Faculty Bibliography

BACKGROUND:A 2021 meta-analysis of 37 randomised controlled trials (RCTs) of vitamin D supplementation for prevention of acute respiratory infections (ARIs) revealed a statistically significant protective effect of the intervention (odds ratio [OR] 0·92 [95% CI 0·86 to 0·99]). Since then, six eligible RCTs have been completed, including one large trial (n=15 804). We aimed to re-examine the link between vitamin D supplementation and prevention of ARIs. METHODS:Updated systematic review and meta-analysis of data from RCTs of vitamin D for ARI prevention using a random effects model. Subgroup analyses were done to determine whether effects of vitamin D on risk of ARI varied according to baseline 25-hydroxyvitamin D (25[OH]D) concentration, dosing regimen, or age. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science, and the ClinicalTrials.gov between May 1, 2020 (end-date of search of our previous meta-analysis) and April 30, 2024. No language restrictions were imposed. Double-blind RCTs supplementing vitamin D for any duration, with placebo or lower-dose vitamin D control, were eligible if approved by a Research Ethics Committee and if ARI incidence was collected prospectively and pre-specified as an efficacy outcome. Aggregate data, stratified by baseline 25(OH)D concentration and age, were obtained from study authors. The study was registered with PROSPERO (no. CRD42024527191). FINDINGS/RESULTS:=0·0%). A funnel plot showed left-sided asymmetry (p=0·0020, Egger's test). INTERPRETATION/CONCLUSIONS:This updated meta-analysis yielded a similar point estimate for the overall effect of vitamin D supplementation on ARI risk to that obtained previously, but the 95% CI for this effect estimate now includes 1·00, indicating no statistically significant protection. FUNDING/BACKGROUND:None.

BACKGROUND & AIMS/OBJECTIVE:Delayed diagnosis of inflammatory bowel disease (IBD) leads to prolonged symptoms and worse long-term outcomes. We sought to evaluate whether race, ethnicity, disease type, and social factors are associated with delayed diagnosis of pediatric IBD. METHODS:We performed a cross-sectional study of newly diagnosed pediatric patients with IBD at 22 United States sites from 2019 to 2022. Parents/guardians reported race, ethnicity, time between symptom onset and diagnosis, and other social determinants of health. Through bivariate and multivariable analyses using generalized estimating equations, we evaluated associations between these factors and diagnosis time defined as ≤60 days, 61 to 180 days, 181 to 365 days, and >365 days. RESULTS:We enrolled 869 participants (mean age at diagnosis, 13.1 years; 52% male; 57% Crohn's disease [CD]; 34% ulcerative colitis [UC]; 8% Hispanic; 30% non-White). Overall, the mean time to diagnosis was 265.9 days. After adjustment, factors associated with longer diagnosis time included CD vs UC (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.9-3.5), 2 or more other health conditions (OR, 1.7; 95% CI, 1.1-2.7), and longer travel time to clinic (>1 hour [OR, 1.7; 95% CI, 1.2-2.4], >2 hours (OR, 1.8; 95% CI, 1.2-2.9] each vs <30 minutes). There was no association with race, ethnicity, birth country, sex, parent education, household income, insurance type, health literacy, and health system distrust. CONCLUSIONS:Consistent with prior literature, diagnostic delay is longer for CD than UC. Reassuringly, time to diagnosis is equitable across racioethnic groups. New models of diagnostic care are needed for communities affected by longer travel times.

BACKGROUND:Multiple surgical virtual reality (VR) simulators are currently available; however, there is lack of comparison between performance after practice on these simulators compared to bench top models. Utilizing the Intuitive Data recorder (IDR) and Objective performance indicators (OPI), we aim to objectively assess robotic surgical skills using a dry lab model. We hypothesize that practicing surgical skills will improve OPIs and that those who practice on the dry lab model will have a greater improvement in their OPIs compared to those who practice with Fundamentals of Robotic Surgery (FRS) SimNow VR. METHODS:The IDR was used to record kinematics as each participant went through five basic surgery tasks on a dry lab benchtop model to record baseline performance. Participants were then randomized to practice on the dry lab model or the corresponding SimNow Virtual reality (VR) tasks. The participants repeated the tasks again on the benchtop model. Statistical analysis was performed using paired samples t tests, independent samples t tests, and ANOVA tests. RESULTS:Twenty-seven surgeons participated in our study ranging from interns to attendings. Randomization to VR vs benchtop practice resulted in 11 and 13 participants in each group. For the rollercoaster, backhand suturing, railroad, and knot tying tasks, a significant improvement in kinematic profiles was observed. Bimanual dexterity, angular motion, and smoothness metrics improved most consistently across the tasks after practice. Kinematic profiles between those practicing on VR versus benchtop had no significant differences. CONCLUSIONS:This study shows that OPIs can be used to benchmark surgical trainees. VR appears to be non-inferior to dry lab model for practice for trainees. We identified patterns in OPI improvement that can be tailored to specific skills depending on the trainees needs. Our study is the first step in developing a standardized training and assessment tool to assess competency in robotic surgery training.

BACKGROUND/UNASSIGNED:The increasing number of organ transplant recipients has led to a rise in cancer diagnoses in this population. Kidney transplant recipients, in particular, have a two-to-four-fold higher risk of developing cancer due to immunosuppressive therapy. The management of gynecologic cancers in this subset of patients presents unique challenges due to anatomical considerations, immunosuppression, and the nephrotoxicity of oncologic treatments.Case Presentation.A 44-year-old woman with a history of polycystic kidney disease underwent a bilateral nephrectomy followed by a living-related intraperitoneal renal transplant. She presented with pelvic pain and was found to have high-grade ovarian adenocarcinoma, possibly arising from endometriosis. Surgical staging included total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and right pelvic lymph node dissection. The patient underwent six cycles of carboplatin and paclitaxel chemotherapy while maintaining stable renal function with close monitoring of immunosuppressive drug levels. Surveillance imaging detected recurrence in the right pelvic lymph nodes, leading to secondary tumor debulking and whole pelvic radiation therapy. Despite a slight increase in creatinine, kidney function remained stable, and the patient has remained disease-free on subsequent follow-ups. CONCLUSION/UNASSIGNED:The management of ovarian cancer in kidney transplant recipients requires a multidisciplinary approach to balance oncologic control with graft preservation. Close monitoring of renal function, careful surgical planning, and tailored chemotherapy and radiation strategies are critical. More research is needed to establish standardized guidelines for managing gynecologic malignancies in transplant patients.

The cost of healthcare spending in foot and ankle surgery continues to rise. Several recent studies about cost effectiveness have been published. These may be difficult to understand and analyze without a background in business and healthcare economics. The goal of this narrative review is to provide the fundamentals for understanding and interpreting healthcare economic studies by defining key terminology and providing examples in the field of foot and ankle surgery. Foot and ankle surgeons should be familiar with the elements that comprise cost-effectiveness for providers, clinicians, researchers, and economists in caring for patients and making healthcare-related decisions.

BACKGROUND & AIMS/OBJECTIVE:There is significant variability in the immediate post-operative and long-term management of patients undergoing per-oral endoscopic myotomy (POEM), largely stemming from the lack of high-quality evidence. We aimed to establish a consensus on several important questions on the after care of post-POEM patients through a modified Delphi process. METHODS:A steering committee developed an initial questionnaire consisting of 5 domains (33 statements): post-POEM admission/discharge, indication for immediate post-POEM esophagram, peri-procedural medications and diet resumption, clinic follow-up recommendations, and post-POEM reflux surveillance and management. A total of 34 experts participated in the 2 rounds of the Delphi process, with quantitative and qualitative data analyzed for each round to achieve consensus. RESULTS:A total of 23 statements achieved a high degree of consensus. Overall, the expert panel agreed on the following: (1) same-day discharge after POEM can be considered in select patients; (2) a single dose of prophylactic antibiotics may be as effective as a short course; (3) a modified diet can be advanced as tolerated; and (4) all patients should be followed in clinic and undergo objective testing for surveillance and management of reflux. Consensus could not be achieved on the indication of post-POEM esophagram to evaluate for leak. CONCLUSIONS:The results of this Delphi process established expert agreement on several important issues and provides practical guidance on key aspects in the care of patients following POEM.

Background Expedited Partner Therapy (EPT) is the practice of treating sexual partner(s) of patients diagnosed with STIs without examining the partner(s) and is effective in reducing reinfection. It has been permissible in Virginia since 2020. This study aimed to assess knowledge and practices surrounding prescription of EPT at an academic medical center in Virginia before and after an online learning module. Methods Data were obtained via online anonymous RedCap surveys. The first was distributed via e-mail to providers who regularly diagnose and treat STIs at an academic medical center in Virginia. The survey assessed provider knowledge and practices regarding EPT and preference of future education. On the basis of the results, an online learning module with information on EPT was created and distributed to the same population of providers. The module contained pre- and post-module surveys evaluating participant knowledge of the legal status, methods of prescription, and attitudes surrounding EPT. Results The initial survey showed that 10% of participants were aware of the new legal status of EPT. In terms of EPT prescription, 4% always prescribed EPT, 14% prescribed it sometimes, and 61% never prescribed it. In the pre-module survey, 31% of respondents correctly identified one option for prescription of EPT. Knowledge surrounding the legal status and prescription methods was significantly improved in the post-module responses, with 100% of participants able to identify one correct prescription option. Conclusion These results show knowledge gaps surrounding the Virginia EPT provision and policy change. These gaps improved with the implementation of an online learning module. Further evaluation is needed to assess the continued implementation of EPT.

BACKGROUND:Despite widespread use of Roux-en-Y gastric bypass (RYGB), there are no standardized limb lengths in the United States. METHODS:A multi-center retrospective cohort study was conducted from 2020 to 2023. Eligible patients who had undergone RYGB were divided into subgroups based on BP limb lengths: short (50-75 cm), intermediate (80-125 cm), and long (150-175 cm). Primary outcomes were total weight loss (TWL) and % TWL at 1 and 2 years. Secondary outcomes were post-operative BMI and % BMI change at 1 and 2 years, micronutrient deficiencies, hypothyroidism, acute kidney injury (AKI) requiring treatment, and remission in associated medical problems. Subgroups were compared using multivariate analysis. RESULTS:Two hundred twenty-eight patients received a long BP limb, 194 patients received an intermediate BP limb, while 152 patients received a short BP limb. Primary outcomes TWL and % TWL were significantly different between the groups at 1 year: TWL and % TWL were greater in patients with long BP limbs. The difference between the long and short BP limb groups increased at the 2-year mark. Patients who had long BP limbs had higher rates of DM remission (12.3% vs 11.9% 6.6%), HTN (8.8% vs 5.7% vs 7.9%), GERD symptoms (14.5% vs 9.8% vs 5.3%), and OSA (8.8% vs 7.7% vs 5.3%). Vitamin A deficiency rates were higher in the long BP limb group. CONCLUSIONS:The results suggest that longer BP limb lengths are conducive to TWL and overall treatment of obesity-related problems without severe rates of complications. Additional longer longitudinal studies are needed to assess the impact of long BP limbs on nutrition and weight loss in the long term.