Education & Certifications
Bachelor of Science, Brown University, Biochemistry (2018)
Recognition and Management of Emergent Spinal Pathology Among First-Line Providers.
Spinal emergencies require prompt identification, management, and surgical referral (if needed) from first-line providers. Diagnostic delays from a failure to recognize emergency conditions can lead to adverse patient outcomes. The objective of this study was to understand the proficiency with which first-line providers can recognize and manage spinal conditions, particularly spinal emergencies. This was a cross-sectional analysis of 143 internal medicine, family medicine, emergency care, and neurology questionnaires collected at a single-site academic center. Participants were predominantly physicians (88.1%, n=126), with a smaller percentage of midlevel providers (11.9%, n=17). Only 35.0% (n=50) of respondents felt "very prepared" to handle spinal emergencies. Bivariate analyses revealed interdepartmental differences in clinical knowledge pertaining to the management of lumbar radiculopathy (P<.0001), epidural abscess (P=.0002), and cervical myelopathy (P<.0001). Following pairwise comparisons of interdepartmental differences, emergency medicine statistically outperformed internal medicine (P=.0007) and neurology (P<.0001) on initial management of lumbar radiculopathy, while also having markedly higher success in identifying and managing epidural abscess with respect to family medicine (P<.0001). The likelihood of appropriate initial treatment of cervical myelopathy was significantly higher for neurology than for emergency medicine (P<.0001). A minority of first-line providers reported being very prepared to handle spinal emergencies. Disparities exist between first-line provider specialties regarding clinical knowledge in managing and proficiently identifying emergent and nonemergent spinal conditions. Because appropriate handling of emergent spinal pathologies is essential to patient outcomes and optimal resource use, measures should be taken to further educate first-line providers regarding the spinal conditions they will be treating. [Orthopedics. 2020;43(x):xx-xx.].
View details for DOI 10.3928/01477447-20200404-07
View details for PubMedID 32271932
Nuclear Export Inhibition Enhances HLH-30/TFEB Activity, Autophagy, and Lifespan.
2018; 23 (7): 1915–21
Transcriptional modulation of the process of autophagy involves the transcription factor HLH-30/TFEB. In order to systematically determine the regulatory network of HLH-30/TFEB, we performed a genome-wide RNAi screen in C. elegans and found that silencing the nuclear export protein XPO-1/XPO1 enhances autophagy by significantly enriching HLH-30 in the nucleus, which is accompanied by proteostatic benefits and improved longevity. Lifespan extension via xpo-1 silencing requires HLH-30 and autophagy, overlapping mechanistically with several established longevity models. Selective XPO1 inhibitors recapitulated the effect on autophagy and lifespan observed by silencing xpo-1 and protected ALS-afflicted flies from neurodegeneration. XPO1 inhibition in HeLa cells enhanced TFEB nuclear localization, autophagy, and lysosome biogenesis without affecting mTOR activity, revealing a conserved regulatory mechanism for HLH-30/TFEB. Altogether, our study demonstrates that altering the nuclear export of HLH-30/TFEB can regulate autophagy and establishes the rationale of targeting XPO1 to stimulate autophagy in order to prevent neurodegeneration.
View details for DOI 10.1016/j.celrep.2018.04.063
View details for PubMedID 29768192
View details for PubMedCentralID PMC5991088
Some outcomes of patients treated operatively for distal humerus fractures are affected by hand dominance.
European journal of orthopaedic surgery & traumatology : orthopedie traumatologie
This study sought to compare postoperative outcomes and complications between patients with distal humerus fractures treated with open reduction and internal fixation (ORIF) of their non-dominant versus dominant arm.A retrospective review of all patients who sustained a distal humerus fracture treated operatively with ORIF at one academic institution between 2011 and 2015 was performed. Measured outcomes included complications, time to fracture union, painful hardware, removal of hardware, Mayo Elbow Performance Index (MEPI), and elbow range of motion. Differences in outcomes between patients who underwent surgery of their dominant upper extremity and those who underwent surgery of their non-dominant extremity were assessed.Sixty-nine patients met inclusion criteria. Forty (58.0%) underwent ORIF of a distal humerus fracture on their non-dominant arm and 29 (42.0%) on their dominant arm. Groups did not differ with respect to demographics, injury information, or surgical management. Mean overall follow-up was 14.1 ± 10.5 months, with all patients achieving at least 6 months follow-up. The non-dominant cohort experienced a higher proportion of postoperative complications (P = 0.048), painful hardware (P = 0.018), and removal of hardware (P = 0.002). At latest follow-up, the non-dominant cohort had lower MEPI scores (P = 0.037) but no difference in elbow arc of motion (P = 0.314).Patients who sustained a distal humerus fracture of their non-dominant arm treated with ORIF experienced more postoperative complications, reported a greater incidence of painful hardware, underwent removal of hardware more often, and had worse functional recovery in this study. Physicians should emphasize the importance of physical therapy and maintaining arm movement especially when the non-dominant arm is involved following distal humerus fracture repair.Level III.
View details for DOI 10.1007/s00590-021-02915-3
View details for PubMedID 33660048
Can We Stratify Quality and Cost for Older Patients With Proximal and Midshaft Humerus Fractures?
Geriatric orthopaedic surgery & rehabilitation
2021; 12: 2151459321992742
This study sought to investigate whether a validated trauma triage tool can stratify hospital quality measures and inpatient cost for middle-aged and geriatric trauma patients with isolated proximal and midshaft humerus fractures.Patients aged 55 and older who sustained a proximal or midshaft humerus fracture and required inpatient treatment were included. Patient demographic, comorbidity, and injury severity information was used to calculate each patient's Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA). Based on scores, patients were stratified to create minimal, low, moderate, and high risk groups. Outcomes included length of stay, complications, operative management, ICU/SDU-level care, discharge disposition, unplanned readmission, and index admission costs.Seventy-four patients with 74 humerus fractures met final inclusion criteria. Fifty-eight (78.4%) patients presented with proximal humerus and 16 (21.6%) with midshaft humerus fractures. Mean length of stay was 5.5 ± 3.4 days with a significant difference among risk groups (P = 0.029). Lower risk patients were more likely to undergo surgical management (P = 0.015) while higher risk patients required more ICU/SDU-level care (P < 0.001). Twenty-six (70.3%) minimal risk patients were discharged home compared to zero high risk patients (P = 0.001). Higher risk patients experienced higher total inpatient costs across operative and nonoperative treatment groups.The STTGMA tool is able to reliably predict hospital quality measures and cost outcomes that may allow hospitals and providers to improve value-based care and clinical decision-making for patients presenting with proximal and midshaft humerus fractures.Prognostic Level III.
View details for DOI 10.1177/2151459321992742
View details for PubMedID 33680532
View details for PubMedCentralID PMC7900848
Pull the Foley: Improved Quality for Middle-Aged and Geriatric Trauma Patients Without Indwelling Catheters.
Journal for healthcare quality : official publication of the National Association for Healthcare Quality
; 42 (6): 341–51
Urinary tract infection (UTI) complications are often attributed to the inappropriate use of urinary catheters.We sought to examine the effectiveness of a hospital-wide policy aimed at reducing the use of indwelling Foley catheters.We completed a retrospective review of prospectively collected data on 577 hip and femur fracture patients aged 55 years and older who were operatively treated at a Level 1 trauma center between October 2014 and March 2019. New standard-of-care guidelines restricting the use of indwelling Foley catheters were implemented starting January 2018, and we compared perioperative outcomes between cohorts.Over a 50% absolute reduction in indwelling Foley catheter use and a near 30% relative reduction in hospital-acquired UTI were achieved. Postpolicy cohort patients without indwelling Foley catheters experienced lower odds of hospital-acquired UTI, higher odds of home discharge, as well as decreased time to surgery, shorter length of stay, and lower total inpatient cost compared with those with indwelling Foley catheters.The policy of restricting indwelling Foley catheter placement was safe and effective. A decrease in indwelling Foley catheter use led to a decrease in the rate of hospital-acquired UTI and positively affected other perioperative outcomes.
View details for DOI 10.1097/JHQ.0000000000000241
View details for PubMedID 33149051
Fascial Hernia After Traumatic Tibial Shaft Fractures: A Cause of Chronic Leg Pain: A Report of 2 Cases.
JBJS case connector
; 10 (1): e0183
This report reviews 2 cases of chronic lower extremity pain after traumatic tibial shaft fractures treated with intramedullary nail fixation. After examination and radiographic evaluation, clinical suspicion and pressure manometry were used to identify fascial herniation and indicate patients for fasciotomy, which ultimately relieved pain.Lower extremity fascial hernias typically present with nonspecific chronic pain. Ultrasonography and magnetic resonance imaging (MRI) can be used to confirm diagnosis. However, in patients with implanted hardware, MRI may be ineffective in detecting hernias because of artifact. Clinical suspicion and pressure manometry are effective ways of identifying patients with this etiology of chronic pain.
View details for DOI 10.2106/JBJS.CC.19.00183
View details for PubMedID 32224669
Can We Accurately Predict Which Geriatric and Middle-Aged Hip Fracture Patients Will Experience a Delay to Surgery?
Geriatric orthopaedic surgery & rehabilitation
2020; 11: 2151459320946021
This study sought to investigate whether a validated trauma triage risk assessment tool can predict time to surgery and delay to surgery.Patients aged 55 and older who were admitted for operative repair or arthroplasty of a hip fracture over a 3-year period at a single academic institution were included. Risk quartiles were constructed using Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) calculations. Negative binomial and multivariable logistic regression were used to evaluate time to surgery and delay to surgery, respectively. Pairwise comparisons were performed to evaluate 30-day mortality rates and demonstrate the effectiveness of the STTGMA tool in triaging mortality risk.Six hundred eleven patients met inclusion criteria with mean age 81.1 ± 10.5 years. Injuries occurred mainly secondary to low-energy mechanisms (97.9%). Median time to surgery (31.9 hours overall) was significantly associated with STTGMA stratification (P = .002). Moderate-risk patients had 33% longer (P = .019) and high-risk patients had 28% longer time to surgery (P = .041) compared to minimal risk patients. Delay to surgery (26.4% overall) was significantly associated with STTGMA stratification (P = .015). Low-risk patients had 2.14× higher odds (P = .009), moderate-risk patients had 2.70× higher odds (P = .001), and high-risk patients had 2.18× higher odds of delay to surgery (P = .009) compared to minimal risk patients. High-risk patients experienced higher 30-day mortality compared to minimal (P < .001), low (P = .046), and moderate-risk patients (P = .046).Patients in higher STTGMA quartiles encountered longer time to surgery, greater operative delays, and higher 30-day mortality.Score for Trauma Triage in the Geriatric and Middle-Aged can quickly identify hip fracture patients at risk for a delay to surgery and may allow treatment teams to optimize surgical timing by proactively targeting these patients.Prognostic Level III.
View details for DOI 10.1177/2151459320946021
View details for PubMedID 32821470
View details for PubMedCentralID PMC7412893
Marriage Status Predicts Hospital Outcomes Following Orthopedic Trauma.
Geriatric orthopaedic surgery & rehabilitation
2020; 11: 2151459319898648
Rising costs of post-acute care facilities for both the patient and payers make discharge home after hospital stay, with or without home help, a favorable alternative for all parties. Our objectives were to assess the effect of marital status, a large source of social support for many, on disposition following hospital stay.Patients were prospectively entered into an institutional review board-approved, trauma database at a large, academic medical center. Patients aged 55 years or older with any fracture injury between 2014 and 2017 were included. Retrospectively, their relationship status was recorded through review of patient records. A status of "married" was separated from those with a status self-reported as "single," "divorced," or "widowed." Multinomial logistic regression was used to assess whether discharge location differs by marital status while controlling for demographics and injury characteristics.Of 1931 patients, 8.3% were divorced, 29.9% were single, 20.0% were widowed, and 41.8% were married. There was a significant correlation between discharge disposition and marital status. Single patients had 1.71 times, and widowed patients had 1.80 times, the odds of being discharged to a nursing home, long-term care facility, or skilled nursing facility compared to married patients after controlling for age, gender, Score for Trauma Triage in the Geriatric and Middle-Aged score, and insurance type. Additionally, single and widowed patients experienced 1.36 and 1.30 times longer length of hospital stay than their married counterparts, respectively.Patients who are identified as "single" or "widowed" should have early social work intervention to establish clear discharge expectations. Early intervention in this way would allow time for contact with close, living relatives or friends who may be able to provide sufficient support so that patients can return home. Increasing home discharge rates for these patients would reduce lengths of hospital stay and reduce post-acute care costs for both patient and payers without materially altering unplanned readmission rates.
View details for DOI 10.1177/2151459319898648
View details for PubMedID 32030312
View details for PubMedCentralID PMC6977201
Regional Anesthesia for Clavicle Fracture Surgery is Safe and Effective.
Journal of shoulder and elbow surgery
Historically, clavicle fracture repairs have been performed under general anesthesia. However, in the last few years, the combination of an interscalene brachial plexus block and a modified superficial cervical plexus block has been described to provide adequate anesthesia for clavicle fracture surgery, with the added benefit of postoperative analgesia. Members of our anesthesiology department began utilizing this block with sedation for a subset of patients undergoing clavicle fracture fixation in March, 2013.This study is a retrospective review of patients who underwent clavicle fracture repair at a single institution between June, 2014 and November, 2017. The decision for type of anesthesia (regional vs. general) was made jointly by the patient, anesthesiologist, and surgeon. Demographic data, relevant perioperative times, and intraoperative pain medication consumption were recorded, and comparisons were made in these variables between the regional and general groups.A total of 110 patients with 110 fractures were included. Fifty-two patients received regional anesthesia only with the combined block, while 58 patients received general anesthesia with an interscalene brachial plexus block. There were no major anesthetic-related complications noted in any patients, and there were no cases in which regional anesthesia had to be converted to general anesthesia because of block failure. Anesthesia start time was significantly longer in the general anesthesia group (29 vs. 20 minutes, p=0.022), as was total case time (164 vs. 131 minutes, p<0.001). Patients in the general group required significantly more intraoperative fentanyl administration (207 vs. 141 mcg, p=0.002).Regional anesthesia using a combined brachial plexus and modified superficial cervical plexus is a reliable, efficacious technique. The combined block appears to be a reasonable alternative to general anesthesia with interscalene brachial plexus block, and may have benefits with regards to anesthesia start time and total case time.Level III; Retrospective Cohort Comparison; Treatment Study.
View details for DOI 10.1016/j.jse.2020.10.009
View details for PubMedID 33197587
Hospital competitive intensity and perioperative outcomes following lumbar spinal fusion.
The spine journal : official journal of the North American Spine Society
2018; 18 (4): 626–31
Interhospital competition has been shown to influence the adoption of surgical techniques and approaches, clinical patient outcomes, and health care resource use for select surgical procedures. However, little is known regarding these dynamics as they relate to spine surgery.This investigation sought to examine the relationship between interhospital competitive intensity and perioperative outcomes following lumbar spinal fusion.This study used the Nationwide Inpatient Sample dataset, years 2003, 2006, and 2009.Patients were included based on the presence of the International Classification of Disease, Ninth Edition, Clinical Modification (ICD-9-CM) codes corresponding to lumbar spinal fusion, as well as on the presence of data on the Herfindahl-Hirschman Index (HHI).The outcome measures are perioperative complications, defined using an ICD-9-CM coding algorithm.The HHI, a validated measure of competition within a market, was used to assess hospital market competitiveness. The HHI was calculated based on the hospital cachement area. Multiple regression was performed to adjust for confounding variables including patient age, gender, primary payer, severity of illness score, primary versus revision fusion, anterior versus posterior approach, national region, hospital bed size, location or teaching status, ownership, and year. Perioperative clinical outcomes were assessed based on ICD-9-CM codes with modifications.In total, 417,520 weighted patients (87,999 unweighted records) were analyzed. The mean cachement area HHI was 0.31 (range 0.099-0.724). The average patient age was 55.4 years (standard error=0.194), and the majority of patients were female (55.8%, n=232,727). The majority of procedures were primary spinal fusions (92.7%, n=386,998) and fusions with a posterior-only technique (81.5%, n=340,271). Most procedures occurred in the South (42.5%, n=177,509) or the Midwest (27.0%, n=112,758) regions. In the multiple regression analysis, increased hospital competitive intensity was associated with an increased total complication rate (odds ratio [OR] 1.52, p<.0001), device-related complications (OR 1.46, p=.0294), genitourinary complications (OR 2.15, p=.0091), infection (OR 3.48, p<.0001), neurologic complications (OR 1.69, p=.0422), total charges (+29%, p=.0034), and inpatient hospital length of stay (LOS) (+16%, p=.0012). The likelihood of complications at state-owned hospitals (OR 2.81, p=.0001) was more highly associated with HHI than at private, non-profit hospitals (OR 1.39, p=.0050). The occurrence of complications at urban teaching hospitals (OR 2.14, p<.0001) was generally more associated with HHI than at urban non-teaching hospitals (OR 1.19, p=.2457).Increased interhospital competitive intensity is associated with increased odds of complications, increased total charges, and prolonged LOS following lumbar spine fusion. These differences are generally highest among state-owned and urban teaching hospitals. Differences in outcome related to hospital competition may be due to suboptimal resource allocation. Identifying differences in perioperative outcomes associated with hospital market competition is important in the contemporary environment of health care reimbursement reform and hospital consolidation. Perioperative outcome disparities between highly competitive and minimally competitive areas should be monitored and further studied.
View details for DOI 10.1016/j.spinee.2017.08.256
View details for PubMedID 28882522
Medical Crowdfunding for Patients Undergoing Orthopedic Surgery.
2018; 41 (1): e58–e63
Crowdfunding for medical expenses is growing in popularity. Through several websites, patients create public campaign profiles to which donors can contribute. Research on medical crowdfunding is limited, and there have been no studies of crowdfunding in orthopedics. Active medical crowdfunding campaigns for orthopedic trauma, total joint arthroplasty, and spine surgery were queried from a crowdfunding website. The characteristics and outcomes of crowdfunding campaigns were abstracted and analyzed. For this study, 444 campaigns were analyzed, raising a total of $1,443,528. Among the campaigns that received a donation, mean amount raised was $4414 (SE, $611). Multivariate analysis showed that campaigns with unspecified location (odds ratio, 0.26; P=.0008 vs West) and those for total joint arthroplasty (odds ratio, 0.35; P=.0003 vs trauma) had significantly lower odds of receipt of any donation. Description length was associated with higher odds of donation receipt (odds ratio, 1.13 per +100 characters; P<.0001). Among campaigns that received any donation, those with Southern location (-65.5%, P<.0001), international location (-68.5%, P=.0028), and unspecified location (-63.5%, P=.0039) raised lower amounts compared with campaigns in the West. Goal amount was associated with higher amount raised (+3.2% per +$1000, P<.0001). Resources obtained through crowdfunding may be disproportionately available to patients with specific diagnoses, those from specific regions, those who are able to craft a lengthy descriptive narrative, and those with access to robust digital social networks. Clinicians are likely to see a greater proportion of patients turning to crowdfunding as it grows in popularity. Patients may ask physicians for information about crowdfunding or request testimonials to support campaigns. Surgeons should consider their response to such requests individually. These findings shed light on the dynamics of medical crowdfunding and support robust personal and professional deliberation. [Orthopedics. 2018; 41(1):e58-e63.].
View details for DOI 10.3928/01477447-20171114-04
View details for PubMedID 29156070
Give me a SINE: how Selective Inhibitors of Nuclear Export modulate autophagy and aging.
Molecular & cellular oncology
2018; 5 (5): e1502511
Autophagy is a cellular recycling process leading to lysosomal degradation of damaged macromolecules, which can protect cells against aging. The transcription factor EB (TFEB), a major transcriptional regulator of genes involved in autophagy and lysosomal function, is emerging as an attractive target for pharmacological modulation. Recently, we demonstrated that inhibiting the function of nuclear export protein exportin 1 (XPO1 or CRM1) with RNAi or with selective inhibitors of nuclear export (SINE) results in the nuclear enrichment of TFEB and enhancement of autophagy in model organisms and human cells. In addition to current efforts to validate the use of SINE in cancer therapies, our work highlights the potential benefits of these drugs toward improving outcomes in neurodegenerative diseases and aging.
View details for DOI 10.1080/23723556.2018.1502511
View details for PubMedID 30263946
View details for PubMedCentralID PMC6154834