United States

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&#39;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.

AMA Research Challenge 2025 

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

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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.

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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
Pulmonary fibrosis is a pathological condition characterized by dysregulated deposition of extracellular matrix (ECM) that stiffens lung tissue and prevents proper lung expansion, and oxygen diffusion. Upon stressors like mechanical stress and profibrotic cytokines such as TGFβ, fibroblasts differentiate into myofibroblasts, which are specialized cells for increased production and deposition of ECM proteins (e.g. collagens, fibronectin, etc.). During differentiation, myofibroblasts undergo a profound metabolic remodeling, with upregulated glycolysis, glutaminolysis and reduced citric acid cycle flux. The resulting metabolites form co-factors necessary for epigenetic modification, such as histone acetylation, leading to the activation of the fibrotic gene program. Acetyl-CoA synthetase 2 (ACSS2) is a cytosolic and nuclear enzyme that synthesizes the metabolite acetyl-CoA from acetate, resulting in histone acetylation and gene activation. We hypothesize that ACSS2 is necessary to activate and maintain myofibroblast differentiation. 
Methods
In vitro, differentiation of primary mouse lung fibroblasts was activated by TGFβ (10ng/mL) to induce the fibrotic gene program and treated with a drug inhibitor of ACSS2 (MDK6149, 10µM). In vivo studies were performed in a quiescent fibroblast-specific Acss2 knockout mouse model (Tcf21-Acss2 KO) and WT aged match controls. Lung fibrosis was induced by intratracheal injection of bleomycin. Histological and functional analyses (eg. FEV0.1 and elastance) were performed at 14 days (peak of fibrosis) and 28 days (resolution of fibrosis) post bleomycin injection. ECM gene expression was assessed using RT-qPCR, Western Blot, and Immunofluorescence. Specific fibrotic gene histone acetylation was determined through Chromatin Immunoprecipitation in TGFβ treated and untreated primary lung fibroblasts.
Results
ACSS2 inhibition significantly decreased specific fibrotic gene histone acetylation, inhibiting myofibroblast differentiation in vitro. Notably, pharmaceutical inhibition of ACSS2 resulted in reversion of differentiation after or, even during continuous TGFβ stimulation. In vivo, while at 14 days Tcf21-Acss2 KO lungs showed a mild decrease in fibrosis, at 28 days these lungs showed a lack of fibrosis resolution. Such continued fibrosis correlated with increased elastance and decreased FEV0.1 compared to wild type.
Conclusion
Our data shows that ACSS2 is a key regulator of in vitro myofibroblast differentiation and persistence. In vivo, ACSS2 expression in lung fibroblasts is necessary for normal lung regeneration after bleomycin-induced fibrosis. Our preliminary data shows that targeting ACSS2 in lung fibroblasts is a promising target to treat and reverse pulmonary fibrosis. 


ACSS2 is a Key Regulator of Lung Myofibroblast Differentiation

Background

Allogeneic hematopoietic cell transplant (allo-HCT) offers curative potential for high-risk leukemia. Infections, graft-versus-host disease (GVHD), and disease relapse after allo-HCT remain major obstacles to successful treatment. These challenges are heightened in relapsed/refractory leukemia due to comorbidities, prior chemotherapy, and residual disease. Optimizing conditioning regimens to enhance engraftment and immune recovery while minimizing toxicity remains essential in this population.
Clofarabine, a purine nucleoside analog, has demonstrated efficacy in conditioning regimens for high-risk leukemia. Prior work supports its use as pre-conditioning (pre-Clo) prior to allo-HCT in relapsed/refractory disease. However, these reports are limited to combinations with conventional GVHD prophylaxis, and it is unclear whether similar outcomes happen with post-transplant cyclophosphamide (PTCy). We hypothesize that pre-Clo may enhance stem cell engraftment and facilitate complete donor chimerism when combined with PTCy.

Methods

We retrospectively studied 240 patients with leukemia (AML, ALL, or CML/MDS) who underwent allo-HCT with PTCy from April 2017 to March 2024. Propensity score matching identified patients receiving pre-Clo conditioning versus controls (fludarabine based). Primary outcomes included neutrophil, platelet, and lymphocyte engraftment, as well as T-cell recovery, and donor chimerism. Engraftment was defined as neutrophils >500/µL, platelets >20,000/µL, and lymphocytes >200/µL. Donor chimerism (total and T-cell) was assessed at multiple post-transplant time points.

Results

72 patients were matched (24 pre-Clo, 48 controls). The pre-Clo group had significantly more patients in non-complete remission (78.6% vs 4.8%; p < 0.01) and higher marrow blast percentage (52.6% vs 0%; p < 0.01). Pre-clo patients showed a delayed neutrophil (median Day 19 vs. 16, p=0.02) and platelet engraftment (median Day 33 vs. 26, p=0.02), while lymphocyte recovery was similar. Among HLA-matched recipients, pre-Clo patients showed significantly higher T cell donor chimerism at day 60 (p=0.04). CD4+ T-cell counts trended lower in the pre-Clo group up to 6 months post-transplant (p = 0.07). Acute and chronic GVHD rates remained similar across groups. Infection incidence was lower in the preClo group, although not statistically significant (73% vs 89%; p = 0.20). Although there were no significant differences in relapse or non-relapse mortality, 2-year overall survival was lower in the pre-Clo group (29% vs 37%, p = 0.013).

Conclusion

Although Pre-Clo was associated with delayed neutrophil and platelet engrafment, immune recovery was similar to controls, despite the higher risk disease status. Enhanced chimerism in HLA-matched transplants may suggest augmented graft-versus-leukemia effects. Further studies are needed to clarify the immunologic impact of pre-Clo in this setting.

Effect of Pre-Conditioning Clofarabine on Engraftment and Cell Recovery in Allogeneic Transplantation Using Post-Transplant Cyclophosphamide

In patients with ACL tears, how does BEAR (Bridge-Enhanced ACL Repair) compare to traditional ACL reconstruction in terms of functional outcomes, failure rates, and return-to-play time?
Raj S. Patel1 , Robert Ablove MD2

Affiliation
1College of Osteopathic Medicine, Lake Erie College of Osteopathic Medicine, Erie, PA 
2UBMD Orthopedics and Sports Medicine, State University at Buffalo, Buffalo, NY

Introduction: 
Bridge-Enhanced ACL Repair (BEAR) is an emerging biologic alternative to the traditional autograft ACL reconstruction (ACLR), where it maintains native tissue and improve postoperative recovery. Developed by Miach Orthopedics, the cost for the surgery is slightly higher than traditional ACLR due to the cost of the implant. Through sparing the need of an autograft that traditional ACLR will make use of, athletic performance is retained. Although there is comparison with short term outcomes, there is a lack of long-term comparative outcomes between ACLR and BEAR. Using data from previous studies comparing BEAR and ACLR, data was extracted to evaluate: 1) functional outcomes differences between BEAR and ACLR: 2) compared failure: and 3) return to play timeframe and sport performance. 

Methods: 
A systematic search of PubMed and Cochrane was conducted to identify randomized control trials and prospective cohort studies competing BEAR to ACLR. Outcomes extracted are International Knee Documentation Committee (IKDC) scores, instrumented anterior posterior (AP) knee laxity, hamstring strength recovery, return to sport ACL scale (ACL-RSI), re-injury rates, and Knee Injury and Osteoarthritis Score (KOOS) for sports. Random effects meta-analysis was performed. Heterogeneity was assessed using I2 statistics.

Results: 
Five studies with n patients (BEAR=261, ACLR=144) met inclusion criteria at 24 months. BEAR showed significant improvement in IKDC scores (mean difference [MD], 4.23; 95% confidence interval [CI], 1.13 to 7.34). No significant difference was found in AP laxity (MD, -0.24mm; 95% CI, -0.93 to 0.46). Hamstring strength significantly favored BEAR (MD, 2.58; 95% CI, 0.91 to 7.27). The RSI-ACL scale did not show significant return at 6 months (MD, 3.83; 95% CI, -3.11 to 10.77) but the KOOS for sports showed at 2 years improvement in sport performance (MD 12.89; 95% CI, 11.42 to 14.37). The pooled risk ratio for re-injury was elevated in BEAR but not statistically significant (MD, 2.58; 95% CI, 0.91 to 7.27). 

Conclusion: 
BEAR demonstrated non-inferior mechanical stability and improved preservation of hamstring strength compared to autograft ACLR, with trends toward faster return to sport. While re-injury risk appears increased, the difference did not reach significance. Further data will be needed to evaluate re-injury risk. BEAR may be a promising option for select patients such as high performing athletes who look to return to sport in an accelerated timeframe and preserve native function and strength. With the BEAR implant costing more than traditional ACLR it is important to collect further long-term data to justify the additional cost. Further long-term dating showing an improvement in return to sports, re-injury rates, and functional outcomes can justify the additional cost. This allows patients to have the option to retain their native ACL tissue and retain athletic performance. 


In patients with ACL tears, how does BEAR (Bridge-Enhanced ACL Repair) compare to
traditional ACL reconstruction in terms of functional outcomes, failure rates,
and return-to-play time?

Background
Hemorrhagic shock is a leading cause of preventable death in trauma patients, particularly in prehospital and austere settings where rapid intervention is limited. While plasma-based resuscitation is essential for hemostatic stabilization, fresh frozen plasma (FFP) use is restricted by logistical demands including storage, thawing, and shelf life. Freeze-dried plasma (FDP) offers potential advantages in portability and field usability. However, no consensus exists on whether FDP is clinically equivalent or superior to FFP. This study aims to test whether FDP provides superior or equivalent survival benefit compared to FFP in early trauma care settings. 

Methods
A meta-analysis was conducted using seven peer-reviewed clinical trials and retrospective cohort studies published between 2012 and 2022. Studies were identified through systematic searches of the PubMed database. Inclusion criteria focused on human trauma patients receiving either FDP or FFP in prehospital or early hospital settings. Key data extracted included survival rates, standard error, and 95% confidence intervals (CI). Pooled survival estimates were calculated using a random-effects model, and heterogeneity was assessed using the I² statistic.

Results
The pooled survival rate for FDP was 83.3% (95% CI: 70.1–96.5%) with no observed heterogeneity (I² = 0%). In comparison, FFP demonstrated a pooled survival of 79.3% (95% CI: 70.2–88.3%) with low heterogeneity. FDP showed slightly higher and more consistent survival outcomes across both military and civilian studies. 

Conclusion
FDP demonstrates comparable or slightly improved survival outcomes relative to FFP in trauma resuscitation, especially in prehospital and resource-limited environments. These findings support its broader integration into trauma systems, particularly where logistical barriers to FFP use exist. Adoption of FDP may improve access to plasma-based resuscitation in both civilian and military protocols. Further prospective studies and investment in domestic FDP production are warranted to evaluate scalability and real-world implementation. 


Freeze-Dried Plasma Versus Fresh Frozen Plasma in Trauma Resuscitation: A Meta-Analysis with Prehospital Implications

Background
Transurethral ultrasound ablation (TULSA-PRO), developed by Profound Medical Inc., is an emerging treatment for localized prostate cancer focused on slowing disease progression while preserving quality of life. The procedure uses directional ultrasound under real-time MRI guidance to thermally ablate targeted prostatic tissue. FDA-cleared in 2019, TULSA-PRO has treated over 3,000 patients to date. This study evaluates early outcomes from a single-center experience at Saint Louis University Hospital (SLUH).
Methods
Twenty-six patients with biopsy-confirmed prostate adenocarcinoma were treated with TULSA-PRO at SLUH between May 2023 and July 2025. Biopsy methods included transrectal ultrasound-guided, MRI fusion, transperineal, and outside hospital biopsies. Patients were categorized by NCCN risk level. Ablation targeted either the whole gland or one side (hemi-gland), based on tumor location and clinical factors. MRI guided both applicator placement and thermal coverage.
Follow-up was conducted at two weeks and then every three months. Data collected included catheter duration, urinary function, complications, and symptom scores (AUASS, IPSS, IIEF, SHIM). Postoperative imaging was obtained in select patients.
Results
The average age at treatment was 69.4 years, and the mean prostate size was 42 cc. Gleason scores were 3+4 in 13 patients, 4+3 in 9, and 3+3 in 4. MRI-visible lesions were present in 10 patients. Ablation times ranged from 26–135 minutes (mean 70.7 min). Hospital stay was 1 day for 21 patients and same-day discharge for 5.
Twelve patients had catheter removal within two weeks, the rest between 13-42 days. Three patients developed urinary tract infections. All patients regained continence within 12 weeks. Scrotal or testicular swelling occurred in 3 cases and resolved conservatively. Erectile dysfunction was reported in 6 patients. Mean pre- and post-op AUASS were 10.4 and 10, respectively. Mean postoperative PSA was 0.221. Early follow-up imaging shows no recurrence in some patients at 12 months.
Conclusion
TULSA-PRO is a safe and well tolerated treatment for localized prostate cancer with low complication rates and preserved continence. Most cases of erectile dysfunction were mild and manageable. Early oncologic outcomes such as PSA reduction and follow-up imaging are encouraging. TULSA-PRO offers a promising option for patients seeking effective cancer control with quality-of-life preservation.

Early Outcomes Following Transurethral Ultrasound Ablation of the Prostate for Prostate Cancer

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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