Faculty Bibliography

INTRODUCTION: Ileal pouch-anal anastomosis (IPAA) is a common surgical procedure in patients with an initial diagnosis of ulcerative colitis (UC), indeterminate colitis (IC), or familial adenomatous polyposis syndrome (FAP). Tobacco smoking has been associated with protection from onset of UC. Smoking has been reported to be both a protective factor and a risk factor for the development of pouchitis. In this systematic review and meta-analysis, we examine the influence of smoking on the risk of pouchitis.
METHOD(S): We identified 16 studies evaluating smoking as a risk factor for developing pouchitis in patients with a history of IPAA in a systematic search performed from inception through May 2020. A meta-analysis was then performed using a random-effects model to generate risk ratios.
RESULT(S): A total of 2,389 IPAA patients were included in the systematic review and meta-analysis. In the included studies, the percentage of patients with a diagnosis of pouchitis ranged from 22% to 72%. The percentage of patients with a history of smoking ranged from 7% to 63%. In total, 919 patients had pouchitis (330 current or former smokers; 589 non-smokers), and 1,470 patients did not have pouchitis (485 current or former smokers; 985 non-smokers). A history of smoking compared with never smoking was not associated with an increased risk of developing pouchitis (RR = 0.96, 95% CI 0.78-1.17, I² 5 68.6%). There was also no significant risk of pouchitis when comparing current smokers versus non-smokers (RR = 1.09, 95% CI 0.93-1.28, I² 5 0%) and former smokers versus non-smokers (RR = 0.95, 95% CI 0.70-1.28, I² 5 79.8%).
CONCLUSION(S): Smoking, past or present, is not associated with an increased risk for the development of pouchitis. This is important to consider when counseling patients on the risks of smoking and pouchitis

OBJECTIVES/OBJECTIVE:The aim of this study was to determine the prevalence of myocarditis among patients presenting with myocardial infarction with nonobstructive coronary arteries (MINOCA) in relation to the angiographic severity of nonobstructive coronary artery disease (CAD). BACKGROUND:MINOCA represents about 6% of all cases of acute myocardial infarction. Myocarditis is a diagnosis that may be identified by cardiac magnetic resonance (CMR) imaging in patients with a provisional diagnosis of MINOCA. METHODS:A systematic review was performed to identify studies reporting the results of CMR findings in MINOCA patients with nonobstructive CAD or normal coronary arteries. Study-level and individual patient data meta-analyses were performed using fixed- and random-effects methods. RESULTS:Twenty-seven papers were included, with 2,921 patients with MINOCA; CMR findings were reported in 2,866 (98.1%). Myocarditis prevalence was 34.5% (95% confidence interval [CI]: 27.2% to 42.2%) overall and was numerically higher in studies that defined MINOCA as myocardial infarction with angiographically normal coronary arteries compared with a definition that permitted nonobstructive CAD (45.9% vs. 32.3%; p = 0.16). In a meta-analysis of individual patient data from 9 of the 27 studies, the pooled prevalence of CMR-confirmed myocarditis was greater in patients with angiographically normal coronary arteries than in those with nonobstructive CAD (51% [95% CI: 47% to 56%] vs. 23% [95% CI: 18% to 27%]; p < 0.001). Men and younger patients with MINOCA were more likely to have myocarditis. Angiographically normal coronary arteries were associated with increased odds of myocarditis after adjustment for age and sex (adjusted odds ratio: 2.30; 95% CI: 1.12 to 4.71; p = 0.023). CONCLUSIONS:Patients with a provisional diagnosis of MINOCA are more likely to have CMR findings consistent with myocarditis if they have angiographically normal coronary arteries.

Objective/UNASSIGNED:Evidence-based medicine practices of medical students in clinical scenarios are not well understood. Optimal foraging theory (OFT) is one framework that could be useful in breaking apart information-seeking patterns to determine effectiveness and efficiency of different methods of information seeking. The aims of this study were to use OFT to determine the number and type of resources used in information seeking when medical students answer a clinical question, to describe common information-seeking patterns, and identify patterns associated with higher quality answers to a clinical question. Methods/UNASSIGNED:Medical students were observed via screen recordings while they sought evidence related to a clinical question and provided a written response for what they would do for that patient based on the evidence that they found. Results/UNASSIGNED:Half (51%) of study participants used only 1 source before answering the clinical question. While the participants were able to successfully and efficiently navigate point-of-care tools and search engines, searching PubMed was not favored, with only half (48%) of PubMed searches being successful. There were no associations between information-seeking patterns and the quality of answers to the clinical question. Conclusion/UNASSIGNED:Clinically experienced medical students most frequently relied on point-of-care tools alone or in combination with PubMed to answer a clinical question. OFT can be used as a framework to understand the information-seeking practices of medical students in clinical scenarios. This has implications for both teaching and assessment of evidence-based medicine in medical students.

OBJECTIVE:High-grade gliomas (HGGs) continue to carry poor prognoses, and patient outcomes depend heavily on the extent of resection (EOR). The utility of conventional image-guided surgery is limited by intraoperative brain shift. More recent techniques to maximize EOR, including intraoperative imaging and the use of fluorescent dyes, combat these limitations. However, the relative efficacy of these two techniques has never been systematically compared. Thus, the authors performed an exhaustive systematic review in conjunction with quantitative network meta-analyses to evaluate the comparative effectiveness of 5-aminolevulinic acid (5-ALA) and intraoperative MRI (IMRI) in optimizing EOR in HGG. They secondarily analyzed associated progression-free and overall survival and performed subgroup analyses by level of evidence. METHODS:PubMed, Embase, Cochrane Central, and Web of Science were searched for studies evaluating conventional neuronavigation, IMRI, and 5-ALA in HGG resection. The primary study endpoint was the proportion of patients attaining gross-total resection (GTR), defined as 100% elimination of contrast-enhancing lesion on postoperative MRI. Secondary endpoints included overall and progression-free survival and subgroup analyses for level of evidence. Comparative efficacy analysis of IMRI and 5-ALA was performed using Bayesian network meta-analysis models. RESULTS:This analysis included 11 studies. In a classic meta-analysis, both IMRI (OR 4.99, 95% CI 2.65-9.39, p < 0.001) and 5-ALA (OR 2.866, 95% CI 2.127-3.863, p < 0.001) were superior to conventional navigation in achieving GTR. Bayesian network analysis was employed to indirectly compare IMRI to 5-ALA, and no significant difference in GTR was found between the two (OR 1.9 favoring IMRI, 95% CI 0.905-3.989, p = 0.090). A handful of studies additionally suggested that the use of either IMRI (2 and 4 studies, respectively) or 5-ALA (2 and 2 studies, respectively) improves progression-free and overall survival. CONCLUSIONS:IMRI and 5-ALA are individually superior to conventional neuronavigation for achieving GTR of HGG. Between IMRI and 5-ALA, neither method is clearly more effective. Future studies evaluating the comparative cost and surgical time associated with IMRI and 5-ALA will better inform any cost-benefit analysis.

RATIONALE AND OBJECTIVES/OBJECTIVE:The automated segmentation of organs and tissues throughout the body using computed tomography and magnetic resonance imaging has been rapidly increasing. Research into many medical conditions has benefited greatly from these approaches by allowing the development of more rapid and reproducible quantitative imaging markers. These markers have been used to help diagnose disease, determine prognosis, select patients for therapy, and follow responses to therapy. Because some of these tools are now transitioning from research environments to clinical practice, it is important for radiologists to become familiar with various methods used for automated segmentation. MATERIALS AND METHODS/METHODS:The Radiology Research Alliance of the Association of University Radiologists convened an Automated Segmentation Task Force to conduct a systematic review of the peer-reviewed literature on this topic. RESULTS:The systematic review presented here includes 408 studies and discusses various approaches to automated segmentation using computed tomography and magnetic resonance imaging for neurologic, thoracic, abdominal, musculoskeletal, and breast imaging applications. CONCLUSION/CONCLUSIONS:These insights should help prepare radiologists to better evaluate automated segmentation tools and apply them not only to research, but eventually to clinical practice.

Myocardial injury after non-cardiac surgery (MINS) is a common post-operative complication associated with adverse cardiovascular outcomes. The purpose of this systematic review was to determine the incidence, clinical features, pathogenesis, management, and outcomes of MINS. We searched PubMed, Embase, Central and Web of Science databases for studies reporting the incidence, clinical features, and prognosis of MINS. Data analysis was performed with a mixed-methods approach, with quantitative analysis of meta-analytic methods for incidence, management, and outcomes, and a qualitative synthesis of the literature to determine associated pre-operative factors and MINS pathogenesis. A total of 195 studies met study inclusion criteria. Among 169 studies reporting outcomes of 530,867 surgeries, the pooled incidence of MINS was 17.9% (95% CI 16.2%-19.6%). Patients with MINS were older, more frequently men, and more likely to have cardiovascular risk factors and known coronary artery disease. Post-operative mortality was higher among patients with MINS than those without MINS, both in-hospital (8.1%, 95% CI 4.4%-12.7% versus 0.4%, 95% CI 0.2%-0.7%; relative risk 8.3, 95% CI 4.2 - 16.6, p<0.001) and at 1-year after surgery (20.6%, 95% CI 15.9%-25.7% versus 5.1%, 95% CI 3.2%-7.4%; relative risk 4.1, 95% CI 3.0 - 5.6, p<0.001). Few studies reported mechanisms of MINS or the medical treatment provided. In conclusion, MINS occurs frequently in clinical practice, is most common in patients with cardiovascular disease and its risk factors, and is associated with increased short- and long-term mortality. Additional investigation is needed to define strategies to prevent MINS and treat patients with this diagnosis.

For individuals with gender dysphoria, gender-affirming surgeries (GAS) are one means of reducing the significant distress associated with primary and secondary sex characteristics misaligned with their gender identity. This article uses a systematic review to examine the existing literature on the psychological benefits of GAS. Findings from this review indicate that GAS can lead to multiple, significant improvements in psychological functioning. Methodological differences in the literature demonstrate the need for additional research to draw more definitive conclusions about the psychological benefits of GAS.

BACKGROUND:Development of diabetic foot ulcers is a common complication of diabetes. Standard-of-care (SOC) therapy alone is often not sufficient to heal these wounds, resulting in application of adjuvant wound therapies including biologic skin substitutes. Although a variety of products exist, it has been difficult to formulate conclusions on their clinical efficacy. We therefore performed a systematic review and meta-analysis on the efficacy of healing diabetic foot ulcers with biologic skin substitutes. METHODS:A systematic review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Four electronic databases (PubMed/MEDLINE, EMBASE [Ovid], Cochrane CENTRAL [Ovid], and Web of Science) were searched from inception through February 27, 2019. Searches included keywords and subject headings pertaining to 3 main concepts: biologic skin substitutes, wound healing, and diabetic foot ulcers. Cochrane randomized controlled trial filters were used to narrow results. Data were extracted from 54 included articles, and risk-of-bias assessments were conducted by 2 independent reviewers. The primary objective was to calculate a pooled risk ratio for the proportion of wounds completely closed by 12 weeks. Secondary objectives included a pooled risk ratio for the proportion of wounds completely closed by 6 weeks and mean time to healing. RESULTS:Twenty-five studies were identified that assessed the proportion of complete wound closure by 12 weeks. We found that wounds treated with biologic dressings were 1.67 times more likely to heal by 12 weeks than those treated with SOC dressings (P < 0.00001). Five studies assessed the proportion of complete wound closure by 6 weeks. Wounds treated with biologic dressings were 2.81 times more likely to heal by 6 weeks than those treated with SOC dressings (P = 0.0001). Descriptively, 29 of 31 studies that assessed time to healing favored biologic dressings over SOC dressings. CONCLUSIONS:This systematic review provides supporting evidence that biologic skin substitutes are more effective than SOC dressings at healing diabetic foot ulcers by 12 weeks. Future studies must address the relative benefits of different skin substitutes as well as the long-term implications of these products and their financial considerations.

BACKGROUND:This study was conducted to examine gaps and opportunities for involvement of librarians in medical education and patient care as well as improve the teaching and assessment of Entrustable Professional Activity 7 (EPA 7) -- the ability to form clinical questions and retrieve evidence to advance patient care. METHODS:The Association of Academic Health Sciences Libraries (AAHSL) Competency-Based Medical Education Task Force surveyed all AAHSL member libraries in October 2016 on health sciences librarian awareness and involvement in teaching and assessing EPA 7. RESULTS:The survey response rate was 54% (88/164 member libraries). While 90% (n = 76) of respondents were regularly engaged in teaching or assessing aspects of EPA 7 only 34 (39%) were involved explicitly in a Core EPA 7 project, 44% (15/34) of these projects were librarian initiated. CONCLUSIONS:Involvement in teaching and assessment of EPA 7 is an untapped opportunity for librarians to collaborate in medical education and patient care. Although librarians are already deeply involved in teaching and assessment of EPA 7 related knowledge, skills, and behaviors, further librarian collaboration can help bolster the planning or updating of existing curricula and assessments of this entrustable professional activity.

Hospital-acquired infections are common in neurointensive care units. We sought to review interventions which may reduce infection rates in neurocritically ill populations. We conducted a systematic review of studies targeting adult patients in neuro-intensive care units (neuro-ICUs) with an intervention designed to prevent ICU-acquired infections. Our outcome of interest was change in the prevalence or rates of infection between active and control arms of these studies. We excluded studies based on the following criteria: no English full-text version available; pediatric population; non-neurosciences ICU population; pre- or intraoperative methods to prevent infection; lack of discrete data for infection rates/prevalence; studies that were purely observational in nature and did not test an intervention; and studies performed in resource limited settings. We initially retrieved 3716 results by searching the following databases: PubMed/MEDLINE, EMBASE via Ovid, and Cochrane CENTRAL via Ovid. No date or language limits were used in the search. Computerized deduplication was conducted using EndNote followed by a confirmatory manual review resulting in 3414 citations. An additional 19 manuscripts were identified through review of references. The screening process followed a standard protocol, using two screeners at the title/abstract level to determine relevance and at the full-text level to determine eligibility for inclusion. The 3427 titles/abstracts were independently screened by two board-certified neurointensivists to determine relevance for full-text review, and 3248 were rejected. The remaining 179 abstracts were reviewed in full text using predetermined inclusion/exclusion criteria. Ultimately, 75 articles met our inclusion criteria and were utilized in the final analysis. The reviewed literature highlights the need for collaborative, multi-disciplinary, and multi-pronged approaches to reduce infections. Rates of VRI, SSI, VAP, CAUTI, and CLABSI can approach zero with persistence and a team-based approach.