Faculty Bibliography

BACKGROUND:Adrenal venous sampling is routinely used to lateralize aldosterone hypersecretion but has an unclear role in adrenocorticotropic hormone-independent autonomous hypercortisolism. We define clinical scenarios where adrenal venous sampling provides value for surgical decision-making. METHODS:We performed a single-center retrospective review of patients undergoing adrenal venous sampling for hypercortisolism (January 2012-April 2025). Lateralization was defined by a lateralization ratio >2 using aldosterone as a reference hormone. We also conducted a scoping review of studies describing adrenal venous sampling use in hypercortisolism identified through a comprehensive literature search. RESULTS:Nine patients with isolated hypercortisolism were included, of which 88.9% were female, with a median age of 60 years (range, 41-76). Seven patients presented with mild autonomous cortisol secretion and 2 with overt Cushing's syndrome. Six patients had bilateral adrenal nodules. Mean nodule size was 2.71 ± 0.85 cm. Eight patients underwent a 1-mg dexamethasone suppression test, with all patients meeting the >1.8 μg/dL threshold for elevated serum cortisol (mean dexamethasone suppression test cortisol: 7.13 ± 4.82 μg/dL). Adrenal venous sampling lateralization corresponded to the larger or unilateral nodule in 5 patients, was nonlateralizing in 3, and correctly lateralized to the smaller nodule in 1 patient with similarly sized lesions (1.9 cm versus 2.0 cm), enabling correct-side surgery and resolution of symptoms of overt Cushing's. Seven isolated hypercortisolism patients underwent adrenalectomy, all with benign pathology. Nine studies were included in the scoping review, demonstrating heterogeneous adrenal venous sampling lateralization criteria. CONCLUSION/CONCLUSIONS:Adrenal venous sampling may be useful in select patients with adrenocorticotropic hormone-independent hypercortisolism and similarly sized bilateral adrenal nodules in order to prevent incorrect-side adrenalectomy or unnecessary bilateral adrenalectomy.

INTRODUCTION/BACKGROUND:Most injuries occur in low- and middle-income countries (LMICs), yet the trauma literature largely reflects high-income countries (HICs), and no research-methodology course is tailored to LMIC acute care surgeons or to trauma-specific infrastructure such as injury registries. We surveyed acute care surgeons to inform an American Association for the Surgery of Trauma (AAST) research-methodology curriculum. METHODS:A voluntary 25-item Research Electronic Data Capture survey developed by the AAST International Relations Committee, covering research experience, infrastructure access, and training priorities, was distributed (January-June 2025) by email and social media to AAST members and partner international trauma organizations. Respondents were classified by World Bank income group and compared using chi-square or Fisher exact tests. RESULTS:Of 132 respondents, 72 (55%) practiced in HICs and 60 (45%) in LMICs. versus HIC peers, LMIC respondents reported less research experience (73% versus 90%; P = 0.01), fewer publications (38% versus 74%; P < 0.001), and markedly less access to a trauma registry (20% versus 86%), statistical support, and a research coordinator (all P ≤ 0.006). A higher proportion of LMIC respondents selected registry design (52% versus 26%), scientific writing (67% versus 46%), and literature appraisal (47% versus 28%), while HIC respondents favored statistics and retrospective research (P < 0.05); and more likely to agree a mentor would help their research (93% versus 60%; P < 0.001). Course interest was high in both groups. CONCLUSIONS:Interest in research-methodology training was strong across income settings, but LMIC surgeons reported distinct, infrastructure-linked needs centered on trauma-registry building, scientific writing, foundational skills, and mentorship. Course design should reflect these differences rather than export a high-income model.

Chimeric antigen receptor (CAR) T-cell (CAR-T) treatment for B-cell acute lymphoblastic leukemia (ALL) induces high initial response rates, but most patients relapse. Low disease burden (often defined as <5% blasts in the bone marrow) is associated with better outcomes. CAR HEMATOTOX (HT) is a score using prelymphodepletion hematologic and inflammatory parameters to predict outcomes in lymphoma. Here, we assess its prognostic utility in a large multicenter adult B-cell ALL cohort. Patients who received brexucabtagene autoleucel across 33 centers in North America were included as part of the Real-World Outcomes Collaborative of CAR-T in Adult ALL (ROCCA) consortium. An independent cohort of 61 patients with ALL treated with an investigational CD19 CAR-T therapy at 1 center was also described. Among 199 ROCCA consortium patients, 43 (22%) patients with HTlow scores had lower rates of delayed neutrophil recovery than those with HThigh scores (26% vs 52%, P = .002) and fewer severe infections (2.5% vs 18.8%, P = .011). They also had higher response rates, overall survival (OS), and event-free survival (EFS), as well as lower nonrelapse mortality and cumulative incidence of relapse. The survival differences remained significant after multivariable adjustment for disease burden and other covariates. In the investigational cohort of 61 patients, patients with HTlow scores had improved OS and EFS, as well as higher peak CAR-T expansion. In summary, CAR HT score is a prognostic factor independent of disease burden in adult ALL. HTlow score is associated with superior outcomes after CD19 CAR-Ts and higher CAR-T expansion in a single-center cohort. These trials were registered at www.clinicaltrials.gov as #NCT01044069 and #NCT01860937.

BACKGROUND:The entity of Philadelphia (Ph)-like acute lymphoblastic leukemia (ALL) accounts for approximately 20-30% of newly diagnosed adults with B-cell ALL cases in the USA. Compared to other B-cell subtypes, Ph-like ALL is associated with overall poor prognosis and inferior outcomes with high measurable residual disease rates following induction therapy, increased risk of treatment failure and relapse, as well as short event-free and overall survival. SUMMARY:Here we aim to highlight Ph-like ALL genetic subtypes and methods of genomic profiling for diagnosis and disease prognostication and to summarize current management approaches for frontline treatment including multiagent chemotherapy, immunotherapy, tyrosine kinase and small molecule inhibitors, and the role of allogeneic stem cell transplantation. KEY MESSAGES:Despite the improvement in the treatment outcomes of adult patients with newly diagnosed B-cell ALL, patients with Ph-like ALL continue to do poorly with standard therapy. Thus, tailored therapeutic studies are indeed warranted to refine frontline treatment approaches and to improve outcomes for patients with Ph-like ALL.

In 2024, the International Anal Neoplasia Society (IANS) published the first consensus guidelines for anal cancer screening, outlining recommendations for patients who are most impacted by anal cancer. This study assesses provider knowledge and practice of these guidelines. A 37-item cross-sectional survey was distributed electronically to physicians, nurse practitioners, and physician assistants across ten specialties within a single health system. The survey assessed familiarity with anal cytology, guideline knowledge, screening practices, and barriers to screening. Descriptive statistics and bivariate analyses compared primary care providers (PCPs) to subspecialists. 87 providers completed the survey (62% physicians, 21% nurse practitioners, 17% physician assistants); 60% were Primary Care Physicians (PCPs) and 40% subspecialists. 55% had never heard of the IANS guidelines, and 76% had never performed an anal Pap test. Among the 70 providers completing the knowledge assessment, the median score was 10/20 (Inter Quartile Range (IQR) 8-12). Providers performed worst when identifying screening recommendations for solid organ transplant recipients (7% correct) and cisgender women with HIV (13% correct). No significant differences were found between PCPs and subspecialists across any measure. Qualitative responses identified scope of practice uncertainty (78%), lack of training (20%), and limited access to high-resolution anoscopy (9%) as primary barriers. Provider knowledge and utilization of anal cancer screening guidelines remain critically low across specialties. These findings highlight the urgent need for institution-wide education, standardized ordering pathways, and clear referral processes to improve screening rates.

The heart and brain are interconnected, and risk factors that impact the heart can negatively affect the brain and cognition. Among the underlying features that foster both poor brain health and poor heart health are obesity, diabetes, physical inactivity and low sleep quality. Obesity and type 2 diabetes are associated with an increased likelihood of cognitive impairment and dementia. Further, obesity is a causal factor in obstructive sleep apnea, leading to intermittent hypoxemia, neuroinflammation and cognitive dysfunction. Cerebrovascular disease with reduced cerebral blood flow brings on stroke and elevates dementia risk. Like cardiovascular disease, cerebrovascular disease is also accelerated in the setting of obesity, likely through the same mechanisms involving endothelial dysfunction and damage to macrovasculature and microvasculature from hypertension, dyslipidemia and inflammation. Obesity is considered a risk factor for recurrent stroke. The protracted low-grade chronic elevation of inflammatory markers found with excess adiposity leads to oxidative stress and promotes both endothelial dysfunction and a pro-thrombotic state. Greater loss of brain volume has been documented in middle-aged and older adults with obesity compared with young adults with obesity. Obesity poses a threat to the cardiovascular and cerebrovascular health and well-being of individuals worldwide. Unfortunately, treatments directed at reducing caloric intake are of limited effectiveness. This review will focus on the latest research into the link between excess adipose tissue and cardiac and brain health, with attention to dietary and lifestyle interventions that may be protective of the integrity and function of the vasculature and brain.

IMPORTANCE/UNASSIGNED:Syringe services programs (SSPs) are an evidence-based intervention to reduce bloodborne disease transmission and other risks related to injection drug use; however, SSP access is uneven. State and local syringe distribution laws may influence variation in the presence and number of SSPs across local jurisdictions. OBJECTIVE/UNASSIGNED:To assess the association between state and local syringe distribution laws and presence of publicly listed SSPs in a sample of US cities. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This cross-sectional study linked state and local laws with information on publicly reported SSPs in 2024 for the largest US municipalities and census-designated places (localities). The outcomes of policy exposure in SSP presence and total number of SSP locations among localities with at least 1 SSP were estimated using a 2-part negative binomial hurdle model, adjusting for state and local policy and demographic and health characteristics. The study team collected the legal data from January 11, 2023, through May 7, 2024. EXPOSURE/UNASSIGNED:State and local syringe distribution policy environment as of December 31, 2022, categorized from most restrictive (state prohibition) to least restrictive (neither state nor locality prohibits syringe distribution). MAIN OUTCOMES AND MEASURES/UNASSIGNED:Publicly reported SSP presence (binary) and total count of SSP locations within each locality as of February 2024. RESULTS/UNASSIGNED:In this study using data from 482 US localities, there was at least 1 SSP in 181 (37.6%) localities. Localities with the least restrictive legal environment had increased odds of SSP presence (adjusted odds ratio, 16.3; 95% CI, 6.0-44.1) compared with those with the most restrictive legal environment. Among localities with 1 or more SSP, localities in the least restrictive legal environment or a legal environment that exempted SSPs from a syringe distribution prohibition had increased rates of SSPs, relative to the most restrictive legal environment (rate ratio for least restrictive policy environment, 2.7; 95% CI, 1.1-6.4; rate ratio for legal environment that exempts SSPs from prohibition, 2.4; 95% CI, 1.1-5.6). Overall, policies that exempted SSPs from syringe distribution prohibitions and those with no syringe distribution prohibitions had the highest estimated SSP counts (1.9 SSPs; 95% CI, 1.5-2.4; 1.5 SSPs; 95% CI, 1.1-1.9, respectively). CONCLUSIONS AND RELEVANCE/UNASSIGNED:This study found that state and local syringe distribution laws were associated with publicly listed SSP presence. Legal environments that prohibit or restrict syringe distribution may limit the presence and total number of SSPs, highlighting the role of policy context in shaping access to harm-reduction services.

ABSTRACT/UNASSIGNED:OBJECTIVES: This case report describes the implementation and outcomes of robotic process automation (RPA) interventions used as an electronic health record (EHR)-based reliability layer for two inpatient quality initiatives: First Contact Provider (FCP) assignment and Admission Medication Reconciliation (AMR) within 24 hours. ABSTRACT/UNASSIGNED:METHODS: RPA bots were created to support two inpatient quality initiatives by monitoring EHR patient lists for predefined care gaps: missing FCP assignment and incomplete AMR. When a gap was identified, the bot opened the patient chart, initiated a secure-message conversation with frontline clinicians and quality improvement (QI) champions, and generated operational reports to support follow-up. Chi-square tests compared FCP before (September 1, 2022-February 28, 2023) versus after implementation (March 1-August 31, 2023), and AMR before (December 1, 2022-May 31, 2023) versus after implementation (June 1-November 30, 2023). ABSTRACT/UNASSIGNED:< 0.001). ABSTRACT/UNASSIGNED:CONCLUSION: Implementation of RPA was associated with substantial improvement in FCP assignment and timely AMR completion. Initiating a bot-enabled secure-chat "virtual safety huddle" may provide a practical EHR reliability layer for rule-based inpatient care gaps.

INTRODUCTION/UNASSIGNED:Patients with Crohn's disease are at increased risk for both colorectal carcinoma and opportunistic infections due to chronic inflammation and long-term immunosuppressive therapy. Fungal infections such as histoplasmosis may mimic malignancy or inflammatory exacerbation, leading to diagnostic delay. CASE PRESENTATION/UNASSIGNED:, confirmed by polymerase chain reaction. The urinary Histoplasma galactomannan antigen test was negative, while serum 1,3 β-D-glucan was positive. The patient was successfully treated with amphotericin B followed by itraconazole, with complete clinical recovery. Retrospective history revealed travel to Ecuador. CONCLUSION/UNASSIGNED:Gastrointestinal histoplasmosis can closely mimic Crohn's flare or malignancy, especially in immunosuppressed patients. Careful histopathologic evaluation and integration of clinical and laboratory findings are essential for timely diagnosis and effective antifungal therapy.