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/UNASSIGNED:The aging and caregiving population is becoming increasingly diverse in the United States, leading to a growing need for culturally adapted interventions to address the unique needs of underrepresented groups, such as Asian Americans. However, interventions targeting Asian Americans and exploring cultural adaptation strategies remain limited in dementia caregiving research. OBJECTIVE/UNASSIGNED:This study aimed to describe the cultural adaptation process of an evidence-based intervention for Chinese and Korean American dementia caregivers, called the New York University Caregiver Intervention-Enhanced Support. METHODS/UNASSIGNED:We conducted a deductive content analysis and categorized our adaptation strategies into 5 elements: content, context, relationship fidelity and core elements, engagement, and cultural competence. Timing and types of responses to each adaptation strategy were also observed. Two authors conducted the initial analysis, and additional team members finalized the synthesis through discussion. The Template for Intervention Description and Replication (TIDieR) checklist was used to guide the methodological rigor. RESULTS/UNASSIGNED:Twenty-four major adaptations were identified and categorized. For content, we translated materials, used culturally relevant terms, incorporated ethnic-specific surveys and resources, created social media support groups on platforms widely used by the targeted population, and extended the time allocated to complete the 6 counseling sessions. Context adaptation included expanding the range of individuals eligible for family counseling sessions to include fictive kin, using online and social media apps for communication, cultural matching and training of staff, and partnerships with relevant community organizations. Relationship fidelity and core elements involved consulting with community experts, conducting focus group interviews with caregivers, having regular meetings with the developer of the original intervention and an experienced New York University Caregiver Intervention-Enhanced Support clinician as well as experts in Chinese and Korean culture, and continuing regular counseling supervision. To enhance engagement, we provided clear explanations of the study procedure, which emphasized the benefits in participants' native languages and matched participants with social workers who shared the same cultural backgrounds. We also used a step-by-step contact approach and prolonged communication, explained staff roles to build rapport, and offered participant compensation. Finally, cultural competence was reflected in tailoring counseling techniques with respect for cultural beliefs, the use of euphemistic language for taboo subjects, and culturally appropriate refreshments to show respect and build interpersonal relationships. CONCLUSIONS/UNASSIGNED:We systematically adjusted a counseling-based intervention, an approach less familiar among Asian Americans, to fit the cultural characteristics of the target population. A contribution of this study is using an integrated, theory-driven approach that combines 2 cultural adaptation frameworks while also capturing real-time adaptations informed by external feedback and self-reflection. This work provides a practical model for adapting evidence-based interventions to serve Chinese and Korean American dementia caregivers and may inform future adaptations for other East Asian populations.

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:Lumbar spinal stenosis (LSS) is a prevalent cause of pain and disability in elderly individuals, characterized primarily by neurogenic claudication resulting from narrowed spinal canals. Traditional treatment for LSS spans from conservative approaches to decompressive surgery, the latter of which poses significant complication risks. Minimally Invasive Lumbar Decompression® (MILD®, Vertos Medical) offers a less invasive alternative, with its efficacy supported by preliminary studies such as the MiDAS ENCORE. OBJECTIVE:This retrospective study evaluates the real-world outcomes of the MILD® procedure in managing LSS accompanied by hypertrophied ligamentum flavum (HLF) in 300 patients who have failed conservative management. STUDY DESIGN/METHODS:A single-center observational study. METHODS:We conducted a retrospective review of 300 patients treated with MILD® at a single center in Northern New Jersey. Patients had documented cases of central LSS with HLF and persistent symptoms despite being treated with conventional therapies. The procedure involved percutaneous lumbar decompression using fluoroscopic guidance. Outcomes measured included scores on the Numeric Pain Rating Scale (NPRS) and patient-reported improvement percentages at intervals of up to one year. RESULTS:MILD® significantly reduced NPRS scores at all follow-up points, with the most substantial improvements noted within 3 months after the operation and sustained benefits up to a year. The average patient-reported improvement in pain and function was robust, beginning as early as 2 weeks after the procedure. No serious adverse events were reported, affirming the procedure's safety. LIMITATIONS/CONCLUSIONS:The absence of a control group and the study's single-center nature might have limited the generalizability of results. These factors highlight the necessity for multicenter controlled trials to validate findings across diverse populations. CONCLUSION/CONCLUSIONS:The MILD® procedure is a safe and effective treatment for LSS, providing significant and sustained improvements in pain and function, making the technique particularly suitable for patients ineligible for surgery or at higher risk of experiencing complications from it.

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.