Education & Certifications

  • Bachelor of Arts, Princeton University, Chemistry (2016)


  • 2021 Autumn - OBGYN 300A Obstetrics and Gynecology Core Clerkship
  • 2021 Spring - ORTHO 398A Clinical Elective in Orthopedic Surgery
  • 2021 Summer - FAMMED 310A Continuity of Care Clerkship
  • 2021 Summer - ORTHO 306A Orthopedics Clerkship
  • 2021 Summer - ORTHO 318A Subinternship in Orthopedic Surgery
  • 2021 Summer - ORTHO 318W Subinternship in Orthopedic Surgery (Away)
  • 2020 Autumn - PSYC 300A Psychiatry Core Clerkship
  • 2020 Spring - MED 334A Nephrology Clerkship
  • 2020 Spring - RAD 301A Diagnostic Radiology and Nuclear Medicine Clerkship
  • 2020 Summer - ANES 306A Critical Care Core Clerkship
  • 2020 Summer - EMED 301A Emergency Medicine Core Clerkship
  • 2020 Summer - MED 313A Ambulatory Medicine Core Clerkship
  • 2020 Winter - ORTHO 306A Orthopedics Clerkship
  • 2020 Winter - SURG 300A Surgery Core Clerkship
  • 2019 Autumn - FAMMED 301A Family Medicine Core Clerkship
  • 2019 Autumn - PEDS 300A Pediatrics Core Clerkship
  • 2019 Summer - MED 300A Internal Medicine Core Clerkship
  • 2019 Summer - NENS 301A Neurology Core Clerkship

All Publications

  • Is Low-value Testing Before Low-risk Hand Surgery Associated With Increased Downstream Healthcare Use and Reimbursements? A National Claims Database Analysis. Clinical orthopaedics and related research Welch, J. M., Zhuang, T., Shapiro, L. M., Harris, A. H., Baker, L. C., Kamal, R. N. 2022


    Minor hand procedures can often be completed in the office without any laboratory testing. Preoperative screening tests before minor hand procedures are unnecessary and considered low value because they can lead to preventable invasive confirmatory tests and/or procedures. Prior studies have shown that low-value testing before low-risk hand surgery is still common, yet little is known about their downstream effects and associated costs. Assessing these downstream events can elucidate the consequences of obtaining a low-value test and inform context-specific interventions to reduce their use.(1) Among healthy adults undergoing low-risk hand surgery, are patients who receive a preoperative low-value test more likely to have subsequent diagnostic tests and procedures than those who do not receive a low-value test? (2) What is the increased 90-day reimbursement associated with subsequent diagnostic tests and procedures in patients who received a low-value test compared with those who did not?In this retrospective, comparative study using a large national database, we queried a large health insurance provider's administrative claims data to identify adult patients undergoing low-risk hand surgery (carpal tunnel release, trigger finger release, Dupuytren fasciectomy, de Quervain release, thumb carpometacarpal arthroplasty, wrist ganglion cyst, or mass excision) between 2011 and 2017. This database was selected for its ability to track patient claims longitudinally with direct provision of reimbursement data in a large, geographically diverse patient population. Patients who received at least one preoperative low-value test, including complete blood count, basic metabolic panel, electrocardiogram, chest radiography, pulmonary function test, and urinalysis within the 30-day preoperative period, were matched with propensity scores to those who did not. Among the 73,112 patients who met our inclusion criteria (mean age 57 ± 14 years; 68% [49,847] were women), 27% (19,453) received at least one preoperative low-value test and were propensity score-matched to those who did not. Multivariable regression analyses were performed to assess the frequency and reimbursements of subsequent diagnostic tests and procedures in the 90 days after surgery while controlling for potentially confounding variables such as age, sex, comorbidities, and baseline healthcare use.When controlling for covariates such as age, sex, comorbidities, and baseline healthcare use, patients in the low-value test cohort had an adjusted odds ratio of 1.57 (95% confidence interval [CI] 1.50 to 1.64; p < 0.001) for a postoperative use event (a downstream diagnostic test or procedure) compared with those who did not have a low-value test. The median (IQR) per-patient reimbursements associated with downstream utilization events in patients who received a low-value test was USD 231.97 (64.37 to 1138.84), and those who did not receive a low-value test had a median of USD 191.52 (57.1 to 899.42) (adjusted difference when controlling for covariates: USD 217.27 per patient [95% CI 59.51 to 375.03]; p = 0.007). After adjusting for inflation, total additional reimbursements for patients in the low-value test cohort increased annually.Low-value tests generate downstream tests and procedures that are known to provide minimal benefit to healthy patients and may expose patients to potential harms associated with subsequent, unnecessary invasive tests and procedures in response to false positives. Nevertheless, low-value testing remains common and the rising trend in low-value test-associated spending demonstrates the need for multicomponent interventions that target change at both the payer and health system level. Such interventions should disincentivize the initial low-value test and the cascade that may follow. Future work to identify the barriers and facilitators to reduce low-value testing in hand surgery can inform the development and revision of deimplementation strategies.Level III, therapeutic study.

    View details for DOI 10.1097/CORR.0000000000002255

    View details for PubMedID 35608508

  • Google Trends Analysis Shows Increasing Public Interest in Platelet-Rich Plasma Injections for Hip and Knee Osteoarthritis. The Journal of arthroplasty Cohen, S. A., Zhuang, T., Xiao, M., Michaud, J. B., Amanatullah, D. F., Kamal, R. N. 2021


    BACKGROUND: Osteoarthritis is a chronic musculoskeletal condition that frequently affects the hip and knee joints. Given the burden associated with surgical intervention for hip and knee osteoarthritis, patients continue to search for potential nonoperative treatments. One biologic therapy with mixed clinical and basic science evidence for treating osteoarthritis is platelet-rich plasma injections into the affected joint. We used the Google Trends tool to provide a quantitative analysis of national interest in platelet-rich plasma injections for hip and knee osteoarthritis.METHODS: Google Trends parameters were selected to obtain search data from January 2009 to December 2019. Various combinations of "arthritis," "osteoarthritis," "PRP," "platelet-rich plasma," "knee," and "hip" were entered into the Google Trends tool and trend analyses were performed.RESULTS: Three linear models were generated to display search volume trends in the United States for platelet-rich plasma and osteoarthritis, hip osteoarthritis, and knee osteoarthritis, respectively. All models showed increased Google queries as time progressed (P < .001), with R2 ranging from 0.837 to 0.940. Seasonal, income-related, and geographic variations in public interest in platelet-rich plasma for osteoarthritis were noted.CONCLUSION: Our results demonstrate a significant rise in Google queries related to platelet-rich plasma injections for osteoarthritis of the hip and knee since 2009. Surgeons treating hip and knee osteoarthritis patients can expect continued interest in platelet-rich plasma, despite inconclusive clinical and basic science data. Trends in public interest may inform patient counseling, shared decision-making, and directions for future clinical research.

    View details for DOI 10.1016/j.arth.2021.05.040

    View details for PubMedID 34172346

  • Perioperative Laboratory Markers as Risk Factors for Surgical Site Infection After Elective Hand Surgery. The Journal of hand surgery Zhuang, T., Shapiro, L. M., Fogel, N., Richard, M. J., Gardner, M. J., Kamal, R. N. 2021


    PURPOSE: The purpose of this study was to test the null hypothesis that there is no association between perioperative laboratory markers (serum albumin and hemoglobin A1c [HbA1c]) and incidence of surgical site infection (SSI) after soft tissue upper extremity surgery.METHODS: We analyzed patient-level data from a large, insurance-based database containing supplemental laboratory results. We identified patients undergoing soft tissue upper extremity surgery (defined as carpal tunnel release, trigger finger release, wrist ganglion excision, cubital tunnel release, Dupuytren partial fasciectomy, or first dorsal compartment release) with serum albumin or HbA1c measurements within 90 days of surgery. We stratified patients into cohorts based on serum albumin concentration (<3.5 g/dL) and HbA1c (≥7%) thresholds. The primary outcome was incidence of SSI within 30 days following surgery. We constructed multivariable logistic regression models to adjust for patient demographics and baseline comorbidities using the Elixhauser comorbidity index.RESULTS: Patients with hypoalbuminemia experienced an SSI incidence of 3.5% compared to 0.9% in patients with normal serum albumin. In multivariable analysis, the odds ratio of SSI with hypoalbuminemia was 3.32 (95% CI, 2.32-4.65). Patients with HbA1c ≥ 7% experienced an SSI incidence of 1.1% compared to 0.7% in patients with HbA1c < 7%. Multivariable analysis revealed odds ratios for SSI of 1.47 (95% CI, 1.02-2.11) in patients with HbA1c ≥ 7% compared to those with HbA1c < 7%.CONCLUSIONS: Hypoalbuminemia and elevated HbA1c (in patients with diabetes) are risk factors for SSI within 30 days following soft tissue upper extremity surgery. Preoperative measurement of these laboratory markers may be a useful tool for risk stratification and identification of high-risk patients for nutritional or glycemic optimization.TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

    View details for DOI 10.1016/j.jhsa.2021.04.001

    View details for PubMedID 34016493

  • Using Google Trends Data to Track Healthcare Use for Hand Osteoarthritis. Cureus Cohen, S. A., Zhuang, T., Xiao, M., Michaud, J. B., Shapiro, L., Kamal, R. N. 2021; 13 (3): e13786


    Background Google Trends (GT) is a free tool that provides analysis of search traffic for specified terms entered into the Google search engine. In this study, we evaluate the association between public interest in hand osteoarthritis (OA) as determined by GT search volumes and healthcare usage related to hand OA. Methodology We compiled GT data from 2010 to 2017 for the following group of hand OA-related search terms: "hand osteoarthritis," "hand arthritis," "hand swelling," "hand stiffness," and "chronic hand pain." Claims associated with hand OA codes were obtained from an administrative database (14.8 million patients) using International Classification of Diseases codes from 2010 to 2017. We performed trend analysis using univariate linear regression of GT data and hand OA claims. A month-by-month analysis of variation from yearly GT means was conducted for hand OA-related search terms. Results There was increased public interest in hand OA-related search terms from January 2010 to December 2017. Univariate linear regression of GT data for hand OA-related search terms compared with hand OA claims demonstrated a significant positive correlation (p < 0.001, r = 0.707). Peak public interest in hand OA-related search terms was observed in July, May, and June. Conclusions This study demonstrates the ability of GT to track healthcare use related to hand OA. Our data also add to the evidence for monthly variations in public interest related to hand OA. Clinics and surgery centers can employ GT data to anticipate resource utilization by hand OA patients.

    View details for DOI 10.7759/cureus.13786

    View details for PubMedID 33842160

    View details for PubMedCentralID PMC8025802

  • Cost-Effectiveness of Open Versus Endoscopic Carpal Tunnel Release. The Journal of bone and joint surgery. American volume Barnes, J. I., Paci, G. n., Zhuang, T. n., Baker, L. C., Asch, S. M., Kamal, R. N. 2021; 103 (4): 343–55


    Carpal tunnel syndrome is the most common upper-extremity nerve compression syndrome. Over 500,000 carpal tunnel release (CTR) procedures are performed in the U.S. yearly. We estimated the cost-effectiveness of endoscopic CTR (ECTR) versus open CTR (OCTR) using data from published meta-analyses comparing outcomes for ECTR and OCTR.We developed a Markov model to examine the cost-effectiveness of OCTR versus ECTR for patients undergoing unilateral CTR in an office setting under local anesthesia and in an operating-room (OR) setting under monitored anesthesia care. The main outcomes were costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We modeled societal (modeled with a 50-year-old patient) and Medicare payer (modeled with a 65-year-old patient) perspectives, adopting a lifetime time horizon. We performed deterministic and probabilistic sensitivity analyses (PSAs).ECTR resulted in 0.00141 additional QALY compared with OCTR. From a societal perspective, assuming 8.21 fewer days of work missed after ECTR than after OCTR, ECTR cost less across all procedure settings. The results are sensitive to the number of days of work missed following surgery. From a payer perspective, ECTR in the OR (ECTROR) cost $1,872 more than OCTR in the office (OCTRoffice), for an ICER of approximately $1,332,000/QALY. The ECTROR cost $654 more than the OCTROR, for an ICER of $464,000/QALY. The ECTRoffice cost $107 more than the OCTRoffice, for an ICER of $76,000/QALY. From a payer perspective, for a willingness-to-pay threshold of $100,000/QALY, OCTRoffice was preferred over ECTROR in 77% of the PSA iterations. From a societal perspective, ECTROR was preferred over OCTRoffice in 61% of the PSA iterations.From a societal perspective, ECTR is associated with lower costs as a result of an earlier return to work and leads to higher QALYs. Additional research on return to work is needed to confirm these findings on the basis of contemporary return-to-work practices. From a payer perspective, ECTR is more expensive and is cost-effective only if performed in an office setting under local anesthesia.Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.

    View details for DOI 10.2106/JBJS.19.01354

    View details for PubMedID 33591684

  • Is Uncontrolled Diabetes Mellitus Associated with Incidence of Complications After Posterior Instrumented Lumbar Fusion? A National Claims Database Analysis. Clinical orthopaedics and related research Zhuang, T. n., Feng, A. Y., Shapiro, L. M., Hu, S. S., Gardner, M. n., Kamal, R. N. 2021


    Previous research has shown that diabetes mellitus (DM) is associated with postoperative complications, including surgical site infections (SSIs). However, evidence for the association between diabetes control and postoperative complications in patients with DM is mixed. Prior studies relied on a single metric for defining uncontrolled DM, which does not account for glycemic variability, and it is unknown whether a more comprehensive assessment of diabetes control is associated with postoperative complications.(1) Is there a difference in the incidence of SSI after lumbar spine fusion in patients with uncontrolled DM, defined with a comprehensive assessment of glycemic control, compared with patients with controlled DM? (2) Is there a difference in the incidence of other select postoperative complications after lumbar spine fusion in patients with uncontrolled DM compared with patients with controlled DM? (3) Is there a difference in total reimbursements between these groups?We used the PearlDiver Patient Records Database, a national administrative claims database that provides access to the full continuum of perioperative care. We included 46,490 patients with DM undergoing posterior lumbar fusion with instrumentation. Patients were required to be continuously enrolled in the database for at least 1 year before and 90 days after the index procedure. Patients were divided into uncontrolled and controlled DM cohorts, as defined by ICD-9 diagnostic codes. These are based on a comprehensive assessment of glycemic control, including consideration of patient self-monitoring of blood glucose levels, hemoglobin A1c, and the presence/severity of diabetes-related comorbidities. The cohorts differed only by age, insurance type, and Elixhauser comorbidity score. The primary outcome was the incidence of SSI, divided into superficial and deep, within 90 days postoperatively. Secondary complications included the incidence of cerebrovascular events, acute kidney injury, pulmonary embolism, pneumonia, urinary tract infection, blood transfusion, and total reimbursements. These are the sum of reimbursements occurring within 90 days of surgery, which capture the total professional and facility cost burden to the health payer (such as the insurer). We constructed multivariable logistic regression models to adjust for the effects of age, insurance type, and comorbidities.After adjusting for potentially confounding variables including age, insurance type, and comorbidities, we found that patients with uncontrolled DM had an odds ratio for deep SSI of 1.52 (95% confidence interval 1.16 to 1.95; p = 0.002). Similarly, patients with uncontrolled DM had adjusted odds ratios of 1.25 (95% CI 1.01 to 1.53; p = 0.03) for cerebrovascular events, 1.36 (95% CI 1.18 to 1.57; p < 0.001) for acute kidney injury, 1.55 (95% CI 1.16 to 2.04; p = 0.002) for pulmonary embolism, 1.30 (95% CI 1.08 to 1.54; p = 0.004) for pneumonia, 1.33 (95% CI 1.19 to 1.49; p < 0.001) for urinary tract infection, and 1.27 (95% CI 1.04 to 1.53; p = 0.02) for perioperative transfusion. Patients with uncontrolled DM had higher median 90-day total reimbursements than patients with controlled DM: USD 27,915 (interquartile range 5472 to 63,400) versus USD 10,263 (IQR 4101 to 49,748; p < 0.001).Our findings encourage surgeons to take a full diabetic history beyond the HbA1c value, including any self-monitoring of glucose measurements, time in acceptable range for continuous glucose monitors, and/or consideration of the presence/severity of diabetes-related complications before lumbar spine fusion, as HbA1c does not fully capture glycemic control or variability. We emphasize that uncontrolled DM is a clinical, rather than laboratory, diagnosis. Comprehensive diabetes histories should be incorporated into existing preoperative diabetes care pathways and elective surgery could be deferred to improve glycemic control. Future development of an index measure incorporating multidimensional measures of diabetes control (such as continuous or self-glucose monitoring, diabetes-related comorbidities) is warranted.Level III, therapeutic study.

    View details for DOI 10.1097/CORR.0000000000001823

    View details for PubMedID 34014844

  • A Cost-Effectiveness Analysis of Smoking-Cessation Interventions Prior to Posterolateral Lumbar Fusion. The Journal of bone and joint surgery. American volume Zhuang, T., Ku, S., Shapiro, L. M., Hu, S. S., Cabell, A., Kamal, R. N. 2020


    BACKGROUND: Smoking cessation represents an opportunity to reduce both short and long-term effects of smoking on complications after lumbar fusion and smoking-related morbidity and mortality. However, the cost-effectiveness of smoking-cessation interventions prior to lumbar fusion is not fully known.METHODS: We created a decision-analytic Markov model to evaluate the cost-effectiveness of 5 smoking-cessation strategies (behavioral counseling, nicotine replacement therapy [NRT], bupropion or varenicline monotherapy, and a combined intervention) prior to single-level, instrumented lumbar posterolateral fusion (PLF) from the health payer perspective. Probabilities, costs, and utilities were obtained from published sources. We calculated the costs and quality-adjusted life years (QALYs) associated with each strategy over multiple time horizons and accounted for uncertainty with probabilistic sensitivity analyses (PSAs) consisting of 10,000 second-order Monte Carlo simulations.RESULTS: Every smoking-cessation intervention was more effective and less costly than usual care at the lifetime horizon. In the short term, behavioral counseling, NRT, varenicline monotherapy, and the combined intervention were also cost-saving, while bupropion monotherapy was more effective but more costly than usual care. The mean lifetime cost savings for behavioral counseling, NRT, bupropion monotherapy, varenicline monotherapy, and the combined intervention were $3,291 (standard deviation [SD], $868), $2,571 (SD, $479), $2,851 (SD, $830), $6,767 (SD, $1,604), and $34,923 (SD, $4,248), respectively. The minimum efficacy threshold (relative risk for smoking cessation) for lifetime cost savings varied from 1.01 (behavioral counseling) to 1.15 (varenicline monotherapy). A PSA revealed that the combined smoking-cessation intervention was always more effective and less costly than usual care.CONCLUSIONS: Even brief smoking-cessation interventions yield large short-term and long-term cost savings. Smoking-cessation interventions prior to PLF can both reduce costs and improve patient outcomes as health payers/systems shift toward value-based reimbursement (e.g., bundled payments) or population health models.LEVEL OF EVIDENCE: Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

    View details for DOI 10.2106/JBJS.20.00393

    View details for PubMedID 33038088

  • The Influence of Cost Information on Treatment Choice: A Mixed-Methods Study. The Journal of hand surgery Zhuang, T., Kortlever, J. T., Shapiro, L. M., Baker, L., Harris, A. H., Kamal, R. N. 2020


    PURPOSE: To test the null hypothesis that exposure to societal cost information does not affect choice of treatment for carpal tunnel syndrome (CTS).METHODS: We enrolled 304 participants using the Amazon Mechanical Turk platform to complete a survey in which participants were given the choice between carpal tunnel release (CTR) or a less-expensive option (orthosis wear) in a hypothetical mild CTS scenario. Patients were randomized to receive information about the societal cost of CTR (cost cohort) or no cost information (control). The primary outcome was the probability of choosing CTR measured on a 6-point ordinal scale. We employed qualitative content analysis to evaluate participants' rationale for their choice. We also explored agreement with various attitudes toward health care costs on an ordinal scale.RESULTS: Participants in the cost cohort exhibited a greater probability of choosing surgery than those in the control cohort. The relative risk of choosing surgery after exposure to societal cost information was 1.43 (95% confidence interval, 1.11-1.85). Among participants who had not previously been diagnosed with CTS (n= 232), the relative risk of choosing surgery after exposure to societal cost information was 1.55 (95% confidence interval, 1.17-2.06). Lack of personal monetary responsibility frequently emerged as a theme in those in the cost cohort who chose surgery. The majority (94%) of participants expressed at least some agreement that health care cost is a major problem whereas only 58% indicated that they consider the country's health care costs when making treatment decisions.CONCLUSIONS: Participants who received societal cost information were more likely to choose the more expensive treatment option (CTR) for mild CTS.CLINICAL RELEVANCE: Exposure to societal cost information may influence patient decision making in elective hand surgery. A complete understanding of this influence is required prior to implementing processes toward greater cost transparency for diagnostic/treatment options. Sharing out-of-pocket costs with patients may be a beneficial approach because discussing societal cost information alone will likely not improve value of care.

    View details for DOI 10.1016/j.jhsa.2020.05.019

    View details for PubMedID 32723572

  • Quality Measures to Reduce Opioid Use After Common Soft Tissue Hand and Wrist Procedures. The Journal of hand surgery 2020


    To develop quality measures that are clinically important, feasible, usable, and scientifically acceptable for reducing opioid use after soft tissue procedures of the hand and wrist, and which can be used to evaluate quality in hand surgery.A consortium of 9 fellowship-trained hand/upper-limb surgeons with expertise in quality measure development used the RAND Corporation/University of California Los Angeles Delphi Appropriateness method to evaluate the validity of 2 quality measures for reducing opioid use, based on 4 quality indicators (clinical importance, feasibility, usability, and scientific acceptability). Panelists rated each measure on a scale of 1 (definitely not important/feasible/usable/supported) to 9 (definitely important/feasible/usable/supported) in 2 voting rounds with an intervening face-to-face discussion. Agreement was assessed using predetermined criteria. A measure was considered a valid quality measure if it received a median score of 7 or higher for all 4 indicators with no more than 2 panelists rating outside the range of 7 to 9.Panelists achieved agreement on the 4 quality indicators for measuring the proportion of patients undergoing carpal tunnel release, trigger finger release, first dorsal compartment release, or ganglion cyst excision who received structured counseling on opioid use. Panelists also achieved agreement on the 4 quality indicators for measuring the proportion of patients without recent opioid use who did not fill an opioid prescription within 30 days after these procedures. Both candidate quality measures were considered valid.Using a validated consensus-building approach, we developed process and outcome quality measures for reducing opioid use after soft tissue hand surgery that were demonstrated to be valid according to 4 quality indicators.In the era of value-based health care, hand surgeons are assuming increasing responsibility in the prevention of excess opioid prescribing. Quality measures for reducing opioid overprescription can help promote the delivery of evidence-based, high-quality care in hand surgery.

    View details for DOI 10.1016/j.jhsa.2020.03.007

    View details for PubMedID 32408999

  • Which Decisions For Management of Carpal Tunnel Syndrome and Distal Radius Fractures Should Be Shared? The Journal of hand surgery Zhuang, T., Shapiro, L. M., Ring, D., Akelman, E., Ruch, D. S., Richard, M. J., Ladd, A., Blazar, P., Yao, J., Kakar, S., Harris, A. H., Got, C., Kamal, R. N. 2020


    To evaluate, from the surgeon's perspective, the importance, feasibility, and appropriateness of sharing decisions during an episode of care of carpal tunnel syndrome (CTS) or distal radius fracture in patients aged greater than 65 years.A consortium of 9 fellowship-trained hand/upper-limb surgeons used the RAND Corporation/University of California Los Angeles Delphi Appropriateness method to evaluate the importance, feasibility, and appropriateness of sharing 27 decisions for CTS and 28 decisions for distal radius fractures in patients aged greater than 65 years. Panelists rated each measure on a scale of 1 (definitely not important/feasible/appropriate) to 9 (definitely important/feasible/appropriate) in 2 voting rounds with an intervening face-to-face discussion. Panelist agreement and disagreement were assessed using predetermined criteria.Panelists achieved agreement on 16 decisions (29%) as important, 43 (78%) as feasible, and 17 (31%) as appropriate for sharing with patients. Twelve decisions met all 3 of these criteria and were therefore considered important, feasible, and appropriate to share with patients. Examples in CTS included decisions to perform extra confirmatory diagnostic testing, to have surgery, and to perform a steroid injection into the carpal tunnel. Examples in distal radius fracture management included the decision to have surgery, type of pain medication prescribed after surgery, and whether to remove the implant. The remaining 43 decisions did not reach consensus on the importance, feasibility, and appropriateness of sharing with patients.Using a validated consensus-building approach, we identified 12 decisions made during an episode of care for CTS or distal radius fracture that were important, feasible, and appropriate to share with patients from the surgeon's perspective. These decisions merit inclusion in shared decision-making models (eg, preoperative patient preference elicitation tools or decision aids) to align patient preferences with care decisions.Understanding which aspects of care are important, feasible, and appropriate to share with patients may improve patient-centered care by aligning patient preferences with care decisions.

    View details for DOI 10.1016/j.jhsa.2020.03.008

    View details for PubMedID 32340760

  • A Cost-Effectiveness Analysis of Corticosteroid Injections and Open Surgical Release for Trigger Finger. The Journal of hand surgery Zhuang, T. n., Wong, S. n., Aoki, R. n., Zeng, E. n., Ku, S. n., Kamal, R. N. 2020


    To evaluate the cost-effectiveness of corticosteroid injection(s) versus open surgical release for the treatment of trigger finger.Using a US health care payer perspective, we created a decision tree model to estimate the costs and outcomes associated with 4 treatment strategies for trigger finger: offering up to 3 steroid injections before to surgery or immediate open surgical release. Costs were obtained from a large administrative claims database. We calculated expected quality-adjusted life-years for each treatment strategy, which were compared using incremental cost-effectiveness ratios. Separate analyses were performed for commercially insured and Medicare Advantage patients. We performed a probabilistic sensitivity analysis using 10,000 second-order Monte Carlo simulations that simultaneously sampled from the uncertainty distributions of all model inputs.Offering 3 steroid injections before surgery was the optimal strategy for both commercially insured and Medicare Advantage patients. The probabilistic sensitivity analysis showed that this strategy was cost-effective 67% and 59% of the time for commercially insured and Medicare Advantage patients, respectively. Our results were sensitive to the probability of injection site fat necrosis, success rate of steroid injections, time to symptom relief after a steroid injection, and cost of treatment. Immediate surgical release became cost-effective when the cost of surgery was below $902 or $853 for commercially insured and Medicare Advantage patients, respectively.Multiple treatment strategies exist for treating trigger finger, and our cost-effectiveness analysis helps define the relative value of different approaches. From a health care payer perspective, offering 3 steroid injections before surgery is a cost-effective strategy.Economic and Decision Analyses II.

    View details for DOI 10.1016/j.jhsa.2020.04.008

    View details for PubMedID 32471754

  • Arthrodesis of the Foot or Ankle in Adult Patients with Congenital Clubfoot. Cureus Zhuang, T., El-Banna, G., Frick, S. 2019; 11 (12): e6505


    Background Although clubfoot that was corrected in childhood rarely recurs in adulthood, persistent deformities or arthritic pain may require further treatment during adulthood. Little evidence exists on the operative procedures utilized in adult clubfoot patients, who were previously treated for congenital clubfoot in childhood, for residual or recurrent deformity or pain. Objective The objective of this study is to characterize the types and frequencies of procedures utilized in adult clubfoot patients, who were previously treated for congenital clubfoot in childhood. Methods A two-pronged approach was employed to describe the operative procedures used in adult clubfoot patients. First, a literature review of all reported cases of operative treatment in adult clubfoot patients who were previously treated in childhood was performed. Second, an analysis of the operative treatments used in adult patients with a diagnosis of congenital clubfoot was conducted using a large, administrative claims database. Results In the literature review, arthrodesis was the most cited operative treatment and reported in four out of the eight studies included. Osteotomies were also reported in the literature. In the database analysis, 94 hindfoot arthrodesis procedures were identified in 73 patients, out of 1,198 adult patients in the database with a diagnosis of congenital clubfoot. Sixty-two patients out of 1,198 adult clubfoot patients received osteotomies. An insufficient number of total ankle arthroplasties were reported for further analysis. Conclusions Operative treatment in adult clubfoot patients who were treated for congenital clubfoot in childhood includes hindfoot arthrodesis and osteotomy procedures. Total ankle arthroplasty has not been reported in the literature for these patients.

    View details for DOI 10.7759/cureus.6505

    View details for PubMedID 32025426

    View details for PubMedCentralID PMC6988724

  • Selective Photo-Oxygenation of Light Alkanes Using Iodine Oxides and Chloride CHEMCATCHEM Liebov, N. S., Goldberg, J. M., Boaz, N. C., Coutard, N., Kalman, S. E., Zhuang, T., Groves, J. T., Gunnoe, T. 2019; 11 (20): 5045–54
  • Does Societal Cost Information Affect Patient Decision-Making in Carpal Tunnel Syndrome? A Randomized Controlled Trial. Hand (New York, N.Y.) Kortlever, J. T., Zhuang, T., Ring, D., Reichel, L. M., Vagner, G. A., Kamal, R. N. 2019: 1558944719873399


    Background: Despite studies demonstrating the effects of out-of-pocket costs on decision-making, the effect of societal cost information on patient decision-making is unknown. Given the considerable societal impact of cost of care for carpal tunnel syndrome (CTS), providing societal cost data to patients with CTS could affect decision-making and provide a strategy for reducing national health care costs. Therefore, we assessed the following hypotheses: (1) there is no difference in treatment choice (surgery vs no surgery) in a hypothetical case of mild CTS between patients randomized to receive societal cost information compared with those who did not receive this information; (2) there are no factors (eg, sex, experience with a previous diagnosis of CTS, or receiving societal cost information) independently associated with the choice for surgery; and (3) there is no difference in attitudes toward health care costs between patients choosing surgery and those who did not. Methods: In this randomized controlled trial using a hypothetical scenario, we prospectively enrolled 184 new and return patients with a nontraumatic upper extremity diagnosis. We recorded patient demographics, treatment choice in the hypothetical case of mild CTS, and their attitudes toward health care costs. Results: Treatment choice was not affected by receiving societal cost information. None of the demographic or illness factors assessed were independently associated with the choice for surgery. Patients declining surgery felt more strongly that doctors should consider their out-of-pocket costs when making recommendations. Conclusions: Providing societal cost information does not seem to affect decision-making and may not reduce the overall health care costs. For patients with CTS, health policy could nudge toward better resource utilization and finding the best care pathways for nonoperative and invasive treatments.

    View details for DOI 10.1177/1558944719873399

    View details for PubMedID 31517517

  • The Use of Preoperative Antibiotics in Elective Soft-Tissue Procedures in the Hand: A Critical Analysis Review. JBJS reviews Shapiro, L. M., Zhuang, T., Li, K., Kamal, R. N. 2019

    View details for DOI 10.2106/JBJS.RVW.18.00168

    View details for PubMedID 31436581

  • Financial Distress Is Associated With Delay in Seeking Care for Hand Conditions. Hand (New York, N.Y.) Zhuang, T., Eppler, S. L., Shapiro, L. M., Roe, A. K., Yao, J., Kamal, R. N. 2019: 1558944719866889


    Background: As medical costs continue to rise, financial distress due to these costs has led to poorer health outcomes and patient cost-coping behavior. Here, we test the null hypothesis that financial distress is not associated with delay of seeking care for hand conditions. Methods: Eighty-seven new patients presenting to the hand clinic for nontraumatic conditions completed our study. Patients completed validated instruments for measuring financial distress, pain catastrophizing, and pain. Questions regarding delay of care were included. The primary outcome was self-reported delay of the current hand clinic visit. Results: Patients who experience high financial distress differed significantly from those who experience low financial distress with respect to age, race, annual household income, and employment status. Those experiencing high financial distress were more likely to report having delayed their visit to the hand clinic (57% vs 30%), higher pain catastrophizing scores (17.7 vs 7.6), and higher average pain in the preceding week (4.5 vs 2.3). After adjusting for age, sex, and pain, high financial distress (adjusted odds ratio [OR] = 4.90) and pain catastrophizing score (adjusted OR = 0.96) were found to be independent predictors of delay. Financial distress was highly associated with annual household income in a multivariable linear regression model. Conclusions: Patients with nontraumatic hand conditions who experience higher financial distress are more likely to delay their visit to the hand clinic. Within health care systems, identification of patients with high financial distress and targeted interventions (eg, social or financial services) may help prevent unnecessary delays in care.

    View details for DOI 10.1177/1558944719866889

    View details for PubMedID 31409138

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


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

    View details for PubMedID 30579689

  • Mechanism of Hydrocarbon Functionalization by an Iodate/Chloride System: The Role of Ester Protection ACS CATALYSIS Schwartz, N. A., Boaz, N. C., Kalman, S. E., Zhuang, T., Goldberg, J. M., Fu, R., Nielsen, R. J., Goddard, W. A., Groves, J. T., Gunnoe, T. 2018; 8 (4): 3138–49
  • Alkyl Isocyanates via Manganese-Catalyzed C-H Activation for the Preparation of Substituted Ureas JOURNAL OF THE AMERICAN CHEMICAL SOCIETY Huang, X., Zhuang, T., Kates, P. A., Gao, H., Chen, X., Groves, J. T. 2017; 139 (43): 15407–13


    Organic isocyanates are versatile intermediates that provide access to a wide range of functionalities. In this work, we have developed the first synthetic method for preparing aliphatic isocyanates via direct C-H activation. This method proceeds efficiently at room temperature and can be applied to functionalize secondary, tertiary, and benzylic C-H bonds with good yields and functional group compatibility. Moreover, the isocyanate products can be readily converted to substituted ureas without isolation, demonstrating the synthetic potential of the method. To study the reaction mechanism, we have synthesized and characterized a rare MnIV-NCO intermediate and demonstrated its ability to transfer the isocyanate moiety to alkyl radicals. Using EPR spectroscopy, we have directly observed a MnIV intermediate under catalytic conditions. Isocyanation of celestolide with a chiral manganese salen catalyst followed by trapping with aniline afforded the urea product in 51% enantiomeric excess. This represents the only example of an asymmetric synthesis of an organic urea via C-H activation. When combined with our DFT calculations, these results clearly demonstrate that the C-NCO bond was formed through capture of a substrate radical by a MnIV-NCO intermediate.

    View details for DOI 10.1021/jacs.7b07658

    View details for Web of Science ID 000414506400023

    View details for PubMedID 28976738

  • Involvement of nitric oxide synthase in matrix metalloproteinase-9-and/or urokinase plasminogen activator receptor-mediated glioma cell migration BMC CANCER Zhuang, T., Chelluboina, B., Ponnala, S., Velpula, K., Rehman, A. A., Chetty, C., Zakharian, E., Rao, J. S., Veeravalli, K. 2013; 13: 590


    Src tyrosine kinase activates inducible nitric oxide synthase (iNOS) and, in turn, nitric oxide production as a means to transduce cell migration. Src tyrosine kinase plays a key proximal role to control α9β1 signaling. Our recent studies have clearly demonstrated the role of α9β1 integrin in matrix metalloproteinase-9 (MMP-9) and/or urokinase plasminogen activator receptor (uPAR)-mediated glioma cell migration. In the present study, we evaluated the involvement of α9β1 integrin-iNOS pathway in MMP-9- and/or uPAR-mediated glioma cell migration.MMP-9 and uPAR shRNAs and overexpressing plasmids were used to downregulate and upregulate these molecules, respectively in U251 glioma cells and 5310 glioma xenograft cells. The effect of treatments on migration and invasion potential of these glioma cells were assessed by spheroid migration, wound healing, and Matrigel invasion assays. In order to attain the other objectives we also performed immunocytochemical, immunohistochemical, RT-PCR, Western blot and fluorescence-activated cell sorting (FACS) analysis.Immunohistochemical analysis revealed the prominent association of iNOS with glioblastoma multiforme (GBM). Immunofluorescence analysis showed prominent expression of iNOS in glioma cells. MMP-9 and/or uPAR knockdown by respective shRNAs reduced iNOS expression in these glioma cells. RT-PCR analysis revealed elevated iNOS mRNA expression in either MMP-9 or uPAR overexpressed glioma cells. The migration potential of MMP-9- and/or uPAR-overexpressed U251 glioma cells was significantly inhibited after treatment with L-NAME, an inhibitor of iNOS. Similarly, a significant inhibition of the invasion potential of the control or MMP-9/uPAR-overexpressed glioma cells was noticed after L-NAME treatment. A prominent reduction of iNOS expression was observed in the tumor regions of nude mice brains, which were injected with 5310 glioma cells, after MMP-9 and/or uPAR knockdown. Protein expressions of cSrc, phosphoSrc and p130Cas were reduced with simultaneous knockdown of both MMP-9 and uPAR.Taken together, our results from the present and earlier studies clearly demonstrate that α9β1 integrin-mediated cell migration utilizes the iNOS pathway, and inhibition of the migratory potential of glioma cells by simultaneous knockdown of MMP-9 and uPAR could be attributed to the reduced α9β1 integrin and iNOS levels.

    View details for DOI 10.1186/1471-2407-13-590

    View details for Web of Science ID 000329345100001

    View details for PubMedID 24325546

    View details for PubMedCentralID PMC3878845