Faculty Bibliography

BACKGROUND:The objectives of this study were to determine if financial considerations affect reconstructive decision-making, and conversely if reconstructive choice affects downstream financial burden. METHODS:We conducted mixed-methods study with a convergent design. Patients undergoing mastectomy with or without reconstruction were administered the Comprehensive Score for Financial Toxicity (COST) questionnaire before and after surgical treatment, where COST ≤20 indicated financial toxicity (FT). Multivariable regression models were used to identify predictors of FT and changes in COST score. Additionally, we conducted semi-structured interviews with patients who screened positive for FT to comprehensively capture experiences with financial burden. RESULTS:There were 1,029 patients with a COST score prior to mastectomy, with a 30.6% rate of FT. Significant predictors of FT included age (OR 0.97), race (Asian OR 2.12, Black OR 2.66, compared to White), marital status (divorced/separated OR 2.70, single OR 2.43, compared to partnered), and neighborhood-level socioeconomic deprivation (OR 1.15) (p<0.02). Receipt of reconstruction was not significantly associated with baseline FT, nor were type and timing among those who underwent reconstruction (N=739). Additionally, receipt, type, and/or timing of reconstruction were not significantly associated with a change in COST score (full cohort N=446, reconstruction cohort N=297). Interviews yielded 3 themes: prioritizing outcomes over financial implications, difficulties navigating and maintaining insurance coverage, and a need for greater transparency and access to financial resources. CONCLUSION/CONCLUSIONS:Bidirectional relationships between FT and receipt, type, and timing of reconstruction did not reach statistical significance. Additional patient-centric financial navigation and price transparency are warranted to mitigate financial burden.

BACKGROUND/UNASSIGNED:For over a decade, STAT surgery has been the standard of care (SOC) for treating significant cauda equina syndromes (CES). Nevertheless, too many spinal surgeons, physician extenders, and other medical professionals still wrongly believe they have up to 24-48 hours to treat CES. METHODS/UNASSIGNED:To counter this misconception, we reviewed the evolution of treatment for significant CES from the outdated dominant protocols of < 48 h, to 24 - < 48 h, to < 24 h, to 0-< 24 h, to the present SOC; STAT, "prompt", surgery performed "the sooner the better". RESULTS/UNASSIGNED:A 2014 study found that there is no support in the literature for delaying CES surgery for up to 48 h, and further; "... the earlier the surgical intervention, the more beneficial the effect for compressed nerves." Subsequent studies advocated for < 24 h for early CES, finding they resulted in improved outcomes including bladder function especially for those with incomplete/partial (ICES) vs. total/retention CES (RCES). One study, involving 20,924 CES patients, showed the best improvement for surgery performed within 0 - < 24 h, leading to the present SOC for treating significant CES, as STAT or "the sooner the better". CONCLUSION/UNASSIGNED:Based on the up-to-date literature, the present SOC for managing significant CES is STAT surgery. Notably, the American Association of Neurological Surgeons (AANS) "guidelines" (published 4/5/24 on (www. aans.org)) cited the present treatment for CES; "Prompt surgery is the best treatment for patients with CES;" with the Merriam-Webster definition of prompt as "immediate" or "without delay". We agree that the present SOC for treating significant CES is STAT or "prompt" surgery.

BACKGROUND/UNASSIGNED:To examine the relationships between state Medicaid total Long-Term Services and Supports (LTSS) expenditures and the LTSS rebalancing ratio (i.e., the proportion allocated to Home- and Community-Based Services [HCBS]) with the self-reported health of spousal caregivers of community-dwelling older adults with dementia. METHODS/UNASSIGNED:This study used multiple data sources, including the Health and Retirement Study (HRS) and annual Medicaid LTSS user and expenditure reports. The analytic sample included 1,232 respondent-waves of spousal caregivers who participated in at least one of the seven HRS waves between 2008 and 2020 and provided care for their community-dwelling spouse with dementia. We employed generalized linear models (GLMs) for both bivariate and multivariable analyses, with the outcome of interest being a dichotomous variable for self-reported poor health. RESULTS/UNASSIGNED:Each additional $1,000 of annual LTSS spending per older adult was associated with a marginally significant 4.2-percentage point reduction in the probability of reporting poor health (Average Marginal Effect [AME] in percentage points [PP] = -4.21, 95 % Confidence Interval [CI] = -9.12-0.70, p = 0.093). However, no statistically significant association was observed between the LTSS rebalancing ratio and spousal caregivers' self-reported health (AME in PP = 2.22, 95 % CI = -2.07-6.49, p = 0.310). CONCLUSIONS/UNASSIGNED:Higher state Medicaid LTSS spending per older adult was moderately associated with better self-reported health among spousal caregivers of individuals with dementia. As the demand for informal caregiving continues to rise, this study underscores the importance of state investments in protecting caregivers' health and highlights the need to incorporate caregiver-focused assessments into the design and evaluation of LTSS policies.

INTRODUCTION/BACKGROUND:Accurate preoperative evaluation of pancreatic cysts is essential. However, cytology and biochemical analysis are often limited by low cellularity, and risk stratification is critical for management. PancreaSeq Genomic Classifier (GC) analyzes cyst fluid for molecular alterations to aid diagnosis and risk assessment. MATERIALS AND METHODS/METHODS:We retrospectively analyzed 219 pancreatic cysts from 206 patients using PancreaSeq GC, integrating molecular findings with cytology, biochemical, imaging, surgical pathology, and follow-up. RESULTS:PancreaSeq GC successfully analyzed 216/219 cysts (99%) and detected alterations in 182 (83%). Among cases with both cytology and molecular data (n = 201), concordance was high in cytologically mucinous neoplasms (94%) and atypical cases (95%). Notably, among cases reported as negative for malignancy or nondiagnostic on cytology (n = 128), PancreaSeq GC identified mucinous neoplasms in 82 cases (64%), demonstrating added value in limited samples. Surgical pathology correlation (n = 24) showed excellent performance for distinguishing mucinous from nonmucinous cysts (area under the curve [AUC] = 0.94, P < 0.001). Risk stratification for detection of any dysplasia yielded an AUC of 0.78 (P = 0.006), and for high-grade dysplasia an AUC of 0.74 (P = 0.046). PancreaSeq GC reliably predicted neuroendocrine tumors, but the sensitivity for focal high-grade dysplasia in mucinous neoplasms and serous cystadenoma was limited. Compared with carcinoembryonic antigen (CEA), cyst fluid glucose showed higher sensitivity but lower specificity for mucinous cyst detection. CONCLUSIONS:PancreaSeq GC provides significant diagnostic and risk-stratification value that complements cytological evaluation, particularly in indeterminate or nondiagnostic cytology specimens and when biochemical data are unavailable. Integration of molecular findings improves cyst classification and dysplasia risk assessment. Multidisciplinary assessment remains essential, given the assay's limited sensitivity for focal high-grade dysplasia and serous cystadenomas.

IMPORTANCE/UNASSIGNED:The management of infectious and inflammatory lesions of the breast remains controversial. The expert panel focused on management recommendations for 3 of the most common infectious breast conditions, as very few evidence-based guidelines for the management of these conditions exist. OBSERVATIONS/UNASSIGNED:Clinicians should distinguish between infectious and noninfectious lactational mastitis (LM) because the former often requires interventions whereas the latter requires supportive care only. Patients with infectious LM often have thick fluid collections that are not amenable to aspiration and usually require a stab incision with drain placement (but no packing) to resolve the infection. Operative drainage is only required if the patient cannot tolerate an office procedure. If a phlegmon is present, antibiotics should be prescribed for at least 10 days. The diagnosis of granulomatous mastitis (GM) requires pathology confirmation with characteristic findings on core biopsy. Cystic neutrophilic granulomatous mastitis (CNGM) is a specific form of GM associated with a granulomatous reaction to Corynebacterium infection and should be empirically treated with doxycycline. For patients without findings characteristic of CNGM and no other associated bacterium identified, there is no role for empiric antibiotic use. Granulomatous mastitis cases often recur and can take up to 18 months to resolve. Patients who have GM cases with worsening symptoms should be treated with repeated intralesional steroid injections; surgical excision or repeated aspirations should be avoided. Cases refractory to intralesional steroid injection may require oral steroids or even advanced biologic agents such as methotrexate or azathioprine. Periductal mastitis with squamous metaplasia of lactiferous ducts (PDM-SMOLD) is a distinct entity from other periductal mastitis cases that can present with recurrent abscesses and should be treated with antibiotics and aspiration for fluid collections. Operative excision for PDM-SMOLD is required for those patients who present with a fistula or recurrent episodes typically using a radial incision to remove the diseased ducts within and below the nipple. CONCLUSIONS AND RELEVANCE/UNASSIGNED:Evidence-informed, consensus-, and expert opinion-based guidelines for the management of infectious and inflammatory conditions of the breast were developed. Clinicians can use these guidelines to appropriately manage these conditions for which clinical care often varied in the past.

Urologic oncologic emergencies represent a relatively narrow yet diverse group of critical conditions that require prompt recognition and intervention to prevent potentially life-threatening complications. These oncologic emergencies may arise as direct consequences of a malignancy, including local invasion, or as sequelae of surgical or therapeutic interventions. Common urologic emergencies include malignant obstructive uropathy or ureteral obstruction, which may lead to urosepsis or acute kidney injury; large volume hematuria and hemorrhagic cystitis, which both can result in substantial blood loss; renal hemorrhage, which can lead to hemodynamic instability; fistula formation; and postsurgical urinary leaks. Radiologists play a key role in promptly detecting and evaluating such emergencies and can help differentiate expected post-treatment findings from urgent or potentially life-threatening complications. Imaging not only helps to diagnose these emergencies but can also guide subsequent management strategies and thus is essential for optimizing patient outcomes. This review article aims to highlight the clinical and multi-modality imaging manifestations of urologic oncologic emergencies and their potential management strategies.

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:Tools for predicting heart failure (HF) in CKD patients remain limited. We aimed to study whether standard ECG features or heart rate variability parameters predict de novo HF hospitalization in individuals with CKD. METHODS:Utilizing a large NYU ECG database linked with electronic health records (2012-2021), we analyzed a cohort of patients with pre-existing CKD. Besides standard ECG features, we extracted heart rate variability (measures the time between consecutive heart beats in milliseconds) features from the ECGs as predictors. The index ECG was the first ECG performed after the index eGFR date (baseline) and was required to be done prior to initiation of dialysis, end-stage kidney disease (ESKD), or transplant. The primary outcome was time to index HF hospitalization (≥30 days after the index ECG) based on discharge ICD-10 codes. LASSO-penalized Cox regression was used to identify predictors. Sensitivity analyses used Fine-Gray competing risk models for death and ESKD. RESULTS:Among 11,409 individuals (median age: 72; ∼50% male) with a median of 976 days, 880 individuals (8%) experienced an index HF hospitalization. Models incorporating ECG and clinical parameters had excellent discrimination (C-statistic 0.76 in the training set and 0.73 in the validation set). Among ECG features, the PR interval, corrected QT, and T axis were independently associated with higher risks of index HF hospitalization ≥30 days after the index ECG in both primary models (p<0.001 for all) and in models accounting for competing risks (p<0.01 for all). History of arrhythmia (hazard ratio (HR, 1.60, 95% CI: 1.36-1.88), valvular disease (HR1.51, 95% CI: 1.27-1.81), and diabetes (HR 1.41, 95% CI: 1.22-1.65) were the strongest clinical predictors. HRV parameters were not independently associated with HF. CONCLUSIONS:Although ECG-derived HRV indices were not independently associated with risk of HF, several standard ECG features are associated with HF hospitalization in CKD.

INTRODUCTION/BACKGROUND:Children with immune thrombocytopenia (ITP) may have an increased risk of perioperative bleeding. However, current pediatric ITP guidelines do not address this management setting. We aimed to describe perioperative management and outcomes in pediatric patients with ITP by platelet count, type of surgery, and ITP-directed treatment strategies. METHODS:We conducted a retrospective analysis of patients with ITP ages 0-24 years who underwent tooth extraction, tonsillectomy and adenoidectomy, appendectomy, and/or splenectomy at six centers in the United States and Canada between 2019 and 2024. RESULTS:/L where hematology was not involved in perioperative management. Medication side effects were reported in 7% (3/43) of patients receiving ITP-directed therapies. CONCLUSIONS:/L. Perioperative bleeding risk appears to be low in pediatric ITP under current management practices.

BackgroundMisalignment between actual and perceived balance ability provides relevant information to understand functional deficits and fall risk. However, few studies have provided a continuous quantification of misalignment in neurological populations such as people with Parkinson's disease (PD).ObjectiveDetermine whether a continuous quantification of misalignment between actual and perceived balance ability, discordance, relates to functional outcomes such as quality of life and cognition.MethodsActual (gait velocity), and perceived (Activities of Balance Confidence) balance, cognition (measured via a computer-based cognitive assessment), and mobility-related quality of life were captured in a clinical sample of 95 people with PD. Primary outcomes were quality of life and cognitive domains frequently altered in people with PD (global cognition & executive function). Secondary cognitive domains assessed were attention, memory, visuo-spatial, verbal function, and information processing. Linear and non-linear models assessed the relationship between discordance, quality of life, and cognition.ResultsDiscordance related to mobility-related quality of life, such that under-confidence was related to poorer quality of life. Non-linear (quadratic) models were shown to fit the discordance-Global cognition (p = 0.02) data better than linear models such that over- and under-confidence related to poorer cognition. Secondary cognitive domains were not robustly related to discordance.ConclusionsIn a clinical sample of people with PD, discordance was related to mobility-related quality of life and global cognition. Global cognition further exhibited a possible non-linear relationship to discordance indicating that over- or under-confidence may relate to poorer cognition. This work underscores the functional relevance of misalignment of actual and balance abilities.