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  Representation and Outcomes of Catheter Ablation for Treatment of Atrial Fibrillation among Patients with Obesity: A Systematic Review of Randomized Control Trials

  Danielle Dircks, Eh M. Khaing, James Aguto, Jmaylia Mimms, William Schleifer, Jason Payne, Arthur Easley, Faris Khan MD, John Windle, Shane Tsai, Daniel Anderson MD, Gleb Haynatzki, and Niyada Naksuk

  Background: The prevalence and impact of obesity on outcomes of atrial fibrillation (AF) ablation randomized controlled trials (RCTs) have not been well studied.

  Objective: To examine the proportion of participants with obesity enrolled in RCTs of AF ablation and outcomes of ablation when subgroup analysis of participants with obesity were available.

  Methods: We systematically searched PubMed and EMBASE for AF ablation RCTs published between January 1, 2015 to May 31, 2022. When body mass index (BMI) data were available, normal distribution was assumed and a z score was used to estimate the proportion of obesity. Results categorized by BMI or body weight status were reviewed. Authors were contacted for additional information.

  Results: Of 148 eligible RCTs with 30174 participants, 144 (97.30%) RCTs did not report the proportion of participants with obesity, while published information regarding BMI was available in 63.51%. Three trials excluded patients based on BMI. Using reported BMI, we estimated the proportion of participants with obesity varied greatly across these trials, ranging from 5.82%-71.9% (median 38.02%, interquartile 29.64%, 49.10%). Patients with obesity were represented in a greater proportion among trials conducted in North America (50.23%) and Asia (44.72%), compared to others (32.16%), p < .001. Subgroup analysis or analysis adjusting for BMI was reported in only 13 (8.78%) RCTs; four (30.77%) of these suggested that BMI or body weight might negatively affect primary outcomes.

  Conclusion: Obesity is a common comorbidity among AF patients. However, most AF ablation RCTs underreported the proportion of participants with obesity and its impact on the primary outcomes.

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  Persistent Barriers to Implementation of Long-Acting Injectable Antiretroviral Therapy

  Jessica Hack, Adati Tarfa, Harlan Sayles, and Nada Fadul

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  Development and Evaluation of an Interdisciplinary Rotation for Anesthesia Residents in Laryngology

  Cole J. Homer, Kristy Carlson, Faye Haggar, Chris Bingcang, Andrea Dutoit, TJ Lockhart, Evan Ryan, and Jayme Dowdall

  The medical fields of anesthesiology and otolaryngology (ENT – ears, nose, throat) are defined by overlapping clinical expertise as it relates to the management of airway issues. As a result of this shared clinical domain, interdisciplinary educational experiences provide an opportunity for collaboration and a broadened experience for resident physician learning. Our institution developed a two-week rotation in otolaryngology for first-year anesthesiology interns with the goal of utilizing interdisciplinary coaching to develop both technical and non-technical skills in airway management. The purpose of this project is to perform a formal evaluation of this rotation and share our training methods and processes.

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  Hospital Re-admission, Length of Stay, and Chief Complaints of Patients Experiencing Housing Instability

  Andrew S. Leavitt, Jainaha K. Srikumar, Rizwan M. Siddiqui, Luke R. Siedhoff, Jennifer Liu, and Jenenne Geske

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  Labeled

  Hannah E. Manoj

  To explore the extent to which stigma permeates the field of psychiatry, this project, entitled “LABELED”, involved writing a series of structured poems for ten commonly stigmatized mental illnesses: anorexia nervosa, antisocial personality disorder, attention-deficit hyperactivity disorder, bipolar disorder, borderline personality disorder, generalized anxiety disorder, major depressive disorder, obsessive-compulsive disorder, schizophrenia, and substance use disorder. The shortest poems in each set focus on stereotypes and first impressions commonly held about these disorders while the longer poems center around the identity of these individuals beyond their diagnoses. Amongst each set of poems, there is a recontextualization of the words shared between them to further demonstrate the deconstruction of negative stereotypes and humanization of the patients that occurs after going beyond one’s initial assumptions.

  Each section is distinguished by a derogatory term that has historically been used to refer to these patients, highlighting what is all too often the very first impression one has of these patients. The poems in each set are named for descriptions of what may be observed in an initial presentation to an emergency department, a new patient visit at an outpatient clinic, and finally the established patient visit to model a patient’s navigation through the healthcare system. The progressive lengthening and greater inclusion of detail in the longer poems mirrors how we get to deepen our understanding of patients as we spend more time with them.

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  Anti-MAA Antibodies Increase Disease Severity in a Mouse Model of Inflammatory Bowel Disease

  William P. McGuire III, Michael J. Duryee, Rizwan Ahmad, Punita Dhawan, Amar B. Singh, and Geoffrey M. Thiele

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  The Peptidyl Arginine Deiminase Inhibitor BB-CLA Decreases the Inflammatory and Fibrotic Responses in Macrophages and Rheumatoid Arthritis Synovial Fibroblasts Exposed to Fibrinogen Modified with Malondialdehyde-Acetaldehyde Adduct and Citrulline

  Jack E. Mordeson, Nozima Aripova, Michael J. Duryee, James R. O'Dell, Bryant England, Daniel Anderson, Ted R. Mikuls, and Geoffrey M. Thiele

  Background. Peptide citrullination and adduction with malondialdehyde-acetaldehyde adduct (MAA) are involved in the pathogenesis of rheumatoid arthritis (RA). Anti-cyclic citrullinated peptide antibodies are >90% specific for the diagnosis of RA, and MAA co-localizes with citrullinated proteins in RA synovial fluid. In addition, macrophages demonstrate increased expression of peptidyl arginine deiminase-2 (PAD2), an isozyme of PAD, in response to these MAA-adducted proteins. PAD catalyzes protein citrullination and may mediate the immunogenic transformation of synovial proteins and subsequent auto-antibody formation in RA. Here, we determine whether inhibition of PAD effects inflammatory and fibrotic markers in macrophages and RA human fibroblast-like synoviocytes (HFLS-RA) in response to stimulation with MAA and citrulline (CIT)-modified fibrinogen (FIB).

  Methods. U-937 cells were differentiated into activated macrophages and subsequently stimulated with unmodified FIB, FIB-MAA, FIB-CIT, or FIB-MAA-CIT in the presence (treatment group) and absence (control group) of BB-CLA for 48 hours. Supernatants collected from the media were assessed by ELISA for interleukin-1b (IL-1b), interleukin-6 (IL-6), interleukin-8 (IL-8), and monocyte chemoattractant protein-1 (MCP-1). HFLS from RA patients were stimulated with treatment and control supernatants from the macrophage cultures and assessed via immunofluorescent staining for the fibrotic markers vimentin and type II collagen.

  Results. The effect of PAD inhibition on inflammatory cytokine levels (Figure 1) was pronounced with FIB-CIT and FIB-MAA-CIT stimulations and mild with FIB and FIB-MAA stimulations. If fold decrease could not be calculated due to cytokine levels reaching 0, it is denoted as *0. Macrophages stimulated with FIB, FIB-MAA, FIB-CIT, and FIB-MAA-CIT, respectively, showed decreases in IL-1b (*0, *0, 4-fold, 6-fold, respectively), IL-6 (*0, *0, *0, 3-fold), IL-8 (*0, 1.6-fold, 8-fold, 14-fold), and MCP-1 (1.3-fold, 2-fold, 15-fold, 17-fold). In the absence of PAD inhibition, control group cytokine levels generally followed the trend of FIB-MAA-CIT > FIB-CIT > FIB-MAA > FIB. A similar pattern of cellular response was observed (Figure 2) in HFLS-RA cells stimulated with macrophage supernatants from the treatment group, where vimentin (1.3-fold for FIB, 2-fold for FIB-MAA, 2-fold for FIB-CIT, 4-fold for FIB-MAA-CIT) and type II collagen (9-fold, 11-fold, 18-fold, 21-fold) expression were diminished compared with the control group. In the absence of PAD inhibition, mean pixel density levels followed FIB-MAA-CIT > FIB-CIT > FIB-MAA > FIB for both anti-vimentin and anti-type II collagen staining. Conclusions. This study provides insight into the degree to which inflammatory and fibrotic responses from macrophages and HFLS to MAA and CIT modified fibrinogen may be PAD-mediated. MAA and CIT modification of fibrinogen increased inflammatory cytokines from macrophages and fibrotic proteins from HFLS-RA. BB-CLA markedly diminishes these responses. These observations further the understanding of the roles of MAA and CIT modified antigen in the joint synovium of RA patients, and the therapeutic use of PAD inhibitors in RA treatment.

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  Pearls for Surgical Dermatology: Common Sense Solutions for Common Problems

  Richard Maxwell Regester; Amy Cannella MD, MS, RhMSUS; Wesley Chong; Ally Glaser; Amy Rau; and Anthony J. Griess MD

  Introduction:
  Efficiency and precision in surgical dermatology are crucial for optimizing patient outcomes and procedural success. This study presents a collection of practical surgical pearls designed to address common challenges encountered in dermatologic surgery. By implementing these streamlined techniques, practitioners can improve hemostasis, enhance visualization, and reduce surgical tension while maintaining favorable cosmetic results.

  Methods & Key Techniques:
  Several surgical pearls were compiled based on clinical experience and literature review. Key strategies include:

  • Forceps-Assisted Cautery for Hemostasis: A technique that enhances efficiency by directing electrical current through forceps to neutralize bleeding vessels without additional clamps or sutures.
  • Nasal Ala Hemostasis with Q-Tip Support: Utilizing a cotton-tipped applicator within the nares to provide back pressure and improve bleeding control.
  • Plicating Stitch for Linear Closure: A subcutaneous suture placed before wedge removal to minimize scar length and maintain aesthetic outcomes.
  • Towel Clamp & High-Tensile Sutures for Scalp Flaps: Methods to facilitate tension-free closure and expedite wound approximation.
  • Q-Tip-Assisted Punch Biopsy Hemostasis: A simple technique for maintaining hemostasis while preparing sutures.
  • Tragus Displacement for Conchal Bowl Procedures: A method using a rake retractor to improve surgical access and visualization.

  Conclusion:
  These surgical pearls offer low-cost, high-impact modifications that can be seamlessly integrated into dermatologic surgery to enhance efficiency and patient outcomes. By incorporating these techniques, clinicians can reduce procedural complexity, improve hemostasis, and optimize cosmetic results while maintaining patient comfort.

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  Evaluating Medical Usage and Injury Prevalence at the 2024 College World Series

  Roarick Schollmeyer, JD Gregerson, Benjamin Stevens, Katie Weaver, and Joseph Lippert

  Large-scale events such as the College World Series (CWS) pose unique challenges for medical services due to high crowd density, prolonged event durations, and variable environmental conditions. This study aimed to assess the medical usage rate (MUR) and injury prevalence at the 2024 CWS to inform future event planning and emergency medical preparedness. A retrospective analysis was conducted using patient encounter data collected between June 14 and June 24, 2024. Data sources included Union Medical event services, which documented on-site treatments and dispositions, and Omaha Fire Department EMS records detailing prehospital care. The MUR was calculated as the number of patients treated per 10,000 attendees. A total of 361 medical encounters were recorded among 377,814 attendees, yielding an MUR of 9.55 per 10,000. The most common medical presentations included heat-related illnesses (47.4%), minor trauma (22.2%), and general medical complaints (16.9%). Alcohol- and drug-related incidents were notably low (1.1%), which may reflect underreporting or a genuinely low incidence. Daily MUR fluctuations suggested an influence of external factors such as weather conditions and game scheduling. These findings highlight the need for targeted preventative strategies, particularly for heat-related illnesses, and adaptable medical staffing to accommodate variable medical demand. Future research should evaluate year-to-year trends in MUR at the CWS and compare these findings with other major sporting events to optimize medical preparedness and emergency response strategies.

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  Hospital Admissions of Patients Experiencing Housing Instability

  Rizwan M. Siddiqui, Jainaha K. Srikumar, Andrew S. Leavitt, Luke R. Siedhoff, Jenenne Geske, and Jennifer Liu

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  Medical Impact of the College World Series on the Omaha Community

  Benjamin Stevens, JD Gregerson, Roarick Schollmeyer, Katie Weaver, and Joseph Lippert