United States

Abstract Title
E-Cigarette Use Impairs Innate and Adaptive Immune Responses, Delaying Pulmonary Repair
Authors: Ivan Marrufo1, Armando Marrufo2, Ferrah Kheradmand2
1 University of North Texas Health Sciences Center
2 Department of Medicine-Pulmonary, Critical Care, &amp; Sleep Medicine, Baylor College of Medicine

Background
E-cigarettes are marketed as safer alternatives to traditional cigarettes and are widely used by adults and young adults. However, heated aerosolized components—particularly propylene glycol (PG), vegetable glycerol (VG), and vitamin E acetate (VEA)—have been linked to e-cigarette or vaping-associated lung injury (EVALI). Since 2020, over 2,800 cases and 68 deaths have been reported. VEA, detected in bronchoalveolar lavage fluid of EVALI patients, may increase susceptibility to viral infections and disrupt both innate and adaptive pulmonary immune responses. Therefore, we hypothesize that VEA toxin within e-cigarette liquid alters both the innate and adaptive pulmonary immune function.

Methods
Mice were exposed to either air, PG/VG, or VEA for 2 weeks, followed by an 8-week recovery. Lung immune cells were analyzed by flow cytometry. Single-cell suspensions were stained with antibodies to identify macrophage and T cell subpopulations.

Results
The results demonstrate that after a 2-week exposure to VEA, there was a significant increase in the total lung macrophage population compared to air-exposed controls. Lung macrophages were categorized into alveolar macrophages, resident cells native to the lungs, and monocyte-derived macrophages, originating from circulating monocytes and functioning in tissue repair and inflammation. Within the total macrophage population, VEA exposure led to a significant increase in monocyte-derived (CD11b⁺) and intermediate (CD11b⁺SiglecF⁺) macrophages, with a trend toward increased alveolar macrophages (SiglecF⁺). Following a 2-week exposure and an 8-week recovery period, VEA-exposed mice showed sustained increases in monocyte-derived (CD11b⁺) and intermediate (CD11b⁺SiglecF⁺) macrophage populations, alongside a decreasing trend in alveolar (SiglecF⁺) macrophages. Among adaptive immune cells, total T-lymphocytes were significantly increased after the 2-week exposure and 8-week recovery. Specifically, there was a significant increase in CD8⁺ T cells and a significant decrease in CD4⁺ T cells in VEA-exposed mice. Within the CD4⁺ T cell subset, pro-inflammatory Th1 cells were significantly decreased following VEA exposure and recovery.

Conclusion 
An increase in CD8⁺ T cells and a decrease in CD4⁺ T cells may contribute to heightened susceptibility to viral infections. Furthermore, the observed decrease in alveolar macrophages—alongside an increase in monocyte-derived and intermediate macrophage populations following a 2-week VEA exposure and 8-week recovery—may reflect a compensatory replacement mechanism driven by alveolar macrophage death.




2025 AMA Research Challenge – Member Premier Access

E-Cigarette Use Impairs Innate and Adaptive Immune Responses, Delaying Pulmonary Repair


Abstract Title
E-Cigarette Use Impairs Innate and Adaptive Immune Responses, Delaying Pulmonary Repair
Authors: Ivan Marrufo1, Armando Marrufo2, Ferrah Kheradmand2
1 University of North Texas Health Sciences Center
2 Department of Medicine-Pulmonary, Critical Care, & Sleep Medicine, Baylor College of Medicine

Background
E-cigarettes are marketed as safer alternatives to traditional cigarettes and are widely used by adults and young adults. However, heated aerosolized components—particularly propylene glycol (PG), vegetable glycerol (VG), and vitamin E acetate (VEA)—have been linked to e-cigarette or vaping-associated lung injury (EVALI). Since 2020, over 2,800 cases and 68 deaths have been reported. VEA, detected in bronchoalveolar lavage fluid of EVALI patients, may increase susceptibility to viral infections and disrupt both innate and adaptive pulmonary immune responses. Therefore, we hypothesize that VEA toxin within e-cigarette liquid alters both the innate and adaptive pulmonary immune function.

Methods
Mice were exposed to either air, PG/VG, or VEA for 2 weeks, followed by an 8-week recovery. Lung immune cells were analyzed by flow cytometry. Single-cell suspensions were stained with antibodies to identify macrophage and T cell subpopulations.

Results
The results demonstrate that after a 2-week exposure to VEA, there was a significant increase in the total lung macrophage population compared to air-exposed controls. Lung macrophages were categorized into alveolar macrophages, resident cells native to the lungs, and monocyte-derived macrophages, originating from circulating monocytes and functioning in tissue repair and inflammation. Within the total macrophage population, VEA exposure led to a significant increase in monocyte-derived (CD11b⁺) and intermediate (CD11b⁺SiglecF⁺) macrophages, with a trend toward increased alveolar macrophages (SiglecF⁺). Following a 2-week exposure and an 8-week recovery period, VEA-exposed mice showed sustained increases in monocyte-derived (CD11b⁺) and intermediate (CD11b⁺SiglecF⁺) macrophage populations, alongside a decreasing trend in alveolar (SiglecF⁺) macrophages. Among adaptive immune cells, total T-lymphocytes were significantly increased after the 2-week exposure and 8-week recovery. Specifically, there was a significant increase in CD8⁺ T cells and a significant decrease in CD4⁺ T cells in VEA-exposed mice. Within the CD4⁺ T cell subset, pro-inflammatory Th1 cells were significantly decreased following VEA exposure and recovery.

Conclusion 
An increase in CD8⁺ T cells and a decrease in CD4⁺ T cells may contribute to heightened susceptibility to viral infections. Furthermore, the observed decrease in alveolar macrophages—alongside an increase in monocyte-derived and intermediate macrophage populations following a 2-week VEA exposure and 8-week recovery—may reflect a compensatory replacement mechanism driven by alveolar macrophage death.




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Chelsea Amo Tweneboah, MD, Alexander Kaiteris, DO, and Ryan F. Heslin, MD MBA

Introduction:
Atrial Fibrillation is highly prevalent amongst a population that is older, has persistent atrial fibrilation, has structural heart disease,and other diseases including but not limited to the following: Heart, COPD, and obesity. Cathter ablation is achieved through the termination of triggers induced through the pulmonary veins. Patients who respond favorably to such a procedure are usually below the age of 70, symptomatic, no other arrhythmia present, normal cardiac function, normal BMI, and normal thyroid function to name a few. Different outcomes are said to determine the success of an ablation procedure include rhythm outcome post-procedure after single or multiple ablations, rhythm outcome with and without antiarrhythmics, rhythm outcome through monitoring, and the outcome of underlying clinical issues such as left ventricular function that may affect rhythm control. The clinical benefits of ablation, include symptomatic relief and, significant increase in exercise tolerance, increase in left ventricular ejection fraction, and reduced mortality. We present a case of a young male who presented with pre-excited atrial fibrillation and the effectiveness of catheter ablation given his presentation. 

Case Description:
An 18-year-old male presented to our institution with complaints of palpitations. The patient was found to have pre-excited atrial fibrillation with rapid conduction on electrocardiogram (ECG). He was found to have a left-sided accessory pathway with bidirectional conduction during an electrophysiological study (EPS). Patient was initially bolused with amiodarone which converted him back to sinus rhythm. The electrophysiology team was contacted for further management and patient underwent SVT Ablation on two sepearte occasions. Ablation resulted in the loss of pre-excitation in the bypass tract. During the procedure, patient subsequently developed atrial fibrillation in which he underwent a cardioversion in which he was converted back sinus rhythm Due to the patient’s post-operative left-sided abdominal and chest pain, he underwent a computed tomography (CT) scan, which revealed a pulmonary infarction. A hypercoagulable workup including Antithrombin III activity, Anticardiolipin, IgG/IgM antibodies, Factor V Leiden, Beta 2 glycoprotien IgM/IgG antibodies, and Protein C and S were all within normal limits. His family history was negative family for bleeding or clotting disorders. He was prescribed a short course of apixaban for the pulmonary infarction. His pleuritic pain and exercise capacity improved, without the development of respiratory symptoms. The patient has remained in sinus rhythm without further occurrence of Afib. 

Discussion:
Our case highlights the successful termination of a pre-excitation atrial fibrillation in a young healathy male. The effectiveness of an ablation technique requires the precise identification of the trigger of a given arrhythmia. Pulmonary vein isolation through ablation has been the main means of effectively reducing recurrence, improving patients' quality of life, and allowing individuals to achieve symptom control. Catheter ablation is currently a class `I indication for patients who have symptomatic supraventricular tachycardia This ablation procedure has about a 95% success rate being able to terminate arrhythmias with minimal complications effectively. One benefit of ablation is the reduction of mortality and thromboembolism. In comparison to antiarrhythmic drug therapy, there are benefits in the reduction of stroke incidences and increased survival especially noted in older populations. Although several risk factors makes one susceptible to atrial fibrillation including left atrial enlargement, structural heart disease, and left ventricular systolic or diastolic dysfunction, clinicians must prioritize an individual’s risk of developing atrial fibrillation as this task remains difficult and uncertain.


The Utility of Pulmonary Vein Isolation in Patients with Pre Excited Atrial Fibrillation

Background
Renal cell carcinoma (RCC) can invade the renal vein or inferior vena cava, forming a tumor thrombus associated with worse prognosis. However, the molecular drivers underlying tumor thrombus extension remain poorly understood. We aimed to identify gene expression differences between RCC tumors with thrombus extension (RITE) and those without (non-RITE) to uncover molecular mechanisms and biomarkers associated with tumor invasiveness.

Methods
We analyzed bulk RNA-seq profiles from 721 RCC tumor samples spanning 45,408 genes, collected at nephrectomy from three cohorts: Rodriguez (U.S., n = 71), Wang (China, n = 174), and TCGA-KIRC (n = 477). Differential expression analysis was conducted using PyDESeq2 on RITE (n = 96) versus non-RITE (n = 66) tumors, using thresholds of adjusted p < 0.05 and |log₂FC| ≥ 1. Functional enrichment was performed using Enrichr and g:Profiler, and prognostic relevance assessed via GEPIA (TCGA-KIRC).

Results
A total of 6,317 differentially expressed genes (DEGs) were identified. Among the top upregulated transcripts was lncRNA CERS6-AS1, previously implicated in tumor progression in other cancers. Notably, TCGA-KIRC survival analysis revealed that high expression of CERS6-AS1 was associated with significantly worse overall survival (HR = 1.8, log-rank p = 0.00037). Pathway enrichment of other RITE-associated DEGs showed upregulation of genes involved in chylomicron assembly and lipid metabolism, including APOA4, MTTP, APOC3, and APOE. Additional enrichment was observed in pathways related to the acute inflammatory response and oxidative phosphorylation.

Conclusion
RITE tumors display distinct transcriptomic signatures characterized by lipid metabolic reprogramming, immune pathway activation, and elevated expression of CERS6-AS1, a marker of poor prognosis. These insights advance our understanding of tumor thrombus biology and may inform prognostic biomarker discovery and therapeutic targeting in RCC, laying the groundwork for future translational studies.

Decoding RITE Biology: Differential Gene Expression in Renal Cell Carcinoma With and Without Venous Extension

Background
Metastatic paraganglioma (mPGL) is a rare and aggressive neuroendocrine tumor that
arises outside the adrenal gland and often resists standard treatments like
chemotherapy and surgery. These conventional options typically show limited
effectiveness and carry significant side effects. However, recent advancements in
precision medicine, such as Peptide Receptor Radionuclide Therapy (PRRT),
immunotherapy, and molecular profiling, have revolutionized therapeutic approaches. PRRT, particularly with 177Lu-DOTATATE, has demonstrated promising results in
targeting somatostatin receptor-positive tumors, improving progression-free survival, and enhancing patients' quality of life. Additionally, immune checkpoint inhibitors (e.g., pembrolizumab, nivolumab) and targeted therapies (e.g., sunitinib, cabozantinib) are
being explored, with emerging evidence suggesting their potential in specific genetic
subsets.Advances in genetic profiling, including next-generation sequencing, allow for
risk stratification and personalized therapy based on mutations such as SDHB, SDHD, and VHL.Minimally invasive techniques like embolization and thermal ablation are also
gaining traction for palliative control. While traditional chemotherapy remains an option, combining it with targeted agents like sunitinib or cabozantinib offers new
potential.However, more research is needed to compare the efficacy and safety of these
novel approaches. Objective: This study evaluates emerging therapies for metastatic paraganglioma,
including PRRT, immunotherapy, and molecular-targeted agents, to assess their clinical
efficacy and safety. We analyze the role of PRRT in tumor control, investigate
checkpoint inhibitors, and explore how genetic profiling (SDHB mutations) informs
treatment selection. Additionally, we examine combination approaches and minimally
invasive techniques to optimize therapeutic strategies for this high-risk population. Methods
A systematic review was conducted per PRISMA guidelines using PubMed, Cochrane, and ScienceDirect (2014–2024). Controlled keywords identified studies on mPGL
outcomes related to PRRT, targeted therapy, and immunotherapy. Experts were
consulted, and reference lists reviewed. Studies were screened, quality assessed, and thematically synthesized. Results
From an initial pool of 54,365 studies, 120 met the inclusion criteria. PRRT showed
favorable tumor control and tolerability in patients with high somatostatin receptor
expression. Targeted therapies were particularly effective in cases with SDHB
mutations. Immunotherapies demonstrated promise in PD-L1-positive tumors. Personalized and combination therapies yielded better outcomes, though small sample
sizes and variability between studies limited broad conclusions. Conclusion
Emerging therapies, especially PRRT, immunotherapy, and molecular-targeted
treatments, are reshaping the management of metastatic paraganglioma. Genetic
profiling supports a more personalized approach. While current findings are promising,
further large-scale studies are needed to confirm long-term benefits and refine
treatment strategies.

Redefining the Treatment Paradigm: Systematic Review of Novel Therapies in Metastatic Paraganglioma

Introduction: Rotator cuff (RC) injury is the leading cause of shoulder pain and disability. Arthroscopic RC repair has grown in popularity, with usage rising from 60% in 2007 to 83% in 2016. Studies suggest women report more pain and worse functional outcomes than men post-surgery, but research on sex-based differences beyond these factors is limited. This study examines differences in emergency department (ED) visits, complications, and 2-year reoperation rates following arthroscopic repair of atraumatic, complete RC tears.
Methods: The TriNetX Diamond Network, a global health research database, was queried using International Classification of Disease-10 and Current Procedural Terminology codes between January 2010 and April 2018. Patients diagnosed with complete RC tear who underwent arthroscopic shoulder surgery with complete RC repair were included. Patients with prior RC tears or arthroscopic shoulder surgery were excluded. Male and female cohorts were propensity-matched for age and three comorbidities within 1 year of RC repair. Rates of ED visits at 5 and 14 days postoperatively, complications at 1-month postoperatively, and repeat arthroscopy and arthroplasty at 1-year and 2-years postoperatively were analyzed.
Results: Of 108,852 patients identified (55.0% male), 48,208 females were 1:1 propensity-matched to males. Females had significantly higher rates of ED visits compared to males within 14 days postoperatively (2.69% vs 2.49%; P=0.045). Males had significantly higher rates of infection at 1-month postoperatively (0.14% vs 0.07%, P=0.001). Within 2 years postoperatively, females had higher rates of conversion to shoulder arthroplasty (1.03% vs 0.62%, P<0.0001), but similar rates of overall secondary shoulder surgeries (7.49% vs 7.71%, P=0.198). 
Conclusions: In this large, matched cohort study, female patients had higher rates of early ED visits and conversion to arthroplasty within 2 years, while males experienced more infections within 1 month. However, overall complication rates were low for both cohorts.

Sex-Based Differences in Postoperative Outcomes for Patients Undergoing Primary Arthroscopic Rotator Cuff Repair: A Propensity Matched Analysis

Abstract Title
Advancing Academic Insights and Clinical Outcomes: The Role of Resmetirom in MASH Therapy

Background
Metabolic dysfunction associated steatohepatitis (MASH, formerly NASH) is a leading cause of liver transplantation and is linked to increased cardiovascular mortality. Until recently, no medications were approved for this prevalent condition. Resmetirom is a liver-targeted, selective thyroid hormone receptor-β agonist that enhances hepatic fat metabolism and reduces lipotoxicity. In 2024, it became the first FDA-approved therapy for MASH with fibrosis (F2–F3 stages), based on its ability to significantly improve MASH histological activity and fibrosis endpoints. This review aims to synthesize current evidence on resmetirom’s efficacy and safety in MASH therapy.

Methods
A comprehensive search of PubMed from year 2015 to 2025 was conducted for clinical studies evaluating resmetirom in MASH. Seven relevant publications, including phase 2 and 3 Clinical and Randomized controlled trials, were identified. Data on histological outcomes, metabolic effects, and adverse events were extracted and qualitatively reviewed.

Results
Across the selected studies, resmetirom demonstrated consistent therapeutic benefits. A pivotal 36-week phase II trial showed resmetirom significantly reduced hepatic fat content by 30% relative to placebo (p<0.0001). Treated patients also experienced improvements in liver histology, with a trend toward NASH resolution. In a large phase III trial (MAESTRO-NASH), resmetirom 80 mg and 100 mg achieved NASH resolution (approximately 26-30% of patients) at nearly triple the rate of placebo (10%), and more patients had ≥1 stage fibrosis improvement versus placebo (24-26% vs 14%). Resmetirom therapy additionally led to beneficial reductions in LDL cholesterol (-14% to -16%) and liver enzyme levels in patients. The drug was generally well-tolerated; rates of serious adverse events did not differ from placebo. Mild gastrointestinal side effects (primarily transient diarrhea and nausea) were more frequent with resmetirom (risk ratio: 1.7-1.8 vs placebo), but no other significant safety concerns emerged.

Conclusion
Resmetirom meaningfully advances MASH treatment by promoting histological resolution of steatohepatitis and regression of fibrosis, while also improving lipid and liver profiles. It’s favorable efficacy risk profile, as evidenced by multiple trials, supports resmetirom’s pivotal role as the first pharmacotherapy for MASH. Ongoing studies and post-approval observations will further clarify its long-term impact on clinical outcomes and inform optimal integration into MASH management.


Advancing Academic Insights and Clinical Outcomes: The Role of Resmetirom in MASH Therapy

A Rare Case of Microscopic Polyangiitis with Copositivity for ANA and Anti-dsDNA Antibodies

Background
Microscopic Polyangiitis (MPA) is a rare, small-vessel autoimmune vasculitis primarily affecting the kidneys and lungs. It is associated with anti-myeloperoxidase (MPO) antineutrophil cytoplasmic antibodies (ANCAs) and characterized by pauci-immune necrotizing glomerulonephritis. Diagnosis is confirmed with renal biopsy, revealing crescentic glomerulonephritis without immune complex deposition. Treatment involves high-dose glucocorticoids and either cyclophosphamide or rituximab, followed by maintenance therapy with azathioprine or mycophenolate mofetil. Plasmapheresis may be considered in severe cases. Early diagnosis and appropriate treatment are crucial for improving patient outcomes.

Case Presentation
We present a 74-year-old woman with a history of hypertension, stroke, carotid artery disease, and hypothyroidism, admitted for acute kidney injury (AKI) with a serum creatinine increase from 1.04 mg/dL to 8.5 mg/dL, elevated blood urea nitrogen, and metabolic acidosis. Initial laboratory findings indicated leukocytosis, anemia, and reactive thrombocytosis. Serology revealed positive antinuclear antibodies (ANA) and anti-dsDNA, suggesting systemic lupus erythematosus (SLE), but previous tests demonstrated elevated MPO antibodies, raising suspicion for ANCA-associated vasculitis (AAV). A CT-guided renal biopsy demonstrated necrotizing crescentic glomerulonephritis with no immune complex deposition, consistent with MPA. The patient was treated with high-dose intravenous methylprednisolone, followed by a tapering oral regimen, and underwent seven sessions of plasmapheresis. Despite intervention, she required chronic hemodialysis. She was discharged with a tunneled internal jugular catheter for thrice-weekly hemodialysis and planned outpatient rituximab therapy for MPA.

Discussion
This case underscores the diagnostic complexity of AAV, particularly when serological markers overlap with those of SLE. The patient's presentation with rapidly progressive glomerulonephritis, elevated anti-MPO antibodies, and pauci-immune necrotizing crescentic glomerulonephritis on biopsy strongly supports a diagnosis of MPA. However, the concurrent presence of ANA and anti-dsDNA antibodies, typically associated with SLE, complicates the clinical picture. Renal biopsy findings of necrotizing crescentic glomerulonephritis and the absence of immune complex deposition on immunofluorescence further favor MPA over lupus nephritis. Patients with AAV who test positive for ANA and anti-dsDNA often exhibit severe renal damage, including higher serum creatinine levels and lower estimated glomerular filtration rates. This case highlights the importance of renal biopsy in distinguishing between MPA and SLE, as overlapping serological markers can lead to misdiagnosis. Early and accurate diagnosis is crucial, as the management for these conditions differ significantly. In patients with AAV and concurrent lupus markers, treatment regimens may need to be intensified, and close monitoring is essential to address the increased risk of renal failure and other complications.

A Rare Case of Microscopic Polyangiitis with Copositivity for ANA and Anti-dsDNA Antibodies

Background: Emergency contraception (EC) is critical for preventing unintended pregnancies following unprotected or inadequately protected sexual intercourse. While oral levonorgestrel (LNG) pills are the standard FDA-approved EC method, the levonorgestrel intrauterine device (LNG-IUD) is emerging as an alternative, offering both immediate EC and long-term contraception benefits. This study evaluates the efficacy of LNG-IUD compared to oral-LNG for EC. The objective is to conduct a systematic review and meta-analysis of studies evaluating the efficacy of the levonorgestrel intrauterine device for emergency contraception, comparing its efficacy in preventing pregnancy with that of oral levonorgestrel.

Methods: A systematic review and meta-analysis were conducted following PRISMA 2020 guidelines. PubMed, Scopus, and Medline were searched up to December 16, 2024, using keywords related to postcoital contraception, levonorgestrel, and intrauterine devices. Five studies from two countries, totaling 920 participants, met the population, intervention, comparison, outcome, and settings (PICOS) criteria focusing on women of reproductive age using LNG-IUD or oral LND as EC. Risk of bias was assessed using the mixed methods appraisal tool (MMAT), and a random-effects model was applied due to significant heterogeneity.

Results: The LNG-IUD, when indirectly compared to oral LNG for EC, demonstrated a natural log of the odds risk ratio (ORR) of –0.51 (95% CI: -3.86-2.83, p=0.77), suggesting a lower risk of pregnancy with the LNG-IUD. However, the wide confidence interval and lack of statistical significance, as reflected by the high p value, likely results from limited studies available for this dataset.

Conclusion: This review found no statistically significant difference in efficacy between LNG-IUD and oral-LNG for emergency contraception, likely due to wide confidence intervals and limited data, supporting LNG-IUD as an alternative. LNG-IUD offers comparable efficacy to other EC options and the added benefit of long-term contraception, underscoring the importance of additional direct studies to expand emergency contraception options for women. Significance: The findings suggest that LNG-IUD could be a promising alternative to oral LNG for emergency contraception, offering both immediate and long-term contraceptive benefits. Expanding access to LNG-IUDs for EC could provide women with more options and flexibility in reproductive health management, emphasizing the need for further research to validate its efficacy and inform clinical practice.

Comparing the Efficacy of Levonorgestrel Intrauterine Device and Oral Levonorgestrel for Emergency Contraception: A Systematic Review and Meta Analysis

Background
Direct admissions are a common modality for admission to pediatric hospitals nationwide. Safe and efficient facilitation of direct admissions has patient and system-level implications. Requests for direct admission were handled by pediatric residents at our tertiary, free-standing academic children’s hospital prior to transitioning to faculty coverage during daytime, weekday hours in August 2023.
Following implementation of these Pediatric Hospital Medicine faculty admission control shifts, we compared faculty/attending and resident performance on patient and system-level outcomes to inform future education and quality improvement initiatives targeting improved facilitation of direct admissions. 

Methods
Manual chart review was performed for all direct admissions to general medicine between August 2023 and May 2025. Encounters were separated into resident-handled and faculty-handled cohorts. Analysis included statistical comparison of time from call request to acceptance, number of additional pages or calls (beyond the initial call), time from initiation request to admission, length of stay, ICU utilization, and discharge timing.

Results
1271 encounters were reviewed. Resident-handled direct admissions had a longer time from call initiation to acceptance compared to faculty (29.3 vs 20 min, p=0.0000078), more additional pages/calls prior to acceptance (21.1/100 vs 7.2/100 patients, p=1. 2x10^-14), shorter length of stay (2.0 vs 3.8 days, p=0.000016), and higher odds of discharge within 12 hours (OR 6.8, 95% CI 3.1-14.8) and 24 hours (OR 1.3, 95% CI 1.02-1.7). There was no difference in mean time from call initiation to admission, time from acceptance to admission, or ICU utilization metrics.

Conclusion
The results suggest differences in system-level outcomes without differences in patient-level outcomes. Faculty required less time and fewer additional pages to facilitate acceptance of a direct admission. Faster acceptance and fewer pages likely have a positive impact on facility and access center satisfaction. However, these factors did not correlate with more timely arrival to our facility, highlighting the complex interplay of other factors affecting the direct admission process. Within the faculty cohort, there was decreased incidence of discharge within 12 and 24 hours. This finding, paired with no statistically significant difference in ICU utilization between cohorts, suggests that more timely decision making did not compromise recognition of appropriateness for direct admission. Further study is needed to assess the impact of enhanced efficiency of direct admission acceptance on throughput and referral incidence, implications to resident learning and well-being, and performance of quality improvement initiatives to enhance the direct admission process.

Comparative Analysis of Faculty vs. Resident Performance in Facilitation of Direct Admissions

Background: 
Previous studies have primarily focused on medical and psychosocial outcomes of living donor hepatectomy, with limited data on financial implications for donors. While programs like the National Living Donor Assistance Center (NLDAC) offer income reimbursement for lost wages, not all donors qualify. To be eligible, both donor and recipient must be U.S. citizens, and the recipient’s income must be below 350% of the federal poverty guidelines—$54,775 for a single-person household in 2025. Although these criteria help prioritize those most in need, some donors still fall through the cracks. This study aimed to evaluate the quality of life of living liver donors, with a focus on post-donation financial burdens, to identify gaps in current support systems.

Methods: 
Over a 24-year period, 402 donor hepatectomies were performed at Lahey Hospital in Burlington, MA. In 2024, donors were contacted by phone up to three times over three weeks and surveyed about their post-donation experiences.

Results:
A total of 129 living donors completed the survey (response rate: 32%). Twenty-four reported negative financial impacts from donation, with 18 attributing this to lost wages. Donors reported a median time away from work of 10 weeks (SD = 8.3), with a mean of 11.2 weeks. Other financial burdens included travel, lodging, and follow-up visits. Six donors reported difficulty obtaining life insurance, and two said their premiums increased due to hepatectomy-related complications (diabetes and elevated liver function tests). Consistent with prior studies, 35 donors reported complications related to donation, including peri-incisional paresthesia, changes in eating habits, hernia, nerve issues, and current liver disease. Despite this, 98.4% said they would still donate knowing their recovery experience, 97% were happy they donated, and 93.7% would recommend living donation. Additionally, 82.9% are registered organ donors.

Conclusion:
While donors consistently report satisfaction with their decision to donate, financial burdens have remained unchanged over the 24-year study period. Donors frequently cited lost wages as a challenge. Even after our center implemented a Philanthropic Liver Fund in 2010 (to reimburse travel and lodging), two donors still struggled with those expenses, and nine reported wage-related burdens. To our knowledge, this is one of the largest single-center investigations of financial outcomes after living liver donation and shows that addressing these unmet needs is essential to supporting donors and ensuring equitable access to liver transplantation.

Financial Burdens after Living Donor Liver Transplantation: A 24-Year Single-Center Analysis

Background
Coronary heart disease (CHD) is a leading cause of death in the U.S. with disproportionate impacts driven by social and structural inequalities. Social determinants of health (SDOH) such as income, education, healthcare access, housing, and neighborhood safety play a critical role in cardiovascular outcomes. Kansas City, shaped by a history of racial and economic segregation, presents a unique opportunity to explore these relationships. While CHD disparities have been described regionally, few studies have quantified how specific SDOH influences CHD at the community level.

Methods
We analyzed data from 70 zip codes across Kansas City, Missouri and Kansas, using 37 SDOH indicators from publicly available sources-American Community Survey, CDC PLACES, EPA, National Center for Health Statistics, Neighborhood Atlas, and Open Data KC databases. Our population was 62% White, 20% African American, and 18% other. Pearson correlations assessed bivariate relationships. Predictors with variance inflation factor (VIF) <5 were excluded to minimize multicollinearity. Ordinary least squares regression modeled CHD prevalence across zip codes, which yielded a final model with nine predictors after VIF filtering. The Benjamini-Hochberg method corrected for multiple comparisons.

Results
CHD prevalence showed strong positive correlations with mobility impairment (r=0.903), disability (r=0.810), physical inactivity (r=0.731), smoking (r=0.705), and obesity (r=0.590), all statistically significant (p<0.001). Protective effects were found with binge drinking (r=-0.835) and life expectancy (r=-0.419). The negative correlation with binge drinking may reflect confounding factors like underreporting or differences in healthcare infrastructure.
The final multivariable regression model (R²=0.791, F-statistic=29.10, MSE=0.202) identified eight predictors of CHD. Surprisingly, college graduation and unemployment were positively associated with CHD, while area deprivation, income, physician checkups, life expectancy, obesity, and binge drinking were negative predictors. The associations between median household income, routine checkups, life expectancy, and obesity with CHD prevalence are consistent with prior studies.

Conclusion
Our study highlights strong associations between SDOH and CHD in Kansas City, emphasizing the role of mobility limitations, smoking, and obesity. The unique finding with binge drinking likely reflects limitations with self-reporting measures, rather than providing a true protective effect. Expanding access to physical activity programs, smoking cessation resources, and chronic disease management, particularly in zip codes with high rates of disability and limited mobility, may help mitigate CHD risk and advance health equity in the Kansas City region. Future work should focus on validating these findings in various urban populations and explore how integrated interventions at the local level can sustainably reduce CHD prevalence.

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