Faculty Bibliography

BACKGROUND:There are risks associated with excessive intravenous fluid (IVF) administration in critically ill children. Previous efforts have described opportunities to reduce positive cumulative fluid balance (CFB) in this population but have not been widely implemented. In the wake of Hurricane Helene, a national IVF shortage led to the implementation of IVF conservation guidelines. We sought to determine if this was associated with a reduction in IVF use and CFB. METHODS:The present study is a four-site cohort study of critically ill children utilizing a federated data collection framework to extract patient age, sex, weight, and daily fluid intake/output for days 1-4 of all admissions 28 days prior to and 28 days after the implementation of IVF conservation guidelines. Guidelines were individualized per institution. Total fluid intake, total IVF intake, % intake from IVF, and % CFB were compared between pre- and post-IVF conservation groups. RESULTS:All sites had similar conservation recommendations. There were 633 patients admitted pre- and 619 patients admitted post-IVF conservation guideline implementation, with similar age and weight distributions. There was no significant difference in IVF use pre- and post-IVF conservation; 29-35% of patients had > 5% CFB on day 1 pre-IVF conservation while 27-39% did post-conservation, with increasing numbers on day 2. CONCLUSIONS:Even in the setting of a national IVF shortage, simple recommendations without structured change were insufficient to change IVF administration practices. This indicates additional practices will be needed to reduce IVF intake and % CFB in this vulnerable population.

Serotonergic psychedelics and 3,4-methylendioxtmethamphetamine (MDMA) are promising treatments for mental disorders with a continuously evolving evidence base. We searched Pubmed/Scopus/clinical trial registries up to 08july2025 for double-blind randomized controlled trials (RCTs) testing MDMA or serotonergic psychedelics in patients with mental disorders. Primary outcomes were change in disease-specific symptoms and all-cause discontinuation. Standardized mean differences (SMD) and relative risk (RR) were estimated using random-effects meta-analysis. Risk of bias (RoB) was assessed with Cochrane's RoB-tool version 2 and certainty of evidence with GRADE. The review is maintained as living systematic review (https://ebipsyche-database.org/). We included 30 RCTs (1480 participants; female=45.8 %; with psychological support=83.3 %; high RoB=83.3 %). In post-traumatic stress disorder (PTSD), MDMA reduced PTSD symptoms compared to any control (k = 11; SMD=-0.85 [-1.09; -0.60]; I²=0 %; GRADE=low). In major depressive disorder (MDD), psilocybin/ayahuasca/LSD reduced depressive symptoms (k = 8; SMD=-0.62 [-0.97; -0.28]; I²=55 %; GRADE=very low). In anxiety disorders, both MDMA and serotonergic psychedelics reduced anxiety symptoms (SMD_MDMA=-1.18 [-2.04; -0.32]; I²=0 %; k = 2; GRADE=low and SMD_serotonergic=-0.88 [-1.70; -0.06]; I²=54 %;k = 5; GRADE=very low). In alcohol use disorder, neither psilocybin nor LSD reduced abstinence rates (k = 6; RR=1.42 [0.89; 2.26]; I²=7 %; GRADE=very low). In attention-deficit hyperactivity disorder (ADHD), LSD did not reduce ADHD symptoms (k = 1; SMD=0.22 [-0.32; 0.76]; GRADE=very low). Moderate certainty in evidence was only found for MDMA on PTSD symptoms when compared to placebo. MDMA/serotonergic psychedelics were not associated with higher risk of all-cause discontinuation (RR_MDMA=0.74 [0.32; 1.72]; RR_serotonergic=0.81 [0.56; 1.15]). Overall, MDMA/serotonergic psychedelics are promising for the treatment of PTSD, MDD, and anxiety disorders with moderate to large effect sizes. Pragmatic trials, long-term, head-to-head trials exploring the role of psychological support, aiming to identify predictors of response, and accounting for expectancy and functional unblinding are needed. Studies addressing these limitations will likely be required for regulatory approval of psychedelic drugs.

OBJECTIVE:To determine whether administration of antenatal corticosteroids to patients with twin gestations at risk for late preterm delivery is associated with reduced risk for neonatal respiratory morbidity compared with unexposed twins. METHODS:This was a multicenter, retrospective cohort study in a large, urban health network (2013-2022) of patients with twin gestations at risk for preterm delivery between 34 0/7 and 36 6/7 weeks of gestation. Patients were excluded if they received antenatal corticosteroids before 34 weeks of gestation or had pregestational diabetes, single-twin death before 34 weeks, or oral steroid exposure during pregnancy. Neonates were excluded if they had major congenital anomalies. The primary outcome was a composite of neonatal respiratory morbidity requiring respiratory support within 72 hours of birth, including continuous positive airway pressure (CPAP) or high-flow nasal cannula for 2 hours or more, supplemental oxygen of 30% for 2 hours or more, extracorporeal membrane oxygenation, mechanical ventilation, and fetal or neonatal death. Secondary outcomes included neonatal hypoglycemia and indications for neonatal intensive care unit (NICU) admission. Adjusted and unadjusted relative risks with 95% CIs were calculated. RESULTS:During the study period, 366 twin gestations and 722 patient-neonate dyads were included: 162 gestations (321 neonates) in the exposed group and 204 (401 neonates) in the unexposed group. There was no difference in the composite outcome of respiratory morbidity in those exposed to antenatal corticosteroids (23.4% vs 20.4%, P=.40, adjusted relative risk [RR] 1.00, 95% CI, 0.71-1.42). The composite was driven mostly by rates of CPAP use (21.2% vs 18.5%, P=.41, adjusted RR 1.05, 95% CI, 0.73-1.53) and high-flow nasal cannula use (6.2% vs 2.2%, P=.02, RR 2.77, 95% CI, 1.16-6.66). Antenatal corticosteroid exposure was associated with a lower risk of need for supplemental oxygen (0.6% vs 3.5%, P=.02, RR 0.18, 95% CI, 0.04-0.79) and mechanical ventilation (0.6% vs 3.2%, P=.03, RR 0.19, 95% CI, 0.04-0.87). Although antenatal corticosteroids exposure was not associated with higher rates of hypoglycemia (44.2% vs 41.7%, P=.57, adjusted RR 0.99, 95% CI, 0.82-1.19), exposure was associated with a higher risk of having hypoglycemia as the only indication for NICU admission (10.3% vs 5.2%, P=.03, RR 1.96, 95% CI, 1.07-3.59). CONCLUSION/CONCLUSIONS:In a large, multicenter, network-wide retrospective cohort study of patients with twin gestations at risk for late preterm birth, antenatal corticosteroid use was not associated with a decrease in overall respiratory morbidity but was associated with a decreased risk of need for supplemental oxygen and mechanical ventilation, as well as a higher risk of NICU admission for hypoglycemia. These results underscore the ongoing need to elucidate the risks and benefits of late preterm antenatal corticosteroids for patients with twin gestations at risk for late preterm birth.

BACKGROUND AND AIMS/OBJECTIVE:Prophylactic colonic endoscopic submucosal dissection (ESD) defect closure may reduce delayed adverse events (DAEs) such as bleeding and perforation associated with ESD and facilitate same day discharge. We compared the effect of colonic ESD defect closure (closed group) with no closure (open group) on DAEs and overnight hospital admission. METHODS:We performed a Western multicenter retrospective study on patients who underwent colon ESD. Rectal lesions were excluded. DAEs were defined as adverse events within 2 weeks of ESD. Primary outcome measures were DAEs and overnight hospital admission. Multivariate analyses were performed. RESULTS:560 patients underwent colon ESD and 364 (71.8%) patients had complete defect closure. Closed group had a significantly lower rate of delayed bleeding (1.7% vs 5.6%, p = 0.03) compared to open group. Multivariate analysis with adjusted odds ratios (aOR) revealed right sided polyps (aOR = 7.0) and anticoagulation/antiplatelet agents (aOR = 6.6) increased the risk while defect closure (aOR = 0.2) decreased the risk of delayed bleeding. Defect closure amplified the reduction in risk of delayed bleeding (2.4% vs 10.4%, p = 0.014) for right-sided polyps. Malignant polyps significantly increased the risk of delayed perforation (aOR = 3.3) and overnight hospitalization (aOR = 2.9). Defect closure (aOR = 0.6), traction use (aOR = 0.6) and topical hemostatic agent use (aOR = 0.4) significantly reduced the risk of overnight hospitalization. CONCLUSION/CONCLUSIONS:Prophylactic closure of colon ESD defects was associated with a significant reduction in delayed bleeding with number needed to treat (NNT) of 25.6 (especially for right sided polyps, NNT 12.5), and post-procedural overnight hospitalization. Prospective studies are needed to further validate these results.

Malignancy associated with ileal neobladders or ileal conduits in postradical cystectomy patients is rare. Yet, recurrent urothelial carcinoma or new primary cancers, such as adenocarcinoma, enteric type (EA), are potential complications that pose significant clinical challenges. This study aimed to evaluate the incidence, clinical outcomes, and management strategies for malignancies in patients with ileal neobladders or ileal conduits. A retrospective review was conducted at 3 large academic institutions, identifying 10 cases of malignant tumors arising in ileal neobladders or ileal conduits over a period of 10 years. The study cohort included 9 male and 1 female patient aged 56 to 92 years (mean age = 68.2 y). Data on clinical presentation, management, pathology, and outcomes were collected, with a focus on recurrence and disease-specific survival rates. Seven of 10 patients (all males) were initially diagnosed with invasive high-grade urothelial carcinoma (IHGUC), whereas 3 patients had a history of bladder augmentation with colonic tissue (BA) for benign etiologies. Of patients with IHGUC, 2 patients received neoadjuvant chemotherapy, 1 received a combination of chemotherapy agents, and 3 patients underwent intravesical BCG therapy. All IHGUC exhibited conventional morphology without divergent differentiation. Pathologic staging of the cystectomy for IHGUC ranged from pTa to pT3a, with 4 cases showing lymph node metastasis. IHGUC recurrence was detected in 6 of 7 patients with a latency period range of 7 months to 6.7 years (mean 37 mo) and all tumors again exhibiting conventional morphology without divergent differentiation. IHGUC recurrence demonstrated a pathologic stage ranging from pT2 to pT4, and 5 died (mean = 4.2 mo), whereas 1 patient remains alive and on surveillance. EA occurred in 4 patients, including 3 BA patients and 2 foci in 1 patient with a neobladder for IHGUC. Staging of patients with EA ranged from pTis to pT2 developing 31 to 55 years postsurgery. Three of 5 EA cases were associated with a precursor lesion including 2 tubular adenoma with high-grade dysplasia, and 1 sessile serrated lesion with dysplasia. EA patients had relatively favorable outcomes compared with IHGUC patients,  with all surviving patients currently on surveillance though with one case demonstrating nodal metastasis. Although rare, malignancies in ileal neobladders or ileal conduits are a serious complication. Although IHGUC recurrence often leads to poor survival, EA patients-especially those with prior bladder augmentation-seem to be associated with better survival outcomes. The long latency period for IHGUC recurrence and the favorable prognosis for EA underscore the need for vigilant long-term surveillance.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Histiocytoses are diverse hematopoietic diseases with disabling neurologic involvement. Recently, targeted mitogen-activated protein kinase pathway inhibitors have been used with clinical and radiologic response; however, some patients are unable to tolerate these treatments or have isolated and/or refractory neurologic, ocular, or head and neck (NOHN) disease. Intra-arterial administration of chemotherapy has conferred favorable responses in various neoplasms; however, treatment and outcomes across histiocytosis subtypes have not been examined. METHODS:Patients with biopsy-proven histiocytosis involving NOHN structures underwent an outpatient interventional procedure with angiography, selective catheterization, and intra-arterial infusion of melphalan, with target arteries depending on the site of disease. Patients were followed with radiologic (i.e., PET/CT, CT, MRI, or ophthalmic ultrasound and optical coherence tomography) and quantified functional assessments (i.e., vision, speech, or balance) as appropriate. Complete or partial radiologic and functional response rates were captured as well as frequency of subsequent progression. RESULTS:Eighteen patients underwent 74 total treatment instances. For 14 patients with radiologically evaluable tumorous disease, 10 (71%) had partial or complete response and the remaining 4 had stable disease; 3 of 14 (21%) had subsequent radiologic progression. Of 13 functionally evaluable patients, including 6 with neurodegenerative histiocytosis, 12 (92%) experienced functional improvement; 7 of 13 (54%) had subsequent functional worsening consistent with disease progression. There were no intraprocedural complications; 3 patients required hospitalization following treatment, including 1 patient with allergic reaction to melphalan. DISCUSSION/CONCLUSIONS:For patients with tumorous and neurodegenerative histiocytosis, intra-arterial melphalan represents a safe and highly effective treatment with potential to improve neurologic function. Additional study may clarify patients most suitable for this intervention. This novel treatment modality may represent a practice-changing innovation for refractory histiocytosis involving neurologic and ocular structures, as well as neurodegenerative forms. The treatment delivery form is novel, and future work should be directed at studying the efficacy of this modality to other forms of neurologic, ocular, head, and neck cancers. CLASSIFICATION OF EVIDENCE/METHODS:This study provides Class IV evidence that in patients with tumorous or neurodegenerative histiocytosis, selective angiographic catheterization and intra-arterial infusion of melphalan result in radiologic and functional improvement.

Breast cancer screening recommendations have been established historically for women, but, have been less clearly outlined for men. For average-risk men and younger men less than 25 year of age, imaging is not usually appropriate as a screening test for breast cancer. For men of higher-than-average risk, screening with mammography as annual surveillance imaging is usually appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.