Faculty Bibliography

OBJECTIVES/OBJECTIVE:To evaluate whether ballistic (gunshot) injuries increase the rate of severity of heterotopic ossification (HO) compared with blunt trauma in patients with periarticular elbow fractures. DESIGN/METHODS:Retrospective cohort. SETTING/METHODS:Single Level 1 trauma center. PATIENT SELECTION CRITERIA/UNASSIGNED:Study inclusion required patients of mature skeletal age diagnosed with a periarticular elbow fracture (OTA/AO 13A-C) with a minimum of 6 weeks radiographic follow-up between 2018 and 2024. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Data on demographics, injury characteristics, and surgical management were collected for the ballistic trauma cohort and blunt trauma cohort. HO was assessed using the Hastings/Brooker Classification. Secondary outcomes included postinjury stiffness defined as a flexion/extension arc of motion <100 degrees, revision surgery, and complications. Descriptive statistics were used to compare frequencies of categorical outcome variables between blunt and ballistic cohorts, and multivariable logistic regressions were used to identify risk factors for elbow HO occurrence and severity and all secondary outcomes. RESULTS:A total of 171 patients met inclusion criteria including 65 Gunshot Wound (GSW)-related fractures (38%). Patients with GSW were younger [29.2 (range: 18-62) vs. 43.8 years (range: 18-93)] and more often male (84.6% vs. 51.9%). Overall HO occurrence was 61.4%. GSW was not significantly associated with HO (63.1% vs. 60.4%, P = 0.607). Distal humerus fractures were associated with increased HO risk [odds ratios (OR) 2.15] and severity (OR 2.63) compared with proximal radius/ulna injuries. Stiffness occurred in 73.7% of patients and was more common in distal humerus injuries than in proximal radius/ulna fractures (OR 2.50; P = 0.030). No significant differences were found in stiffness, revision surgery, or complication rates between GSW and non-GSW groups (OR 1.36; 95% CI: 0.537-3.455; P = 0.51). CONCLUSIONS:Ballistic injury did not significantly increase HO risk or stiffness compared with blunt trauma in a civilian population. Consistent with the literature, fracture location, specifically distal humerus fractures compared with proximal radius/ulna injuries, seems to be an important driver for HO prevalence and severity. Identifying HO risk factors after periarticular elbow trauma can help clinicians stratify patient risk and guide preventive strategies for managing these complex injuries. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:The natural history of renal oncocytoma (RO) following surgical resection remains unclear. We examined a cohort of post-nephrectomy patients with RO, focusing on the management of synchronous and metachronous tumors and their clinical course under surveillance. METHODS:This retrospective, single-institution study analyzed patients from 1990 to 2020 with at least 24 months of follow-up. Patient characteristics and management of synchronous and metachronous tumors were recorded. Cox regression identified risk factors for metachronous tumors, while Kaplan-Meier and log-rank tests assessed metachronous-free survival (MFS). RESULTS:Among 328 patients (median follow-up: 109 months), 19% (n = 63) had synchronous renal tumors on preoperative imaging. Of these, 27 underwent additional procedures, revealing renal cell carcinoma (RCC)/cortical neoplasm (n = 7), benign lesions (n = 5), or secondary RO (n = 13). Two specimens were unavailable. Metachronous renal lesions developed in 8.5% (n = 28), with 18 undergoing active surveillance. Among 8 patients undergoing biopsy or surgery, 3 had RCC/cortical neoplasm, 4 had RO, and 1 specimen was inconclusive. 5-year MFS were 98.8% in patients with a single lesion at diagnosis and 88% for patients with presence of synchronous renal lesions (P = .004). Higher BMI (HR 1.09, CI 1.01-1.17, P = .026) and synchronous lesions at diagnosis (HR 2.67, CI 1.16-6.14, P = .021) were significant risk factors for metachronous tumors. CONCLUSION/CONCLUSIONS:Patients with RO have a very low risk of harboring RCC in synchronous or metachronous lesions, supporting active surveillance as a safe strategy. However, those with synchronous kidney tumors at diagnosis face an increased risk of metachronous disease and may require closer monitoring.

BACKGROUND AND OBJECTIVE/OBJECTIVE:The role of consolidative nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) patients treated with immune checkpoint inhibitors remains unknown. As patients derive variable benefit from immunotherapy (IO), an understanding of how treatment response is associated with long-term outcomes could inform patient surgical selection. We thus conducted a retrospective study to evaluate whether radiographic and pathologic tumor responses after IO are associated with survival in patients undergoing CN at a high-volume academic center. METHODS:We identified mRCC patients treated with at least one IO-containing regimen followed by CN between 2015 and 2024. A radiographic response was assessed using the Response Evaluation Criteria in Solid Tumors. A pathologic response was measured using the percentage of residual viable tumor (RVT), with a major pathologic response (MPR) defined as RVT <10%. Outcomes included progression-free (PFS) and overall (OS) survival, analyzed using Cox proportional hazards models. KEY FINDINGS AND LIMITATIONS/UNASSIGNED:Sixty patients underwent CN after IO. The median time to nephrectomy was 9 mo (interquartile range: 7, 14), and the 2-yr OS rate was 75% (95% confidence interval [CI]: 60-85%). Fifteen patients (26%) had an MPR and 21 patients (35%) had a radiographic response of the primary tumor. The radiographic response was protective but not significantly associated with PFS or OS. The MPR was significantly associated with PFS (hazard ratio [HR]: 0.05, 95% CI: 0.01-0.41; p = 0.005) and OS (HR: 0.07, 95% CI: 0.01-0.88; p = 0.039). CONCLUSIONS AND CLINICAL IMPLICATIONS/CONCLUSIONS:Patients with an MPR at nephrectomy had longer PFS and OS. A pathologic response helps guide postnephrectomy treatment timing and sequencing, although future efforts should further validate the utility of post-IO pathologic endpoints.

PURPOSE/OBJECTIVE:Oligometastatic clear-cell renal cell carcinoma (ccRCC) represents a heterogeneous entity that can, in select cases, be managed with primary tumor resection and complete local treatment at all metastatic sites, rendering a patient metastatic with no evidence of disease (M1 NED). M1 NED patients have improved overall survival, although previous cohorts are relatively small and heterogeneous. We sought to identify the natural history of M1 NED ccRCC to clinical trial findings and to optimize management strategies. MATERIALS AND METHODS/METHODS:Patients with synchronous metastatic ccRCC treated with local therapy alone and considered radiographically M1 NED at our institution between 1989 and 2023 were retrospectively evaluated. Survival probabilities used a combination of Kaplan-Meier estimator, log-rank test, and multivariable Cox proportional hazards regression. When available, limited genomic data obtained using the MSK-IMPACT targeted panel was correlated with outcomes. RESULTS:85 patients met inclusion criteria. One-year disease free survival (DFS) was 53% (95% CI: 42 to 63%). Sarcomatoid features predicted shorter DFS (HR 2.62, CI: 1.08, 6.34, P = 0.03). Time from first disease recurrence to second recurrence was longer among patients with initial DFS ≥2 years (median 42 vs. 15 months, log-rank P = 0.005). A total of 18 patients (21%) underwent targeted genomic sequencing; higher fraction of genome altered and CDKN2A copy number loss were associated with shorter DFS. Findings were limited by cohort size. CONCLUSIONS:Most M1 NED ccRCC patients will experience disease recurrence, although certain baseline risk factors appear to predict earlier recurrence. Prognostic biomarkers are needed to predict outcomes and facilitate patient management.

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported adverse events of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2024 for articles related to endoscopic submucosal dissection. Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Virtual urgent care (VUC) has become an increasingly utilized resource for acute care delivery. Frequent utilization of VUC may reflect unmet longitudinal care needs and contribute to fragmented care. While high-utilizer patterns are well described in emergency departments, they have not been systematically characterized in telemedicine. We evaluated a clinical decision support (CDS) nudge designed to identify and address high utilizers of VUC at a large academic health system. An electronic health record alert triggered when patients met predefined high-utilizer criteria (>3 visits in 30 days, >12 in six months, or >20 in 12 months) and prompted providers to document a structured follow-up plan using a SmartPhrase. Among 473 eligible patients, 162 (34%) received the SmartPhrase. After adjustment for baseline utilization using negative binomial regression, SmartPhrase use was associated with a 22% relative reduction in VUC visits over the subsequent 30 days (incidence rate ratio 0.78, p = .03). Bootstrapped analyses confirmed a significant reduction in the SmartPhrase group (-1.47 visits; 95% CI [-2.19 to -0.62]), while no significant change occurred in the comparison group. These findings suggest that a low-cost, workflow-integrated CDS nudge may reduce short-term telehealth overutilization by prompting structured follow-up discussions and encouraging longitudinal care planning.

BACKGROUND:Redo/revisional ileal pouch-anal anastomosis (IPAA) surgery is technically challenging and more likely to require mesenteric lengthening maneuvers, largely due to mesenteric reach issues, which may affect the perfusion of the critical sites in the pouch. Indocyanine green fluorescence angiography (ICG-FA) offers real-time assessment of tissue perfusion and may reduce the risk of complications, such as anastomotic leak. We aimed to evaluate the impact of intraoperative ICG-FA on surgical outcomes in patients undergoing redo/revisional IPAA surgery. METHODS:This is a retrospective case-control study with 1:1 propensity score matching based on data from a high-volume quaternary inflammatory bowel disease center. Patients who underwent redo/revisional IPAA surgery between September 2016 and December 2023 were included. The primary objective was to evaluate the direct impact of ICG-FA on intraoperative decision-making, measured by the rate of change in surgical plan. Secondary objectives included an exploratory comparison of short- and long-term outcomes, such as anastomotic leak and major complications. RESULTS:A total of 46 patients were included, with 23 patients in each of the ICG and non-ICG groups. ICG-FA led to intraoperative changes in surgical management in 2 patients (8.7%), including one pouch augmentation with resection of the tip of the J pouch and one pouch excision. The 30-day major complication rate was lower in the ICG group (11.1%) compared to non-ICG (18.2%), though not statistically significant (p = 1.00). No significant difference was found in long-term complication rates after adjusting for a marked disparity in follow-up duration between the groups. No adverse reactions related to ICG-FA were observed. CONCLUSIONS:ICG-FA is a safe and feasible adjunct during redo/revisional IPAA surgery. Its use may guide intraoperative decision-making, leading to timely revisions.

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.

• The authors present supravalvular stenosis from congenital and iatrogenic etiologies. • Multimodality imaging is essential for diagnosing supravalvular stenosis. • Echocardiography assesses severity, while CCT provides diagnostic clarity.