Senior Scholars Program

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ABOUT THIS COLLECTION

The Senior Scholars Program at UMass Chan Medical School provided an opportunity for scholarly activities that served not only as an introduction to the philosophy of research based on answering questions through hypothesis generation, information gathering, experimentation, and critical interpretation, but as a tool for growth in an evidence-based health care environment. Each student participated in "Senior Scholars Presentation Day" by preparing a poster about their research project and sharing their learning experience with medical school peers and faculty members. This collection includes selected student posters, abstracts, and published journal articles authored by Senior Scholars. The Senior Scholars Program ended in 2024.

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Rigid Plate Fixation for Reconstruction of Symptomatic Sternal Nonunion: A Retrospective Review
(eScholarship@UMassChan, 2023-04-26) Sjoquist, Jan; Joo, Alex; Bello, Ricardo; Dunn, Raymond M; Raymond Dunn, MD; Surgery; T.H. Chan School of Medicine; Jan Sjoquist
Background: Median sternotomy, the most common approach to open cardiac surgery, is performed in over 500,000 patients annually in the United States. This approach involves an incision from the manubrium to xyphoid and vertical division of the bony sternum. Wire cerclage remains the standard technique for sternal closure after median sternotomy. Complications following median sternotomy include infection, hematoma, seroma, and sternal nonunion or dehiscence. Sternal nonunion occurs when either significant bony motion, fracture, or separation occurs with the two sternal halves. It is clinically defined as greater than 6 months of pain, clicking, or sternal instability. This represents a failure of primary cerclage “fixation.” Risk factors for nonunion after sternotomy include obesity, bilateral internal mammary artery harvesting, diabetes, and off-midline sternotomy. While sternal nonunion has an incidence of less than 1%, this complication can serve as a nidus for life-threatening infection and can cause significant discomfort for the patient. There is currently no standard-of-care treatment for sternal nonunion after median sternotomy. In fact, sternal nonunion most commonly goes untreated, leaving patients continuously symptomatic. Rigid plate fixation (RPF) has been employed in certain cases for primary sternal closure in patients at higher risk for sternal healing complications. RPF has been shown to significantly reduce the incidence of complications and mortality after median sternotomy in high-risk patients when compared to wire cerclage. We have recently employed traditional orthopedic techniques of bony debridement, anatomic bony reduction, and have extended the use of RPF to patients with symptomatic sternal nonunion. Objectives: The goal of this retrospective review is to investigate and describe long term clinical outcomes in patients at our institution who have undergone RPF for sternal nonunion after median sternotomy. Our objectives are to investigate long term outcomes and complications in patients at our institution who have undergone rigid plate fixation for sternal nonunion after median sternotomy. Methods: All patients who underwent sternal reconstruction for sterile sternal nonunion between 2017 and 2023 were reviewed. Patients were excluded if they underwent prophylactic RPF during primary sternotomy or if they did not meet the clinical definition of sternal nonunion. Data regarding demographics, risk factors, initial sternotomy procedure, nonunion presentation, reconstructive procedure, and clinical and radiographic follow up. For sternal reconstruction, all patients underwent debridement of nonviable sternal tissue, rigid fixation with locking plates and screws with or without pectoralis muscle advancement flaps, layered closure, and incisional negative pressure wound therapy (NPWT). A total of 18 eligible patients, 14 male and 4 female, were identified. Average age was 63 years. Preoperative risk factors included obesity (n = 14), smoking (n = 9), diabetes (n = 8), and LIMA harvest (n = 16). Indication for median sternotomy included coronary artery bypass grafting (n = 16) and aortic valve replacement (n = 2). Patients presented with symptoms of sternal nonunion an average of 4.5 months after initial sternotomy. The most common presenting symptoms were pain (n = 17) and sternal clicking (n = 14). 8 patients (44%) showed evidence of fractured sternal wires. Results: Average time from symptom presentation to sternal reconstruction was 3.2 months. Average time from initial sternotomy to reconstruction was 7.7 months. Regarding the sternal reconstruction procedure, 100% of patients underwent debridement of sternal edges and rigid plate fixation using locking plates and screws. Bilateral pectoralis advancement flaps were performed in 17 patients (94%). The average clinical follow-up period was 3 years, ranging from 39 days to 4.9 years. 100% of patients had sternal nonunion confirmed by CT scan and demonstrated clinical evidence of sternal healing. Complications following RPF included seroma (n=3), hematoma (n = 2), and wound infections (n = 2). One patient presented with osteomyelitis/mediastinitis one month post sternal reconstruction, with full resolution after receiving IV and oral antibiotics. Another patient had all hardware removed after presenting with cellulitis and CT evidence of perihardware infection 3 months post reconstruction. Sternal union was noted at time of hardware removal. Conclusion: Rigid plate fixation is a reliable method of treatment for symptomatic sternal nonunion and should be offered to all patients demonstrating signs and symptoms of sternal nonunion after median sternotomy.
Evaluation of In-Office MRI/US Fusion Transperineal Prostate Biopsy via Free-hand Device during Routine Clinical Practice
(2021-05-25) Briggs, Logan G; Kim, Michelle; Gusev, Andrew; Rumpf, Florian; Feldman, Adam; McGovern, Francis; Tabatabaei, Shahin; Dahl, Douglas M; Adam Feldman; T.H. Chan School of Medicine
Objectives: To describe our recent experience with in-office transperineal prostate biopsy, including the adoption of software-assisted MRI/US fusion technology. Technological improvements have recently allowed transperineal biopsy to be effectively integrated into outpatient practices with negligible risk of infection. Methods: We retrospectively reviewed a cohort of men undergoing transperineal prostate biopsy from 2018-2020, at a single institution. We compared this to another cohort of men undergoing transrectal fusion biopsy from 2014-2018, matched to the first cohort based on age, PSA, and presence of prostate cancer diagnosis prior to biopsy. All patients underwent systematic transperineal templated biopsies in addition to fusion biopsies of MRI-visible lesions. Baseline characteristics, MRI findings, biopsy results, and complications were analyzed and compared between the 2 groups. Results: One-hundred and thirty men underwent transperineal prostate biopsy, and 130 men underwent transrectal fusion biopsy. Of those who underwent transperineal biopsy, 30% underwent fusion biopsy while all men with the transrectal biopsy underwent fusion biopsy. Men who underwent transperineal vs transrectal biopsy demonstrated lower infection rates (0% vs 0.8%, P = .31) with fewer prophylactic antibiotics prescribed at provider's discretion (48% vs 100%), yet higher total post-biopsy complication rates (6.1% vs 0.8%, P = .036). Conclusion: Our initial experiences with transperineal prostate biopsy confirm prior findings demonstrating feasibility in outpatient urologic practice without infectious complication. Software-assisted MRI/US fusion technology can be successfully integrated with transperineal biopsies to target suspicious lesions. Higher rates of non-infectious complications were observed compared with transrectal biopsy. Further analysis is needed to determine whether risk profiles improve over the learning curve of this newly implemented approach.
A machine learning approach to predict progression on active surveillance for prostate cancer
(2021-08-29) Nayan, Madhur; Salari, Keyan; Bozzo, Anthony; Ganglberger, Wolfgang; Lu, Gordan; Carvalho, Filipe; Gusev, Andrew; Schneider, Adam; Westover, Brandon M; Feldman, Adam S; Adam Feldman; T.H. Chan School of Medicine
Purpose: Robust prediction of progression on active surveillance (AS) for prostate cancer can allow for risk-adapted protocols. To date, models predicting progression on AS have invariably used traditional statistical approaches. We sought to evaluate whether a machine learning (ML) approach could improve prediction of progression on AS. Patients and methods: We performed a retrospective cohort study of patients diagnosed with very-low or low-risk prostate cancer between 1997 and 2016 and managed with AS at our institution. In the training set, we trained a traditional logistic regression (T-LR) classifier, and alternate ML classifiers (support vector machine, random forest, a fully connected artificial neural network, and ML-LR) to predict grade-progression. We evaluated model performance in the test set. The primary performance metric was the F1 score. Results: Our cohort included 790 patients. With a median follow-up of 6.29 years, 234 developed grade-progression. In descending order, the F1 scores were: support vector machine 0.586 (95% CI 0.579 - 0.591), ML-LR 0.522 (95% CI 0.513 - 0.526), artificial neural network 0.392 (95% CI 0.379 - 0.396), random forest 0.376 (95% CI 0.364 - 0.380), and T-LR 0.182 (95% CI 0.151 - 0.185). All alternate ML models had a significantly higher F1 score than the T-LR model (all p <0.001). Conclusion: In our study, ML methods significantly outperformed T-LR in predicting progression on AS for prostate cancer. While our specific models require further validation, we anticipate that a ML approach will help produce robust prediction models that will facilitate individualized risk-stratification in prostate cancer AS.
Venous thromboembolism risk stratification in trauma using the Caprini risk assessment model
(2021-10-23) Hazeltine, Max D; Guber, Robert D; Buettner, Hannah; Dorfman, Jon D; Jon Dorfman; Surgery; T.H. Chan School of Medicine
Introduction: The Caprini risk assessment model is widely used for venous thromboembolism (VTE) but has limited data in trauma. The study objective was to determine if the Caprini risk assessment model could effectively risk stratify trauma patients. Materials and methods: We performed a retrospective review of trauma patients aged ≥18 years, admitted for greater than 24 h at a level one trauma center from January 1, 2018, to December 31, 2018. Demographic and clinical data were analyzed to generate Caprini scores. Multiple logistic regression assessed odds of inpatient VTE. Results: A total of 1279 patients met study eligibility, with a total of 33 VTE (2.6%). When comparing those with VTE to those without, the mean age was lower (52.5 vs 59.5, p = 0.06, respectively), sex distribution was similar, but mean body mass index was higher (30.2 vs 27.4, p = 0.019, respectively). The mean Caprini score was 9.9, and 75.5% had a score >4, the traditional Caprini high-risk cutoff. The VTE group had a higher mean Injury Severity Score (17.8 vs 12.6, p = 0.011), and mean Caprini score (16.4 vs 9.8, p < 0.001). Multiple logistic regression found Caprini score, not Injury Severity Score, was associated with higher odds of VTE (adjusted odds ratio 1.06, 95% confidence interval 1.02-1.10), after adjusting for Injury Severity Score, any missed doses of VTE chemoprophylaxis, and VTE prophylaxis type. Conclusions: Higher Caprini scores are associated with elevated odds of inpatient VTE within hospitalized trauma patients. These data support using the Caprini risk assessment model in the trauma population, which may aid in risk stratification.
Female Relatives as Lay Doulas and Birth Outcomes: A Systematic Review
(2022-04-01) Nguyen, Hau Huu; Heelan-Fancher, Lisa; Lisa Heelan-Fancher; T.H. Chan School of Medicine
Continuous labor support provided by professional doulas is associated with improved birth outcomes for pregnant women and their infants. However, there is limited data on the impact of using female relatives as lay doulas. This systematic review included nine published studies that examined the association between use of female relatives as lay doulas with childbirth outcomes. In some study populations, there was a decrease in the number of cesarean births and length of labor, and in all studies, there was improved maternal birth satisfaction. However, the woman's chosen female relative often did not receive education regarding labor support skills before providing continuous support. Educational programs designed to teach labor support skills to female relatives are needed.
A study protocol for a Pilot Masked, Randomized Controlled Trial Evaluating Locally-applied Gentamicin versus Saline in Open Tibia Fractures (pGO-Tibia) in Dar es Salaam, Tanzania
(2021-02-10) von Kaeppler, Ericka P; Donnelley, Claire; Ali, Syed H.; Roberts, Heather J; Ibrahim, John M; Wu, Hao-Hua; Eliezer, Edmund N; Porco, Travis C; Haonga, Billy T; Morshed, Saam; Shearer, David W; Amna Diwan; T.H. Chan School of Medicine
Background: Open tibia fractures are a major source of disability in low- and middle-income countries (LMICs) due to the high incidence of complications, particularly infection and chronic osteomyelitis. One proposed adjunctive measure to reduce infection is prophylactic local antibiotic delivery, which can achieve much higher concentrations at the surgical site than can safely be achieved with systemic administration. Animal studies and retrospective clinical studies support the use of gentamicin for this purpose, but no high-quality clinical trials have been conducted to date in high- or low-income settings. Methods: We describe a protocol for a pilot study conducted in Dar es Salaam, Tanzania, to assess the feasibility of a single-center masked randomized controlled trial to compare the efficacy of locally applied gentamicin to placebo for the prevention of fracture-related infection in open tibial shaft fractures. Discussion: The results of this study will inform the design and feasibility of a definitive trial to address the use of local gentamicin in open tibial fractures. If proven effective, local gentamicin would be a low-cost strategy to reduce complications and disability from open tibial fractures that could impact care in both high- and low-income countries. Trial registration: ClinicalTrials.gov, Registration # NCT03559400 ; Registered June 18, 2018.
Increased IgE-Mediated Food Allergy With Food Protein-Induced Allergic Proctocolitis
(2020-09-01) Martin, Victoria M; Virkud, Yamini V; Phadke, Neelam A; Su, Kuan-Wen; Seay, Hannah; Atkins, Micaela R; Keet, Corinne; Shreffler, Wayne G; Yuan, Qian; Victoria Martin; T.H. Chan School of Medicine
Immunoglobulin E–mediated food allergy (IgE-FA) can be life-threatening in children, and rates are rising in the United States. We now know that early introduction of allergenic foods can reduce the risk of IgE-FA. Food protein-induced allergic proctocolitis (FPIAP) (also called cow’s milk protein allergy and/or intolerance or non–IgE-mediated milk allergy) is an early, common form of food allergy presenting with bloody or mucoid stools, often together with fussiness and feeding difficulty. Not thought to be associated with IgE-FA, FPIAP is treated with avoidance of the trigger antigen, most commonly milk, for the first year of life. Guidelines recommend an oral challenge after short dietary elimination to confirm the diagnosis, but this is rarely done in clinical practice. Given that FPIAP is associated with both eczema8 and diet restriction, we hypothesized that children with FPIAP would be at increased risk for IgE-FA.
Histopathology of the Incudomalleolar Joint in Cases of "Indeterminate" Presbycusis
(2021-02-23) Roychowdhury, Prithwijit; Castillo-Bustamante, Melissa; Polanik, Marc; Kozin, Elliott D; Remenschneider, Aaron K; Aaron Remenschneider; Otolaryngology; T.H. Chan School of Medicine
Age-related hearing loss (presbycusis) is a prevalent condition attributed primarily to inner ear dysfunction. Little is known about age-related changes in the ossicular joints or their contribution to presbycusis. Herein, we performed a histopathologic analysis of the incudomalleolar joint (IMJ) in specimens from the National Temporal Bone Registry with audiometrically confirmed presbycusis but without histologically observed sensory, neural, strial, or mixed features. Seventeen “indeterminate” presbycusis (IP) ears and 13 young, normal-hearing ears were examined. The age was 73.2 ± 9.5 years for the IP group and 32.1 ± 9.5 for the young group (P < .05). The joint space between the 2 ossicles was 23% wider in the IP group (139 ± 26.2 µm) compared to young ears (113 ± 49.0 µm) (P = .02). We report that IP ears have a wider IMJ than young ears. These findings have implications for understanding the etiology of presbycusis in indeterminate cases.
High-Frequency Conductive Hearing following Total Drum Replacement Tympanoplasty
(2020-02-25) Polanik, Marc D; Trakimas, Danielle R; Black, Nicole L; Cheng, Jeffrey T; Kozin, Elliott D; Remenschneider, Aaron K; Aaron Remenschneider; Otolaryngology; T.H. Chan School of Medicine
Objectives: Conventional reporting of posttympanoplasty hearing outcomes use a pure-tone averaged air-bone gap (ABG) largely representing a low-frequency sound conduction. Few studies report high-frequency conductive hearing outcomes. Herein, we evaluate high-frequency ABG in patients following temporalis fascia total drum replacement. Study design: Case series with chart review. Setting: Tertiary care center. Subjects and methods: All patients who underwent type 1 tympanoplasty using a lateral graft total drum replacement technique between August 2016 and February 2019 were identified. Patients with pre- and postoperative audiograms were included. Low-frequency ABG was calculated as the mean ABG at 250, 500, and 1000 Hz. High-frequency ABG was calculated at 4 KHz. Pre- and postoperative ABGs were compared. Results: Twenty-three patients were included, and the mean age at surgery was 44 years (range, 9-68 years). Perforation etiology was from trauma (n = 14) or chronic otitis media (n = 9). Preoperative mean low-frequency ABG was 27.8 ± 12.6 dB and mean high-frequency ABG was 21.5 ± 15.1 dB (P = .044). Postoperatively, the mean low-frequency ABG was significantly reduced by 15.5 ± 13.3 dB (P < .001) while the mean high-frequency ABG insignificantly changed (reduced by 2.6 ± 16.2 dB, P = .450). Conclusion: In a series of patients undergoing temporalis fascia total drum replacement, low-frequency ABG improved; however, high-frequency conductive hearing loss persists. Conventional methods of reporting ABG may not identify persistent high-frequency ABG. These results merit further study across a range of tympanoplasty graft materials and surgical techniques.
In-Office Repair of Tympanic Membrane Perforation
(2021-12-01) Roychowdhury, Prithwijit; Polanik, Marc D; Kozin, Elliott D; Remenschneider, Aaron K; Aaron Remenschneider; Otolaryngology; T.H. Chan School of Medicine
BACKGROUND: Chronic tympanic membrane (TM) perforations are a common cause of conductive hearing loss in adult patients. The gold-standard approach to repair of TM perforations involves surgical elevation of the remnant TM via a postauricular or endaural incision to enable grafting (1). Endoscopic TM repair in awake patients in the clinic setting using a novel graft design may permit perforation closure while avoiding general anesthesia and decreasing operative time (2,3). CASE REPORT: A 42-year-old female with a chronic, left sided tympanic membrane perforation in the anterior–inferior quadrant (15% of TM area) presented with a mild conductive hearing loss on audiometry. In-office repair of the perforation was performed with immediate subjective hearing improvement. Four months post-procedure, the TM was intact, and her prior air-bone gap had closed. CONCLUSION: In-office endoscopic repair of TM perforations using a novel graft design in awake patients offers a viable alternative to traditional in-OR approach for tympanoplasty.
Do high-frequency air-bone gaps persist after ossiculoplasty?
(2020-06-26) Polanik, Marc D; Trakimas, Danielle R; Castillo-Bustamante, Melissa; Cheng, Jeffrey T; Kozin, Elliott D; Remenschneider, Aaron K; Aaron Remenschneider; Otolaryngology; T.H. Chan School of Medicine
Objectives: Conventional reporting of postoperative hearing outcomes utilizes a pure-tone averaged air-bone gap (ABG) that is biased toward low frequencies. Consequently, a high-frequency ABG after otologic surgery may go unnoticed. In this study, we evaluate changes in low- and high-frequency ABG following ossiculoplasty. Study design: Retrospective review. Subjects and setting: Consecutive series of patients who underwent ossiculoplasty at a single tertiary care center. Patients with pre- and postoperative audiograms were included. Methods: Low-frequency ABG was calculated as the mean ABG at 250, 500, and 1000 Hz. High-frequency ABG was calculated at 4 kHz. Pre- and postoperative ABGs were compared. Results: Thirty-seven consecutive patients were included. Mean age at surgery was 38 years (range, 7-77 years). Reconstruction materials included: cartilage (N = 4), hydroxyapatite cement (N = 5), and partial or total ossicular replacement prostheses (N = 20 and N = 8, respectively). Postoperatively, the mean low-frequency ABG improved by 11.9 ± 15.1 dB (P < .0001) and the mean high-frequency ABG improved by 5.9 ± 16.0 dB (P = .030). Low-frequency ABG closure was significantly larger than high-frequency ABG closure (P = .007). Mean postoperative persistent high-frequency ABG was 22.0 ± 13.8 dB. Conclusion: In this series, ossiculoplasty improved ABG across all frequencies, but greater improvements were observed at low frequencies when compared to high frequency. Current reporting standards may not identify persistent high-frequency ABG. Additional study of the mechanisms of high-frequency sound conduction in reconstructed middle ears is needed to improve high-frequency hearing outcomes in ossiculoplasty. Level of evidence: Level 4.
A Systematic Review of Nonautologous Graft Materials Used in Human Tympanoplasty
(2020-07-27) Ghanad, Iman; Polanik, Marc D; Trakimas, Danielle R; Knoll, Renata M; Castillo-Bustamante, Melissa; Black, Nicole L; Kozin, Elliott D; Remenschneider, Aaron K; Aaron Remenschneider; Otolaryngology; T.H. Chan School of Medicine
Objectives: Nonautologous graft materials may solve several dilemmas in tympanoplasty by obviating the need for graft harvest, facilitating consistent wound healing, and permitting graft placement in the clinical setting. Prior studies of nonautologous grafts in humans have shown variable outcomes. In this systematic review, we aim to 1) summarize clinical outcomes and 2) discuss limitations in the literature regarding nonautologous grafts for tympanoplasty in humans. Methods: A literature review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The study size, etiology and duration of perforation, type of nonautologous graft, and postoperative closure rate were assessed. Results: The PRISMA approach yielded 61 articles, including 3,247 ears that met inclusion criteria. Studies evaluated nonautologous grafts including paper patch, gelatin sponge, growth factors, porcine small-intestinal submucosa, among others. Traumatic perforations (62.3%) were most commonly studied, whereas postinfectious perforations (31.9%) and other etiologies (5.8%) comprised a minority of cases. Acute perforations of <8 weeks duration constituted just over half of all treated ears. Overall closure rate was 82.1%, with significantly higher closure rates in acute (89.9%) versus chronic perforations (64.9%, P < .01), regardless of material. A median postoperative air-bone gap of 5.6 dB was found in the 23% of studies reporting this metric. Conclusions: The majority of publications reviewing nonautologous materials in tympanoplasty evaluate acute or traumatic perforations, and few rigorously report hearing outcomes. Given available data, porcine submucosa and basic fibroblast growth factor may hold promise for chronic perforation closure. Future studies should report closure rates and hearing outcomes in perforations >8 weeks duration. Laryngoscope, 131:392-400, 2021.
Early diagnosis and intervention of calciphylaxis leading to rapid resolution
(2021-04-24) Rrapi, Renajd; Chand, Sidharth; Gabel, Colleen; Ko, Lauren; Moore, Kevin J; Steele, David; Kroshinsky, Daniela; Daniela Kroshinsky; T.H. Chan School of Medicine
Calciphylaxis is a rare life-threatening disorder characterized by skin necrosis due to calcium deposition within small- and medium-sized vessels and subsequent thrombosis leading to tissue ischemia.1,2 Though the exact pathogenesis of calciphylaxis is poorly understood, risk factors such as chronic kidney disease can promote calcium deposition and vascular calcification contributing to the disease process.3 This condition presents with poor healing, painful skin lesions, which initially may be confused with mimickers, such as cellulitis; peripheral vascular disease, warfarin necrosis, or vasculitis.4 While calciphylaxis is considered a rare disease predominantly affecting patients with chronic kidney disease on renal replacement therapy, there has been an increase in clinical awareness, which may be reflected in the increase in incidence.4 Despite calciphylaxis having a high morbidity and 1-year mortality as high as 80% in some cases,4 no randomized controlled trials examining longitudinal outcomes and treatment efficacy have been published.4 This report discusses 3 cases of early calciphylaxis diagnosis and treatment leading to rapid resolution and survival, highlighting the impact of timely recognition and intervention.
Preoperative functional status predicts 2-year mortality in patients undergoing fenestrated/branched endovascular aneurysm repair
(2021-02-04) Flanagan, Colleen P; Crawford, Allison S; Arous, Edward J; Aiello, Francesco A; Schanzer, Andres; Simons, Jessica P; Jessica Simons; Surgery; T.H. Chan School of Medicine
Background: Fenestrated/branched endovascular aneurysm repair (F/BEVAR) is a minimally invasive alternative for patients at high risk of open repair of complex aortic aneurysms. Nearly all investigative study protocols evaluating F/BEVAR have required a predicted life expectancy of >2 years for study inclusion. However, accurate risk models for predicting 2-year survival in this patient population are lacking. We sought to identify the preoperative predictors of 2-year survival for patients undergoing F/BEVAR. Methods: The prospectively collected data for all consecutive F/BEVAR procedures, performed in an institutional review board-approved registry and/or a physician-sponsored investigational device exemption (IDE) trial (IDE no. G130210), were reviewed (November 2010 to February 2019). We assessed 44 preoperative patient characteristics, including comorbidities, preoperative functional status, aneurysm morphologies, and repair techniques. Preoperative functional status was defined as totally dependent (any impairment in activities of daily living or residing in a skilled nursing facility), partially dependent (any impairment in instrumental activities of daily living), or independent (no impairment in activities of daily living or instrumental activities of daily living). Using the results of univariate analysis (P < .2), a Cox proportional hazards model was constructed to identify the independent predictors of 2-year all-cause mortality. Results: For the 256 consecutive patients who had undergone F/BEVAR (6 common iliac [2.3%], 94 juxtarenal [41%], 35 pararenal [14%], 119 thoracoabdominal [47%], and 2 arch [0.8%] aneurysms), the 2-year mortality was 18%. On Cox modeling, the only independent preoperative predictor contributing to 2-year mortality was functional status (totally dependent: hazard ratio [HR], 5.4; 95% confidence interval [CI], 1.8-16; P = .0024; partially dependent: HR, 4.5; 95% CI, 2.4-8.7; P < .0000019). A history of an implanted anti-arrhythmic device was protective (HR, 0.4; 95% CI, 0.2-0.99; P = .0495). Factors such as age, congestive heart failure, chronic kidney disease, diabetes, chronic obstructive pulmonary disease, aneurysm extent, and previous aortic surgery, were not significant. The 2-year mortality for the independent (n = 176; 69%), partially dependent (n = 69; 27%), and totally dependent (n = 10; 3.9%) groups was 11%, 33%, and 40%, respectively. Conclusions: For patients undergoing F/BEVAR, decreased preoperative functional status was the strongest predictor of 2-year mortality, with totally dependent patients experiencing poor survival. The traditional risk factors were not independently significant, perhaps reflecting the high prevalence of severe chronic illness in these high-risk patients participating in an IDE trial. For the independent patients, the 2-year F/BEVAR survival rate was 89%, equivalent to patient survival after infrarenal EVAR. Therefore, for independent patients, it would be reasonable to expand the indication for F/BEVAR to low-risk patients.
A Structured Mentorship Elective Deepens Personal Connections and Increases Scholarly Achievements of Senior Surgery Residents
(2020-08-27) Schultz, Kurt S; Hess, Donald T; Sachs, Teviah E; Tseng, Jennifer F; Pernar, Luise I M; Jennifer Tseng; T.H. Chan School of Medicine
Objectives: Surgery residents have few opportunities to work closely with attending surgeons or conduct research during clinical time. We hypothesized that a mentorship elective with a required research project would benefit residents' career development, including their personal connections with faculty mentors, and would help them build their academic portfolio. Design: We created a mentorship elective designed as a one-on-one apprenticeship. Completion of a scholarly project was a core component of the elective. Residents, faculty, and the most senior resident ('non-mentee') on the same service as the elective resident were interviewed after the completion of their rotation. Setting: University-based surgery residency at Boston Medical Center, Boston, MA. Participants: All 5 residents in postgraduate year 4 (PGY-4) participated in the mentorship elective during the 2019 to 2020 academic year. Residents identified their faculty mentor. All mentees (5/5), most mentors (4/5), and all non-mentees (4/4) were interviewed. Results: All mentees reported interacting with their mentor daily, performing clinical duties or discussing their research project. For mentees, the top factor when selecting their mentor was the mentor's clinical expertise, and the most valuable aspect of the rotation was developing a relationship with their mentor. All mentors responded that their mentee gained an understanding of running an academic surgical practice and developed research skills. Four of 5 mentees completed critical portions of their scholarly project during the elective with one publishing in a peer-reviewed journal, 2 having their work accepted to a national conference, and one creating vascular surgery educational videos. All stated the elective was valuable. Conclusions: A structured apprenticeship rotation allowed for closer relationships with attending surgeons and increased the scholarly achievement of PGY-4 surgery residents. We provide an example of how to incorporate a successful elective rotation into the surgery curriculum that strengthens resident career development and research productivity.
Patient and Clinician Impressions of Cognitive Impairment in Parkinson's Disease
(2020-10-27) Ngo, Angeline B; Smith, Kara M; Kara Smith; Neurology; T.H. Chan School of Medicine
We investigated patient and clinician impressions of cognitive impairment and whether they correlated with objective measures of cognitive impairment. Cognitive categorization, neuropsychological assessment scores, and Montreal Cognitive Assessment scores were documented at baseline, 3 years, and 7 years for 388 PD patients in the Parkinson's Progression Markers Initiative (PPMI). We found that both patient and clinician impressions of cognitive decline were significantly associated with gold-standard criteria for cognitive impairment to a similar degree. Both patient and clinician perspectives should be considered in determining cognitive status and should be followed up with diagnostic testing.
Controversies in defining a surgical site infection following Mohs micrographic surgery: A literature review
(2020-08-20) Hanly, Ailish M; Daniel, Vijaya T; Mahmoud, Bassel H; Bassel Mahmoud; Dermatology; T.H. Chan School of Medicine
Mohs micrographic surgery (MMS) is widely used to treat nonmelanoma skin cancer. The most frequent complication of MMS is surgical site infections (SSI), with incidences ranging from 0.07% to 4.34%. Variations among studies in the definition of SSI used may contribute to the wide range of rates reported. The Centers for Disease Control and Prevention (CDC) has defined SSI as occurring within 30 days of a procedure and meeting at least 1 of 4 characteristics, including purulent drainage, positive wound culture, clinical criteria, or diagnosis of SSI by the surgeon/attending physician. However, this definition is infrequently used in the literature. The lack of a consensus definition of SSI after MMS renders the true prevalence of SSI unknown, hindering the development of informed antibiotic and infection-control guidelines. Here, we sought to review the existing literature on infection rates after MMS and variations among the criteria for SSI reported.
Clinical mimickers of calciphylaxis: A retrospective study
(2021-03-17) Gabel, Colleen K; Blum, Amy E; François, Josie; Chakrala, Teja; Dobry, Allison S; Garza-Mayers, Anna Cristina; Ko, Lauren N; Nguyen, Emily D; Shah, Radhika; John, Jessica St; Nigwekar, Sagar U; Kroshinsky, Daniela; Daniela Kroshinsky; Dermatology; T.H. Chan School of Medicine
Background: Calciphylaxis is an ischemic vasculopathy with high morbidity and mortality. Early and accurate diagnosis is critical to management of calciphylaxis. Clinical mimickers may contribute to delayed or misdiagnosis. Objective: To assess the rate and risk factors for misdiagnosis and to identify clinical mimickers of calciphylaxis. Methods: A retrospective medical record review was conducted of patients with calciphylaxis at a large urban tertiary care hospital between 2006 and 2018. Results: Of 119 patients diagnosed with calciphylaxis, 73.1% were initially misdiagnosed. Of patients not initially misdiagnosed, median time to diagnosis from initial presentation was 4.5 days (interquartile range, 1.0-23.3), compared to 33 days (interquartile range, 13.0-68.8) in patients who were initially misdiagnosed (P = .0002). The most common misdiagnoses were cellulitis (31.0%), unspecified skin infection (8.0%), and peripheral vascular disease (6.9%). Patients who were misdiagnosed frequently received at least 1 course of antibiotics. Patients with end-stage renal disease were less likely to be misdiagnosed than those without this disease (P = .001). Limitations: Single-center, retrospective study. Conclusions: Understanding the risk factors for misdiagnosis of calciphylaxis is an opportunity for further education concerning this rare disease.
Assessment of outcomes of calciphylaxis
(2020-10-29) Gabel, Colleen K; Nguyen, Emily D; Chakrala, Teja; Blum, Amy E; François, Josie; Chand, Sidharth; Rrapi, Renajd; Baker, Olesya; Dobry, Allison S; Garza-Mayers, Anna Cristina; Ko, Lauren N; Shah, Radhika; St John, Jessica; Nigwekar, Sagar U; Kroshinsky, Daniela; Daniela Kroshinsky; Dermatology; T.H. Chan School of Medicine
Background: Calciphylaxis is a rare thrombotic vasculopathy characterized by high morbidity and mortality. There is a paucity of studies examining longitudinal outcomes. Objective: To assess mortality, days spent in the hospital, and amputations in patients with calciphylaxis. Methods: A retrospective medical record review was conducted in 145 patients diagnosed with calciphylaxis at an urban tertiary care hospital from January 2006 to December 2018. Results: Six-month mortality was 37.2%, and 1-year mortality was 44.1%. Patients with nephrogenic calciphylaxis had worse survival than those with nonnephrogenic calciphylaxis (P = .007). This difference in survival disappeared when limiting mortality to deaths due to calciphylaxis. Age (P = .003) and end-stage renal disease (P = .01) were risk factors associated with 1-year mortality. Diabetes mellitus was associated with greater total hospitalization days (coefficient, 1.1; 95% confidence interval, 1.01-1.4); bedside debridement was associated with fewer hospitalization days (coefficient, 0.8; 95% confidence interval, 0.7-0.9). Amputations were not associated with any of the examined risk factors. The use of warfarin followed by a transition to nonwarfarin anticoagulation was associated with decreased hazard of death (P = .01). Limitations: Retrospective nature. Conclusions: Calciphylaxis remains a complex, heterogeneous disease. Mortality is lower in patients with nonnephrogenic disease. These findings may be incorporated during discussions regarding the goals of care to facilitate informed shared decision making.
Assessment of outcomes of calciphylaxis lesions treated with intralesional sodium thiosulfate
(2020-07-28) Gabel, Colleen K; Nguyen, Emily D; Dobry, Allison S; Baker, Olesya; Garza-Mayers, Anna Cristina; Ko, Lauren N; Shah, Radhika; St John, Jessica; Strazzula, Lauren; Nigwekar, Sagar U; Kroshinsky, Daniela; Daniela Kroshinsky; Dermatology; T.H. Chan School of Medicine
Calciphylaxis, also known as calcific uremic arteriolopathy, is a life-threatening cutaneous ischemic vasculopathy. Current treatment includes intravenous sodium thiosulfate (IVSTS); however, its use has limitations. Intralesional sodium thiosulfate (ILSTS) is a promising localized alternative that warrants additional study. This retrospective study assessed outcomes of patients treated with ILSTS.

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