Faculty Bibliography

Emergency preparedness is a critical component of patient safety in outpatient dialysis settings, where patients rely on life-sustaining treatments multiple times each week. Disruptions caused by natural disasters, infrastructure failures, or other emergencies can threaten the continuity of dialysis care and place this vulnerable population at significant risk. Tabletop exercises have emerged as an effective strategy for strengthening emergency readiness by allowing health care teams to rehearse response procedures in a structured, low-risk environment. These scenario-based simulations promote active engagement, interdisciplinary communication, and real-time problem-solving, while helping organizations identify operational gaps in existing emergency protocols. This article describes the creation and implementation of a tabletop exercise for a rapidly escalating emergency - a hurricane with a changing path and rapid intensification.

Appendiceal tumors are uncommon, and their coexistence as collision tumors is exceedingly rare, with fewer than 20 cases reported to date. The objective is to report a multi-center case series and literature review of appendiceal collision tumors, providing a comprehensive summary of clinicopathological features and outcomes. Electronic records from five tertiary centers (2016-2024) were searched. Cases with appendiceal collision tumors composed of a neuroendocrine tumor (NET) and a second component of low- or high-grade appendiceal mucinous neoplasm (LAMN/HAMN) or adenocarcinoma were included. Additional cases with the same diagnostic combinations were identified through a PubMed literature search since 2000. Clinical, pathologic, and survival data were collected and analyzed. Thirty-three cases were identified, including 17 multi-institutional and 16 literature-derived cases, with an estimated incidence of 0.11% among appendectomies. Most tumors consisted of localized NET and LAMN. Gastrointestinal (GI) symptoms were present in 62.5-65.6% of cases, and tumors were identified by imaging in 53.1-75.0%. Outcome tracks the higher-stage and grade component. Patients with localized tumors had excellent outcomes (2-year progression-free survival [PFS] and overall survival [OS]: 100%). In contrast, cases with metastatic LAMN/HAMN had 2-year PFS 66.7% and OS 100%, while those with metastatic adenocarcinoma had 2-year PFS 0% and OS 66.7%. This study represents the largest series and literature review of appendiceal collision tumors to date. These rare tumors most often consist of localized NET and LAMN, typically present with GI symptoms, are often detected by imaging. The prognosis is dictated by the component of higher stage and grade.

OBJECTIVES/OBJECTIVE:The National Surgical Quality Improvement Program-Pediatric (NSQIP-P) recommends reducing computed tomography (CT) scan use to <25% in children with suspected appendicitis. Our multidisciplinary team developed a pediatric appendicitis clinical pathway that emphasizes the use of ultrasound as first-line imaging and reserves CT for patients with both non-diagnostic ultrasounds and agreement from pediatric emergency medicine and surgery teams. METHODS:For this local study, all cases of patients aged younger than 19 years who were diagnosed with appendicitis from 2021 to 2023 were reviewed, with emergency department (ED) length of Stay (LOS) as a balancing measure. A series of Plan-Do-Study-Act cycles was used to implement the clinical pathway and to involve multiple teams. A Statistical Process Control chart was generated and possible special cause variations were analyzed using Six Sigma rules. RESULTS:Ultrasound was the first-line imaging in over 90% of total cases. However, CT utilization steadily decreased from 39% to 22% by the end of our initiative. This was paralleled by a sharp increase in surgical consults before CT scan order from 21% to 41%, and a decrease in non-diagnostic ultrasounds from 35% to 20% across the 3 years of the study. ED LOS decreased from 538 to 435 minutes on average. In addition, 2 patients underwent an MRI in quarter 4 of 2023, demonstrating its potential in the workflow. CONCLUSIONS:Overall, by implementing a clinical pathway this team was able to significantly reduce CT scan utilization in the diagnosis of pediatric appendicitis. STUDY TYPE AND EVIDENCE LEVEL/UNASSIGNED:Cohort study, level III.

OBJECTIVE:Fatigue and depression are common and disabling symptoms in people with Multiple Sclerosis (PwMS). This study aimed to examine the relationship between discordant fatigue measures and depression severity in PwMS. METHODS:A retrospective analysis was conducted on 712 PwMS evaluated over 14 years at a comprehensive MS center. All participants completed the Fatigue Severity Scale (FSS), Modified Fatigue Impact Scale (MFIS), and Beck Depression Inventory (BDI) as part of routine clinical care. Fatigue score concordance was defined as both FSS and MFIS being above or below the threshold; discordance was defined as one above and one below. Statistical analyses compared demographic, clinical, and depression-related variables between groups. RESULTS:Of the 712 patients (75.3% female; mean EDSS 2.8), 78.9% demonstrated concordant fatigue scores, while 21.1% showed discordance-most commonly with elevated MFIS and low FSS. The discordant group had significantly higher mean BDI scores (23.0 vs. 9.8; P < 0.0001) and elevated suicidality scores, despite similar clinical characteristics. CONCLUSIONS:PwMS with discordant fatigue profiles, particularly those with higher MFIS than FSS scores, exhibit significantly greater depressive symptoms. Discordance between fatigue measures may serve as a clinical marker for underlying depression, supporting the need for comprehensive psychosocial evaluation in this subgroup.

BACKGROUND:Antifibrotics including nintedanib and pirfenidone are effective in slowing the decline of lung function for patients with idiopathic pulmonary fibrosis (IPF). However, their adoption rates are remarkably low, and substantial proportions of patients undergo dose reduction or treatment discontinuation because of the high incidence of adverse events. RESEARCH QUESTION/OBJECTIVE:What is the impact of treatment modification on all-cause mortality and hospitalization? STUDY DESIGN AND METHODS/METHODS:Using a large administrative database, we identified patients with IPF who initiated antifibrotics. A nested case-control design was used to match cases and controls at a 1:1 ratio and conditional logistic regression was performed to estimate the effect of antifibrotic adherence and dosing. Adherence was measured using the proportion of days covered (PDC). Both adherence and dosing were determined based on the exposure period between antifibrotic initiation (cohort entry date) and outcome occurrence (index date). RESULTS:Adherence (PDC ≥ 0.75) was associated with lower risk of mortality (OR=0.563, p<0.001), regardless of which antifibrotic was used. Patients on reduced dose had a significantly greater risk of mortality compared to those on standard dose (OR=1.57, p=0.024), but this was only seen in those who started nintedanib. For hospitalization, adherence was associated with a lower risk (OR=0.692, p=0.016) overall, and reduced doses were associated with a higher risk (OR=1.667, p=0.008) only among patients who started nintedanib. Among patients who started pirfenidone, neither adherence nor dose was associated with the risk of hospitalization. INTERPRETATION/CONCLUSIONS:Results of this study suggest that antifibrotic adherence and dosing are important factors that influence mortality and hospitalization. A multidisciplinary approach involving nutritionists, drug clinical educators, and other key stakeholders to facilitate early access, affordable treatment, and adverse event mitigation may enhance adherence and ultimately improve patient outcomes.

INTRODUCTION/BACKGROUND:Endoscopic retrograde cholangiopancreatography (ERCP) is essential for pancreaticobiliary disease management; however, there are risks associated with the procedure, particularly post-ERCP pancreatitis (PEP). Glucagon-like peptide-1 receptor agonists (GLP-1 RAs), widely used in metabolic disease, possess anti-inflammatory and cytoprotective properties that may influence periprocedural outcomes. Their impact on ERCP adverse events remains unclear; therefore, we aimed to investigate whether GLP-1 influences short-term postprocedural outcomes using a large real-world database. METHODS:We conducted a retrospective cohort study using the TriNetX US Collaborative Network, identifying adults (18 y or older) who underwent ERCP between January 2015 and December 2024. Patients were categorized based on documented preprocedure GLP-1 receptor agonist exposure. Propensity score matching (1:1) was performed using demographic, clinical, procedural, and pharmacologic covariates to minimize confounding, yielding 2 well-balanced cohorts. Thirty-day post-ERCP outcomes-including acute pancreatitis, cholangitis, sepsis, gastrointestinal bleeding, biliary stricture, choledocholithiasis, and repeat ERCP-were assessed using ICD-10 and CPT codes. Risk ratios (RRs) and hazard ratios (HRs) with 95% CIs were calculated. RESULTS:Of 250,502 patients with ERCP screened, 21,818 propensity-matched individuals were included in the final analysis. Compared with matched nonusers, patients receiving GLP-1 receptor agonists had significantly lower 30-day rates of all major ERCP-related adverse events. GLP-1 RA exposure was associated with reduced risks of acute pancreatitis (RR: 0.47, 95% CI: 0.43-0.51), cholangitis (RR: 0.56, 95% CI: 0.50-0.62), sepsis (RR: 0.51, 95% CI: 0.46-0.57), gastrointestinal bleeding (RR: 0.49, 95% CI: 0.40-0.61), biliary stricture (RR: 0.52, 95% CI: 0.48-0.55), repeat ERCP (RR: 0.53, 95% CI: 0.48-0.58), and choledocholithiasis (RR: 0.66, 95% CI: 0.62-0.71). Results were consistent across time-to-event analyses over the 30-day follow-up period. CONCLUSIONS:In this large real-world analysis, preprocedure GLP-1 RA therapy was associated with markedly reduced 30-day ERCP-related adverse events, most notably PEP. These findings highlight a potential protective role of GLP-1 signaling in the periprocedural inflammatory response and support prospective studies evaluating GLP-1 RAs as adjunctive prophylactic agents in ERCP. Further prospective studies are needed.

Stereotactic body radiotherapy (SBRT) is established as standard therapy for organ-confined prostate cancer (PC) based on 5-yr phase 2-3 outcomes, but 10-yr data are lacking. Here, we report 10-yr results of a trial conducted at 21 centers. Patients were treated from January 2008 to April 2010. SBRT was delivered on a noncoplanar robotic platform with real-time motion management, to a total dose of 40 Gy in five fractions. Adjuvant hormone therapy was not allowed. Late toxicities (>90 d) were assessed with Common Terminology Criteria for Adverse Events version 3 (CTCAE v3). Biochemical failure is defined as nadir+2. Relapses are defined as biochemical or clinical failure or salvage/systemic PC therapy. Out of 310 evaluable patients, median age 68 yr; 172 were low-risk (LR), and 138 patients were intermediate-risk (IR). Median follow-up was 9 yr. Ten-yr cumulative grade 3 gastrointestinal (GI) or genitourinary (GU) toxicities were 1.4% and 1.5% in the LR and IR cohorts, respectively. There were no grade 4-5 events observed. Ten year grade 2+ GI and GU toxicity rates were 2.1% and 14% respectively. Overall survival in 10 yr was 84%. Overall, relapse-free survival (RFS) was 90%; 94% in the LR cohort, 86% in the IR cohort, and 92% versus 77% in the favorable vs unfavorable intermediate subgroups. In this multi-institutional trial, the 10-yr follow-up demonstrates that prostate SBRT yields minimal toxicity and favorable RFS.