Faculty Bibliography

Salvage chemotherapy and autologous stem cell transplantation (ASCT) offer the opportunity to cure eligible patients with relapsed diffuse large B-cell lymphoma (DLBCL). Epigenetic alterations such as aberrant DNA methylation patterns have been linked to chemotherapy resistance in DLBCL. Oral Azacitadine (AZA) is a hypomethylating agent that inhibits DNA methyltransferase and has provided evidence of chemotherapy sensitization in DLBCL. In this phase I trial the safety and feasibility of two dose levels of AZA were investigated in combination with standard cytotoxic chemotherapy rituximab, ifosfamide, carboplatin, and etoposide (R-ICE) in relapsed DLBCL patients who were candidates for ASCT.

BACKGROUND:Prosthetic joint infection (PJI) after total shoulder arthroplasty (TSA) is a devastating complication. Cephalosporins are considered the standard of care for antibiotic prophylaxis during TSA procedures; however reported β-lactam allergies may result in the use of less effective alternatives which are associated with higher infection and complication rates. The aim of this study is to evaluate the relationship between reported β-lactam allergies, antibiotic choice, and revision rates in TSA. METHODS:A retrospective chart review was conducted on all TSA procedures performed at a single institution between January 2015 and January 2025. Information was collected regarding reported allergies to antibiotics including allergy severity and specific reactions. Additionally, all antibiotics administered during the procedures, intraoperative reactions to administered antibiotics, surgical complications, and subsequent revision procedures were collected. Revision procedures were categorized as septic or aseptic based on preoperative diagnosis. Perioperative antibiotics and patient allergies were categorized into penicillins, cephalosporins, clindamycin, vancomycin and other. RESULTS:Data from 4,232 TSAs were collected. 23% of patients had a reported antibiotic allergy and 15% had a β-lactam allergy. Cephalosporins were administered in 94% of all TSAs, but use declined with increasing β-lactam allergy severity, dropping from 90% in mild cases to 44% in severe cases, with corresponding increases in clindamycin and vancomycin use. Higher allergy severity was strongly associated with reduced cephalosporin use and increased alternative antibiotic use (OR = 0.40, p<.001). Notably, cephalosporins were given to patients labeled as having anaphylactic reactions to penicillins or cephalosporins with no adverse events reported. Overall, intraoperative cephalosporin prophylaxis was significantly associated with decreased all-cause revision odds (OR = 0.47, p<.001) and the presence of a β-lactam allergy was associated with increased likelihood requiring a revision procedure for a presumed septic etiology. CONCLUSIONS:The severity of reported β-lactam allergies strongly influences perioperative antibiotic selection despite evidence that most reported allergies are unreliable, unnecessarily increasing patient risk for PJI. Lack of cephalosporin prophylaxis was associated with increased revision rates, underscoring the clinical and economic value of appropriate antibiotic use. Given the high prevalence of mislabeled β-lactam allergies, established delabeling strategies using allergy testing or test-dosing in the operating room may offer a safe and effective means to increase first-line antibiotic use and improve stewardship. LEVEL OF EVIDENCE/METHODS:Level III, Retrospective Cohort Comparison, Prognosis Study.

OBJECTIVE/UNASSIGNED:Violence against healthcare workers (HCWs), especially in emergency departments and trauma centers (TCs), is a significant and growing problem. HCWs have the highest numbers and annual rates of workplace violence (WPV) compared with any other private industry sector. There is less information about the rates of violence and stalking against trauma providers in TCs. We hypothesized that a majority of trauma surgeons and team members have experienced deliberate assaults in their TCs. Our secondary hypothesis was that a majority of trauma providers consider WPV a significant issue in their workplace. METHODS/UNASSIGNED:The American Association for Surgery of Trauma Disaster Committee invited 2,100 members to participate in an online survey in May and July 2024. Questions evaluated practice type, TC characteristics, training, experience with WPV, beliefs about WPV prevention, and potential WPV prevention strategies interventions. RESULTS/UNASSIGNED:The survey response rate was 10.9%, yet the prevalence of WPV in TCs was reported to be high. 63.9% of respondents were aware of a deliberate assault on an HCW in their TC or system. 42.5% had been assaulted personally, and 7.5% suffered injury as a result of a deliberate assault. Respondents generally agreed on the need for WPV prevention measures such as prevention education, metal detectors, armed police, or security, and were aware of deaths and disabilities among HCWs after assaults. However, they did not personally see WPV as a significant issue in their TCs. CONCLUSIONS/UNASSIGNED:There is a high prevalence of WPV with significant effects on the entire trauma workforce, including elevated levels of emotional distress, burnout, post-traumatic stress disorder, and long-term irreversible physical injuries and deaths. Respondents agreed on the need for preventive measures but did not view WPV as a major issue in their own TCs. Research into this discrepancy, as well as effective strategies to reduce WPV in TCs, would support advocacy for improved legislation and policies aimed at preventing WPV in healthcare. LEVEL OF EVIDENCE/UNASSIGNED:V - Survey of expert opinion.

KEY POINTS/CONCLUSIONS:In this cohort study of 720,348 adults referred for kidney transplantation from 2014 to 2025, only 48% were evaluated and 19% were waitlisted. Progression from referral to evaluation, waitlisting and kidney transplantation was limited by individual, center-level, and geographic factors. Some centers evaluated and waitlisted patients at rates far below the national average, and low-volume centers had lower rates of transplantation. BACKGROUND:Kidney transplantation is a cost-effective, lifesaving treatment of kidney failure, compared with dialysis. Unfortunately, most patients with kidney failure never undergo transplantation. METHODS:Using Epic Cosmos electronic health record data on all patients referred for kidney transplantation from 2014 to 2025, we assessed the stage-specific progression and attrition in the process of evaluation, waitlisting, and kidney transplantation. Center-level and individual (socioeconomic, geographic, and insurance status) factors associated with access to evaluation, waitlisting, and kidney transplantation were characterized using modified Poisson regression. RESULTS:Among 720,348 referred candidates, the median age was 55 years (interquartile range [IQR], 42-64); 47% of patients were White, 52% were male, and 87% were English speaking. Eighty-five percent of patients lived in urban areas. Of the referred candidates, 48% initiated evaluation, 19% were waitlisted, and 10% ultimately underwent transplantation. Among the referred patients who initiated evaluation, the median (IQR) time to evaluation initiation was two (1-4) months after referral; among the patients who were waitlisted, the median (IQR) time to waitlisting was four (2-9) months after evaluation initiation. Patients who were never married (0.94; 95% confidence interval [CI], 0.93 to 0.94), had severe obesity (0.70; 95% CI, 0.69 to 0.72), or were from rural zip codes (relative risk, 0.98; 95% CI, 0.97 to 1.00) were less likely to initiate evaluation. Low-volume centers had lower relative rates of transplantation (0.92; 95% CI, 0.88 to 0.96). In centers with documentation for nonprogression to evaluation, reasons for removal included not meeting criteria/not a candidate (18%), patient decision (13%), unable to contact (12%), death (4%), and financial/insurance complications (7%). CONCLUSIONS:Our study shows substantial attrition before kidney transplant waitlisting.

OBJECTIVE:DISSOLVE I and II examined efficacy and safety of nanoencapsulated sirolimus (NAS) plus pegadricase (NASP) in patients with uncontrolled gout (UG). METHODS:In these double-blind, placebo-controlled Phase 3 trials of NASP, patients were randomized 1:1:1 to infusions of high-dose (HD) or low-dose (LD) NAS plus pegadricase (HD NASP, LD NASP, respectively) or placebo, given every 4 weeks for 6 doses. The primary endpoint was proportion of patients with serum urate (SU) <6 mg/dL for ≥80% of the time during Weeks 21-24. Secondary endpoints included health-related quality of life, tophus resolution, tender joints, and gout flares. Safety was also assessed. RESULTS:Overall, 265 patients received HD NASP, LD NASP, or placebo. SU response during Weeks 21-24 was significantly higher with NASP than placebo (HD NASP: 51%; LD NASP: 43%; placebo: 8%; p<0.0001 for both doses vs placebo). Common adverse events included gout flares (HD NASP: 42.5%; LD NASP: 44.3%; placebo: 43.3%), infections (HD NASP: 23.0%; LD NASP: 18.2%; placebo: 16.7%), and stomatitis (HD NASP: 9.2%; LD NASP: 3.4%; placebo: 0%). Infusion reactions within 1 hour were infrequent (4%) in NASP-treated patients. During Weeks 1-12, the proportion of patients with flares was similar between NASP- and placebo-treated patients; thereafter, it decreased in NASP-treated patients but remained unchanged with placebo. CONCLUSION/CONCLUSIONS:NASP treatment resulted in a significantly higher proportion of patients with complete SU response during Weeks 21-24 compared to placebo and was generally well-tolerated. NASP, an every-4-week treatment, can markedly alleviate disease burden in patients with UG.

BACKGROUND:Methadone is the gold standard treatment for opioid use disorder (OUD). In the U.S., methadone is usually only available through licensed opioid treatment programs (OTPs), but a 2021 federal rule provided an opportunity for OTPs to provide methadone on mobile medication units (MMUs). MMUs operate under the license of an OTP and are subject to complex regulatory requirements. New York State provided grant funding to support OTPs to adopt MMUs, aligned with the broader goal to improve methadone access statewide. This study explored barriers and facilitators to MMU implementation across New York State from the perspectives of treatment staff and administrators. METHODS:We conducted semi-structured interviews between June 2024 and June 2025 with 16 staff from four OTPs that adopted MMUs and one residential treatment program served by an MMU. Interviews were audio-recorded, transcribed, and analyzed using a hybrid deductive-inductive thematic analysis approach to identify implementation barriers and facilitators. RESULTS:Staff described a variety of potential models for using MMUs to expand access. In New York City, MMUs were used to serve a residential substance use program. In upstate NY, MMUs were deployed to reduce travel distance in counties with few OTP options. Key facilitators of MMU implementation included leadership persistence in the face of community pushback, creativity and workarounds in the face of logistical hurdles, and support from the state agency. Key barriers included community resistance to MMUs, unclear or inconsistent guidance from the Drug Enforcement Administration, and a variety of operational challenges, such as vehicle maintenance and workforce shortages. Staff generally were positive about the opportunity to use MMUs to address access challenges. CONCLUSIONS:MMUs provide a novel approach to expand methadone access, particularly to populations not currently served by brick-and-mortar OTPs. Early implementers can provide important lessons about how to manage start-up challenges, which can guide later adopters.

BACKGROUND:Despite prevalent gender discrimination in medical education, its influence on personal and professional development, foundational competencies in medical training per the Association of American Medical Colleges (AAMC), remains unclear. This retrospective cross-sectional study assesses how experiences of gender discrimination in medical school influence personal and professional identity formation (PPIF) among males and females. METHODS:Deidentified student-level data were procured from the AAMC data warehouse for 37,610 MD students who matriculated in 2014-2015 and took the Graduation Questionnaire (GQ) between 2016-2020. Gender discrimination frequency was categorized as 'Never', 'Isolated', and 'Recurrent' from GQ responses to questions about denial of opportunities, offensive remarks, and lower evaluations due to gender. Students self-reported their sex as male, female or declined to answer. PPIF was assessed using two separate GQ metrics assessing student agreement on a 5-point Likert scale that their medical school fostered and nurtured their development as a person and a future physician, respectively, and dichotomized. RESULTS:Female students experienced higher rates of isolated (12.6%) and recurrent (20.1%) gender discrimination than males (4.3% isolated, 6.2% recurrent). Females reported slightly lower personal (71.2%) but similar professional development (92.2%) rates compared to males (73.4% personal, 91.2% professional). Both sexes experiencing gender discrimination had lower likelihoods of PPIF than their counterparts without these experiences. If recurrent discrimination occurred, the aRR (95%CI) of professional development was 0.89 (0.87-0.90) for females and 0.78 (0.74-0.81) for males, while for personal development, it was 0.69 (0.67-0.71) for females and 0.61 (0.58-0.66) for males. Compared to females, males showed sharper declines in professional development as discrimination frequency increased from never to isolated (aRR = 0.93, 95% CI [0.92-0.94], p < 0.001) and isolated to recurrent (aRR = 0.95, 95% CI [0.93-0.97], p < 0.001). CONCLUSIONS:Gender discrimination negatively influences PPIF for both female and male medical students. Efforts to combat discrimination in medical training and promote holistic student development should be considered. Future work is needed to understand the influence of gender discrimination on the comprehensive development of gender-diverse medical students.

BACKGROUND:Robotic Ivor-Lewis esophagectomy is increasingly adopted due to its minimally invasive approach and favorable outcomes. Anastomotic leak remains the most serious complication after esophagectomy, with reported rates of 5-18%. We describe a reinforced, stapled, single-layer, thoracic anastomosis which has resulted in no leaks in 50 consecutive patients. METHODS:We performed a retrospective review of consecutive patients who underwent robotic Ivor-Lewis esophagectomy by a two-surgeon team. RESULTS:From January 2022 to February 2026, 50 patients were included with a median age of 70 years. Indications for surgery were malignancy in 47 patients, most commonly adenocarcinoma (85.1%) and benign disease in 3 patients. Median operative time was 237 min, median actual blood loss was 35 mL and median lymph node yield was 20. R0 resection was achieved in all 47 malignant cases. Complete pathologic response (pCR) was observed in 13 out of 38 patients that received neoadjuvant therapy (34.2%). There were no conversions, and median LOS was 4 days. No anastomotic leaks were detected clinically, radiographically, or biochemically and there was no 30- or 90-day mortality. At a median follow-up of 26.8 months, 1- and 2-year overall survival rates were 88.2 and 84.6%, respectively. CONCLUSIONS:This technique, when properly executed, is reproducible, safe, and can afford R0 resection and thorough thoracic lymph node dissection, with promising results. Prospective, multicenter studies are needed to compare this approach to alternative anastomotic techniques.