Faculty Bibliography

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.

INTRODUCTION/BACKGROUND:Necrotizing fasciitis is a rapidly progressive infection associated with high mortality and complications. It mainly involves subcutaneous tissue and fascia. More quality data on disparities in clinical outcomes of necrotizing fasciitis must be provided. Our study aims to identify gender and racial disparities in necrotizing fasciitis outcomes. METHODS:We used data from the Nationwide Inpatient Sample database from 2016 to 2020. As appropriate, the Chi-square and t-test were used to test for associations between categorical and continuous variables. Multivariate logistic regression models, adjusted for key confounders, were used to obtain odds ratios for in-hospital mortality and various complications. Similarly, multivariate linear regression models were created for continuous outcome variables. RESULTS:Among 118,775 patients with necrotizing fasciitis, women (adjusted odds ratio [aOR] 1.18, 95 ​% confidence interval [CI]: 1.07-1.30, p ​= ​0.001), Asian (aOR 1.49 (95 ​% CI: 1.10-2.02, p ​= ​0.01), and Hispanic (aOR: 1.16; 95 ​% CI: 1.0-1.35; p ​= ​0.045) patients had significantly higher in-hospital mortality than White patients. In comparison with men, women were more likely to require invasive mechanical ventilation and blood transfusions and develop ARDS. They are less likely to develop AKI, acute myocardial infarction, or venous thromboembolism and require non-invasive mechanical ventilation (p ​< ​0.05 for all comparisons). Similarly, certain racial minority groups were also at a heightened risk for complications, such as AKI requiring hemodialysis, ARDS, venous thromboembolism, sudden cardiac arrest, and need for blood transfusion, among others (p ​< ​0.05 for all comparisons). As compared to white patients, African American (1.7 days longer, p ​< ​0.001), Asian (4.3 days longer, p ​< ​0.001), and Hispanic (0.6 days longer, p ​= ​0.048) patients had a significantly longer length of hospital stay. Asian, African American, and Hispanic patients also had substantially higher hospitalization costs, amounting to an additional $17,596.07 (p ​< ​0.001), $5899.60 (p ​< ​0.001), and $4356.55 (p ​< ​0.01), respectively, versus White patients. Native American patients did not have any significant difference in the cost of hospitalization as compared to White patients. CONCLUSION/CONCLUSIONS:Females and racial minorities are at increased risk of mortality and higher healthcare resource utilization in necrotizing fasciitis. There is a need to develop equitable management strategies and health policy interventions to address these disparities effectively.

Spinocerebellar ataxia type 14 (SCA14) is an autosomal dominant neurodegenerative disorder characterized by adult-onset cerebellar ataxia, and occasionally pyramidal signs, cognitive changes, sensory changes, myoclonus, and tremor. SCA14 results from heterozygous gain-of-function pathogenic variants in PRKCG, which encodes protein kinase Cγ. The aim was to elucidate the molecular mechanism of disease in a 60-year-old man with SCA14 due to a novel heterozygous variant in PRKCG c.154T > C p.(C52R). Next-generation sequencing was completed in the proband, targeted variant analysis was conducted in his family, and biochemical functional assays were performed. The C52R variant segregated with disease. Like other C1A domain variants, it had increased basal activity yet was unresponsive to agonist stimulation and was relatively resistant to down-regulation. This expands the genetic landscape of SCA14 and supports the condition as a gain-of-function disease, with variants in the C1A domain having leaky activity yet unresponsiveness to agonist stimulation.

OBJECTIVE:To assess the association between skilled nursing facility (SNF) utilization and Alzheimer's disease and related dementias (ADRD) both before and during the COVID-19 pandemic. DESIGN/METHODS:An observational cohort study. SETTING AND PARTICIPANTS/METHODS:The study included community-dwelling respondents aged 65 or older. METHODS:This study analyzed data from 3 waves of the Health and Retirement Study and employed multivariable, individual-level regressions. The primary outcomes were any SNF stays, the number of SNF stays, and the total number of SNF days, in the past 2 years of the survey. Respondents were classified as cognitively normal, having cognitive impairment but not dementia (CIND), or having ADRD. RESULTS:The study included 23,654 respondent-years, representing 12,529 unique respondents. Before the pandemic, differences in any SNF stays, and the number of SNF stays between the cognitively normal and CIND and ADRD groups were statistically insignificant in multivariable regressions. During the pandemic, compared with respondents with normal cognition, those with CIND had higher odds of any SNF stays (OR, 1.53; 95% CI, 1.06-2.20) and more SNF stays (incidence rate ratio [IRR], 2.40; 95% CI, 1.30-4.40); similarly, the ADRD group showed higher odds of any SNF stays (OR, 1.68; 95% CI, 1.08-2.59) and more SNF stays (IRR, 2.48; 95% CI, 1.36-4.47) than cognitively normal older adults. The total number of SNF days for CIND and ADRD respondents remained statistically insignificantly different from those of the cognitively normal group, both before and during the pandemic, in regression analyses. CONCLUSIONS AND IMPLICATIONS/CONCLUSIONS:This cohort study suggests that the pandemic was associated with increased differences in any SNF stays and number of transitions to SNFs between cognitively normal individuals and those with CIND or ADRD. These findings provide a foundation for understanding the potential impact of a public health emergency on post-acute care utilization among older adults with varying degrees of cognitive impairment.

Tardive dyskinesia (TD) is a syndrome that causes chronic, involuntary, and disruptive movements of the body and/or face that is a severe, potentially irreversible adverse effect of long-term antipsychotic use. It has wide-reaching effects on patients' well-being, quality of life,¹ and treatment adherence.² Thus, TD is debilitating, leading to social withdrawal,³ and workplace absenteeism.¹ Current data on tardive dyskinesia treatment are limited, and prevention, primarily through the modification of antipsychotic regimens, remains the most effective strategy.⁴ Recent systematic review has shown valbenazine and vitamin E are the only treatments significantly more effective compared to placebo in treatment of TD, although valbenazine is associated with significant side effects.⁵ We present a case of a 76-year-old female with a diagnosis of Bipolar II Disorder (BD) who developed TD after treatment with lurasidone for 10 years. After struggling with both her BD and TD symptoms for 3 years, she sought care at our clinic where we prescribed 300 mg daily of lithium. At her follow-up visit 5 weeks later, her TD symptoms were greatly improved, with sustained benefits observed at following visits. This article reviews the literature discussing the interplay between lithium and TD and presents a case report of TD improvement after lithium augmentation for treatment-resistant depression. While this case suggests a potential role in TD treatment, the role of lithium in TD treatment remains controversial.