Faculty Bibliography

BACKGROUND:The gracilis flap is a versatile muscle flap that can be utilized as a muscle only or myocutaneous flap for soft tissue coverage, as well as for reconstruction of facial animation or extremity function. Few studies have compared donor site complications of free and pedicled gracilis flaps, including the effect of skin paddle harvest on donor site morbidity. METHODS:We performed a retrospective review of patients who underwent a free or pedicled gracilis flap at our institution from 2013-2023. Gracilis flaps were categorized as: pedicled gracilis muscle flaps used for vaginectomy in gender reaffirming surgery, free gracilis muscle flaps, and free gracilis myocutaneous flaps. Outcome variables were duration of drain placement and complications including seroma, hematoma, infection, dehiscence, and persistent numbness. RESULTS:We identified 128 gracilis flaps including 19 free myocutaneous flaps, 35 free muscle flaps, and 74 pedicled muscle flaps. Free myocutaneous flaps required longer drain placement as compared to free muscle flaps or pedicled flaps (13.6 vs 8.4 vs 7.4 days, respectively, p=0.002). Free myocutaneous flaps displayed a higher complication rate (36.8%) as compared to pedicled muscle flaps (10.8%), or free muscle flaps (11.4%, p=0.020). After adjusting for age, BMI, and ASA status, free myocutaneous flaps demonstrated higher odds of major donor site complication as compared to pedicled muscle flaps (OR 1.23, p<0.001), while free muscle flaps were not associated with increased odds of major complication (OR 1.08, p=0.117). Of the documented complications, the most common were surgical site infection (36.8%), hematoma (21.1%) and seroma (21.1%). CONCLUSION/CONCLUSIONS:The inclusion of a skin paddle during gracilis flap harvest is associated with increased duration of drain placement and donor site complications including surgical site infection, hematoma, and seroma. These factors should be carefully considered in the context of patients' reconstructive needs and other risk factors.

CONTEXT/BACKGROUND:Traumatic musculoskeletal injuries may result in chronic pain and mobility limitations, decreasing quality of life, and increasing predisposition to comorbid disorders. Osteopathic manipulative treatment (OMT) utilizes palpatory assessment and application of manual forces as an adjunct intervention for musculoskeletal disease. Multiple studies have demonstrated OMT's potential benefits for a range of disease states, but data on osteopathic OMT are limited. OBJECTIVES/OBJECTIVE:The objective of our study was to understand the potential benefits of a novel OMT for trauma outpatient program for the care of injured patients suffering chronic pain and mobility limitations. METHODS:In 2021, the New York University (NYU) Langone Hospital - Long Island Level 1 Trauma Center established a novel outpatient OMT for Trauma Program (OTP). We performed a retrospective analysis of OTP patients seen from January 1, 2021 to December 31, 2022 with the chief complaint of refractory chronic (persistent ≥3 months since inciting injury) postinjury pain and mobility limitations (inclusion criterion). We excluded patients missing follow-up, then extracted and analyzed patient demographic, injury-specific, and OMT data. Data are presented as frequencies (percentages) or medians (interquartile range [IQR]). RESULTS:Forty-three patients (75.4 % of patients treated at the outpatient OTP) reported a mechanism of injury (MOI). Of these, 30 (69.8 %) met the inclusion criteria, and seven met the exclusion criterion, yielding 23 total patients for the analysis (40.3 % of the total OTP population). 73.9 % were female aged 46 (39-59) years old. Patients presented 3.00 (0.58-20) years since etiologic injury. MOIs included 56.5 % motor vehicle collisions (MVC), 21.7 % falls, 8.7 % penetrating, and 13.0 % sports-related or lifting injuries. Patients reported 3 (2-4) treatment modalities tried and 2 (1-3) medications attempted prior to the OTP. After the first OMT session, 95.7 % of patients reported subjective improvement in pain with a decrease in pain score 3 (3-7) out of 10. After OMT, patients also self-reported ease of activities of daily living (ADLs, 82.6 %), improved sleep hygiene (26.1 %), improved anxiety/mood (65.2 %), and decreased use of analgesic medication (13.0 %). Four (17.4 %) reported post-OMT complication of 2-3 days of self-limited, mild musculoskeletal pain. Univariate logistic regression models demonstrate that OMT benefited patients regardless of time since inciting injury. CONCLUSIONS:OMT may benefit refractory chronic traumatic pain and mobility limitations regardless of the time since inciting the injury. This is the first major publication from the OTP and bolsters proof-of-concept for an organized OMT program at a level 1 trauma center. Further study, including comparative analysis with more formalized pain assessments utilizing validated tools as well as standardized OMT session surveys, is warranted.

BackgroundMalignant bowel obstruction (MBO) is a complex clinical entity and there remains a relative lack of high-quality comparative trials on surgical management, in part due to a heterogeneous patient population and different treatment modalities which contribute to challenges in trial design and completion. SWOG S1316 is the only prospective randomized trial evaluating surgical vs non-surgical management of MBO and involved a trial framework in which patients were recruited for a randomization pathway as well as a patient choice pathway. Importantly, successful completion of S1316 required numerous amendment modifications to the trial during its course. We aimed to highlight aspects of S1316 trial design, execution, and modification that potentially contributed to trial completion.MethodsIterative qualitative content analysis of trial modification amendments through the course of the trial from 2015 to 2020.Results133 unique amendments were made to S1316 from 2015 to 2020. We found four dominant domains for the amendments: Accrual Barriers, Study Design Changes, Data Collection Issues, and Clarifications. Accrual amendments were essential to completing the trial and included increasing participating sites from six to 30 (including international sites) and the inclusion of Spanish-speaking participants (11% of final study population).ConclusionsContent analysis of S1316 trial amendments highlighted that Accrual amendments were important in trial completion. Future investigators may benefit from better anticipating trial modifications as they design their studies. It is likely that rapid initiation of trial amendments can lead to improved accrual and study completion.

BACKGROUND:Despite decreased mortality over the past several decades, the prognosis of brain abscesses remains dependent on intracranial location and causative organism. Deep-seated brain abscesses carry a risk of intraventricular rupture, an event with reported mortality near 80%. Coccidioidomycosis from the fungus Coccidioides immitis, endemic to the American Southwest, is growing in incidence but uncommonly produces deep brain abscesses, making management unclear.The authors report the diagnosis and management of a solitary thalamic Coccidioides abscess without meningitis. OBSERVATIONS/METHODS:A 59-year-old female presented with 1 week of gait instability, left facial weakness, dysarthria, and intermittent headache, but no meningismus. Cranial imaging was consistent with abscess or, less likely, a neoplasm, and a stereotactic brain biopsy was pursued. Despite negative fungal cultures and lack of serum antibody detection, findings of pathognomonic spherules in pathology tissue with confirmatory polymerase chain reaction testing helped diagnose coccidioidomycosis. The patient's symptoms resolved 3 weeks postoperatively with a dexamethasone taper and, due to relapse risk, planned lifelong fluconazole therapy. The patient self-discontinued fluconazole at 11 months postoperatively but remained disease free at 1 year. LESSONS/CONCLUSIONS:C. immitis can present as solitary brain abscesses despite negative fungal cultures. Postoperative dexamethasone and long-term fluconazole can clear the pathogen and suppress recurrence. https://thejns.org/doi/10.3171/CASE25381.

Machine translation supported by artificial intelligence (AI) may enhance linguistically-concordant care for patients speaking languages other than English. This assessment of free-text inpatient discharge instructions in Arabic, Armenian, Bengali, simplified Chinese, Somali, and Spanish compared linguist, clinician, and family caregiver evaluations of translations generated by (1) ChatGPT-4o, (2) professional linguists, and (3) human-in-the-loop (AI-generated, professional linguist post-edited). Likert scales (1-5; higher is better) evaluated linguistic and clinical characteristics of each translation. ChatGPT-4o exhibited variable performance relative to professional translations, with poorest ratings for digitally underrepresented languages (Armenian and Somali). Conversely, human-in-the-loop translations achieved comparable, often better, outcomes to professional translations for all languages, (e.g., Armenian mean overall quality: 3.9 [95% CI 3.7-4.2] vs. professional 3.6 [3.4-3.9], p = 0.01), were most frequently preferred (46.5% vs. 28.4%) and had shorter mean translation time (7.1 [5.4-8.8] vs. 16.8 [13.7-19.9] min, p < 0.001). Human-in-the-loop strategies may enable safe, efficient, equitable machine translation application in clinical practice.

IMPORTANCE/UNASSIGNED:Many patients are diagnosed with benign breast lesions; however, evidence- and consensus-based guidelines for the management of benign breast disease (BBD) are limited. OBSERVATIONS/UNASSIGNED:The American Society of Breast Surgeons (ASBrS) and the Society of Breast Imaging (SBI) developed guidelines for the management of benign fibroepithelial lesions (FELs) using a modified Delphi consensus methodology and public comment. There was strong consensus that core biopsy-proven concordant fibroadenomas without atypia only require excision if they were symptomatic, patient preferred, attained a certain size, or demonstrated substantive growth over time on clinical examination. There was strong consensus that when removing a fibroadenoma, complete excision without transection of the mass is recommended and surgeons should consider aesthetics, sensation, and other factors when selecting incision placement. Patients with core biopsy-proven concordant fibroadenomas do not require imaging follow-up and may return to age-appropriate screening. Many benign phyllodes tumors (BPTs) present as an FEL on core biopsy, and these lesions along with any lesions with suspicion of or concern for phyllodes tumors (PTs) require surgical excisional biopsy with complete excision of the mass. Re-excision of a BPT is not required for patients with a positive margin for BPT, but a margin re-excision may be considered if the mass was transected or there is concern of residual disease after excisional biopsy. Patients with BPT who have undergone excision do not require follow-up imaging and may return to age-appropriate screening. CONCLUSIONS AND RELEVANCE/UNASSIGNED:Evidence-informed, consensus and expert opinion-based guidelines for the management of benign FELs of the breast were developed. These guidelines provide clarification on the controversial management of benign FELs of the breast. Any practicing clinicians who treat patients with benign FELs should integrate these guidelines into treatment of their patients.

BACKGROUND:Germline pathogenic variants in TP53 cause Li-Fraumeni syndrome, with significantly elevated cancer risk from infancy. Accurate classification of TP53 variants is essential to guide clinical management and surveillance, yet many variants remain classified as variants of uncertain significance (VUS). To improve classification accuracy and reduce the proportion of VUS, the ClinGen TP53 Variant Curation Expert Panel (VCEP) has updated its specifications. METHODS:The updated specifications incorporate the latest ClinGen recommendations and methodological advances, providing greater granularity for multiple evidence types, and also introduce the novel use of variant allele fraction as evidence of pathogenicity, particularly in the context of clonal hematopoiesis. Whenever feasible, the VCEP followed a data-driven approach using likelihood ratio-based quantitative analyses to guide code application and determine strength modifications, while also factoring in expert judgment. Proposed modifications were first discussed in working group meetings and then subjected to comprehensive review during monthly general VCEP meetings to reach consensus. RESULTS:The performance of new specifications was compared to that of the old specifications for 43 pilot variants, and led to both decreased VUS and increased certainty, with clinically meaningful classifications for 93% of variants. CONCLUSIONS:The updated TP53 specfications are expected to reduce VUS rates, increase inter-laboratory concordance, and improve medical management for individuals with germline TP53 variants. The most current version is available at the ClinGen Criteria Specifications Registry (CSpec): https://cspec.genome.network/cspec/ui/svi/svi/GN009 .