Faculty Bibliography

Neoadjuvant therapy (NAT) is increasingly used for pancreatic ductal adenocarcinoma (PDAC); yet most patients only achieve partial response. Pathological treatment response grading focuses on assessing residual tumor burden, often overlooking changes in tumor microenvironment (TME). To address this gap, we compared tumor cells and TME of 13 NAT-naïve and 23 post-NAT PDACs using integrated spatial pathomics and transcriptomics, with validation in an independent single-cell spatial dataset. NAT significantly reduced tumor burden (14.7%-6.2%, p = 0.004), but systemic comparison of 13 cytomorphometric features of tumor cells alone did not reliably distinguish between naïve and NAT cases. In contrast, NAT profoundly remodeled TME by increasing cancer-associated fibroblast (CAF) and CD8⁺ T cell densities, promoting CD8⁺ T cell-tumor cell proximity and fibrosis, reducing tumor-associated neutrophils, and redistributing tertiary lymphoid structures (TLSs). Spatial transcriptomics shows NAT induced apoptosis, DNA-damage response, and AGC-kinase (S_TK_X) signaling in tumor cells, and upregulated complement pathway, p53 signaling, and cellular senescence program in TME. Cross-platform single-cell spatial analysis revealed decreased regulatory T cells (Treg) and a shift from myofibroblastic (mCAF) to inflammatory CAF (iCAF). Importantly, post-NAT patients with more fibrosis had longer overall survival (p = 0.02), and higher B-cell density showed a favorable trend (p = 0.06). Together, these results suggest that beyond tumor debulking, NAT induces a coordinated TME remodeling characterized by fibroblast reprogramming, matrix fibrosis, and immune spatial reorganization. Incorporating assessment of NAT-induced stromal and immune changes into TRG may improve prognostication and guide more precise therapy in post-NAT PDAC.

After decades of efforts by academic and professional organizations and by governmental agencies to promote advance care planning, less than half of adults in the USA have formally executed advance directives. For patients who have completed these documents, studies find limited impact on end-of-life care. In this paper, we discussed ways in which bias towards certain values in the health care enterprise including ethnocentrism, the centering of one set of cultural norms, may contribute to the public's ambivalence and the relative inefficacy of advance directives. We offer a more expansive perspective on this aspect of clinical care with the goal of serving all patients more effectively.

BACKGROUND AND AIMS/OBJECTIVE:Piecemeal endoscopic mucosal resection (EMR) is the standard of care for large, nonpedunculated colon polyps but is associated with recurrence rates of 9% to 31%. Current guidelines recommend 6-month surveillance for all patients, although this may not be necessary for lower-risk cases. METHODS:We retrospectively reviewed patients who underwent piecemeal EMR of ≥20-mm colon polyps between 2018 and 2021. Patients were stratified into 6- or 12-month surveillance groups based on polyp features. Recurrence rates and associated factors were compared. RESULTS:Among 193 patients, recurrence was higher in the 6-month (31.5%) than in the 12-month group (14.3%, P < .05). Among patients with recurrence, the 6-month follow-up group had more tubulovillous adenomas (P < .05) on index colonoscopy. Tubulovillous histology in the initial polyp was the only factor associated with recurrence. CONCLUSIONS:A risk-stratified approach may safely extend surveillance to 12 months for lower-risk patients after piecemeal EMR, reducing unnecessary procedures without compromising care.

A pilot online, video-based abortion care curriculum nationally positively affected obstetrics-gynecology residents' clinical knowledge, providing residency programs with a useful, centralized educational resource.

BACKGROUND AND AIMS/OBJECTIVE:Prophylactic colonic endoscopic submucosal dissection (ESD) defect closure may reduce delayed adverse events (DAEs) such as bleeding and perforation associated with ESD and facilitate same day discharge. We compared the effect of colonic ESD defect closure (closed group) with no closure (open group) on DAEs and overnight hospital admission. METHODS:We performed a Western multicenter retrospective study on patients who underwent colon ESD. Rectal lesions were excluded. DAEs were defined as adverse events within 2 weeks of ESD. Primary outcome measures were DAEs and overnight hospital admission. Multivariate analyses were performed. RESULTS:560 patients underwent colon ESD and 364 (71.8%) patients had complete defect closure. Closed group had a significantly lower rate of delayed bleeding (1.7% vs 5.6%, p = 0.03) compared to open group. Multivariate analysis with adjusted odds ratios (aOR) revealed right sided polyps (aOR = 7.0) and anticoagulation/antiplatelet agents (aOR = 6.6) increased the risk while defect closure (aOR = 0.2) decreased the risk of delayed bleeding. Defect closure amplified the reduction in risk of delayed bleeding (2.4% vs 10.4%, p = 0.014) for right-sided polyps. Malignant polyps significantly increased the risk of delayed perforation (aOR = 3.3) and overnight hospitalization (aOR = 2.9). Defect closure (aOR = 0.6), traction use (aOR = 0.6) and topical hemostatic agent use (aOR = 0.4) significantly reduced the risk of overnight hospitalization. CONCLUSION/CONCLUSIONS:Prophylactic closure of colon ESD defects was associated with a significant reduction in delayed bleeding with number needed to treat (NNT) of 25.6 (especially for right sided polyps, NNT 12.5), and post-procedural overnight hospitalization. Prospective studies are needed to further validate these results.

OBJECTIVE:To increase the rate of low dose aspirin (LDA) counseling and treatment in patients with 2 or more moderate risk factors of preeclampsia(PMRF) from 9% to 50% within a four-month period after implementation of interventions. STUDY DESIGN/METHODS:A single-institution quality improvement initiative aimed at LDA screening and counseling of those with PMRF. Two groups were evaluated: pre-intervention (January - April 2022) and post-intervention (January - April 2023). This initiative focused on identifying PMRF and monitoring rates of LDA counseling and treatment. Rates were assessed at two-week intervals and presented on a run chart to visualize trends and measure progress over time. Providers underwent education utilizing preeclampsia (PEC) screening flowsheets and integrated a clinical decision-making (CDM) tool in initial prenatal visit documentation using a smart-tool. Patients were provided with educational flyers. RESULTS:In the pre-intervention group (n=126), 8.7% of patients received counseling on PMRF risk factors and LDA use, 7.9% were treated with LDA. In the post-intervention group (n=112) 52.7% of patients received counseling on PMRF risk factors and LDA use, and 35.7% were treated with LDA. There was an 83.5% increase in the percentage of patients counseled following intervention implementation. A progressive increase was noted in counseling rates within the 18 weeks post-intervention. CONCLUSION/CONCLUSIONS:Integrating PEC screening flowsheets, clinical decision-making tools, and patient education flyers effectively enhances LDA counseling for patients with ≥2 PMRF with additional benefits seen in high-risk patients. These interventions offer a replicable model to enhance guideline adherence and reduce preeclampsia risk in vulnerable populations.

E-learning has revolutionized medical education by providing flexible, accessible, and interactive learning opportunities. This article explores the transformative impact of e-learning on gastroenterology education, highlighting the advancements and benefits brought by the American Society for Gastrointestinal Endoscopy (ASGE) platforms. ASGE's e-learning platforms offer specialized content, interactive tools, and continuous updates, enhancing the learning experience for gastroenterologists.

BACKGROUND/UNASSIGNED:weeks to detect genetic abnormalities; however, a majority of providers opt to perform CVS after 11 weeks. This study evaluated the feasibility of CVS performed at varying gestational ages, comparing chorionic villi (CV) yield and procedural outcomes among early, typical, and late procedures. MATERIALS AND METHODS/UNASSIGNED:weeks). The primary outcome was median CV weight. Secondary outcomes included need for culture, time to microarray results, and a subanalysis of abnormal chromosomal microarray analysis (CMA) results, obstetric, and neonatal outcomes. RESULTS/UNASSIGNED:Of 719 patients, 8.1% underwent early, 83.2% typical, and 8.8% late CVS. The early cohort had a lower body mass index (BMI). Early CVS was most frequently performed transvaginally and for the indication of prior affected pregnancy, and less likely for abnormal genetic screening or ultrasound findings. Median villi weight did not differ significantly, and 89% of all procedures yielded adequate tissue, defined as ≥5 mg. The time to the microarray result was shortest in the typical group. There were no significant differences in other secondary outcomes of need for culture, number of passes, or procedure-related complication rates. There was no case of limb anomalies. CONCLUSION/UNASSIGNED:CVS performed before 11 weeks and after 14 weeks demonstrated comparable microarray outcomes and demonstrate the technical feasibility and diagnostic adequacy of CVS performed outside the typical gestational window. The results also support the availability of early CVS for cytogenetic testing in early pregnancy loss, where management may not allow for direct tissue testing. Prospective studies are warranted to validate these results and refine recommendations for optimal timing of CVS.

INTRODUCTION/BACKGROUND:Multiple sclerosis (MS) is a chronic, immune-mediated neurological disease, leading to significant morbidity. Over 25 disease-modifying therapies (DMTs) are approved for MS; however, older patients may benefit less from high-efficacy DMTs. We compared the risk of severe infections (SIs) and annualized relapse rate (ARR) by age (< 45 and ≥ 45 years) between diroximel fumarate (DRF) and anti-CD20 monoclonal antibodies (mAbs) in patients with MS. METHODS:This retrospective study utilized the Komodo Health Claims database to identify patients treated with DRF or anti-CD20 agents. Patients were propensity score matched 1:1 on baseline characteristics and stratified by age (younger: < 45 years; older: ≥ 45 years). Infection-related encounters were identified by diagnosis codes; SIs required hospitalization or intravenous antibiotics. MS relapses were based on inpatient or outpatient claims and associated treatments. RESULTS:Between 2016 and 2025, 2894 propensity score-matched patients with MS who initiated DRF (n = 1447) or anti-CD20s (n = 1447) were included. DRF-treated patients had a lower proportion of SIs at 12 and 24 months compared with anti-CD20-treated patients (p ≤ 0.002 at 24 months). Younger DRF-treated patients had significantly fewer SIs (p = 0.005), while older DRF-treated patients had lower non-SI rates. COVID-19-related SIs were also significantly lower in DRF-treated patients (p < 0.001). ARRs were similar between the two groups. CONCLUSION/CONCLUSIONS:DRF-treated patients with MS had a significantly lower risk of SI compared with anti-CD20-treated patients, with no difference in ARR. More real-world studies are needed to understand the efficacy and safety of DMTs in the setting of de-escalation in aging patients with MS.

PURPOSE/OBJECTIVE:The purpose of this study was to evaluate the effect that associated glenohumeral dislocations have on outcomes following surgical treatment of proximal humerus fractures. METHODS:This IRB-approved study reports on 301 patients, who underwent operative treatment for proximal humerus fractures at an academic medical center from January 2006 to January 2023. Fractures were classified according to the Neer system. Patients were separated into two cohorts based on whether a glenohumeral dislocation was present at the time of initial injury. Outcomes measured included the Disabilities of the Arm, Shoulder, and Hand (DASH) score, shoulder range of motion (forward elevation, external rotation, internal rotation), readmission rates, complications, hardware removal, and need for revision surgery. Independent samples t-tests and chi-squared analysis were used for continuous and categorical variables, respectively. A binary logistic regression was performed to analyze the influence of these factors on complication rate. RESULTS:230 patients sustained an isolated fracture (PHF) and 71 sustained a fracture-dislocation (FD). Significant differences were observed between the FD and PHF groups in all measured outcomes. The FD group had a poorer DASH score (24.38 ± 19.09 vs 10.54 ± 13.67; P < 0.001) and reduced range of shoulder motion in forward elevation (114° ± 40° vs 162° ± 19°; P < 0.001), external rotation (40° ± 19° vs 66° ± 19°; P < 0.001), and internal rotation (57° ± 26° vs 82° ± 21°; P < 0.001). Readmission rates were higher in the FD group (0.28 ± 0.85 vs 0.05 ± 0.28; P < 0.001). The FD cohort also had a higher rate of complications (25.35% vs 6.52%; P < 0.001), need for removal of hardware (14.08% vs 3.04%; P = 0.002), and overall revision surgery (11.27% vs 1.30%; P < 0.001). The FD cohort demonstrated a greater incidence of AVN (12.68% vs 4.35%; P = 0.012). No significant difference was observed regarding rates of fracture healing and recurrent dislocation. Multivariate analysis in the form of binary logistic regression indicated that fracture-dislocation significantly increased the complication risk (OR = 3.310, 95% CI = 1.42-7.70; P = 0.005). CONCLUSION/CONCLUSIONS:Proximal humerus fracture-dislocations are associated with worse functional outcomes and higher complication rates compared to those without dislocations. These findings highlight the potential need for specialized treatment strategies to mitigate the impact of dislocation on recovery.