Faculty Bibliography

Separation of patients by insurance status in ambulatory care settings is a long-standing practice in academic medicine. This payer-based segregation of patients between resident and faculty outpatient practices may lead to inequitable quality of care. Informed by replies to a free-response text question for residents and program directors within the 2023 U.S. obstetrics and gynecology in-service examination, we provide commentary on this structural inequity within obstetrics and gynecology. The purpose of this commentary is to discuss the differences in patient population served, gaps in resources in resident clinics, quality of care and moral injury, limited continuity of care, and training and supervision. Further work is needed to guide systemic integration efforts and to explore the effects of program integration on patient health outcomes. We nonetheless urge academic medical centers to consider organizational shifts toward payer-integrated care.

OBJECTIVE:Preterm birth (PTB) remains one of the biggest public health challenges with both obstetric and perinatal implications. While a prior PTB is a known risk factor for recurrence, the understanding of the influence of factors such as race/ethnicity, gestational age, PTB subtypes, and interpregnancy intervals (IPI) remains limited. This study aimed to assess whether these factors modify PTB recurrence risk. METHODS:We conducted a retrospective cohort study of singleton pregnancies in Kaiser Permanente Southern California (2009-2022) using electronic health record data from 82,610 women with two pregnancies and 14,925 women with three. PTB subtypes, spontaneous (sPTB) and indicated (iPTB), were identified through natural language processing. Logistic regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI). RESULTS:A first PTB was associated with a 6-fold increased risk of PTB in the second pregnancy compared to an uncomplicated pregnancy (23.29% vs. 4.98%, respectively; aOR, 5.60, 95% CI: 5.23-5.99). Those with a history of sPTB (aOR: 5.32, 95% CI: 4.87, 5.81) and iPTB (aOR: 8.26, 95% CI: 7.18, 9.50) had increased risk for the same respective subtype at their second pregnancy. PTB recurrence risk persisted across race/ethnicity categories. In women with PTB in both prior pregnancies, the risk for PTB in a third pregnancy was significantly higher (aOR 14.59, 95% CI 11.28-18.88). The recurrence of PTB between 1st and 2nd pregnancy was substantially higher for those who delivered at 20-33 weeks of gestation, regardless of PTB subtype. Non-Hispanic Black and Asian/Pacific Islander women had higher recurrence risk compared to non-Hispanic Whites. CONCLUSION/CONCLUSIONS:These findings highlight disparities in PTB recurrence by race/ethnicity and PTB subtype among a large integrated healthcare system in Southern California, underscoring the need for targeted interventions, particularly for sPTB.

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.

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.

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.

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.