United States

Glioblastoma Multiforme (GBM) is one of the most common and aggressive high-grade primary brain tumors that arises from the glial cells of the central nervous system and occurs most often in the frontal and temporal lobes. Despite current treatment options, long-term prognosis of GBM remains low with no significant improvement rates. Chimeric antigen receptor (CAR)-expressing T cells target the B cell marker CD19 and have shown increased efficacy in B cell lymphomas, and lymphoblastic leukemias suggesting benefits in GBM. This study aims to quantify the persistence of CAR-T cells in the context of GBM tumor volume following neurosurgical debulking procedure. A radiology software known as the mint Lesion was utilized to provide Tumor Response Assessment by Criteria (TRAC) reports that consist of volumetric measurements of the tumor lesions (target enhancing lesions, non-target enhancing lesions, and non-target non-enhancing lesions). Fluorescence-activated cell sorting (FACS) analysis takes a sample mixture of cells and sorts them into different populations based on specific biomarkers and characteristics. B7-H3 CAR-T cell persistence was increased in patients with a larger post-surgical tumor volume (3.04% Subject 001 with 2438 mm² volume and 2.38% Subject 003 with 224 mm² tumor volume). However, the number of CAR-T cells per 1 mm² was significantly reduced in patients with a larger post-surgical tumor volume (0.0012 cells/mm² Subject 001 and 0.010 cells/mm² Subject 003). This study shows that although there is an overall increased CAR-T cell persistence for a larger tumor volume, the number of CAR-T cells per 1 mm² is significantly smaller for larger tumor volumes, while illustrating that a larger post-surgical tumor bulk volume is correlated with an increased CAR-T cell persistence within 1-week post-infusion. These findings provide novel information and complement other correlative studies as part of the Phase 1 interventional clinical trial for glioblastoma patients.

AMA Research Challenge 2023

Glioblastoma Multiforme Tumor Volume and Persistence of Chimeric Antigen Receptor T Cells Following Neurosurgical Debulking

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Background
Healthcare disparity is the United States has been a long-standing issue. A disease of interest is diabetic retinopathy, one of the leading causes of blindness in the United States, as the minorities are disproportionately affected. Treatment regimens often consist of panretinal photocoagulation (PRP) and intravitreal injections (IVI) with anti-vascular endothelial growth factor (anti-VEGF). However, the efficacy of the treatment regimens as demonstrated in clinical trials have been limited in real-world settings as these necessitate frequent follow-ups, a challenge given that 25 to 51% of patients with diabetic retinopathy are lost to follow-ups. Furthermore, the effect of LTFU in itself on final outcomes have not been studied to date. Therefore, we examined factors associated with LTFU, the effect of LTFU on proliferative diabetic retinopathy, and its interaction with different treatments.

Methods
A retrospective cohort study at a large safety net hospital examined 271 eyes of 271 patients with PDR that received PRP or IVI over a 2-year period. LTFU was defined as failure to return to care for at least 6 months. Baseline patient characteristics were collected. Ocular data was gathered at the visit before being LTFU, the return visit after being LTFU, and the final clinic visit. Univariate analyses and multivariate regression with adjustment for multiple comparisons to control confounders were conducted. 

Results
A history of LTFU was associated with subsequent neovascularization elsewhere (NVE) and tractional retinal detachment (TRD) but not with final visual acuity (VA). Among those LTFU, those who received IVI were not at higher risk of TRD than those receiving PRP.

Conclusion
Undergoing PRP is associated with LTFU. LTFU is independently associated with subsequent development of NVE and TRD, but not with the final visual acuity. One rationale in opting for PRP over IVI for managing PDR was the risk of the patient being LTFU, but our study did not demonstrate a difference between those who received PRP prior to LTFU and those who received IVI prior to LTFU in terms of the rate of subsequent TRD formation. Further studies should expand upon those findings to design better interventions strategies. 


Out of Sight, Not Out of Mind: The Effect of Loss to Follow-Up on on Proliferative Diabetic Retinopathy

Introduction: 
Current AAOS guidelines recommend that children younger than thirty-six months with a femur fracture be evaluated for non-accidental trauma. However, the likelihood of abuse in walking-age children presenting with these fractures has been found to be less than 10%. These guidelines could subject up to 63% of cases to unnecessary evaluation by Child Protective Services. The purpose of this study was to identify how patient age and femur fracture morphology impact the likelihood that providers assess a fracture as non-accidental and pursue further investigation of possible child abuse. 

Methods:
This study evaluated a questionnaire completed by 75 clinicians from multiple specialties. There were 5 subgroup populations (6, 12, 18, 24, 35 months old) combined with diaphyseal and metaphyseal femur fracture types. For each age group, the same radiograph was presented and described as an oblique diaphyseal fracture in one scenario and spiral diaphyseal fracture in another. Similarly, some cases were described as a corner fracture in one scenario and classic metaphyseal lesion in another. This design assessed if fracture nomenclature, in addition to patient age, impacted clinician suspicion of abuse. Participants assessed case presentations and reported their perceived likelihood the case represented non-accidental trauma utilizing a Likert scale from 1 to 5 corresponding to a percent likelihood. They also reported the percent likelihood they would pursue further investigation. 

Results:
75 questionnaires were analyzed. Mean likelihood of abuse rating in all fracture types for patients 18-35 months was 3.8, corresponding to 61-80% perceived likelihood of abuse. Mean likelihood for further investigation of child abuse in patients 18-35 months of age was 3.7, corresponding to 61-80% clinician likelihood to further investigate. Fracture nomenclature did not significantly impact clinician ratings. In the linear mixed model, the strongest predictors of perceived high likelihood of abuse were respondent specialty, with emergency medicine (p<0.001) and advanced practice providers (p=0.006) having the highest likelihood ratings. 

Conclusions: 
Clinicians are trained to have a high index of suspicion for child abuse in pediatric patients. However, this study demonstrates a high assessment of chance for abuse and low threshold for pursuing further investigation for femoral shaft fractures in walking-age children which contradicts literature that reports actual rates of non-accidental trauma to be lower than 10%. This bias may exhaust hospital and community resources in evaluating toddler femur fractures for abuse and cause unnecessary stress for patients and families.

Common Misperceptions of Child Abuse in Toddler Femur Fractures

Introduction: Hand-foot-mouth disease (HFMD) is a common childhood infectious disease. Atypical skin findings of HFMD, often associated with coxsackievirus A6 (CVA6), were first reported in 2008, with increasing reports worldwide since. Atypical lesions of HFMD often involve sites beyond the palms and soles and tend to have unusual, polymorphic morphology. 
Methods: A systematic review was conducted on clinical features and outcomes of pediatric HFMD with atypical cutaneous manifestations.
Results: Eighty-five studies were included, representing 1,359 cases with mean age 2.4 years and a male predominance of 61%. The most reported morphologies were vesicles (53%), papules (49%), and bullae (36%). Other morphologies included eczema herpeticum-like (19%), purpuric/petechial (7%), and Gianotti Crosti-like (4%). Common atypical sites included the arms and/or legs (47%), face (45%), and trunk (27%). CVA6 was identified in 63% of cases. Symptoms resolved in a mean of 10 days. Overall, 16% of cases received treatment, most commonly with acyclovir, intravenous antibiotics, or topical steroids. The most common complications were nail changes (21%) and desquamation (4%) which occurred a mean of three and two weeks after symptoms, respectively. 
Conclusion: Due to unusual morphologies resembling other conditions, HFMD with atypical cutaneous findings may be misdiagnosed, leading to inappropriate and unnecessary investigations, hospitalization, and treatment. Greater awareness of atypical presentations of HFMD is warranted to improve patient care and counseling on infection control precautions.

Atypical Cutaneous Findings of Hand-Foot-Mouth Disease in Children: A Systematic Review

Background: Life adversities, such as neighborhood disadvantage and lower household incomes, are associated with well-established impairments on language development, which predict academic difficulties throughout school. These language delays are observable by age 2, but it remains unclear if adversities experienced in utero affect neurological underpinnings of language development before delays emerge. Of interest are 3 white matter tracts implicated in early language skills: the corpus callosum (CC), inferior fronto-occipital fasciculus (IFOF), and uncinate (Unc).

Methods: A longitudinal cohort of 160 term-born (>36 weeks gestation) neonates were recruited from the eLABE study at Washington University, which oversampled St. Louis families exposed to poverty. Structural equation modeling was used to create 2 latent constructs of prenatal adversity. The first, “social disadvantage”, aggregates neighborhood disadvantage, family income, insurance status, maternal education, and diet. The second, “maternal psychosocial stress”, models maternal depression, stress, life adversities, and perceived discrimination. At birth, diffusion MRI data were collected, and parameters for white matter tract development were created using probabilistic tractography in FSL. In-person follow-up at age 2 evaluated child language skills. To assess the independent and interactive effects of prenatal adversities and neonatal white matter microstructure on language skills, stepwise linear regression models were conducted after adjustment for child sex, gestational age, and postmenstrual age at scan. 


Results: Prenatal social disadvantage (p=.00) and maternal psychosocial stress (p=.00) predicted significantly lower language scores by age 2. However, in a joint model, only the effects due to social disadvantage remained significant. Lower CC fractional anisotropy predicted significantly lower language scores (p=.02) independently of social disadvantage (p=.00). IFOF and Unc were not predictive of language ( p > .05). To examine the relationship between CC maturation and social disadvantage, a moderation analysis was conducted after dichotomizing families’ income into above and below 200% the federal poverty line (FPL), as most federal assistance programs use this value as a threshold for benefit eligibility. The interaction term was not significant (p= .11), but upon plotting results by income group, the slope for infants above 200% FPL was somewhat stronger. 

Conclusion: This study suggests that prenatal adversity, particularly social disadvantage, and immature CC myelination are strong predictors of language delays by age 2. These data can be used as empirical evidence to advocate for increased funding of federal assistance programs that benefit pregnant people (ex., WIC) and downstream fetal brain development. By continuing to explore the relationship between prenatal adversities on fetal brain development and emerging language skills, future studies will continue to identify specific neurological markers of early language development to allow clinicians to intervene before delays emerge.

The Effects of Prenatal Adversity and Neonatal White Matter Microstructure on Child Language Skills at Age 2

Background
Breast cancer related lymphedema effects one in five breast cancer survivors. This debilitating complication is due to transection and obstruction of lymph flow during surgery. Although lymphedema has been met with new surgical and clinical treatments, little is known about the anatomy of the lymphatic system. Diagnostic dyes have become a vital tool in surgery and lymphatic mapping. Microsurgeons utilize florescent Indocyanine green (ICG) distally in extremities to identify afferent lymphatic pathways. In immediate lymphatic reconstruction (ILR) following mastectomies, ICG helps microsurgeons locate transected channels for anastomosis to a neighboring vein, restoring lymph flow. Isosulfane blue (ISB) is an easily visible dye favored by breast surgeons. In axillary reverse mapping, surgeons inject ISB into the proximal upper extremity, allowing them to locate and preserve lymphatic channels wherever possible. The benefit of utilizing both ICG and ISB during axillary dissection and ILR is reliable visualization of lymphatics intraoperatively. Using dual-dye technique, we aim to differentiate afferent lymphatic drainage from the distal and proximal upper extremity into the axilla.

Methods
To identify the distal and proximal lymphatic zones in breast cancer patients receiving ILR following axillary dissection, ICG and ISB were injected in the ipsilateral arm. ICG was injected intradermally at the first and third webspace and volar wrist, while ISB was injected at the same depth into the upper medial arm. Operative reports were reviewed to determine how often each dye was visualized during axillary dissection. Details of the anastomoses were also documented.

Results
Twenty-six breast cancer patients undergoing ILR following axillary lymph node dissection were reviewed. Twenty-one patients met the criteria of dual-dye technique. ICG was seen in 100% of axillary dissections. ISB was seen with ICG in 61.9% of procedures, indicating a shared lymphatic pathway. ISB was never seen alone. The average lumen size of all lymphatic channels was 1.12mm. An average of 2.46 channels were bypassed to an average of 1.65 veins per procedure. Venous lumen size ranged from 1 to 3 mm. 

Conclusion
Dual-dye technique allows for visualization of axillary lymphatic drainage by the breast and plastic surgeons intraoperatively. Utilizing dyes with different visual properties enabled us to determine if lymphatic flow originated from the distal or proximal upper extremity. This technique could provide useful anatomic data in correlating the development of lymphedema to regional lymphatic drainage within the arm, allowing potential anastomotic connections and clinical treatments. 


Differentiating Afferent Lymphatic Pathways Using Dual-Dye Technique During Immediate Lymphatic Reconstruction

Background: Clinical Practice Guidelines (CPGs) aim to offer guidance to physcians to improve patient outcomes. The Reporting Items for Practice Guidelines in Healthcare (RIGHT) Working Group created a set of rules for CPGs to aid guideline presentation and communication. CPGs in Plastic and Reconstructive surgery have not yet been evaluated by CPG metrics, such as RIGHT. This investigation aims to assess and recognize areas for improvement in currently available guidelines. 
Methods: Three reviewers extracted and reviewed all 5 guidelines listed on the American Society of Plastic Surgeons (ASPS) website in March 2023 and scored them according to the RIGHT checklist. RIGHT criteria in the form of 22 distinct statements were broken down into 35 items, and guidelines were assigned a “1” if they met the criteria and a “0” otherwise. Interrater agreeability through Fleiss’s kappa scores calculated for each guideline. 
Results: Among the 5 PRS guidelines checked against the RIGHT criteria, Fleiss’s kappa interrater agreeability ranged from 0.762 to 0.962, indicating strong agreement among independent raters. However, 4 (22.9%) RIGHT items were not met by any ASPS guidelines. There was a mean adherence of 21 RIGHT items. Guidelines were most lacking in categories concerning reporting of quality and review processes. 
Conclusion: Overall, many RIGHT framework recommendations were met fully by ASPS guidelines, but there is room for improvement in disclosure of the guideline development process. By evaluating fidelity to the RIGHT checklist, specific and actionable opportunities for improvement to guideline language and reporting can be implemented after identification.

Evaluation of Plastic Surgery Clinical Practice Guidelines Using the RIGHT Checklist

Background:
First-line treatment for major depressive disorder (MDD) include cognitive behavioral therapy (CBT) and/or antidepressant medications (ADM). However, these treatments can be highly effective in one patient but ineffective in another. Previous treatment selection biomarker studies using resting state fMRI implicate differential subcallosal connectivity to the left anterior insula, left ventromedial prefrontal, and left periaqueductal gray in CBT and medication remitters (Dunlop AJP 2017). Structural connectivity changes that might mediate these functional connectivity patterns are unknown. Therefore, we evaluated pretreatment White matter (WM) integrity in treatment naïve MDD patients as a function of differential 3-month clinical outcome to monotherapy with CBT or ADM. 
Methods
A retrospective analysis of diffusion-weighted imaging scans (DWI) was performed in 167 treatment naive MDD patients randomized to 12 weeks of CBT or ADM. Subjects were grouped into CBT or ADM remitters (HDRS17 score <7 at 10 and 12 weeks) and CBT or ADM failure (HDRS score change <30%). A Whole brain fractional anisotropy (FA) map was calculated for each subject using Fdt toolbox in FMRIB and Tract-Based Spatial Statistics (TBSS) generated for statistical comparison across outcome groups. A voxel-wise 2 x 2 ANOVA: treatment (CBT/ADM) by outcome (remitter/nonresponder) was performed using the AFNI 3dMVM toolbox. Lastly, regional WM changes were correlated with HDRS score changes with treatment. 
Results
A significant treatment by outcome interaction was identified affecting WM tracts adjacent to the left anterior insula, left supplementary motor area, and left hippocampus (p < 0.001). Post hoc analysis revealed ADM remitters and CBT nonresponders show higher FA values in the left insula and SMA compared to both ADM nonresponders and CBT remitters, similar to the location and differential pattern of functional connectivity. In contrast, ADM remitters and CBT nonresponders show lower FA in the left hippocampus compared to ADM nonresponders and CBT remitters. The left SMA and hippocampus showed significant correlation (R2=0.05 p<0.005) with HDRS score improvement in all groups. The VMPFC and SMA showed similar results within the ADM group. The CBT group showed significant correlation with the DLPFC (R2=0.17 p<0.005).
Conclusion
These findings identify differential WM integrity in WM tracts adjacent to the insula, SMA, and hippocampus in remitters and failures to CBT and ADM. These structural and functional connectivity patterns may define imaging biotypes that guide optimal first line MDD treatment selection. Finally, these findings implicate WM connectivity in differential predictive outcomes in MDD treatment success by treatment.

White matter markers for treatment outcomes in major depressive disorder

Background
Pack-year history is an invaluable clinical tool for measuring tobacco-associated disease risk and determining eligibility for lung cancer screening with low-dose computed tomography. Patient-reported measures of smoking history have demonstrated strong test-retest reliability across various survey methods, but the variation between research and clinical settings suggests that non-standardized smoking history interview questions in community practice may not always reveal the true extent of a patient’s tobacco exposure. To date, no study has compared patient responses to differently phrased questions assessing the same measure of smoking history. We hypothesize there is a significant discordance between patient-reported number of years smoked and calculated elapsed time between age at initiation and age at cessation (or present age if current smoker).

Methods
This was a two-month prospective survey-based study conducted at the Western Michigan University Homer Stryker M.D. School of Medicine's Internal Medicine resident clinic in Kalamazoo, Michigan, including patients with a documented smoking history in their electronic medical records. Through verbal interviews, we collected data on number of years smoked, packs per day, and age of smoking initiation/cessation. Primary outcome variables were total years smoked and calculated pack-years. Secondary outcome variables were gender, age, and age of smoking initiation.

Results
There were 124 respondents (36% male, 63% female, 1% non-binary) with an average age of 55 and average smoking history of 1.2 packs per day. Of them, 46% were current and 54% were former smokers. Using a paired sample one-tail t-test, we compared patient-reported years smoked (M=22.06, SD=12.44) to calculated years based on age of initiation/cessation (M=24.03, SD=13.53), which showed a significant mean difference of 1.97 years (95% CI 1.16- 2.78, t=4.05, p<0.001). This discordance translated to a 21.29% increase in pack-years (from 24.32 to 29.50 pack-years) and a mean difference of 5.21 pack-years (95% CI 1.04-9.38, t=2.07, p=0.02).

Conclusion
Our study underscores the importance of critically evaluating the ways in which we gather a patient’s smoking history. When compared to pack-years calculated using age of smoking initiation/cessation, our sample population tended to underestimate their exposure by over 5 pack-years—a clinically significant difference for someone at high risk who might not otherwise receive screening imaging. Often a pivotal moment in adolescence, participants recalled their age of smoking initiation with greater precision compared to their estimations of total exposure. These results call for urgent reevaluation of the tobacco history interview, its notation in electronic medical records, and the methodology of taking a substance abuse history in general.

Rethinking the Smoking History Interview: A Prospective Survey-based Study

Using deep learning to augment radiologist interpretation of brain MRIs for Alzheimer’s disease

Objective: Femoral endarterectomy is a common vascular procedure. Previous data have shown that it is associated with elevated risk of surgical site infection (SSI) that is estimated to be 15% or higher. Obesity is a known risk factor for SSI. Presence of an overhanging pannus may be associated with increased risk of wound infections, due to decreased local hygiene and increased frictional forces. The aim of the current study was to study the relationship between pannus size and SSI after femoral endarterectomy performed at a rural tertiary medical center. 
Methods: Retrospective chart review was used to evaluate femoral endarterectomy performed between January 1, 2010 and December 31, 2019. Patients were excluded if they did not have a CTA or CT abdomen/pelvis within 6 months of endarterectomy. Cases were identified using CPT code, and basic demographic data and preoperative risk factors were identified. Incidence of postoperative wound infection was recorded. Perioperative CT scans were evaluated using TeraRecon to measure the area of the subcutaneous tissue overlying the common femoral artery on the operative leg, hypothesized to be a surrogate for pannus size. 
Results: The total number of participants was 250, with a 17% incidence of SSI. There was a significant difference in pannus size in those who developed postoperative SSI (30.5 cm2 ± 17.2 cm2) compared to those who did not (24.5 cm2 ± 13.7 cm2) (p =0.022). Pannus area was on average 6cm2 larger in those who developed postoperative SSI. BMI, obesity, hypertension, and diabetes were associated with pannus area but were not strong predictors of SSI. BMI and pannus size were strongly correlated, although BMI was more variable as pannus size increased. A 5cm2 increase in pannus size was associated with an absolute relative risk of SSI of 1.10. In patients with pannus size ≤26cm2, 12% had an SSI; in patients with pannus >26cm2, 24% had an SSI; the relative risk of SSI for pannus >26cm2 was 1.99. 
Conclusions: This study highlights a novel method to measure pannus size, which is a stronger predictor than BMI alone for postoperative SSI after femoral endarterectomy. This can help guide preoperative risk identification and decision making, and assign more aggressive postoperative infection prevention measures to patients at risk of SSI.

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Out of Sight, Not Out of Mind: The Effect of Loss to Follow-Up on on Proliferative Diabetic Retinopathy