Faculty Bibliography

BACKGROUND:Little is known about the prognostic significance of pancreatic duct (PD) dilation following pancreatoduodenectomy for intraductal papillary mucinous neoplasms (IPMN). Although PD dilation is typically the hallmark radiographic feature of IPMN, other causes of PD dilation exist, including anastomotic stricture, pancreatitis, senescence, and postsurgical passive dilation. Therefore, PD dilation after pancreatoduodenectomy for IPMN represents a diagnostic and management dilemma. The purpose of this study was to evaluate the significance of PD dilation after pancreatoduodenectomy for noninvasive IPMN. METHODS:All patients who underwent pancreatoduodenectomy for noninvasive IPMN at nine pancreatic academic centers between 2013 and 2018 were included. Variables were entered prospectively into institutional databases and retrospectively reviewed for the purpose of this study. Dilation of the PD remnant was defined as a duct diameter of ≥5 mm, according to international guidelines. RESULTS:Four-hundred and eighty-one patients were included in this study. The mean age of the patients was 66 years (range 30-90). Patients were surveilled for a median of 4.5 (+/-2.3; max 10.6) years. During follow-up, 132 patients (27.4%) developed PD dilation in the remnant tissue after a median of 3.3 years. Multivariable analysis demonstrated that older age at the time of pancreatoduodenectomy (P=0.01) and longer surveillance duration (P=0.002) were predictors of PD dilation. Interestingly, neither the pathological IPMN subtype (branch-duct vs. main duct/mixed, P=0.96) nor the preoperative PD diameter (P=0.14) was associated with an increased risk of PD dilation in the remnant. During follow-up, IPMN recurrence was suspected in the remaining 72 patients (18.4%), solely because of ductal dilation on cross-sectional imaging in 97% (70/72). Completion pancreatectomy was performed in only 16 patients (3.3%), of whom only four (0.8%) had invasive carcinoma. Three of these four patients had high-grade dysplasia in the original pancreatoduodenectomy specimen, whereas only one had a low-grade dysplastic lesion initially. On multivariable analysis, no variable was predictive of IPMN recurrence in the remnant. CONCLUSIONS:New main duct dilation in the pancreatic remnant after pancreatoduodenectomy for IPMN is common, occurring in 27% of the patients. The duration of surveillance is the main factor associated with remnant PD dilation, suggesting that this is likely a physiologic phenomenon. Although recurrence of IPMN in the remnant is often suspected, only 0.8% of patients develop an invasive carcinoma in the pancreatic remnant requiring completion pancreatectomy.

BACKGROUND:The need for evidence to inform interventions to prevent mass shootings (MS) in the USA has never been greater. METHODS:Data were abstracted from the Gun Violence Archive, an independent online database of US gun violence incidents. Descriptive analyses consisted of individual-level epidemiology of victims, suspected shooters and weapons involved, trends and county-level choropleths of population-level incident and fatality rates. Counties with and without state-level assault weapons bans (AWB) were compared, and we conducted a multivariable negative binomial model controlling for county-level social fragmentation, median age and number of gun-related homicides for the association of state-level AWB with aggregate county MS fatalities. RESULTS:73.3% (95% CI 72.1 to 74.5) of victims and 97.2% (95% CI 96.3 to 98.3) of shooters were males. When compared with incidents involving weapons labelled 'handguns', those involving a weapon labelled AR-15 or AK-47 were six times more likely to be associated with case-fatality rates greater than the median (OR=6.1, 95% CI 2.3 to 15.8, p<0.00001). MS incidents were significantly more likely to occur on weekends and during summer months. US counties in states without AWB had consistently higher MS rates throughout the study period (p<0.0001), and the slope for increase over time was significantly lower in counties with AWB (beta=-0.11, p=0.01). In a multivariable negative binomial model, counties in states with AWB were associated with a 41% lower incidence of MS fatalities (OR=0.58, 95% CI 0.37 to 0.97, p=0.02). CONCLUSIONS:Counties located in states with AWB were associated with fewer MS fatalities between 2014 and 2022.

OBJECTIVE:We aimed to better understand patients' treatment preferences and quantify the level of cancer risk at which treatment preferences change (risk threshold) to inform better counseling of patients with intraductal papillary mucinous neoplasms (IPMNs). SUMMARY BACKGROUND DATA/BACKGROUND:The complexity of IPMN management provides an opportunity to align treatment with individual preference. METHODS:We surveyed a sample of healthy volunteers simulating a common scenario: undergoing an imaging study that incidentally identifies an IPMN. In the scenario, the estimated risk of cancer in the IPMN was 5%. Patients were asked their treatment preference (surgery or surveillance), to quantify the level of cancer risk in the IPMN at which their treatment preference would change (i.e. risk threshold), and their level of cancer anxiety as measured on a 5-point Likert scale. We examined associations between participant characteristics, treatment preferences, and risk threshold using multivariable linear regression. RESULTS:The median risk threshold among the 520 participants was 25% (IQR 2.3-50%). The risk threshold had a bimodal distribution: 40% of participants had a risk threshold between 0-10% and 47% had a risk threshold above 30%. When informed that the risk of cancer was 5%, 62% of participants (n=323) preferred surveillance, and the remaining 38% (n=197) preferred surgery. After adjusting for potential confounders, participants who expressed "worry" or "extreme worry" about the malignancy risk of IPMN had significantly lower risk thresholds than participants who were "not at all worried" (Coefficient -12, 95%CI -21 to -2, P=0.015 and Coefficient -18, 95%CI -29 to -8, P<0.001, respectively). CONCLUSIONS:Participants varied in treatment preference and risk threshold of incidentally identified IPMNs. Given the uncertainty in estimating the true malignant potential of IPMNs, a better understanding of a patient's risk threshold, as influenced by patient concern about malignancy, will help inform the shared decision-making process.

PURPOSE/OBJECTIVE:Complications can and do occur with implants and their restorations with causes having been proposed for some single implant complications but not for others. METHODS:A review of pertinent literature was conducted. A PubMed search of vibration, movement, and dentistry had 175 citations, while stress waves, movement, and dentistry had zero citations as did stress waves, movement. This paper discusses the physics of vibration, elastic and inelastic collision, and stress waves as potentially causative factors related to clinical complications. RESULTS:Multiple potential causes for interproximal contact loss have been presented, but it has not been fully understood. Likewise, theories have been suggested regarding the intrusion of natural teeth when they are connected to an implant as part of a fixed partial denture as well as intrusion when a tooth is located between adjacent implants, but the process of intrusion, and resultant extrusion, is not fully understood. A third complication with single implants and their crowns is abutment screw loosening with several of the clinical characteristics having been discussed but without determining the underlying process(es). CONCLUSIONS:Interproximal contact loss, natural tooth intrusion, and abutment screw loosening are common complications that occur with implant retained restorations. Occlusion is a significant confounding variable. The hypothesis is that vibration, or possibly stress waves, generated from occlusal impact forces on implant crowns and transmitted to adjacent teeth, are the causative factors in these events. Since occlusion appears to play a role in these complications, it is recommended that occlusal contacts provide centralized stability on implant crowns and not be located on any inclined surfaces that transmit lateral forces that could be transmitted to an adjacent tooth and cause interproximal contact loss or intrusion. The intensity, form, and location of proximal contacts between a natural tooth located between adjacent single implant crowns seem to play a role in the intrusion of the natural tooth. Currently, there is a lack of information about the underlying mechanisms related to these occurrences and research is needed to define any confounding variables.

Parental help-seeking preferences may help explain the treatment gap in child mental health. This study examined mothers' and fathers' help-seeking behaviors for child mental health to further understand their individual preferences for treatment. A total of 394 mothers and fathers completed questionnaires assessing the types of help sought for mental health concerns for a target child (age 3-7 years), as well as measures representing illness profile, predisposing characteristics, and barriers/facilitators proposed to influence help-seeking. Parents often sought informal rather than professional help. Regression modelling indicated mothers' different help-seeking behaviors were significantly associated with illness profile (marital quality, child mental health, parental education), predisposing factors (parental attributions, child age), and family income, while fathers' different help-seeking behaviors were significantly associated with child demographics (age, gender). The results support expanding treatments into nonclinical settings and improving child mental health literacy to improve appropriate parental help-seeking for child mental health concerns.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:This study assessed the vocal health of performers returning to full-time performance after the COVID-19 pandemic shutdown and investigated how differences in voice usage, exposure to voice care professionals, and vocal pathology before and during the pandemic contributed to variability in self-perceived and instrumental vocal outcome measures. STUDY DESIGN/METHODS:This was a prospective, case-control observational study conducted at a single outpatient site. METHODS:Twenty-two patients, 11 cases and 11 controls, were enrolled for the study. All participants were full-time singing professionals prior to the COVID-19 pandemic. Cases were recruited from patients presenting to a tertiary care voice center for vocal or pharyngeal complaints. Controls were healthy volunteers recruited from the general population of professional singers in the surrounding metropolitan area. All participants provided responses to the Voice Handicap Index-10, Evaluation of Ability to Sing Easily, and Laryngopharyngeal Measure of Perceived Sensation validated questionnaires as well as a study survey with questions regarding vocal use and history prior to and during the pandemic. All participants underwent instrumental acoustic and videostroboscopic voice evaluations. RESULTS:Cases had poorer outcome measures overall and were more likely to report their voices were worse at study enrollment when compared to their prepandemic perception (P = 0.027). Cases tended to be older and less likely to have pursued alternative employment during the pandemic that involved increased speaking voice use (27% vs 55%), but these differences were not statistically significant. CONCLUSIONS:There was a variable response among performers to the prolonged hiatus from performing during the COVID-19 pandemic. Those with poorer outcomes tended to be older and may have used their voice less during the pandemic. These findings are consistent with detraining periods in the exercise physiology literature and support the construct of treating vocal performers as vocal athletes.

OBJECTIVE:To investigate singers' vocal load by documenting three types of vocal doses (time, cycle, and distance doses) and sound pressure levels during the four phases of rehearsal and how the vocal doses vary between singers across rehearsals in the musical Nine, written by Maury Yeston. METHODS/DESIGN/METHODS:Five student-singers participating in the musical Nine gave informed consent to participate in the study. All five participants were assigned female at birth and female-identifying individuals. They attached a KayPENTAX APM 3300 dosimeter sensor to their lower neck and wore the accelerometer during four three-hour rehearsals throughout the rehearsal process (the music learning phase, the choreography learning phase, the blocking learning phase, and the dress rehearsal) of the musical. The dosimeter records neck vibrations at a rate of 20 samples per second. but it does not record linguistic content. RESULTS:A dosimetric analysis of five student singers identified variability in voice production throughout the rehearsal process. According to the dosimetry findings, singers employed extensive low-frequency voicing below the first passaggio, with belting and mixed vocal strategies as the predominant stylistic choices when performing in Nine. Additionally, the singers used an occasional head voice effect at specific moments. The roles of Carla, Saraghina, La Fleur, and Ensemble One and Two required specific vocal ranges due to the musical score. CONCLUSIONS:Researchers have yet to establish a safe baseline vocal dose for singers. The vocal dose is affected by many factors, such as duration of phonation, frequency range, SPL, and styles of vocalism required by the score. Louder and heavier vocalization produces larger distance doses, representing the cumulative load placed on vibrating tissue. The cycle dose, distance dose, and SPL reported in this study varied within and between singers. The phonation density graphs show this variability and the low tessitura required by the score. Time doses ranged from 4% to 7% of rehearsal time; this short dose suggests that the rehearsals provided healthy conditions for the successful rehearsal process with efficient attention to the vocalization of a score that requires heavy vocal styles, including belting. While the rehearsal pace was not alarming, the demands of the score alone may prove to be much greater than the vocal dose reported through the rehearsal. Further studies are needed to establish the overall dose of each Broadway role to serve as parameters for vocal pacing and voice care.

Acute rheumatic fever (ARF) is an immune-mediated nonsuppurative complication of group A streptococcal (GAS) pharyngitis. Approximately 470,000 new cases of ARF occur annually, with a more significant disease burden in developing countries with higher rates of untreated or inadequately treated GAS infections. Globally, over 275,000 deaths yearly are attributed to rheumatic heart disease (RHD). The most significant contributors to the spread of GAS pharyngitis are household overcrowding, poor sanitation, and inadequate access to healthcare. The pathophysiology of ARF is characterized by an aberrant immune response to GAS infection triggered by molecular mimicry between GAS antigens and self-antigens. This immune response typically manifests 2 to 4 weeks after the initial GAS infection and may lead to the development of carditis, valvulitis, Sydenham chorea, subcutaneous nodules, erythema marginatum, and polyarthritis that is usually migratory. The severity and distribution of these manifestations vary significantly between individuals making the diagnosis of ARF challenging. Early recognition of ARF using the modified Jones criteria is essential in treating acute infection and preventing complications. A major long-term consequence is RHD, which carries significant morbidity and mortality.

OBJECTIVES/UNASSIGNED:Innovative methods for pulpal diagnosis are becoming increasingly important in endodontics, as traditional diagnostic techniques often lack the precision and reliability needed for confident decision making. Molecular diagnostic approaches, like biomarker analysis and advanced sampling methods, represent a step forward in clinical practice. This narrative review aims to identify key biomarkers associated with pulpal inflammation, compare published cutoff points for these biomarkers, and briefly review molecular methods and sampling techniques. SEARCH STRATEGY/UNASSIGNED:This study is a narrative review of literature identified by a web-based search on PubMed. Original scientific articles, such as clinical studies, reviews, and case reports, were included. RESULTS/UNASSIGNED:Several biomarkers have been associated with pulp inflammation and have been reported as statistically significant, including interleukin 1, 6, and 8; tumor necrosis factor-α; vascular endothelial growth factor; fibrocyte growth factor acidic; and matrix metalloproteinases 8 and 9. Although some cutoff points for these biomarkers have been identified, further research is necessary to refine their clinical applicability. Various sample collection methods, such as gingival crevicular fluid, dentinal fluid, pulpal tissue, and pulpal blood, have been used. Among the analytical techniques, enzyme-linked immunosorbent assay and Luminex protein assays have proven to be the most accurate, sensitive, and specific for evaluating pulpal inflammation.

OBJECTIVES/OBJECTIVE:Achieving optimal adherence to antiretroviral therapy (ART) and viral suppression is still insufficient for attaining the UNAIDS 95-95-95 target of 2030, especially among adolescents with HIV (AWHIV). This study sought to develop a model to predict poor adherence risk among AWHIV and identify associated risk factors. DESIGN/METHODS:We utilized machine learning to predict future ART adherence among AWHIV leveraging its ability to analyze complex, multidimensional data. METHODS:We leveraged a dataset from a 6-year (2012-2018) longitudinal randomized control trial (RCT) with 635 AWHIV in Uganda. We evaluated six machine learning models and retained one with the highest area under receiver operating characteristic (AUROC), and area under precision-recall curve (AUPRC). We further identified principal factors associated with ART adherence based on the best model. RESULTS:The random forest model outperformed others, with mean AUROC: 0.71 [BC 95% confidence interval (CI) (0.69-0.72)] and AUPRC: 0.55 (BC 95% CI 0.53-0.58). The principal risk factors of poor adherence were poor adherence history; poverty; biological relationship to caregiver; self-concept; savings confidence; duration on ART; frequency discussing sensitive topics with caregivers; household size; economic group assignment; and school enrollment. CONCLUSION/CONCLUSIONS:Our findings support potential use of machine learning methods and sociobehavioral data for predicting poor ART adherence risk among AWHIV. The predictive tool can help identify AWHIV at the highest risk of treatment failure, and enable early targeted interventions. However, the tool is still preliminary and its accuracy could be improved by incorporating HIV phenotypic and clinical data. CLINICAL TRIAL NUMBER/BACKGROUND:ClinicalTrials.gov ID:NCT01790373.