Faculty Bibliography

This study aimed to assess factors impacting obstetric triage time to disposition. The primary and secondary hypotheses were that high-risk patients and patients evaluated during periods with less staffing would experience prolonged length of stay (LOS), respectively.This single-site, retrospective cohort study analyzed 9,704 obstetric triage visits of 6,182 patients between January 1, 2022, to February 28, 2023. Inclusion criteria included patients 18 years or older with one or more evaluations. Exclusion criteria included scheduled admissions, unknown chief complaints, triage time under 10 minutes, and patients under 18 years old. A total of 6,612 visits representing 4,390 patients were included. The visits were stratified by disposition: admission versus nonadmission (transfer or discharge). Descriptive statistics analyze continuous variables. Frequencies and percentages were calculated for categorical variables. SAS was used for chi-square or Fisher's exact test for categorical variables and the two-sample t-test or Mann-Whitney test for continuous data. Statistical significance was p-value < 0.05.Of 6,612 visits, 3,475 admissions, and 3,137 nonadmissions occurred. The most common chief complaints were contractions (42%), amniotic fluid index evaluation (18%), and preeclampsia evaluation (8%). Admitted compared with nonadmitted patients had shorter LOS (64 minutes vs. 185 minutes, p < 0.001). Admitted compared with nonadmitted patients had shorter LOS by chief complaint, gestational age, high-risk maternal-fetal medicine status, time of day, and day of the week (all p < 0.001).Nonadmitted, maternal-fetal medicine and preterm patients evaluated during daytime and weekdays had significantly longer LOS. Vulnerable populations and target times for triage workflow improvement were identified. · Patient and unit factors influenced LOS.. · Nonadmitted patients had triple the LOS.. · High-risk patients had longer LOS.. · Daytime and weekday visits had longer LOS..

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.

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.

OBJECTIVE:Preterm birth (PTB) remains one of the biggest public health challenges with both obstetric and perinatal implications. While a prior PTB is a known risk factor for recurrence, the understanding of the influence of factors such as race/ethnicity, gestational age, PTB subtypes, and interpregnancy intervals (IPI) remains limited. This study aimed to assess whether these factors modify PTB recurrence risk. METHODS:We conducted a retrospective cohort study of singleton pregnancies in Kaiser Permanente Southern California (2009-2022) using electronic health record data from 82,610 women with two pregnancies and 14,925 women with three. PTB subtypes, spontaneous (sPTB) and indicated (iPTB), were identified through natural language processing. Logistic regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI). RESULTS:A first PTB was associated with a 6-fold increased risk of PTB in the second pregnancy compared to an uncomplicated pregnancy (23.29% vs. 4.98%, respectively; aOR, 5.60, 95% CI: 5.23-5.99). Those with a history of sPTB (aOR: 5.32, 95% CI: 4.87, 5.81) and iPTB (aOR: 8.26, 95% CI: 7.18, 9.50) had increased risk for the same respective subtype at their second pregnancy. PTB recurrence risk persisted across race/ethnicity categories. In women with PTB in both prior pregnancies, the risk for PTB in a third pregnancy was significantly higher (aOR 14.59, 95% CI 11.28-18.88). The recurrence of PTB between 1st and 2nd pregnancy was substantially higher for those who delivered at 20-33 weeks of gestation, regardless of PTB subtype. Non-Hispanic Black and Asian/Pacific Islander women had higher recurrence risk compared to non-Hispanic Whites. CONCLUSION/CONCLUSIONS:These findings highlight disparities in PTB recurrence by race/ethnicity and PTB subtype among a large integrated healthcare system in Southern California, underscoring the need for targeted interventions, particularly for sPTB.

Marijuana use is common and increasing due to decriminalization, legalization, and expansion of medical use. As a result, the proportion of vascular patients with marijuana is also expected to increase, raising questions if cannabis use affects the incidence and outcomes of vascular disease. Active ingredients of cannabis have been shown to interact with receptors found on vascular endothelium, promoting oxidative stress and endothelial dysfunction. However, current clinical studies have yet to demonstrate a relationship between marijuana use and atherosclerosis. Nonetheless, cannabis arteritis is a rare condition where cannabis is hypothesized to induce vascular inflammation. Future research with high-quality studies is needed to clarify the impact of marijuana use on vascular diseases.

PURPOSE/OBJECTIVE:Both MRI and PSMA PET/CT are often utilized for staging of intermediate-risk (IR) and high-risk (HR) prostate cancer (PCa). Recent studies found that PSMA PET/CT was superior to MRI in correctly identifying final pathological tumor stage, dominant nodule, extraprostatic extension (EPE), and small areas of clinically significant PCa. We sought to determine if PSMA PET/CT was superior to MRI in both locoregional staging of PCa and potential focal therapy planning. METHODS:We retrospectively analyzed our prospectively collected, IRB-approved database of all patients who underwent prostatectomy at one institution between 10/1/2019-2/29/2024. Patients were excluded if they did not pre-operatively undergo both MRI and PSMA PET/CT. 2 × 2 tables were used to compare each modality to the "gold standard" of prostatectomy specimen in both the proper detection of laterality and presence of EPE. Sensitivities and specificities were compared using a chi-squared test. HR v. IR groups were compared using a Wilcoxon rank sum test for continuous variables and Fisher's exact test for categorical variables. Results were considered significant at p < 0.05. RESULTS:580 patients underwent prostatectomy within the specified timeframe. 78 patients met inclusion criteria. MRI was more sensitive in the detection of EPE than PSMA PET/CT (23.5% v. 7.8%, p = 0.0294). MRI and PSMA PET/CT were similar in the specificity of EPE detection. In the identification of laterality, MRI was more specific (86.7% v. 56.7%, p = 0.0099), while sensitivities were similar between the modalities. CONCLUSIONS:MRI was superior to PSMA PET/CT in the proper detection of both EPE and laterality in patients with IR and HR PCa.

BACKGROUND:The gracilis flap is a versatile muscle flap that can be utilized as a muscle only or myocutaneous flap for soft tissue coverage, as well as for reconstruction of facial animation or extremity function. Few studies have compared donor site complications of free and pedicled gracilis flaps, including the effect of skin paddle harvest on donor site morbidity. METHODS:We performed a retrospective review of patients who underwent a free or pedicled gracilis flap at our institution from 2013-2023. Gracilis flaps were categorized as: pedicled gracilis muscle flaps used for vaginectomy in gender reaffirming surgery, free gracilis muscle flaps, and free gracilis myocutaneous flaps. Outcome variables were duration of drain placement and complications including seroma, hematoma, infection, dehiscence, and persistent numbness. RESULTS:We identified 128 gracilis flaps including 19 free myocutaneous flaps, 35 free muscle flaps, and 74 pedicled muscle flaps. Free myocutaneous flaps required longer drain placement as compared to free muscle flaps or pedicled flaps (13.6 vs 8.4 vs 7.4 days, respectively, p=0.002). Free myocutaneous flaps displayed a higher complication rate (36.8%) as compared to pedicled muscle flaps (10.8%), or free muscle flaps (11.4%, p=0.020). After adjusting for age, BMI, and ASA status, free myocutaneous flaps demonstrated higher odds of major donor site complication as compared to pedicled muscle flaps (OR 1.23, p<0.001), while free muscle flaps were not associated with increased odds of major complication (OR 1.08, p=0.117). Of the documented complications, the most common were surgical site infection (36.8%), hematoma (21.1%) and seroma (21.1%). CONCLUSION/CONCLUSIONS:The inclusion of a skin paddle during gracilis flap harvest is associated with increased duration of drain placement and donor site complications including surgical site infection, hematoma, and seroma. These factors should be carefully considered in the context of patients' reconstructive needs and other risk factors.

BackgroundMalignant bowel obstruction (MBO) is a complex clinical entity and there remains a relative lack of high-quality comparative trials on surgical management, in part due to a heterogeneous patient population and different treatment modalities which contribute to challenges in trial design and completion. SWOG S1316 is the only prospective randomized trial evaluating surgical vs non-surgical management of MBO and involved a trial framework in which patients were recruited for a randomization pathway as well as a patient choice pathway. Importantly, successful completion of S1316 required numerous amendment modifications to the trial during its course. We aimed to highlight aspects of S1316 trial design, execution, and modification that potentially contributed to trial completion.MethodsIterative qualitative content analysis of trial modification amendments through the course of the trial from 2015 to 2020.Results133 unique amendments were made to S1316 from 2015 to 2020. We found four dominant domains for the amendments: Accrual Barriers, Study Design Changes, Data Collection Issues, and Clarifications. Accrual amendments were essential to completing the trial and included increasing participating sites from six to 30 (including international sites) and the inclusion of Spanish-speaking participants (11% of final study population).ConclusionsContent analysis of S1316 trial amendments highlighted that Accrual amendments were important in trial completion. Future investigators may benefit from better anticipating trial modifications as they design their studies. It is likely that rapid initiation of trial amendments can lead to improved accrual and study completion.

CONTEXT/BACKGROUND:Traumatic musculoskeletal injuries may result in chronic pain and mobility limitations, decreasing quality of life, and increasing predisposition to comorbid disorders. Osteopathic manipulative treatment (OMT) utilizes palpatory assessment and application of manual forces as an adjunct intervention for musculoskeletal disease. Multiple studies have demonstrated OMT's potential benefits for a range of disease states, but data on osteopathic OMT are limited. OBJECTIVES/OBJECTIVE:The objective of our study was to understand the potential benefits of a novel OMT for trauma outpatient program for the care of injured patients suffering chronic pain and mobility limitations. METHODS:In 2021, the New York University (NYU) Langone Hospital - Long Island Level 1 Trauma Center established a novel outpatient OMT for Trauma Program (OTP). We performed a retrospective analysis of OTP patients seen from January 1, 2021 to December 31, 2022 with the chief complaint of refractory chronic (persistent ≥3 months since inciting injury) postinjury pain and mobility limitations (inclusion criterion). We excluded patients missing follow-up, then extracted and analyzed patient demographic, injury-specific, and OMT data. Data are presented as frequencies (percentages) or medians (interquartile range [IQR]). RESULTS:Forty-three patients (75.4 % of patients treated at the outpatient OTP) reported a mechanism of injury (MOI). Of these, 30 (69.8 %) met the inclusion criteria, and seven met the exclusion criterion, yielding 23 total patients for the analysis (40.3 % of the total OTP population). 73.9 % were female aged 46 (39-59) years old. Patients presented 3.00 (0.58-20) years since etiologic injury. MOIs included 56.5 % motor vehicle collisions (MVC), 21.7 % falls, 8.7 % penetrating, and 13.0 % sports-related or lifting injuries. Patients reported 3 (2-4) treatment modalities tried and 2 (1-3) medications attempted prior to the OTP. After the first OMT session, 95.7 % of patients reported subjective improvement in pain with a decrease in pain score 3 (3-7) out of 10. After OMT, patients also self-reported ease of activities of daily living (ADLs, 82.6 %), improved sleep hygiene (26.1 %), improved anxiety/mood (65.2 %), and decreased use of analgesic medication (13.0 %). Four (17.4 %) reported post-OMT complication of 2-3 days of self-limited, mild musculoskeletal pain. Univariate logistic regression models demonstrate that OMT benefited patients regardless of time since inciting injury. CONCLUSIONS:OMT may benefit refractory chronic traumatic pain and mobility limitations regardless of the time since inciting the injury. This is the first major publication from the OTP and bolsters proof-of-concept for an organized OMT program at a level 1 trauma center. Further study, including comparative analysis with more formalized pain assessments utilizing validated tools as well as standardized OMT session surveys, is warranted.