United States

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&#39; 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.


AMA Research Challenge 2025 

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

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AMA Research Challenge 2023

Join the AMA Research Challenge poster symposium and semifinals to explore top research posters, score posters in the semifinals (an AMA member exclusive opportunity) and attend education sessions with experienced physicians to learn tips to advance your research and career. 

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.


poster

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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

Abstract Title:
Successful Split Transplantation of a Horseshoe Kidney to Two Patients

Introduction:
Horseshoe kidneys are a rare congenital anomaly resulting from fusion of the kidneys during development. Their unique anatomy including fusion at the lower poles, variable vasculature, and collecting system anomalies, have made them challenging to use in renal transplantation. However, with a shortage of donor kidneys, horseshoe kidneys are increasingly being considered viable for transplantation. En bloc transplantation involves transplanting the entire horseshoe kidney into one recipient, while split transplantation divides the kidney at the isthmus for transplantation into two recipients and may require nonstandard surgical techniques. 

Case Description:
Backtable examination of a low-KDPI deceased donor kidney revealed a horseshoe kidney with 5 arteries, 4 veins and 2 ureters. The urinary collecting system was assessed with BK ultrasound to ensure no communication across the isthmus of the kidney. The two renal moieties were sharply separated. To reduce the risk of major bleeding following reperfusion a sliding-clip renorrhaphy was performed to compress the cut edge of the graft using Hemo-Lock clips and fine monocryl suture. Standard reconstruction techniques were used to simplify the vascular anastomoses required, resulting in 1 large Carrel patch per graft with preservation of all arterial inflow. One graft required two separate venous anastomoses. Implantation was performed into a 33 year-old Type 1 diabetic male and a 75 year-old hypertensive male with prolonged anticipated time to transplant. Post-reperfusion bleeding was mild, controlled with direct suture ligation of sizable bleeding vessels and application of a TachoSil fibrin sealant “cap” over the cut edge of the graft. Both grafts had immediate function and the recipients were discharged without complication. One recipient was re-admitted on POD 6 with a moderate, non-compressive hematoma which resolved without intervention or transfusion. Eight months after transplant both patients are doing well with excellent graft function.

Discussion: 
Split horseshoe kidney transplantation presents several challenges including complex vascular reconstructions, management of the urinary collecting system, and control of post-reperfusion hemorrhage. The choice between en bloc transplantation and kidney splitting should be made with preoperative imaging and intraoperative anatomical assessment. Implantation of a split kidney is feasible and safe with careful judgment and utilization of uncommon surgical techniques to manage the above factors. As organ shortages continue to increase, horseshoe kidneys remain a valuable and underutilized resource for transplantation.


Successful Split Transplantation of a Horseshoe Kidney to Two Patients

Background 
Currently, there is a lack of standardized pharmacological protocols for managing primary headaches in the emergency department (ED). With nearly five million ED visits in the United States each year for headache complaints and a growing concern of increased patient census levels in the ED, efficient treatment strategies that foster timely, safe patient care are needed. This study aimed to examine how the type of pharmacological treatment was associated with length of stay for patients presenting to the ED for care of primary headaches. 

Methods 
This was a retrospective chart review of patients seen at the ED of an academic hospital between January 1, 2022, and December 31, 2022, with a chief complaint of primary headache. Patients with a secondary cause of headache (infection, trauma, or recent procedure involving the head), patients admitted to the hospital, and those under eighteen years of age were excluded. The primary predictor, pharmacological treatment, was classified into medication type (analgesics, antiemetics, anti-inflammatories, etc.), with patients able to receive treatment with any combination of medication type. The primary outcome was length of stay (LOS) from timing of first medication administration to discharge (minutes). Differences in medication types and LOS were determined using linear regression, controlling for patient sex and age, and whether medications were administered with fluids (yes/no). 

Results 
A total of 299 patients (74.2% female, average age of 40.4 years +/- 14.6 years) were included in the analysis. Most patients (66.3%, n=189) received three different medication types, 14.4% (n=41) received one type of medication, and 9.5% (n=27) received two types. No patients were prescribed opioids. The median LOS from medication administration to discharge was 122 (IQR 85-169) minutes. Compared to analgesics alone, patients prescribed a combination of analgesics/antiemetics/antiinflammatories had an increase of 65 minutes (β=65.1, 95% CI: 32.7-97.4) for LOS, and a combination of analgesics/antiemetics had an increase in 37 minutes (β=37.7, 95% CI:16.5-59.1). Regardless of medication class prescribed, IV fluids increased the time from first medication administration to discharge by 52 minutes (95% CI: 36-68 minutes, p<0.001). Of note, no opioids were administered. 

Conclusion 
In patients presenting to the ED with primary headaches, treatment with multiple pharmacological agents did not result in quicker recovery or faster time to discharge compared with analgesics alone. Further, the use of IV fluids increased LOS. Future research evaluating treatment protocols using patient-reported recovery rates would help create comprehensive, patient-centered guidelines to optimize headache management further. 


What a Headache: Pharmacologic Management and Its Association with Emergency Department Throughput in Primary Headache Presentations

Evaluating the Effect of Educational Interventions on Opioid Prescribing Practices for Hysterectomies

Nicholas Ernst1, Andrew Moore1, Laura Jackson, PhD1, MS, Annabelle D’Agostino, MPH1, Yasmin Abedin, MPH, MD2, Lori Spoozak, MD2

1University of Kansas School of Medicine, University of Kansas Medical Center, Kansas City, KS
2Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, KS

Background
Post-operative opioid prescribing contributes significantly to the opioid epidemic, with hysterectomy being one of the most common gynecologic surgeries linked to excess prescribing. Despite national guidelines, prescribing practices at discharge remain inconsistent, posing risks for opioid misuse, dependence, and diversion. Prior strategies, such as Enhanced Recovery After Surgery (ERAS) protocols, have shown success in reducing inpatient opioid use through multimodal pain management, but their impact on outpatient prescribing remains limited without additional measures. This study evaluated the impact of a multi-faceted quality improvement intervention consisting of a provider education series, a Restricted Opioid Prescribing Protocol (ROPP), and an opioid calculator, hypothesizing it would significantly reduce opioid prescribing at discharge and improve standardization among providers.
Methods
(IRB: STUDY00160958) This retrospective cohort study included patients who underwent hysterectomy during three defined time periods: Pre-ERAS (Feb–Aug 2020), Post-ERAS (May–Nov 2023), and Post-QI (July 2024–Jan 2025) at a single academic medical center. Patients were stratified by surgical approach: total abdominal hysterectomy (TAH), robot-assisted laparoscopic hysterectomy (RALH), total laparoscopic hysterectomy (TLH), and vaginal hysterectomy (VH). The primary outcome was mean morphine milligram equivalents (MME) prescribed at discharge. Secondary outcomes included prescribing variability, refill requests, and post-operative complications. Independent t-tests were used to compare groups, with p<0.05 considered statistically significant.
Results
A total of 668 patients were included. Opioid prescribing decreased significantly across all surgical types following ERAS implementation and further declined after the QI initiative. From Pre-ERAS to Post-ERAS, mean MME significantly decreased in TAH (183.13 to 141.52, p<0.05), RALH (178.82 to 101.69, p<0.01), TLH (178.50 to 109.72, p<0.01), and VH (136.72 to 99.11, p<0.05). From Post-ERAS to Post-QI, additional significant reductions were observed in TAH (141.52 to 68.08, p<0.01), RALH (101.69 to 73.26, p<0.01), TLH (109.72 to 73.56, p<0.01), and VH (99.11 to 82.50, p<0.05). Standard deviations decreased, reflecting reduced variability. Importantly, opioid reductions were not associated with increases in refill requests, emergency department visits, or readmissions, indicating adequate pain control was maintained.
Conclusion
This study demonstrates that our quality improvement initiative incorporating structured education, ROPP, and an opioid calculator into an existing ERAS protocol significantly decreased both the amount and variability of opioid prescribing following hysterectomy. The intervention proved effective across hysterectomy types. Future analyses will evaluate sustained impact over time, differences by prescriber training level, and effect on inpatient opioid use. Findings support wider implementation of standardized prescribing interventions as part of opioid stewardship efforts.

Evaluating the Effect of Educational Interventions on Opioid Prescribing Practices for Hysterectomies

Empathy is a critical component of healthcare. In the pediatric realm, empathy plays an important role in understanding how both the patient and their parents are feeling, and then sharing those feelings with them to better create an environment of healing and mutual understanding. The presence or lack of physician empathy has implications in patient outcomes, the patient-physician relationship, and overall patient happiness. The aim of this literature review is to synthesize and summarize findings from a variety of studies on physician empathy in the pediatric setting with the goal of enhancing patient care. Google scholar and PubMed were used to find relevant studies that were published in the last five years, using keywords like “pediatric” “empathy” “communication” and “physician empathy.” In the literature review, a variety of study types were included, such as surveys, meta-analyses, and qualitative studies. One of the key findings was that most research has been done with the caregivers of pediatric patients versus pediatric patients themselves. This is a gap that should be filled in the future, as one study showed that kids understand more than physicians assume and want to be involved in their care. Some advances have been made in improving communication, for example a study found that empathy, partnership, and respect all increased with family centered rounds. Other studies have found that communication training can increase perceived physician empathy and mindfulness. When taken as a whole, these studies show that communication training and an emphasis on including caregivers in decisions improve perceived physician empathy. Future research should include studies specifically on improving communication and empathy with pediatric patients themselves versus their caregivers, as presently most research done is with caregivers. Improving empathy with these steps can improve the quality of care and outcomes, as well as increasing patient and family satisfaction. 


Fostering Physician Empathy in the Pediatric Setting

Rising grocery prices and a growing interest in homesteading have driven a surge in poultry-related sales in the United States, ranging from keeping backyard chickens to buying eggs from local backyard chicken farmers. In North Carolina (NC), little is known about the backyard poultry community, yet extensive networks of poultry owners, primarily raising chickens, exist across the state. Several studies have explored the antimicrobial resistance (AMR) profile of the backyard poultry environment and the interaction between families and their chickens. However, with the expansion of flocks and diverse backyard operation styles, more information is needed about these interactions at the human-animal interface.
This pilot study aimed to characterize the husbandry practices of a sample of central NC backyard poultry owners and investigate the prevalence and AMR profiles of Salmonella spp., Escherichia coli (E. coli), and Campylobacter spp. isolated from their flocks’ environments. Increasing resistance to antibiotics like penicillin and macrolides poses challenges in treating human and animal infections. A two-fold approach was used: interviews with participants, and bacterial cultures from fecal, soil, and environmental samples. A semi-structured questionnaire facilitated discussions about poultry practices, flock interactions, and medication use. Adult participants were recruited through online poultry groups. From January to June 2024, focus groups and individual interviews were conducted with 18 participants from five NC counties. Thematic analysis revealed that most owners raised poultry for egg production and companionship. Biosecurity practices and medication usage varied. Most participants reported good poultry health and primarily used social media and online communities for information-sharing.
A total of 99 samples were collected across 15 farms, including nasopharyngeal swabs, fecal matter, environmental swabs, water bowl swabs, soil samples, and bedding samples. After a double-culture enrichment procedure, analysis by Kirby-Bauer disc diffusion showed that 41% (41/99) of samples tested positive for E. coli, and 46% (46/99) tested positive for Campylobacter. Of the E. coli isolates, 61% (25/41) contained extended-spectrum beta-lactamases (ESBL), which confer resistance to beta-lactam antibiotics, and 31.7% (13/41) exhibited the TEM gene encoding ESBL. Additionally, 91.3% (42/46) of Campylobacter strains were resistant to erythromycin, a macrolide antibiotic. This resistance contributes to the spread of harder-to-treat infections in both poultry and humans. These findings provide insight into backyard poultry husbandry practices and human-animal interactions. Future research, involving more participants and continuous environmental sampling, could help inform public health interventions aimed at improving husbandry practices and biosecurity.

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