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:Near-infrared autofluorescence (NIRAF) spectroscopy is an emerging adjunct for intraoperative parathyroid identification. However, its ability to differentiate between normocellular, hyperplastic, or adenomatous parathyroids remains unexplored. We hypothesize that parathyroid adenomas have lower NIRAF ratios than normocellular parathyroids since the likely fluorophore is the calcium-sensing receptor (CaSR), which is downregulated in adenomas. METHODS:In vivo NIRAF ratios for each identified parathyroid gland were recorded for patients undergoing thyroidectomy or parathyroidectomy from 08/2023 to 12/2023 at a single institution. Parathyroids were categorized as normocellular by visual inspection and hyperplastic or adenomatous by final histology. RESULTS:Of the 44 patients included (66% underwent parathyroidectomy and 34% underwent thyroidectomy), 137 parathyroids were identified intraoperatively with 66 resected and analyzed histologically. A total of 71 (52%) parathyroids were normocellular, 45 (33%) were hyperplastic, and 21 (15%) were adenomatous. Among the resected parathyroids, there was moderate agreement (81%) between visual categorization and final histology for hyperplasia versus adenoma (κ = 0.6). Parathyroid adenomas had lower median NIRAF ratios than normocellular parathyroids (p = 0.0005). Median NIRAF ratios were not significantly different between normocellular and hyperplastic parathyroids (p = 0.35) nor between hyperplastic parathyroids and adenomas (p = 0.04). The performance of NIRAF spectroscopy in differentiating parathyroid pathology is poor based on receiver operator characteristics analysis. CONCLUSION:Parathyroid adenomas have lower NIRAF ratios than normocellular parathyroids. However, the performance of using NIRAF ratios to differentiate between parathyroid pathology is poor. Therefore, the differences in NIRAF ratios are unlikely to be sufficient at point-of-care use to distinguish between various parathyroid pathologies. As NIRAF ratios are highest in normocellular parathyroid glands, NIRAF appears to be most useful in detecting normal parathyroid glands.

BACKGROUND:Osteoporosis is a significant cause of morbidity and mortality in the aging population. Individuals with type 2 diabetes mellitus (T2D) typically have higher bone density yet also a higher rate of fractures. Blacks, meanwhile, have a lower incidence of osteoporosis compared to European Americans. Serum bicarbonate may be a risk factor for bone loss, but studies are conflicting, and little is known about this relationship in T2D or Blacks. METHODS:We examined the longitudinal relationship between serum bicarbonate and change in bone density in 300 participants with T2D in the African American-Diabetes Heart Study (AA-DHS). Serum bicarbonate was measured at baseline, and bone density was assessed using CT volumetric bone mineral density (vBMD) scans of the thoracic and lumbar vertebrae at baseline and after five years of follow-up. Multivariate linear regression models assessed associations between baseline serum bicarbonate and longitudinal change in vBMD, adjusted for multiple confounders. RESULTS:, p < 0.001), without a clear threshold effect or differences by sex. CONCLUSIONS:In this cohort of Blacks with T2D, higher baseline serum bicarbonate levels were associated with improved changes in bone density over time. Further studies are needed to determine if alkali supplementation would ameliorate loss of bone density in this population.

BACKGROUND:Four-dimensional computed tomography is routinely used to localize parathyroid disease, with consistently excellent parathyroid gland localization rates reported. This study evaluated whether pairing 4-dimensional computed tomography results with preoperative clinical variables can accurately predict single-gland disease in primary hyperparathyroidism. METHODS:Patients with primary hyperparathyroidism who underwent both 4-dimensional computed tomography imaging and parathyroidectomy between January 2019 and September 2021 at a large academic health system were included. Patient demographics, preoperative characteristics, and peri- and postoperative data were collected. The accuracy of 4-dimensional computed tomography in correctly identifying patients with single-gland disease with and without preoperative calcium and parathyroid hormone levels was calculated. Single-gland disease was defined by intraoperative parathyroid hormone decrease >50% and a hypercellular gland on pathology. RESULTS:One hundred seventy-five patients had 4-dimensional computed tomography results suggestive of single gland disease. One hundred fifty-two patients (87%) were predicted correctly to have single-gland disease. The predictive accuracy increased when stratifying by preoperative calcium (≥10.5 mg/dL, ≥11 mg/dL, and ≥12 mg/dL) and parathyroid hormone levels (≥65 pg/mL, ≥100 pg/mL, and ≥200 pg/dL). The accuracy further increased when stratifying by age (≤50 years). Accuracy for single gland disease was 100% when combined with any of the following: (1) calcium ≥12 mg/dL, (2) parathyroid hormone ≥200 pg/dL, or (3) calcium ≥11 mg/dL in patients ≤50 years. CONCLUSION/CONCLUSIONS:Four-dimensional computed tomography alone accurately predicted single gland disease in 87% of patients with primary hyperparathyroidism. When combined with preoperative calcium, parathyroid hormone and age thresholds, predictive accuracy for single-gland disease approached 100%. Given the high likelihood of single-gland disease in these scenarios, clinicians may consider offering focused unilateral parathyroidectomy without intraoperative parathyroid hormone monitoring in selected patients.

OBJECTIVES/OBJECTIVE:Addressing minor yet significant frustrations, or "pebbles," in the workplace can reduce physician burnout, as noted by the American Medical Association. These "pebbles" are small workflow issues that are relatively easy to fix but can significantly improve the workday when resolved. This quality improvement project aimed to enhance clinician well-being in an emergency department (ED) affiliated with an academic institution through human-centered design by actively engaging clinicians to identify these "pebbles" and for a dedicated team to address them. METHODS:A task force comprised of three emergency physicians collaborating with emergency medicine leadership was established. After educating clinicians about "pebbles," clinicians were able to anonymously submit pebbles based on recall of frustrations in a baseline survey at the start of the project, as well as submit pebbles in real time by a QR code that was placed in easily noticeable areas. The task force met bimonthly to categorize, prioritize, and assign ownership of the pebbles. Progress was communicated to staff via a monthly "stop light" report. An anonymous survey assessed the impact on clinician well-being among 68 emergency clinicians within seven months of starting the project. RESULTS:Over seven months, 284 pebbles were submitted (approximately 40 per month). The feasibility of addressing pebbles was characterized by a color scale: green (easy to fix): 149 (53%); yellow (more complex): 111 (39%); and red (not feasible, "boulder"): 24 (8%). Categories of pebbles included the following: equipment/supply: 115 (40%); nursing/clinical: 86 (30%); process: 64 (23%); and information technology/technology: 19 (7%). A total of 214 pebbles (75%) were completed. Among 51 respondents (75% response rate), the self-reported impact on well-being of having pebbles addressed was as follows: extremely effective: 16 (31%); very effective: 25 (49%); moderately effective: 8 (16%); slightly effective: 2 (4%); and not effective 0 (0%). CONCLUSION/CONCLUSIONS:In addition to improving personal resilience, improving well-being in the ED involves addressing efficiency of practice. This project highlights the positive impact of resolving small, feasible issues identified by clinicians, which resulted in 80% of respondents rating the project as very to extremely effective in improving their well-being. Most pebbles were related to equipment and easily fixed, while issues involving human interactions (eg, communications between consultants and EM) were more challenging. Regular meetings and accountability facilitated progress. This approach is replicable across medical specialties and practice settings, offering a low-cost method to enhance clinician work environments and well-being.

Homocysteine is an amino acid derived from methionine which is metabolized via vitamin B₆ (pyridoxine)- and vitamin B₁₂ (cobalamin)-dependent pathways. Supplementation of B vitamins has been shown to effectively reduce plasma homocysteine levels. Previous research has also demonstrated an association between lower plasma homocysteine levels and decreased risk of myocardial infarction, stroke, and venous thromboembolism. However, whether supplementation of B vitamins is associated with risk reduction in thromboembolic events and confers clinical benefits remains inconclusive. This review examines clinical trials published over the past 29 years to assess the effects of B vitamin supplementation on thrombotic risk reduction and homocysteine metabolism. The findings from these studies are inconsistent, and the impact of B vitamins on thrombosis prevention remains uncertain. Given the conflicting evidence, further clinical and translational research is necessary to clarify the role of B vitamin supplementation in thrombosis risk reduction.