The number of Medicare beneficiaries increases as the population of the United States grows and ages. 1 In 2010, the number of beneficiaries was estimated to be 42 million, climbing to 60 million in 2020. By 2030, it is projected that 80 million citizens will be covered by Medicare. 2 In the private insurance sector, reimbursement largely relies on the feefor-service model, which is derived from the national fee schedule established by Medicare. In procedural-based care, all procedures are reimbursed by means of their CPT code. Each CPT code is assigned a work relative value unit (wRVU). The wRVU value assigns a numeric value to a physician's "work product," which when factored in geographically, corresponds to a specific physician reimbursement. 3 Many studies have compared the relationship between inflation and physician reimbursement for procedures within other surgical specialties. [4][5][6][7][8] These studies demonstrate that Medicare reimbursement remained stagnant despite increases Background: Over the past decade across multiple surgical specialties, Medicare reimbursement rates have remained stagnant, failing to keep pace with inflation. An internal comparison of subspecialties within plastic surgery has not yet been attempted. The goal of this study was to investigate the trends in reimbursement from 2010 to 2020 and compare across the subspecialties of plastic surgery. Methods: The Physician/Supplier Procedure Summary was used to extract the annual case volume for the top 80% most-billed CPT codes within plastic surgery. Codes were defined into the following subspecialties: microsurgery, craniofacial surgery, breast surgery, hand surgery, and general plastic surgery. The Medicare physician reimbursement was weighted by case volume. The growth rate and compound annual growth rate were calculated and compared against an inflation-adjusted reimbursement value. Results: On average, inflation-adjusted growth in reimbursement for the procedures analyzed in this study was −13.5%. The largest decrease in growth rate was within the field of microsurgery (−19.2%), followed by craniofacial surgery (−17.6%). These subspecialties also had the lowest compound annual growth rate (−2.11% and −1.91%, respectively). For case volumes, microsurgery increased case volumes by an average of 3% per year, whereas craniofacial surgery increased case volumes by an average of 5% per year. Conclusions: After adjusting for inflation, all subspecialties had a decrease in growth rate. This was particularly evident in the fields of craniofacial surgery and microsurgery. Consequently, practice patterns and patient access may be negatively affected. Further advocacy and physician participation in reimbursement rate negotiation may be essential to adjust for variance and inflation.

Background: The relationship between procedural complexity and relative value units (RVUs) awarded has been studied within some specialties, but it has not yet been compared across different surgical disciplines. This study aims to analyze the association of RVUs with operative time as a surrogate for complexity across surgical specialties, with a focus on plastic surgery. Methods: A retrospective review of surgical cases was conducted with the 2019 National Surgical Quality Improvement Program database. The top 10 most performed procedures per surgical specialty were identified based on case volume. Only cases with a single CPT code were analyzed. A subanalysis of plastic surgery procedures was also conducted to include unilateral and bilateral procedures with a frequency greater than 20. Results: Overall, operative time correlated strongly with work RVUs (R = 0.86). Orthopedic surgery had one of the shortest average operative times with the greatest work RVUs per hour, in contrast to plastic surgery, with the greatest average operative time and one of the lowest work RVUs per hour. Of the plastic surgery procedures analyzed, only five were valued on par with the average calculated from all other specialties. The most poorly rewarded procedure for time spent is unilateral free flap breast reconstruction. Conclusions: Of all the surgical specialties, plastic surgery has the lowest RVUs per hour and the highest average operative time, leading to severe potential undervaluation compared with other specialties. This study suggests that further reevaluation of the current RVU system is needed to account for complexity more equitably as well as encourage value-based care.

Objectives HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) is a neuroinflammatory autoimmune disease characterized by high levels of infected immortalized T cells in circulation, which makes it difficult for antiretroviral (ART) drugs to work effectively. In previous studies, we established that Apigenin, a flavonoid, can exert immunomodulatory effects to reduce neuroinflammation. Flavonoids are natural ligands for the aryl hydrocarbon receptor (AhR), which is a ligand activated endogenous receptor involved in the xenobiotic response. Consequently, we tested Apigenin’s synergy in combination with ART against the survival of HTLV-1-infected cells. Methods First, we established a direct protein-protein interaction between Apigenin and AhR. We then demonstrated that Apigenin and its derivative VY-3-68 enter activated T cells, drive nuclear shuttling of AhR, and modulate its signaling both at RNA and protein level. Results In HTLV-1 producing cells with high AhR expression, Apigenin cooperates with ARTs such as Lopinavir (LPN) and Zidovudine (AZT), to impart cytotoxicity by exhibiting a major shift in IC50 that was reversed upon AhR knockdown. Mechanistically, Apigenin treatment led to an overall downregulation of NF-κB and several other pro-cancer genes involved in survival. Conclusions This study suggest the potential combinatorial use of Apigenin with current first-line antiretrovirals for the benefit of patients affected by HTLV-1 associated pathologies.

Immune checkpoint (ICP) mediators play pivotal roles in regulating a broad spectrum of immune responses against cancer and infectious diseases. In previous studies we have established the role of negative checkpoint receptors (NCRs, PD-1, TIGIT, LAG-3, etc.) in determining the quality of anti-HTLV-1 cytolytic (CTL) response in controlling proviral load and maintaining a asymptomatic state in majority of infected individuals. Interestingly, ICPs can be released in the soluble form and carried on the surface of small extracellular vesicles (50–200 nm) known as exosomes that possess immunomodulatory activity. Consequently, we profiled ICPs in isolated exosomes and culture media of HTLV-1 cell lines representing both HAM/TSP and ATLL. High levels of BTLA (B-and T-Lymphocyte Attenuator) and its ligand HVEM (Herpes virus entry mediator) along with PD-1 (Programmed cell death receptor-1) and its ligand PD-L2 (not PD-L1) were observed in soluble and exosomal forms as well in the sera of HAM patients that carry high proviral load and viral proteins such as Tax. HTLV-1 infection, Tax protein and/or IFNy could serve as causative mechanism for increased ICP levels in HAM patients. Indeed, treatment with anti-retroviral drugs significantly reduced ICP levels confirming specificity of our observations. Functionality of exosomal BTLA/HVEM is being validated in the ongoing studies along with their direct role in regulating CD8 T-cell functions and cytolytic potential upon blockade to provide a novel therapeutic target for HAM/TSP and other neuroinflammatory diseases. Supported by grants from NIH: 1R01NS0971-47, T32-MH079785

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