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Comparative Diagnostic Accuracy of Pre-Test Clinical Probability Scores for the Risk Stratification of Patients With Suspected Pulmonary Embolism: A Systematic Review and Bayesian Network Meta-Analysis
No full textBackground: The primary evaluation of pulmonary embolism (PE) is complicated by the presence of various pre-test clinical probability scores (pCPS) with different cut-offs, all equally recommended by guidelines. This lack of consensus has led to practice variability, unnecessary imaging, and worse patient outcomes. We aim to provide more definitive insights through a holistic comparison of available pCPS. Methods: PubMed, Embase and Web of Science, and Google Scholar were searched for studies evaluating pCPS in patients clinically suspected of PE until June 2023. Risk of bias was evaluated using QUADAS-2. Included pCPS were evaluated based on their diagnostic accuracy in: (1) Ruling-out PE (2) Utilization of imaging, and (3) Differentiating between patients needing d-dimer from imaging. Diagnostic test accuracy indices were synthesized using beta-binomial Bayesian methods. Results: Forty studies (37,027 patients) were included in the meta-analysis. Three-tier revised Geneva (RG) and three-tier Wells performed similarly in ruling-out PE (negative likelihood ratio (LR-) [95% credible interval (CI)]: 0·39[0·27–0·58] vs 0·34[0·25–0·45]). However, RG performed better in utilization of imaging (LR + : 6·65[3·75–10·56] vs 5·59[3·7–8·37], p \u3c 0.001) and differentiating between patients needing d-dimer vs imaging (diagnostic odds ratio (DOR): 8·03[4·35–14·1] vs. 7·4[4·65–11·84], p \u3c 0.001). The two-tier Wells score underperformed in all aspects (LR-: 0·56[0·45–0·68], LR + : 2·43[1·81–3·07], DOR: 4·41[2·81–6·43]). PERC demonstrated a reliable point estimate for ruling out PE, albeit with a wide CI (LR-: 0·36[0·17–0·78]). Conclusions: RG outperforms other pCPS for primary evaluation of suspected PE. While the difference is not large, RG\u27s independence from subjective items supports its recommendation over three-tier Wells. Two-tier Wells underperforms significantly compared to the rest of pCPS. PERC shows considerable promise for minimizing unnecessary D-dimer testing in crowded emergency departments; however, more evidence is needed before its definitive recommendation. Protocol registration: PROSPERO (CRD42023464118)
Review of the Etiology, Diagnosis, and Therapy of Left Atrial Thrombus
No full textThrombi in the left atrial appendage (LAA) are an important cause of systemic thromboembolism in patients with atrial fibrillation. The gold standard for the diagnosis of LAA thrombi is a transesophageal echocardiogram, although cardiac multidetector computed tomography, intracardiac echocardiogram, and cardiac magnetic resonance imaging are alternative diagnostic imaging modalities. When an LAA thrombus is diagnosed, effective anticoagulation is recommended for at least 3 weeks or until thrombus resolution is confirmed on repeat transesophageal echocardiogram. Recent prospective research shows the efficacy of nonvitamin K oral anticoagulants in the treatment of LAA thrombus, which offers a promising alternative to vitamin K antagonists. As an alternative approach, left atrial aspiration thrombectomy has been described in case reports, though there is limited evidence comparing its efficacy to anticoagulation alone
Sarcoidosis-Specific Cutaneous Lesion Distribution in Clinical Assessment for Cardiac Sarcoidosis
No full textEffectiveness of Using Telehealth to Increase Parent Skill Acquisition and Implementation of Behavioral Protocols
No full textInTouch Week of September 15, 2025
No full textFounder’s Dinner Set for October 22 NYMC Receives $400,000 Grant for Pediatric Cancer Research from Hyundai Hope on Wheels M1 Students and Alumni Connect at Networking Soiree Free Campus Food Pantries Available to Support Students Tailgate Gear Savings In the Community: NYMC Community Rallies Together at Donate Life Club Blood Drive In the Community: SIGN Walks for Epilepsyhttps://touroscholar.touro.edu/in_touch/1374/thumbnail.jp
InTouch Week of October 27, 2025
No full textFounder’s Dinner Honors Leadership and Inspires Generosity SOM Class of 2029 Officially Don Their White Coats for the First Time 32nd Annual Faculty Author Awards Highlights Faculty Excellence Mill Etienne, M.D. ’02, M.P.H., Awarded Prestigious AAMC Award for Humanism in Medicine NYMC Goes Orange for Physical Therapy Month Students Carve Out Creativity at the NYMC Pumpkin Carving Contest For Medical Students, the Pre-Matriculation Program Continues to Evolve NYMC/WMC Ophthalmology Alumni Gather for Inaugural Reception at AAO Conference in Orlando Fire Safety Training at BSB for Students, Faculty, and Staff TCDM Goes to the Dominican Republic on a Volunteer Mission Triphttps://touroscholar.touro.edu/in_touch/1378/thumbnail.jp
2024 Touro University System Faculty Publications
No full textThe 2024 edition of the Faculty Publications Book of the Touro University System. This bibliography contains the published works of affiliated authors during 2024, arranged by academic unit.https://touroscholar.touro.edu/facpubs/1014/thumbnail.jp
Altered States: Studies of Monoamine Neuromodulation and the Differential Behavioral Actions of Prefrontal to Dorsal Raphe Projections in Normal and Narcoleptic Mice
No full textSerotonergic dorsal raphe neurons of the midbrain regulate numerous brain functions, including sleep-wake states. Activation of α1 receptors located on dorsal raphe neurons produces a noisy depolarization of serotonergic neurons and prolongs the postspike after hyperpolarization, but how these actions interact to influence the encoding of inputs into the firing of action potentials is not well understood. Prior studies in pyramidal neurons indicate that combination of synaptic noise and AHP magnitude can divisively or multiplicatively alter firing gain. Thus, in Aim 1 we investigated how α1 receptor activation alters spike encoding in serotonergic dorsal raphe neurons. Using whole cell recordings in brain slices, we found that phenylephrine (α1 receptor agonist) actions resulted in decreased steady state, but not initial, firing rate to enhance spike frequency adaptation over a wide range of input currents. Further, these actions resulted in a subtractive effect on steady state firing gain such that more current was required to drive firing. Since spike frequency adaptation functions as a high-pass filter, we suggest the collective actions of phenylephrine on dorsal raphe serotonergic neurons are to accentuate this high-pass filter to preserve or enhance encoding of rapidly varying inputs, like those related to transient behavioral events, while suppressing sensitivity to slowly varying inputs. These actions mirror those of orexin receptor activation on dorsal raphe neurons and are expected to be directly and indirectly disrupted by loss of orexin signaling. Orexin deficiency causes type 1 narcolepsy, a sleep disorder characterized by fragmented sleep-wake states, excessive daytime sleepiness, and cataplexy. Cataplexy episodes are bouts of muscle atonia without loss of consciousness and can be triggered by salient emotional states. Orexin modulation of dorsal raphe serotonergic neurons has been implicated in cataplexy, but inputs to dorsal raphe comprising the dysregulated circuit in the absence of orexin remain to be identified. Evidence exists that prefrontal cortex inhibition suppresses cataplexy and since its afferents project to dorsal raphe, in Aim 2 we investigated whether this circuit was involved in mediating cataplexy. We hypothesized that in the absence of orexinergic signaling, activation of prefrontal cortex inputs to dorsal raphe neurons would lead to greater disynaptic inhibition and promote cataplexy. To test this, we expressed light-gated excitatory channels (Chronos) in prefrontal cortex neurons and optically stimulated axon terminals in dorsal raphe in wild type and orexin peptide null mice while observing cataplexy-like episodes. To observe emotionally induced cataplexy effects, chocolate was provided at dark onset. We observed no effects of activating the prefrontal cortex to dorsal raphe circuitry on spontaneous, or emotionally induced, cataplexy bout frequency or duration. We then sought to confirm whether inhibition of prefrontal cortex would suppress cataplexy. We tested this by expressing excitatory DREADD receptors in prefrontal cortex GABA neurons so that we could suppress output while observing behavior following dark onset, with and without chocolate. We were not able to detect effects on cataplexy expression resulting from activating local GABA prefrontal cortex neurons, which contradicts the limited literature. We suggest alternate pathways which may be involved in cataplexy modulation by orexin for future study. Prefrontal cortex has been linked to mood disorders with corresponding sleep abnormalities, and is capable of regulating consciousness, but whether direct projections to dorsal raphe modulate arousal is unknown. In Aim 3 we tested this possibility by expressing Chronos in prefrontal cortex neurons and optically stimulating terminals in dorsal raphe in wild type and orexin-null mice while observing behavior after lights off. Sleep-like behavior (bout number, total duration) increased and latency to first epoch reduced in wild type mice, even when access to chocolate was provided. These effects were absent in orexin-null mice, where conversely, stimulation resulted in less time spent in sleep-like behavior and did not overcome the arousing effect of chocolate. Together the findings demonstrate prefrontal cortex output to dorsal raphe increases propensity for sleep-like episodes and this is sufficiently powerful to suppress wake-promoting effects of chocolate, and notably this is a novel circuit for arousal regulation which requires orexin neuropeptides. Combined, our results suggest that during aroused states, activation of orexin and alpha-1 receptors excite serotonergic dorsal raphe neurons and tune their temporal responsiveness by accentuating their high-pass filter characteristics to favor spiking in response to higher-frequency synaptic inputs. Prefrontal cortex circuitry to dorsal raphe did not appear to be involved in regulating cataplexy-like behavior in orexin null mice, but considerably increased sleep-like behavior in wild type mice even under conditions of high emotional arousal. This suggests the circuitry from prefrontal cortex to dorsal raphe can provide a signal that increases sleep pressure, a novel finding. Surprisingly, this signaling required orexin, which may be necessary for serotonergic dorsal raphe neurons to adequately encode sleep need
Preeclampsia’s Cardiovascular Aftermath a Comprehensive Review of Consequences for Mother and Offspring
No full textPreeclampsia (PE), a multisystem hypertensive disorder affecting 2–8% of pregnancies, has emerged as a novel risk factor for cardiovascular disease (CVD) in affected mothers and in their offspring. Between 10 and 15 years following gestation, women with a history of PE have double the risk of CVD, nearly 4 times the risk of hypertension, and increased all-cause mortality. Offspring exposed to PE in utero carry an increased risk of CVD and congenital heart defects. Due to the multifactorial nature of both PE and CVD, a clear dependency has been difficult to establish. The interplay between CVD and PE is an area of active investigation, likely involving placental, genetic, and epigenetic factors resulting in enduring endothelial, vascular, and immune dysfunction. Fetal developmental programming induced by adverse intrauterine environments, epigenetic changes triggered by oxidative stress, and underlying genetic predisposition play pivotal roles in the development of CVD in offspring exposed to PE. Though the literature has discussed the cardiovascular outcomes associated with PE for nearly a decade, patient risk perception and health care provider awareness remain low, representing a substantial missed opportunity for early intervention in this vulnerable population. This review article will discuss the pathophysiology of preeclampsia, its intersection with CVD, and the long-term cardiovascular consequences for affected mothers and their offspring. Our objective is to increase health care provider awareness and garner greater research interest in this important topic
Endovascular Therapy versus Medical Management in Isolated Anterior Cerebral Artery Acute Ischemic Stroke: A Multinational Multicenter Propensity Score-Weighted Study
No full textBackground Isolated anterior cerebral artery occlusions (ACAo) in patients with acute ischemic stroke present significant challenges due to their rarity. The efficacy and safety of endovascular therapy (EVT) in comparison with best medical therapy (BMT) for ACAo remains unclear. This study aimed to assess the outcomes of these treatments. Methods This multinational, multicenter study analyzed data from the MAD-MT registry. Data were collected retrospectively from 37 sites across North America, Asia, and Europe. Inverse probability of treatment weighting (IPTW) was applied to balance confounding variables. The primary outcome was functional independence (modified Rankin Scale (mRS) scores of 0-2) at 90 days. Secondary outcomes included excellent outcomes (mRS 0-1), mortality at 90 days, and NIH Stroke Scale (NIHSS) score on day 1 post treatment. Results Of the 108 patients, 36 received BMT and 72 underwent EVT. The median age was 75 years, and 56% were male. At 90 days, 40% of patients achieved mRS 0-2, with no significant difference between EVT and BMT (38% vs 45%, p=0.46). Procedural success (mTICI 2b-3) was 91% in the EVT group, with a sICH rate of 2.9%. IPTW-adjusted analysis showed no significant difference between EVT and BMT for functional independence (OR 1.17, 95% CI 0.23 to 6.02, p=0.85), mortality (25% vs 21%, p=0.71) or day 1 NIHSS scores (Beta 2.2, 95% CI -0.51 to 4.8, p=0.11). Conclusions EVT showed high procedural success but did not significantly improve functional outcomes or mortality compared with BMT in patients with ACAo. Further randomized trials are needed to clarify EVT\u27s role in ACAo