Faculty Bibliography

Fibromyalgia (FM) is a complex chronic musculoskeletal pain disorder with an elusive pathogenesis, with a strong implication of immune interactions. We recently found that IL-5 and the adaptive immune system mediates pain outcomes in fibromyalgia (FM) patients and preclinical models of FM-like chronic widespread pain (CWP). However, there is an active debate if FM/CWP has an autoimmune etiology. Preclinical models of CWP utilize a repeated insult paradigm, which resembles a primary, then secondary response similarly observed in the antibody response, in which the subsequent event causes a potentiated pain response. Recent translational studies have implicated immunoglobulins (Ig) and B-cells in FM/CWP pathophysiology. To understand if these are involved in preclinical models of CWP, we performed comprehensive B-cell phenotyping in the bone marrow, circulation, and popliteal (draining) lymph nodes in the two-hit acidic saline model of CWP. We found increased MHC class II-expressing B-cells in peripheral blood, increased activated plasma cells in peripheral blood, and increased memory B-cells in the bone marrow. Interestingly, acidic pH (4.0) injected mice have reduced levels of IgG1, independent of treatment with IL-5. We have demonstrated that the acidic saline model of CWP induces T-cell mediated activation of B-cells, increased active plasma cells, and increased memory B-cells in female mice.

The incidence of substance use and behavioral addictions continues to increase throughout the world. The Global Burden of Disease Study shows a growing impact in disability-adjusted life years due to substance use. Substance use impacts families, communities, health care, and legal systems; yet, the vast majority of individuals with substance use disorders do not seek treatment. Within the United States, new legislation has attempted to increase the availability of buprenorphine, but the impact of substance use continues. Although medications and group support therapy have been the mainstay of treatment for substance use, lifestyle medicine offers a valuable adjunct therapy that may help strengthen substance use recovery through healthy neuroplastic changes.

Despite therapeutic treatments and the growing utilization of multimodal therapies, gastric cancer (GC) remains a highly aggressive malignancy with high mortality worldwide. Much of the complexity in treating GC is due to the high incidence of peritoneal metastasis (PM), with mean overall survival typically ranging from 4 to 10 months. With current systemic therapy, targeted therapies, and immunotherapies continuing to remain ineffective for GC/PM, there has been a significant growing interest in intraperitoneal (IP) therapies for the treatment of GC/PM. In this review, we summarize the development of PM and evolving treatment strategies for GC/PM. Furthermore, we explore the various advancements and outcomes of IP therapies, including heated intraperitoneal chemotherapy (HIPEC), neoadjuvant HIPEC, and pressurized intraperitoneal aerosolized chemotherapy (PIPAC).

We describe a rare but interesting complication of totally endoscopic robotic mitral valve repair in a patient with severe mitral regurgitation. The mitral valve was repaired robotically by standard techniques, and the intraoperative transesophageal echocardiogram demonstrated no residual mitral regurgitation. However, there was unexpected hypokinesia of the posterior and lateral walls of the left ventricle, with subsequent electrocardiography showing acute ST elevations of the lateral segment. Immediate cardiac catheterization revealed occlusion of the left circumflex artery. Aspiration thrombectomy was performed and a drug-eluting stent placed to restore the contour, thus preventing potential morbidity of the patient.

A knowledge gap may exist when attempting to identify the pathogenetic mechanisms resulting in the syndrome of inappropriate antidiuretic hormone (SIADH) or hypotonic hyponatremia. Ectopic secretion of antidiuretic hormone [ADH] is the classic cause of SIADH. But another form of inappropriate secretion of ADH occurs when interleukin 6 is activated. Hypotonic hyponatremia can also occur in patients with cerebral salt wasting, but the secretion of ADH is appropriate, responding to volume depletion induced by excessive natriuresis. Reset osmostat (RO) is another cause of hypotonic hyponatremia caused by an unknown anomaly in the hypothalamus. This review discusses the pathophysiology of and the identical laboratory findings found in classic ectopic ADH secretion, interleukin 6-mediated ADH secretion, cerebral salt wasting-induced ADH secretion, and RO. This review also discusses potential methods to discern which hypotonic hyponatremic syndrome is present and current recommendations for treatment.

BACKGROUND/UNASSIGNED:Cow's milk allergy (CMA) is the most complex and common food allergy in infants. Elimination of cow's milk from the diet and replacement with a specialized formula for infants with cow's milk allergy who cannot be breastfed is an established approach to minimize the risk of severe allergic reactions while avoiding nutritional deficiencies. Given the availability of multiple options, such as extensively hydrolyzed cow's milk-based formula (eHF-CM), aminoacid formula (AAF), hydrolyzed rice formula (HRF), and soy formula (SF), there is some uncertainty regarding which formula might represent the most suitable choice with respect to health outcomes. The addition of probiotics to a specialized formula has also been proposed as a potential approach to possibly increase the benefit. We systematically reviewed specialized formulas for infants with CMA to inform the updated World Allergy Organization (WAO) DRACMA guidelines. OBJECTIVE/UNASSIGNED:To systematically review and synthesize the available evidence about the use of specialized formulas for the management of individuals with CMA. METHODS/UNASSIGNED:We searched from inception PubMed, Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and the websites of selected allergy organizations, for randomized and non-randomized trials of any language investigating specialized formulas with or without probiotics. We included all studies irrespective of the language of the original publication. The last search was conducted in January 2024. We synthesized the identified evidence quantitatively or narratively as appropriate and summarized it in the evidence profiles. We conducted this review following the PRISMA, Cochrane methods, and the GRADE approach. RESULTS/UNASSIGNED:GG) showed no significant effect, as supported by low to very low CoE. CONCLUSIONS/UNASSIGNED:Currently available studies comparing eHF-CM, AAF, HRF, and SF provide very low certainty evidence about their effects in infants with IgE-mediated and non-IgE-mediated CMA. Our review revealed several limitations in the current body of evidence, primarily arising from concerns related to the quality of studies, the limited size of the participant populations and most importantly the lack of diversity and standardization in the compared interventions. It is therefore imperative for future studies to be methodologically rigorous and investigate a broader spectrum of available interventions. We encourage clinicians and researchers to review current World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines for suggestions on how to use milk replacement formulas in clinical practice and what additional research would be the most beneficial.

Medical ethics education is crucial for medical students and trainees, helping to shape attitudes, beliefs, values, and professional identities. Exploration of ethical dilemmas and approaches to resolving them provides a broader understanding of the social and cultural contexts in which medicine is practiced, as well as the ethical implications of medical decisions, fostering critical thinking and self-reflection skills imperative to providing patient-centered care. However, exposure to medical ethics topics and their clinical applications can be limited by curricular constraints and the availability of institutional resources and expertise. Podcasts, among other Free Open Access Medical Education (FOAMed) resources, are a novel educational tool that offers particular advantages for self-directed learning, a process by which learners engage in asynchronous educational opportunities outside of traditional academic or clinical settings. Podcasts can be readily distributed to wide audiences and played at any time, reducing barriers to access and offering a level of flexibility that is not possible with traditional forms of education and is well-suited to busy schedules. Podcasts can also use real voices and storytelling to make the content memorable and eminently human. This paper describes the development, production process, and impact of Core IM's "At the Bedside," a podcast focusing on issues in medical ethics and the medical humanities, intending to supplement standard bioethics curricula in an accessible, relevant, and engaging way. The authors advocate for broad incorporation of podcasts into medical ethics education.

Population aging presents a growing societal challenge and imposes a heavy burden on the healthcare system in many Asian countries. Given the limited availability of formal long-term care (LTC) facilities and personnel, family caregivers play a vital role in providing care for the increasing population of older adults. While awareness of the challenges faced by caregivers is rising, discussions often remain within academic circles, resulting in the lived experiences, well-being, and needs of family caregivers being frequently overlooked. In this review, we identify four key priority areas to advance research, practice, and policy related to family caregivers in Asia: (1) Emphasizing family caregivers as sociocultural navigators in the healthcare system; (2) addressing the mental and physical health needs of family caregivers; (3) recognizing the diverse caregiving experiences across different cultural backgrounds, socioeconomic status, and countries of residence; and (4) strengthening policy support for family caregivers. Our review also identifies deficiencies in institutional LTC and underscores the importance of providing training and empowerment to caregivers. Policymakers, practitioners, and researchers interested in supporting family caregivers should prioritize these key areas to tackle the challenge of population aging in Asian countries. Cross-country knowledge exchange and capacity development are crucial for better serving both the aging population and their caregivers.

OBJECTIVE/UNASSIGNED:To better characterize the cochlear apex in relation to surgically relevant landmarks to guide surgeons and improve procedural success of apical electrode placement. STUDY DESIGN/UNASSIGNED:Retrospective image analysis. SETTING/UNASSIGNED:Tertiary referral center. PATIENTS/UNASSIGNED:Cochlear implant recipients with available preoperative computed tomography (CT) imaging. INTERVENTION/UNASSIGNED:None. MAIN OUTCOME MEASURE/UNASSIGNED:Cochlear dimensions and cochlear apex distance measures to surgically relevant middle ear landmarks and critical structures. RESULTS/UNASSIGNED:Eighty-two temporal bone CT scans were analyzed utilizing multiplanar reformats. The average lateral width of promontory bone over the cochlear apex was 1.2 mm (standard deviation [SD], 0.3). The anteroposterior distance from the round window (avg, 4.2 mm; SD, 0.5), oval window (avg, 3.3 mm; SD, 0.3), cochleariform process (avg, 2.3; SD, 0.5), and superior-inferior distance from the cochleariform process (avg, -0.9; SD, 0.8) to the cochlear apex were measured. The relationship of the cochlear apex to critical structures was highly variable.A newly developed stapes vector was created and found to mark the posterior/superior boundary of the apex in 94% of patients. When a vector parallel to the stapes vector was drawn through the round window, it marked the anterior/inferior boundary of the cochlear apex in 89% of patients. CONCLUSIONS/UNASSIGNED:This study assists in characterizing cochlear apex anatomy and its relation to surrounding structures as a means of improving procedural accuracy and reducing trauma during apical cochleostomy. Understanding both distance relationships and expected boundaries of the apex could help to inform future surgical approaches.