Faculty Bibliography

Separation of patients by insurance status in ambulatory care settings is a long-standing practice in academic medicine. This payer-based segregation of patients between resident and faculty outpatient practices may lead to inequitable quality of care. Informed by replies to a free-response text question for residents and program directors within the 2023 U.S. obstetrics and gynecology in-service examination, we provide commentary on this structural inequity within obstetrics and gynecology. The purpose of this commentary is to discuss the differences in patient population served, gaps in resources in resident clinics, quality of care and moral injury, limited continuity of care, and training and supervision. Further work is needed to guide systemic integration efforts and to explore the effects of program integration on patient health outcomes. We nonetheless urge academic medical centers to consider organizational shifts toward payer-integrated care.

OBJECTIVE:Tethered cord syndrome (TCS) is a significant cause of debilitation in patients with spinal dysraphisms or tumors. Management of TCS has historically centered on intradural detethering surgery, which is associated with a substantial risk of retethering, symptom recurrence, and repeat surgery. Vertebral column resection (VCR) has recently gained popularity as a treatment option via spinal shortening, but the literature on long-term outcomes is sparse. The objective of this study was to explore long-term clinical outcomes in a series of patients undergoing VCR for recurrent TCS. METHODS:A retrospective review was conducted of all consecutive patients undergoing VCR for recurrent TCS at a single center between 2014 and 2024. Demographic and radiological characteristics were recorded, including spinal column height reduction as well as symptom improvement rates regarding sensorimotor dysfunction, pain, and incontinence at the latest follow-up. Intra- and postoperative complications were noted, and pre- and postoperative symptomology was compared using McNemar's test at a significance level of p < 0.05 to identify improvements. RESULTS:Twenty surgeries in 19 patients (median age 19 years) involving 10 males (52.6%) were assessed. The most common etiology of TCS was lipomyelomeningocele (n = 7, 36.8%), followed by lipoma (n = 6, 31.6%). Patients underwent a mean of 3.4 previous detethering procedures. Osteotomy was most commonly performed at the L1 level (n = 11, 55.0%), and the mean spinal column height reduction was 16.5 mm. At a mean follow-up of 43.1 (range 12-101) months, resolution of symptoms was observed in 10 patients with back pain (71.4%; p = 0.043), 10 patients with leg pain (66.7%; p = 0.004), 9 patients with lower extremity weakness (75.0%; p = 0.008), 4 patients with urinary incontinence (44.4%; p = 0.371), and 1 patient with fecal incontinence (33.3%; p > 0.99). Complications included a CSF leak in 1 patient and repeat VCR in 1 patient. CONCLUSIONS:These results suggest that in select patients with recurrent TCS, VCR represents a treatment option with high rates of symptomatic improvement and a relatively low risk of retethering as observed over several years of follow-up. These results add to the body of literature supporting VCR and provide a compelling basis for future prospectively designed studies.

IMPORTANCE/UNASSIGNED:One-quarter of US women who are at risk for cervical cancer delay screening. Self-collected (SC) cervical screening was recently US Food and Drug Administration (FDA)-approved in the US for use in a health care setting only; an at-home SC option is crucial to address clinic-related barriers to screening. OBJECTIVE/UNASSIGNED:To clinically validate the use of an SC device that was designed for optimal at-home performance, safety, ease-of-use, and dry storage and transport. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This nonrandomized clinical trial used a prospective method comparison study design. Participants aged 25 to 65 years were recruited from 16 clinical sites in the US including community and academic practices from November 20, 2023, to April 5, 2024. Data analysis was conducted from April to August 2024. INTERVENTION/UNASSIGNED:Eligible participants collected a sample with the SC method, followed by a clinician-collected (CC) sample. The SC sample was eluted into PreservCyt at the laboratory and both samples were tested on an FDA-approved high risk human papillomavirus (hrHPV) test approved for primary screening. Participants were followed up for safety and completed usability and screening preference surveys. MAIN OUTCOME AND MEASURES/UNASSIGNED:The primary outcome measures were positive percentage agreement (PPA) and negative percentage agreement for detection of hrHPV between the SC and CC samples. Other study measures included clinical sensitivity for high grade cervical dysplasia and usability. RESULTS/UNASSIGNED:Of 609 screening-eligible participants, 599 (262 aged 30-39 years [43.7%]; 583 identified as female [97.3%]) had paired SC-CC samples, of which 582 had valid paired samples included in the end point analysis. Among the 582 evaluable paired samples, the PPA between SC compared with paired CC samples for detection of hrHPV was 95.2% (95% CI, 92.1%-97.1%; 278 of 292 participants). The absolute clinical sensitivity for detection of high-grade cervical dysplasia was 95.8% (95% CI, 86.0%-98.8%; 46 of 48 participants), equivalent to the CC (relative sensitivity, 1.00). Nearly all participants (555 of 601 participants [92.3%]) reported that the device instructions were easy or very easy to understand and also that they would choose SC if they knew the results were comparable to CC results (560 of 602 participants [93.0%]). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this nonrandomized clinical trial, SC samples collected with the device showed equivalent clinical sensitivity and exceeded the PPA end point for cervical screening. This SC method was found to be easy to use and to be a preferred option with high clinical performance intended for use in an at-home setting. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT06120205.

OBJECTIVE:To evaluate the Maryland All-Payer Model's impact on the rate of elective major joint replacement surgery. STUDY DESIGN/METHODS:A retrospective cohort study of patients in Maryland undergoing elective major joint replacement between 2011 and 2018 was performed using a 20% fee-for-service Medicare sample in a difference-in-difference framework with patients undergoing hip fracture repair serving as controls. METHODS:Among Maryland residents, there were 7147 Medicare fee-for-service patients undergoing elective major joint replacement and 1008 Medicare fee-for-service beneficiaries undergoing hip fracture repair. We used patient-level generalized linear models with a negative binomial family function and a log link function to estimate the association of the All-Payer Model with the rate of elective major joint replacement surgery. RESULTS:Under the All-Payer Model, the rate of elective major joint replacement surgery increased more than that of hip fracture repair (adjusted relative risk, 1.31; 95% CI, 1.15-1.51). Compared with hospitals without affiliates in adjacent states (Maryland-only hospitals), those with affiliates (Maryland hospitals with affiliates) saw rates of elective major joint replacement grow more slowly (adjusted relative risk, 0.87; 95% CI, 0.80-0.95) after the All-Payer Model. Furthermore, major joint replacement rates for Maryland residents at affiliated hospitals in adjacent states increased from 4.26 per 10,000 in the preintervention period to 5.23 per 10,000 in the postintervention period. CONCLUSIONS:Under the All-Payer Model, population-based rates of elective major joint replacement surgery increased more rapidly than did rates of hip fracture repair. Although rates of major joint replacement at Maryland hospitals with affiliates grew more slowly than for Maryland-only hospitals, rates among Maryland residents increased at the affiliates in adjacent states.

BACKGROUND:While cardiovascular benefits of tirzepatide, a glucose-dependent insulinotropic peptide/glucagon-like peptide-1 receptor agonist in patients with type 2 diabetes mellitus (T2DM), and its comparative effectiveness vs glucagon-like peptide-1 receptor agonists (GLP-1RAs) is studied in randomized controlled trials, real-world outcomes may provide critical insights. OBJECTIVES/OBJECTIVE:The purpose of this study was to examine the cardiovascular benefits of tirzepatide vs GLP-1RA in people living with overweight or obesity, with T2DM, age ≥40 years, and pre-existing ischemic heart disease (IHD). METHODS:receiving either tirzepatide or GLP-1RA were identified and divided into 2 groups (tirzepatide vs GLP-1RA). After propensity score matching, Cox-proportional HRs were used to compare efficacy and safety outcomes during 1-year follow-up. RESULTS:Among 47,719 adults, 753 received tirzepatide, and 46,966 were on GLP-1RA. After propensity score matching, each group had 751 adults (mean age 59.9 ± 8.9 years, 46.5% females, 74.8% White adults in the tirzepatide group). Treatment with tirzepatide was associated with lower primary composite outcomes of acute myocardial infarction, ischemic stroke, and all-cause mortality (HR: 0.60, 95% CI: 0.43-0.84, P < 0.001). Individually, acute myocardial infarction (HR: 0.59, 95% CI: 0.38-0.91) and all-cause mortality (HR: 0.35, 95% CI: 0.14-0.88, P = 0.001) were also found to be favorable in the tirzepatide group. CONCLUSIONS:, and pre-existing IHD.

OBJECTIVE:We examined if thyroid autoimmunity is relevant to the relationship between maternal TSH levels and pregnancy outcomes. DESIGN/METHODS:Retrospective cohort analysis of data from two randomized controlled trials (RCTs). SUBJECTS/METHODS:Participants of the Pregnancy in Polycystic Ovary Syndrome (PPCOS II, n = 746) and the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS, n = 832 with unexplained infertility) RCTs. EXPOSURE/METHODS:Pre-trial intervention levels of thyroid stimulating hormone (TSH) at threshold of ≥2.0 mU/L and thyroid peroxidase antibody (TPO-Ab) at titer threshold of ≥30 U/mL. MAIN OUTCOME/RESULTS:Live birth (primary outcome), pregnancy loss and preterm birth (secondary outcomes). Generalized linear model (GLM) analyses examined the relationship between exposure to TSH and TPO-Ab at specified thresholds with the specified outcomes; covariates adjusted for included age, body mass index, race, ethnicity, education, smoking, duration of infertility, PCOS (versus unexplained infertility) and randomized intervention arm in the respective RCTs. RESULTS:On adjusted analyses, live birth was significantly reduced in the exposed population (those with TSH ≥2.0 mU/L and TPO-Ab ≥30 U/mL, n= 117/1578, 7.4%, adjusted risk ratio [ARR] 0.55, 95% CI 0.35- 0.87) compared to the unexposed (those with TSH <2.0 mU/L and TPO-Ab <30 U/mL, n=865/1578, 54.8%). Furthermore, the risk of pregnancy loss and of early preterm birth (<32 weeks) was significantly higher in the exposed compared to the unexposed (ARR for pregnancy loss was 1.66, 95% CI 1.14- 2.42, and ARR for early preterm birth was 4. 82 (95% CI 1.53- 15.19). CONCLUSIONS:In women with TPO-Ab titers ≥30 U/mL, pregnancy outcomes may be compromised at TSH threshold of ≥2 mU/L. These findings of an interaction between TSH and TPO for pregnancy outcomes merit further investigation in prospective studies.

PURPOSE/OBJECTIVE:To assess the association between neoadjuvant therapy and overall survival (OS) in patients with left-sided resectable pancreatic cancer (RPC) compared to upfront surgery. BACKGROUND:Left-sided pancreatic cancer is associated with worse OS compared to right-sided pancreatic cancer. Although neoadjuvant therapy is currently seen as not effective in patients with RPC, current randomized trials included mostly patients with right-sided RPC. METHODS:International multicenter retrospective study including consecutive patients after left-sided pancreatic resection for pathology-proven RPC, either after neoadjuvant therapy or upfront surgery in 76 centers from 18 countries on 4 continents (2013-2019). Primary endpoint is OS from diagnosis. Time-dependent Cox regression analysis was performed to investigate the association of neoadjuvant therapy with OS, adjusting for confounders at time of diagnosis. Adjusted OS probabilities were calculated. RESULTS:=0.96) involvement. CONCLUSIONS:Neoadjuvant therapy in patients with left-sided RPC was associated with improved OS compared to upfront surgery. The impact of neoadjuvant therapy increased with larger tumor size and higher serum CA19-9 at diagnosis. Randomized controlled trials on neoadjuvant therapy specifically in patients with left-sided RPC are needed.