Faculty Bibliography

OBJECTIVES/OBJECTIVE:Medicare-funded home health (HH) provides short-term nursing, physical therapy, and other services to over 3.5 million older adults each year. Currently, half of HH episodes are "community-entry," meaning the patient was referred without an immediately preceding hospitalization. The 2020 implementation of a new payment system-the Patient-Driven Groupings Model (PDGM)-reduced traditional Medicare reimbursement for community-entry HH (CEHH). We investigated shifts in CEHH care delivery following PDGM implementation. DESIGN/METHODS:Cross-sectional study of national 2019 and 2021 linked HH claims, assessment, HH agency, and geographic data. SETTING AND PARTICIPANTS/METHODS:Traditional Medicare beneficiaries receiving a CEHH episode in 2019 or 2021 (n = 577,602). METHODS:HH is provided through clinician visits to the patient's home; therefore, visits are the primary unit of care delivery. We modeled the number of visits overall and by service type (eg, nursing, physical therapy) using national data for CEHH patients pre-PDGM (ie, 2019) and post-PDGM (ie, 2021). Models adjust for relevant patient, HH agency, and geographic characteristics (including monthly county-level COVID-19 infection rates). RESULTS:Following PDGM, there was an 18% decrease in total visits received, with the largest decreases in the number of physical therapy (-13%), occupational therapy (-17%), and aide (-16%) visits. Reductions in visits were greatest at HH agencies with lower Medicare Advantage penetration (and thus, greater exposure to PDGM) and for-profit agencies. CONCLUSIONS AND IMPLICATIONS/CONCLUSIONS:Findings raise questions about HH agencies' ongoing ability to meet the needs of patients with complex, overlapping clinical and social needs following PDGM implementation. Ongoing monitoring of how these care delivery changes impact outcomes for CEHH patients is essential to ensure that HH can continue to help high-need older adults safely age in place.

BACKGROUND:Studies on patients have shown that normal anatomic motion is often not achieved with current total knee arthroplasty (TKA) designs. The purpose of this study was to determine whether anatomic motion could be restored using a design where intercondylar guiding surfaces were positioned between the medial and lateral femoral condyles. METHODS:A crouching machine was constructed, which included simulations of the collateral ligaments, the quadriceps mechanism, the hamstrings, and the gastrocnemius. Medial pivot, medially congruent, ultracongruent, and replica intercondylar TKAs were designed and 3-dimensionally printed. The femoral-tibial kinematics were measured by determining lateral and medial contacts, as the knee underwent flexion and extension from 12 to 130°. RESULTS:The replica intercondylar design showed an almost constant position of the medial contact, with a progressive posterior displacement laterally during flexion. In contrast, the other designs showed nearly parallel motion with minimal variation in contact location. CONCLUSIONS:It was concluded that intercondylar guiding surfaces could produce anatomical motion in a TKA where the cruciate ligaments were resected.

Pediatric autoimmune hemolytic anemia (AIHA) is a heterogeneous disease with significant morbidity due to the underlying condition and its treatment. Evidence-based guidelines for evaluation and management are lacking. Data from 399 patients with AIHA followed at 15 pediatric centers were collected to identify factors associated with secondary diagnoses, recurrent/chronic course, therapeutic efficacy, and mortality. Most had AIHA associated with secondary diagnoses including Evans syndrome (37%, 142/385), other autoimmunity (22%, 86/392), and inborn errors of immunity (IEI, 18%, 68/379). Of 305 patients tested, 82% had abnormal functional immune results. Genetic testing for an IEI was sent in 31% (109/348) with pathogenic findings identified in 32% of those tested. Patients with IEI or other autoimmunity more frequently had abnormal immunoglobulin and complement testing. Prevalence of IEI was not different between those presenting with or without infection. The median number of treatments for the first AIHA episode was 2 (range: 0-17). Of those with warm AIHA, 31% received steroid-sparing therapy during the first episode. Patients with recurrent AIHA (42%) had a higher rate of abnormal immune tests (OR=2.29, p=0.012), Evans syndrome (OR= 4.85; p<0.001), IEI (OR=3.88, p<0.001), and other autoimmune disorders (OR=3.29; p<0.001). With median follow up of 4.9 years (range: 0-19.4 years), 72/257 (28%) with warm AIHA continued to have active disease on treatment. Of the 399 patients, 10 died, all of whom had secondary diagnoses. Expansive immune evaluation, monitoring, and targeted treatments directed at immune diagnoses are needed for pediatric AIHA, highlighting the need for evidence-based pediatric AIHA guidelines.

BACKGROUND/UNASSIGNED:Cardiac stress testing is a cornerstone of risk stratification and management in patients with chronic coronary disease, yet the consistency and accuracy of its interpretation remain poorly defined. This analysis evaluated variation in the interpretation of myocardial ischemia between enrollment sites and core laboratories in the ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches). METHODS/UNASSIGNED:ISCHEMIA was a global (37 countries, 2012-2018) randomized trial of an initial invasive versus conservative strategy in patients with chronic coronary disease and moderate or severe ischemia. This analysis included participants with site-interpreted qualifying stress tests-nuclear, echocardiography (echo), cardiac magnetic resonance, or exercise tolerance test-and independent core laboratory adjudication. Core laboratories, serving as the reference standard, reinterpreted tests blinded to site results. A trinary outcome variable (site underestimation, concordance, or overestimation) was defined by comparing site-determined ischemia levels to standardized core lab assessments. Adjusted mixed-effects logistic regression models with random site intercepts assessed variability. RESULTS/UNASSIGNED:Among 6971 participants (mean age, 62.8 years; 73% men), site interpretations showed 0% no/mild (by design), 43% moderate, and 57% severe ischemia. Core labs reclassified these as 8% none, 11% mild, 30% moderate, and 51% severe ischemia. For the imaging modalities, median site-core lab agreement rates were ≈55%; nearly 25% of site-classified moderate/severe cases were downgraded to no or mild ischemia by core labs. Adjusted median odds ratios for site overestimation were 2.36 (95% CI, 2.02-2.82; nuclear), 1.98 (95% CI, 1.62-2.60; echo), 1.89 (95% CI, 1.0-5.41; cardiac magnetic resonance), and 2.15 (95% CI, 1.76-2.79; exercise tolerance test). Adjusted median odds ratios for underestimation ranged from 1.25 to 1.77. CONCLUSIONS/UNASSIGNED:In ISCHEMIA, enrollment sites frequently overestimated or underestimated the severity of myocardial ischemia compared with core laboratory assessments, highlighting the need for strategies to improve the consistency and accuracy of stress testing interpretation in patients with chronic coronary disease. REGISTRATION/UNASSIGNED:URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.

The rapid expansion of plasma proteomic data and protein quantitative trait loci (pQTLs) provides an opportunity to identify genes that confer disease risk through their effect on plasma protein abundance. We conducted an Alzheimer's disease (AD) proteome-wide association study (PWAS) integrating publicly available plasma cis-pQTL data (1348 European American and 1385 African American genetically determined protein models) with AD dementia GWAS summary statistics. Whereas the African American PWAS identified one candidate [apolipoprotein E (APOE)] and multiple suggestive genes, the European American PWAS identified 18 genes with putative causal relationships with AD through cis regulation of plasma protein abundance. Thirteen of these candidate genes were additionally supported by colocalization and complementary causal-inference analyses such as summary data-based Mendelian randomization. Four of these proteins were not previously detected in AD GWAS [complement decay-accelerating factor (CD55), leukocyte immunoglobulin-like receptor B1 (LILRB1), scavenger receptor class A member 5 (SCARA5), and signal regulatory protein alpha (SIRPA)]. A subset of candidate gene-associated proteins was associated with 8- and 20-year dementia risk, markers of AD pathology, and a CSF proteomic signature enriched for immune and metabolic processes. Putative causal proteins were enriched for adaptive (lymphocyte-mediated) immunity and, compared with GWAS candidates, showed less enrichment for synaptic and amyloid regulatory processes. LILRB1 and SIRPA, two immunoregulatory proteins not previously implicated in AD GWAS, showed the strongest mechanistic link to AD in the European American PWAS. These results shed additional light on AD etiology and enable the prioritization of potential AD therapeutic targets in peripheral circulation.

BACKGROUND/UNASSIGNED:We conducted a head-to-head study comparing outcomes among commonly used implant brands, Allergan, Mentor, and Sientra, used in breast reconstruction. METHODS/UNASSIGNED:A multicenter retrospective review of patients undergoing acellular dermal matrix-assisted implant-based breast reconstruction (IBR) with Allergan, Mentor, or Sientra implants between January 2014 and July 2022 was conducted. Primary outcomes included rates of return to the operating room for implant removal. Secondary outcomes included complications occurring within 30 days, between 31 and 60 days, and after 60 days. RESULTS/UNASSIGNED:. One hundred ninety-nine (17.2%) breasts underwent adjuvant radiation and 168 (14.5%) underwent neoadjuvant chemotherapy. Implants were most often inserted in the prepectoral plane (n = 584, 50.6%). After 60 days, there were no significant differences in overall complication rates between brands. One hundred sixty-one (13.9%) breasts underwent eventual reoperation, including unplanned explantation (n = 95, 8.2%), elective revision (n = 94, 8.1%), oncological indications (n = 20, 1.7%), and infection (n = 15, 1.3%). Indications for unplanned explantation included infection (n = 26, 2.3%), capsular contracture (n = 15, 1.3%), and nonhealing wounds (n = 14, 1.2%). There were no differences in other complications or reoperations between cohorts. Body mass index, diabetes mellitus, smoking history, chemotherapy, radiation, skin-sparing mastectomy, type of incision, and tissue expander use were independent predictors of postoperative complications. CONCLUSIONS/UNASSIGNED:Low rates of complications among Allergan, Mentor, and Sientra implants in IBR support their continued use. No single brand was superior to others regarding complication profile in our study. Patient characteristics and operative approach seem more predictive of postoperative outcomes than the implant brand alone.

INTRODUCTION/BACKGROUND:More than half of older adults with Alzheimer's Disease and Related Dementias (ADRD) are undiagnosed, limiting timely access to person-centered care. Therefore, clinicians, researchers, and population health managers need scalable, reproducible approaches to monitor both prevalence and diagnostic gaps. We evaluated whether a decision-analytic modeling framework can translate a limited number of clinician-adjudicated cases of ADRD into a probabilistic computational phenotype for accurate, population-level assignments of probable ADRD in the emergency department (ED) setting using routinely collected electronic health record (EHR) data. METHODS:Retrospective cohort study of 5000 adults aged ≥ 65 years from nine EDs within a large integrated health system (2014-2022). We randomly selected 500 individuals for clinician adjudication of dementia status (reference cohort), reserving the remaining 4500 as a phenotyping cohort. We developed the phenotype as a logistic regression model trained on adjudicated cases, embedding pattern-mixture multiple imputation to address information bias. We applied decision-curve analysis to evaluate clinical utility across probabilistic thresholds. We applied the phenotype to assign dementia status to 4500 unadjudicated patients and compared clinical characteristics to adjudicated cases. RESULTS:The mean (SD) age was 77.4 (9.0) years; 55.4% were women; 102 individuals (20.4%) had clinician-adjudicated ADRD. The model demonstrated good discrimination (AUROC 0.87; 95% CI 0.82-0.91). Decision-curve analysis revealed net clinical benefit across examined thresholds (predicted probabilities 12%-32%), identifying an additional 16-18 probable ADRD cases per 100 older adults. Among those without ADRD-related diagnosis codes, net benefit ranged from 8 to 13 additional correct identifications per 100. Phenotype-assigned cases closely resembled clinician-adjudicated cases (standardized mean differences ≤ 0.20). CONCLUSIONS:A probabilistic computational phenotype derived from routinely collected EHR data accurately reproduced clinician-adjudicated ADRD status and demonstrated net clinical benefit, including among ED patients whose ADRD was not captured by diagnosis codes. Adoption of this replicable framework may enable healthcare organizations to strengthen ADRD surveillance and reduce underdiagnosis.

BACKGROUND:Endoscopic sleeve gastroplasty (ESG) is increasingly utilized for treating obesity, but some patients may subsequently present for conversion to a surgical procedure. Foreign material or distorted anatomy may make conversion more challenging. The preoperative evaluation, intraoperative findings, and postoperative outcomes of converting ESG to bariatric surgery are not well described. METHODS:Bariatric surgery patients at a single center with history of ESG were identified by review of electronic medical records from 2016 to 2026. Background characteristics, preoperative imaging, endoscopic findings, intraoperative details, and outcomes were obtained by chart review. Intraoperative videos were obtained when possible. RESULTS:. Most patients (19/20, 95%) underwent preoperative esophagram, which showed a tubularized stomach in half of cases (10/19, 53%) but no radiopaque materials precluding conversion to surgery. Preoperative endoscopy (n = 5) and intraoperative endoscopy (n = 3), when performed, revealed no apparent gastroplasty. Intraoperative findings included mild adhesions around the stomach, with sutures sometimes visible, but an otherwise native stomach not requiring any changes to the staple line. Mean total weight loss was 29.1% at 1 year postoperatively. No stapler misfires occurred, and none of the postoperative complications were related to the gastric staple line. There were no gastric staple line leaks or bleeds. CONCLUSION/CONCLUSIONS:In our experience, sleeve gastrectomy and gastric bypass were both technically feasible and relatively straightforward to perform in patients with a history of ESG.

OBJECTIVE:To evaluate the effectiveness and safety of endovenous ablation across racial and ethnic groups by comparing rates of endovenous heat-induced thrombosis (EHIT) and recanalization. METHODS:We retrospectively analyzed 13,335 endothermal ablation procedures (radiofrequency or laser) performed from 2012 to 2022 at a single outpatient center. Patient demographics, including self-identified race/ethnicity (Asian, Black, Hispanic, White), were recorded. Post-procedural duplex ultrasound was conducted at 3-7 days, 3-6 months, and then every 6-12 months. EHIT (classes 1-4) and recanalization of the treated vein were identified on follow-up imaging. Outcomes were compared across racial/ethnic groups using univariable and multivariable logistic regression. RESULTS:Among 13,335 ablations (8,187 radiofrequency and 5,148 laser) in 3,218 patients, 67.1% were performed in women. Mean follow-up was 25.8 ± 12.9 months (range, 3-72 months). EHIT incidence was highest in Black patients (3.0%), followed by Asian (2.6%), White (1.7%), and Hispanic (1.4%) patients; the difference between Black and White patients was significant (p < 0.001), while other pairwise comparisons were not. Procedural success (no EHIT or recanalization) was high and comparable across groups: 96.1% in Asians, 95.2% in Blacks, 96.1% in Hispanics, and 96.2% in Whites. On multivariable analysis, Black race was associated with higher EHIT risk (OR = 1.92, p < 0.001), and Asian race with higher recanalization risk (OR = 1.65, p = 0.045). Additional predictors of recanalization included advanced disease (CEAP 6; p < 0.05), while the ablation of the great, anterior, or small saphenous veins was protective compared with perforator veins (all p < 0.001). Predictors of EHIT included older age (p < 0.0001) and prior recanalization (p < 0.0001), while laser ablation was associated with a significantly lower EHIT risk compared with radiofrequency (p < 0.0001). Baseline disease severity also varied: Black patients were more likely to present with advanced disease (CEAP 5-6) than Hispanic and Asian patients (p < 0.0001). CONCLUSIONS:Endovenous ablation is a safe and effective treatment for chronic venous insufficiency across different racial/ethnic groups, with overall success rates of 95-96%. However, racial differences were observed in complication rates and baseline severity: Black patients had higher EHIT risk and more advanced disease at presentation, while Asian patients had a slightly higher recanalization risk. These findings highlight the need for tailored post-ablation surveillance and improved early access to care to address differences in minority populations.

OBJECTIVE/UNASSIGNED:Obsessive-compulsive disorder (OCD) is one of the common mental disorders globally. However, there are limited studies on the prevalence of OCD and four other disorders categorized under obsessive-compulsive and related disorders, namely, hoarding disorder, excoriation disorder, body dysmorphic disorder, and trichotillomania. The authors sought to fill the epidemiological gap in the literature. METHODS/UNASSIGNED:criteria, were included. A Bayesian hierarchical linear mixed model was used to estimate the lifetime prevalence of OCD at the global, regional, and national levels, with estimates reported with 95% credible intervals. The authors examined the association between OCD prevalence and the Socio-demographic Index (SDI), and estimated age-specific point prevalence of OCD. RESULTS/UNASSIGNED:criteria. Lifetime prevalence of OCD was negatively correlated with SDI, indicating lower prevalence estimates in countries with higher SDI. The age-specific prevalence of OCD increased sharply in the teen years and peaked in the late 20s to early 30s. Point prevalence ranged across studies from 0.98% to 5.81% for hoarding disorder, from 2.33% to 7.68% for excoriation disorder, from 0.44% to 15.21% for body dysmorphic disorder, and from 0.0% to 2.12% for trichotillomania. CONCLUSIONS/UNASSIGNED:This study estimated the global prevalence of OCD according to diagnostic criteria, underscoring the role of diagnostic definitions in shaping epidemiological understanding.