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.

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.

OBJECTIVE:Preeclampsia remains one of the leading causes of perinatal mortality worldwide. Little is known of the modifiable risk factors that can be identified and addressed early in pregnancy to reduce the risk of preeclampsia and its associated adverse outcomes. We sought to determine if there is a synergistic effect of pre-pregnancy body-mass index and obstructive sleep apnea on the risk of preeclampsia. STUDY DESIGN/METHODS:We conducted a retrospective cohort study of singleton pregnancies delivered in Kaiser Permanente Southern California hospitals between January 1, 2010, and December 31, 2020 (n=342,349). Preeclampsia and sleep apnea were ascertained using clinical diagnosis codes. Body-mass index in kg/m2 measured during prenatal care visits was categorized as normal (18.5 to 24.9), overweight (25 to 29.9), and obese (≥30). Multivariable logistic regression was used to estimate adjusted relative risks (adjusted RR) and 95% confidence intervals (CI). RESULTS:Compared to normal weight in a pregnancy, overweight (adjusted RR: 1.6; 95% CI: 1.5, 1.7) and obese body mass index (adjusted RR: 2.5; 95% CI: 2.4, 2.6) were associated with an increased risk of preeclampsia. Independent of pre-pregnancy body-mass index, a pregnancy with obstructive sleep apnea was associated with an increased risk of preeclampsia (adjusted RR: 2.2; 95% CI: 1.8, 2.6). Compared to normal weight without the diagnosis of obstructive sleep apnea in a pregnancy, overweight (adjusted RR: 4.6; 95% CI: 2.9, 7.4) and obese body mass index (adjusted RR: 3.8; 95% CI: 3.2, 4.6) with the diagnosis of obstructive sleep apnea were associated with an increased risk of preeclampsia. CONCLUSIONS:Obstructive sleep apnea and elevated body-mass index have independent and additive relationship with preeclampsia. Overweight women at-risk of preeclampsia should be advised of a higher likelihood of developing preeclampsia when both conditions occur together and may benefit from close monitoring and early interventions for these modifiable risk factors.

INTRODUCTION/BACKGROUND:on the amount of FFP needed to normalize the R-time. METHODS:(ΔPV) and ΔR-time within 24 h of administration of FFP. Responders were divided in high and low based on a decrease in R-time > 5 min after the administration of FFP. Data presented as mean ± SD and median with interquartile range were analyzed with parametric and non-parametric tests as applicable. RESULTS:before transfusions but it was affected by the amount FFP and the resulting ΔPV (483 ± 173 vs. 296 ± 99 and 17.0% ± 6.6% vs. 8.6% ± 3.0%; p < 0.05). CONCLUSIONS:is the key element required to estimate the volume of FFP needed to correct a prolonged R-time.

OBJECTIVE:To evaluate the Maryland All-Payer Model's impact on the rate of elective major joint replacement surgery. STUDY DESIGN/METHODS:A retrospective cohort study of patients in Maryland undergoing elective major joint replacement between 2011 and 2018 was performed using a 20% fee-for-service Medicare sample in a difference-in-difference framework with patients undergoing hip fracture repair serving as controls. METHODS:Among Maryland residents, there were 7147 Medicare fee-for-service patients undergoing elective major joint replacement and 1008 Medicare fee-for-service beneficiaries undergoing hip fracture repair. We used patient-level generalized linear models with a negative binomial family function and a log link function to estimate the association of the All-Payer Model with the rate of elective major joint replacement surgery. RESULTS:Under the All-Payer Model, the rate of elective major joint replacement surgery increased more than that of hip fracture repair (adjusted relative risk, 1.31; 95% CI, 1.15-1.51). Compared with hospitals without affiliates in adjacent states (Maryland-only hospitals), those with affiliates (Maryland hospitals with affiliates) saw rates of elective major joint replacement grow more slowly (adjusted relative risk, 0.87; 95% CI, 0.80-0.95) after the All-Payer Model. Furthermore, major joint replacement rates for Maryland residents at affiliated hospitals in adjacent states increased from 4.26 per 10,000 in the preintervention period to 5.23 per 10,000 in the postintervention period. CONCLUSIONS:Under the All-Payer Model, population-based rates of elective major joint replacement surgery increased more rapidly than did rates of hip fracture repair. Although rates of major joint replacement at Maryland hospitals with affiliates grew more slowly than for Maryland-only hospitals, rates among Maryland residents increased at the affiliates in adjacent states.

OBJECTIVE:Tethered cord syndrome (TCS) is a significant cause of debilitation in patients with spinal dysraphisms or tumors. Management of TCS has historically centered on intradural detethering surgery, which is associated with a substantial risk of retethering, symptom recurrence, and repeat surgery. Vertebral column resection (VCR) has recently gained popularity as a treatment option via spinal shortening, but the literature on long-term outcomes is sparse. The objective of this study was to explore long-term clinical outcomes in a series of patients undergoing VCR for recurrent TCS. METHODS:A retrospective review was conducted of all consecutive patients undergoing VCR for recurrent TCS at a single center between 2014 and 2024. Demographic and radiological characteristics were recorded, including spinal column height reduction as well as symptom improvement rates regarding sensorimotor dysfunction, pain, and incontinence at the latest follow-up. Intra- and postoperative complications were noted, and pre- and postoperative symptomology was compared using McNemar's test at a significance level of p < 0.05 to identify improvements. RESULTS:Twenty surgeries in 19 patients (median age 19 years) involving 10 males (52.6%) were assessed. The most common etiology of TCS was lipomyelomeningocele (n = 7, 36.8%), followed by lipoma (n = 6, 31.6%). Patients underwent a mean of 3.4 previous detethering procedures. Osteotomy was most commonly performed at the L1 level (n = 11, 55.0%), and the mean spinal column height reduction was 16.5 mm. At a mean follow-up of 43.1 (range 12-101) months, resolution of symptoms was observed in 10 patients with back pain (71.4%; p = 0.043), 10 patients with leg pain (66.7%; p = 0.004), 9 patients with lower extremity weakness (75.0%; p = 0.008), 4 patients with urinary incontinence (44.4%; p = 0.371), and 1 patient with fecal incontinence (33.3%; p > 0.99). Complications included a CSF leak in 1 patient and repeat VCR in 1 patient. CONCLUSIONS:These results suggest that in select patients with recurrent TCS, VCR represents a treatment option with high rates of symptomatic improvement and a relatively low risk of retethering as observed over several years of follow-up. These results add to the body of literature supporting VCR and provide a compelling basis for future prospectively designed studies.

IMPORTANCE/UNASSIGNED:One-quarter of US women who are at risk for cervical cancer delay screening. Self-collected (SC) cervical screening was recently US Food and Drug Administration (FDA)-approved in the US for use in a health care setting only; an at-home SC option is crucial to address clinic-related barriers to screening. OBJECTIVE/UNASSIGNED:To clinically validate the use of an SC device that was designed for optimal at-home performance, safety, ease-of-use, and dry storage and transport. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This nonrandomized clinical trial used a prospective method comparison study design. Participants aged 25 to 65 years were recruited from 16 clinical sites in the US including community and academic practices from November 20, 2023, to April 5, 2024. Data analysis was conducted from April to August 2024. INTERVENTION/UNASSIGNED:Eligible participants collected a sample with the SC method, followed by a clinician-collected (CC) sample. The SC sample was eluted into PreservCyt at the laboratory and both samples were tested on an FDA-approved high risk human papillomavirus (hrHPV) test approved for primary screening. Participants were followed up for safety and completed usability and screening preference surveys. MAIN OUTCOME AND MEASURES/UNASSIGNED:The primary outcome measures were positive percentage agreement (PPA) and negative percentage agreement for detection of hrHPV between the SC and CC samples. Other study measures included clinical sensitivity for high grade cervical dysplasia and usability. RESULTS/UNASSIGNED:Of 609 screening-eligible participants, 599 (262 aged 30-39 years [43.7%]; 583 identified as female [97.3%]) had paired SC-CC samples, of which 582 had valid paired samples included in the end point analysis. Among the 582 evaluable paired samples, the PPA between SC compared with paired CC samples for detection of hrHPV was 95.2% (95% CI, 92.1%-97.1%; 278 of 292 participants). The absolute clinical sensitivity for detection of high-grade cervical dysplasia was 95.8% (95% CI, 86.0%-98.8%; 46 of 48 participants), equivalent to the CC (relative sensitivity, 1.00). Nearly all participants (555 of 601 participants [92.3%]) reported that the device instructions were easy or very easy to understand and also that they would choose SC if they knew the results were comparable to CC results (560 of 602 participants [93.0%]). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this nonrandomized clinical trial, SC samples collected with the device showed equivalent clinical sensitivity and exceeded the PPA end point for cervical screening. This SC method was found to be easy to use and to be a preferred option with high clinical performance intended for use in an at-home setting. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT06120205.