Faculty Bibliography

BACKGROUND:Fewer than 20% of donated lungs are transplanted. We examined the impacts of donor management and recovery at an in-hospital donor care unit (DCU) established in 2021 versus the donor hospital (DH). METHODS:(P/F ratio) were examined as a hypothesized effect modifier. We projected the national impact of improved utilization on lung transplant volume. RESULTS:After adjusting for donor differences, lung utilization was 88% higher (aRR: 1.88; 95% CI: 1.40, 2.53) in the DCU versus DH setting. Median P/F ratio increased from 275 to 348 mmHg (p<0.0001) in the DCU and explained approximately 38% of the improvement in lung utilization. Non-lung organ utilization was either improved or non-inferior in the DCU. Lung graft survival and pulmonary function were similar for recipients of DCU versus DH-managed donors. Nationally, an 88% improvement in lung utilization among donors not currently transferred to a DCU could theoretically result in ≥300 more lung transplants per year. CONCLUSIONS:Lung transplantation can be nearly doubled through lung-centric donor management in a DCU, without sacrificing recipient outcomes nor the utilization of other organs. Donor management practices to optimize lung utilization should be proliferated by establishing more DCUs and, where feasible, applying lung-centric protocols in donor hospitals.

BACKGROUND:Fast-track (FT) protocol is an established but not standardized approach in cardiac surgery. We aimed to describe our FT protocol and to compare outcomes before and after the protocol implementation (non-FT group and FT group, respectively). METHODS:Fast-track protocol was implemented in March 2021 in our institution. All patients who underwent median sternotomy from January 2018 to June 2024 were identified. Patient characteristics and outcomes were compared between the FT group and non-FT group, using propensity-score matching. RESULTS:A total of 456 patients, primarily aortic valve replacement, mitral valve repair or replacement, and root and ascending aortic surgery, were included. Of 456, 261 patients were the FT group and 195 patients were the non-FT group. In the FT group, 91.6% of patients were extubated in the OR (vs. 42.1% in the non-FT group, p < 0.001). In the FT group, 193 (73.9%) were discharged within 2 or 3 days after surgery. After propensity-score matching, the median hospital length of stays (LOS) was significantly shorter in the FT group (3 days vs. 4 days, p < 0.001). Baseline characteristics, operations, and perioperative outcomes were similar between the groups, including 30-day mortality (0.5% vs. 0.5%, p = 1.0), prolonged ventilation (1.1% vs. 1.1%, p = 1.0), discharge to home (1.6% vs. 2.2%, p = 0.72), and readmission (3.8% vs. 4.3%, p = 0.80). CONCLUSIONS:The FT protocol was associated with decreased hospital LOS. Additionally, this study suggested that discharge within 3 postoperative days is feasible after most valve surgeries.

Kidneys from donation after circulatory death (DCD) donors historically had lower recovery and utilization than kidneys from donation after brain death (DBD) donors. However, the organ shortage and advances in organ preservation have increased interest in DCD transplantation. We used OPTN data to study temporal changes in U.S. DCD kidney recovery and transplantation. The percent DCD among kidney donors increased from 21.0% (Era1: 2016-2019) to 30.6% (Era2: 2020-2022) and 42.4% (Era3: 2023-2025). By 2025Q2, more than half (50.4%) of kidney donors were DCDs. Wide variability persisted across eras in percent DCD by recovering OPO (Era1 range: 0%-38%, Era2: 0%-49%, Era3: 0.4%-60%) and by transplanting center (Era1 range: 0%-48%, Era2: 0%-58%, Era3: 0%-60%). Transplanted DCD kidneys in Era3 (vs Era1 & Era2) were more likely to have donor age >60, diabetes, hypertension, obesity, and death due to cardiovascular disease or stroke; 86.8% were pumped. Though the recovered DCD kidney nonuse rate rose from 20.8% (Era1) to 29.9% (Era2) and 35.4% (Era3), nonused DCD kidney donors were age and had more comorbidities in Era 3 compared to earlier eras. Given that half of kidney donors are now DCD, refinements in DCD donor selection and management are needed to optimize recovery and utilization.

BACKGROUND:Degenerative disc disease (DDD) with cartilaginous endplate degeneration and Modic type 1 or 2 changes is increasingly recognized as a source of chronic vertebrogenic and discogenic low back pain. Because the intervertebral disc and vertebral endplates function as a biological and biomechanical unit, regenerative strategies targeting both structures may better address the disc-endplate complex. CASE SERIES/METHODS:Thirteen consecutive patients with chronic refractory vertebrogenic and/or discogenic low back pain, MRI evidence of DDD with Modic type 1 or 2 changes, and failure of conservative management underwent combined intradiscal, peridiscal, and subchondral bone marrow aspirate concentrate (BMAC) injections under fluoroscopic guidance. Four patients had previously undergone basivertebral nerve radiofrequency ablation. The cohort included 6 men and 7 women with a mean age of 56.2 ± 17.5 years. Follow-up ranged from 4 to 15 months. Mean Visual Analog Scale scores decreased from 7.3 ± 2.0 at baseline to 2.1 ± 1.6 at latest follow-up, a mean reduction of 5.2 ± 1.8 points (72.7% ± 19.5%). All patients achieved at least 50% pain reduction and reported functional improvement. Twelve patients (92.3%) were satisfied or very satisfied, and all would recommend the procedure. No major procedure-related complications were observed. CONCLUSION/CONCLUSIONS:Combined intradiscal, peridiscal, and subchondral BMAC injections were associated with substantial pain reduction, functional improvement, high patient satisfaction, and no major complications in this small retrospective case series. Larger prospective controlled studies are needed to confirm these preliminary findings.

Interventional procedures that target the sympathetic nervous system and specific autonomic and sensory ganglia are widely used for refractory visceral, neuropathic, and cancer-related pain. They can provide substantial, often durable analgesia but carry a small yet clinically important risk of serious adverse events. This is the third part of our narrative-review series on the safety of interventional pain procedures, following Part 1 (spinal pain injections) and Part 2 (procedures for back pain), both published in the Journal of Pain Research. It is a structured but non-systematic narrative review (PubMed, Scopus, Embase, and the Cochrane Library; 1980-2026). We examine the complications of image-guided and neuroablative procedures directed at the trigeminal (Gasserian), sphenopalatine, stellate, thoracic sympathetic, celiac/splanchnic, lumbar sympathetic, superior and inferior hypogastric, and impar ganglia and plexuses; we outline the pharmacology of phenol and ethanol and compare them with conventional radiofrequency and cryoneurolysis. Most reported complications are mild, self-limiting, and physiologically predictable, such as hypotension, diarrhea, transient sensory change, and Horner syndrome. Serious events-paraplegia, spinal cord infarction, retropharyngeal hematoma, meningitis, visceral perforation, and anesthesia dolorosa-appear uncommon, but their true incidence remains uncertain and varies by procedure, and much of the evidence derives from isolated case reports. They reflect either anatomical proximity to critical neurovascular structures or unintended spread of the neurolytic agent. Across techniques, the determinants of safety comprise real-time image guidance, meticulous needle placement, incremental dosing, contrast confirmation, attention to anticoagulation status, and careful patient selection.

As interest in donation after circulatory death for heart transplantation (DCD-HT) grows, the need to standardize protocols and address ongoing controversies becomes increasingly apparent. However, efforts toward standardization are complicated by the fact that numerous organ procurement organizations, transplant centers, and academic societies have each posited their own protocols. While some degree of variability is inevitable and sometimes necessary, variability regarding end-of-life care, definitions for reported metrics, and standards for allograft assessment may lead to inefficiencies in scaled execution and worsen ethical controversies for donors at the end of life. This review analyzes key areas of variation in contemporary DCD-HT protocols, including donor selection, management during withdrawal of life-sustaining therapy, allograft ischemic parameters, and more, and examines ongoing controversies across preoperative, peri-withdrawal, and intraoperative phases. By synthesizing current practices and identifying critical gaps, we aim to support the development of more standardized, ethically robust, and clinically effective protocols for DCD-HT.

BACKGROUND/UNASSIGNED:Pain chronicization is commonly used to describe the transition from acute to chronic pain driven by central mechanisms. OBJECTIVE/UNASSIGNED:To reassess its clinical relevance by comparing neurobiological models with patient observation. METHODS/UNASSIGNED:Conceptual analysis integrating experimental data and clinical experience. The analysis particularly considers animal models, human neuroimaging and ICD‑11 chronic pain categories. RESULTS/UNASSIGNED:While central sensitization is well established experimentally, clinical observation rarely shows a clear transition from acute to chronic pain. Chronic pain is typically heterogeneous, discontinuous and influenced by multiple factors. Neuroimaging findings are largely associative and lack temporal and causal definition. The distinction between chronic primary and secondary pain is clinically useful but does not demonstrate a biological conversion. CONCLUSION/UNASSIGNED:Pain chronicization should be considered a theoretical construct rather than a clinically demonstrable process, and interpreted with caution in individual patients.

BACKGROUND/UNASSIGNED:Related to a lack of a perceived fiduciary obligation, the health insurance industry has not historically been supportive of the efforts of providers who treat pain. In the United States and several other nations, the early years of this millennium were marked by a prescription opioid crisis, resulting in abuse, addiction and hundreds of thousands of deaths. OBJECTIVE/UNASSIGNED:The temporal contiguity between payors' withdrawal of support for interdisciplinary pain management and the onset of the prescription opioid crisis has been noted in the literature, as were payors' global instruction to physicians to just prescribe medications. STUDY DESIGN/UNASSIGNED:This is a perspective on health policy. RESULTS/UNASSIGNED:With the explosion of interventional technology and techniques over the past decades, physicians have been able to provide more effective and certainly safer pain management to sufferers of chronic pain. However, over the past several years, payors' willingness to reimburse for previously covered interventional treatments has waned, causing considerable suffering for patients and frustration for clinicians. These payors include the Centers for Medicare and Medicaid Services as well as private insurers. LIMITATIONS/UNASSIGNED:This is a perspective article with limited literature on the topic. CONCLUSION/UNASSIGNED:At present, clinicians are being told to resort to medications, despite a dearth of novel, safe pharmacological agents appropriate for chronic pain management. The availability of restorative, behavioral and alternative medicine approaches is limited in terms of insurance reimbursement. Accordingly, noncoverage of interventional approaches to chronic pain management has the potential to indirectly result in another prescription opioid crisis, which neither our patients nor providers deserve.

ObjectiveTo systematically evaluate donor site pain control interventions for iliac crest-based secondary alveolar bone grafting (ABG).DesignSystematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines.SettingOriginal scientific investigations.Patients, ParticipantsPatients undergoing iliac crest-based secondary ABG.InterventionsDonor site analgesics and minimally invasive harvest techniques.Main Outcome Measure(s)Pain scores, opioid consumption, length of stay, ambulation variables, complications, and pain assessment scales used.Results33 studies met the inclusion criteria, encompassing 1925 patients. The most frequently studied methods for donor site pain control were analgesic infusion pumps or catheters (8, 24.2%), local bupivacaine (8, 24.2%), local liposomal bupivacaine (5, 15.2%), transversus abdominis plane blocks (4, 12.1%), and bupivacaine-soaked sponges (4, 12.1%). Most studies evaluated pain scores (21, 63.6%), opioid consumption (17, 51.5%), and length of stay (17, 51.5%). The most used pain assessment scales were generic numeric (1-10) pain rating scales (9, 27.3%), the Visual Analog Scale (9, 27.3%), and the Wong-Baker FACES Scale (3, 9.1%). Use of locally administered liposomal bupivacaine was associated with improved donor site pain scores, reduced opioid consumption, and shorter length of stay. Alternative interventions exhibited variable efficacy.ConclusionsAcross the available evidence, despite notable variations in bone graft harvest techniques, intraoperative medication dosages, and pain assessment methods, locally administered liposomal bupivacaine was associated with favorable donor site pain control. The significant heterogeneity in the documentation of postoperative pain highlights the need for standardized pain assessment protocols to reliably assess the relative efficacy of donor site pain control strategies for secondary ABG.

Previous epidemiological studies have shown that E-cigarette and tobacco users are more likely to develop COVID-19 symptoms than non-users. To investigate the underlying mechanisms, we examined the effects of nicotine, the major component of tobacco and E-cigarette, and its major metabolite, cotinine, on the susceptibility of human respiratory epithelial cells to SARS-CoV-2 infection. We found that pre-treatment with nicotine and cotinine significantly and additively enhanced viral infection. While nicotine increased the expression of the viral receptor ACE2 and the serine protease TMPRSS2, cotinine upregulated cysteine protease cathepsin B and promoted viral spike protein cleavage. These findings suggest that nicotine and cotinine enhance SARS-CoV-2 infection at the cell entry stage through distinct mechanisms. Using a SARS-CoV-2 pseudovirus system, we further investigated the effects and mechanisms of nicotine and cotinine on viral entry. We found that both compounds enhanced pseudovirus infection, but with different time courses. Nicotine's effect correlated with the upregulation of ACE2 and TMPRSS2, whereas cotinine's effect corresponded with increased cathepsin B and viral spike protein cleavage. The cathepsin B inhibitor E64d completely abolished cotinine-enhanced viral spike protein cleavage and viral entry. In contrast, ACE2 and TMPRSS2 inhibitors (chloromethylketone and camostat) had limited effects on viral spike protein cleavage and only partially reduced the viral entry enhancement induced by nicotine and cotinine. These results indicate that nicotine promotes virus-receptor binding and cell entry, while cotinine facilitates viral entry through cathepsin B-mediated spike protein cleavage.IMPORTANCEThis study highlights the potential risks of tobacco and E-cigarette use in increasing susceptibility to COVID-19. We show that the major neurostimulant in tobacco and E-cigarette, nicotine, and its metabolite, cotinine, additively enhance SARS-CoV-2 infection in human respiratory epithelial cells by promoting viral entry. Specifically, nicotine and cotinine upregulate the expression of distinct, yet complementary sets of key cellular proteins required for viral entry. These findings suggest that both tobacco smoking and E-cigarette vaping may exacerbate COVID-19 infection rates and severity and provide new insights into how nicotine and cotinine contribute to viral susceptibility. This research underscores the need for public health measures to address the heightened risk posed by tobacco smoking and E-cigarette vaping to encounter the SARS-CoV-2 infection.