Faculty Bibliography

STUDY OBJECTIVE/OBJECTIVE:Emergency department (ED) visits among older adults represent critical transition points in health care, often resulting in substantial downstream utilization. We aimed to quantify health care contact days in the 30 days following a treat-and-release ED visit among older adults and examine associations with demographic and clinical characteristics. METHODS:We conducted a pooled cross-sectional analysis of 2016-2021 Medicare Current Beneficiary Survey data. The sample included treat-and-release ED visits among beneficiaries ≥ 65 years. Health care contact days were categorized as institutional (ED, hospital, skilled nursing facility, hospice) and ambulatory (outpatient visits, labs, imaging, procedures, or treatments). We applied zero-inflated Poisson regression to estimate the likelihood and intensity of health care contact. RESULTS:The analytic sample comprised 10,964 treat-and-release ED visits. Within 30 days, 22.5% of visits resulted in institutional contact and 84.4% in ambulatory contact. On average, each ED visit was followed by 4.3 total contact days (3.0 ambulatory, 1.3 institutional) within 30 days. Having ≥ 2 chronic conditions was associated with greater odds of both institutional (OR: 1.46, 95% CI: 1.28-1.66) and ambulatory contact (OR: 1.44, 95% CI: 1.25-1.66). Dementia was associated with reduced odds of ambulatory contact (OR: 0.51, 95% CI: 0.37-0.72). CONCLUSIONS:Older adults experience frequent and sustained health care contact following treat-and-release ED visits, with particularly high intensity among those with multi-morbidity. Reduced ambulatory follow-up among patients with dementia highlights a potential gap in care coordination after ED discharge.

INTRODUCTION/BACKGROUND:We hypothesized that, in patients at high risk for RE, giving sucralfate prophylactically would reduce the need for opioid pain medication. METHODS AND MATERIALS/METHODS:Patients were enrolled from January 2023 to April 2025 at a single tertiary care center. Patients were randomized to receive 1 gram twice a day within the first five fractions of radiotherapy (RT), with frequency increased during RT at clinician discretion, or standard supportive care. The proportion of patients who took any opioids over the previous 24 hours at the end of the treatment course was compared between groups using logistic regression with the stratification variables and concurrent chemotherapy status as covariates. RESULTS:The trial was closed early due to lack of differences between arms with 117 patients randomized (n=56 in the experimental arm). Rates of opioid use were 30% in both groups (absolute adjusted decrease in the prophylactic sucralfate arm -0.4%; 95% CI -14%, 13%, p>0.9). Rates of grade 2 - 3 RE were non-significantly lower in the prophylactic sucralfate arm (59% vs 69%, absolute adjusted risk decrease 11%; 95% CI -7.2%, 28%; p=0.2). In patients receiving very high esophageal dose (V60 Gy ≥15%), all controls (n=4) experienced grade 2-3 RE compared to only half of those in the experimental arm (6 of 12) (Fisher's exact test p=0.2). CONCLUSIONS:We did not find evidence to support early use of sucralfate in patients at high risk of radiation esophagitis. Limited medical options for the management of RE warrant the continued need to explore further avenues to combat this painful condition.

BACKGROUND AND IMPORTANCE/UNASSIGNED:Closed reduction is an important adjunct in the surgical management of traumatic cervical facet dislocations, particularly jumped and locked facets. By restoring normal spinal alignment, successful closed reduction allows the surgeon to proceed with surgical stabilization via an anterior-first approach, obviating the need to rotate a dislocated, biomechanically unstable cervical spine, thereby minimizing the risk of iatrogenic spinal cord injury. While closed reduction has traditionally been achieved with Gardner-Wells tongs and weights, this reduction method requires the patient to remain bedbound for prolonged periods of time, is not MRI-compatible, and is associated with inconsistent results. CLINICAL PRESENTATION/UNASSIGNED:We present two patients with bilaterally jumped and locked cervical facets, in whom a closed manual reduction technique was used, allowing rapid spinal realignment prior to surgical stabilization. We provide a detailed video illustration of this technique, emphasizing the steps involved and relevant technical nuances. While this technique might have been previously used and rarely reported, it has not, to the best of our knowledge, been described in a detailed, step-by-step fashion. CONCLUSION/UNASSIGNED:Closed manual reduction of traumatic cervical facet dislocations can be performed safely and effectively in the operating room prior to definitive surgical stabilization of the spine. This technique should not be attempted in patients with severe spinal cord compression or neurologic compromise. The importance of adequate muscle relaxation provided by general anesthesia and continuous intraoperative feedback provided by live fluoroscopy and neurophysiologic monitoring cannot be overemphasized.

INTRODUCTION/BACKGROUND:This multicenter randomized controlled trial (RCT) sought to determine if dual-mobility bearings (DM) reduce dislocations in patients at high-risk for instability undergoing primary total hip arthroplasty (THA) compared to single bearing (SB) femoral heads. METHODS:A total of 555 patients undergoing primary posterior approach THA were randomized to DM (n = 271; 42 mm mean effective head, range 36 to 55) or SB heads (n = 284; 28 mm [n = 2], 32 mm [n = 42], 36 mm [n = 168], 40 mm [n = 61], 44 mm [n = 11]). High-risk criteria included: prior lumbosacral fusion (n = 170) or other inclusions (age ≥ 75, preoperative combined flexion-adduction-internal rotation ≥ 115°, substance abuse, inflammatory arthritis, neuromuscular disorder, removal of hardware, cognitive impairment, acute displaced femoral neck fracture, and kyphosis/scoliosis; n = 385). There were 28 patients (5.0%) lost to follow-up before 90 days, leaving 527 patients followed for a median of 23 months (range, 3.0 to 87.2). RESULTS:There were two dislocations in the DM group and six in the SB group (0.7 versus 2.1%, P = 0.29). There was no difference in 2-year dislocation-free survivorship between cohorts (DM: 99.0 versus SB: 97.6%; P = 0.63). There were 16 hips revised (DM: 2.2 versus SB: 3.5%; P = 0.45), with no difference in 2-year all-cause revision-free survivorship (DM: 97.5 versus SB: 96.4%; P = 0.53). Infection was the most common revision indication (two DM [0.7%] versus five SB [1.8%]). There were no differences in patient reported outcome measures at any time point (P > 0.05). CONCLUSION/CONCLUSIONS:In this multicenter RCT, DM bearings were associated with a threefold reduction in dislocation risk, but given the lower than anticipated overall dislocation rate, this difference did not reach statistical significance. Further follow-up is required to capture late dislocations or instability.

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental condition in  children and young people worldwide. Robust estimates of its incidence, prevalence, and burden are essential for informing public health policy and planning. Using data from the Global Burden of Disease Study 2021 (GBD 2021), this global population-based analysis assessed ADHD among individuals under 20 years of age across 204 countries and territories from 1990 to 2021. The study examined incidence, prevalence, and disability-adjusted life years (DALYs) associated with ADHD. In 2021, there were an estimated 46,890,733 (95% uncertainty interval [UI]: 32,136,904-67,271,064) prevalent cases and 4,111,621 (2,775,203-5,954,941) incident cases globally in individuals under 20 years. ADHD accounted for 574,979 (294,277-977,557) DALYs, with a global prevalence rate of 1.78% (1.22-2.55%) and an incidence rate of 0.16% (0.11-0.23%). The global DALY rate was 21.8 (11.2-37.1) per 100,000 population. Prevalence and incidence were highest in Australia, with rates of 5.62% (4.16-7.46%) and 0.49% (0.34-0.66%), respectively. Between 1990 and 2021, global prevalence and incidence rates decreased modestly by 6.0 and 5.81%, respectively. Across all GBD regions, prevalence was higher in males than females (2.52 vs 0.99%) and increased with higher socio-demographic index levels. Overall, the GBD 2021 study provides the most comprehensive global estimates of ADHD burden in young people. These findings are important for guiding policymakers and stakeholders, although potential methodological limitations suggest that the prevalence, incidence, and burden of ADHD may be underestimated.

BACKGROUND/UNASSIGNED:Recent observational studies have suggested that early treatment (<12 hours from diagnosis) of intermediate risk pulmonary embolism (PE) with catheter-based therapies may reduce morbidity and mortality. However, the effect of early versus late mechanical thrombectomy on acute pulmonary hemodynamics and right ventricular mechanics is less well defined. METHODS/UNASSIGNED:Patients enrolled in SYMPHONY-PE were divided into one of 2 groups based on the time from baseline CT pulmonary angiography to mechanical thrombectomy: Early <12 hours versus late ≥12 hours. The primary safety end point was the rate of major adverse events within 48 hours, as adjudicated by an academic independent safety board. The primary efficacy end point was the core-lab assessed mean change in right ventricle-to-left ventricle ratio from baseline to 48 hours. RESULTS/UNASSIGNED:=0.431) between groups, and there were no mortalities. The differences in efficacy outcomes were greatest in higher-risk patients per the Composite Pulmonary Embolism Shock score. CONCLUSIONS/UNASSIGNED:Early mechanical thrombectomy was associated with larger reductions in right ventricle-to-left ventricle ratio and mean pulmonary artery pressure, with no significant differences in safety event rates compared with patients who underwent late thrombectomy. Randomized trials are needed to test these associations. REGISTRATION/UNASSIGNED:URL: https://www.clinicaltrials.gov; Unique identifier: NCT06062329.

BACKGROUND:Transcatheter aortic valve replacement (TAVR) has become a cornerstone in the management of aortic valve disease. However, delayed complications after hospital discharge and readmission remain in an issue following TAVR. We aimed to evaluate the impact of remote monitoring systems on clinical outcomes after TAVR. METHODS:All patients who underwent TAVR from September 2014 through January 2019 were included retrospectively. Additionally, all patients, clinically indicated for TAVR from 9/1/2018 through 8/30/2021, were screened, and patients who agreed were prospectively enrolled. Medtronic Care Management Service (MCMS) was used to monitor patients following TAVR after discharge (Medtronic, Minneapolis, MN). RESULTS:A total of 1078 patients were included. Among them, 843 (78.2 %) patients were discharged with MCMS (MCMS group) and 235 (21.8 %) patients were discharged without (non-MCMS group). Overall, the mean age was 81.5 years, and mean STS-PROM was 5.53 %. Baseline conduction defect was observed in 427 (39.6 %). Peripheral artery disease was more common in the MCMS group while a history of myocardial infarction was more likely seen in the non-MCMS group. After propensity-score matching, length of hospital stays was significantly shorter in the MCMS group (1.42 days vs. 1.82 days in the non-MCMS group, p < 0.001). Readmission rates and new permanent pacemaker insertion rates were similar between the two groups. All-cause mortality, 30-day and 90-day mortality were comparable between the groups. CONCLUSIONS:MCMS was easily applicable to a clinical practice and may reduce length of hospital stays in patients undergoing TAVR without increasing readmission or mortality.