Faculty Bibliography

BACKGROUND:Increased efforts to understand the reasons for the rise in pedestrian related traffic fatalities have demonstrated that these injuries occur in minority and lower income neighborhoods. The purpose of our study was to characterize the patient population suffering from pedestrian injuries in suburban setting, to determine whether the incidence of pedestrian injuries is associated with the social deprivation index (SDI) and to identify zip codes with a higher incidence of pedestrian injuries. METHODS:Single center, descriptive, retrospective cohort study of all patients suffering from pedestrian injuries admitted to our Level I Trauma Center (01/2014-10/2022). Demographic characteristics were summarized by groups and presented using the median (IQR) or frequency (%). Spearman's rank correlation was computed to assess the relationship between incidence of pedestrian injuries and SDI. ArcGIS was utilized to map the number of pedestrians injured, SDI, and percentage of households without a vehicle by zip code. RESULTS:719 patients identified had suffered pedestrian injuries. Median age of injury was 49(IQR 29-64), and median ISS was 8(IQR 4-14). There was a weak, but significant positive correlation between incidence of pedestrian injuries and SDI [r = .16; p-value = 0.02]. The zip code with the most injuries was Hempstead. CONCLUSIONS:Hempstead has the highest number of pedestrian injuries, highest SDI and highest percentage of households without a vehicle. However, overall correlation between incidence of pedestrian injuries and SDI was weak, suggesting that SDI may not be the only factor. Future research should focus on investigating other factors such as the presence of multilane arterial roads in these areas.

Allergic Contact dermatitis (ACD) is effectively diagnosed and treated through the identification of causative allergens via patch testing (PT). Selection of allergens, along with the application and interpretation of PT results, necessitates specialized education and training. Our objective was to investigate the extent to which contact dermatitis (CD) education and PT training are components of the curriculum in Allergy and Immunology (A/I) training programs in the United States, and to assess where knowledge gaps may exist. A voluntary 16 item survey was sent to Program and Associate Program Directors (PDs) in A/I associated with the American Academy of Allergy, Asthma, and Immunology (AAAAI) in 2021. A total of 23 out of 84 (27%) A/I training programs responded. Of the responding programs, 22% did not have a faculty member who performs PT and 25% do not have fellows perform PT. However, programs that performed more patch tests tended to use custom and expanded series, used the patient's personal products, and provided patients with a personal avoidance plan (loadings > 0.65). With respect to scholarly activity, 30% of programs had published an article on CD in the last 3 years. In conclusion, the key findings of our survey include that programs that perform PT are more likely to provide expanded and customized panels, provide patients with an individualized avoidance plan, and present scholarly activity on the topic. Given the importance of CD in allergy practices, our results indicate that more instruction in this topic is needed in A&I fellowship programs.

Mesenteric malperfusion is a rare complication of aortic dissection associated with high mortality. Diagnosis requires a high degree of suspicion as treatment is time-sensitive, necessitating early revascularization to prevent bowel necrosis, sepsis, and multi-organ failure. Advances in endovascular techniques have improved outcomes and survival over traditional approaches. Management of type A aortic dissection with mesenteric malperfusion has shifted from central aortic repair first to a two-stage approach with revascularization and delayed aortic repair. Thoracic endovascular aortic repair has become the standard treatment for type B aortic dissection with mesenteric malperfusion. However, finding the balance between aortic repair and treating mesenteric malperfusion remains a challenge. This review highlights current strategies and promising research into new endovascular techniques and refining treatment pathways.

A key treatment for patients with multiple myeloma is high-dose melphalan followed by autologous stem cell transplant (ASCT). It can provide a deep response with long-term remission. However, some patients progress quickly, and it is not clear why that is. Here, we performed single-cell RNA and T-cell receptor (TCR) sequencing of the immune microenvironment of 40 patients before and after ASCT to determine if differences in the immune composition could define those who would progress. Clear differences in cell populations were identified in progressors, including increased T-cell infiltration, decreased TCR diversity, and decreased frequency of monocytes and CD56bright NK cells. We identified cell interactions that predicted progression including increased frequency of CD8+ exhausted T cells and stromal cells and decreased frequency of CD56bright NK cells and plasmacytoid dendritic cells. We propose and validate a model of progression that can also be determined by flow cytometry. Together these data highlight the importance of the immune microenvironment in understanding responses to ASCT.

OBJECTIVES/OBJECTIVE:To evaluate mail-in semen collection services for cryopreservation, focusing on costs, transparency, and efficacy due to the advancements of direct access to fertility testing and treatment. METHODS:Using Google, we identified eight prominent companies offering mail-in sperm cryopreservation services. We analyzed their costs, storage practices, marketing strategies, and prescription requirements. For comparison, we examined academic institutions offering similar services, exploring differences in pricing, processes, and accessibility. RESULTS:The average upfront cost to process and freeze sperm was $730 (range $329 to $1575) with 10-year storage costs of $3117, on average (range $1450 to $5500), which may or may not be guaranteed to remain level. Not all services disclosed future costs such as transport, thawing, and disposal fees, with some firms being less transparent. Two firms offered client depositor storage on-site and the remainder outsourced to partner labs scattered around the country. One facility offered storage of tissue samples for men with azoospermia; none of the companies required men to have an order from their doctor to use the service. CONCLUSIONS:Mail-in cryopreservation services provide convenience but present challenges, including varying costs, transparency issues, and potential limitations in medical oversight. Integrating these services into traditional healthcare settings could optimize patient outcomes and satisfaction.

We carried out a single-cell (sc) multiomic analysis on a series of MYD88 mutated Waldenström macroglobulinemia (WM) cases and identified two distinct subtypes of disease, memory B-cell-like (MBC-like) and plasma cell-like (PC-like), based on their expression of key lineage defining genes. Biologically, the subtypes are characterized by their variable capacity to differentiate fully towards a plasma cell (PC) and exhibit unique transcriptomic, chromatin accessibility, and genomic profiles. The MBC-like subtype is unable to differentiate beyond the memory B-cell (MBC) stage, upregulates key MBC genes, and is characterized by upregulated BCR and AKT/mTOR signaling. In contrast, the PC-like subtype can partially differentiate towards a PC, upregulates key PC genes, has enhanced NF-kB signaling, and has an upregulated unfolded protein response. Pseudotime trajectory analysis of combined scRNA-sequencing and scATAC-sequencing supports the variable differentiation capacity of each subtype and implicate key transcription factors SPI1, SPIB, BCL11A, and XBP1 in these features. The existence and generalizability of the two disease subtypes were validated further using hierarchical clustering of bulk RNA-seq data from a secondary set of cases. The biological significance of the subtypes was further established using whole genome sequencing, where it was shown that CXCR4, NIK, and ARID1A mutations occur predominantly in the MBC-like subtype and 6q deletions in the PC-like subtype. We conclude that the variable differentiation blockade seen in WM manifests itself clinically as two disease subtypes with distinct epigenetic, mutational, transcriptional, and clinical features with potential implications for WM treatment strategies.

Placental abruption has classically been defined as the premature separation of a normally located placenta before delivery of the fetus. Traditionally, this diagnosis was based on clinical symptoms, including vaginal bleeding, pain, and fetal distress. This definition, however, preceded the advent of obstetric ultrasound. Ultrasound frequently identifies various hemorrhagic lesions, such as retroplacental, subchorionic, intraamniotic, intraplacental, and preplacental hematomas in both symptomatic and asymptomatic patients. These variable ultrasound findings lead to new challenges as to what to define as an abruption, particularly in the absence of symptoms. This ambiguity in defining placental abruption affects clinical decision-making and hinders our understanding of the pathophysiology of abruption, presenting challenges in studying abruption. It is likely that these varying sonographic findings may precede the classic presentation of vaginal bleeding and pain and therefore are often concealed abruptions. This commentary highlights the importance of developing clear diagnostic guidelines for placental abruption, given its association with severe outcomes including a high rate of perinatal mortality and maternal morbidity. We aim to elucidate the complexities of ultrasound diagnosis in placental abruption, advocating for precise criteria to better guide clinical practice. We propose that these ultrasound findings of hemorrhagic placental lesions after 20 weeks of gestation in asymptomatic patients should be considered part of the spectrum of abruption, while in symptomatic patients should be taken as confirmation of the diagnosis of abruption.

OBJECTIVE:Surgery for mitral valve disease in patients with mitral annular calcification (MAC) remains challenging. There is no consensus on the ideal management strategy or patient selection, and perioperative and periprocedural morbidity and mortality rates remain high. The recent surge of patients presenting with MAC has been accompanied by increased interest in MAC surgery and interventions. This expert consensus document is meant to provide a simplified outline for managing MAC, including patient selection, imaging, and surgical and transcatheter therapeutic options, with a particular focus on conventional surgical techniques and hybrid approaches. METHODS:The American Association for Thoracic Surgery Clinical Practice Standards Committee assembled an international panel of cardiac surgeons and structural heart interventionalists with established expertise in the field of MAC. A comprehensive literature review was performed by the panel and a medical librarian. Clinical recommendations were developed utilizing a modified Delphi method. RESULTS:Expert consensus was reached on 33 recommendations, with class of recommendation and level of evidence, for each of 5 main topics: (1) preoperative evaluation for patients with MAC, patient selection, and indications for intervention; (2) standard surgical techniques in MAC; (3) hybrid procedures in MAC; (4) transcatheter MAC interventions; and (5) complications and bailout of MAC surgery and interventions. CONCLUSIONS:Despite the complexity and heterogenicity of patients presenting with MAC, consensus on several key recommendations was reached by this American Association for Thoracic Surgery expert panel. These recommendations provide guidance for cardiac surgeons and structural heart interventionists in treating most patients who present with MAC.