Faculty Bibliography

OBJECTIVES/UNASSIGNED:To evaluate the incidence and degree of rectal wall infiltration (RWI) of spacer gel used during prostate radiotherapy among two practitioners experienced in using rectal spacers. MATERIALS AND METHODS/UNASSIGNED:Consecutive patients with prostate cancer who received prostate radiotherapy after hydrogel rectal spacer insertion in August 2023-August 2024 by two experienced practitioners were retrospectively included. Post-implant magnetic resonance imaging examinations were evaluated by two radiologists for RWI: 0 (no abnormality), 1 (rectal wall edema), 2 (superficial RWI), and 3 (deep RWI). Scores 2-3 were considered positive for RWI and their location and degree of RWI (radial, longitudinal, and circumferential) were also categorized. Inter-reader agreement was assessed with Cohen's Kappa. RESULTS/UNASSIGNED:215 men were included. Agreement was substantial between the radiologists for RWI scores (Kappa, 0.697; 95% confidence interval, 0.594-0.800). RWI scores were 0 in 80.5% (173/215), 1 in 7.9% (17/215), 2 in 10.7% (23/215), and, 3 in 0.9% (2/215) of the men. Altogether, RWI was present (scores 2-3) in 11.6% (25/215), most commonly in the mid-gland and apex with median radial, longitudinal, and circumferential involvement of 3.2 mm, 8.6 mm, and 11.5%. None of these patients demonstrated any significant rectal toxicity. CONCLUSION/UNASSIGNED:RWI was very uncommon for experienced practitioners. The degree of RWI was focal and not associated with increased complications.

BACKGROUND/UNASSIGNED:Can we document that posterior cervical surgery (i.e., Laminoforaminotomy (LF) and Laminectomy (L) with Posterior Fusion (PF)) exposes patients to fewer adverse events (i.e., including negligence, multiple risks, negligence, errors, and mistakes) vs. anterior cervical surgery (i.e., Anterior Cervical Diskectomy/Fusion (ACDF) or Anterior Corpectomy/Fusion (ACF))? METHODS/UNASSIGNED:Posterior cervical surgery avoids many of the adverse events uniquely attributed to anterior cervical operations. These include; avoiding fusions with LF vs. ACDF for disc herniations, a lower rate of pseudarthrosis, the avoidance of direct laceration/indirect traction-related carotid/jugular vascular and/or dysphagia/esophageal injuries, fewer neural/cord injuries, vertebral artery injuries, and cerebrospinal fluid (CSF) leaks/dural tears (i.e., particularly with Ossification of the Posterior Longitudinal Ligament (OPLL)). RESULTS/UNASSIGNED:Posterior cervical surgery also poses no direct risks to the following anteriorly-located nerves: recurrent laryngeal nerve (i.e., vocal cord paralysis), phrenic nerve (i.e., diaphragmatic paralysis), the Vagus nerve (i.e., hypotension, reflux, arrhythmias), and sympathetic trunk (i.e., Horner's Syndrome). However, posterior cervical surgery is generally associated with a higher risk of infection (i.e., 2-10%) vs. anterior surgery (i.e., > 1%), more posterior muscle pain, and a higher risk of kyphosis. CONCLUSIONS/UNASSIGNED:Posterior cervical surgery exposes patients to many fewer adverse events vs. anterior cervical surgery. We therefore recommend that in appropriately chosen patients, posterior cervical surgical approaches should be chosen over anterior surgery.

BACKGROUND/UNASSIGNED:In this short review/perspective, we asked what the frequencies would be for both postoperative spinal epidural hematomas (SpEH) and postoperative surgical site infections (SSI) in predominantly posterior lumbar procedures performed with or without the placement of wound drains? METHODS/UNASSIGNED:Many spine surgeons are trained to use wound drains to decrease the risk of postoperative SpEH, despite the potential increased risk of SSI. Alternatively, avoiding drains may increase the risk of SpEH but likely decrease the potential for SSI. RESULTS/UNASSIGNED:Performing predominantly posterior lumbar procedures with or without wound drains resulted in largely comparable frequencies of postoperative spinal epidural hematomas (SpEH; range of 0.10%-0.69%) and postoperative surgical site infections (SSI: range of 0.75%-7.3%). Notably, however, two studies documented that drains increased transfusion requirements, with one study showing a prolongation of the in-hospital length of stay. Critically, these series emphasized the importance of early/emergent diagnosis (i.e., with MR) and surgical treatment of SpEH to minimize residual neurological deficits. CONCLUSION/UNASSIGNED:Here, we showed that patients undergoing predominantly lumbar spine surgery performed with or without wound drains demonstrated comparable frequencies of postoperative SpEH and SSI. Nevertheless, spine surgeons must assess on a case-by-case basis whether, based on their education, training, and experience, placing a wound drain is appropriate for their particular patient.

Covid 19 patients often present with elevated D-dimer levels. The purpose of this study is to evaluate the role of D-Dimer levels in Covid 19 patients to predict mortality and venous thromboembolism (VTE) events. This is a retrospective chart review study from 1 April 2020 to 30 June 2020, during the peak Covid pandemic. A total of 350 patients were enrolled in this study; 69 (19.7%) patients died; 12 (3.4%) had a deep venous thrombosis; and 8 (2.3%) had a pulmonary embolism outcome. Peak D-dimer levels were collected with median levels of 765 ng/ml (266, 3135). Patients with VTE outcomes had significantly higher levels of peak D-dimers than patients in the non-VTE group (4876 vs 680, p < 0.0001). Patients who died had higher peak D-dimer levels than those who survived (4690 vs 501, p < 0.0001). The optimal cutoff point in peak D-dimer in predicting VTE events was 1437, yielding a sensitivity of 84.2% and a specificity of 65.0%. The optimal cutoff point in peak D-dimer in predicting mortality was 2004, yielding a sensitivity of 71.0% and a specificity of 77.9%. This study suggests that D-dimer levels can be elevated in Covid 19 hospitalized patients and can serve as indicators for mortality and VTE events.

INTRODUCTION/UNASSIGNED:Addressing systemic bias in medical school assessment is an urgent task for medical education. This paper outlines recommendations on topic areas for further research on systemic bias, developed from a workshop discussion at the 2023 annual meeting of the Society of Directors of Research in Medical Education. MATERIALS AND METHODS/UNASSIGNED:During the workshop, directors engaged in small-group discussions on guidelines to address bias in assessment practices following a proposed categorization of 'Do's,' 'Don'ts,' and 'Don't knows' and listed their insights using anonymous sticky notes, which were shared and discussed with the larger group of participants. The authors performed a content analysis of the notes through deductive and inductive coding. We reviewed and discussed our analysis to reach consensus. RESULTS/UNASSIGNED:The workshop included 31 participants from 28 institutions across the US and Canada, generating 51 unique notes. Participants identified 23 research areas in need of further study. The inductive analysis of proposed research areas revealed four main topics: 1) The role of interventions, including pre-medical academic interventions, medical-education interventions, assessment approaches, and wellness interventions; 2) Professional development, including the definition and assessment of professionalism and professional identity formation; 3) Context, including patient care and systemic influences; and 4) Research approaches. DISCUSSION/UNASSIGNED:While limited to data from a single workshop, the results offered perspectives about areas for further research shared by a group of directors of medical education research units from diverse backgrounds. The workshop produced valuable insights into the need for more evidence-based interventions that promote more equitable assessment practices grounded in real-world situations and that attenuate the effects of bias.

The United States faces a shortage of primary care physicians. To address this, there have been pioneering efforts to develop accelerated pathways with a primary care focused curriculum for undergraduate medical education. The New York University Grossman Long Island School of Medicine (NYU GLISOM) was conceptualized as the first standalone, accelerated, tuition-free program in the US in over 100 years, with mission-centered curriculum on primary care and health system leadership. The aim of this article is to map the process for the development of a three-year integrated curriculum, describe the pedagogical approach that guided the design of the longitudinal courses, share the student and faculty's perspective about the curriculum, and describe the early outcomes of the first two graduate classes. A major key driver for curricular design is integrating longitudinal courses of Clinical Ambulatory Practice Experience (CAPE), Health Systems Science (HSS), and Learning Community - Social Sciences, Humanities, Ethics and Professionalism (LC-SHEP) over three years and active learning through Problem Based Learning (PBL). We have successfully operationalized an accelerated, standalone, integrated medical school curriculum mission-centered on primary care and health system leadership. Our outcomes reveal a higher percentage (76% N =45) of NYU GLISOM students entering primary care compared to national benchmarks. The integration of the longitudinal courses of HSS, LC-SHEP, and CAPE is a key pillar to reinforce the tenants of primary care and health system leadership. Focused interview of graduates from the pioneer cohort consistently stated that the longitudinal courses prepared them well for residency in primary care and as a health systems' change agent. Despite the challenges of an accelerated program, NYU GLISOM successfully integrated the longitudinal courses with optimal performance and achievement of educational program objectives. Our experience can serve as a model for innovation and design of an accelerated three-year primary care curriculum.

INTRODUCTION/UNASSIGNED:Over the past decade, the growth of accelerated three-year MD (3YMD) programs has flourished. In 2015, with support from the Josiah Macy Jr. Foundation, the Consortium of Medical Pathway Programs (CAMPP) started with eight North American medical schools. The objective of this paper is to evaluate the current state of the 3YMD programs. MATERIAL AND METHODS/UNASSIGNED:Since 2015, the CAMPP has tracked new and prospective 3YMD programs. An electronic survey collecting curricular and programmatic information about the programs was disseminated to all members of the CAMPP in August 2023. The survey included elements related to year of initiation, number of graduates, and curricular elements. RESULTS/UNASSIGNED:Of the schools with known established three-year MD programs, 29 of 32 programs responded (response rate 90%). There is growth of Accelerated Medical Pathway Programs over time with almost 20% of United States Allopathic Medical Schools having or developing an accelerated program. There have been 817 graduates from these programs from 2013-2023. Most schools include an opportunity for a 'directed pathway' experience for students. A directed pathway is where a student completes the MD degree in three-years and then has a direct placement into an affiliated residency program, provided they meet the goals and objectives of the curriculum. Most of the schools report a mission to reduce medical student debt and build a workforce for a specialty, for a population of patients, or geographical distribution. CONCLUSIONS/UNASSIGNED:Accelerated three-year medical pathway programs have grown significantly over the last decade, consistent with an overall effort to redesign medical curricula, reduce debt and contribute to the workforce.

Despite therapeutic treatments and the growing utilization of multimodal therapies, gastric cancer (GC) remains a highly aggressive malignancy with high mortality worldwide. Much of the complexity in treating GC is due to the high incidence of peritoneal metastasis (PM), with mean overall survival typically ranging from 4 to 10 months. With current systemic therapy, targeted therapies, and immunotherapies continuing to remain ineffective for GC/PM, there has been a significant growing interest in intraperitoneal (IP) therapies for the treatment of GC/PM. In this review, we summarize the development of PM and evolving treatment strategies for GC/PM. Furthermore, we explore the various advancements and outcomes of IP therapies, including heated intraperitoneal chemotherapy (HIPEC), neoadjuvant HIPEC, and pressurized intraperitoneal aerosolized chemotherapy (PIPAC).

Metabolites can double as a signaling modality that initiates physiological adaptations. Metabolism, a chemical language encoding biological information, has been recognized as a powerful principle directing inflammatory responses. Cytosolic pH is a regulator of inflammatory response in macrophages. Here, we found that L-malate exerts anti-inflammatory effect via BiP-IRF2BP2 signaling, which is a sensor of cytosolic pH in macrophages. First, L-malate, a TCA intermediate upregulated in pro-inflammatory macrophages, was identified as a potent anti-inflammatory metabolite through initial screening. Subsequent screening with DARTS and MS led to the isolation of L-malate-BiP binding. Further screening through protein‒protein interaction microarrays identified a L-malate-restrained coupling of BiP with IRF2BP2, a known anti-inflammatory protein. Interestingly, pH reduction, which promotes carboxyl protonation of L-malate, facilitates L-malate and carboxylate analogues such as succinate to bind BiP, and disrupt BiP-IRF2BP2 interaction in a carboxyl-dependent manner. Both L-malate and acidification inhibit BiP-IRF2BP2 interaction, and protect IRF2BP2 from BiP-driven degradation in macrophages. Furthermore, both in vitro and in vivo, BiP-IRF2BP2 signal is required for effects of both L-malate and pH on inflammatory responses. These findings reveal a previously unrecognized, proton/carboxylate dual sensing pathway wherein pH and L-malate regulate inflammatory responses, indicating the role of certain carboxylate metabolites as adaptors in the proton biosensing by interactions between macromolecules.

A knowledge gap may exist when attempting to identify the pathogenetic mechanisms resulting in the syndrome of inappropriate antidiuretic hormone (SIADH) or hypotonic hyponatremia. Ectopic secretion of antidiuretic hormone [ADH] is the classic cause of SIADH. But another form of inappropriate secretion of ADH occurs when interleukin 6 is activated. Hypotonic hyponatremia can also occur in patients with cerebral salt wasting, but the secretion of ADH is appropriate, responding to volume depletion induced by excessive natriuresis. Reset osmostat (RO) is another cause of hypotonic hyponatremia caused by an unknown anomaly in the hypothalamus. This review discusses the pathophysiology of and the identical laboratory findings found in classic ectopic ADH secretion, interleukin 6-mediated ADH secretion, cerebral salt wasting-induced ADH secretion, and RO. This review also discusses potential methods to discern which hypotonic hyponatremic syndrome is present and current recommendations for treatment.