, typically every other day, by Finnegan scoring.

A better approach is indicated with the 2012 AAP guidelines that indicate the first-line approach to NAS should be nonpharmacological. The approach should be that used for any crying baby, i.e., holding, swaddling, on-demand feeding, and parents rooming in with the infant. NAS infants without significant other medical problems are best cared for in a regular nursery or hospital unit rather than a NICU. With these simple interventions, some NAS infants may not need medications, and if they do, may be weaned sooner.

Additionally, medication management can be more successful if using combinations of a narcotic plus an additional agent such as clonidine or phenobarbital. Medications may be safely weaned more quickly than every other day. Using such a combined approach, the Yale New Haven Hospital has significantly reduced NAS infant LOS, total narcotic dose, and cost while increasing rates of breast feeding.

Key Takeaways

1. Treat NAS first by providing high quality nursing care with infants out of an ICU, swaddled, fed and held when first exhibiting withdrawal symptoms.
2. Use combination narcotic and other medication if pharmacologic treatment is needed.
3. Wean aggressively by symptoms. TH

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Presenters: David Pressel, MD, PhD, FAAP, FHM, Emily Fingado, MD, FAAP, and Jessica Tomaszewski, MD, FAAP

Summary: Patients may engage in violent behaviors that pose a danger to themselves or others. Behavioral emergencies may be rare, can be dangerous, and staff may feel ill-trained to respond appropriately. Patients with ingestions, or underlying psychiatric or developmental difficulties, are at highest risk for developing a behavioral emergency.

The first strategy in handling a potentially violent patient is de-escalation, i.e., trying to identify and rectify the behavioral trigger. If de-escalation is not successful, personal safety is paramount. Get away from the patient and get help. If a patient needs to be physically restrained, minimally there should be one staff member per limb. Various physical devices, including soft restraints, four-point leathers, hand mittens, and spit hoods may be used to control a violent patient. A violent restraint is characterized by the indication, not the device. Medications may be used to treat the underlying mental health issue and should not be used as PRN chemical restraints.

After a violent patient is safely restrained, further steps need to be taken, including notification of the attending or legal guardian if a minor; documentation of the event, including a debrief of what occurred; a room sweep to ensure securing any dangerous items (metal eating utensils); and modification of the care plan to strategize on removal of the restraints as soon as is safe.

Hospitals should view behavioral emergencies similarly to a Code Blue. Have a specialized team that responds and undergoes regular training.

Key Takeaways

1. Behavioral emergencies occur when a patient becomes violent.
2. De-escalation is the best response.
3. If not successful, maintain personal safety, control and medicate the patient as appropriate, and document clearly. TH

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Presenters: David Pressel, MD, PhD, FAAP, FHM, Emily Fingado, MD, FAAP, and Jessica Tomaszewski, MD, FAAP

Summary: Patients may engage in violent behaviors that pose a danger to themselves or others. Behavioral emergencies may be rare, can be dangerous, and staff may feel ill-trained to respond appropriately. Patients with ingestions, or underlying psychiatric or developmental difficulties, are at highest risk for developing a behavioral emergency.

The first strategy in handling a potentially violent patient is de-escalation, i.e., trying to identify and rectify the behavioral trigger. If de-escalation is not successful, personal safety is paramount. Get away from the patient and get help. If a patient needs to be physically restrained, minimally there should be one staff member per limb. Various physical devices, including soft restraints, four-point leathers, hand mittens, and spit hoods may be used to control a violent patient. A violent restraint is characterized by the indication, not the device. Medications may be used to treat the underlying mental health issue and should not be used as PRN chemical restraints.

After a violent patient is safely restrained, further steps need to be taken, including notification of the attending or legal guardian if a minor; documentation of the event, including a debrief of what occurred; a room sweep to ensure securing any dangerous items (metal eating utensils); and modification of the care plan to strategize on removal of the restraints as soon as is safe.

Hospitals should view behavioral emergencies similarly to a Code Blue. Have a specialized team that responds and undergoes regular training.

Key Takeaways

1. Behavioral emergencies occur when a patient becomes violent.
2. De-escalation is the best response.
3. If not successful, maintain personal safety, control and medicate the patient as appropriate, and document clearly. TH

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Presenters: David Pressel, MD, PhD, FAAP, FHM, Emily Fingado, MD, FAAP, and Jessica Tomaszewski, MD, FAAP

Summary: Patients may engage in violent behaviors that pose a danger to themselves or others. Behavioral emergencies may be rare, can be dangerous, and staff may feel ill-trained to respond appropriately. Patients with ingestions, or underlying psychiatric or developmental difficulties, are at highest risk for developing a behavioral emergency.

The first strategy in handling a potentially violent patient is de-escalation, i.e., trying to identify and rectify the behavioral trigger. If de-escalation is not successful, personal safety is paramount. Get away from the patient and get help. If a patient needs to be physically restrained, minimally there should be one staff member per limb. Various physical devices, including soft restraints, four-point leathers, hand mittens, and spit hoods may be used to control a violent patient. A violent restraint is characterized by the indication, not the device. Medications may be used to treat the underlying mental health issue and should not be used as PRN chemical restraints.

After a violent patient is safely restrained, further steps need to be taken, including notification of the attending or legal guardian if a minor; documentation of the event, including a debrief of what occurred; a room sweep to ensure securing any dangerous items (metal eating utensils); and modification of the care plan to strategize on removal of the restraints as soon as is safe.

Hospitals should view behavioral emergencies similarly to a Code Blue. Have a specialized team that responds and undergoes regular training.

Key Takeaways

1. Behavioral emergencies occur when a patient becomes violent.
2. De-escalation is the best response.
3. If not successful, maintain personal safety, control and medicate the patient as appropriate, and document clearly. TH

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

WAIKOLOA, HAWAII – Toenail onychomycosis is a common condition in the general population, but it’s three- to fourfold more prevalent in certain at risk populations where it can have serious and even life-threatening consequences, Dr. Theodore Rosen observed at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

He cited a recent systematic review led by Dr. Aditya K. Gupta, professor of dermatology at the University of Toronto, whom Dr. Rosen hailed as one of the world’s great fungal disease authorities. Dr. Gupta and coworkers concluded that while the prevalence of dermatophyte toenail onychomycosis is 3.2% worldwide in the general population, it climbs to 8.8% in diabetics, 10.2% in psoriatics, 10.3% in the elderly, 11.9% in dialysis patients, 5.2% in renal transplant recipients, and 10.4% in HIV-positive individuals. The highest prevalence of onychomycosis due to non-dermatophyte molds was seen in psoriasis patients, at 2.5%, while elderly patients had the highest prevalence of onychomycosis caused by yeasts, at 6.1% (J Eur Acad Dermatol Venereol. 2015 Jun;29[6]:1039-44).

“Onychomycosis is especially important in those who are immunocompromised and immunosuppressed, for two reasons. One is that really odd organisms that aren’t Trichophyton rubrum or T. interdigitale can be involved: saprophytes like Scopulariopsis, Acremonium, Aspergillus, and Paecilomyces. And some of these saprophytes, like Fusarium, can get from the nail and nail bed into the bloodstream and can kill,” explained Dr. Rosen, professor of dermatology at Baylor College of Medicine in Houston.

“Onychomycosis, aside from the fact that it looks bad and often leads to pain, can also lead to breaks in the skin which then result in secondary bacterial infections. In fact, after motor vehicle accidents, onychomycosis and tinea pedis combined are the most common cause of lower extremity cellulitis leading to hospitalization in the United States,” he continued.

The go-to treatments for onychomycosis in patients with a bad prognostic factor are oral itraconazole (Sporanox) and terbinafine. Don’t be unduly swayed by the complete cure rates reported in clinical trials and cited in the product package inserts; they don’t tell the full story because of important differences in study design, according to Dr. Rosen.

He recommended that physicians familiarize themselves with posaconazole (Noxafil) as an antifungal to consider for second-line therapy in difficult-to-cure cases of onychomycosis in immunosuppressed patients. This is off-label therapy. The approved indications for this triazole antifungal agent are prophylaxis of invasive Aspergillus and Candida infections in severely immunocompromised patients, as well as treatment of oropharyngeal candidiasis. But this is a potent agent that provides broad-spectrum coverage coupled with a favorable safety profile. It performed well in a phase IIb randomized, placebo- and active-controlled, multicenter, investigator-blinded study of 218 adults with toenail onychomycosis (Br J Dermatol. 2012 Feb;166[2]:389-98).

Dr. Rosen reported serving on scientific advisory boards for Anacor, Merz, and Valeant.

SDEF and this news organization are owned by the same parent company.

[email protected]

WAIKOLOA, HAWAII – Toenail onychomycosis is a common condition in the general population, but it’s three- to fourfold more prevalent in certain at risk populations where it can have serious and even life-threatening consequences, Dr. Theodore Rosen observed at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

He cited a recent systematic review led by Dr. Aditya K. Gupta, professor of dermatology at the University of Toronto, whom Dr. Rosen hailed as one of the world’s great fungal disease authorities. Dr. Gupta and coworkers concluded that while the prevalence of dermatophyte toenail onychomycosis is 3.2% worldwide in the general population, it climbs to 8.8% in diabetics, 10.2% in psoriatics, 10.3% in the elderly, 11.9% in dialysis patients, 5.2% in renal transplant recipients, and 10.4% in HIV-positive individuals. The highest prevalence of onychomycosis due to non-dermatophyte molds was seen in psoriasis patients, at 2.5%, while elderly patients had the highest prevalence of onychomycosis caused by yeasts, at 6.1% (J Eur Acad Dermatol Venereol. 2015 Jun;29[6]:1039-44).

“Onychomycosis is especially important in those who are immunocompromised and immunosuppressed, for two reasons. One is that really odd organisms that aren’t Trichophyton rubrum or T. interdigitale can be involved: saprophytes like Scopulariopsis, Acremonium, Aspergillus, and Paecilomyces. And some of these saprophytes, like Fusarium, can get from the nail and nail bed into the bloodstream and can kill,” explained Dr. Rosen, professor of dermatology at Baylor College of Medicine in Houston.

“Onychomycosis, aside from the fact that it looks bad and often leads to pain, can also lead to breaks in the skin which then result in secondary bacterial infections. In fact, after motor vehicle accidents, onychomycosis and tinea pedis combined are the most common cause of lower extremity cellulitis leading to hospitalization in the United States,” he continued.

The go-to treatments for onychomycosis in patients with a bad prognostic factor are oral itraconazole (Sporanox) and terbinafine. Don’t be unduly swayed by the complete cure rates reported in clinical trials and cited in the product package inserts; they don’t tell the full story because of important differences in study design, according to Dr. Rosen.

He recommended that physicians familiarize themselves with posaconazole (Noxafil) as an antifungal to consider for second-line therapy in difficult-to-cure cases of onychomycosis in immunosuppressed patients. This is off-label therapy. The approved indications for this triazole antifungal agent are prophylaxis of invasive Aspergillus and Candida infections in severely immunocompromised patients, as well as treatment of oropharyngeal candidiasis. But this is a potent agent that provides broad-spectrum coverage coupled with a favorable safety profile. It performed well in a phase IIb randomized, placebo- and active-controlled, multicenter, investigator-blinded study of 218 adults with toenail onychomycosis (Br J Dermatol. 2012 Feb;166[2]:389-98).

Dr. Rosen reported serving on scientific advisory boards for Anacor, Merz, and Valeant.

SDEF and this news organization are owned by the same parent company.

[email protected]

WAIKOLOA, HAWAII – Toenail onychomycosis is a common condition in the general population, but it’s three- to fourfold more prevalent in certain at risk populations where it can have serious and even life-threatening consequences, Dr. Theodore Rosen observed at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

He cited a recent systematic review led by Dr. Aditya K. Gupta, professor of dermatology at the University of Toronto, whom Dr. Rosen hailed as one of the world’s great fungal disease authorities. Dr. Gupta and coworkers concluded that while the prevalence of dermatophyte toenail onychomycosis is 3.2% worldwide in the general population, it climbs to 8.8% in diabetics, 10.2% in psoriatics, 10.3% in the elderly, 11.9% in dialysis patients, 5.2% in renal transplant recipients, and 10.4% in HIV-positive individuals. The highest prevalence of onychomycosis due to non-dermatophyte molds was seen in psoriasis patients, at 2.5%, while elderly patients had the highest prevalence of onychomycosis caused by yeasts, at 6.1% (J Eur Acad Dermatol Venereol. 2015 Jun;29[6]:1039-44).

“Onychomycosis is especially important in those who are immunocompromised and immunosuppressed, for two reasons. One is that really odd organisms that aren’t Trichophyton rubrum or T. interdigitale can be involved: saprophytes like Scopulariopsis, Acremonium, Aspergillus, and Paecilomyces. And some of these saprophytes, like Fusarium, can get from the nail and nail bed into the bloodstream and can kill,” explained Dr. Rosen, professor of dermatology at Baylor College of Medicine in Houston.

“Onychomycosis, aside from the fact that it looks bad and often leads to pain, can also lead to breaks in the skin which then result in secondary bacterial infections. In fact, after motor vehicle accidents, onychomycosis and tinea pedis combined are the most common cause of lower extremity cellulitis leading to hospitalization in the United States,” he continued.

The go-to treatments for onychomycosis in patients with a bad prognostic factor are oral itraconazole (Sporanox) and terbinafine. Don’t be unduly swayed by the complete cure rates reported in clinical trials and cited in the product package inserts; they don’t tell the full story because of important differences in study design, according to Dr. Rosen.

He recommended that physicians familiarize themselves with posaconazole (Noxafil) as an antifungal to consider for second-line therapy in difficult-to-cure cases of onychomycosis in immunosuppressed patients. This is off-label therapy. The approved indications for this triazole antifungal agent are prophylaxis of invasive Aspergillus and Candida infections in severely immunocompromised patients, as well as treatment of oropharyngeal candidiasis. But this is a potent agent that provides broad-spectrum coverage coupled with a favorable safety profile. It performed well in a phase IIb randomized, placebo- and active-controlled, multicenter, investigator-blinded study of 218 adults with toenail onychomycosis (Br J Dermatol. 2012 Feb;166[2]:389-98).

Dr. Rosen reported serving on scientific advisory boards for Anacor, Merz, and Valeant.

SDEF and this news organization are owned by the same parent company.

[email protected]

Injectable soft-tissue fillers continue to be popular in the cosmetic arena. In the United States there are many fillers currently on the market and many more coming through the pipeline. A multitude of products are available outside the United States. As with any procedure, the more fillers we inject, the more complications we are bound to see.

Conrad et al (Modern Plastic Surgery. 2015;5:14-18) performed a retrospective analysis of patients treated over a 10-year period with soft-tissue injections (1559 patients) looking for cases complicated by abscess formation. Four patients were identified (0.3% of total patients). The authors discussed the 4 cases, the patients’ medical history and experience with other injectable agents, and the management of each complication.

Case 1 was a 52-year-old woman with systemic lupus erythematosus on a low-dose steroid who presented with an inflammatory response in the lower lip 7 days following injection with a hyaluronic acid (HA)–based gel filler in 2011. Her history was notable for prior HA filler in 2008 and polyacrylamide filler in 2009 and 2010. She was treated with 4 sessions of incision and drainage (I&D) and systemic clindamycin. Most of the cultures were negative, but one showed streptococci.

Case 2 was a 56-year-old woman treated in the nasolabial fold with HA in 2009. She developed inflammation shortly after and an abscess at the site a month later. She was treated with clindamycin both times, though cultures were negative. Furthermore, the abscess was treated with I&D and an intralesional steroid. She was a smoker and had been treated with a polymethyl methacrylate filler in 2002 and subsequently in 2013 with no issues.

Case 3 was a 39-year-old woman injected with an HA filler in the upper and lower lips in 2011. One month later she developed abscesses in both areas that were treated twice with I&D. Cultures were negative. She had a history of polyacrylamide injections of the nasolabial fold in 2009. The patient’s medical history was notable for scleroderma.

Case 4 was a 58-year-old woman injected with an HA filler in 2009 in the prejowl sulcus and nasolabial fold. She developed recurrent sterile abscesses in the areas 8 months after treatment that were managed by drainage of the areas and intralesional steroid injections over the ensuing 6 months. The scars were then excised, lasered 6 weeks later, and then filled in with expanded polytetrafluoroethylene implants, followed by 1 more session of laser resurfacing. She had a history of polymethyl methacrylate filler in 2002.

All patients eventually recovered. The authors stressed 3 important factors in managing dermal filler complications: (1) identifying the causative pathogen, (2) choosing the appropriate treatment of delayed-onset abscess formation, and (3) identifying the risk factors for patients at risk for abscess formation.

The issue of biofilms complicates the ability to identify the bacterial agent, yet biofilms are becoming recognized as the causative factors in what were previously thought of as sterile abscesses. The authors suggested using a peptide nucleic acid fluorescent in situ hybridization test to identify the biofilm bacteria. Conrad et el also discussed the development of slippery liquid-infused porous surfaces technology to coat the inside of syringes to help prevent biofilm formation.

The management of these patients is tricky because it is difficult to differentiate between a biofilm abscess and a hypersensitivity reaction. For this reason, the authors advocated using hyaluronidase versus intralesional steroids in the initial management to make the area more susceptible to antibiotics and to avoid promoting the growth of bacteria with the use of steroids. For patient risk factors, the authors focused on the fact that 2 of 4 patients had concomitant autoimmune disorders—scleroderma and systemic lupus erythematosus—that may have predisposed them to infection. Lastly, 2 patients had prior polyacrylamide injections and the authors also speculated if the positive charge of this filler attracted bacteria.

What’s the issue?

The use of fillers will continue to increase as there are more fillers with novel properties entering the market. As with new technology, only time will tell if we will see any particular type of reaction or risk for infection with them. The issue of biofilm bacterial contamination is real. It is recognized as one of the causes of capsular contraction following breast implant surgery. The etiology may not be from contamination during production but from contamination of the filler after injection due to any transient bacteremia that the patient may experience. A concern is that dental manipulation (eg, dental cleaning, filling of dental caries, periodontal surgery) during the 2- to 4-week postfiller period may “seed” bacteria into the area and cause the bacteria to settle and grow on the foreign substance. For patients who have semipermanent or permanent fillers such as polyacrylamide, polymethyl methacrylate beads, or poly-L-lactic acid, biofilm risk is greater and can occur months to years after the procedure. I have personally seen 2 cases of poly-L-lactic acid filler develop red, tender, sterile abscesses 1 year after placement in the tissue. Both cases responded to prolonged clarithromycin use (2 months). However, these cases highlight the fact that the fillers persist long after we place them, and any bacteremia, even mild, can cause an unsightly reaction.

Have you seen delayed soft-tissue filler reactions in your practice? Given this information, will you change the way you advise patients on dental procedures in the 2- to 4-week postfiller period?

We want to know your views! Tell us what you think.

Injectable soft-tissue fillers continue to be popular in the cosmetic arena. In the United States there are many fillers currently on the market and many more coming through the pipeline. A multitude of products are available outside the United States. As with any procedure, the more fillers we inject, the more complications we are bound to see.

Conrad et al (Modern Plastic Surgery. 2015;5:14-18) performed a retrospective analysis of patients treated over a 10-year period with soft-tissue injections (1559 patients) looking for cases complicated by abscess formation. Four patients were identified (0.3% of total patients). The authors discussed the 4 cases, the patients’ medical history and experience with other injectable agents, and the management of each complication.

Case 1 was a 52-year-old woman with systemic lupus erythematosus on a low-dose steroid who presented with an inflammatory response in the lower lip 7 days following injection with a hyaluronic acid (HA)–based gel filler in 2011. Her history was notable for prior HA filler in 2008 and polyacrylamide filler in 2009 and 2010. She was treated with 4 sessions of incision and drainage (I&D) and systemic clindamycin. Most of the cultures were negative, but one showed streptococci.

Case 2 was a 56-year-old woman treated in the nasolabial fold with HA in 2009. She developed inflammation shortly after and an abscess at the site a month later. She was treated with clindamycin both times, though cultures were negative. Furthermore, the abscess was treated with I&D and an intralesional steroid. She was a smoker and had been treated with a polymethyl methacrylate filler in 2002 and subsequently in 2013 with no issues.

Case 3 was a 39-year-old woman injected with an HA filler in the upper and lower lips in 2011. One month later she developed abscesses in both areas that were treated twice with I&D. Cultures were negative. She had a history of polyacrylamide injections of the nasolabial fold in 2009. The patient’s medical history was notable for scleroderma.

Case 4 was a 58-year-old woman injected with an HA filler in 2009 in the prejowl sulcus and nasolabial fold. She developed recurrent sterile abscesses in the areas 8 months after treatment that were managed by drainage of the areas and intralesional steroid injections over the ensuing 6 months. The scars were then excised, lasered 6 weeks later, and then filled in with expanded polytetrafluoroethylene implants, followed by 1 more session of laser resurfacing. She had a history of polymethyl methacrylate filler in 2002.

All patients eventually recovered. The authors stressed 3 important factors in managing dermal filler complications: (1) identifying the causative pathogen, (2) choosing the appropriate treatment of delayed-onset abscess formation, and (3) identifying the risk factors for patients at risk for abscess formation.

The issue of biofilms complicates the ability to identify the bacterial agent, yet biofilms are becoming recognized as the causative factors in what were previously thought of as sterile abscesses. The authors suggested using a peptide nucleic acid fluorescent in situ hybridization test to identify the biofilm bacteria. Conrad et el also discussed the development of slippery liquid-infused porous surfaces technology to coat the inside of syringes to help prevent biofilm formation.

The management of these patients is tricky because it is difficult to differentiate between a biofilm abscess and a hypersensitivity reaction. For this reason, the authors advocated using hyaluronidase versus intralesional steroids in the initial management to make the area more susceptible to antibiotics and to avoid promoting the growth of bacteria with the use of steroids. For patient risk factors, the authors focused on the fact that 2 of 4 patients had concomitant autoimmune disorders—scleroderma and systemic lupus erythematosus—that may have predisposed them to infection. Lastly, 2 patients had prior polyacrylamide injections and the authors also speculated if the positive charge of this filler attracted bacteria.

What’s the issue?

The use of fillers will continue to increase as there are more fillers with novel properties entering the market. As with new technology, only time will tell if we will see any particular type of reaction or risk for infection with them. The issue of biofilm bacterial contamination is real. It is recognized as one of the causes of capsular contraction following breast implant surgery. The etiology may not be from contamination during production but from contamination of the filler after injection due to any transient bacteremia that the patient may experience. A concern is that dental manipulation (eg, dental cleaning, filling of dental caries, periodontal surgery) during the 2- to 4-week postfiller period may “seed” bacteria into the area and cause the bacteria to settle and grow on the foreign substance. For patients who have semipermanent or permanent fillers such as polyacrylamide, polymethyl methacrylate beads, or poly-L-lactic acid, biofilm risk is greater and can occur months to years after the procedure. I have personally seen 2 cases of poly-L-lactic acid filler develop red, tender, sterile abscesses 1 year after placement in the tissue. Both cases responded to prolonged clarithromycin use (2 months). However, these cases highlight the fact that the fillers persist long after we place them, and any bacteremia, even mild, can cause an unsightly reaction.

Have you seen delayed soft-tissue filler reactions in your practice? Given this information, will you change the way you advise patients on dental procedures in the 2- to 4-week postfiller period?

We want to know your views! Tell us what you think.

Injectable soft-tissue fillers continue to be popular in the cosmetic arena. In the United States there are many fillers currently on the market and many more coming through the pipeline. A multitude of products are available outside the United States. As with any procedure, the more fillers we inject, the more complications we are bound to see.

Conrad et al (Modern Plastic Surgery. 2015;5:14-18) performed a retrospective analysis of patients treated over a 10-year period with soft-tissue injections (1559 patients) looking for cases complicated by abscess formation. Four patients were identified (0.3% of total patients). The authors discussed the 4 cases, the patients’ medical history and experience with other injectable agents, and the management of each complication.

Case 1 was a 52-year-old woman with systemic lupus erythematosus on a low-dose steroid who presented with an inflammatory response in the lower lip 7 days following injection with a hyaluronic acid (HA)–based gel filler in 2011. Her history was notable for prior HA filler in 2008 and polyacrylamide filler in 2009 and 2010. She was treated with 4 sessions of incision and drainage (I&D) and systemic clindamycin. Most of the cultures were negative, but one showed streptococci.

Case 2 was a 56-year-old woman treated in the nasolabial fold with HA in 2009. She developed inflammation shortly after and an abscess at the site a month later. She was treated with clindamycin both times, though cultures were negative. Furthermore, the abscess was treated with I&D and an intralesional steroid. She was a smoker and had been treated with a polymethyl methacrylate filler in 2002 and subsequently in 2013 with no issues.

Case 3 was a 39-year-old woman injected with an HA filler in the upper and lower lips in 2011. One month later she developed abscesses in both areas that were treated twice with I&D. Cultures were negative. She had a history of polyacrylamide injections of the nasolabial fold in 2009. The patient’s medical history was notable for scleroderma.

Case 4 was a 58-year-old woman injected with an HA filler in 2009 in the prejowl sulcus and nasolabial fold. She developed recurrent sterile abscesses in the areas 8 months after treatment that were managed by drainage of the areas and intralesional steroid injections over the ensuing 6 months. The scars were then excised, lasered 6 weeks later, and then filled in with expanded polytetrafluoroethylene implants, followed by 1 more session of laser resurfacing. She had a history of polymethyl methacrylate filler in 2002.

All patients eventually recovered. The authors stressed 3 important factors in managing dermal filler complications: (1) identifying the causative pathogen, (2) choosing the appropriate treatment of delayed-onset abscess formation, and (3) identifying the risk factors for patients at risk for abscess formation.

The issue of biofilms complicates the ability to identify the bacterial agent, yet biofilms are becoming recognized as the causative factors in what were previously thought of as sterile abscesses. The authors suggested using a peptide nucleic acid fluorescent in situ hybridization test to identify the biofilm bacteria. Conrad et el also discussed the development of slippery liquid-infused porous surfaces technology to coat the inside of syringes to help prevent biofilm formation.

The management of these patients is tricky because it is difficult to differentiate between a biofilm abscess and a hypersensitivity reaction. For this reason, the authors advocated using hyaluronidase versus intralesional steroids in the initial management to make the area more susceptible to antibiotics and to avoid promoting the growth of bacteria with the use of steroids. For patient risk factors, the authors focused on the fact that 2 of 4 patients had concomitant autoimmune disorders—scleroderma and systemic lupus erythematosus—that may have predisposed them to infection. Lastly, 2 patients had prior polyacrylamide injections and the authors also speculated if the positive charge of this filler attracted bacteria.

What’s the issue?

The use of fillers will continue to increase as there are more fillers with novel properties entering the market. As with new technology, only time will tell if we will see any particular type of reaction or risk for infection with them. The issue of biofilm bacterial contamination is real. It is recognized as one of the causes of capsular contraction following breast implant surgery. The etiology may not be from contamination during production but from contamination of the filler after injection due to any transient bacteremia that the patient may experience. A concern is that dental manipulation (eg, dental cleaning, filling of dental caries, periodontal surgery) during the 2- to 4-week postfiller period may “seed” bacteria into the area and cause the bacteria to settle and grow on the foreign substance. For patients who have semipermanent or permanent fillers such as polyacrylamide, polymethyl methacrylate beads, or poly-L-lactic acid, biofilm risk is greater and can occur months to years after the procedure. I have personally seen 2 cases of poly-L-lactic acid filler develop red, tender, sterile abscesses 1 year after placement in the tissue. Both cases responded to prolonged clarithromycin use (2 months). However, these cases highlight the fact that the fillers persist long after we place them, and any bacteremia, even mild, can cause an unsightly reaction.

Have you seen delayed soft-tissue filler reactions in your practice? Given this information, will you change the way you advise patients on dental procedures in the 2- to 4-week postfiller period?

We want to know your views! Tell us what you think.

Quantifying bone marrow uptake of FDG (¹⁸fluorodeoxyglucose) improved the diagnostic accuracy of PET/CT for predicting bone marrow involvement in patients with follicular lymphoma, based on the results of a retrospective study.

Visual evidence of focal increased uptake on PET/CT indicates marrow involvement in follicular lymphoma; however, diffuse uptake is a nonspecific finding. Measuring the mean bone marrow standardized uptake value (BM SUV mean) improves PET/CT diagnostic accuracy, Dr. Chava Perry and his colleagues at Tel Aviv Sourasky Medical Center reported in Medicine [(Baltimore). 2016 Mar;95(9):e2910].

The researchers evaluated 68 consecutive patients with follicular lymphoma; 16 had bone marrow involvement – 13 had biopsy-proven involvement and 3 had a negative biopsy with increased medullary uptake that normalized after treatment. BM FDG uptake was diffuse in 8 of them and focal in the other 8.

While focal increased uptake is indicative of bone marrow involvement, diffuse uptake can be associated with false-positive results, as it was in the case of 17 patients (32.7% of those with diffuse uptake). Overall, visual assessment of scan results had a negative predictive value of 100% and a positive predictive value (PPV) of 48.5%.

On a quantitative assessment, however, BM SUV mean was significantly higher in patients with bone marrow involvement (SUV mean of 3.7 [1.7-6] vs. 1.4 [0.4-2.65]; P  less than .001). On the receiver operator curve (ROC) analysis, a BM SUV mean  exceeding  2.7 had a positive predictive value of 100% for bone marrow involvement (sensitivity of 68%). A BM SUV mean  less than 1.7 had an negative predictive value of 100% (specificity of 73%).

A mean standardized uptake value (BM SUV mean) below 1.7 may spare the need for bone marrow biopsy while a BM SUV mean above 2.7 is compatible with bone marrow involvement, although biopsy may still be recommended to exclude large cell transformation, the researchers concluded.

[email protected]

On Twitter @maryjodales

Quantifying bone marrow uptake of FDG (¹⁸fluorodeoxyglucose) improved the diagnostic accuracy of PET/CT for predicting bone marrow involvement in patients with follicular lymphoma, based on the results of a retrospective study.

Visual evidence of focal increased uptake on PET/CT indicates marrow involvement in follicular lymphoma; however, diffuse uptake is a nonspecific finding. Measuring the mean bone marrow standardized uptake value (BM SUV mean) improves PET/CT diagnostic accuracy, Dr. Chava Perry and his colleagues at Tel Aviv Sourasky Medical Center reported in Medicine [(Baltimore). 2016 Mar;95(9):e2910].

The researchers evaluated 68 consecutive patients with follicular lymphoma; 16 had bone marrow involvement – 13 had biopsy-proven involvement and 3 had a negative biopsy with increased medullary uptake that normalized after treatment. BM FDG uptake was diffuse in 8 of them and focal in the other 8.

While focal increased uptake is indicative of bone marrow involvement, diffuse uptake can be associated with false-positive results, as it was in the case of 17 patients (32.7% of those with diffuse uptake). Overall, visual assessment of scan results had a negative predictive value of 100% and a positive predictive value (PPV) of 48.5%.

On a quantitative assessment, however, BM SUV mean was significantly higher in patients with bone marrow involvement (SUV mean of 3.7 [1.7-6] vs. 1.4 [0.4-2.65]; P  less than .001). On the receiver operator curve (ROC) analysis, a BM SUV mean  exceeding  2.7 had a positive predictive value of 100% for bone marrow involvement (sensitivity of 68%). A BM SUV mean  less than 1.7 had an negative predictive value of 100% (specificity of 73%).

A mean standardized uptake value (BM SUV mean) below 1.7 may spare the need for bone marrow biopsy while a BM SUV mean above 2.7 is compatible with bone marrow involvement, although biopsy may still be recommended to exclude large cell transformation, the researchers concluded.

[email protected]

On Twitter @maryjodales

Quantifying bone marrow uptake of FDG (¹⁸fluorodeoxyglucose) improved the diagnostic accuracy of PET/CT for predicting bone marrow involvement in patients with follicular lymphoma, based on the results of a retrospective study.

Visual evidence of focal increased uptake on PET/CT indicates marrow involvement in follicular lymphoma; however, diffuse uptake is a nonspecific finding. Measuring the mean bone marrow standardized uptake value (BM SUV mean) improves PET/CT diagnostic accuracy, Dr. Chava Perry and his colleagues at Tel Aviv Sourasky Medical Center reported in Medicine [(Baltimore). 2016 Mar;95(9):e2910].

The researchers evaluated 68 consecutive patients with follicular lymphoma; 16 had bone marrow involvement – 13 had biopsy-proven involvement and 3 had a negative biopsy with increased medullary uptake that normalized after treatment. BM FDG uptake was diffuse in 8 of them and focal in the other 8.

While focal increased uptake is indicative of bone marrow involvement, diffuse uptake can be associated with false-positive results, as it was in the case of 17 patients (32.7% of those with diffuse uptake). Overall, visual assessment of scan results had a negative predictive value of 100% and a positive predictive value (PPV) of 48.5%.

On a quantitative assessment, however, BM SUV mean was significantly higher in patients with bone marrow involvement (SUV mean of 3.7 [1.7-6] vs. 1.4 [0.4-2.65]; P  less than .001). On the receiver operator curve (ROC) analysis, a BM SUV mean  exceeding  2.7 had a positive predictive value of 100% for bone marrow involvement (sensitivity of 68%). A BM SUV mean  less than 1.7 had an negative predictive value of 100% (specificity of 73%).

A mean standardized uptake value (BM SUV mean) below 1.7 may spare the need for bone marrow biopsy while a BM SUV mean above 2.7 is compatible with bone marrow involvement, although biopsy may still be recommended to exclude large cell transformation, the researchers concluded.

[email protected]

On Twitter @maryjodales

LOS ANGELES – Among infants at risk for allergic disease, egg introduction at 4 months cuts the risk of egg sensitization at 12 months by about half, according a randomized, placebo-controlled, double blind trial from Australia.

“This is what we hoped to find.” Introducing egg early “is certainly safe, and it may promote tolerance,” said senior investigator Dr. Dianne Campbell, professor and chair of pediatric allergy and clinical immunology at the Children’s Hospital at Westmead, which is affiliated with the University of Sydney.

Four-month-old children were randomized to 350 mg of pasteurized raw whole egg powder or – as a control – rice powder sprinkled once daily on their weaning food until month 8, at which time parents in both groups were encouraged to add eggs to their children’s diets. At least one of each child’s parents had a history of atopic disease, including asthma, eczema, hay fever, or food allergy. Even so, all of the infants had negative (less than 2 mm) skin prick tests (SPTs) at baseline. Compliance by parent diary was 89% in the rice and 81% in the egg groups.

At 12 months, SPTs were positive (3 mm or more) for whole egg in 25 of 122 (20%) children in the rice group, but only 13 of 122 (11%) in the egg group (odds ratio, 0.46; 95% confidence interval, 0.22-0.95; P = .03). Whole egg IgG4 and IgG4/IgE ratios to egg, ovalbumin, and ovomucoid were also higher in the egg group, indicating developing tolerance (P less than .0001 for each).

About 10% of the children originally in the egg group broke out in hives after their first few doses, and were withdrawn from the study. “This intervention may not be for everybody. There will be individuals who react” and it’s impossible, at this point, to predict who they will be. “We cannot prevent allergy in everyone,” said lead investigator Dr. John Tan, a pediatric immunologist at the hospital.

Overall, however, early introduction was safe. There was no anaphylaxis in the trial, and no cardiovascular or respiratory complications. Rates of eczema and peanut allergy were similar at 12 months between the two groups, meaning that early egg introduction did not increase the risk of atopy.

The findings echo results from several recent pediatric egg allergy studies, as well as findings from recent peanut trials. Slowly, it’s becoming clear that delaying the introduction of at least some allergenic foods – a common practice for years – doesn’t prevent allergies and may, in fact, promote them.

Despite those findings, there remains “a big disconnect between the [new] research and what we [still] recommend” in Australia, the United States, and elsewhere. Delaying food introductions was medical “dogma for 20 years, from highly esteemed societies,” and it corresponded with a marked increase in food allergies, but “it’s very hard to turn these things around,” Dr. Campbell said at the American Academy of Allergy, Asthma, and Immunology annual meeting.

The Australian government is reworking its infant feeding guidelines to incorporate the new evidence. “Our revised guidelines will say that there’s strong evidence for peanut and moderate evidence for egg” in favor of early introduction in children who are not sensitized by 4 or so months old, she said.

The trial was powered to detect differences in SPT, not actual egg allergies, which were diagnosed in 13 children (11%) in the rice group and eight (7%) in the egg group; the difference was not statistically significant. “Not all kids who are sensitized will be allergic,” she noted.

The study groups were well matched; there were about equal numbers of boys and girls in each, and, in both groups, about 15% of children were exposed to second hand smoke at home and almost all were breastfed.

The work was funded by the Australian government, among others. The investigators have no disclosures.

[email protected]

LOS ANGELES – Among infants at risk for allergic disease, egg introduction at 4 months cuts the risk of egg sensitization at 12 months by about half, according a randomized, placebo-controlled, double blind trial from Australia.

“This is what we hoped to find.” Introducing egg early “is certainly safe, and it may promote tolerance,” said senior investigator Dr. Dianne Campbell, professor and chair of pediatric allergy and clinical immunology at the Children’s Hospital at Westmead, which is affiliated with the University of Sydney.

Four-month-old children were randomized to 350 mg of pasteurized raw whole egg powder or – as a control – rice powder sprinkled once daily on their weaning food until month 8, at which time parents in both groups were encouraged to add eggs to their children’s diets. At least one of each child’s parents had a history of atopic disease, including asthma, eczema, hay fever, or food allergy. Even so, all of the infants had negative (less than 2 mm) skin prick tests (SPTs) at baseline. Compliance by parent diary was 89% in the rice and 81% in the egg groups.

At 12 months, SPTs were positive (3 mm or more) for whole egg in 25 of 122 (20%) children in the rice group, but only 13 of 122 (11%) in the egg group (odds ratio, 0.46; 95% confidence interval, 0.22-0.95; P = .03). Whole egg IgG4 and IgG4/IgE ratios to egg, ovalbumin, and ovomucoid were also higher in the egg group, indicating developing tolerance (P less than .0001 for each).

About 10% of the children originally in the egg group broke out in hives after their first few doses, and were withdrawn from the study. “This intervention may not be for everybody. There will be individuals who react” and it’s impossible, at this point, to predict who they will be. “We cannot prevent allergy in everyone,” said lead investigator Dr. John Tan, a pediatric immunologist at the hospital.

Overall, however, early introduction was safe. There was no anaphylaxis in the trial, and no cardiovascular or respiratory complications. Rates of eczema and peanut allergy were similar at 12 months between the two groups, meaning that early egg introduction did not increase the risk of atopy.

The findings echo results from several recent pediatric egg allergy studies, as well as findings from recent peanut trials. Slowly, it’s becoming clear that delaying the introduction of at least some allergenic foods – a common practice for years – doesn’t prevent allergies and may, in fact, promote them.

Despite those findings, there remains “a big disconnect between the [new] research and what we [still] recommend” in Australia, the United States, and elsewhere. Delaying food introductions was medical “dogma for 20 years, from highly esteemed societies,” and it corresponded with a marked increase in food allergies, but “it’s very hard to turn these things around,” Dr. Campbell said at the American Academy of Allergy, Asthma, and Immunology annual meeting.

The Australian government is reworking its infant feeding guidelines to incorporate the new evidence. “Our revised guidelines will say that there’s strong evidence for peanut and moderate evidence for egg” in favor of early introduction in children who are not sensitized by 4 or so months old, she said.

The trial was powered to detect differences in SPT, not actual egg allergies, which were diagnosed in 13 children (11%) in the rice group and eight (7%) in the egg group; the difference was not statistically significant. “Not all kids who are sensitized will be allergic,” she noted.

The study groups were well matched; there were about equal numbers of boys and girls in each, and, in both groups, about 15% of children were exposed to second hand smoke at home and almost all were breastfed.

The work was funded by the Australian government, among others. The investigators have no disclosures.

[email protected]

LOS ANGELES – Among infants at risk for allergic disease, egg introduction at 4 months cuts the risk of egg sensitization at 12 months by about half, according a randomized, placebo-controlled, double blind trial from Australia.

“This is what we hoped to find.” Introducing egg early “is certainly safe, and it may promote tolerance,” said senior investigator Dr. Dianne Campbell, professor and chair of pediatric allergy and clinical immunology at the Children’s Hospital at Westmead, which is affiliated with the University of Sydney.

Four-month-old children were randomized to 350 mg of pasteurized raw whole egg powder or – as a control – rice powder sprinkled once daily on their weaning food until month 8, at which time parents in both groups were encouraged to add eggs to their children’s diets. At least one of each child’s parents had a history of atopic disease, including asthma, eczema, hay fever, or food allergy. Even so, all of the infants had negative (less than 2 mm) skin prick tests (SPTs) at baseline. Compliance by parent diary was 89% in the rice and 81% in the egg groups.

At 12 months, SPTs were positive (3 mm or more) for whole egg in 25 of 122 (20%) children in the rice group, but only 13 of 122 (11%) in the egg group (odds ratio, 0.46; 95% confidence interval, 0.22-0.95; P = .03). Whole egg IgG4 and IgG4/IgE ratios to egg, ovalbumin, and ovomucoid were also higher in the egg group, indicating developing tolerance (P less than .0001 for each).

About 10% of the children originally in the egg group broke out in hives after their first few doses, and were withdrawn from the study. “This intervention may not be for everybody. There will be individuals who react” and it’s impossible, at this point, to predict who they will be. “We cannot prevent allergy in everyone,” said lead investigator Dr. John Tan, a pediatric immunologist at the hospital.

Overall, however, early introduction was safe. There was no anaphylaxis in the trial, and no cardiovascular or respiratory complications. Rates of eczema and peanut allergy were similar at 12 months between the two groups, meaning that early egg introduction did not increase the risk of atopy.

The findings echo results from several recent pediatric egg allergy studies, as well as findings from recent peanut trials. Slowly, it’s becoming clear that delaying the introduction of at least some allergenic foods – a common practice for years – doesn’t prevent allergies and may, in fact, promote them.

Despite those findings, there remains “a big disconnect between the [new] research and what we [still] recommend” in Australia, the United States, and elsewhere. Delaying food introductions was medical “dogma for 20 years, from highly esteemed societies,” and it corresponded with a marked increase in food allergies, but “it’s very hard to turn these things around,” Dr. Campbell said at the American Academy of Allergy, Asthma, and Immunology annual meeting.

The Australian government is reworking its infant feeding guidelines to incorporate the new evidence. “Our revised guidelines will say that there’s strong evidence for peanut and moderate evidence for egg” in favor of early introduction in children who are not sensitized by 4 or so months old, she said.

The trial was powered to detect differences in SPT, not actual egg allergies, which were diagnosed in 13 children (11%) in the rice group and eight (7%) in the egg group; the difference was not statistically significant. “Not all kids who are sensitized will be allergic,” she noted.

The study groups were well matched; there were about equal numbers of boys and girls in each, and, in both groups, about 15% of children were exposed to second hand smoke at home and almost all were breastfed.

The work was funded by the Australian government, among others. The investigators have no disclosures.

[email protected]

The Orthopaedic Sports Medicine Fellowship Match was first established in 2008 as a joint-sponsored venture between the American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America to pair applicants with participating training programs.¹ Operated under the San Francisco Match,² the current fellowship match process was adopted to systematically coordinate training appointments and eliminate the role of “exploding offers,” which are pressured early decisions predicated on immediate acceptance. Other advantages of this system include its operation through a central application service to avoid redundancy of submitted paperwork, as well as to create greater awareness and to publicize training options and standardization of the match timeline.¹

In its current state, the orthopedic sports medicine match represents 96 programs with 230 positions, accounting for approximately 97% of training programs and fellowship positions.¹ While unaccredited options remain available through the Match, many programs have migrated towards American Council for Graduate Medical Education (ACGME) accreditation because of an increased focus on objective learning metrics during fellowship and the requirement for Subspecialty Certification in Orthopaedic Sports Medicine through the American Board of Orthopaedic Surgery.³ However, other programs have also eschewed the increasing constraints and administrative resources associated with ACGME accreditation, particularly among fellowships based at community-based hospitals or private practices that lack formal affiliation with academic institutions or residency training programs.

Along with a greater understanding of the historical background of the match process, fellowship applicants must also appreciate the relative merits of fellowship training. More than 90% of orthopedic surgery residents now pursue further subspecialty fellowship training, with some individuals opting for 2 additional fellowship opportunities.⁴ As a so-called “nontraditional applicant,” I represent a different demographic, returning to fellowship after years of clinical practice while serving in the military. Individual preferences notwithstanding, I wanted to take the opportunity to emphasize some important considerations in deliberating between different fellowship programs.

• Geography. Your eventual desired practice location may play a role in determining fellowship location or, at least, region of the country. Additionally, this can be an important factor in family happiness. In competitive markets, such as the Northeast or the West Coast, you may make inroads and establish professional connections that result in potential job opportunities. Conversely, other programs may adopt anticompetitive measures to limit local practice options.
• Training setting. Despite the trending consolidation of fellowship training programs in affiliated university and hospital-based teaching systems, many community-based programs and private-practice models thrive, providing an alternative to traditional academic training centers. The latter may provide more in-depth exposure to practice management, billing/coding, and ancillary services. The former typically offer a more structured, academically oriented environment with formal teaching conferences and a broader department hierarchy.
• Program size. Some applicants may prefer a larger, more diverse array of teaching staff or fellows, while others gravitate toward fewer, more personal mentoring relationships that allow more intimate familiarity with practice habits or surgical techniques.
• Associated training programs. Affiliations with a residency or physician-extender training program can offer benefits and drawbacks, including offloading clerical work, shared hands-on experience in the clinic and operating room, and midlevel supervisory responsibilities. This can offer useful opportunities to formulate an individual teaching style and valuable mentoring relationships. However, it can also impose greater time requirements or detract from one-on-one teaching with staff.
• Reputation. Applicants may attach distinction to a well-established regional or national reputation associated with a given training program. Often, certain programs may carry prestige as a result of their academic name, hospital affiliation, or accomplishments. This can offer certain marketing advantages for patient recruitment. However, less renowned programs may provide better training opportunities and confer higher esteem among your professional colleagues. Program reputation can change dramatically with time, so this should be balanced with other potential strengths and overall training experience.
• Practice “niches”/areas of interest. With increasing adoption of arthroscopic techniques among practicing surgeons and a relative excess of sports medicine–trained orthopedists, it is paramount to develop a novel skill set during fellowship to differentiate you from other graduates. I sought a sports medicine fellowship that would offer me a broad-based exposure to arthroscopic and open knee and shoulder reconstruction, chondral restoration techniques, hip arthroscopy and preservation, and shoulder arthroplasty. Opportunities in elbow reconstruction, foot and ankle arthroscopy, and pediatric sports medicine may also be valuable as a distinguishing factor in searching for jobs after training.
• Marketability. Closely intertwined with reputation and scope of practice, an institution’s marketability is another intangible attribute to consider. Professional or collegiate team coverage offers significant market value for patient advertising, and it is frequently publicized by orthopedic practices and hospital systems. Additionally, the importance of ACGME accreditation should also be considered.
• Nonmedical training. This is increasingly important in subsequent subspecialty training. Further education on the business aspects of orthopedic surgery should be emphasized. Additionally, dedicated curricula on professional or leadership development are important for career progression.
• Mentorship. Throughout the interview process, one of my foremost priorities was a strong and enduring pattern of mentorship. Fellowship offers the opportunity to establish 1 or multiple mentors in your subspecialty. These individuals will be instrumental in the development of your early professional career and your approach to clinical practice. From discussions about complicated patients to advice on contract negotiations, your ideal mentor should champion your early successes and work generously on your behalf, even long after fellowship has ended. 

• Research opportunities. Given my academic career goals, I actively pursued a program with rich clinical and laboratory resources, and an established infrastructure for accomplishing high-quality, relevant research. Interested individuals should gauge the availability of research support staff, biomechanical or bench-level laboratory collaboration, grant or institutional research funding, cadaveric specimens, or clinical outcomes data for research conducted by fellows. However, not all fellowship applicants have a vested interest in research during fellowship, so I would encourage inquiries regarding core research requirements and expectations.
• Clinical exposure. This encompasses several different and equally important variables, including diversity of clinical or surgical caseloads, case complexity, operative exposure, athletic team coverage, and office or clinical experience. Interestingly, this latter aspect of training is often neglected but cannot be overemphasized. Outpatient clinical evaluation is key to honing important physical examination techniques and critically evaluating patients’ outcomes postoperatively.
• Surgical autonomy. Hands-on operative experience and surgical autonomy vary widely among fellowship programs. Most fellowships advocate for a graduated level of surgical responsibility dependent on individual abilities and staff comfort, while others offer greater potential for independence. Conversely, some programs espouse more of an “observership” model, and arthroscopic simulators and/or cadaveric skills laboratories are designed to complement operative experience. While most fellowship applicants desire maximal case participation, we must also recognize the value in watching talented surgeons performing technically demanding procedures.
• Family. You cannot put a premium on your personal contentment and family’s well-being. Proximity to a support network can be important with the work demands and time constraints of fellowship.

Despite financial obligations and significant time commitments, the fellowship match process offers an incredible range of programs and practice environments. Inevitably, no program can completely fulfill all your criteria, but you should be able to tailor your learning style, professional ambitions, and personal preferences with an excellent training program. For many, fellowship represents the last, and perhaps most integral, stage of formal surgical training. Considering all factors of your chosen fellowship program will ensure a rich and fulfilling educational experience.

The Orthopaedic Sports Medicine Fellowship Match was first established in 2008 as a joint-sponsored venture between the American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America to pair applicants with participating training programs.¹ Operated under the San Francisco Match,² the current fellowship match process was adopted to systematically coordinate training appointments and eliminate the role of “exploding offers,” which are pressured early decisions predicated on immediate acceptance. Other advantages of this system include its operation through a central application service to avoid redundancy of submitted paperwork, as well as to create greater awareness and to publicize training options and standardization of the match timeline.¹

In its current state, the orthopedic sports medicine match represents 96 programs with 230 positions, accounting for approximately 97% of training programs and fellowship positions.¹ While unaccredited options remain available through the Match, many programs have migrated towards American Council for Graduate Medical Education (ACGME) accreditation because of an increased focus on objective learning metrics during fellowship and the requirement for Subspecialty Certification in Orthopaedic Sports Medicine through the American Board of Orthopaedic Surgery.³ However, other programs have also eschewed the increasing constraints and administrative resources associated with ACGME accreditation, particularly among fellowships based at community-based hospitals or private practices that lack formal affiliation with academic institutions or residency training programs.

Along with a greater understanding of the historical background of the match process, fellowship applicants must also appreciate the relative merits of fellowship training. More than 90% of orthopedic surgery residents now pursue further subspecialty fellowship training, with some individuals opting for 2 additional fellowship opportunities.⁴ As a so-called “nontraditional applicant,” I represent a different demographic, returning to fellowship after years of clinical practice while serving in the military. Individual preferences notwithstanding, I wanted to take the opportunity to emphasize some important considerations in deliberating between different fellowship programs.

• Geography. Your eventual desired practice location may play a role in determining fellowship location or, at least, region of the country. Additionally, this can be an important factor in family happiness. In competitive markets, such as the Northeast or the West Coast, you may make inroads and establish professional connections that result in potential job opportunities. Conversely, other programs may adopt anticompetitive measures to limit local practice options.
• Training setting. Despite the trending consolidation of fellowship training programs in affiliated university and hospital-based teaching systems, many community-based programs and private-practice models thrive, providing an alternative to traditional academic training centers. The latter may provide more in-depth exposure to practice management, billing/coding, and ancillary services. The former typically offer a more structured, academically oriented environment with formal teaching conferences and a broader department hierarchy.
• Program size. Some applicants may prefer a larger, more diverse array of teaching staff or fellows, while others gravitate toward fewer, more personal mentoring relationships that allow more intimate familiarity with practice habits or surgical techniques.
• Associated training programs. Affiliations with a residency or physician-extender training program can offer benefits and drawbacks, including offloading clerical work, shared hands-on experience in the clinic and operating room, and midlevel supervisory responsibilities. This can offer useful opportunities to formulate an individual teaching style and valuable mentoring relationships. However, it can also impose greater time requirements or detract from one-on-one teaching with staff.
• Reputation. Applicants may attach distinction to a well-established regional or national reputation associated with a given training program. Often, certain programs may carry prestige as a result of their academic name, hospital affiliation, or accomplishments. This can offer certain marketing advantages for patient recruitment. However, less renowned programs may provide better training opportunities and confer higher esteem among your professional colleagues. Program reputation can change dramatically with time, so this should be balanced with other potential strengths and overall training experience.
• Practice “niches”/areas of interest. With increasing adoption of arthroscopic techniques among practicing surgeons and a relative excess of sports medicine–trained orthopedists, it is paramount to develop a novel skill set during fellowship to differentiate you from other graduates. I sought a sports medicine fellowship that would offer me a broad-based exposure to arthroscopic and open knee and shoulder reconstruction, chondral restoration techniques, hip arthroscopy and preservation, and shoulder arthroplasty. Opportunities in elbow reconstruction, foot and ankle arthroscopy, and pediatric sports medicine may also be valuable as a distinguishing factor in searching for jobs after training.
• Marketability. Closely intertwined with reputation and scope of practice, an institution’s marketability is another intangible attribute to consider. Professional or collegiate team coverage offers significant market value for patient advertising, and it is frequently publicized by orthopedic practices and hospital systems. Additionally, the importance of ACGME accreditation should also be considered.
• Nonmedical training. This is increasingly important in subsequent subspecialty training. Further education on the business aspects of orthopedic surgery should be emphasized. Additionally, dedicated curricula on professional or leadership development are important for career progression.
• Mentorship. Throughout the interview process, one of my foremost priorities was a strong and enduring pattern of mentorship. Fellowship offers the opportunity to establish 1 or multiple mentors in your subspecialty. These individuals will be instrumental in the development of your early professional career and your approach to clinical practice. From discussions about complicated patients to advice on contract negotiations, your ideal mentor should champion your early successes and work generously on your behalf, even long after fellowship has ended. 

• Research opportunities. Given my academic career goals, I actively pursued a program with rich clinical and laboratory resources, and an established infrastructure for accomplishing high-quality, relevant research. Interested individuals should gauge the availability of research support staff, biomechanical or bench-level laboratory collaboration, grant or institutional research funding, cadaveric specimens, or clinical outcomes data for research conducted by fellows. However, not all fellowship applicants have a vested interest in research during fellowship, so I would encourage inquiries regarding core research requirements and expectations.
• Clinical exposure. This encompasses several different and equally important variables, including diversity of clinical or surgical caseloads, case complexity, operative exposure, athletic team coverage, and office or clinical experience. Interestingly, this latter aspect of training is often neglected but cannot be overemphasized. Outpatient clinical evaluation is key to honing important physical examination techniques and critically evaluating patients’ outcomes postoperatively.
• Surgical autonomy. Hands-on operative experience and surgical autonomy vary widely among fellowship programs. Most fellowships advocate for a graduated level of surgical responsibility dependent on individual abilities and staff comfort, while others offer greater potential for independence. Conversely, some programs espouse more of an “observership” model, and arthroscopic simulators and/or cadaveric skills laboratories are designed to complement operative experience. While most fellowship applicants desire maximal case participation, we must also recognize the value in watching talented surgeons performing technically demanding procedures.
• Family. You cannot put a premium on your personal contentment and family’s well-being. Proximity to a support network can be important with the work demands and time constraints of fellowship.

Despite financial obligations and significant time commitments, the fellowship match process offers an incredible range of programs and practice environments. Inevitably, no program can completely fulfill all your criteria, but you should be able to tailor your learning style, professional ambitions, and personal preferences with an excellent training program. For many, fellowship represents the last, and perhaps most integral, stage of formal surgical training. Considering all factors of your chosen fellowship program will ensure a rich and fulfilling educational experience.

The Orthopaedic Sports Medicine Fellowship Match was first established in 2008 as a joint-sponsored venture between the American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America to pair applicants with participating training programs.¹ Operated under the San Francisco Match,² the current fellowship match process was adopted to systematically coordinate training appointments and eliminate the role of “exploding offers,” which are pressured early decisions predicated on immediate acceptance. Other advantages of this system include its operation through a central application service to avoid redundancy of submitted paperwork, as well as to create greater awareness and to publicize training options and standardization of the match timeline.¹

In its current state, the orthopedic sports medicine match represents 96 programs with 230 positions, accounting for approximately 97% of training programs and fellowship positions.¹ While unaccredited options remain available through the Match, many programs have migrated towards American Council for Graduate Medical Education (ACGME) accreditation because of an increased focus on objective learning metrics during fellowship and the requirement for Subspecialty Certification in Orthopaedic Sports Medicine through the American Board of Orthopaedic Surgery.³ However, other programs have also eschewed the increasing constraints and administrative resources associated with ACGME accreditation, particularly among fellowships based at community-based hospitals or private practices that lack formal affiliation with academic institutions or residency training programs.

Along with a greater understanding of the historical background of the match process, fellowship applicants must also appreciate the relative merits of fellowship training. More than 90% of orthopedic surgery residents now pursue further subspecialty fellowship training, with some individuals opting for 2 additional fellowship opportunities.⁴ As a so-called “nontraditional applicant,” I represent a different demographic, returning to fellowship after years of clinical practice while serving in the military. Individual preferences notwithstanding, I wanted to take the opportunity to emphasize some important considerations in deliberating between different fellowship programs.

• Geography. Your eventual desired practice location may play a role in determining fellowship location or, at least, region of the country. Additionally, this can be an important factor in family happiness. In competitive markets, such as the Northeast or the West Coast, you may make inroads and establish professional connections that result in potential job opportunities. Conversely, other programs may adopt anticompetitive measures to limit local practice options.
• Training setting. Despite the trending consolidation of fellowship training programs in affiliated university and hospital-based teaching systems, many community-based programs and private-practice models thrive, providing an alternative to traditional academic training centers. The latter may provide more in-depth exposure to practice management, billing/coding, and ancillary services. The former typically offer a more structured, academically oriented environment with formal teaching conferences and a broader department hierarchy.
• Program size. Some applicants may prefer a larger, more diverse array of teaching staff or fellows, while others gravitate toward fewer, more personal mentoring relationships that allow more intimate familiarity with practice habits or surgical techniques.
• Associated training programs. Affiliations with a residency or physician-extender training program can offer benefits and drawbacks, including offloading clerical work, shared hands-on experience in the clinic and operating room, and midlevel supervisory responsibilities. This can offer useful opportunities to formulate an individual teaching style and valuable mentoring relationships. However, it can also impose greater time requirements or detract from one-on-one teaching with staff.
• Reputation. Applicants may attach distinction to a well-established regional or national reputation associated with a given training program. Often, certain programs may carry prestige as a result of their academic name, hospital affiliation, or accomplishments. This can offer certain marketing advantages for patient recruitment. However, less renowned programs may provide better training opportunities and confer higher esteem among your professional colleagues. Program reputation can change dramatically with time, so this should be balanced with other potential strengths and overall training experience.
• Practice “niches”/areas of interest. With increasing adoption of arthroscopic techniques among practicing surgeons and a relative excess of sports medicine–trained orthopedists, it is paramount to develop a novel skill set during fellowship to differentiate you from other graduates. I sought a sports medicine fellowship that would offer me a broad-based exposure to arthroscopic and open knee and shoulder reconstruction, chondral restoration techniques, hip arthroscopy and preservation, and shoulder arthroplasty. Opportunities in elbow reconstruction, foot and ankle arthroscopy, and pediatric sports medicine may also be valuable as a distinguishing factor in searching for jobs after training.
• Marketability. Closely intertwined with reputation and scope of practice, an institution’s marketability is another intangible attribute to consider. Professional or collegiate team coverage offers significant market value for patient advertising, and it is frequently publicized by orthopedic practices and hospital systems. Additionally, the importance of ACGME accreditation should also be considered.
• Nonmedical training. This is increasingly important in subsequent subspecialty training. Further education on the business aspects of orthopedic surgery should be emphasized. Additionally, dedicated curricula on professional or leadership development are important for career progression.
• Mentorship. Throughout the interview process, one of my foremost priorities was a strong and enduring pattern of mentorship. Fellowship offers the opportunity to establish 1 or multiple mentors in your subspecialty. These individuals will be instrumental in the development of your early professional career and your approach to clinical practice. From discussions about complicated patients to advice on contract negotiations, your ideal mentor should champion your early successes and work generously on your behalf, even long after fellowship has ended. 

• Research opportunities. Given my academic career goals, I actively pursued a program with rich clinical and laboratory resources, and an established infrastructure for accomplishing high-quality, relevant research. Interested individuals should gauge the availability of research support staff, biomechanical or bench-level laboratory collaboration, grant or institutional research funding, cadaveric specimens, or clinical outcomes data for research conducted by fellows. However, not all fellowship applicants have a vested interest in research during fellowship, so I would encourage inquiries regarding core research requirements and expectations.
• Clinical exposure. This encompasses several different and equally important variables, including diversity of clinical or surgical caseloads, case complexity, operative exposure, athletic team coverage, and office or clinical experience. Interestingly, this latter aspect of training is often neglected but cannot be overemphasized. Outpatient clinical evaluation is key to honing important physical examination techniques and critically evaluating patients’ outcomes postoperatively.
• Surgical autonomy. Hands-on operative experience and surgical autonomy vary widely among fellowship programs. Most fellowships advocate for a graduated level of surgical responsibility dependent on individual abilities and staff comfort, while others offer greater potential for independence. Conversely, some programs espouse more of an “observership” model, and arthroscopic simulators and/or cadaveric skills laboratories are designed to complement operative experience. While most fellowship applicants desire maximal case participation, we must also recognize the value in watching talented surgeons performing technically demanding procedures.
• Family. You cannot put a premium on your personal contentment and family’s well-being. Proximity to a support network can be important with the work demands and time constraints of fellowship.

Despite financial obligations and significant time commitments, the fellowship match process offers an incredible range of programs and practice environments. Inevitably, no program can completely fulfill all your criteria, but you should be able to tailor your learning style, professional ambitions, and personal preferences with an excellent training program. For many, fellowship represents the last, and perhaps most integral, stage of formal surgical training. Considering all factors of your chosen fellowship program will ensure a rich and fulfilling educational experience.

This year’s Match Day takes place on Friday, March 18.

Do you remember when you opened your letter? Do you know someone who is matching this year? Share your stories with SHM on Twitter @SHMLive and use the official Match Day 2016 hashtag, #Match2016, and #FutureofHospitalMedicine, plus encourage your students to do so as well. Follow along with the excitement and join in the conversation throughout the day.

It’s hard to believe, but Match Day 2017 is closer than you think. Fourth-year medical students can visit www.futureofhospitalmedicine.org for all of the resources needed to be successful, including:

• Residency match application checklist
• Application tool kit
• An overview of matching for fellowship applicants
• National Residency Matching Program FAQs
• Information on how to register to match

This year’s Match Day takes place on Friday, March 18.

Do you remember when you opened your letter? Do you know someone who is matching this year? Share your stories with SHM on Twitter @SHMLive and use the official Match Day 2016 hashtag, #Match2016, and #FutureofHospitalMedicine, plus encourage your students to do so as well. Follow along with the excitement and join in the conversation throughout the day.

It’s hard to believe, but Match Day 2017 is closer than you think. Fourth-year medical students can visit www.futureofhospitalmedicine.org for all of the resources needed to be successful, including:

• Residency match application checklist
• Application tool kit
• An overview of matching for fellowship applicants
• National Residency Matching Program FAQs
• Information on how to register to match

This year’s Match Day takes place on Friday, March 18.

Do you remember when you opened your letter? Do you know someone who is matching this year? Share your stories with SHM on Twitter @SHMLive and use the official Match Day 2016 hashtag, #Match2016, and #FutureofHospitalMedicine, plus encourage your students to do so as well. Follow along with the excitement and join in the conversation throughout the day.

It’s hard to believe, but Match Day 2017 is closer than you think. Fourth-year medical students can visit www.futureofhospitalmedicine.org for all of the resources needed to be successful, including:

• Residency match application checklist
• Application tool kit
• An overview of matching for fellowship applicants
• National Residency Matching Program FAQs
• Information on how to register to match