Faculty Bibliography

BACKGROUND AND OBJECTIVE/OBJECTIVE:Alcohol withdrawal syndrome (AWS) is a serious complication of alcohol use disorder. Although benzodiazepines are the mainstay of treatment, some patients may be resistant to them, requiring rapidly escalating doses. Phenobarbital has emerged as an effective adjunct therapy in severe alcohol withdrawal, but studies have yielded inconsistent results and carry safety risks. The purpose of our study was to examine the effectiveness and the potential harm of phenobarbital in AWS. METHODS:In this multi-center, retrospective cohort study, patients who were admitted for AWS and received phenobarbital with benzodiazepine were compared to patients who received benzodiazepine monotherapy. The primary outcome was time to AWS resolution. Other secondary and safety outcomes included length of stay (LOS), rate of mechanical ventilation, and incidence of aspiration pneumonia. RESULTS:The phenobarbital group received significantly higher doses of benzodiazepines compared to the benzodiazepine monotherapy group (660 mg vs 340 mg, p < 0.0001). After adjustment, the use of phenobarbital was associated with significantly reduced time to AWS resolution (141.65 h vs 165.72 h, p < 0.0001). However, the use of phenobarbital was associated with the likelihood of mechanical ventilation (19.42 %vs. 0.96 %, p < 0.0001), aspiration pneumonia (22.33 % vs 5.77 %, p = 0.0006), and increased hospital LOS (8 days vs. 6 days, p = 0.0197). In the combination group, earlier phenobarbital initiation (within 24 h) was associated with significantly lower cumulative benzodiazepine dose (530 mg vs 887.50 mg, p = 0.002) and hospital LOS (6 days vs 10 days, p = 0.0017). CONCLUSION AND RELEVANCE/CONCLUSIONS:In our study, patients who received phenobarbital in combination with benzodiazepines had a quicker resolution of AWS but also had a higher incidence of mechanical ventilation, prolonged hospital LOS, and an increased risk of aspiration pneumonia. For patients at high risk of severe alcohol withdrawal, earlier initiation of phenobarbital appeared to yield the most optimal benefit.

Neoadjuvant therapy (NAT) is increasingly being used for pancreatic ductal adenocarcinoma (PDAC). This study investigates how NAT differentially impacts PDAC's carcinoma cells and the tumor microenvironment (TME). Spatial transcriptomics was used to compare gene expression profiles in carcinoma cells and the TME of 23 NAT-treated versus 13 NAT-naïve PDACs. Findings were validated by single-nucleus RNA sequencing (snRNA-seq) analysis. NAT induces apoptosis and inhibits proliferation of carcinoma cells and coordinately upregulates multiple complement genes (C1R, C1S, C3, C4B and C7) within the TME. Higher TME complement expression following NAT is associated with increased immunomodulatory and neurotrophic cancer-associated fibroblasts (CAFs); more CD4⁺ T cells; reduced immune exhaustion gene expression, and improved overall survival. snRNA-seq analysis demonstrates C3 complement is mainly upregulated in CAFs. These findings suggest that local complement dynamics could serve as a novel biomarker for prognosis, evaluating treatment response, and guiding therapeutic strategies in NAT-treated PDAC patients.

INTRODUCTION/BACKGROUND:Despite the well-documented safety of transesophageal echocardiograms (TEEs), inpatient gastroenterology (GI) services are called to clear patients for the procedure when they have GI symptoms or comorbidities ranging from mild to clinically significant. We aimed to assess the clinical utility of such consults in preventing TEE complications. METHODS:We performed a prospective cohort study of all inpatients at our institution who had a TEE ordered from 7/1/2021 through 7/1/2022. Patients' demographic information, indications for TEE, complications from TEE, 30-day readmission rates, GI team recommendations, and results of any GI-related interventions were collected and analyzed. RESULTS:There were 732 patients who had a TEE ordered during our study period, of whom 641 (87.51%) underwent the procedure. Of the 91 (12.49%) who did not have a TEE, none were canceled due to a GI-related concern. There were 23 of 641 patients (3.59%) with complications from the TEE, none of which were GI-related. The GI team was consulted on 36 patients (4.96% of TEEs ordered) and cleared 22 of 36 (61.11%) with no further testing while the remaining 14 of 36 patients (38.89%) underwent workups that were largely normal. Patients who had a GI consult before their TEE had a significantly longer time between their TEE being ordered and the TEE being performed compared with those who did not have a GI consult before their TEE (4.50 days vs 0.77 days, P < 0.01). DISCUSSION/CONCLUSIONS:Inpatient GI team workups to clear patients for a TEE found no contraindications to TEEs, did not change patient care plans, and led to increased hospital costs and lengths of stay.

BACKGROUND:Rhinoplasty is one of the most commonly performed facial surgeries in the USA. There exist many major and minor nasal tip support structures that impact tip projection. Overprojection may result from anatomic factors or may occur iatrogenically during primary rhinoplasty. Achieving reliable, reproducible, and stable results is the aim of nasal tip deprojection rhinoplasty. This technique is designed to decrease nasal tip deprojection in patients with an overly projected nasal tip. METHODS:A retrospective chart review of 2,003 rhinoplasty cases in the senior author's practice was conducted between July 2014 and June 2022. The inclusion criteria were cosmetic or functional rhinoplasty cases with nasal tip deprojection, with a minimum of 12 months of follow-up. Outcomes of interest included the rate of operative revisions and the rate of postoperative infection. RESULTS:447 patients met the inclusion criteria. The mean age of our study group was 32.1 years old, with 409 females. 291 cases were primary rhinoplasties. Mean follow-up period was 22.4 months. Eight patients (1.8%) required empiric antibiotics postoperatively, with 17 patients (3.8%) requiring operative revision. CONCLUSIONS:Our case series demonstrates that combining resection of the medial crura with lateral crural steal and a columellar strut graft allows us to achieve considerable nasal tip deprojection. The comprehensive patient follow-up with a mean of 22.4 months further supports the reliability of our technique.

This comprehensive review examines the effects of various infections on pregnancy, focusing on maternal symptoms, fetal outcomes, diagnostic methods, and placental pathology. The paper covers bacterial, viral, and parasitic infections, their mechanisms of transmission, clinical presentations, and histopathologic findings in the placenta. It emphasizes the importance of early detection and intervention, highlighting the challenges in diagnosis due to often asymptomatic presentations. The review also discusses the placenta's role as a protective barrier and its immune defense mechanisms against pathogens. Overall, this paper serves as a comprehensive resource for understanding the complex interplay between maternal infections, placental pathology, and fetal outcomes.

BACKGROUND:Cancer-treatment-related cutaneous adverse events (cAEs) are common and may severely impact quality of life (QoL) and decrease treatment outcomes. The Latin American Cutaneous Oncology Management (LACOM) project provides clinical insights into cancer-treatment-related cAEs, offering tools for preventing and managing cAEs. METHODS:LACOM I focuses on integrating education, prophylactic measures, and skincare in cancer treatment to improve treatment adherence, outcomes, and patients' and survivors' QoL. RESULTS:The LACOM panel provides evidence and opinion-based best practice recommendations for oncology skincare programs to support all stakeholders in the Latin American healthcare setting (Argentina, Chili, Colombia, Ecuador, Panama, Peru, and Mexico) working with oncology patients throughout the entire continuum of care to achieve optimal outcomes, improving cancer patients and survivors' QoL. Oncology skincare programs comprise hygiene, moisturization, and sun protection with products that should be safe and help to minimize cAEs and improve skin conditions. CONCLUSIONS:Integrating education, general measures, and skincare programs into cancer treatment should encourage the adoption of a proactive role of skincare from the beginning of treatment and ongoing, supporting optimal outcomes and improving cancer patients' and survivors' QoL. J Drugs Dermatol. 2025;24(3):262-268. doi:10.36849/JDD.8565.

Placental abruption is a complete or partial separation of the placenta from the uterine decidua. Clinical manifestations include vaginal bleeding, abdominal pain, uterine contractions, and abnormalities in the fetal heart rate tracing. Placental abruption occurs in 0.4% to 1.0% of all pregnancies. However, the pathophysiology remains incompletely understood. We present a review of the pathophysiology, diagnosis, and management of placental abruption, exploring overlapping processes which contribute to premature placental separation. Classic findings and limitations of ultrasound in evaluating placental abruption are explained. Finally, we discuss the management of placental abruption based on gestational age, fetal status, and maternal hemodynamic stability.

BACKGROUND:Neoadjuvant chemotherapy (NC) for early pancreatic ductal adenocarcinoma (PDAC) remains controversial. We investigate the adoption of NC and its impact on survival in clinical T1 (cT1) PDAC. METHODS:National Cancer Database (2006-2017) was reviewed for cT1 PDAC. Patients receiving NC and surgery were compared with patients undergoing upfront surgery (US). RESULTS:A total of 5886 patients were included. NC use increased from 4.8% in 2006 to 18.8% in 2017. The NC group (n = 618) versus the US group (n = 5268) had: younger age (66 years vs. 68 years), smaller tumor size (2 cm vs. 2.2 cm), more pancreas head tumors (77% vs. 70.6%), lower lymph-vascular invasion (25.9% vs. 40.6%), and less lymph node positivity (43.6% vs. 54.5%), p < 0.001. Factors associated with receipt of NC were: younger age, recent year of diagnosis, and treatment at an academic program. In the NC group versus the US group, median OS was 35.2 months versus 28.3 months, p < 0.001. Factors associated with improved survival included: well differentiated pathology, R0 surgical margins, and receipt of chemotherapy. CONCLUSION/CONCLUSIONS:In cT1 PDAC, chemotherapy is associated with improved survival. In a surgery-first approach, only 59% of patients receive adjuvant chemotherapy. These data suggest consideration of neoadjuvant therapy for early pancreatic cancer.

BACKGROUND:Squamous cells are uncommon in thyroid fine needle aspirations (FNAs) presenting diagnostic challenges. We report our multi-institutional experience. MATERIALS AND METHOD/METHODS:The electronic data were searched for thyroid FNAs containing squamous cells at the Johns Hopkins Medicine, New York University Langone Hospital, United States, and Fimlab Laboratories, Finland (2001-2023). The patients' demographics, clinical history, and pathologic diagnosis were recorded. RESULTS:One hundred and seven cases (103 patients) were identified 35 males and 68 females (median age 58 years). Forty-eight cases (44.9%) were malignant, primary carcinomas with squamous features, such as anaplastic thyroid carcinoma (ATC), and metastatic or directly invasive squamous cell carcinomas (SqCC) including oral, oropharyngeal (HPV-related), esophageal, and laryngeal SqCC. Twenty-seven cases (25.2%) contained benign squamous cells with cystic background, suggestive of developmental cysts. Nineteen cases (17.8%) contained metaplastic benign squamous cells within an adenomatoid nodule. Seven cases (6.5%) contained atypical squamous cells. Four cases (3.7%) showed squamous cells with bacterial or fungal organisms, suggestive of esophageal fistula/diverticulum, and two cases (1.9%) contained benign squamous cells with unknown source. Thirty-six cases had surgical follow-up, 33 (91.7%) were concordant (23 metastatic or directly invasive SqCC, 8 undifferentiated/ATC, and 10 papillary thyroid carcinoma). Ancillary studies were used confirming HPV-related SqCC, or therapeutic targets (BRAF V600E), with highly variable staining in ATC. CONCLUSION/CONCLUSIONS:Squamous cells in thyroid FNAs carry a broad differential diagnosis with variable prognoses. It is crucial to interpret squamous cells in the context of clinical and radiographic findings for optimal patient care.

BACKGROUND:Colorectal cancer (CRC) is a common malignancy with the propensity to metastasize. Common sites of metastasis include the liver, lungs, and peritoneum, with peritoneal metastases (PMs) having the worst prognosis. Unfortunately, systemic chemotherapy is often less effective in the treatment of PMs. Therefore, removal of all visible tumor via cytoreductive surgery along with intraperitoneal (IP) therapies has been used. METHODS:A comprehensive review of the literature was conducted using MEDLINE/PubMed and Web of Science with an end date of September 1, 2024, regarding cytoreductive surgery and heated IP chemotherapy for CRC PMs. RESULTS:Recent studies have called into question the utility of IP chemotherapy in the treatment of CRC PMs. However, regardless of IP chemotherapy, cytoreductive surgery has demonstrated an additional survival benefit for patients with PM secondary to CRC. DISCUSSION/CONCLUSIONS:This study reviews the pathophysiology of CRC PM, the current treatment paradigms, and a pathway for improving outcomes in patients with CRC PM.