Faculty Bibliography

Women with a history of surgical correction for adolescent idiopathic scoliosis are often denied neuraxial anesthesia during labor and delivery due to concerns of technical difficulties, anesthetic failures, inadvertent dural punctures, and hardware infections. We report four successful neuraxial procedures by four different anesthesiologists in three patients with previous posterior spinal instrumentation and fusion who delivered at our institution. The procedures include spinal anesthesia for cerclage, epidural analgesia for labor followed by successful conversion to epidural anesthesia for intrapartum cesarean delivery, spinal anesthesia for cesarean delivery, and epidural analgesia for vaginal delivery. Modern surgical techniques improve success rates of neuraxial anesthesia. Antenatal anesthesia consultation, knowledge of the lowest instrumented vertebra, familiarity with neuraxial ultrasound and multidisciplinary collaboration between orthopedic, obstetric, and anesthesiology teams are key. Anesthesiologists should offer and attempt neuraxial anesthesia if desired by these patients. Neuraxial anesthesia should not be withheld from them because they have spine instrumentation.

Myeloproliferative neoplasms (MPNs) are a spectrum of clonal hematologic malignancies, characterized by an acquired somatic mutation in hematopoietic stem cells (HSC). Consequent constitutive activation of the JAK/STAT signaling pathway ultimately leads to HSC clonal expansion, a heightened inflammatory state, and aberrant trafficking of the malignant stem cells to sites of extramedullary hematopoiesis. While polycythemia vera (PV), essential thrombocythemia (ET), and myelofibrosis (MF) are distinct disease entities, each with their own diagnostic criteria, risk stratification, and molecular profiles, they share a common pathogenesis and exist on a spectrum, with overlapping clinical features, propensity for thrombohemorrhagic events, and risk for transformation to acute leukemia. Interferon alpha (IFN-α) has both anti-proliferative and immunomodulatory effects on MPN HSCs, and therefore is an effective treatment modality for PV, ET, and MF. In this review, we discuss the rationale for IFN-α use in MPNs, examine the evidence supporting its use, and convey practical considerations.

Myelofibrosis (MF) is a chronic myeloproliferative neoplasm characterized by progressive cytopenias, splenomegaly, and constitutional symptoms. The hallmark of MF pathophysiology is constitutive activation of JAK/STAT signaling, which, in the majority of cases, is associated with an acquired mutation in one of three driver mutations, JAK2, CALR, or MPL. Our growing understanding of the molecular biology of MPNs has resulted in regulatory approval of four JAK inhibitors (JAKi), which have demonstrated efficacy in improving symptom burden and reducing spleen size. Despite clear benefits of JAKi therapy, including evidence of improved survival, these therapeutic interventions have not established an ability to modify disease in terms of resolution of bone marrow fibrosis or molecular remissions. Therefore, recent emphasis has been on the development of novel therapies with informed targets outside of the JAK/STAT signaling pathway. Moreover, combination approaches utilizing JAK and non-JAK targeting agents underscore the potential for disease modification along with deeper and more durable clinical responses. Emerging combination strategies and their clinical development will be reviewed here, including investigations that pair JAKi therapy with BCL-2 family inhibitors, BET inhibitors, restored p53 cell death signals, telomerase inhibitors, PIM1 kinase inhibitors, and mutant CALR targeted therapies. While several combination clinical trials suggest improved spleen and symptom responses and the possibility of disease modification, toxicity profiles and optimal sequencing remain areas of active investigation.

Background Obesity is a global epidemic. The prevalence of obesity has significantly increased in recent decades and is expected to impact a large portion of the US population. Hypertension continues to be one of the most common complications associated with obesity, and the overlap between these two conditions has been growing over time. However, mortality trends in patients with obesity and hypertension have not been investigated in the literature. Objectives This study aimed to investigate mortality trends, stratified by sex, race, age groups, and geographic distribution, in the US population between 1999 and 2020. Methods Death certificates from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) were examined and analyzed between 1999 and 2020 for patients with obesity and hypertension as the contributing causes of death. The age-adjusted mortality rates (AAMRs) and annual percent changes (APCs) per 100000 people were calculated by sex, race, age group, and geographic region. Results Among individuals aged ≥15, a total of 294854 deaths occurred in individuals with obesity and hypertension between 1999 and 2020. The overall AAMR increased from 1.08 in 1999 to 12.14 in 2020. The AAMR has steadily increased since 1999, with a sudden spike occurring between 2018 and 2020 during the COVID-19 pandemic. This trend has been observed across nearly all variables analyzed in our study. Our results exhibited a 28% increase in mortality related to obesity and hypertension during the early years of the COVID-19 pandemic. During the study period, men had a higher overall AAMR than women (men, 5.92; women, 4.32). Mortality was highest among the 55-74-year-old age group, followed by the 75-plus-year-old, 35-54-year-old, and finally 15-34-year-old age groups, which displayed the lowest AAMR (AAMR: 55-74, 11.76; 75+, 10.83; 35-54, 4.73; and 15-34, 0.54). Among the races, non-Hispanic (NH) Blacks had the highest overall AAMR (9.81), followed by NH American Indians or Alaskan Natives (6.01), NH Whites (4.64), Hispanics (4.08), and NH Asians or Pacific Islanders (1.17). However, NH Whites showed the highest average APC (AAPC) (11.44), indicating a possible future shift in mortality. By geographic region, the Southern United States had the highest AAMR, followed by the Western, Midwestern, and Northeastern regions. Non-metropolitan areas had consistently higher obesity- and hypertension-related AAMRs (5.63 overall) compared to metropolitan areas (4.99 overall). Conclusion In our retrospective analysis of death certificate data from 1999 to 2020, we found that age-adjusted mortality rates among individuals with both obesity and hypertension consistently displayed an increasing trend across all demographic groups. The overall rising AAMRs, compounded by the disproportionately high average annual percent changes among White individuals and those aged 15-34, raise serious concerns for the healthcare system. These findings have significant implications for public health policy. Focused interventions are essential to curb the upward trajectory of mortality in this population, as early intervention can greatly help tackle the dual burden of obesity and hypertension, which are largely preventable.

INTRODUCTION/UNASSIGNED:negative myeloproliferative neoplasm (MPN) driven by recurrent acquired somatic mutations in hematopoietic stem cells and characterized by progressive bone marrow fibrosis, cytopenias, and extramedullary hematopoiesis. Janus kinase inhibitors (JAKi) improve splenomegaly and MF symptom burden but without achieving molecular remission or clear disease course modification. Novel therapies targeting epigenetic dysregulation through bromodomain and extra-terminal domain (BET) proteins have emerged as a key therapeutic approach, aimed at reducing pro-inflammatory and oncogenic transcription to deepen clinical responses in combination with JAKi therapy. AREAS COVERED/UNASSIGNED:This review summarizes the biology, preclinical data, and emerging clinical data in the development of novel BET inhibitor (BETi). Trials assessing the efficacy of pelabresib, ABBV-744, INCB057643, BMS-986158, and OPN-2853 are detailed herein. EXPERT OPINION/UNASSIGNED:BET protein inhibition is a promising therapeutic target complementing JAK inhibition by co-targeting inflammatory pathways, fibrosis, and clonal proliferation. Pelabresib is a pan-BETi furthest in development demonstrating clinical benefit with ongoing trials. Research into novel pan-and selective-BETis both as monotherapy and in combination with JAKis or other mechanism-based therapies is ongoing. Whether BETi therapy in MF will ultimately deliver substantial anti-clonal activity to modify disease biology and meaningfully impact clinical outcomes is yet to be determined.

Idasanutlin is a small molecule inhibitor that restores p53 activity, triggering apoptosis. Two trials (phase 1/2) of idasanutlin therapy in polycythemia vera patients that were intolerant or refractory to hydroxyurea resulted in substantial clinical and molecular responses. Here the long term outcomes of these patients are reported.

INTRODUCTION/BACKGROUND:The transition from resident to junior faculty in academic emergency medicine (EM) may be shaped not only by formal training and institutional policies but also by the "unwritten curriculum," a set of norms and expectations embedded in institutional culture. However, the unwritten curriculum and its potential to impact junior faculty development remains largely unexplored. Little is known about how junior faculty perceive, experience, and navigate these informal expectations, or the formal and informal structures that influence this process. In this study we aimed to explore junior faculty members' experiences with the unwritten curriculum in academic EM, with a focus on how they interpret and navigate institutional norms and identify supports and barriers encountered during their early faculty development. METHODS:Within their first five years, EM faculty at academic institutions distinct from their residency training sites completed an anonymous, iteratively developed survey designed to explore experiences with the unwritten curriculum, informed by Schlossberg's transition theory framework. The primary analytic focus was identification of themes describing how junior faculty perceive and navigate implicit institutional norms. Open-ended responses underwent thematic analysis using a structured codebook, applied by two independent reviewers with consensus-based coding and adjudication by a third when disagreements arose. RESULTS:A total of 35 junior faculty members completed the survey. All participants indicated influence of the unwritten curriculum on their professional development. Major themes identified include the unspoken importance of mentorship and peer guidance; implicit expectations and norms surrounding engagement, productivity, and visibility; work-life integration; cultural adjustment; scholarly output; and gaps in onboarding, feedback, and role clarity. Participants emphasized challenges in navigating departmental politics, understanding hierarchical nuances, and balancing unspoken expectations for committee involvement and informal social participation. Additionally, unclear feedback processes, inconsistent evaluation expectations, and cultural norms for active engagement were noted as barriers to integration and professional growth. CONCLUSION/CONCLUSIONS:Junior faculty in academic EM described the unwritten curriculum as a meaningful influence on their early faculty experience. Within this sample, participants highlighted mentorship, feedback transparency, and structured faculty development as potential mechanisms to support navigation of implicit expectations during the transition to junior faculty. These findings reflect individual perceptions rather than program characteristics and should be interpreted within the context of the study's scope.

OBJECTIVES/UNASSIGNED:The scholarly activity requirement by the Accreditation Council for Graduate Medical Education (ACGME) is broadly defined and variably applied by residency programs. The scholarly productivity of trainees is variable and it is unknown why some may struggle to meet this requirement. This study aims to explore the perspectives of residents who struggled in completing scholarship during residency. METHODS/UNASSIGNED:We performed a qualitative study using a constructivist paradigm and conducted semi-structured interviews at four ACGME-accredited emergency medicine residency programs. The programs reflect diverse locations and training formats. We invited residents who self-identified as struggling with scholarship. Two researchers independently performed a content analysis of interview transcripts. We resolved discrepancies through in-depth discussion and negotiated consensus. RESULTS/UNASSIGNED:We interviewed 13 residents (6 Male and 7 Female; median age 31; 7 PGY-3, 3 PGY-4, 3 post-graduation). Many participated in scholarship before residency. We identified three major themes: barriers/challenges to scholarly activity, recommendations to programs to support residents in scholarly work, and strategies for residents to mitigate challenges. Challenges to scholarly activity included lack of understanding of the scholarly project requirement, lack of time, lack of perceived value, and mentorship challenges. Participants recommended programs set clear expectations, provide infrastructure, and facilitate high-quality mentorship, including a faculty champion. Participants advised residents to start the project early, seek out good mentorship, and find a meaningful, but simple, project. CONCLUSIONS/UNASSIGNED:Our study reveals that even residents with prior experience can struggle with scholarship and we identified multiple barriers trainees face. Strategically investing in infrastructure, clarifying expectations, and prioritizing mentorship represents an actionable roadmap that may transform the scholarly project from a burdensome requirement into a meaningful educational opportunity.

BACKGROUND:Despite the important role of Geriatricians in our society, there is a shortage of Geriatric Medicine specialists. This study surveyed fellows enrolled in ACGME approved Geriatric Medicine fellowships in the United States for insight into why they joined a Geriatric Medicine fellowship. METHODS:Survey links were sent to all Geriatric Medicine Program Directors from July-Sept in 2019 and 2020 and we asked them to share the surveys with their fellows. Survey responses were summarized using descriptive statistics. The Likert-scaled dataset was analyzed with percentage of responses for each item related to "influence" and "barrier" domains. We examined the associations between variables using the Chi-Square test. The free-text fields were analyzed using inductive thematic analysis. RESULTS:There were 149 respondents (80% female) and approximately half of the respondents were from foreign medical schools (52%). Geriatric Medicine was the first fellowship choice for 75% of respondents. Among respondents who were US medical graduates, 89% chose Geriatric Medicine as first-choice specialty for fellowship, in contrast to 61.5% among the Foreign Medical Graduates (FMGs) (p < 0.001). Major reasons why fellows chose Geriatric Medicine were unique career opportunities and care of complex patients. The largest barrier/concern for pursuing Geriatric Medicine fellowship was the low salary associated with the field. CONCLUSIONS:As the first national survey of Geriatric Medicine fellows evaluating their reasons for pursuing a Geriatric Medicine fellowship, these results can be used by Geriatric Medicine fellowship programs and health care systems to improve recruitment into Geriatric Medicine fellowships.