Faculty Bibliography

IMPORTANCE/OBJECTIVE:Pelvic floor physical therapy (PFPT) is a first-line treatment for pelvic floor disorders, though it is frequently an uncovered benefit. Data on insurance acceptance among PFPT offices is limited; therefore, its true accessibility is unknown. OBJECTIVES/OBJECTIVE:Our primary objective was to characterize the effect of insurance coverage on access to PFPT in a national sample. Our secondary objective was to identify factors associated with Medicaid acceptance. STUDY DESIGN/METHODS:This cross-sectional analysis utilized a "secret shopper" methodology. Investigators contacted 200 PFPT offices across 8 states, 4 with expanded Medicaid access, using a script to evaluate insurance acceptance, wait times, and cost. The agreement between Medicaid and commercial insurance acceptance was tested using the McNemar test. Logistic regression identified factors associated with Medicaid acceptance. RESULTS:Of 200 PFPT offices, 141 (70%) accepted commercial insurance and 94 (47%) accepted Medicaid (χ2=35.8, P<0.001); 53 accepted neither (26.6%). Factors associated with Medicaid acceptance included location in nonexpansion states (adjusted odds ratio [aOR], 2.0; 95% CI, 1.02-4.00, P=0.045), acceptance of commercial insurance (aOR, 6.72, 95% CI; 2.22-20.38, P<0.001), academic affiliation (aOR, 17.54; 95% CI, 6.93-44.36, P<0.001), and nonurban location (aOR, 3.10, 1.23-7.18, P=0.016). Mean wait time for Medicaid was 4.6 weeks versus 3.1 weeks for non-Medicaid offices (P=0.004). In all, 117 PFPTs (58.5%) reported a cash cost for an initial visit: median cost was $190.62 (SD=73.77), range $70-$450. CONCLUSIONS:Our analysis reveals significant PFPT disparities for Medicaid beneficiaries, underscores barriers to access for Medicaid patients, and highlights opportunities for policy interventions to promote equity.

T-cell lymphomas are a heterogeneous group of lymphoid neoplasms with a variable prognosis. They can be further divided into cutaneous T-cell lymphomas and peripheral T-cell lymphomas. Treatment options are relatively limited for patients with relapsed or refractory disease. Janus kinase (JAK) inhibitors have emerged as promising new drugs for these lymphomas, as increasing evidence supports the JAK and signal transducer and activator of transcription (STAT) pathway as a potential target. The objective of this review is to summarize the current evidence supporting the use of JAK inhibitors in the treatment of T-cell lymphomas and highlight areas for future research. Although many JAK inhibitors have been developed for the treatment of autoimmune conditions, only a subset of these have been tested in T-cell lymphomas and reported in the literature. These include abrocitinib, cerdulatinib, golidocitinib, ruxolitinib, tofacitinib, and upadacitinib. Other drugs are currently being tested in clinicals trials, including pacritinib and ivarmacitinib, but results are not yet available. Most of the published data are for ruxolitinib, which was found to have a clinical benefit rate of up to 53% in patients with PTCL with activating JAK and/or STAT mutations. Response durations are limited, which may be overcome through combination therapies in the future. JAK inhibitors are associated with multiple adverse effects, including cytopenias and infections, and long-term safety data are lacking for newer agents. Future studies will need to clarify long-term safety and efficacy through well-designed clinical trials involving larger groups of patients.

OBJECTIVE:Exposure to antidepressants, particularly agents that work through serotonin-reuptake inhibition, may increase potential for bleeding, especially among patients with other bleeding risk factors. There is limited guidance for clinicians in the use of serotonin reuptake inhibitors (SRIs) and other antidepressants in the setting of increased bleeding risk. METHODS:A PubMed literature search was conducted for English-language articles (1992-2024) examining the bleeding risk associated with antidepressants. Physicians from the Association of Medicine and Psychiatry then convened to develop consensus recommendations. RESULTS:Consensus recommendations were established for managing antidepressant use in patients with medical and psychiatric comorbidities. Additionally, a clinical decision algorithm was created to assist clinicians in assessing the appropriateness of antidepressant prescribing in patients at risk for bleeding. CONCLUSIONS:The proposed algorithm can aid clinicians in determining whether antidepressant (including SRI) initiation, discontinuation, or dose adjustment should be considered for patients susceptible to bleeding. These guidelines preserve a role for clinical judgment in selection of treatments that balance the risks and benefits, which may be particularly relevant for patients with complex medical and psychiatric comorbidities. Additional studies are needed to better guide clinical decision making.

BACKGROUND:The number of graduates from accelerated 3-year MD (A3YP) programs has increased over the past decade. Previous work showed that A3YP graduates perform comparably to non-accelerated (4-year) graduates from the same medical schools on mid-year and end-year Accreditation Council of Graduate Medical Education (ACGME) harmonized milestones. In shifting to the residency program perspective, it remains unclear how the performance of A3YP graduates compares to non-accelerated graduates including traditional 4-year, international, and osteopathic medical school graduates. OBJECTIVE:To compare the intern performance of A3YP graduates compared with non-accelerated graduates using mid-year and end-year ACGME milestones in Internal Medicine (IM) residency programs. DESIGN/METHODS:The study employed a retrospective cohort design, hypothesizing that graduates from A3YPs were comparable to non-accelerated graduates in the same program. PARTICIPANTS/METHODS:108 interns who graduated from A3YP were compared to 3,542 interns from non-accelerated programs at the same 34 IM residency programs. MAIN MEASURES/METHODS:Descriptive statistics were provided for ACGME milestone performance. Cross-classified random-effects regression was used to account for residency program effects and estimate group differences. KEY RESULTS/RESULTS:After controlling for residency programs, the milestone ratings of A3YP graduates were higher in all competency domains at mid-year except practice-based learning and improvement (PBLI) at .04 (P = .089) (coefficients ranged from 0.08 for medical knowledge (MK) (P < .001) to 0.23 in professionalism (PROF) (P < .001)). These differences persisted at the end-year period (coefficients ranged from 0.05 in PBLI (P = .039) to 0.17 in PROF (P < .001)) except MK at .02 (P = .656). Patient care differences were 0.15 (P < .001) at mid- and 0.14 (P = .005) at end-year. CONCLUSIONS:This study contributes to the literature demonstrating that interns graduating from A3YP are at least equivalent in terms of milestone assessment and possibly better in the competencies of PC and PROF than their non-accelerated counterparts.

Segmental peripheral nerve injuries, particularly those involving long nerve gaps, pose a significant challenge in reconstructive surgery. Conventional strategies, such as nerve autografts or processed allografts, are often limited by inadequate length or poor regenerative outcomes, especially in traumatized wound beds. Nerve flaps offer the theoretical advantage of enhanced axonal regeneration through improved perfusion and support of Schwann cell viability but are rarely used due to technical complexity and limited donor options. We present a unique case of a free sural nerve flap used to reconstruct a 7-cm segmental defect of the tibial nerve following blast trauma in a 23-year-old man. A composite flap consisting of the sural nerve and lesser saphenous vein was harvested with preservation of the bridging adipofascial tissue to maintain perfusion to the nerve. The lesser saphenous vein was anastomosed to the retrograde peroneal artery distally and ligated proximally, whereas the sural nerve was divided and used as a double-barrel cable graft across the defect. Intraoperative Doppler and SPY angiography confirmed perfusion of the nerve through the preserved adipofascial connections. The patient was recently seen in our clinic at 17 weeks postoperation. He demonstrated undetectable 2-point discrimination in all nerve distributions of his foot but is ambulatory. This case demonstrates the feasibility and potential utility of a free vascularized sural nerve flap for reconstructing extensive peripheral nerve defects, particularly in cases where standard techniques are inadequate.

BACKGROUND/UNASSIGNED:Umbrella reviews, or overviews of reviews, synthesize information using systematic reviews (SRs) as their unit of analysis. Although a formal guideline exists for reporting umbrella reviews of healthcare interventions (i.e. Preferred Reporting Items for Overviews of Reviews [PRIOR]), no formal guideline exists for conducting and/or reporting umbrella reviews of observational studies that examine epidemiological associations. OBJECTIVE/UNASSIGNED:To review the existing guidance on conducting and/or reporting umbrella reviews of observational studies on epidemiological associations, as part of the process of developing a formal reporting guideline. METHODS/UNASSIGNED:We reviewed the scoping review conducted in the context of PRIOR development and identified documents through forward citation search in PubMed, Scopus, and manual search in Google Scholar, Google Search up to December 22, 2024. Documents, regardless of format, were included if they provided guidance for conducting and/or reporting umbrella reviews of observational studies (including meta-research studies of their features). Title/abstract screening and data extraction were performed independently and in duplicate and summarized narratively by stages of the umbrella review process. RESULTS/UNASSIGNED:The search retrieved 4491 unique records, with 96 full texts assessed and eight documents included. These documents, published between 2014 and 2023, offered guidance across seven topic areas, but overall guidance on conducting and/or reporting is limited. These areas include the answerable questions, prerequisite considerations, the scope of umbrella reviews, searching for SRs, primary data collection, analysis, presentation, and assessing the certainty/quality of the body of evidence. CONCLUSION/UNASSIGNED:There is a need for dedicated, practical, and evidence-based formal reporting guidelines for umbrella reviews of observational studies on epidemiological associations. This review lays the groundwork for developing the PRIOR-extension for such studies: the Preferred Reporting Items for Umbrella Reviews of Cross-sectional, Case-control, and Cohort Studies.

BACKGROUND:2-octyl cyanoacrylate (2-OCA) topical skin adhesives are widely used for surgical wound closure but are increasingly associated with allergic contact dermatitis (ACD). We conducted a systematic review and meta-analysis to define the incidence, clinical features, and risk factors for 2-OCA-associated ACD. STUDY DESIGN/METHODS:A PRISMA systematic review of PubMed, Embase, and Web of Science (2008-2025) identified studies reporting cutaneous hypersensitivity to 2-OCA in human wound closure. Randomized, observational, and case-based reports were included. Risk of bias was assessed using ROBINS-I and RoB 2. Incidence from analytic cohorts was pooled using a random-effects model with prespecified subgroup analyses by surgical specialty. RESULTS:Seventy-four studies comprising 26,330 exposed patients were included; 20 analytic cohorts (25,442 patients) contributed to meta-analysis. The pooled ACD incidence was 4% (95% CI 3-5%) with substantial heterogeneity (I²=94.5%; prediction interval 0-12%). Incidence was 4% in orthopedic cohorts and 8% in plastic surgery cohorts, with lower rates in dermatology and obstetrics/gynecology (p=0.015 for subgroup differences). Re-exposure markedly increased risk, with reaction rates rising from 1-3% after initial exposure to >20% in staged or repeat procedures in several cohorts. Prior adhesive/contact allergy and cosmetic acrylate exposure were also strong risk factors. Diagnosis was primarily clinical, with selective patch testing. Management typically involved adhesive removal and topical corticosteroids; systemic therapy was reserved for severe cases. CONCLUSIONS:ACD to 2-OCA is a clinically meaningful and likely under-recognized complication of surgical wound closure. Re-exposure is strongly associated with increased postoperative reaction rates, supporting preoperative risk assessment and caution in repeat adhesive use.

End-stage renal disease and the number of patients relying on hemodialysis are increasing. Hemodialysis access, such as autogenous arteriovenous (AV) fistulas, prosthetic AV grafts, and tunneled catheters, is essential yet also a major source of morbidity. This focused narrative review summarizes the best practices for access planning. Complications after AV fistulas are reviewed, including stenosis, thrombosis, infection, central venous stenosis, steal syndrome, ischemic monomelic neuropathy, high-output cardiac failure, and aneurysmal degeneration. Multidisciplinary collaboration between nephrology, vascular surgery, and clinicians taking care of dialysis patients is essential to optimize long-term outcomes for patients dependent on hemodialysis. This review is intended for non-nephrologists taking care of dialysis-dependent patients in their practice.