Faculty Bibliography

BACKGROUND:Results from national surveys indicate that many older adults reported delayed medical care during the acute phase of the COVID-19 pandemic, yet few studies have used objective data to characterize healthcare utilization among vulnerable older adults in that period. In this study, we characterized healthcare utilization during the acute pandemic phase (March 7-October 6, 2020) and examined risk factors for total disruption of care among older adults with multiple chronic conditions (MCC) in New York City. METHODS:This retrospective cohort study used electronic health record data from NYC patients aged ≥ 50 years with a diagnosis of either hypertension or diabetes and at least one other chronic condition seen within six months prior to pandemic onset and after the acute pandemic period at one of several major academic medical centers contributing to the NYC INSIGHT clinical research network (n=276,383). We characterized patients by baseline (pre-pandemic) health status using cutoffs of systolic blood pressure (SBP) < 140mmHg and hemoglobin A1C (HbA1c) < 8.0% as: controlled (below both cutoffs), moderately uncontrolled (below one), or poorly controlled (above both, SBP > 160, HbA1C > 9.0%). Patients were then assessed for total disruption versus some care during shutdown using recommended care schedules per baseline health status. We identified independent predictors for total disruption using logistic regression, including age, sex, race/ethnicity, baseline health status, neighborhood poverty, COVID infection, number of chronic conditions, and quartile of prior healthcare visits. RESULTS:Among patients, 52.9% were categorized as controlled at baseline, 31.4% moderately uncontrolled, and 15.7% poorly controlled. Patients with poor baseline control were more likely to be older, female, non-white and from higher poverty neighborhoods than controlled patients (P < 0.001). Having fewer pre-pandemic healthcare visits was associated with total disruption during the acute pandemic period (adjusted odds ratio [aOR], 8.61, 95% Confidence Interval [CI], 8.30-8.93, comparing lowest to highest quartile). Other predictors of total disruption included self-reported Asian race, and older age. CONCLUSIONS:This study identified patient groups at elevated risk for care disruption. Targeted outreach strategies during crises using prior healthcare utilization patterns and disease management measures from disease registries may improve care continuity.

The benefits and challenges of electronic health records (EHRs) as data sources for clinical and epidemiologic research have been well described. However, several factors are important to consider when using EHR data to study novel, emerging, and multifaceted conditions such as postacute sequelae of SARS-CoV-2 infection or long COVID. In this article, we present opportunities and challenges of using EHR data to improve our understanding of long COVID, based on lessons learned from the National Institutes of Health (NIH)-funded RECOVER (REsearching COVID to Enhance Recovery) Initiative, and suggest steps to maximize the usefulness of EHR data when performing long COVID research.

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.

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: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.

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: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.

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.