Faculty Bibliography

Orthognathic surgery requires precise manipulation of skeletal structures in close proximity to highly sensitive nerve, vascular, and airway anatomy. Rare iatrogenic injuries including hemorrhage and neurovascular compromise are reported and can have devastating sequelae including stroke, blindness, and death. Established technologies have primarily focused on positional accuracy rather than enhancing patient safety. This review investigates the adoption of intraoperative navigation in orthognathic surgery to reduce the risk of iatrogenic complications. Following PRISMA guidelines, a systematic search of PubMed, Embase, Web of Science, and Cochrane Library was conducted to identify original studies reporting on the application and outcomes of intraoperative navigation in orthognathic surgery. Data were extracted on indications, surgical procedures, navigation technologies, primary purpose for use, and outcomes. Thirty studies met inclusion criteria, and most were published after 2015 (63.3%). The majority (96.7%) used navigation to enhance accuracy of skeletal segment positioning; only 6.7% of studies reported use of intraoperative navigation to identify and avoid critical anatomic structures. BrainLab systems were most frequently used (40.0%), followed by Stryker (13.3%) and Aurora/Northern Digital Inc. (10.0%). Extensive evidence across multiple surgical specialties validates the efficacy of intraoperative navigation in reducing injury to critical structures and in limiting blood loss, operative time, and reoperation rates. Current literature supports intraoperative navigation as a highly accurate modality for orthognathic surgery but rarely addresses its potential to mitigate severe iatrogenic complications. Evidence from other surgical disciplines substantiates its role in enhancing safety, underscoring the need for high-level studies focused on complication prevention in orthognathic surgery.

BACKGROUND:Under the HOPE Act, transplants from donors with HIV to recipients with HIV (HIV D+/R+) have been largely limited to kidney and liver. However, recent modifications to HOPE research guidelines allow broader participation of cardiothoracic programs. METHODS:To quantify potential cardiothoracic HOPE donors, we used SRTR data (3/2016-12/2024) to identify 101,200 donors without HIV and 273 HOPE donors (with true and false positive HIV tests). Using logistic regression, we predicted the probability of having a heart or lung(s) used for transplant among donors without HIV that had a kidney or liver used. We then applied model parameters to HOPE donors that had a kidney or liver used to estimate the number of HOPE donors that might have been cardiothoracic donors if the practice were expanded. RESULTS:Among donors without HIV, cardiothoracic donation was associated with age, cause of death, hepatitis C, hypertension, diabetes, smoking, cardiovascular disease, blood gas, and circulatory death. Applying our model, an estimated 41.0% (N=111), 18.7% (N=51), and 15.2% (N=41) of HOPE donors were potential heart, any lung (single or double), or double-lung donors, as compared to 32.3%, 21.8%, and 18.2% of abdominal organ donors without HIV, respectively. This translated to an annual 13-18 potential heart and 5-8 potential lung transplants (of which 4-6 would be double-lung transplants) from HOPE donors. CONCLUSIONS:If HIV D+/R+ is more widely expanded to cardiothoracic transplantation, 41% of HOPE kidney and liver donors have potential to donate a heart and almost 20% to donate a lung to candidates with HIV.

Providing care to pediatric oncology patients involves delivering sensitive information to families, addressing diverse psychosocial needs, and navigating patient and family emotions. Psychosocial providers embedded within pediatric oncology clinics are uniquely qualified to address communication gaps between patients and providers, provide support to patients, and facilitate collaborative discussions between patients and the medical team. This quality improvement project aimed to describe the impact of including psychosocial providers in critical conversations between medical teams and families. Through conversation tracking, members of the psychosocial team recorded their involvement in thirty-six critical conversations. The psychosocial team offered various interventions including therapeutic processing, emotional assessment, medical translation, psychosocial support, child-focused support, and facilitation of discussions between families and medical providers. While challenges were identified including time and availability, physicians noted several benefits of psychosocial involvement, particularly in addressing emotional needs and enhancing communication with families. Psychosocial providers also noted benefits including demonstrating alignment with the medical team and enhancing the support that they are able to provide the family following the conversation. By integrating psychosocial support into critical conversations, medical providers can foster a patient-centered approach to care and optimize care delivery to effectively support families facing childhood cancer diagnoses.

To build a knowledge-based treatment planning model using RapidPlan for esophageal cancer in the upper, mid and lower thoracic sites while comparing the performance of the model with and without the use of avoidance sectors. Plans from 45 patients with esophageal tumors requiring treatment in the upper (8), middle (15) and lower (22) thoracic regions were selected for training. Prescribed dose ranged from 41.4Gy to 56Gy (1.8-2 Gy/fraction) with simultaneous integrated boost (SIB). Clinical plans were re-planned without the use of avoidance sectors. Plans with reduced V105%(cc) to the planning target volume (PTV) while meeting criteria for organs at risk (OARs) were chosen to build the model. The model was validated on 23 plans by comparing the clinical plan to the RapidPlan with and without the use of avoidance sectors. RapidPlan without avoidance sectors reduced the V105%(cc) by 100.1 cc (p< 0.001), compared to the clinical plan, while also reducing the maximum dose. The lung V5 Gy was increased by 5.5% on average (p = 0.02). Doses to the heart, stomach, kidney, large bowel, small bowel and the spinal cord were not compromised. Using avoidance sectors with RapidPlan did not improve plan homogeneity or coverage over the clinical plan, while increasing the V20 Gy to the lungs by 2.8% (p = 0.01). Mean heart dose was increase by 1.1 Gy (p = 0.04), while kidney V18Gy (%) and spinal cord maximum were increased by 7.2% (p = 0.02) and 3.8 Gy respectively (p = 0.01). Volume of the prescription dose outside the PTV was lower by as much as 67 cc while using RapidPlan without avoidance sectors compared to the clinical plan and conformity index (CI) was improved by 7%-8% compared to the clinical plan. Using avoidance sectors worsened the CI by 3%-5% compared with the CP. The RapidPlan model configured for upper, mid and lower thoracic regions without the use of avoidance sectors significantly reduces volumes of the higher doses in the target and therefore potential likelihood of esophageal toxicity without excessively increasing lung dose.

Primary erythromelalgia (PEM) is a rare neuropathic pain disorder characterized by debilitating burning pain of the extremities relieved by cold exposure. We report a pediatric patient who developed severe, full-thickness lower extremity ulcerations infected with Alternaria alternata and complicated by osteomyelitis following consistent direct skin cooling with window air conditioning. This case demonstrates serious infectious complications that can arise from cooling measures commonly employed for PEM symptom relief.

BACKGROUND/UNASSIGNED:Endocrine findings in premature adrenarche have been characterized by elevated DHEAS levels in the past. METHODS/UNASSIGNED:We reviewed 44 female patients, aged 4 to 8 years, with premature adrenarche who were seen at our center between 2019 and 2023. Data were collected on the traditional androgens (DHEA and DHEAS) and novel 11-oxo-androgens. 11-oxo-androgens, DHEAS, and DHEA levels were measured using Liquid chromatography/tandem mass spectrometry (LC/MS-MS) assays in commercial laboratories (Lab Corp). RESULTS/UNASSIGNED:The majority, 89% of patients from the youngest group (4-5year olds), presented with apocrine odor as the only symptom of premature adrenarche. We have demonstrated that DHEA and DHEAS levels were within the normal range in many girls with premature adrenarche, whereas 11-oxo-androgens, particularly 11-hydroxyandrostenedione and 11β-hydroxytestosterone, were elevated. Out of those with normal DHEAS, 75 % had elevated 11-hydroxyandrostenedione, and 77.8% of those patients with normal DHEA had the same elevated oxo-adrogen. Additionally, advanced bone age greater than 1 year compared to chronological age was positively associated with 11-ketotestosterone (Spearman correlation coefficient = 0.32, 95% CI: 0.01-0.57, p=0.0429) and 11β-hydroxy testosterone (Spearman correlation coefficient=0.32, 95% CI: 0.01-0.58, p=0.0395). CONCLUSION/UNASSIGNED:We propose that 11-oxoandrogens are a more sensitive steroid to be measured in premature adrenarche.

BACKGROUND:The benefits of achieving endoscopic remission among older adults with inflammatory bowel disease (IBD) who have mild persistent disease activity are unknown. METHODS:This was a retrospective study of adults ≥ 60 with IBD who had mild or no disease activity on endoscopy from January 1, 2018-January 1, 2023. The primary outcome was a composite of major IBD-specific adverse events (hospitalizations, surgery, and prescription of corticosteroids for IBD-related symptoms) within 1 year of endoscopic assessment. Our secondary outcome was a composite of 1-year morbidity-related events (mortality, all-cause hospitalization, infection requiring antibiotics, venous thromboembolism, cardiovascular events, and osteoporotic fractures). We also assessed outcomes at 5 years. RESULTS:Among 504 patients, 192 (38.1%) had mild endoscopic disease and 312 (61.9%) were in endoscopic remission, with a median disease duration of 11 years. On multivariable analysis, mild endoscopic disease activity increased the odds of a 1-year adverse IBD-specific outcome (aOR 4.16, 95% CI 2.10-8.24), with similar results at 5 years. Furthermore, mild endoscopic disease was associated with increased odds of experiencing an adverse morbidity-related outcome within 1 year as compared to endoscopic remission (aOR 1.56, 95% CI 1.01-2.43). CONCLUSIONS:Among older adults with prevalent IBD, mild endoscopic disease activity, as compared to endoscopic remission, was associated with increased odds of adverse IBD-specific and morbidity-related outcomes at 1 year, with this risk persisting for IBD-specific outcomes at 5 years. These findings highlight the importance of achieving endoscopic remission, which may confer both short- and longer-term benefits in this population.