Faculty Bibliography

BACKGROUND:The Veterans Affairs New York Harbor Healthcare System is 1 of 50 Veterans Affairs sites participating in the Veterans Affairs Lipid Optimization Reimagined Quality Improvement Project. Veterans Affairs sites worked with an American Heart Association quality improvement consultant to develop and deploy a plan to achieve low-density lipoprotein cholesterol (LDL-C) <70 mg/dL in >30% of veterans with atherosclerotic cardiovascular disease and uncontrolled LDL-C (LDL-C ≥70 mg/dL), and meaningful LDL-C lowering. METHODS:In this pre-post designed project, health coaches applied a root-cause analysis framework, used medication possession ratio to assess adherence, and used motivational interviewing principles to improve medication adherence and lifestyle habits. Health coaches tailored interventions to address adherence barriers (if medication possession ratio <0.8) or facilitated medication intensification (if medication possession ratio ≥0.8). To evaluate the impact of health coaches on outcomes, we compared baseline and follow-up data pre-post to evaluate LDL-C lowering and assess LDL-C control. RESULTS:=0.091). CONCLUSIONS:Health coach-delivered interventions to improve medication adherence and encourage lifestyle modifications led to significant LDL-C reduction, with 42.6% achieving control, surpassing the 30% program benchmark, and lowered LDL-C level.

PURPOSE/OBJECTIVE:To evaluate the effectiveness of Smart Crutch Tips™ in promoting adherence to prescribed early partial weight-bearing (PWB) protocols and to assess patient experience with real-time weight-bearing feedback during home rehabilitation. METHODS:Twenty patients with lower extremity fractures prescribed partial weight-bearing (PWB) were randomized into two groups utilizing real-time feedback crutch tips (RFC). The Intervention group (n = 10) used Smart Crutch Tips™ (ComeBack Mobility Inc., Kiev, Ukraine), which provided real-time feedback on weight-bearing compliance. The Control group (n = 10) also used crutches equipped with Smart Crutch Tips™, but notifications were disabled, allowing passive data collection without patient feedback. Weight-bearing compliance was defined as the percentage of steps within ± 10% of the prescribed target. Secondary outcomes included patient satisfaction and device usability assessed using the System Usability Scale (SUS) throughout the home rehabilitation period. RESULTS:The Intervention group demonstrated significantly greater PWB compliance compared with the Control group (73.6% vs. 21.1%, p < 0.01). The Intervention group reported a mean SUS score of 84.25, indicating excellent usability. No device-related complications or adverse events were observed. Patient satisfaction, assessed through video interviews, was high, with participants in the Intervention group expressing a strong willingness to recommend the device to others with similar injuries and rating it 10 out of 10. CONCLUSION/CONCLUSIONS:Smart Crutch Tips™ significantly improved adherence to prescribed partial weight-bearing protocols following lower extremity fracture surgery. The RFC device demonstrated high usability, excellent patient satisfaction, and no device-related complications during home rehabilitation throughout the study period.

Classic models of the French flag problem depict sharp cell type boundaries emerging from threshold responses to morphogen gradients. How discrete cell type boundaries arise from morphogen signals that vary continuously across developing tissues remains incompletely understood. We use hair follicle dermal condensate (DC) formation to study a sharp developmental transition in which proliferative progenitors undergo cell cycle exit concurrent with molecular differentiation. Using genetic and genomic approaches, we show that Wnt and Hedgehog signaling coordinate separable cellular events during DC commitment. Elevated Wnt signaling promotes cell cycle exit through reduced chromatin binding of the Hedgehog mediator GLI3, while Hedgehog signaling induces differentiation genes in a Wnt-dependent manner and simultaneously elevates Wnt activity. When these responses coincide, differentiation and cell cycle exit occur together, limiting the duration and abundance of intermediate states and producing a sharp boundary. When they do not, intermediate states persist and expand, producing a graded boundary. Thus, a sharp boundary can emerge from a continuous transition that is compressed in time and space.

Stress testing is among the most frequently performed cardiac diagnostic procedures and is widely utilized in both outpatient and inpatient settings performed with and without myocardial perfusion imaging (MPI). Since the 2016 American Society of Nuclear Cardiology (ASNC) guideline, clinical experience with cardiac stress testing has continued to expand and evolve necessitating updates to the previous guidelines. This guideline presents updated practice standards for cardiac stress testing intended to support safe and effective testing across a range of clinical environments, while allowing for individualized risk assessment and protocol adaptation based on patient characteristics, special populations, and site-specific logistics. The current guideline offers practical beginning-to-end guidance on the performance of cardiac stress testing, encompassing patient selection and preparation, stress modalities and protocols, safety considerations, and result interpretation and reporting. The utilization of single photon emission computed tomography (SPECT) and positron emission tomography (PET) in conjunction with stress testing are addressed for stress protocols for each available stressor. This revised guideline is intended for a broad, multidisciplinary audience involved in the performance, interpretation, and oversight of cardiac stress testing. ASNC has developed this updated guideline to recognize the evolution of diagnostic imaging that has taken place since the last iteration of the guideline. These updates are intended to support optimal test selection, standardized patient preparation, and individualized, patient-centric practice of nuclear stress testing in diverse clinical scenarios. Utilizing this guideline, clinicians will optimize diagnostic accuracy, maintain patient safety, and at the same time maximize clinical impact.

BACKGROUND:International travel for organ transplantation (ITOT) reportedly affects ≥2% of global solid organ transplant activity, yet detailed information about ITOT participants, organ types, travel configurations, and clinical settings remains scarce. Previous research has focused on living donor (LD) kidney transplantation for adults, often in the context of organ trafficking, leaving significant gaps in understanding of contemporary ITOT activities. METHODS:A cross-sectional, international online survey was conducted between September 16 and December 15, 2024. Health professionals with experience caring for organ donors or transplant recipients were recruited via professional societies, social media, and personal networks. Participants reported on their most recent experiences of caring for incoming or outgoing transplant recipients and LDs involved in ITOT between January 1, 2023, and August 31, 2024. Data were analyzed using descriptive statistics. RESULTS:Three hundred fifty-three respondents from 64 countries completed the survey; 166 (54%) of the 309 clinically active respondents had cared for ≥1 ITOT patient during the study period. Among 164 recipient cases, most involved adults (74%), kidney transplants (57%), and LD transplants (59%), with 40% occurring in private healthcare settings. Children comprised 23% of recipient cases. At least 164 unique travel routes were identified spanning 45 destination countries, with recipients originating from ≥69 countries and LDs from ≥54 countries. CONCLUSIONS:ITOT is a geographically diverse, global phenomenon. The substantive proportion of pediatric cases, deceased donor transplants, and private-sector procedures underscores the need for strengthened national and international data collection, governance frameworks, and equitable access policies to address the ethical and clinical challenges of ITOT.

OBJECTIVE:Mitotane is e first-line medical treatment for adrenocortical carcinoma (ACC). Mitotane has substantial dr awbacks, including severe toxicity and contralateral gland destruction, whilst effective in only 25-30% of ACCs. To improve patient selection for mitotane therapy, this study aimed to identify tissue biomarkers associated with in vitro mitotane response. DESIGN/METHODS:Retrospective cohort study. METHODS:We performed transcriptomic and proteomic analyses on fresh-frozen human ACC tissues classified as responders (n=13), partial responders (n=10), or non-responders (n=7) based on in vitro mitotane-induced inhibition of cell proliferation. RESULTS:Responders showed distinct transcriptomic and proteomic signatures compared with partial and non-responders, whereas fewer differences were found between the latter groups. Integrating transcriptomic and clinicopathological data indicated that responders frequently had cortisol-producing ACC with metastases or nodal involvement. Furthermore, their transcriptomes aligned with aggressive, proliferative ACC subtypes described previously. Differential expression analysis identified 718 genes and 60 proteins that distinguished responders from non-responders. Pathway and network analyses revealed upregulation of cell cycle and collagen related genes and downregulation of mitochondria related genes and proteins in responders. CONCLUSIONS:In summary, transcriptomic and proteomic profiling offers promise to predict mitotane response in ACC. Our findings suggest that responders exhibit features of aggressive ACC, with distinct molecular characteristics that could serve as biomarkers for treatment selection.

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.

OBJECTIVE:To identify modifiable hospital-level determinants of mortality after pancreas surgery and assess their cumulative protective effects through the development of a Hospital Resource Index (HRI) on a global scale. BACKGROUND:Ninety-day mortality rates after pancreas surgery vary globally (2%-10%); however, institutional factors affecting mortality remain poorly understood. Although caseload volume has driven centralization policies in many health care systems, it is not fully explanatory, and the impact of specific modifiable structural and process-related hospital factors remains unclear. METHODS:We linked patient outcome data from the 2021 PancreasGroup.org global prospective cohort to hospital infrastructure data from the PancreasGroup.org global survey. Binary availability of 20 hospital-level factors was assessed. Factors significantly associated with mortality on univariable multilevel regression were combined into an additive HRI. Multivariable logistic regression evaluated associations between HRI and 90-day mortality. RESULTS:Analyses included 2928 patients from 214 centers across 60 countries. Six hospital factors were significantly associated with lower mortality, including interventional radiology/endoscopy availability, structured nutrition support, evidence-based practice adoption, staff training, equipment maintenance, and favorable nurse-patient ratios. Each additional HRI point was associated with 12% lower mortality odds (OR: 0.88, 95% CI: 0.81-0.95, P=0.001), independent of caseload volume (OR: 0.73, P=0.014, optimal cutoff 55 cases per year), country's development index, and patient and procedural characteristics. Patients at hospitals with all 6 HRI resources had a 54% lower mortality rate compared with those at hospitals with none. CONCLUSIONS:The developed HRI showed cumulative protective effects on mortality after pancreas surgery, with volume remaining independently protective in the adjusted model, providing actionable targets for resource allocation to enhance pancreas surgery outcomes beyond centralization globally.

INTRODUCTION/BACKGROUND:Obtaining adequate informed consent is a fundamental component of surgical care, often conducted by trainees at academic medical centers. However, the quality of trainees' informed consent remains unclear. To guide future instruction, this study assessed trainees' confidence and performance with the informed consent process, stratified by postgraduate year and previous consent education. METHODS:An objective structured clinical examination (OSCE) was developed to assess informed consent discussions between housestaff trainees and standardized patients undergoing primary total knee arthroplasty. A total of 18 orthopaedic residents (six each in postgraduate years [PGYs] 1, 3, and 5) and five clinical fellows in adult reconstruction (PGY-6) participated. Quality of informed consent was assessed with an objective rubric, scored 0 to 2 ("not addressed," "attempted," and "completed"). Trainees completed a post-OSCE survey assessing their confidence and previous training in obtaining informed consent. RESULTS:All 23 trainees considered informed consent "extremely important," and 96% thought that formal training would be "very" or "extremely beneficial." Yet, only 30% recalled receiving consent education, and 39% had never received clinical feedback on their consent process. Average OSCE performance was 16.2/20 (range: 11-19). Common deficiencies were assessing patient comprehension (13% completed) and facilitating shared decision making (39% completed). Only 35% of trainees identified assessing patient comprehension as critical. Performance did not differ significantly by training level. Previous consent education significantly improved trainees' ability to explain procedures (1.7/2.0 vs. 1.2/2.0; P = 0.013) and was associated with better shared decision-making facilitation (1.4/2.0 vs. 1.0/2.0; P = 0.255), although not statistically significant. CONCLUSION/CONCLUSIONS:Orthopaedic trainees value formal informed consent training but lack structured education and informal feedback. While overall performance was strong, consistent deficiencies in assessing comprehension and shared decision making were noted. Seniority alone did not improve performance, while previous formal education improved procedure explanations. These findings support the implementation of structured informed consent curricula across all levels of orthopaedic training.