Faculty Bibliography

OBJECTIVE:To examine the associations between patient out-of-pocket (OOP) costs and nonadherence to glucagon-like peptide 1 receptor agonists (GLP-1a), and the consequent impact on adverse outcomes, including hospitalizations and emergency department (ED) visits. RESEARCH DESIGN AND METHODS/METHODS:This retrospective cohort study used MarketScan Commercial data (2016-2021). The cohort included nonpregnant adults aged 18-64 years with type 2 diabetes who initiated GLP-1a therapy. Participants were continuously enrolled in the same private insurance plan for 6 months before the prescription date and 1 year thereafter. Exposures included average first 30-day OOP costs for GLP-1a, categorized into quartiles (lowest [Q1] to highest [Q4]). Primary outcomes were the annual proportion of days covered (PDC) for GLP-1a and nonadherence, defined as PDC <0.8. Secondary outcomes included diabetes-related and all-cause hospitalizations and ED visits 1 year post-GLP-1a initiation. RESULTS:Among 61,907 adults who initiated GLP-1a, higher 30-day OOP costs were associated with decreased adherence. Patients in the highest OOP cost quartile (Q4: $80-$3,375) had significantly higher odds of nonadherence (odds ratio [OR]1.25; 95% CI 1.19-1.31) compared with those in Q1 ($0-$21). Nonadherence was linked to increased incidence rates of diabetes-related hospitalizations or ED visits (incidence rate ratio [IRR] 1.86; 95% CI 1.43-2.42), cumulative length of hospitalization (IRR 1.56; 95% CI 1.41-1.72), all-cause ED visits (IRR 1.38; 95% CI 1.32-1.45), and increased ED-related costs ($69.81, 95% CI $53.54-$86.08). CONCLUSIONS:Higher OOP costs for GLP-1a were associated with reduced adherence and increased rates of adverse outcomes among type 2 diabetes patients.

IMPORTANCE/UNASSIGNED:Fluorescence-guided surgery aims to improve intraoperative identification of vital structures. Rizedisben is a myelin-binding fluorophore that fluoresces in the blue light (370-425 nm) spectrum to improve intraoperative nerve identification. OBJECTIVE/UNASSIGNED:To determine the optimal safe and clinically effective dose of rizedisben for sustained intraoperative fluorescence of nerve structures. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:A single-arm, open-label, phase 1 study was conducted in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALP) at an urban academic cancer center in New York City between January 2023 and October 2024. Using a dose escalation design, increasing doses of rizedisben were administered after safety was assessed at each level until a clinically effective dose was determined. The obturator nerve served as the reference nerve for measuring fluorescence intensity. Eligible patients were 18 years old and older, diagnosed with prostate cancer, and scheduled for RALP. Patients were recruited in preoperative clinic visits once deemed eligible for the study. Those with prior pelvic surgery or radiation, known central or peripheral nervous system disease, current use of neurotoxic medications, recent exposure to phototoxic drugs, or serious kidney or liver dysfunction were excluded. INTERVENTIONS/UNASSIGNED:Rizedisben was intravenously administered intraoperatively 30 minutes prior to visualization of the obturator nerve. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Safety was assessed through 45 postoperative days. Fluorescence was measured via subjective intraoperative scoring and by post hoc objective image analysis. Clinically effective dose was defined as achieving sustained fluorescence of the obturator nerve in 3 or more of 5 patients in 2 consecutive cohorts, provided fewer than 20% of patients experienced grade 2 or greater toxicity. Sustained fluorescence was defined as moderate or better fluorescence for 90 minutes or longer. At the clinically effective dose, fluorescence assessments of the neurovascular bundles were included. RESULTS/UNASSIGNED:Thirty-eight patients (median [IQR] age, 61.5 [57.8-66.3] years) enrolled in and completed the trial. Dosing was escalated from 0.25 to 3.0 mg/kg. There was 1 grade 2 adverse event (rash) possibly attributable to rizedisben. Sustained fluorescence of the obturator nerve was achieved in all patients at 3.0 mg/kg. Prostate neurovascular bundles demonstrated evidence of fluorescence in 8 of 9 (89%) patients at 3.0 mg/kg. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this phase 1 trial of rizedisben, the 3.0-mg/kg dose was shown to be generally well tolerated and clinically effective. At this dose, there was excellent sustained fluorescence of the obturator nerves, and the neurovascular bundles were visualized in 8 of 9 patients. Based on these data, we are designing phase 2 studies with rizedisben for additional indications. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT04983862.

PURPOSE/OBJECTIVE:Offering the benefits of rigid fixation while minimizing soft tissue dissection, intramedullary implants have become a popular choice among hand surgeons. Their placement often requires traversing or passing in proximity to joint surfaces. This study aimed to assess the damage to the articular cartilage of the base of the proximal phalanx resulting from antegrade placement of threaded headless intramedullary nails. METHODS:A cadaveric study comparing two techniques for antegrade placement of threaded headless intramedullary nails was conducted in 56 digits. The first entailed a single 2.1 mm intramedullary nail placed via the dorsal base of the proximal phalanx, whereas the second used two 1.8 mm intramedullary nails inserted via the collateral recesses of the phalangeal base. All specimens were analyzed for articular surface damage with the cartilage defect measured as a percentage of total joint surface area. Damage to the extensor tendons was also assessed in a subset of specimens. RESULTS:No significant difference in the percentage of articular surface damage was observed, with an average 3.21% ± 2.34% defect in the single 2.1 mm nail group and a 2.71% ± 3.42% mean defect in the two 1.8 mm nails group. There was no articular surface injury in 18% of digits in each group. Damage to extensor tendons was seen in three (9.4%) specimens and in all cases involved either the extensor indicis proprius or extensor digiti minimi. CONCLUSIONS:Hardware insertion using either the dorsal base of the proximal phalanx or the collateral recesses of the phalangeal base both demonstrated minimal articular cartilage damage and infrequent injury to the extensor tendons. CLINICAL RELEVANCE/CONCLUSIONS:With proper technique for antegrade insertion into the proximal phalanx, the cartilage defect observed often encompasses only a small percentage of the overall joint surface area.

OBJECTIVES/OBJECTIVE:Pleural effusions often require invasive sampling to establish underlying etiologies. Transthoracic ultrasound (TUS) has shown promise in the diagnostics of pleural effusions; however, there lacks consensus regarding its clinical application. We evaluated the diagnostic utility of specific TUS findings for exudative effusions, specifically complex parapneumonic effusion and empyema. METHODS:Ultrasound-guided pleural effusion drainage cases were retrospectively reviewed at a single university-based medical center from July 2015 to May 2023. Procedure-related images were reviewed for specific ultrasound findings: anechoic, fibrin, septation, loculation, plankton/swirl sign, hematocrit sign, jellyfish sign, and visceral pleura thickening. Exudative or transudative nature, underlying etiology, and other patient data were collected from chart review. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive likelihood ratio (LR+) were calculated for these findings, either individually or in combination, to predict nature and specific etiology for pleural effusion. A multivariable logistic regression model was constructed to analyze the association between TUS findings and complicated parapneumonic effusion and empyema. RESULTS:A total of 389 cases included, 252 (64.8%) were exudative and 137 (35.2%) were transudative effusions. Findings of anechoic and jellyfish sign were more common in the transudative group, while septation, loculation, and pleural thickening appeared more commonly in exudative effusion (P < 0.05). Absence of all three signs of fibrin, septation, and loculation had 83% sensitivity (95% CI 77-90) and 78% NPV (95% CI 70-86) for transudative effusion. Septation and loculation had 98% specificity (95% CI 95-100) and 94% PPV (95% CI 88-100) for exudative effusion. Fibrin, loculation, and septation, when found concurrently, had 99% specificity (95% CI 98-100) and 96% PPV (95% CI 88-100) for exudative effusion. Multivariable logistic regression showed the presence of septation (odds ratio [OR] 5.3, 95% CI 1.7-16.3, P = 0.0038) and loculation (OR 3.3, 95% CI 1.1-10.0, P = 0.0327) were each independently associated with the likelihood of complicated parapneumonic and empyema cases. CONCLUSIONS:TUS features of loculation or septation are specific and predictive for exudative pleural effusion. The presence of septation and loculation was each associated with a higher likelihood of complicated parapneumonic effusion or empyema. Further studies are needed to validate diagnostic models that incorporate both TUS and clinical features to predict the nature and etiology of pleural effusions.

AIM/OBJECTIVE:This study aimed to explore the efficacy of MRI-based radiomics models, employing various machine learning techniques, in the preoperative prediction of the digital subtraction angiography (DSA) classification of venous malformations (VMs). MATERIALS AND METHODS/METHODS:In this retrospective study, 160 VM lesions from 153 children were categorized into a training set (n=128) and a testing set (n=32). Radiomic features were extracted from preoperative MRI scans. Feature selection was executed using the intraclass correlation coefficient test, z-scores, the K-best method, and the least absolute shrinkage and selection operator. Diverse MRI sequences and machine learning methods underpinned the development of the radiomics models. The models' efficacy was evaluated using receiver operating characteristic curves and the area under the curve (AUC). RESULTS:Out of 4528 radiomic features derived from CET1 and T2 images, 9 features were significantly associated with DSA classification differentiation. The most effective model for predicting VMs' DSA classification incorporated these 9 features and employed a random forest classifier. This model achieved an AUC of 0.917 in the training set and an excellent discrimination AUC of 0.891 in the testing set. CONCLUSION/CONCLUSIONS:The random forest model, utilizing CET1 and T2 sequences, exhibited outstanding predictive performance in the preoperative distinction of VMs' DSA classification.

Patients with myeloproliferative neoplasms (MPNs) are at increased risk for cardiovascular disease. Although thrombosis is a well-recognized complication, emerging evidence indicates that nonthrombotic conditions, including heart failure (HF) and pulmonary hypertension (PH), are also prevalent and associated with adverse cardiovascular and hematologic outcomes. Clinical and preclinical data suggest a shared pathophysiology linking MPNs to the development and progression of cardiomyopathy, HF, and both precapillary and postcapillary PH. Recent studies further support a bidirectional relationship, in which HF and PH are associated with hematologic progression and vice versa. Elucidating the mechanisms underlying these interactions may uncover novel therapeutic targets and inform clinical management. Here, the authors review the pathophysiology and impact of HF and PH in patients with MPNs.

PURPOSE:Consistent, accurate postoperative guidance is crucial for early recovery and patient satisfaction in urology, especially for radical prostatectomy (RP) patients. However, patients often receive inconsistent information, highlighting the need for standardized, evidence-based postoperative care guidelines. MATERIALS AND METHODS:We conducted a comprehensive review and evaluation of current postoperative practices for RP. This involved (1) reviewing existing discharge information at Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center to identify areas of improvement; (2) systematically evaluating inconsistencies in discharge instructions and their impact on patient care; (3) distributing an anonymous survey to urologists in the US and Europe via REDCap to gather insights into global postoperative care practices. The survey included questions on various aspects of postoperative care, such as catheter use, medication regimens, dietary restrictions, and physical activity guidelines. RESULTS:We received 247 survey responses. Despite some consensus on certain postoperative practices and recommendations, significant variability existed, underscoring the lack of standardized guidelines. Notable differences were observed between US and European cohorts, particularly in postoperative length of stay and discharge practices. Only 1.4% of US responders discharged patients 3 or more days postsurgery compared to 46% in Europe. Variability was also noted in recommendations for erectile function medications and postoperative activity restrictions. CONCLUSION:This study underscores the significant variability in postoperative care recommendations for RP and the urgent need for standardized, evidence-based guidelines. Implementing such guidelines will enhance patient recovery, satisfaction, and overall outcomes, improving postoperative care across various surgical procedures.

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.

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.