Loma Linda University

Prostate cancer is the most common noncutaneous malignancy in men. Since the adoption of prostate-specific antigen (PSA) for prostate cancer screening, most prostate cancer has been diagnosed at an early stage when it is still confined to the gland. Focal therapies have been used for decades as an alternative to traditional whole-gland therapies, which have high rates of adverse effects such as erectile dysfunction and incontinence. Transrectal laser focal therapy (LFT) is a relatively new and exciting treatment option that has been shown to be safe and effective in multiple phase I and II clinical trials. MRI-guidance allows for superior visualization of the patient’s anatomy, and real-time MR thermometry allows for close treatment monitoring.

Polyvascular disease, is a prevalent comorbidity among patients with acute heart failure (AHF). Previous research has shown that polyvascular disease is a poor prognostic factor in patients with heart failure. However, data on the relationship between the extent of vascular disease involvement and outcomes in AHF patients are limited. Using the National Inpatient Sample from 2016 to 2019, adult patients with AHF were stratified by number of diseased vascular beds and into heart failure with reduced ejection fraction (HFrEF) and with preserved ejection fraction (HFpEF). The study assessed in-hospital major adverse cardiovascular and cerebrovascular events (MACCE), mortality, cerebrovascular accident (CVA), and major bleeding. Multivariable regression models examined the association between outcomes and number of diseased vascular beds. This analysis included 652,710 patients hospitalized with AHF, of which 42.2% had disease of 1 vascular site and 57.8% had polyvascular disease. As the number of involved vascular beds increased, AHF patients tended to be older and with higher comorbidity burden. The mean length of stay and total hospital charge increased with a greater number of diseased vascular beds (p < 0.001). Moreover, the adjusted odds of MACCE, all-cause mortality, CVA, and major bleeding showed a significant increase with a greater number of diseased vascular beds (p trend < 0.001) with similar trends for patients with HFrEF and HFpEF. The extent of polyvascular disease involvement is associated with higher in-hospital adverse event rates in AHF patients. These findings highlight the importance of comprehensive vascular assessment and targeted interventions to improve outcomes in this high-risk population.

The identity of a doctor is informed by the identity of the person. Life encounters, experiences, and struggles contribute to the personal growth and wisdom of doctors, shaping their perspectives, attitudes, and understanding of themselves. These personal essays, written by doctors and trainees, are about different challenges they have faced in their life journey, including bias and racism, immigration, cultural identity, emotional stressors, fatigue and burnout, work–life balance, and more. This is a subcollection from the book, Becoming a Better Physician, which contains stories from doctors and doctors-to-be about obstacles they faced, how they responded, and how the experience affected their lives, work, or perspectives to make them better physicians.

The striking increase of uterine blood flow during pregnancy is essential for normal fetal development as well as for cardiovascular well‐being of the mother. Yet, the underlying mechanisms of pregnancy‐mediated vasodilatation of the uterine artery are not fully understood. In this study, we test the hypothesis that Rad, a monomeric G protein, is a novel regulatory mechanism in inhibiting CaV1.2 channel currents in uterine artery haemodynamic adaptation to pregnancy in a sheep model. We found that pregnancy significantly upregulates Rad expression and decreases CaV1.2 channel currents in uterine arterial smooth muscle cells. Rad knockdown ex vivo and in vivo increases CaV1.2 activity and channel window currents by reducing steady‐state inactivation in uterine arteries of pregnant sheep, recapitulating the phenotype of uterine arteries in non‐pregnant animals. Moreover, Rad knockdown in vivo in pregnant sheep enhances myogenic tone and phenylephrine‐induced vasoconstriction of uterine arteries. Whereas knockdown of Rad has no effect on mesenteric arterial CaV1.2 channel activity and mean arterial blood pressure, it significantly increases uterine vascular resistance and decreases uterine artery blood flow. Our study reveals a novel cause‐and‐effect mechanism of Rad in pregnancy‐induced suppression of CaV1.2 channel activity in uterine arteries to facilitate increased uterine blood flow, providing new insights into fundamental mechanisms of uterine haemodynamic adaptation to pregnancy. image Key points Pregnancy suppresses CaV1.2 channel currents in uterine arterial smooth muscle cells. Rad, a monomeric G protein, is upregulated in uterine arteries of pregnant sheep. Rad knockdown ex vivo or in vivo increases CaV1.2 channel currents in uterine arteries from pregnant ewes. In vivo knockdown of Rad elevates uterine vascular resistance and decreases uterine blood flow in pregnant sheep. The study reveals a novel mechanism of Rad in pregnancy‐induced suppression of CaV1.2 channel activity in uterine arterial haemodynamic adaptation to pregnancy.

Background Self-reported breast implant illness (BII) has been found to be associated with anxiety as well as medically diagnosed anxiety and depression. Somatic symptom disorder (SSD) is a relatively common mental health condition that includes anxiety and somatic symptoms, often without a clear cause. Methods We evaluated patients with BII symptoms, with or without a history of an anxiety disorder, for findings consistent with SSD. A total of 120 women were evaluated in 2 cohorts, 60 women with somatic symptoms and breast implants desiring explantation as well as 60 women desiring explantation without BII symptoms. Patient demographics, a patient survey, and validated anxiety scale and somatic symptom scale measurements were obtained. Results Patients with a history of an anxiety disorder and BII symptoms had very high levels of anxiety and highly elevated somatic symptom scores. Patients with a combined diagnosis of anxiety and BII symptoms demonstrated an SSD prevalence of 70.2%, with the difference between the BII/anxiety group and other groups statistically significant ( P < 0.01). Other patients with BII symptoms and no history of anxiety had a lower SSD prevalence (21.7%). Patients without a history of BII had little to no SSD inclusion. Conclusions Our data suggest that a significant subset of patients with somatic symptoms have findings consistent with a breast implant–associated somatic symptom disorder. Patients with persistent or excessive thoughts about somatic symptoms will benefit from counseling and referral to an SSD specialist if they wish to maintain breast implants.

Purpose To measure the effect of daily immersion in varying beverages (distilled water, tea, carbonated beverage, and orange juice) on surface roughness and color stability of 3D‐printed denture base resins. Materials and Methods 160 acrylic resin discs (15 × 2.5 mm) were made from heat‐polymerized (HP), and 3D‐printed resins (FormLabs, ASIGA, and NextDent). Resin discs ( N = 40) were immersed in different solutions (distilled water, tea, carbonated beverage, or orange juice; ( n = 10/group)). Surface roughness ( R a , µm) was measured initially ( T 0 ), 6 months post immersion ( T 1 ), and 12 months post immersion ( T 2 ) using a non‐contact profilometer. Color change (∆ E 00 ) was calculated using CIEL2000 at T 1 and T 2 using a spectrophotometer. The data were analyzed using Mann‐Whitney U test and Kruskal‐Wallis test in addition to general linear modeling ( α = 0.05). Results Significant differences in surface roughness ( R a ) were found between the baseline and immersion in distilled water, carbonated beverage, and orange juice ( p < 0.05). HP resin showed increased roughness with all immersion solutions compared to T 0 with the highest value seen at T 1 with tea. ASIGA resin had the highest mean R a of 1.78 (0.43) after carbonated beverage immersion, while FormLabs resin had the lowest mean R a of 0.88 (0.06) after distilled water immersion. Tea immersion did not significantly affect R a among the resins ( p > 0.05). Noticeable color changes were observed after immersion in tea, carbonated beverage, and orange juice. All resins exceeded perceptibility and acceptability thresholds at T 1 and T 2 . The combined effect of time and resin on color change was statistically significant ( p < 0.001), while the combined effects of time/immersion solution, immersion solution/resin, and immersion solution/resin/time were not. Conclusion Carbonated beverage, tea, and orange juice increase the surface roughness of 3D‐printed resins. Tea, carbonated beverage, and orange juice resulted in noticeable color changes of HP and 3D‐printed denture base resins and this change was time‐dependent.

There has been a significant interest in venous congestion in recent years, among which the VExUS score has been prominent, both in clinical practice and research efforts. We have noted some recurrent misconceptions among clinicians which are also reflected in certain research efforts. Notably, the misguided attempt to correlate VExUS to volume status, which is only one of the factors influencing it, as well as attempts to re-interpret VExUS in the context of certain pathologies, which reflects a fundamental misunderstanding of its circulatory perspective. In this article we review the physiological basis of the VExUS assessment as a measure and marker of venous congestion from the organs’ standpoint and its role as part of the emerging concept of fluid tolerance, in hopes to address these misconceptions for clinicians and for important further studies.

Background Arterial stiffness is a crucial factor in determining an increase in systolic blood pressure and pulse pressure and can also predict the development of cardiovascular disease (CVD). The purpose of this study was to examine the relationship between arterial stiffness and future CVD. Methods Out of the original 9704 participants in the Mashhad stroke and heart atherosclerotic disorder (MASHAD) cohort study, we randomly selected 363 healthy participants, 226 normal subjects (who reported symptoms of CVD but were not confirmed) and 292 individuals who had experienced a major cardiovascular event. The SphygmoCor XCEL System (AtCor Medical Incorporation) was utilized to measure pulse wave velocity (PWV), central augmentation index (CAI), cardio‐ankle vascular index (CAVI) and central aortic pressure (CAP). A multivariate multiple regression model was used to analyse the factors associated with non‐invasive arterial stiffness parameters (PWV, CAVI, CAP and CAI) after adjusting for potential confounders. All statistical analyses were conducted using SPSS 21 with a significance level of 0.05. Results The mean PWV was significantly higher in patients who had experienced a confirmed CVD event (P < 0.001). The multivariate multiple regression model results, after adjusting for potential confounders, showed a significant association between PWV and the CVD group (normal vs. healthy and event vs. healthy), as well as between hypertension and obesity with PWV and diabetes with CAI (P < 0.05). Conclusions PWV was found to be associated with CVD and its related risk factors such as diabetes, obesity and hypertension. It may be more effective than other arterial stiffness parameters in predicting CVD in clinical settings.

Aim: Non-alcoholic steatohepatitis (NASH), or metabolic dysfunction-associated steatohepatitis (MASH), is a severe form of non-alcoholic fatty liver disease (NAFLD) or metabolic dysfunction-associated liver disease (MASLD), that may progress to advanced liver disease. Costs associated with progression are not well characterized. This study sought to quantify costs and healthcare resource utilization (HRU) associated with NASH progression. Methods: Patients were included if diagnosed with NASH (ICD-10: K75.81) in 100% Medicare claims data (2015–2021) who were ≥66 years at index (diagnosis), continuously enrolled in Parts A, B and D for ≥12 months prior to and 6 months following index (unless death) and who had no evidence of other causes of liver disease. Patient-time was categorized into five severity states: non-cirrhotic NASH, compensated cirrhosis (CC), decompensated cirrhosis (DCC), hepatocellular carcinoma (HCC) and liver transplant (LT). Annualized HRU and costs were calculated during the study periods overall and stratified by occurrence and timing of progression. Results: In 14,806 unique patients (n = 12,990 non-cirrhotic NASH; 1899 CC; 997 DCC; 209 HCC; 140 LT), mean age and follow-up were 72.2 and 2.8 years, respectively. Average annualized costs increased from baseline following diagnosis, generally scaling with severity: $16,231 to$27,044; $25,122 to$57,705; $40,613 to$181,036; $36,549 to$165,121 and $35,626 to$108,918 in NASH; CC; DCC; HCC; and LT; respectively. Non-cirrhotic NASH and CC patients with progression had higher follow-up spending (1.6x for NASH; 1.7x for CC) than non-progressors (both p < 0.001), 2.8 and 6.1-times higher odds of an inpatient stay and 2.6 and 3.6-times higher odds to be in the top 20% of spenders, respectively, relative to non-progressors (both p < 0.001). Patients progressing within a year had costs 1.4, 1.6, 1.7 and 2.2-times more than year 2, 3, 4 and 5 progressors' costs, respectively, for non-cirrhotic NASH and 1.3, 1.8, 2.0 and 2.2-times more than year 2, 3, 4 and 5 progressors' costs, respectively, for CC. Conclusion: NASH progression is associated with high costs that increase in more severe disease states. Slower progression is associated with lower costs, suggesting a potential benefit of therapies that may delay or prevent progression.

Background Left atrial appendage occlusion (LAAO) is increasingly used as an alternative to oral anticoagulation for stroke prevention in select patients with atrial fibrillation. Data on outcomes in racial and ethnic minority individuals are limited. This analysis assessed differences in the use and outcomes of LAAO by race and ethnicity in a large national registry. Methods and Results This analysis acquired data on patients who underwent WATCHMAN FLX implantation from the retrospective NCDR (National Cardiovascular Data Registry) LAAO registry through September 2022. All patients with an attempted WATCHMAN FLX implantation and known race and ethnicity were included. Baseline characteristics and 1‐year event rates were compared. A total of 97 185 patients were analyzed; 87 339 were White individuals (90%), 3750 Black individuals (3.9%), and 2866 Hispanic individuals (Hispanic/Latinx), 2.9%). Black and Hispanic patients were younger, with a higher incidence of prior stroke and significant bleeding compared with White patients. Black and Hispanic patients were treated with LAAO in smaller numbers relative to their proportion of the US population. Rates of procedural success were similar between groups. Though direct oral anticoagulants were prescribed in most patients across the groups, dual and single antiplatelet therapy were prescribed more often in Black patients. Black patients had significantly higher rates of 1‐year death and bleeding compared with White and Hispanic patients. Conclusions Patients from racial and ethnic minority groups comprise a disproportionately small fraction of all patients who undergo LAAO. Black and Hispanic patients were younger but had significantly higher comorbidities compared with White patients. Procedural success was similar among the groups, but Black patients experienced higher rates of death and bleeding at 1 year.

Patients with metastatic colorectal cancer (mCRC) often require multidisciplinary interventions due to the diversity of symptoms. Palliative treatment offers benefits including improved quality of life, yet sociodemographic disparities influence its utilization. This study aims to characterize these disparities in palliative treatment use among mCRC patients. Utilizing data from the National Cancer Database, we identified patients diagnosed with mCRC between 2016 and 2020. Patients were categorized by metastatic site: peritoneal, liver, lung, or bone/brain/lymph node. Palliative treatment rates were compared across metastatic sites as well as patient and hospital factors. A total of 106,241 patients were identified as having mCRC, with 19,208 (18.08%) receiving palliative treatment; 24.0% of patients with multiple metastatic disease and 14.0% of those with solely peritoneal metastases (PM) utilized palliative treatment (p < 0.001). Furthermore, patients over 75 years of age had a significantly decreased likelihood of receiving palliative treatment compared with younger patients (p = 0.0002). Hispanic patients did not differ significantly from non-Hispanic White populations (p = 0.47). Those in the highest education quartile demonstrated a higher degree of palliative treatment use compared with the lowest education quartile (p = 0.0081). Among patients with mCRC, those with multiple sites of metastatic disease tend to receive higher rates of palliative treatment compared with those with oligometastatic disease. Patients with PM had the lowest rate of receiving palliative treatment. Other determinates of utilizing palliative treatment include younger age groups and higher education. Further research is warranted to understand the patterns of disparities in palliative treatment use among mCRC patients.

Background Topical vitamin E is commonly used for its antioxidant properties in a rapidly expanding anti‐aging market. Cutaneous reaction to vitamin E is rare and can present a difficult diagnosis. Methods We report a unique case of a 46‐year‐old female who developed a severe cutaneous inflammatory chin lesion after topical use of vitamin E oil with a micro‐spike roller. Clinical examination found a friable and fungating mass which prompted biopsy due to suspected malignancy. Pathology ruled out malignancy and revealed chronic inflammation with xanthogranulomatous‐like features. Results The lesion was significantly improved with Kenalog injection treatment over 18 months. A scar excision procedure further enhanced the lesion cosmetically. Conclusions This case highlights the rarity and clinical diversity of vitamin E skin reactions, and their potential to mimic malignancies.

Objective Not much is known regarding musculoskeletal ultrasound (MSUS) practices of rheumatologists in the United States. We sought to determine the current use of MSUS among past participants of the Ultrasound School of North American Rheumatologists (USSONAR) training program and, by extension, MSUS practicing rheumatologists and to understand barriers to its MSUS use. Methods An online survey was sent to 374 participants in the 8‐month USSONAR blended course (Fundamentals in MSUS and Train the Trainer) between 2009 and 2020. Each respondent had a unique identifier linked to their total number of submitted practice scans and examination scores during training. Results The survey response rate was 28.1% (105/374), comprising 82% adult and 18% pediatric rheumatologists. Of the respondents, 71% were MSUS certified: 86.7% performed and/or interpreted diagnostic MSUS, 81.0% performed/interpreted procedural MSUS, 59.8% billed for at least 50% of diagnostic studies, and 78.8% billed for at least 50% of procedural studies. The top reasons for not doing diagnostic and procedural ultrasonography were lack of administrative support and limited time, respectively. For 25% of diagnostic ultrasonography and 12.9% of procedural ultrasonography, billing was done less than 50% of the time. Of the respondents, 78.0% reported that USSONAR training made them better rheumatologists. Conclusion Most USSONAR‐trained rheumatologists are certified, practicing both diagnostic and procedural MSUS and billing for most of their work. However, a substantial number of studies are not being billed due to time constraints, limited administrative support, and legal liability. Participants agreed that USSONAR training made them better rheumatologists.