Citations

ABSTRACT Background Academic departments in medicine face increasing pressure to balance clinical productivity with their broader academic missions, including education, scholarship, mentorship, and service. While clinical work is routinely quantified through relative value units (RVUs), non‐clinical academic contributions are inconsistently measured and often undervalued. Academic Value Unit (AVU) systems have emerged as frameworks to quantify these activities, but adoption remains limited due to inconsistent funding models, lack of standardized frameworks, and minimal evidence demonstrating outcomes such as faculty satisfaction, retention, or return on investment (ROI). Methods This concept paper synthesizes current AVU implementation strategies in emergency medicine and proposes an evidence‐informed six‐step framework for AVU design, funding, and sustainability. The framework was informed by a literature review, analysis of institutional dashboards, and multi‐institutional input from the Society for Academic Emergency Medicine (SAEM) community, including feedback from a national didactic session at the 2025 SAEM Annual Meeting. Results The proposed framework outlines practical steps for AVU implementation: defining mission‐aligned domains, identifying measurable academic activities, establishing transparent weighting systems, integrating real‐time tracking dashboards, developing sustainable blended funding models, and engaging leadership and faculty through iterative review. The model incorporates customizable templates, adaptable activity menus, and suggested ROI metrics that departments can tailor to local institutional priorities and resources. Conclusions AVU systems offer a structured approach to recognizing and incentivizing non‐clinical academic contributions in emergency medicine. A transparent, mission‐aligned framework supported by sustainable funding and measurable ROI metrics may enhance faculty engagement, equity, and long‐term departmental sustainability. Future work should focus on establishing validated benchmarks for AVU weighting, integrating AVUs with faculty development and wellness initiatives, and evaluating longitudinal outcomes such as retention, satisfaction, and equity.

Abstract Background The incidence of gastroesophageal cancer diagnosed at ages younger than 50 years is increasing. Assessment of the clinicopathologic and molecular characteristics of these cancers is limited currently. Methods This analysis used Tempus’ clinicogenomic database to compare patients diagnosed with gastroesophageal cancer at ages younger than 50 vs 50 years and older who completed tumor molecular profiling between December 2017 and July 2024. The spectrum of biomarkers, somatic alterations, and germline alterations were compared between those diagnosed with gastroesophageal cancer at ages younger than 50 years and those aged 50 years and older, and a multivariate analysis was conducted to identify factors associated with longer survival. Results Among 5863 gastroesophageal cancer patients, 785 had gastroesophageal cancer diagnosed at ages younger than 50 years. There were more females (35% vs 25%, P < .001) and fewer White patients (69% vs 80%, P < .001) with gastroesophageal cancer at ages younger than 50 years. Fewer tumors of patients with gastroesophageal cancer at ages younger than 50 years had high tumor mutational burden (3.2% vs 10.2%, P < .001) or high microsatellite instability (1.7% vs 5.1%, P < .001), but there was no difference in PD-L1 positivity (49% vs 51%, P = .3). Higher incidence of somatic CDH1 mutations was seen in those with gastroesophageal cancer at ages younger than 50 years (16.1% vs 6.6%, q < 0.001) with lower incidence of TP53 (65.6% vs 74.1%), CDKN2A (12.5% vs 19.8%), and KRAS (11.7% vs 18.3%, P < .001 for all) alterations. The most statistically significant germline difference was higher incidence of CDH1 (2.2% vs 0.3%, q = 0.001) and TP53 (0.6% vs 0%, q = 0.039) alterations among those with gastroesophageal cancer at ages younger than 50 years. Median survival for patients with metastatic disease was longer for gastroesophageal cancer at ages younger than 50 years (11 vs 8.5 months, P = .002), and gastroesophageal cancer at ages younger than 50 years, ERBB2 amplification, and high microsatellite instability were associated with superior survival. Conclusions Unique molecular and germline profiles were seen in patients with gastroesophageal cancer at ages younger than 50 years, which may suggest differences in causal factors yet undiscovered.

Abstract Background. Pain drives disability and medication use in autoimmune rheumatic diseases (ARDs), even when inflammation is controlled. The extent of pain-related polypharmacy across ARDs and chronic overlapping pain conditions (COPCs) remains poorly characterized. We aimed to quantify first-year pain medication burden following ARD diagnosis and examine variations by disease, COPC status, and time. Methods. Using the Merative MarketScan Commercial Claims database, we identified adults newly diagnosed with rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylitis, psoriatic arthritis, Sjögren’s disease, or systemic sclerosis (2008–2021). We analyzed pain-related medications across ten pharmacologic categories during the first year post-diagnosis. Polypharmacy measures included distinct medication counts, medication categories, ≥ 5 and ≥ 10 medication thresholds, and the Medication Quantification Scale. Findings. Among 149,742 adults with newly diagnosed ARDs, 57.6% had at least one COPC. During the first year after diagnosis, patients filled a mean of 9.0 distinct pain medications and 47.9% met criteria for ≥ 5 medications; 30.5% met criteria for ≥ 10 medications. Ankylosing spondylitis demonstrated the highest medication burden (mean 11.6 medications; 57.5% with ≥ 5 medications; 37.9% with ≥ 10 medications). Patients with fibromyalgia had consistently higher medication burden across ARDs and were the only COPC group in whom prescribing increased after 2015. Overall medication burden rose from 2008 to 2014–2015 and declined thereafter; however, absolute levels remained high. Interpretation. Pain-related polypharmacy is common early after ARD diagnosis and varies substantially by disease and pain phenotype. Despite modest declines after 2015, medication burden remains high, underscoring the need for phenotype-informed, nonpharmacologic, and deprescribing strategies in rheumatology. Funding. NIAMS (K01AR079039).

ABSTRACT In normal health, the liver and lungs enjoy a close anatomic, physiologic, and functional relationship. In the context of pulmonary vascular disease, however, there is accumulating evidence that the interplay between the gut microbiome, hepatic system, and pulmonary vasculature (so‐called “gut‐liver‐lung” axis) plays an important role in driving disease pathogenesis and determining clinical outcomes. Despite recognizing the importance of the gut‐liver‐lung axis in pulmonary vascular disease however, little is known about the clinical characteristics, circulating factors, and physiologic pathways that mediate this important axis of communication. In this clinical and translationally focused review, we provide an overview of liver‐lung communication in normal physiology, and contrast this with gut‐liver‐lung derangements in pulmonary arterial hypertension, portopulmonary hypertension, and hepatopulmonary syndrome. We conclude with identifying key gaps in knowledge that will need to be addressed in order to manipulate the gut‐liver‐lung axis to prevent worsening pulmonary vascular disease, develop novel therapeutics, and improve patient outcomes.

Objective: To evaluate the current literature on the role of collagen peptide supplementation in bone health, focusing on changes in bone turnover markers (BTMs) and bone mineral density (BMD). Data Sources: A search was conducted following PRISMA guidelines in the databases Academic Search Premier, APA PsychInfo, CINAHL Plus, GreenFILE, MEDLINE, and SPORTDiscus. Keywords included “collagen supplementation,” “bone turnover,” and “bone structure.” Studies published between January 2000 and March 2024 were included if they involved human subjects, oral collagen supplementation, and skeletal-related outcomes (BTMs or BMD). Risk of bias was assessed using the modified Physiotherapy Evidence Database (PEDro) scale. Main Results: Fifteen studies met the inclusion criteria. Collagen supplementation was associated with improvements in BTMs such as procollagen type I N-terminal propeptide and C-terminal telopeptide of type I collagen, as well as increases in BMD at whole body, femoral neck, and lumbar spine sites, particularly in postmenopausal women. However, neutral findings and substantial heterogeneity in study design, population characteristics, and dosing protocols were also observed. Conclusions: Collagen supplementation shows promise for supporting bone health, particularly in postmenopausal women, but the evidence remains inconsistent. Future research should address these gaps by focusing on premenopausal populations, standardizing dosing protocols, and exploring broader orthopedic applications, such as reducing stress fractures and enhancing recovery from musculoskeletal injuries.

Abstract Malignant histiocytic neoplasms (MHNs) are rare tumors derived from the mononuclear phagocyte system (MPS), encompassing histiocytic sarcoma, Langerhans cell sarcoma, interdigitating dendritic cell sarcoma, and other high-grade MPS lineage tumors. Despite advances in understanding histiocytic neoplasms, MHNs remain diagnostically challenging and lack standardized treatment algorithms. Current classification systems differ in lineage framing and fail to address mixed or ambiguous phenotypes, contributing to diagnostic uncertainty and inconsistent care. To address these gaps, the Histiocyte Society convened an international working group of pathologists and oncologists, including World Health Organization and International Consensus Classification contributors, to harmonize nomenclature, define minimum diagnostic criteria, and develop pragmatic treatment recommendations. Using a modified Delphi process and case-based review, the group formulated >40 consensus statements spanning classification, pathology, molecular testing, clinical evaluation, and therapeutic strategies. Key recommendations include the adoption of a unified MHN designation, use of a minimum immunophenotypic panel, integration of broad molecular profiling, and the documentation of previous hematopoietic malignancy. Treatment algorithms emphasize surgical resection for unifocal disease and targeted therapy or immune checkpoint inhibition for multifocal disease when actionable mutations or programmed death ligand 1 expression are present. These consensus recommendations aim to reduce diagnostic ambiguity, standardize reporting, and improve outcomes for both pediatric and adult patients. Future priorities include international registries to refine risk stratification and biomarker-driven trials exploring targeted therapy, immunotherapy, and combination approaches.

Abstract Hypoxia constrains cerebral oxygen availability and challenges brain function and stability. Although hypoxia-responsive functional connectivity (HR-FC) reorganizes rapidly with declining arterial oxygen partial pressure, its relationship to local neurovascular activity remains unclear. We examined time-resolved amplitude of low-frequency fluctuations (ALFF) in blood-oxygenation-level dependent (BOLD) fMRI during graded acute hypoxia in healthy adults, performing a continuous cognitive test (Go/No-go task) with concurrent physiological monitoring. Dynamic ALFF and functional connectivity were estimated using a sliding-window approach and analyzed across large-scale brain networks defined by Schaefer’s 17-network parcellation. Severe hypoxia elicited temporally dissociated responses across modalities. Functional connectivity increased monotonically, whereas ALFF exhibited pronounced nonlinear modulation, including phase-dependent divergence across networks. During hypoxic decompensation, the default mode network (DefaultA) showed marked ALFF suppression, whereas a ventral secondary somatosensory-dominant network (SomMotB) exhibited preferential preservation despite similar engagement in HR-FC. Together, these findings indicate that network-level ALFF captures a distinct yet complementary layer of functional dynamics, with a temporal profile distinct from functional connectivity. Spontaneous BOLD dynamics during acute hypoxia reflect structured network-level modulation rather than a uniform suppression attributable solely to reduced oxygen availability. These findings support a conceptual framework of cerebral oxygen budgeting , in which metabolic constraints reshape functional dynamics across brain networks.

Emerging research suggests a potential role for glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in alcohol use disorder (AUD), because GLP-1 receptors are present in the brain regions involved in dopamine signaling and the human reward system. We present the case of a man prescribed GLP-1 RAs for obesity who had concomitant AUD. A 34-year-old man was referred to a family medicine clinic for medication therapy management of obesity. His medical history was notable for bipolar disorder, class 2 obesity, and obstructive sleep apnea (OSA). His Alcohol Use Disorders Identification Test score indicated high-risk alcohol use. Over the course of 10 months using an injectable GLP-1 RA (semaglutide), the patient showed a clinically significant decrease in both body weight and alcohol consumption. Although this patient initially sought care for weight loss goals to improve quality of life and symptoms of OSA, after 10 months of treatment with semaglutide he reported a considerable decrease in alcohol consumption leading to mental, social, and home life improvements. Our aim in presenting this case is to illustrate the potential benefit of GLP-1 RAs for decreasing alcohol consumption levels in a patient with multiple comorbid conditions. The case adds to the growing body of evidence supporting the exploration of GLP-1 RAs for the treatment of AUD. Additionally, it underscores the need to enhance AUD screening efforts within family medicine clinics to identify high-risk persons and provide timely interventions.

Abstract Background and Aims Stroke and systemic embolism are recognized but poorly characterized complications of atrial fibrillation (AF) and left atrial flutter (AFL) catheter ablation. Their incidence, outcomes, and procedural associations remain insufficiently defined. Methods Retrospective global registry was initiated by the European Heart Rhythm Association Scientific Committee. A secure database captured data from ablation centres worldwide on general AF and left AFL ablation activity, as well as detailed information on patients with symptomatic embolic events between 2017 and 2024. Results Overall, 204 centres reported 335 743 ablation procedures and 550 embolic events (incidence 0.16%). Centre-level rate ranged from 0% to 3.1%. Most events were cerebral (94%), followed by peripheral (5%), and combined (1%). Coronary air embolism accounted for 62% of all peripheral events. Intraprocedural events occurred in 93 patients (17%), within 72 h in 357 (78%) and beyond 72 h in 100 (22%); 128 cases (23%) were diagnosed after hospital discharge. Nonparoxysmal AF (0.23% vs 0.15%; P < .001), centre experience, and ablation energy source (radiofrequency, 0.16%; cryoballoon, 0.16%; pulsed field ablation, 0.25%; laserballoon, 0.88%; P < .001) were associated with embolic risk. Median NIHSS score after stroke was 4 (interquartile range, 2–9). Three-month follow-up was available for 518 patients with embolism (95%): 181 (35%) had sequelae and 16 (3%) died. Conclusions Symptomatic embolic events are infrequent but associated with significant morbidity and mortality. Most events occur early, though a substantial proportion arise later. Higher event rates were observed with laser and possibly with pulsed field ablation. A greater centre experience was associated with a lower embolism incidence.

Mediastinal radiation potentiates aortic stenosis and complicates its treatment. We compared the short and midterm-outcomes with transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in patients with prior mediastinal radiation. Electronic databases were searched from inception through December 2024. Dichotomous outcomes were pooled as risk ratios (RRs), and continuous outcomes were pooled as mean differences (MDs) with respective 95% confidence intervals (CIs). Six observational studies were identified, including 2458 TAVR patients and 1873 SAVR patients. In the short-term, TAVR was associated with lower rate of mortality (RR: 0.54; 95% CI: 0.34–0.88), atrial fibrillation (RR: 0.31; 95% CI: 0.15–0.65), acute kidney injury (RR: 0.75; 95% CI: 0.59–0.95), bleeding (RR: 0.37, 95% CI: 0.33–0.42), and shorter length of hospital stay (MD: −4.30; 95% CI: −5.45 to −3.15). One-year mortality was comparable between the 2 groups (RR: 1.04; 95% CI: 0.50–2.13). This meta-analysis of observational studies of patients with prior mediastinal radiation demonstrated that TAVR was associated with better short-term outcomes compared to SAVR. While 1-year mortality appeared similar between the 2 interventions, this finding should be interpreted with caution. However, randomized controlled trials are needed to validate these findings.