Faculty Bibliography

Cefdinir is a third-generation cephalosporin with a wide variety of indications and a strong safety profile. A 24-year-old man began taking cefdinir for an uncomplicated urinary tract infection. Two days later, he began experiencing pleuritic, sharp chest pain and diarrhea and was shown to have mildly elevated troponins. Due to the pleuritic nature of his chest pain improving when leaning forward, as well as elevated troponins and a new small pericardial effusion on echocardiogram, he was diagnosed with myopericarditis thought to be secondary to cefdinir. Cefdinir was subsequently held with diarrhea and chest pain improving shortly afterwards. He was started on ibuprofen 600mg TID for two weeks, as well as colchicine 0.5mg daily for six weeks. The patient finished his treatment regimen and does not endorse recurrence of his chest pain or any symptoms of heart failure, such as orthopnea, lower extremity edema, or shortness of breath.

BACKGROUND/UNASSIGNED:Risankizumab is used for prolongated duration by patients, necessitating further research to characterize the infectious risks involved. CASE PRESENTATION/UNASSIGNED:three weeks after collection. The patient ultimately completed two weeks of oral doxycycline. CONCLUSION/UNASSIGNED:Given the lack of notable risk factors for lung abscess, this case suggests a possible association with Risankizumab, which may have contributed to immunosuppression.

Mitochondria are critical cellular powerhouses that produce adenosine triphosphate to maintain the structure and integrity of the cell. Mitochondria generate 90% of the energy of a cell. Chronic inflammation causes damage to mitochondria. When enough mitochondria are dysfunctional, the involved organ will suffer. Mitochondria become dysfunctional in the setting of chronic inflammation. Under noninflammatory conditions, the body generates new mitochondria (mitochondrial biogenesis) and removes old and damaged mitochondria via mitophagy. When mitochondria are damaged, they "spontaneously" leak out reactive oxygen species, mitochondrial DNA, and damage-associated molecular patterns, generating erroneous innate immune responses. Autophagy is a recycling and housekeeping process that removes dysfunctional components, organelles, and proteins, promoting the recovery and maintenance of cell health. Mitophagy is a specific variant of this process that removes dysfunctional mitochondria from the cell. Mitophagy declines with age, allowing dysfunctional mitochondria to accumulate, and chronic inflammation leads to cardiovascular disease (CVD). In CVD, impairment of both autophagy and mitophagy leads to more chronic inflammation, characterized by hyperactivation of the nucleotide-binding oligomerization domain (NOD)-, leucine-rich repeat (LRR)- and pyrin domain-containing protein 3 (NLRP3) inflammasome, a key component of the immune system. Once activated, it triggers inflammation, leading to excessive cytokine activity, proinflammatory macrophage polarization, pyroptosis, and increased immune cell infiltration into cardiac and vascular tissues. Pyroptosis is a form of inflammatory cell death triggered by programmed cues; however, in autoimmunity and cancer, when overactivated, this process can become detrimental. Adequate regulation of these events reduces oxidative stress, inflammatory cascades, fibrosis, and maladaptive remodeling, thereby improving overall cardiovascular health. Targeted therapeutic enhancement of autophagy and mitophagy represents a promising strategy to modulate immune-driven pathology and improve outcomes in cardiovascular conditions. We will review the mechanisms of how this inflammation causes CVD.

Women with a history of surgical correction for adolescent idiopathic scoliosis are often denied neuraxial anesthesia during labor and delivery due to concerns of technical difficulties, anesthetic failures, inadvertent dural punctures, and hardware infections. We report four successful neuraxial procedures by four different anesthesiologists in three patients with previous posterior spinal instrumentation and fusion who delivered at our institution. The procedures include spinal anesthesia for cerclage, epidural analgesia for labor followed by successful conversion to epidural anesthesia for intrapartum cesarean delivery, spinal anesthesia for cesarean delivery, and epidural analgesia for vaginal delivery. Modern surgical techniques improve success rates of neuraxial anesthesia. Antenatal anesthesia consultation, knowledge of the lowest instrumented vertebra, familiarity with neuraxial ultrasound and multidisciplinary collaboration between orthopedic, obstetric, and anesthesiology teams are key. Anesthesiologists should offer and attempt neuraxial anesthesia if desired by these patients. Neuraxial anesthesia should not be withheld from them because they have spine instrumentation.

Myeloproliferative neoplasms (MPNs) are a spectrum of clonal hematologic malignancies, characterized by an acquired somatic mutation in hematopoietic stem cells (HSC). Consequent constitutive activation of the JAK/STAT signaling pathway ultimately leads to HSC clonal expansion, a heightened inflammatory state, and aberrant trafficking of the malignant stem cells to sites of extramedullary hematopoiesis. While polycythemia vera (PV), essential thrombocythemia (ET), and myelofibrosis (MF) are distinct disease entities, each with their own diagnostic criteria, risk stratification, and molecular profiles, they share a common pathogenesis and exist on a spectrum, with overlapping clinical features, propensity for thrombohemorrhagic events, and risk for transformation to acute leukemia. Interferon alpha (IFN-α) has both anti-proliferative and immunomodulatory effects on MPN HSCs, and therefore is an effective treatment modality for PV, ET, and MF. In this review, we discuss the rationale for IFN-α use in MPNs, examine the evidence supporting its use, and convey practical considerations.

IMPORTANCE/UNASSIGNED:In a phase 2 randomized clinical trial, high-dose vitamin D3 added to standard treatment improved progression-free survival (PFS) compared with standard-dose vitamin D3 in patients with metastatic colorectal cancer (mCRC). OBJECTIVE/UNASSIGNED:To determine if high-dose vitamin D3 added to standard chemotherapy improves outcomes in patients with previously untreated mCRC. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Double-blind phase 3 randomized clinical trial enrolling 455 patients with previously untreated mCRC, conducted in the US through the National Clinical Trials Network from October 2019 to December 2022 (database freeze: July 15, 2024). INTERVENTIONS/UNASSIGNED:mFOLFOX6 (modified FOLFOX6 [5-fluorouracil, leucovorin, oxaliplatin]) or FOLFIRI (5-fluorouracil, leucovorin, irinotecan) plus bevacizumab every 2 weeks with either high-dose vitamin D3 (8000 IU daily × 14 days as loading dose followed by 4000 IU daily) or standard-dose vitamin D3 (400 IU daily) until disease progression, intolerable toxicity, or withdrawal of consent. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary end point was PFS assessed by the unstratified log-rank test. Secondary end points included objective response rate, overall survival, and toxicity. Prespecified subgroup analyses of PFS were performed according to known prognostic factors. RESULTS/UNASSIGNED:Among 455 randomized patients (median age, 59 years; 181 [40%] female) with median follow-up 20 months, the median PFS for high-dose vitamin D3 (n = 228) was 11.8 months (95% CI, 10.3-13.3) vs 10.3 months (95% CI, 9.4-12.2) for standard-dose vitamin D3 (n = 227) (1-sided log-rank P = .25). There were no significant differences in objective response rate between high-dose and standard-dose vitamin D3 (51% [95% CI, 44%-58%] vs 44% [95% CI, 37%-50%], respectively; P = .12), or in overall survival (median, 25.6 vs 27.0 months; 1-sided log-rank P = .66). There were no clinically meaningful differences in the most common grade 3 or greater adverse events between the high- and standard-dose groups, including neutropenia (n = 67 [32%] vs n = 62 [30%]) and hypertension (n = 42 [20%] vs n = 49 [23%]) or in incidence of vitamin D-associated toxicities. CONCLUSIONS AND RELEVANCE/UNASSIGNED:Among patients with previously untreated mCRC, addition of high-dose vitamin D3, vs standard-dose vitamin D3, to standard chemotherapy plus bevacizumab did not improve PFS. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT04094688.

BACKGROUND:Despite the important role of Geriatricians in our society, there is a shortage of Geriatric Medicine specialists. This study surveyed fellows enrolled in ACGME approved Geriatric Medicine fellowships in the United States for insight into why they joined a Geriatric Medicine fellowship. METHODS:Survey links were sent to all Geriatric Medicine Program Directors from July-Sept in 2019 and 2020 and we asked them to share the surveys with their fellows. Survey responses were summarized using descriptive statistics. The Likert-scaled dataset was analyzed with percentage of responses for each item related to "influence" and "barrier" domains. We examined the associations between variables using the Chi-Square test. The free-text fields were analyzed using inductive thematic analysis. RESULTS:There were 149 respondents (80% female) and approximately half of the respondents were from foreign medical schools (52%). Geriatric Medicine was the first fellowship choice for 75% of respondents. Among respondents who were US medical graduates, 89% chose Geriatric Medicine as first-choice specialty for fellowship, in contrast to 61.5% among the Foreign Medical Graduates (FMGs) (p < 0.001). Major reasons why fellows chose Geriatric Medicine were unique career opportunities and care of complex patients. The largest barrier/concern for pursuing Geriatric Medicine fellowship was the low salary associated with the field. CONCLUSIONS:As the first national survey of Geriatric Medicine fellows evaluating their reasons for pursuing a Geriatric Medicine fellowship, these results can be used by Geriatric Medicine fellowship programs and health care systems to improve recruitment into Geriatric Medicine fellowships.

BACKGROUND:The Essentials in Minimally Invasive Gynecologic Surgery (EMIGS) is a new assessment employed by the American Board of Obstetrics and Gynecology to evaluate physicians' surgical skills for certification. The program assesses the minimal laparoscopic skills needed to qualify for the certifying exam. We aimed to use checklist assessments to predict performance on the Running Stitch task of EMIGS OBJECTIVES: We strove to develop and evaluate a novel metric to predict competency in the EMIGS Running Stitch task. Secondarily to assess resident PGY year, prior laparoscopic suturing experience, and prior laparoscopic simulation experience correlation with passage. STUDY DESIGN/METHODS:A novel task specific checklist was developed by expert teaching surgeons to assess the Running Stitch task of EMIG. The checklist was tested for inter-rater reliability. Settings Residency programs at four participating academic centers PARTICIPANTS: 71 participants completed 97 videotaped trials Interventions participants completed a pre-study survey prior to each video-taped laparoscopic skills session (one to four sessions over four months of study). The video and the completed EMIGS task Penrose were evaluated both by the study team with checklists and later by EMIGs MEASUREMENT: The two scores were correlated using linear regression and Bland-Altman plots for agreement. RESULTS:53% of trials received a passing score by AAGL. AAGL and study team checklist scores were moderately correlated (0.73) however study team metrics consistently overrated performance. Laparoscopic case numbers and PGY level correlated with passing score. CONCLUSIONS:Scoring using our novel metric correlated with passing scores but overrated performance. This tool may aid educators in assessment during resident preparation for the EMIGS skills exam, but metrics for grading of this examination remain poorly understood.

BACKGROUND/UNASSIGNED:Lifestyle interventions are effective in reducing cardiovascular disease (CVD) risk, but few target mothers of toddlers and preschool-aged children. Cardiovascular risk factors may emerge or worsen during this life stage due to high child-rearing demands, with the potential to persist long-term. We scoped the literature to synthesize findings and highlight future research opportunities regarding CVD prevention interventions among mothers of young children. METHODS/UNASSIGNED:We searched PubMed, Scopus, Web of Science, CINAHL, Embase, and APA PsycINFO for 2010-2024 peer-reviewed, English-language articles about CVD risk reduction lifestyle interventions for mothers with young children aged 1-5 years. Due to limited initial results, we broadened this demographic criterion to include mothers with children either <1-5 years (infants to young children) or 1-12 years (young to school-age children). RESULTS/UNASSIGNED:= 2). None addressed nicotine exposure nor sleep. Five studies reported statistically significant results for at least one of their outcomes. CONCLUSION/UNASSIGNED:Very few studies discuss lifestyle interventions for CVD prevention among mothers of young children, highlighting a salient gap and opportunities for additional research in this population.