Faculty Bibliography

Platelet-rich plasma (PRP) has emerged as a regenerative treatment option for various foot and ankle pathologies, containing growth factors and anti-inflammatory proteins to promote tissue healing. The most consistent clinical evidence supports PRP use for plantar fasciitis and osteochondral lesions of the talus, with significant improvements in pain and function observed. In contrast, outcomes for Achilles tendon pathologies and ankle osteoarthritis are mixed, demonstrating heterogeneity in PRP preparation and implementation. Future high-quality, standardized studies are necessary to determine the efficacy, optimal protocols, and long-term outcomes of PRP in foot and ankle pathologies.

BACKGROUND/UNASSIGNED:Vascularized composite allotransplantation (VCA) restores form and function in patients with severe disfigurement, yet acute rejection remains common within the first year. In solid organ transplantation, rituximab, a B cell-depleting agent, has been shown to reduce rejection in highly sensitized recipients, and donor-specific antibodies (DSAs) are established biomarkers of rejection. The impact of rituximab and DSAs in VCA remains unclear. This study examined rejection-free survival following rituximab induction and the relationship between positive DSA levels and rejection in VCA recipients. METHODS/UNASSIGNED:This retrospective review analyzed 4 patients who underwent facial transplantation between 2015 and 2023 at our institution. All patients received rituximab and antithymocyte globulin as part of their induction immunosuppression. Rejection-free survival was the primary outcome, with DSA levels assessed at baseline and throughout follow-up. A generalized linear mixed-effects model was used to evaluate the relationship between DSA positivity and rejection. RESULTS/UNASSIGNED:= 0.693). Some patients were DSA-negative during clinical rejection, and some were DSA-positive without signs of rejection. CONCLUSIONS/UNASSIGNED:This is the first study to evaluate rituximab-based induction in a cohort of VCA recipients, demonstrating median rejection-free survival exceeding one and a half years. Although some patients were DSA-positive during rejection episodes, no significant correlation was observed, challenging the predictive value of DSAs as seen in solid organ transplantation and highlighting the need to explore alternative biomarkers for rejection in VCA.

BACKGROUND:Cannabis use among adolescents with depression is prevalent. Dysfunction of the reward system has been implicated in each condition separately, yet rarely examined together. Here, we investigated resting-state properties of reward networks in an adolescent sample with diverse internalizing psychopathology and cannabis use patterns. METHODS: < 0.05). RESULTS:of the postcentral somatosensory area within the Reward Expectancy network. Exploratory analyses further suggested cannabis-related dorsolateral prefrontal and cerebellar dysconnectivity across the whole brain, as well as sex- and age-moderated effects. CONCLUSION/CONCLUSIONS:Our findings provide preliminary evidence for adolescent cannabis use and depression being differentially associated with resting-state reward network properties. Additional research with larger cohort sizes is needed to corroborate findings.

INTRODUCTION/BACKGROUND:Serotonin (5-hydroxytryptamine [5-HT]) plays an important role in early development, and fetal 5-HT has been reported to arise from placental and maternal sources. Previous human studies have established an association between maternal 5-HT levels and neurodevelopmental outcomes in populations with autism. In this study, we analyze umbilical cord blood and placental 5-HT levels at birth to further investigate the relationship of gestational 5-HT levels with birth outcomes and offspring cognitive development. METHODS:Participants were enrolled in the Safe Passage Study conducted by the Prenatal Alcohol and SIDS and Stillbirth (PASS) Network. Infant cord blood and placental samples were collected postdelivery, and 5-HT levels were measured using high-performance liquid chromatography-fluorometric analysis. The Mullen Scales of Early Learning (MSEL) assessed child development at 12 months. Associations between 5-HT levels and birth outcomes or developmental outcomes were assessed using linear regression models. RESULTS:No significant association was found between cord blood (n = 418) and placental (n = 89) 5-HT levels. Preterm birth was associated with lower cord blood 5-HT levels, and increasing gestational age among full-term infants was associated with higher cord blood 5-HT levels. Cord blood 5-HT was significantly associated with the Mullen Scales of Early Learning Composite Score, and follow-up analyses revealed a significant association between cord blood 5-HT and fine motor skills. No association was found between placental 5-HT and the Mullen composite score. CONCLUSION/CONCLUSIONS:To our knowledge, this study is the first to evaluate the relationship between placental 5-HT levels and cord blood 5-HT levels at birth. The lack of association suggests that cord blood 5-HT levels are likely to be a better index of fetal 5-HT exposure. Associations between cord blood 5-HT and child cognitive development are consistent with previous studies showing an association between maternal 5-HT levels and neurodevelopmental trajectories. Further research is needed to better characterize these relationships and to elucidate the distinct contributions of maternal, placental, and fetal 5-HT sources across developmental time points.

BACKGROUND/UNASSIGNED:Skilled nursing facilities (SNFs) play a critical role in postacute recovery for older adults with heart failure (HF), yet the transition from SNF to home remains a vulnerable and understudied phase of care. Although discharge guidelines emphasize clear communication, HF-specific self-care education, medication management, and follow-up coordination, little is known about how these practices are implemented during SNF-to-home transitions. METHODS/UNASSIGNED:We conducted a convergent mixed-methods study across 4 nonprofit SNFs, integrating data from postdischarge patient and caregiver surveys, structured medical record abstraction of discharge instructions, and semi-structured staff interviews. Eligible patients were Medicare beneficiaries aged ≥65 years discharged from SNF to home following HF hospitalization, with SNF stays ≤60 days. Quantitative data were analyzed using descriptive statistics, while qualitative data underwent thematic and directed content analysis. Findings were triangulated across data sources to identify key challenges and actionable strategies. RESULTS/UNASSIGNED:Among 150 respondents, 59% reported receiving written discharge instructions; however, HF-specific self-care elements (eg, daily weight monitoring, low salt diet) were documented in only 15% to 41% of instructions. Although 87% reported receiving a medication list, only 53% had it reflected in the discharge instructions, and adherence support was infrequently addressed (24%). Follow-up coordination was similarly discordant: 37% of respondents reported a scheduled primary care appointment, compared with 13% documented in discharge instructions. Staff interviews revealed nonstandardized discharge workflows, workforce constraints, and reliance on verbal education, contributing to variability in patient preparation and communication across care settings. CONCLUSIONS/UNASSIGNED:SNF-to-home transitions after HF hospitalization are marked by discordance between patient-reported education and written documentation, as well as inconsistent medication and follow-up coordination. These gaps represent modifiable vulnerabilities during a high-risk recovery period. Standardized HF-focused discharge workflows and strengthened cross-setting communication may improve transitional care, while long-term solutions must address structural and workforce constraints.

BACKGROUND:To evaluate whether quantitative craniospinal MRI assessment of baseline tumor burden provides prognostic value in patients with recurrent, previously irradiated medulloblastoma undergoing MEMMAT (Metronomic Antiangiogenic) therapy. METHODS:We analyzed craniospinal MRI of 40 patients with recurrent, previously irradiated medulloblastoma enrolled in the MEMMAT trial (April 1, 2014, and March 31, 2021). Ependymal, leptomeningeal, and local relapse lesions were retrospectively manually segmented on T1-contrast-enhanced (T1CE) and diffusion-weighted imaging (DWI) at baseline and follow-up (best response). Lesion count and volume were quantified. Bland-Altman analyses and intraclass correlation coefficients (ICC) assessed inter-sequence agreement., logistic regression evaluated associations between baseline tumor burden and progressive disease. RESULTS:Patients achieving Complete Response (n = 6/40) showed mean monthly decreases of - 12.7% in T1CE lesion count and - 12.9% in volume. Partial Response patients (n = 9/40) showed similar declines (-10.3% and - 13.0%). Stable Disease patients (n = 5/40) demonstrated minimal decreases (-0.8% and - 2.3%). Progressive Disease patients (n = 16/40) showed increases of 33.7% in lesion count and 56.2% in volume. Logistic regression indicated trends toward higher baseline tumor burden predicting PD (volume OR 1.18, p = 0.08; lesion count OR 1.05, p = 0.075). Agreement between T1CE and DWI was limited (ICC 0.35 for lesion count, 0.47 for volume), with 23% of patients misclassified using either modality alone. Survival analyses demonstrated significantly shorter overall survival in patients with baseline lesion volumes ≥ 5.5 ml (log-rank p = 0.003), while a similar association for progression-free survival did not reach statistical significance (p = 0.053). CONCLUSIONS:Combined intracranial and intraspinal T1CE and intracranial DWI assessment improves response evaluation. Exploratory analyses suggested that higher baseline tumor burden may be associated with progression, although the observed associations were of borderline statistical significance and require validation in larger cohorts.

New York City has the largest homeless population of any city in the United States, with thousands of people experiencing unsheltered homelessness on its streets. These individuals have poor health outcomes and limited connection to care. To better meet their health and social needs, New York City Health+Hospitals, the largest public hospital system in the United States, has implemented the Street Health Outreach and Wellness (SHOW) initiative to bring unsheltered New Yorkers health care, material goods, and connections to transitional housing. This article documents the evolution of the program - from its first iteration as an external contractor-staffed initiative during the coronavirus disease 2019 pandemic to its integration into the health care system in January 2023 - while also highlighting how it is currently operationalized. Since its integration, teams have completed more than 46,000 street engagements, including more than 10,000 clinical visits, 1700 connections to substance use services, and more than 500 connections to homeless shelters. The authors provide key lessons about trust-building, navigating complex organizational hierarchies and partnerships, and the importance of community-based interventions to provide homeless health care.

BACKGROUND/UNASSIGNED:Vascularized composite allotransplantation (VCA) has achieved significant advancements in reconstructive surgery through pioneering efforts in face, upper extremity, and whole-eye transplantations. The VCA program at New York University Langone Health has pursued these efforts since its inception in 2013. METHODS/UNASSIGNED:This review documents the evolution of the VCA program, highlighting 4 critical cases that demonstrate the program's innovative approach to surgical challenges and patient care. Each case study reveals the integration of computerized surgical planning, meticulous preoperative preparations, postoperative outcomes, and key institutional metrics. RESULTS/UNASSIGNED:Notable achievements include the first successful combined face and bilateral hand transplantation, and the first combined face and whole-eye transplantation, with improved procedural efficiencies such as reduced hospital and intensive care unit length of stay and operative durations over time. Furthermore, the program's focus on multidisciplinary collaboration has enhanced patient outcomes and operational procedures. CONCLUSIONS/UNASSIGNED:These efforts not only mark significant milestones in VCA but also contribute to the broader surgical and microsurgical fields by refining techniques that minimize resource use and optimize patient recovery and quality of life.

IMPORTANCE/UNASSIGNED:Buprenorphine-naloxone and extended-release (XR) naltrexone are both efficacious medications for opioid use disorder that reduce unregulated opioid use and improve opioid cravings and treatment retention. While prior comparative effectiveness studies demonstrated superiority of buprenorphine-naloxone over XR naltrexone for relapse and treatment retention, the comparative effectiveness of both treatments for all-cause mortality and nonfatal opioid overdose outcomes has not been rigorously tested. OBJECTIVE/UNASSIGNED:To compare the effectiveness of buprenorphine-naloxone vs XR naltrexone after medically managed opioid withdrawal (MMOW) treatment. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This observational comparative effectiveness study using a target trial emulation framework leveraged individually linked administrative data from the Massachusetts Public Health Data Warehouse to emulate the protocol of the Extended-Release Naltrexone vs Buprenorphine for Opioid Treatment randomized clinical trial. Participants included adults 18 years or older who were discharged from MMOW in Massachusetts between January 1, 2014, and December 31, 2018. Individuals could meet eligibility criteria more than once. Data were analyzed from December 22, 2023, to January 30, 2025. EXPOSURES/UNASSIGNED:Initiation of buprenorphine-naloxone or XR naltrexone therapy within 28 days of MMOW discharge. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Estimated 24-week cumulative incidence of all-cause mortality and nonfatal opioid overdose using inverse probability weighting to adjust for baseline and time-varying confounding. RESULTS/UNASSIGNED:A total of 36 752 unique individuals who met eligibility criteria were identified and contributed 106 052 MMOW discharge episodes; 79 089 (74.6%) episodes were among individuals who were male and 44 463 (42.1%) were among individuals aged 18 to 29 years. By 28 days after MMOW discharge, initiation of buprenorphine-naloxone was observed among 14 194 discharge episodes (13.4%) and initiation of XR naltrexone was observed among 4734 (4.5%) episodes. The adjusted 24-week cumulative incidence of all-cause mortality after MMOW discharge was 1.4% (95% CI, 1.2%-1.7%) for buprenorphine-naloxone and 1.4% (95% CI, 1.1%-1.8%) for XR naltrexone, corresponding to a risk difference of 0.0 percentage points (pp) (95% CI, -0.4 to 0.4 pp). The adjusted 24-week cumulative incidence of nonfatal opioid overdose after MMOW discharge was 11.6% (95% CI, 10.8%-12.3%) for buprenorphine-naloxone and 13.9% (95% CI, 12.9%-15.0%) for XR naltrexone, corresponding to a risk difference of 2.3 pp (95% CI, 1.2-3.6 pp). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this comparative effectiveness study of buprenorphine-naloxone vs XR naltrexone, initiating buprenorphine-naloxone after MMOW discharge was associated with a lower risk of nonfatal opioid overdose at 24 weeks than initiating XR naltrexone, but a similar risk of all-cause mortality.

BACKGROUND/UNASSIGNED:Many strides have been made in the field of vascular composite allotransplantation, and some vascular composite allotransplantation procedures, including upper extremity and facial transplantation, are arguably nearing the standard of care for adult recipients. Although centers devoted to pediatric upper extremity transplantation have been established, very little recent scholarship has addressed the advisability of initiating pediatric facial transplantation (PFTx). METHODS/UNASSIGNED:This conceptual ethical analysis assesses the present risks and benefits associated with PFTx based on a review of the literature combined with our team's clinical experience. RESULTS/UNASSIGNED:Considerations for PFTx include anticipated improvements in quality of life and social integration during a critically important formative developmental phase, ongoing risks associated with immunosuppression and known challenges with nonadherence in adolescent and young adult populations, unknowns about facial growth and continued incorporation of the allograft, the likelihood of need for retransplantation, and issues around decisional capacity and the ability to provide informed consent. CONCLUSIONS/UNASSIGNED:Weighing the risks and benefits of PFTx, particularly the risks associated with long-term immunosuppression and the likely need for retransplantation, we believe that the reservations are such that pediatric patients should not be considered candidates for PFTx at this time.