Faculty Bibliography

BACKGROUND:Jehovah's Witness patients refuse blood transfusion because of their religious beliefs making total hip arthroplasty (THA) challenging. This study aims to determine the safety of THA in Jehovah's Witness patients using standard perioperative protocols as well as evaluate the effectiveness of tranexamic acid (TXA) in controlling blood loss. METHODS:Databases from two tertiary academic centers were queried from 2003 to 2021 to identify THA patients. Demographics, pre- and postoperative hemoglobin (hgb) and hematocrit (hct) lab values, use of TXA intraoperatively, 90-day postoperative hospital utilization, and need for subsequent revision were extracted. Patients who identified as Jehovah's Witness were then compared to a 3:1 propensity score matched cohort of non-Jehovah's Witness patients. Linear regression analysis assessed the effect of intraoperative TXA on change in hgb from pre- to post-THA and logistic regression was used to assess risk of reaching hgb levels < 8.0 g/dL. RESULTS:A total of 207 non-Jehovah's Witness patients and 69 Jehovah's Witness patients who underwent THA were analyzed. Both groups were found to have similar preoperative hgb and hct as well as postoperative hgb, hct, and hgb shift. Of the Jehovah's Witness patients 3 (6.4%) patients reached a hgb < 8.0 g/dL. Additionally, a higher proportion of Jehovah's Witness patients receive intraoperative TXA (55 [79.7%]) compared to non-Jehovah's Witness patients (127 [61.4%]) (p = 0.01; SMD = 0.41). Logistic regression analysis found that Jehovah's Witness did not have greater odds of reaching a hgb < 8.0 g/dL (OR = 1.03 [0.95, 1.10]; p = 0.49) and that patient who received intraoperative TXA had decreased odds of reaching a hgb < 8.0 (OR = 0.87 [0.80, 0.95]; p = 0.001). Multivariate linear regression found that intraoperative TXA was also associated with a smaller decrease in hgb from pre- to post-THA (β = 0.69 [0.16, 1.22]; p = 0.01). Overall, Jehovah's Witness patients had excellent revision-free (97% [93%, 100%]) and infection-free (99% [96%, 100%]) survival at 7 years. CONCLUSION/CONCLUSIONS:Although Jehovah's Witness patients refuse transfusion, THA can be performed safely in these patients with excellent implant survivorship by optimizing preoperative hgb levels and utilizing intraoperative TXA. LEVEL OF EVIDENCE/METHODS:Level III Evidence.

The increasing use of technology in health care and health professions education is an invitation to examine how digital sources of evidence are used in making assessment claims. In this paper, we describe how four sets of terms-primary and secondary data; structured and unstructured data; development and use; and deterministic and generative-can aid in examining how data from digital sources are used in evaluating what learners know and can do. Drawing on multiple examples, this paper shows how the four sets of terms can help both developers and users of technology-based assessment systems.

BACKGROUND:Efforts to reduce cesarean birth overuse have had varied success. De-implementation strategies that incorporate change to organizational characteristics (i.e. culture) can improve adoption and sustainability. This study aimed to identify culture change strategies used by hospitals that achieved significant and sustained cesarean reduction and eliminated racial disparities in cesarean birth. METHODS:Hospitals in California and Florida that (1) engaged in quality initiatives to reduce cesarean births; (2) demonstrated at least a 5% cesarean birth reduction; and (3) sustained the reduction for 18 months after participation were invited to participate. Hospitals that reduced also cesarean racial disparity were prioritized for recruitment. Qualitative, semi-structured interviews were performed with leaders, obstetricians, family physicians, midwives, and nurses providing intrapartum care. Reflexive thematic analysis and values coding were used. RESULTS:35 participants from 6 hospitals (3 in California, 3 in Florida) participated in interviews or focus groups. Nurse-focused strategies included: leadership demonstrating support for proactive labor support (e.g., Spinning Babies, comfort measures, nursing time at bedside); enhanced communication through inter-disciplinary team huddles; clear delineation of roles; and a chain of command that assured nurses could advocate for their patients freely and without retribution. Physician-focused strategies included regular and publicly visible feedback delivered by trusted messengers, drawing attention to successful vaginal births, and highlighting the contributions of labor support. A theme of hiring/retaining for "fit" was articulated at all hospitals, most notably, the hospital that eliminated their cesarean birth racial disparity, where "fit" was conceptualized as empathy, humanism, and a desire to meet community needs. CONCLUSIONS:This study identified specific de-implementation strategies for hospitals to change implementation context, namely culture, to achieve and sustain reduction of cesarean birth. Hospitals looking to sustain culture change should adapt strategies to align with existing clinician values, change attitudes through sharing successful vaginal births, and modify beliefs through education from trusted messengers. Strategies to reduce racial disparities should emphasize designing teams that are aware of and prioritize community needs, including hiring staff from the local community, and partnering with community-based organizations.

Central body fat distribution affects kidney function. Abdominal fat measurements using computed tomography (CT) may prove superior in assessing body composition-related kidney risk in living kidney donors. This retrospective cohort study including 550 kidney donors aimed to determine the association between CT-measured abdominal fat areas and kidney function before and after donor nephrectomy. Donors underwent glomerular filtration rate measurements (¹²⁵I-Iothalamate, mGFR) before and 3 months after donation. Linear regression analyses with body surface area (BSA)-standardized and crude mGFR were performed to assess the association of height-indexed tomographic fat measurements with kidney function. In age-, and sex-adjusted analyses higher levels of total abdominal, visceral, subcutaneous, and intramuscular adipose tissue index were significantly associated with lower mGFR levels before donation (BSA-standardized mGFR: visceral adipose tissue index: Βeta=-0.11, p < 0.001, subcutaneous: Βeta=-0.10, p < 0.001, intramuscular: Βeta=-1.18, p < 0.001, total abdominal: Βeta=-0.07, p < 0.001). Higher tomographic abdominal fat is associated with lower BSA-standardized mGFR after donation and a greater decrease in mGFR between screening and 3 months post-donation. This study shows that CT-measured abdominal fat area is associated with kidney function before and after living kidney donation.

"See Your Dentist Twice a Year" is the standard of care today honored by dentists, requested by patients, and covered by insurance. Where is the scientific evidence to support this dictate? Several systematic reviews could find no support for or against it. When did it start? This paper traces the timeline of the statement and its appearance in toothpaste advertisements. It was first spotted in 1890 as part of a household guide for beauty preservation. Subsequently, the idea became a tagline in dental advertisements for Colgate Ribbon Toothpaste, Dr. Lyon's Dentifrice from 1913, and Pepsodent toothpaste starting in 1926.

Bartonella quintana infection can lead to bacillary angiomatosis, peliosis hepatis, chronic bacteremia, and culture-negative endocarditis. Transmitted by the human body louse (Pediculus humanus humanus), B. quintana infection has become an emerging disease in recent decades among persons experiencing homelessness. By using retrospective laboratory surveillance, we identified 5 cases of left-sided, culture-negative B. quintana endocarditis among persons in New York, New York, USA, during January 1, 2020-November 23, 2023. Identifications were made by using molecular assays. All patients experienced unsheltered homelessness in the year before hospitalization. Of those patients, 4 experienced heart failure, 3 renal failure, and 2 embolic strokes; 2 died. Aortic valve replacement occurred in 4 cases. A history of possible body louse infestation was found in 4 cases. Clinicians should consider housing status and history of lice exposure in patients with suspected bartonellosis and have a low threshold for diagnostic testing and empiric treatment in patients experiencing homelessness.

BACKGROUND:Previous studies evaluated the ability of large language models (LLMs) in medical disciplines; however, few have focused on image analysis, and none specifically on cardiovascular imaging or nuclear cardiology. This study assesses four LLMs-GPT-4, GPT-4 Turbo, GPT-4omni (GPT-4o) (Open AI), and Gemini (Google Inc.)-in responding to questions from the 2023 American Society of Nuclear Cardiology Board Preparation Exam, reflecting the scope of the Certification Board of Nuclear Cardiology (CBNC) examination. METHODS:We used 168 questions: 141 text-only and 27 image-based, categorized into four sections mirroring the CBNC exam. Each LLM was presented with the same standardized prompt and applied to each section 30 times to account for stochasticity. Performance over six weeks was assessed for all models except GPT-4o. McNemar's test compared correct response proportions. RESULTS:GPT-4, Gemini, GPT-4 Turbo, and GPT-4o correctly answered median percentages of 56.8% (95% confidence interval 55.4% - 58.0%), 40.5% (39.9% - 42.9%), 60.7% (59.5% - 61.3%), and 63.1% (62.5%-64.3%) of questions, respectively. GPT-4o significantly outperformed other models (P = .007 vs GPT-4 Turbo, P < .001 vs GPT-4 and Gemini). GPT-4o excelled on text-only questions compared to GPT-4, Gemini, and GPT-4 Turbo (P < .001, P < .001, and P = .001), while Gemini performed worse on image-based questions (P < .001 for all). CONCLUSION/CONCLUSIONS:GPT-4o demonstrated superior performance among the four LLMs, achieving scores likely within or just outside the range required to pass a test akin to the CBNC examination. Although improvements in medical image interpretation are needed, GPT-4o shows potential to support physicians in answering text-based clinical questions.

BACKGROUND:The optimal management of patients with intermediate-risk pulmonary embolism (PE), who have right heart dysfunction (determined by a combination of imaging and cardiac biomarkers) but a normal blood pressure, is uncertain. These patients suffer from reduced functional capacity and a lower quality of life over the long-term, despite use of anticoagulant therapy. Catheter-directed therapy (CDT) is a promising treatment for acute PE that rapidly removes thrombus and potentially improves cardiac dysfunction. However, CDT has risk and is costly, and it is not known whether it improves long-term cardiorespiratory fitness and/or quality of life compared with anticoagulation alone. METHODS:) with cardiopulmonary exercise testing at 3 months and reduce New York Heart Association (NYHA) Class at 12 months compared with No-CDT. These 2 primary efficacy outcomes will be analyzed sequentially using a "gatekeeping" procedure; for NYHA class to be compared, peak oxygen consumption must first be shown to be significantly increased by CDT. Safety and cost-effectiveness will also be assessed. CONCLUSION/CONCLUSIONS:When completed, PE-TRACT will provide important evidence regarding the benefits and risks of CDT to treat intermediate-risk PE compared with anticoagulation alone. TRIAL REGISTRATION/BACKGROUND:clinicaltrials.gov: NCT05591118.