Citations

Importance The emergency department (ED) offers an opportunity to initiate palliative care for older adults with serious, life-limiting illness. Objective To assess the effect of a multicomponent intervention to initiate palliative care in the ED on hospital admission, subsequent health care use, and survival in older adults with serious, life-limiting illness. Design, Setting, and Participants Cluster randomized, stepped-wedge, clinical trial including patients aged 66 years or older who visited 1 of 29 EDs across the US between May 1, 2018, and December 31, 2022, had 12 months of prior Medicare enrollment, and a Gagne comorbidity score greater than 6, representing a risk of short-term mortality greater than 30%. Nursing home patients were excluded. Intervention A multicomponent intervention (the Primary Palliative Care for Emergency Medicine intervention) included (1) evidence-based multidisciplinary education; (2) simulation-based workshops on serious illness communication; (3) clinical decision support; and (4) audit and feedback for ED clinical staff. Main Outcome and Measures The primary outcome was hospital admission. The secondary outcomes included subsequent health care use and survival at 6 months. Results There were 98 922 initial ED visits during the study period (median age, 77 years [IQR, 71-84 years]; 50% were female; 13% were Black and 78% were White; and the median Gagne comorbidity score was 8 [IQR, 7-10]). The rate of hospital admission was 64.4% during the preintervention period vs 61.3% during the postintervention period (absolute difference, −3.1% [95% CI, −3.7% to −2.5%]; adjusted odds ratio [OR], 1.03 [95% CI, 0.93 to 1.14]). There was no difference in the secondary outcomes before vs after the intervention. The rate of admission to an intensive care unit was 7.8% during the preintervention period vs 6.7% during the postintervention period (adjusted OR, 0.98 [95% CI, 0.83 to 1.15]). The rate of at least 1 revisit to the ED was 34.2% during the preintervention period vs 32.2% during the postintervention period (adjusted OR, 1.00 [95% CI, 0.91 to 1.09]). The rate of hospice use was 17.7% during the preintervention period vs 17.2% during the postintervention period (adjusted OR, 1.04 [95% CI, 0.93 to 1.16]). The rate of home health use was 42.0% during the preintervention period vs 38.1% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of at least 1 hospital readmission was 41.0% during the preintervention period vs 36.6% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of death was 28.1% during the preintervention period vs 28.7% during the postintervention period (adjusted OR, 1.07 [95% CI, 0.98 to 1.18]). Conclusions and Relevance This multicomponent intervention to initiate palliative care in the ED did not have an effect on hospital admission, subsequent health care use, or short-term mortality in older adults with serious, life-limiting illness. Trial Registration ClinicalTrials.gov Identifier: NCT03424109

Background: Non-ischemic cardiomyopathies can be primary (p-NICM) which involves mainly the heart muscle or caused by systemic disease with heart muscle involvement as it is seen in systemic infiltrative diseases (i-NICM). There is limited data on the safety and in-hospital outcomes of ventricular tachycardia (VT) ablation in i-NICM. Methods: We identified patients who underwent VT ablation between 2018-2021 using the National Inpatient Sample Database. i-NICM include amyloidosis, hemochromatosis, or sarcoidosis. In-hospital complications include mortality, acute kidney injury (AKI), acute heart failure (AHF), bleeding, vasopressor use, blood transfusion and cardiac tamponade. Multivariate logistic regression analyses were performed. Results : There were 7,420 VT ablations, 7,235 had P-NICM and 185 had i-NICM. A multivariable analysis did not reveal any difference in mortality (adjusted odds ratio [aOR]: 0.81; 95% confidence interval 0.32-1.98; p=0.62), AHF aOR: 0.88 (0.41-1.81; p=0.69, AKI aOR:1.17 (0.83-1.65); p=0.36, blood transfusion aOR: 0.63 (0.25-1.59); p=0.33, vasopressor aOR: 0.86( 0.51-1.49); p=0.61 or pericardial effusion/ tamponade aOR: 1.16 (0.67-2.1); p=0.58 Figure Conclusion: Patients with i-NICM had similar in-hospital complications compared to P-NICM further supporting the safety of VT ablation in managing recurrent VT in patients with i-NICM.

Abstract Primary testicular diffuse large B-cell lymphoma (PT-DLBCL) is a rare and aggressive lymphoma with molecular heterogeneity not well characterize. In this study, we performed next-generation sequencing analysis for a large number of DNA and RNA samples from patients with PT-DLBCL. DNA sequencing analysis identified ≥ 3 chromosomes with copy number variations (CNVs) and microsatellite instability as prognostic biomarkers, rather than MYD88 mutations and genetic subtypes. Remarkably, targeted RNA-seq analysis in 195 patients revealed that TP53 mutations with a ≥ 40% variant allele frequency had significantly adverse prognostic impact, and that a 150-gene expression signature subdivided PT-DLBCL into two distinct clusters, termed as testicular lymphoma tumor (TLT) and microenvironment (ME) subtypes. The TLT subtype featured upregulation of genes involved in B-cell receptor signaling, cell cycle, DNA damage and repair, higher frequencies of CNVs and MYD88 mutations, elder ages, larger tumor sizes, and significantly poorer survival. Genomic microRNA profiling analysis identified significantly differentially expressed microRNAs between 113 PT-DLBCL and 180 systemic DLBCL patients, and further subdivided the PT-DLBCL cohort by microRNA signatures. The subcohort with upregulation of 16 microRNAs associated with PT-DLBCL and testicular tissue expression had significantly better survival. This study revealed characteristic genetic, gene expression, and microRNA profiles and heterogeneity in PT-DLBCL.

ABSTRACT Nowadays, consent to use donor bodies for medical education and research is obtained from the body donors and their families before the donation. Recently, the International Federation of Associations of Anatomists (IFAA) published guidelines that could restrict the appearance of cadaveric images in commercial anatomical resources such as textbooks and other educational products. These guidelines state that the donor must expressly consent to using such images for this purpose. Cadaveric photos and drawings made from dissections of cadavers have been used in anatomy textbooks and atlases for hundreds of years. They are invaluable for anatomy students and clinical/surgical practitioners. The IFAA guidelines should not restrict the use of those older books; to do so would infringe the rights of those seeking knowledge from these resources. As the images in such textbooks and atlases are anonymized and are used for teaching and research, and the donors and their families are informed about this before the donation, we believe no additional consent is needed. It is impossible to separate educational from “commercial” usage entirely in any situation, e.g., publications from publishers and the use of cadavers in medical schools. Therefore, our best efforts to avoid unethical use of cadaveric images by following traditional consent processes are still needed so that more people will reap the benefits from them. As senior textbook/atlas authors/editors from over 10 countries, we believe that using cadaveric images in anatomy textbooks is appropriate, and no additional consent should be necessary. Such usage falls within the good faith of professionals using these invaluable gifts.

IntroductionUnilateral sphenoid sinus opacification on computed tomography is caused by a variety of pathologies including inflammatory and infectious sinusitis, benign and malignant tumors, and encephaloceles. The purpose of this study was to report craniofacial pain locations and outcomes in inflammatory unilateral sphenoid sinusitis (USS) patients who underwent endoscopic sinus surgery (ESS).MethodsA multi‐institutional retrospective cohort study was conducted on all adult patients who had ESS for USS from 2015 to 2022. Patient demographics, presenting symptoms and nasal endoscopy findings, extent of surgical dissection, and craniofacial pain locations and outcomes were recorded. Exclusion criteria included age <18 years, non‐inflammatory etiology, immunodeficiency, invasive fungal sinusitis, lack of follow‐up, lack of preoperative pain location, and neoplasia. Descriptive statistics were calculated.ResultsOf 57 patients with USS, 44 (77.2%) reported craniofacial pain at one or more locations. Retrobulbar (n = 19, 43.2%) was the most common pain location followed by frontal (n = 17, 38.6%) and occipital (n = 10, 22.7%). Surgical intervention resulted in pain resolution in 33/44 patients (75%), with a mean follow‐up of 83.7 (±97.8) days. There were no significant associations between presenting symptoms, imaging findings, endoscopy, surgical extent, or final pathology and the presence or resolution of facial pain (p > 0.05).ConclusionIn USS patients, the most common craniofacial pain locations were retrobulbar, occipital, and frontal, with a minority being vertex. Based on short‐term follow‐up, ESS resolved the craniofacial pain in 75% of cases. There were no clinical variables that predicted the presence or resolution of craniofacial pain.Level of Evidence4 Laryngoscope, 135:1915–1919, 2025

Cardiac amyloidosis (CA) is a progressive condition resulting from the deposition of amyloid fibrils in the heart, which leads to severe diastolic dysfunction and restrictive cardiomyopathy. The disease has two main subtypes: light-chain and transthyretin (TTR) CA, with the latter subdivided into wild-type and hereditary forms. Despite advances in diagnostic imaging, early detection remains a challenge due to non-specific symptoms that mimic other cardiac conditions. Treatment has evolved significantly with targeted therapies like TTR stabilizers, gene silencers, and RNA interference, showing promise in altering disease progression. However, barriers such as high costs, limited availability of genetic testing, and inadequate multidisciplinary care continue to impede comprehensive management. Future strategies should focus on integrating novel gene-editing therapies, expanding access to diagnostics, and enhancing multidisciplinary care models to improve outcomes. Overall, early diagnosis, equitable access to therapies, and personalized management plans are crucial to advancing care for CA patients.

Background Value-based care payment and delivery models such as the recently implemented Merit-based Incentive Payment System (MIPS) aim to both provide better care for patients and reduce costs of care. Gender disparities across orthopaedic surgery, encompassing reimbursement, industry payments, referrals, and patient perception, have been thoroughly studied over the years, with numerous disparities identified. However, differences in MIPS performance based on orthopaedic surgeon gender have not been comprehensively evaluated. Questions/purposes After controlling for potentially confounding variables such as experience, geography, group size, and Medicare beneficiary characteristics, does MIPS performance differ between men and women orthopaedic surgeons? Methods The Medicare Physician and Other Practitioners and the Physician Compare databases were queried for years 2017, the first year MIPS was incorporated, and 2021, the most recent year with MIPS data published, to identify all physicians with a self-reported specialty of orthopaedic surgery. Together, these databases include all physicians who submitted at least 11 Medicare claims each year. Physician gender, US census region, years in practice, group practice size, billing practices, and patient demographic characteristics were collected for each surgeon. The MIPS Performance database was used to extract an overall MIPS performance score for each surgeon for each year. Payment adjustments, which are determined based on overall MIPS performance score, were derived for each surgeon based on the thresholds published by the Centers for Medicare & Medicaid Services. Payment adjustments include a negative adjustment, neutral adjustment, positive adjustment, or exceptional performance bonus and are associated with different thresholds each year. Statistical differences based on surgeon gender were assessed utilizing chi-square tests for categorical data, Student t-test for parametric continuous data, and Wilcoxon signed-rank test for nonparametric continuous data. Univariable and multivariable analyses were performed to analyze the relationship between surgeon gender and MIPS performance. Results After controlling for other patient and surgeon variables, woman gender was associated with a slightly increased MIPS performance score in 2021 (β 1.5 [95% confidence interval (CI) 0.02 to 3.00]; p = 0.047). However, this finding was statistically fragile, with the lower bound 95% CI being very close to the line of no difference. No association between surgeon gender and MIPS performance score was found in 2017 (β 2.2 [95% CI -0.5 to 4.9]; p = 0.11). Additionally, no relationship was found between gender and receiving either an exceptional performance MIPS bonus or a MIPS penalty in either year. Conclusion Women orthopaedic surgeons scored slightly higher on the MIPS in 2021, after controlling for surgeon and patient variables, despite providing care for a higher percentage of dual Medicare-Medicaid eligible patients and more medically complex patients. However, this finding was statistically fragile, with a small effect size, a 95% CI close to 0, and no consistent association in MIPS performance in 2017. Additionally, with no differences in MIPS performance bonuses or penalties, the clinical monetary impact of this difference may be minimal. Clinical Relevance The observed association between surgeon gender and MIPS performance scores in 2021, with women orthopaedic surgeons achieving slightly higher scores, raises interesting questions about potential differences in practice behaviors, communication styles, care quality, or other unmeasured variables. These findings may reflect true differences in how care is delivered or documented as scored by the MIPS. However, given the small effect size, statistical fragility, and inconsistency across years, there is a chance that this finding may be spurious. That being so, future research should aim to validate or refute these findings by examining a broader range of variables including documentation practices, practice behaviors, institutional differences, potential systemic biases in scoring methodologies, and patient outcomes. Understanding whether these differences are true is important to ensure that performance metrics like MIPS accurately and equitably reflect care quality.

Abstract Asthma is a heterogeneous disease with variable presentation and characteristics. There is a critical need to identify underlying molecular endotypes of asthma. We performed the largest transcriptomic analysis of 808 bronchial epithelial cell samples across 11 independent cohorts, including 3 cohorts from the Severe Asthma Research Program. Using seven datasets (218 patients with asthma, 148 healthy control subjects) as discovery cohorts, we identified 505 differentially expressed genes, which we validated in the remaining four datasets. Unsupervised clustering using the 505 differentially expressed genes identified four reproducible clusters of patients with asthma across all datasets, corresponding to healthy control subjects, patients with mild/moderate asthma, and patients with severe asthma with significant differences in several clinical markers of severity, including pulmonary function, Type 2 inflammation, fractional exhaled nitric oxide, and maximum bronchodilator reversibility. Importantly, we found the same clusters in pediatric patients using nasal lavage fluid cells, demonstrating the gene signature and clusters are not confounded by age and are conserved in both lower and upper airways. The four asthma clusters may represent a unifying framework for understanding the molecular heterogeneity of asthma. Further study could potentially enable a precision medicine approach of matching therapies with patients with asthma most likely to benefit.