Faculty Bibliography

BACKGROUND:Acute GI bleeding (AGIB) can be associated with significant mortality. Topical endoscopic hemostatic powders (TEHPs) have become established as one of the endoscopic treatment modalities for AGIBs. There is no dedicated consensus on the role of TEHPs in the GIB algorithm. OBJECTIVE:We aimed to develop expert-led consensus statements to provide guidance on the use of TEHPs in AGIBs. DESIGN/METHODS:A team of 15 experts in the field of acute AGIB from 8 countries was recruited to construct consensus statements on the use of TEHPs. A first meeting was held to define statements. Using the RAND/UCLA appropriateness method, they voted on statements by combining expert collective judgment and best available evidence in a 2-round voting process. Statements were rated on a 9-point interval scale (1 to 9). Four statistical methods were used to delineate statements that satisfied all criteria of appropriateness. For a statement to be considered appropriate, it had to meet all statistical definitions of appropriateness showing consensus agreement. RESULTS:Following round 2, 11 final statements were scored as appropriate, reaching overall consensus. Key recommendations include that TEHPs are effective in achieving hemostasis in malignancy-related GIBs, can be used as "salvage" therapy for nonvariceal GIBs and can be used as a bridge to definitive nonendoscopic therapy. CONCLUSION/CONCLUSIONS:We present a dedicated international consensus statement aimed at providing guidance to clinicians on best practice use of TEHPs in patients with AGIBs. There was consensus among the panel on the need for future trials to compare the use of different hemostatic powders in patients presenting with GIB.

BACKGROUND:Telemedicine is a critical military medicine capability in austere, remote, and denied environments where prolonged casualty care and knowledge gaps exist. Despite significant military investment in telemedicine, the literature lacks detailed lessons from real-world cases. METHODS:U.S. Air Force Pararescue missions between 1 January 2010 and 31 December 2020 that included telemedicine consultation were reviewed. Participating flight surgeons (FS) and Pararescuemen (PJ) were interviewed, and available after-action reports were analyzed. Mission parameters, outcomes, and technical or human factors affecting communication were evaluated. RESULTS:Across 13 telemedicine consultations, the 28 patients experienced: cave entrapment (13), trauma (7), burns (4), and illness (4). Consultations were from PJ to FS (11), U.S. Coast Guard to FS (1), and FS to neurosurgery (1). Secondary consultations (7) were from FS to dental (1), dermatology, burn/critical care, orthopedics (2), pediatric anesthesiology, and thoracic surgery specialists. Missions used voice over mobile or satellite phone, text, and email. Recommendations commonly involved medication selection (6), advisement against mission launch (3), and burn care (2). Consultation effectiveness was impacted by unclear directions (3) and degraded communications (2). CONCLUSION/CONCLUSIONS:Telemedicine is valuable to PJs during complicated cases and rarely performed procedures, but cannot replace pre-deployment medical exposure and training. Rehearsals may optimize telemedicine, and training should focus on synchronizing a shared mental model of the patient using well-understood patient report and evaluation tools (ATMIST and MARCH PAWS). Telemedicine may reduce human error, give medics the confidence to take action, and limit the psychological impact of difficult care decisions.

OBJECTIVE/UNASSIGNED:To evaluate the safety of alopecia treatments during pregnancy, in-vitro fertilization (IVF), and polycystic ovary syndrome (PCOS) workup, with a focus on potential maternal and fetal risks. DATA SOURCES/UNASSIGNED:A comprehensive literature search was conducted across PubMed, Web of Science, and Scopus from November 2024 to December 2024. Search terms included medication names in combination with "pregnancy," "IVF," "in-vitro fertilization," and "PCOS." STUDY SELECTION/UNASSIGNED:Peer-reviewed studies addressing the use of therapies for androgenetic alopecia, alopecia areata, and scarring alopecias in the contexts of pregnancy, IVF, and PCOS were included. Articles evaluating maternal safety, fetal risks, and treatment timing were prioritized. Only English-language publications were reviewed. RESULTS/UNASSIGNED:Despite increasing therapeutic options for alopecia, significant knowledge gaps remain regarding their safety during pregnancy. Pregnant women are often excluded from clinical trials, leading to a reliance on older treatments with limited data on dosing or pharmacokinetics in the pregnant population. Unfortunately, there are few alopecia medications with robust safety data in pregnancy, and many medications are contraindicated during this period. Some medications may be used with caution, while others require additional investigation. During IVF, there are alopecia medications with potential benefit in women experiencing implantation failure or PCOS. For patients undergoing PCOS workup, some alopecia medications may impact hormonal labs or mask PCOS symptoms. CONCLUSION/UNASSIGNED:There is a critical need for more targeted research on alopecia treatments in pregnancy, IVF, and PCOS contexts. This review provides current evidence to guide clinicians and support informed, individualized treatment decisions during this vulnerable period.

BACKGROUND:AQST-109 is an investigational epinephrine prodrug sublingual film for anaphylaxis treatment, with well-characterized pharmacokinetics (PK) and pharmacodynamics (PD) in healthy adults. It is unclear how oral symptoms during allergic reactions may affect absorption and these parameters. OBJECTIVE:To compare AQST-109's PK and PD in adults with oral allergy syndrome (OAS) undergoing oral allergen challenge (OAC) to elicit symptoms METHODS: This was a phase 2, two-part, open-label, randomized, fixed-sequence, stratified, crossover study to evaluate the PK and PD of single (12mg) and repeat doses (12mg × 2) of AQST-109 in adults with screening-confirmed OAS administered with and without OAC, to single (0.3mg) and repeat doses (0.3mg × 2) of manual IM epinephrine injection (IM-EPI) given without OAC. Geometric means for PK and PD parameters were analyzed for PK, PD, and safety subsets. RESULTS:During screening OAC, 94.4% of n=36 subjects experienced moderate or severe oral symptoms. Pharmacodynamics were not impacted by OAC following single- and repeat-dose of AQST-109 vs without OAC. AQST-109 PK values were similar with or without OAC. Single and repeat-dosing PD parameters were higher with AQST-109 after OAC vs IM-EPI without OAC, and were non-significantly higher for AQST-109 with vs without OAC. Almost all participants experienced a related mild treatment-emergent adverse event, with four considered moderate in severity, and no new safety signals identified compared to prior studies. CONCLUSION/CONCLUSIONS:AQST-109 PK and PD are not diminished with oral symptoms and changes, supporting reliable absorption in allergic reactions with such contexts.

OBJECTIVE:Pediatric tracheostomy emergencies are high-acuity events requiring rapid, coordinated team-based care. This study assessed objective team performance and used in situ simulation to identify systems factors, including latent safety threats (LSTs) and resilience supports, that influence pediatric tracheostomy emergency readiness across diverse clinical settings. METHODS:In situ simulations of pediatric tracheostomy emergencies (obstructed or partially dislodged tubes) were conducted across inpatient floors, critical care units, and emergency departments at 11 pediatric hospitals. Time to completion of critical actions was recorded using the NeoCHART+™ for PEAK-II mobile application. Structured debriefs identified LSTs and resilience supports at unit and hospital levels. Multivariable Cox proportional hazards models assessed predictors of time-critical actions (tube replacement, suction, first effective ventilation) and the percentage of critical actions completed. RESULTS:Sixty-seven baseline simulations were conducted across 11 institutions. Seventy-seven percent of teams replaced an identical tracheostomy tube within 5 minutes (median 188.4 seconds, [IQR 165.3, 204.6]). Teams reported a median of 3.2 LSTs per simulation (IQR 3.0, 4.0). Common LSTs included attempted ventilation through occluded tracheostomy tubes, unclear leadership, ambiguous role definitions, and non-standardized equipment locations. Teams with a RT and at institutions with a dedicated tracheostomy team performed time-critical actions faster. DISCUSSION/CONCLUSIONS:In situ simulation revealed LSTs, resilience supports, and performance variability that may influence effective pediatric tracheostomy emergency response at the systems level. IMPLICATIONS FOR PRACTICE/CONCLUSIONS:Variability identified in systems factors and team performance can guide targeted interventions to improve pediatric tracheostomy emergency preparedness.

PURPOSE: Cardiovascular (CV) toxicity is prevalent in cancer survivors due to shared risk factors, direct CV injury from cancer therapy (CT), and development/exacerbation of CV risk factors during treatment. Succinct guidance on the minimum standard of CV care required of cancer care providers (CCPs) can improve outcomes for survivors. This clinical practice statement (CPS) is aimed at CCPs focused on identification, prevention, and management of CVD in individuals with cancer. METHODS: The International Cardio-Oncology Society and Multinational Association of Supportive Care in Cancer identified members with expertise across oncology, cardiology, and cancer survivorship. Key questions/areas of practice recommendations related to CV risk and CVD were identified across the cancer trajectory.Working groups performed targeted literature reviews and consensus was reached for all recommendations. RESULTS: 5 over-arching clinical practice recommendations for CCPs were identified: (1) perform a CV risk assessment prior to starting CT (2) identify and facilitate CV-related care during CT; (3) ensure measures are taken to mitigate the risk of cancer therapy related CV toxicity (CTR-CVT) prior to and during CT; (4) monitor CV status and risk factors during therapy and refer to the appropriate health care provider if CV risk factors are uncontrolled or new signs/symptoms develop; and (5) re-assess CV risk following completion of CT (periodically for those with advanced disease on life long treatment) and develop a CV surveillance plan. CONCLUSIONS: CCPs play a pivotal role in identifying and addressing CTR-CVT. This CPS provides specific, succinct, and actionable behaviours that can be readily implemented in cancer care globally.

BACKGROUND:Chronic axial spinal pain is one of the leading causes of disability. The literature demonstrates that expenditures for low back and neck pain continue to rise, not only in parallel with increasing disability, but also with escalating healthcare costs, accounting for the highest spending among multiple disease categories. Based on current evidence utilizing controlled diagnostic blocks, facet joints, nerve root dura, and sacroiliac joints have been identified as potential sources of spinal pain. STUDY DESIGN/METHODS:A systematic review of the diagnostic accuracy of spinal facet joint nerve blocks. OBJECTIVE:To determine the diagnostic accuracy of spinal facet joint nerve blocks in chronic spinal pain. METHODS:Methodological quality of the included studies was assessed using the Quality Appraisal of Reliability Studies (QAREL) instrument. Only diagnostic accuracy studies meeting at least 50% of the predefined inclusion criteria were included in the analysis.The strength of evidence was graded using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. Levels of evidence were classified using a modified best evidence synthesis, ranging from Level I to Level V.Data sources included relevant literature identified through PubMed and other electronic searches published from 1966 through September 2025, Cochrane reviews, and manual searches of the bibliographies of primary and review articles. OUTCOME MEASURES/METHODS:Eligible studies were required to use placebo-controlled or comparative local anesthetic blocks. A positive diagnostic standard was defined as at least 50% pain relief from baseline scores along with the ability to perform previously painful movements. RESULTS:The available evidence demonstrated Level I for lumbar facet joint nerve blocks, based on 18 studies employing dual diagnostic blocks, demonstrating 75% to 80% pain relief, with an average prevalence of 16% to 45% and estimated or presumed false-positive rates of 25% to 50%.Evidence for the diagnosis of cervical facet joint pain using cervical facet joint nerve blocks is Level II, derived from 12 controlled diagnostic accuracy studies, showing substantial heterogeneity and internal inconsistency. Reported prevalence ranged from 36% to 67% with ≥ 80% pain relief and estimated or presumed false-positive rates of 26% to 63%.The level of evidence for the diagnostic accuracy of thoracic facet joint nerve blocks is Level II, based on 3 studies using dual diagnostic blocks, demonstrating 80% or greater pain relief, with prevalence ranging from 34% to 48% and estimated or presumed false-positive rates ranging from 42% to 58%. LIMITATIONS/CONCLUSIONS:Limitations of this systematic review include the limited number of studies involving the thoracic spine, ongoing debate regarding the appropriate reference standard, challenges in determining false-positive rates, concerns regarding the appropriateness of diagnostic blocks, the scarcity of recent publications, and issues related to clinical utility. CONCLUSION/CONCLUSIONS:There is Level I evidence for the diagnostic accuracy of lumbar facet joint nerve blocks and Level II evidence for cervical and thoracic facet joint nerve blocks in the evaluation of chronic spinal pain.

PURPOSE/UNASSIGNED:Vesicourethral anastomotic stenosis (VUAS) occurs after 1 to 3% of robotic-assisted radical prostatectomies (RARPs). Pelvic fascia-sparing techniques preserve more native anatomy and may reduce stenoses, but evidence is lacking. The aim of this study was to compare stenosis incidence, management, and outcomes after standard vs pelvic fascia-sparing RARP. MATERIALS AND METHODS/UNASSIGNED:We conducted a multi-institutional retrospective study of 910 standard, 409 Retzius-sparing, and 272 hood RARP during February 2012-September 2025. Standard and hood techniques used 18Fr urethral catheters, and the Retzius-sparing technique used 18Fr suprapubic catheters. The primary end point was cystoscopically confirmed VUAS requiring intervention within 12 months. Urinary continence was assessed using the validated Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP). Multivariable logistic regression assessed factors associated with VUAS. RESULTS/UNASSIGNED:= .046). CONCLUSIONS/UNASSIGNED:There were no VUAS after Retzius-sparing RARP, and Retzius-sparing vs standard approach was associated with lower odds of stenosis. Endoscopic management with structured self-catheterization achieved high success without worsening incontinence. Prospective studies are needed to validate our findings.