Faculty Bibliography

We estimated the extent to which different pain management practices, considered together as well as individually, mediated the relationship between chronic pain or physical disability and new-onset opioid use disorder (OUD) in a large cohort of adult Medicaid patients. Considering the plausibility of the assumptions required to identify different mediational estimands, we estimated natural indirect effects when considering mediation through the group of mediators together and estimated interventional indirect effects when considering mediation through each pain management practice individually. We estimated each effect using a nonparametric one-step estimator. The pain management variables we examined mediated all of the total effect of chronic pain on OUD risk and nearly half of the total effect of physical disability on OUD risk. High-dose, long-duration opioid prescribing and co-prescription of opioids with benzodiazepines, gabapentinoids, and muscle relaxants each contributed substantially to the increased risk of OUD due to chronic pain (contributing to 10-37% of the overall effect) and more moderately to the increased risk of OUD due to physical disability (contributing to 3-19% of the overall effect). Antidepressant or anti-inflammatory prescribing and physical therapy generally did not contribute to increased OUD risk, and, in some cases, even contributed to small reductions in risk.

BACKGROUND/UNASSIGNED:As life expectancy rises, identifying causes and risk factors for incident acute ischemic stroke (AIS) among the oldest-old (≥80 years) is increasingly important. We examined whether the effect of age at stroke on AIS subtype is mediated by embolic risk factors and whether these factors improve AIS prediction. METHODS/UNASSIGNED:-VASc) and compared preinclusion and postinclusion of embolic risk factors. RESULTS/UNASSIGNED:-VASc: C statistics, 0.63 [95% CI, 0.59-0.67]). CONCLUSIONS/UNASSIGNED:These findings suggest that identification and control of embolic risk factors are critical to reduce stroke risk as people age, and better stroke-specific prediction tools are needed.

PURPOSE OF REVIEW/OBJECTIVE:Recent high-quality outcomes research shows that anesthetic technique in nonoperating room anesthesia influences procedural performance, intraprocedural stability, and recovery. RECENT FINDINGS/RESULTS:In gastrointestinal endoscopy, noninvasive oxygenation strategies reduce hypoxemia, and remimazolam provides improved cardiopulmonary stability compared with propofol. Sedation depth may also affect the detection of serrated polyps. In bronchoscopy and interventional pulmonology, remimazolam and regional analgesic strategies improve respiratory and hemodynamic tolerance. In neurointerventional radiology and electrophysiology, general anesthesia does not consistently improve major outcomes and may prolong procedures or increase complications. In electroconvulsive therapy, processed electroencephalogram-guided timing and anesthetic dose reduction may reduce airway interventions while preserving effectiveness. SUMMARY/CONCLUSIONS:Recent evidence across a diverse selection of nonoperating room anesthesia environments demonstrates outcomes that have advanced the field and inform anesthetic decisions.

BACKGROUND:Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy is an established treatment for medication-refractory tremor with limited evidence in patients aged >80 years. OBJECTIVE:To retrospectively compare safety and efficacy of MRgFUS in under-80 versus over-80 patients without prior balance disturbances or unstable comorbidities. METHODS:One hundred thirty five consecutive patients with essential tremor or tremor-predominant Parkinson's disease underwent unilateral MRgFUS thalamotomy. Patients were stratified into under-80 (n: 97, median age 71 years) and over-80 (n: 38, median age 82 years). Tremor severity was scored with the Fahn-Tolosa-Marin Clinical Rating Scale. Outcomes included intraoperative tremor suppression and SE occurrence, resolution, and improvement. RESULTS:Older patients showed higher baseline tremor severity (U: 383.5; p: 0.02). Tremor reduction >50% occurred in 95.6% of cases, with complete resolution in 77.0%. Higher target temperature predicted better tremor control (OR [95% CI]: 4.03 [1.39-11.65]; p: 0.01), whereas greater baseline tremor (OR [95% CI]: 0.90 [0.83-0.99]; p: 0.02) and SDR <0.4 (OR [95% CI]: 0.14 [0.02-0.85]; p: 0.03) predicted poorer outcomes. Age ≥ 80 did not affect intraprocedural tremor control (OR [95% CI]: 0.83 [0.15-4.70]; p: 0.83) and longitudinal mixed-effects analysis confirmed sustained 1-year tremor control, unaffected by advanced age. SEs occurred in 71.1%, mostly balance disturbances. After a mean follow-up of 43.7 weeks, 60.4% improved and 46.9% fully resolved, with only 1.5% severe persistent SEs. Age ≥ 80 did not influence SE rates (OR [95% CI]: 0.60 [0.27-1.33]; p: 0.20), resolution (OR [95% CI]: 0.56 [0.25-1.26]; p: 0.16), or improvement (OR [95% CI]: 0.60 [0.28-1.30]; p: 0.19). CONCLUSIONS:MRgFUS thalamotomy yields comparable outcomes in carefully selected patients aged >80 years and in younger individuals.

BACKGROUND:The need for evidence to inform interventions to prevent mass shootings (MS) in the USA has never been greater. METHODS:Data were abstracted from the Gun Violence Archive, an independent online database of US gun violence incidents. Descriptive analyses consisted of individual-level epidemiology of victims, suspected shooters and weapons involved, trends and county-level choropleths of population-level incident and fatality rates. Counties with and without state-level assault weapons bans (AWB) were compared, and we conducted a multivariable negative binomial model controlling for county-level social fragmentation, median age and number of gun-related homicides for the association of state-level AWB with aggregate county MS fatalities. RESULTS:73.3% (95% CI 72.1 to 74.5) of victims and 97.2% (95% CI 96.3 to 98.3) of shooters were males. When compared with incidents involving weapons labelled 'handguns', those involving a weapon labelled AR-15 or AK-47 were six times more likely to be associated with case-fatality rates greater than the median (OR=6.1, 95% CI 2.3 to 15.8, p<0.00001). MS incidents were significantly more likely to occur on weekends and during summer months. US counties in states without AWB had consistently higher MS rates throughout the study period (p<0.0001), and the slope for increase over time was significantly lower in counties with AWB (beta=-0.11, p=0.01). In a multivariable negative binomial model, counties in states with AWB were associated with a 41% lower incidence of MS fatalities (OR=0.58, 95% CI 0.37 to 0.97, p=0.02). CONCLUSIONS:Counties located in states with AWB were associated with fewer MS fatalities between 2014 and 2022.

BACKGROUND:Cervical spine fusion causes limited neck mobility, a known risk factor for increased difficulty of endotracheal intubation. Cervical spine fusion surgeries are increasingly performed. The objective of this study was to determine the relationship between previous cervical spine fusion and subsequent endotracheal intubation. MATERIALS AND METHODS/METHODS:This retrospective study included adult patients undergoing elective surgery requiring endotracheal intubation between 2015 and 2023. We used multivariable logistic regression to identify variables independently associated with the primary outcome: requiring more than one intubation attempt. Sensitivity analyses examined the outcome within only fusion patients. RESULTS:We identified 938 patients, 436 with a history of cervical fusion, with 493 intubation attempts, and 502 nonfusion patients with 543 intubation attempts. The majority of the sample (91.5%) had fusion involving C3 or below, with 6.2% having a C1/C2 fusion(2.3% were missing the level of fusion). The success of the first attempt was 89.2% versus 92.6%, 8.5% versus 6.6% second attempt, and 2.3% versus 0.8% third attempt for fusion versus nonfusion patients, respectively. Requiring more than one attempt was associated with short thyromental distance, using multiple laryngoscopes, mouth trauma, and trainee status, but not with spinal fusion status (OR=1.29; 95% confident interval=079-2.12; P=0.312). CONCLUSION/CONCLUSIONS:Patients with a history of cervical spine fusion undergoing elective intubation experience similar rates of first intubation attempt failure compared with those without fusion when controlling for provider experience. Requiring more than one intubation attempt was associated with short thyromental distance, using multiple laryngoscopes, a trainee provider, and mouth trauma, but not a history of cervical fusion.

INTRODUCTION/BACKGROUND:Accurate preoperative evaluation of pancreatic cysts is essential. However, cytology and biochemical analysis are often limited by low cellularity, and risk stratification is critical for management. PancreaSeq Genomic Classifier (GC) analyzes cyst fluid for molecular alterations to aid diagnosis and risk assessment. MATERIALS AND METHODS/METHODS:We retrospectively analyzed 219 pancreatic cysts from 206 patients using PancreaSeq GC, integrating molecular findings with cytology, biochemical, imaging, surgical pathology, and follow-up. RESULTS:PancreaSeq GC successfully analyzed 216/219 cysts (99%) and detected alterations in 182 (83%). Among cases with both cytology and molecular data (n = 201), concordance was high in cytologically mucinous neoplasms (94%) and atypical cases (95%). Notably, among cases reported as negative for malignancy or nondiagnostic on cytology (n = 128), PancreaSeq GC identified mucinous neoplasms in 82 cases (64%), demonstrating added value in limited samples. Surgical pathology correlation (n = 24) showed excellent performance for distinguishing mucinous from nonmucinous cysts (area under the curve [AUC] = 0.94, P < 0.001). Risk stratification for detection of any dysplasia yielded an AUC of 0.78 (P = 0.006), and for high-grade dysplasia an AUC of 0.74 (P = 0.046). PancreaSeq GC reliably predicted neuroendocrine tumors, but the sensitivity for focal high-grade dysplasia in mucinous neoplasms and serous cystadenoma was limited. Compared with carcinoembryonic antigen (CEA), cyst fluid glucose showed higher sensitivity but lower specificity for mucinous cyst detection. CONCLUSIONS:PancreaSeq GC provides significant diagnostic and risk-stratification value that complements cytological evaluation, particularly in indeterminate or nondiagnostic cytology specimens and when biochemical data are unavailable. Integration of molecular findings improves cyst classification and dysplasia risk assessment. Multidisciplinary assessment remains essential, given the assay's limited sensitivity for focal high-grade dysplasia and serous cystadenomas.