Faculty Bibliography

OBJECTIVE:To compare characteristics between men and women as they seek medical care for their urinary incontinence (UI), examining patients' experience both with primary care (PCP) and UI specialists. METHODS:This is a cross-sectional study utilizing the National Association for Continence (NAFC)-sponsored adult patient-reported survey data from March 2020 to April 2020. Descriptive statistics were calculated as percentages, and comparisons were performed using a chi-squared test for categorical variables. The statistical significance level was set at p < 0.05. RESULTS:Two hundred sixty-six individuals with UI who had sought medical care completed the survey during the study period. One hundred twenty-four (47%) were women (W) and 142 (53%) were men (M). The study population was older, with the majority of respondents either 45-64 (35%) or 65+ (48%). Most participants sought care for their UI within 2 years of UI onset (59%) and first spoke to their PCP about their UI (64.7%). Women were more likely to endorse a severe emotional impact (OR 1.63, CI 1.04-2.56, p = 0.04) and physical impact (OR 1.90, CI 1.19-3.04, p = 0.01) of their UI on their life. In patients who spoke to their PCP about their UI, women were more likely to bring it up at a routine checkup, while men were more likely to make an appointment to discuss their UI. Men were more likely to endorse that their PCP had spoken to them about a wide range of treatment options and were more likely to have been started on a treatment plan. Men were also more likely to be started on a medication for their UI by their PCP compared to women. PCP referral rates to specialty care were higher amongst men. For those who received a referral, there was a high rate of specialist follow-up (94.0% vs. 98.5% p = 0.19). Men were mostly referred to urology (W 47% vs. 94% M, p < 0.01), with women more frequently referred to gynecology (W 15.9% vs. 0% M, p < 0.01) and urogynecology (W 25.0% vs. 0.9% M, p < 0.01). Specialists were more likely to speak about absorbent products with men compared to women (M 52.5% vs. W 30.7%, p = 0.002). CONCLUSIONS:Though women endorsed more severe impact of UI on their life, men were more likely to be counseled on a wide range of treatment options, started on a treatment plan, prescribed medication for their UI, and be referred to specialty care for treatment of their UI. TRIAL REGISTRATION/BACKGROUND:This study was not registered with clinicaltrials.gov because it used previously collected, deidentified data. CLINICALTRIALS/RESULTS:gov indicates that observational studies should be registered as a Patient Registry for prospective data collection, which does not apply to this study as the patients included in this survey are not followed.

INTRODUCTION/UNASSIGNED:Older adults with chronic kidney disease (CKD) likely face higher dementia risk because of vascular injury and chronic inflammation, potentially intensified among racially minoritized groups and those in rural or deprived neighborhoods. We quantified this association and examined variation by race and ethnicity, urbanicity, and neighborhood deprivation. METHODS/UNASSIGNED:We identified 211,321 older adults with CKD stages 3 to 5 from the Medicare 5% sample (2010-2022) using International Classification of Diseases (ICD)-9 and/or ICD-10 codes. Zone Improvement Plan (ZIP)-code level urbanicity was defined using Rural-Urban Commuting Area Codes, and neighborhood deprivation was derived from the American Community Survey. We used cause-specific hazard models with time-varying CKD stage (reference = stage 3) to quantify the adjusted hazard ratio (aHR) of dementia and included interaction terms to test the differential effect of these associations by race and/or ethnicity, urbanicity, and neighborhood deprivation. RESULTS/UNASSIGNED:= 0.04). Among older Black (stage 4 aHR: 1.38, 95% CI: 1.28-1.48; stage 5 aHR: 2.01, 95% CI: 1.88-2.15) and Hispanic adults (stage 4 aHR: 1.33, 95% CI: 1.10-1.62; stage 5 aHR: 1.98, 95% CI: 1.67-2.34), stages 4 and 5 were associated with a higher risk of dementia. Among older adults in high-deprivation neighborhoods, stage 5 was associated with a higher risk of dementia (aHR: 1.89, 95% CI: 1.80-1.99). CONCLUSION/UNASSIGNED:CKD stages 4 and 5 were associated with a higher dementia risk, particularly among older Black adults and those in high-deprivation neighborhoods. These findings may inform targeted interventions for early detection and management of cognitive decline in advanced CKD.

BACKGROUND:The aim of this study is to present early outcomes following revision of failed TAA using a low-profile, transfibular TAA prosthesis. METHODS:This was a retrospective review of 11 ankles (11 patients; average 72.1 years-old) who underwent revision TAA using the transfibular trabecular metal (TM) prosthesis. Modes of failure included aseptic loosening/subsidence (n = 7) and periprosthetic joint infection (PJI, n = 4). Demographic, radiographic, and patient-reported outcomes were analyzed at minimum 2-years. RESULTS:Average time to revision TM TAA was 9 years (range, 2-22), All 4 cases with PJI were successfully treated with two-stage revision. There was significant improvement in VAS and AOS Pain (both p < 0.05). Mean coronal (90.7°) and sagittal (86.1°) alignment were within normal limits. There was 1 (9%) revision, 4 (36%) reoperations. CONCLUSION/CONCLUSIONS:In select patients with failed TAA who wish to avoid fusion or amputation, revision arthroplasty using a transfibular approach may be a possible alternative. LEVEL OF EVIDENCE/METHODS:IV, Case-Series.

BACKGROUND:A prominent premaxilla in bilateral cleft lip presents significant orthopedic and surgical challenges. Although presurgical infant orthopedics (PSIO) is widely used, evidence linking orthopedic response to clinically meaningful outcomes remains limited. This study evaluated orthopedic response, need for lip adhesion, and final aesthetic outcomes using blinded expert-panel assessments. METHODS:Fifty consecutive bilateral cleft patients treated with PSIO were reviewed, including 25 treated with nasal elevator and lip taping (NE) and 25 treated with Presurgical Lip-Alveolus-Nose Approximation (PLANA). Twenty-seven patients with prominent premaxilla underwent blinded assessment of orthopedic response by 3 cleft surgeons and 3 orthodontists. Final aesthetic outcomes were evaluated in a separate blinded assessment of 50 postoperative cases, mixing patients with and without prominent premaxilla to minimize recognition bias. RESULTS:The prevalence of prominent premaxilla was similar between groups (60.0% versus 48.0%; P=0.571). Lip adhesion was required more frequently in NE-treated than PLANA-treated patients (46.7% versus 8.3%; P=0.043). Patients treated with PLANA demonstrated superior orthopedic outcomes for premaxillary position, columellar length, and overall PSIO response (all P<0.001). Patients with prominent premaxilla achieved final nasal, lip, and overall nasolabial appearance ratings comparable to those without prominent premaxilla (all P>0.05). Evaluators showed poor ability to identify initially prominent premaxilla based on final appearance alone. Overall PSIO response correlated with final nasolabial appearance (ρ=0.48, P=0.024). CONCLUSIONS:Although a prominent premaxilla represents a more challenging initial deformity, it did not predict inferior final appearance. Better orthopedic response was associated with more favorable final aesthetic outcomes, supporting the clinical relevance of effective presurgical orthopedic correction.

BACKGROUND:Patient dual eligibility status for Medicare and Medicaid is known to be a well-established proxy for socioeconomic vulnerability. Many studies have examined the impact that dual eligibility status has on patient outcomes after total joint arthroplasty (TJA), but its association with surgeon-level reimbursement after TJA remains insufficiently characterized. This study evaluated whether surgeon dual eligibility proportion was independently associated with standardized Medicare reimbursement per procedure for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) in 2023. METHODS:A cross-sectional retrospective analysis of a Medicare database was performed for 2023. A total of 4,506 THA surgeons performing 161,221 procedures and 6,618 TKA surgeons performing 297,919 procedures were identified. Surgeons performing primary THA and primary TKA in 2023 were identified and stratified into quartiles based on the proportion of their patient panel that was dual-eligible. The primary outcome was mean standardized Medicare reimbursement per procedure. Multivariable linear regressions were used to evaluate independent associations. Surgeon panel covariates included Hierarchical Condition Category (HCC) risk score, minority beneficiary proportion, and practice rurality. RESULTS:For THA, mean standardized reimbursement declined from $1,002 in Q1 to $971 in Q4 (P < 0.001). For TKA, mean reimbursement declined from $1,005 in Q1 to $981 in Q4 (P < 0.001). A higher dual eligibility proportion was independently associated with lower reimbursement for both THA (β = -1.58, P < 0.001) and TKA (β = -1.04, P < 0.001) after adjustment for rurality, HCC risk score, and minority beneficiary proportion per surgeon. CONCLUSIONS:Among surgeons performing primary TJA, a higher dual-eligible patient proportion was associated with reduced standardized reimbursement, despite the greater medical comorbidity and psychosocial complexity characterizing this population. These findings suggest that existing reimbursement frameworks may be associated with lower reimbursement for surgeons who disproportionately serve socioeconomically disadvantaged patients, with potential implications for equitable access to total joint arthroplasty. LEVEL OF EVIDENCE/METHODS:Level III, retrospective cross-sectional study.

BACKGROUND:Palliative care skills are essential in surgical practice, but time constraints and lack of faculty expertise are barriers to implementing palliative care education in surgical training. This study describes and assesses a 5-hour palliative care curriculum designed to fit within demanding residency programs. METHODS:The palliative care curriculum was delivered to general surgery residents at a single institution by faculty surgeons over the course of five 1-hour sessions. Palliative care competence was assessed by a palliative care competence survey completed by residents at baseline and after completion of the palliative care curriculum. The palliative care curriculum survey assessed 3 domains (attitudes, knowledge, and behavior) on a 5-point Likert scale to create a composite score and domain subscores reported as mean (standard deviation). RESULTS:The study included 62 survey respondents, most of whom were in their first year of training (n = 32, 59.7%). Overall survey scores were significantly higher after palliative care curriculum participation (3.92 [0.43]) when compared with baseline (3.56 [0.61]), P = .008; this was also demonstrated in the knowledge domain (3.73 [0.55] vs 3.32 [0.69], P = .011) and the behavior domain (3.44 [0.7] vs 3.28 [0.78], P = .023). The improvement in scores was demonstrated in both univariate and multivariate analyses (P < .05). CONCLUSION/CONCLUSIONS:Participation in this 5-hour palliative care curriculum for surgical residents is associated with improved attitudes, knowledge, and behaviors in palliative care. This palliative care curriculum provides a framework for palliative care education across a variety of residency programs based on available time and faculty resources.

INTRODUCTION/BACKGROUND:Repetitive head impacts (RHIs) have been linked to later life neurodegeneration, yet the in vivo structural correlates of cumulative biomechanical loading remain unclear. We examined whether regional ventricular morphology in former American football players reflects exposure burden and traumatic encephalopathy syndrome (TES) classification. METHODS:Participants included 170 male former football players and 54 age-matched asymptomatic male controls from the Diagnostics, Imaging, and Genetics Network for the Objective Study and Evaluation of Chronic Traumatic Encephalopathy Research Project. Subject-specific manual segmentation quantified lateral ventricle, inferior horn, third ventricle, and fourth ventricle volumes. Group and exposure associations were tested using generalized least squares models. RESULTS:Former players showed larger left inferior lateral ventricle volume than controls, with the largest effects among professional players. Greater cumulative linear and rotational acceleration exposure was associated with enlargement across lateral ventricular and inferior horn regions. DISCUSSION/CONCLUSIONS:Regional ventricular enlargement may represent an in vivo marker of cumulative biomechanical loading after RHI exposure.

IMPORTANCE:There are 3.5 million prostate cancer survivors in the US, with a need for evidence-based lifestyle recommendations that improve survivorship. OBJECTIVE:To assess whether consumption of specific dietary fats after diagnosis is associated with long-term survival among patients with nonmetastatic prostate cancer. DESIGN, SETTING, AND PARTICIPANTS:This study, nested in the Health Professionals Follow-Up Study, a cohort of male health professionals from across 50 US states ongoing since 1986, included participants with confirmed nonmetastatic prostate cancer between 1986 and January 2019, followed up through December 2022. Statistical analysis was conducted from July 2024 to May 2026. EXPOSURES:Dietary data were collected every 4 years from validated food frequency questionnaires and used to estimate intake of saturated, polyunsaturated, monounsaturated, trans, plant, and animal fat after cancer diagnosis. MAIN OUTCOMES AND MEASURES:Main outcomes were all-cause mortality and death from prostate cancer, other cancers, cardiovascular disease, and other causes during a median 12.8 years (IQR, 8.1-16.8 years) of follow-up through 2022. Hazard ratios (HRs) and 95% CIs from multivariable Cox proportional hazards regression and multivariate nutrient-density models examined associations with mortality, adjusting for demographic, epidemiologic, and clinical factors. RESULTS:Among 4884 patients with nonmetastatic prostate cancer, the mean (SD) age at diagnosis was 69.5 (6.9) years. During follow-up, 3040 deaths from any cause were confirmed. When comparing patients in the highest quintile of saturated fat consumption with those in the lowest quintile, higher postdiagnostic saturated fat intake was associated with greater all-cause (HR, 1.24 [95% CI, 1.05-1.47), cardiovascular (HR, 1.42 [95% CI, 1.02-1.98]), and other cancer mortality (HR, 1.42 [95% CI, 0.93-2.17]). Animal fat, a major source of saturated fats, was also positively associated with all-cause mortality (HR, 1.14 [95% CI, 0.97-1.33]), as well as deaths from other cancers (HR, 1.49 [95% CI, 1.00-2.21]). Replacing 10% of calories from animal fats with plant-based fats (HR, 0.84 [95% CI, 0.76-0.93]) and replacing 5% of calories from saturated fats with monounsaturated fats (HR, 0.80 [95% CI, 0.70-0.91]) was associated with a decrease in all-cause mortality. There were no associations between dietary fats and prostate cancer mortality. CONCLUSIONS AND RELEVANCE:In this cohort study of patients with nonmetastatic prostate cancer, saturated fats, including animal fats, were associated with greater all-cause mortality owing to deaths from cardiovascular disease and other cancers. Diets rich in monounsaturated and polyunsaturated fats and plant-based fats after prostate cancer diagnosis were associated with improved survival outcomes for patients. These findings support evidence-based recommendations for patients and clinicians around dietary fat consumption to improve survivorship outcomes in the clinical setting of nonmetastatic prostate cancer.

BACKGROUND/UNASSIGNED:Clinical genetic evaluation for patients with dilated cardiomyopathy (DCM) is minimally implemented, and models of care are not well defined. To understand current genetic care for DCM, a systematic needs assessment was conducted. METHODS/UNASSIGNED:Principal investigators of the DCM Consortium convened at the Summer Scientific Symposium in July 2025. An electronic needs assessment was conducted among the 24 principal investigators in advance to define current care models by evaluating which genetic evaluation components recommended by the Heart Failure Society of America were conducted, by whom, and the time required for each component. Descriptive statistics were generated to characterize model features. Focus group discussions explored barriers and facilitators to implementing genetic services. RESULTS/UNASSIGNED:=0.023). Notably, 88% of principal investigators used genetic information for treatment decisions, including implantable cardioverter defibrillator placement (83%; n=20) and cardiac transplantation (63%; n=15). Major facilitator themes from focus group discussions included having a genetic counselor as part of the heart failure team and developing authoritative standards directing provision of DCM genetic services. Barrier themes included operational challenges, limited personnel, clinician under-recognition, need for new service delivery models, and billing/reimbursement. CONCLUSIONS/UNASSIGNED:DCM genetic care models and components were highly variable across the 24 sites of the DCM Consortium, although all sites discussed similar factors that enable or hinder the implementation of genetic services for DCM. Understanding the basis of practice model variability may provide insight to yield more scalable care approaches.

Age is the greatest risk factor for mortality and morbidity. We previously reported premature ageing in PKP2 arrhythmogenic cardiomyopathy (PKP2-ACM). However, depiction of cardiomyocyte molecular anatomy in premature ageing remains incomplete. Furthermore, the relationship between myocyte premature ageing and the molecular components of electrical homeostasis in PKP2-deficient hearts remains understudied. Therefore, we aimed to identify molecular anatomical changes of premature ageing in PKP2-deficient adult cardiomyocytes, the corresponding gene cohort and its imprint in the human electrocardiogram (ECG). We used a murine model of cardiomyocyte-specific PKP2 knockout. Molecular anatomy was resolved by expansion and structured illumination microscopy, allowing 3D-nanometric visualization, and by serial block-face scanning electron microscopy. We used omics databases to distill a subset of genes related to ageing and PKP2 deficiency containing single nucleotide polymorphisms (SNPs) with an ECG-relevant genomic signature. We found increased DNA damage and reduced abundance of transcriptionally repressed heterochromatin at the lamin-associated domain (LAD), and disrupted mitochondria ultrastructure at the intercalated disc. Genes dysregulated in ageing hearts and PKP2-deficient cells were distilled to identify those in the PKP2 human left ventricular gene network (by GTEx) that contain SNPs with an imprint in the human ECG (based on ECG GWAS). These findings indicate that in PKP2 deficiency, transcriptionally repressed heterochromatin in the LAD is vulnerable to damage, and erasing of otherwise transcriptionally inaccessible genomic regions, consistent with premature cellular ageing and transcriptional reprogramming. Multi-omics analysis indicates that reduced PKP2 expression accelerates cardiomyocyte ageing, and the age-related gene network contributes to dysfunction of cell metabolism and arrhythmia risk in PKP2-ACM. KEY POINTS: We used advanced imaging technology to unveil DNA damage and loss of heterochromatin architecture in the lamin-associated domain (LAD), and mitochondrial remodelling at the intercalated disc, as features of premature myocyte ageing in adult PKP2-deficient murine cardiomyocytes. Multi-omics analysis identified a network of genes dysregulated by ageing and by PKP2 deficiency. Cross-correlation with the ECG GWAS database found a subset of single nucleotide polymorphisms with an imprint in the human electrocardiogram. These results provide novel insight into the mechanisms of transcriptional remodelling and take an initial step toward a better understanding of the oligogenic bases of arrhythmia risk in PKP2-deficient hearts.