Faculty Bibliography

INTRODUCTION/BACKGROUND:To help address the continuing epidemic of firearm-related trauma in the United States (US), we conducted a detailed analysis of recent trauma center discharge data and compared firearm-related injuries to mechanisms such as falls, pedestrian injuries, and motor vehicle crashes. METHODS:We combined Trauma Quality Improvement Program (TQIP) data for 2011 to 2022 and analyzed variables for patient demographics, injury mechanisms, disposition, and hospital characteristics over time. Analyses consisted of descriptive statistics, bar plots, time series plots, and comparative tables. RESULTS:There were 3,597,688 US trauma hospital discharges in the TQIP data set for 2011 to 2022 of which 307,062 (8.4%) involved firearms-a higher proportion than those involving pedestrian injuries (3.8%), pedal cycles (2.0%), or motorcycles (6.2%). The case-fatality rate of inpatient hospital deaths for firearm injuries was 8.8%, surpassed only by that of pedestrian injuries (9.9%). Firearms accounted for the youngest patient population over the 12-year study period for the six injury mechanisms analyzed. Over time, firearm-related assaults increased from 75.7% of all firearm injuries in 2011 to 88.6% in 2020. Most, if not all, of this increase appeared to occur in the post-2014 time period. CONCLUSIONS:Better defining national injury trends allows for targeted injury prevention efforts, prioritized research endeavors, and optimized resource allocation.

OBJECTIVE/UNASSIGNED:During septal myectomy, once the heart is arrested and drained of blood on cardiopulmonary bypass, transesophageal echocardiography can no longer assess septal thickness. In the present study, we evaluated the effectiveness of on-pump intracardiac echocardiography (OPIE) for real-time intraoperative septal thickness assessment in patients with preoperative thickness ≤2.0 cm. Our hypothesis was that OPIE measurements would be conconcordant with the pre- and postcardiopulmonary bypass transesophageal echocardiography measurements that are at present the primary operative guides. METHODS/UNASSIGNED:We retrospectively reviewed patients with hypertrophic cardiomyopathy and septal thickness ≤2.0 cm on transthoracic echocardiography who underwent septal myectomy from July 2017 to July 2024. The OPIE probe was introduced into the left-ventricular chamber during cardioplegic arrest, with repeated measurements to assess the depth and adequacy of resection. Septal thickness was evaluated pre-myectomy using transthoracic echocardiography, cardiac magnetic resonance imaging, transesophageal echocardiography, and OPIE. Lin's concordance correlation coefficients and Bland-Altman analyses were used to evaluate agreement between modalities. RESULTS/UNASSIGNED:A total of 220 patients were included with preoperative thickness ≤2.0, 56 of whom underwent myectomy with OPIE guidance. Preresection transesophageal echocardiography and OPIE demonstrated the strongest agreement of all the imaging modalities (Lin's concordance correlation coefficient, 0.81; 95% CI, 0.72-0.88), with minimal bias (-0.73) and the narrowest limits of agreement (-3.76, +2.31]. OPIE-derived resection thickness estimates were tightly clustered. In the OPIE cohort, there was 1 ventricular septal defect (1.8%) and no 30-day mortality. CONCLUSIONS/UNASSIGNED:OPIE is a reliable tool for intraoperative assessment of septal thickness, particularly in patients with mild hypertrophy.

BACKGROUND:Some pulse oximeters perform worse in people with darker skin, and this may be due to inadequate diversity of skin pigment in device development study cohorts. Guidance is needed to accurately and equitably characterize skin pigment to ensure diversity in research cohorts. We tested multiple methods for characterizing skin pigment to assess comparability and impact on cohort diversity. OBJECTIVES/OBJECTIVE:Assess reliability and comparability of common skin pigment measurement methods Compare findings from different anatomical sites Demonstrate that pigment cannot be assumed from US National Institutes for Health (NIH) race categories. METHODS:We used three subjective methods (perceived Fitzpatrick pFP, Monk Skin Tone MST and Von Luschan VL) and two objective methods (Konica Minolta CM-700d spectrophotometer and Delfin Skin Color Catch DSCC colorimeter) for individual typology angle (ITA), across multiple measurement sites in adults. We calculated ΔE to estimate operator perceptibility thresholds for subjective methods and to determine reproducibility for objective methods. We used each method to categorize participants as 'light, medium, or dark' and compared the impact of method selection on cohort diversity. RESULTS:We studied 789 participants, with 33,856 assessments. The MST had the widest luminosity range, and VL had the least discernible adjacent categories. With 'dark' defined as ITA <-30°, 14% of participants were categorized 'dark' as compared to 26% by pFP or 16% by MST. Approximately half of the 'dark' cohort had an ITA <-50°. With an ITA threshold <-50°, only 7% of the cohort was categorized as 'dark.' When 'Black or African American' self-identification was used to define 'dark', 23% of the cohort was categorized as such. Each self-assigned NIH race category included a wide range of ITA and subjective scale categories. Both ITA and L* from the KM-700d and DSCC demonstrated strong correlation (⍴ > 0.7). CONCLUSION/CONCLUSIONS:Common methods for skin pigment characterization, especially the use of race or subjective scales, have significant limitations. When applied to the same cohort, different methods yield significantly different results, and some may overestimate diversity. Previously published ITA thresholds for defining 'dark' skin are too light and lead to underrepresentation of people with darker skin.

BACKGROUND AND PURPOSE/OBJECTIVE:Accurate localization of the ventral intermediate nucleus (VIM) within the dentatorubrothalamic tract (DRTT) is critical for effective neurosurgical treatment of essential tremor (ET). This study evaluated the feasibility and anatomical specificity of quantitative susceptibility mapping (QSM) for direct VIM/DRTT visualization, comparing it with conventional diffusion tractography-based reconstructions. MATERIALS AND METHODS/METHODS:Twenty-seven participants (10 healthy controls, 17 ET patients) were enrolled across two institutions and imaged on 3T MRI systems. QSM-defined VIM/DRTT regions were manually segmented based on characteristic hypointense susceptibility contrast. Whole-brain diffusion tractography was performed to reconstruct the DRTT, pyramidal tract (PT), and medial lemniscus (ML) tracts. Spatial overlap between QSM-and tractography-defined VIM/DRTT regions was calculated, as well as overlap with neighboring PT and ML tracts to assess specificity. RESULTS:Two participants were excluded due to insufficient VIM/DRTT streamlines in tractography reconstruction. In healthy controls, QSM-and tractography-defined VIM/DRTT showed high spatial correspondence (left: 87.6 ± 5.1%; right: 85.3 ± 6.5%). ET patients exhibited slightly lower overlap (mean range: 71.5 - 85.1%). Overlap with neighboring PT and ML tracts was minimal (<3.3%), confirming high anatomical specificity of QSM-derived VIM/DRTT regions. CONCLUSIONS:QSM enables direct visualization of the VIM/DRTT with high spatial agreement to conventional tractography-based approaches while demonstrating minimal overlap with adjacent tracts. These findings support QSM as a complementary or standalone imaging modality for improved, patient-specific neurosurgical targeting in ET. ABBREVIATIONS/BACKGROUND:DBS = deep brain stimulation; DRTT = dentatorubrothalamic tract; ET = essential tremor; ML = medial lemniscus; MRgFUS = MR-guided focused ultrasound; VIM = ventral intermediate nucleus; PT = pyramidal tract; QSM = quantitative susceptibility mapping; WM = white matter.

OBJECTIVE:The CDC recommends initiating opioids for pain treatment at the lowest effective dose and duration. We examine how interactions between dose, duration, and other medication factors (e.g., drug type) influence opioid use disorder (OUD) risk-a gap not considered by CDC guidelines. SUBJECTS/METHODS:Using Medicaid claims data (2016-2019) from 25 states, we analyzed opioid-naïve adults, newly diagnosed with musculoskeletal pain who initiated opioids within three months of diagnosis. A 6-month washout confirmed no prior opioid exposure or musculoskeletal diagnosis. METHODS:Initial opioids were categorized by "dose-days supplied" (low [>0-20 mg MME] to very high [>90 mg MME] dose, and short [1-7 days] to moderate [>7-30 days] supply), and by opioid type; physical therapy (PT) sessions were also recorded. Using Poisson regression models, we estimated the OUD risk associated with dose-days categories, adjusting for baseline demographics, clinical characteristics, and medications. We separately examined opioid dose-days and PT, and assessed PT's moderating effect on dose-days' impact. RESULTS:Among 30,536 patients, half initiated opioids at 20-50 MME for 1-7 days, and 20% received PT. OUD risk was 2-3 times higher for opioids initiated for >7-30 days compared to 1-7 days across doses, and 5.5 times higher for opioids initiated for >7-30 days at > 90 MME versus 1-7 days at < 20 MME. PT alone, neither affected OUD risk nor mitigated the increased risk from longer or higher-dose opioids. CONCLUSIONS:Our findings support the need for careful opioid prescribing and alternative pain management strategies, as the observed associations between initial prescription characteristics and OUD were not mitigated by adjunctive PT. PERSPECTIVE/CONCLUSIONS:This study demonstrated that initial opioid prescriptions of 7-30 days, especially above 90 MME/day, increased OUD risk in opioid-naïve patients with musculoskeletal pain; physical therapy did not mitigate the risk. Different opioids posed varied risks, even at the same dose and duration. Careful prescribing and alternative pain management are essential.

BACKGROUND:Neuromodulation is a rapidly advancing field in pain medicine, providing targeted, reversible interventions for patients with chronic pain unresponsive to conventional therapies. Advances in waveform technology, device design, and stimulation strategies have shifted neuromodulation from a last-resort approach to a core element of multidisciplinary pain management. Despite its growing adoption, variability in training, terminology, and clinical implementation underscores the need for consensus-driven frameworks to ensure safety, efficacy, and uniformity across practice settings. OBJECTIVES/OBJECTIVE:This review aims to define current and emerging concepts in neuromodulation, summarize the supporting evidence, and offer clinicians an evidence-informed framework for individualized application in chronic pain management. STUDY DESIGN/METHODS:Narrative review. METHODS:We conducted a comprehensive synthesis of neuromodulation strategies spanning spinal cord stimulation (SCS), dorsal root ganglion stimulation (DRGS), peripheral nerve stimulation (PNS), motor cortex stimulation (MCS), deep brain stimulation (DBS), and targeted drug delivery (TDD). The review integrates data from published studies and reviews to cover emerging concepts, classifications, indications, technological advancements, device features, clinical applications, and practical guidance for patient-specific decision-making. RESULTS:Over the past decade, neuromodulation use has expanded significantly, driven by technological and mechanistic innovations. Peripheral nerve stimulation (PNS) has become increasingly precise for focal neuropathic pain, demonstrating efficacy in migraine, hemiplegic shoulder pain, persistent spinal pain syndrome, post-amputation neuropathic pain, trigeminal neuralgia, plexus injuries, and multifidus dysfunction. SCS remains a mainstay for widespread neuropathic pain, including CRPS, painful diabetic neuropathy, and post-surgical syndromes, with innovations such as 10-kHz high-frequency and burst stimulation offering paresthesia-free analgesia and improved patient satisfaction. DRGS provides targeted relief for localized neuropathic pain, including post-herniorrhaphy and post-thoracotomy syndromes, with more predictable outcomes. Neurophysiological refinements, including differential target multiplexed (DTM) stimulation and closed-loop systems with evoked compound action potential (ECAP) feedback, enable real-time spinal control and consistent analgesia. Multiphase and surround-inhibition paradigms further enhance segmental coverage, energy efficiency, and rapid analgesic onset. TDD has evolved into a precise adjunctive therapy, with programmable pumps delivering morphine, baclofen, and ziconotide safely, minimizing systemic exposure while allowing individualized dosing. Collectively, these innovations support precision-guided, personalized neuromodulation with durable efficacy and improved patient-centered outcomes across diverse chronic pain conditions. LIMITATIONS/CONCLUSIONS:Heterogeneity in published evidence and the lack of large-scale, head-to-head randomized trials for certain waveforms and technologies limit the conclusions of this review. CONCLUSIONS:Neuromodulation continues to advance at the intersection of neuroscience, bioengineering, and clinical practice. Harmonizing definitions, classifications, and education will guide future innovation and help ensure that neuromodulation fulfills its promise of safe, effective, and equitable patient care.

AIM/OBJECTIVE:Postoperative delirium (POD) is a frequent neurological complication following surgery, often leading to poor prognoses. The red blood cell distribution width (RDW) to albumin ratio (RAR), an emerging indicator of inflammation and nutrition, was extensively utilized for prognostic evaluation of neurological disorders in elderly patients. However, the relationship between RAR and POD was not evaluated. This study aimed to investigate the independent risk factors for POD and assess the predictive value of preoperative RAR among elderly patients who had gastrointestinal tumors. METHODS:We conducted a retrospective analysis to collect perioperative data on 203 patients aged 65 years or older undergoing gastrointestinal tumor surgery from November 2023 to August 2024. The risk factors for POD were detected through univariate and multivariate logistic regression analyses. Propensity score matching (PSM) was employed to make their clinical characteristics balanced. RESULTS:Out of 203 patients, 30 (14.8%) experienced POD, with a median age of 70 (range 67-76). Hypertension, creatinine, MCH, and RAR were determined as independent risk factors for POD through multivariate logistic regression analysis. In the post-PSM cohort, RAR was still verified as a factor influencing POD. CONCLUSIONS:Hypertension, creatinine, MCH, and RAR were recognized as independent risk factors for postoperative delirium in patients following gastrointestinal tumor surgery. Particularly, the preoperative RAR served as a more efficient index for predicting POD. TRIAL REGISTRATION/BACKGROUND:Chinese Clinical Trial Center: ChiCTR2400094315.