Faculty Bibliography

Traumatic abdominal flank hernias are rare and challenging but more common than previously recognized. There is no consensus on the management of traumatic flank hernias. The majority of studies have been conducted in the setting of blunt trauma; however, there is a paucity of literature on penetrating trauma. We present the case of a man in his thirties with a persistent left flank hernia after sustaining penetrating abdominal wall trauma from a tree branch two years earlier and undergoing multiple subsequent reconstructive surgeries, including both open and minimally invasive approaches. Flank hernia repair is most commonly performed with mesh and can be accomplished using either an open or minimally invasive approach, either at the time of trauma or in a delayed fashion. In selected patients, definitive repair of traumatic abdominal wall defects may be delayed until acute injuries and contamination have resolved. In this patient, intra-abdominal injuries required immediate operative management, whereas definitive reconstruction of the subsequent symptomatic flank hernia was performed in a delayed fashion.

STUDY DESIGN/METHODS:Multicenter retrospective cohort study. PURPOSE/OBJECTIVE:To compare 2-year sagittal alignment outcomes between two-row vertebral body tethering (2RVBT) and posterior spinal fusion (PSF) in adolescent idiopathic scoliosis (AIS). BACKGROUND:PSF remains the gold standard for AIS correction; however, concerns regarding motion loss and adjacent segment disease have encouraged development of fusionless techniques such as vertebral body tethering (VBT). While VBT has demonstrated promising coronal correction, evidence regarding its effects on sagittal alignment is limited. METHODS:Ninety-nine AIS patients (49 2RVBT, 50 PSF) with ≥ 2-year follow-up were analyzed. Radiographic parameters included sagittal vertical axis (SVA), cervical sagittal vertical axis (cSVA), cervical lordosis (CL), pelvic tilt (PT), L4-S1 lordosis, T1 pelvic angle (TPA), and pelvic incidence-lumbar lordosis mismatch (PI-LL). The minimal clinically important difference (MCID) was prespecified as 5 mm for sagittal axis and 10° for lordosis, with pediatric thresholds of 3 mm and 5° based on AIS literature. Institutional Review Board approval was obtained at all participating centers. Inclusion criteria were AIS diagnosis, age ≤ 16 years at surgery, lumbar instrumentation, and ≥ 2-year follow-up. Exclusion criteria included neuromuscular/syndromic scoliosis and prior spinal surgery. RESULTS:2RVBT patients were younger, more skeletally immature (Risser 1.6 ± 0.8 vs. 2.6 ± 1.8, p = 0.001), and more frequently female (97% vs. 84%, p = 0.048). At baseline, sagittal parameters differed between groups, with lower SVA, cervical lordosis, and L4 to S1 lordosis, and higher cSVA in the 2RVBT group. At 2 years, 2RVBT maintained greater L4-S1 lordosis (36.0° vs. 18.3°, p = 0.001) and cSVA (3.4 mm vs. - 3.7 mm, p = 0.001), with lower CL (-4.3° vs. 7.0°, p = 0.001). Between-group changes from baseline to 2 years did not exceed MCID thresholds. Findings were unchanged in a Risser matched sensitivity analysis, with balanced baseline demographics and sagittal parameters and no between group changes exceeding prespecified MCID thresholds. CONCLUSION/CONCLUSIONS:2RVBT and PSF produce comparable sagittal alignment changes at 2 years, with no between-group differences in change from baseline exceeding MCID thresholds. 2RVBT preserves motion without compromising sagittal balance in skeletally immature AIS patients.

OBJECTIVE/UNASSIGNED:To examine the effect of DT56a (Femarelle®), a non-hormonal oral treatment for the management of menopause, on symptoms of vulvovaginal atrophy (VVA)/genitourinary syndrome of menopause (GSM) in postmenopausal women. METHODS/UNASSIGNED: = 12) postmenopausal women with severe VVA (100% parabasal cells on cervical cytology) and at least one severe VVA symptom were recruited for a 12-week open-label pilot study. At baseline and week 12, participants underwent physical examination, Pap smear, vaginal ultrasound, vaginal cultures, vaginal pH assessment, and vaginal maturation index evaluation. Subjects also completed questionnaires assessing atrophy symptoms and quality of life using the Utian Quality of Life (UQoL) scale. Follow-up at 24 months was available for several participants. RESULTS/UNASSIGNED:After 12 weeks of treatment, all patients showed a significant reduction in vaginal pH. In addition, 11 of the 12 women demonstrated significant improvement in the vaginal maturation index and UQoL questionnaire scores. CONCLUSIONS/UNASSIGNED:DT56a significantly improved subjective and objective parameters of VVA/GSM, including vaginal pH, vaginal maturation index, and quality of life. These findings support its potential role as a non-hormonal systemic treatment option for women with VVA/GSM.

BACKGROUND:Posterior circulation large-vessel occlusion strokes have significant morbidity and mortality, but patient selection for acute interventions remains understudied. Multiple computed tomography (CT)-based scores exist, including the CT perfusion-based critical area perfusion score (CAPS), CT angiography-based basilar artery treatment management and posterior circulation CT angiography scores, and CT angiography source image or noncontrast CT-based posterior circulation Alberta Stroke Program Early CT Score, but their predictive values for long-term outcomes after thrombectomy have not been directly compared. METHODS:We conducted a retrospective multicenter cohort study of patients with basilar artery occlusions treated with endovascular thrombectomy. Four CT-based scores were assessed: posterior circulation Alberta Stroke Program Early CT Score, basilar artery treatment management score, posterior circulation CT angiography score, and CAPS. The primary outcome of interest for the study was a favorable functional outcome at 3 months (modified Rankin Scale score, 0-3). We calculated sensitivity, specificity, positive and negative predictive values, and generated receiver operating characteristic curves measuring area under the curve (AUC), which were compared with nonparametric methods. RESULTS:=0.23, respectively). CAPS ≤3 demonstrated 100% sensitivity and negative predictive value (95% CI, 92.6-100.0%; 95% CI, 75.7-100.0%, respectively) for good outcome but had low specificity (24.0% [95% CI, 14.3-37.4]). CONCLUSIONS:The CT perfusion-based CAPS had the best performance for predicting good functional outcome at 3 months and had high sensitivity and negative predictive values though our finding is limited by the small number of patients who had CAPS >3. The CAPS should be validated in prospective studies.

INTRODUCTION/BACKGROUND:We describe bleeding and cramping patterns during the first 90 days after intrauterine device (IUD) placement. METHODS:This was a planned sub-analysis of a prospective cohort study of IUD users in the United States who initiated the copper T380A (Cu-IUD) or the levonorgestrel 52 mg intrauterine device (LNG IUD) at any time in the menstrual cycle. Participants rated bleeding and cramping from 1 (no bleeding or cramping) to 4 (heavy bleeding or severe cramping). We included participants providing ≥ 60 days of continuous responses and described overall bleeding/cramping. RESULTS:Of 230 participants enrolled, 137 (60%) met inclusion criteria (Cu-IUD n = 69, 50% and LNG IUD n = 68, 50%). Cu-IUD users reported fewer days with any bleeding (26 days, IQR 18-31) compared with LNG IUD users (38 days, IQR 27-55, p < 0.001). LNG IUD users reported more spotting days (median 31 [IQR 17-41] vs. 13 [IQR 10-20], p < 0.01). Total bleeding/spotting days were similar for each IUD type regardless of placement timing or prior contraceptive method. Median reported cramping days were similar for both IUDs (Cu-IUD 18, IQR 7-29 and LNG IUD 18, IQR 10-38, p = 0.18). Cramping was most common in the week following placement for both IUD types, decreased over the 90-day period, and did not vary by IUD type. CONCLUSION/CONCLUSIONS:LNG IUD users reported more days with any bleeding in the first 90 days after placement overall compared with Cu-IUD users, largely driven by more than twice the number of spotting days. Cramping was most common in the first week following IUD placement and decreased over time. TRIAL REGISTRATION/BACKGROUND:Clinicaltrials.Gov Identifier: NCT01730911.

Health literacy is a foundational component of providing accessible pediatric care, influencing whether families can understand, access, and use health information. As families increasingly rely on online health resources, health literacy skills applied to digital information, or e-health literacy, has become an evolving dimension of pediatric health literacy. The concept of health literacy extends beyond an individual's abilities, intersecting with the demands placed on individuals by healthcare systems. There is a growing focus on organizational health literacy (OHL), which reflects how effectively systems support equitable communication, but this remains infrequently assessed or implemented. Limited parent, child, and adolescent health literacy is common and disproportionately affects families with lower income, minoritized racial/ethnic backgrounds, lower educational attainment, and who use languages other than English for care. Limited health literacy has been associated with decreased disease-specific knowledge, suboptimal health behaviors, and worse clinical outcomes. Although health literacy-informed strategies can improve comprehension and outcomes, best practices, such as teach-back, remain underutilized across pediatric care settings. The rapid expansion of digital tools offers new opportunities to enhance health literacy-informed communication but also introduces challenges related to equity, accuracy, and safety. Advancing pediatric health literacy requires coordinated efforts: embedding health literacy principles into institutional and national policies, integrating universal health literacy precautions into clinical workflows, expanding clinician and patient health literacy education, and advancing health literacy-focused research, including on digital interventions and artificial intelligence (AI)-supported communication. Prioritizing these efforts is essential to creating health literate-systems that enable all families to access, understand and use health information.

BACKGROUND:Idiopathic clubfoot is a complex congenital foot and ankle anomaly commonly treated with the Ponseti method. While gross motor function and activity level are similar in children with clubfoot treated with this method compared with children without clubfoot, data are lacking on sports participation following this treatment. This study aimed to describe the prevalence of sports participation among children with idiopathic clubfoot treated with the Ponseti method. METHODS:This was a multicenter retrospective cross-sectional study. Patients aged 5 to 17 years were included if they had been diagnosed with idiopathic clubfoot and treated with the Ponseti method during infancy. Parents of subjects were asked to complete a 1-time REDCap survey that included basic demographic questions, 2 validated activity scores (PROMIS Physical Activity Short Form and PACE+), and questions relating to sports participation. The comparison group consisted of the siblings of patients with clubfoot. RESULTS:One hundred fifty-one patients with clubfoot and 45 siblings without clubfoot were included from 4 institutions. In the clubfoot group, 72.2% of participants were male compared with 60% in the sibling group ( P =0.12). Median PROMIS-PA t-scores were 53.3 [interquartile range (IQR) 8.6] and 56.3 (IQR 13.2) in the clubfoot and sibling groups, respectively ( P =0.016). The median PACE+ scores were 4 (IQR 3.5) in the clubfoot group and 4.75 (IQR 2.75) ( P =0.261) in the sibling group. Sports participation was reported in 120 (79.5%) patients with clubfoot and 43 siblings (95.6%) ( P =0.006). Soccer, baseball, basketball, football, and swimming were the most commonly played sports in both groups. CONCLUSIONS:Children treated for idiopathic clubfoot with the Ponseti method remain active and participate in sports similar to their siblings. Further prospective studies examining sports participation and injury prevalence are needed to better understand long-term clinical and functional outcomes in patients treated with the Ponseti method for idiopathic clubfoot. STUDY DESIGN/METHODS:Retrospective. LEVEL OF EVIDENCE/METHODS:Level IV.

BACKGROUND/UNASSIGNED:Early-onset colorectal cancer (EOCRC), diagnosed in adults under the age of 50 years, is a significant public health challenge in the United States (US). While traditional colorectal cancer (CRC) incidence in older populations has declined due to screening, rates among younger adults are rising, likely driven by shifting birth cohort exposures to modifiable risk factors. This study aims to quantify the longitudinal burden of EOCRC and evaluates the contribution of dietary and metabolic risks from 1990 to 2023. METHODS/UNASSIGNED:Using data from the Global Burden of Disease (GBD) 2023 study, we analyzed age-specific incidence, mortality, prevalence, and disability-adjusted life years (DALYs) for EOCRC. Trends were evaluated using joinpoint regression to calculate annual percent changes (APCs). Risk factor attribution was performed for dietary, metabolic, and behavioral exposures. Future burdens were projected to 2050 using mixed-effects and autoregressive integrated moving average (ARIMA) models. RESULTS/UNASSIGNED:Between 1990 and 2023, the age-specific incidence rate (ASIR) of EOCRC increased by 47.1%, rising from 8.01 to 11.79 per 100,000. Age-specific mortality rose from 2.48 to 3.00, and DALYs increased from 125.41 to 150.82. Males consistently carried a higher burden, with widening sex disparities in incidence by 2023 (13.10 in males versus 10.44 in females). By 2023, diet high in processed meat (18.4%) surpassed diet low in whole grains (17.6%) as the leading modifiable contributor to EOCRC mortality, followed by high body-mass index and smoking. Under a risk-reduction scenario, projected mortality could decline by more than 50% by 2050 (1.14 per 100,000) compared to the reference trend (2.42 per 100,000). CONCLUSIONS/UNASSIGNED:The EOCRC burden in the US has intensified over three decades. The shifting dominance toward processed meat and metabolic dysfunction highlights a critical need for targeted primary prevention. Achieving significant mortality reductions by 2050 will require population-level interventions addressing dietary quality and metabolic health early in life.

BACKGROUND:Accurate measurement of pharmacy access is central to understanding spatial inequities in healthcare availability. The two-step floating catchment area (2SFCA) method is widely used to integrate proximity and availability, yet key challenges remain unresolved in dense urban settings, including catchment sensitivity, and the lack of uncertainty quantification despite reliance on survey-based population estimates. OBJECTIVE:To assess catchment sensitivity to specification using a mode-adjusted 2SFCA approach while propagating uncertainty from the American Community Survey (ACS). METHODS:We conducted a cross-sectional analysis of pharmacy access across 2222 census tracts in New York City using multiple distance- and time-based catchments. We applied a mode-adjusted 2SFCA method that incorporates walking and driving accessibility by decomposing populations demand using tract-level transportation proportions from the ACS. Uncertainty in access estimates was quantified via hierarchical Monte Carlo simulation propagating the margins of errors from the ACS. We used cross-tabulation to quantify agreement in classifying tracts as having fewer than one pharmacy per 10,000 residents across transportation modes. RESULTS:Relative pharmacy access patterns were stable across a wide range of catchment specifications, indicating limited sensitivity to reasonable changes in distance or travel-time thresholds in this dense urban setting. The mode-adjusted approach increased median access and introduced additional variability by accounting for transportation differences. Uncertainty in access estimates was generally negligible but may matter where driving and walking catchments do not overlap. CONCLUSIONS:These findings suggest that, in New York City, catchment size and ACS uncertainty have limited impact on access estimates, while transportation differences and border effects play a larger role.