Faculty Bibliography

INTRODUCTION AND PROBLEM STATEMENT/UNASSIGNED:Competency in brain death/death by neurologic criteria (BD/DNC) determination is an Accreditation Council for Graduate Medical Education (ACGME) milestone in neurology residency and neurocritical care fellowship; however, trainees have limited clinical exposure and receive inconsistent training across institutions. Simulation offers a standardized, safe environment to teach and assess BD/DNC, but multi-institutional implementation remains unstudied. The aim of this study was to evaluate the feasibility of implementing a consensus-based BD/DNC curriculum and to assess its impact on trainee confidence. LEARNING OBJECTIVES/UNASSIGNED:By the end of the curriculum, trainees will be confident in assessing BD/DNC prerequisites, performing a complete neurologic examination, safely conducting and interpreting apnea testing, and accurately declaring BD/DNC. METHODS AND CURRICULUM DESCRIPTION/UNASSIGNED:test. RESULTS/UNASSIGNED:Nineteen participants (9 female [47%]; predominantly PGY-4 trainees) were enrolled. Median [IQR] pre-post composite confidence scores improved significantly across all domains: "Setup and Family Counseling," 4 [3.5-4] to 4.5 [4-5]; "Prerequisites," 4 [4-5] to 4.5 [4-5]; "Neurologic Examination," 4 [4-4] to 4.5 [4-5]; and "Apnea Test and Declaration of BD/DNC," 3 [3-4] to 5 [4-5]. The effect sizes (Wilcoxon r) ranged from 0.79 to 0.88 across domains. There were no significant differences in the magnitude of improvement between high-fidelity and low-fidelity groups. After curriculum implementation, 13 of 19 participants (68%) self-assessed their ACGME BD/DNC milestone competency to be level 4 or 5. DISCUSSION AND LESSONS LEARNED/UNASSIGNED:This multi-institutional pilot demonstrated that a consensus-based BD/DNC simulation curriculum is feasible and improves trainee confidence despite limited previous clinical exposure. Key lessons include the feasibility of multicenter collaboration, standardizing core practices while accommodating local variability, and designing adaptable curricula that achieve similar outcomes across resource-diverse settings.

PURPOSE/OBJECTIVE:To determine the association between labral width as measured on preoperative magnetic resonance imaging (MRI) and patient-reported outcomes, achievement of clinically significant thresholds, and reoperation rates in hip arthroscopy for femoroacetabular impingement syndrome (FAIS) at minimum 10-year follow-up. METHODS:A retrospective review of a prospectively gathered database of hip arthroscopy patients from August 2012 to June 2014 was conducted. Inclusion criteria were patients ≥18 years with clinically and radiographically confirmed FAIS and labral tearing who underwent primary hip arthroscopy with labral repair or debridement and had ≥10 years of follow-up. MRI labral width measurements were performed by 2 blinded musculoskeletal radiologists at standardized clockface locations using a validated technique. Outcomes were assessed using the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). Patients were classified as hypoplastic if they had a labral width below the mean on 2 or more views. Outcomes and reoperation rates were compared between groups using independent samples t-tests for continuous variables and chi-square tests for categorical variables. RESULTS:were included, with a mean follow-up of 11.30 ± 0.47 years. Patients were categorized into hypoplastic (n = 42) and nonhypoplastic (n = 41) groups. There was no significant difference between hypoplastic and nonhypoplastic groups with respect to age, sex, smoking status, or intraoperative procedures. Additionally, there were no significant intergroup differences in mHHS or NAHS improvement at 5 or 10 years postoperatively. Both groups showed high achievement of the mHHS minimal clinically important difference threshold at 10-year follow-up with no significant difference (nonhypoplastic: 90.3% vs hypoplastic: 85.2%, P = .549). There was also no difference achievement of the patient acceptable symptom state (nonhypoplastic: 64.5% vs. hypoplastic: 70.4%, P = .636). However, the hypoplastic group had a significantly higher rate of revision arthroscopy (28.6% vs 9.8%, P = .030) and conversion to total hip arthroplasty (21.4% vs 4.9%, P = .026) when compared with the nonhypoplastic group. CONCLUSIONS:Hypoplastic labral width on preoperative MRI was associated with an increased risk of revision hip arthroscopy and conversion to total hip arthroplasty at 10 year follow-up in patients with FAIS. LEVEL OF EVIDENCE/METHODS:Level III, retrospective comparative case series.

INTRODUCTION/BACKGROUND:State regulations governing opioid treatment programs (OTPs) vary widely in their restrictiveness, yet how state policies relate to the availability of services offered within OTPs remains understudied. In this study, we compare the availability of medication for opioid use disorder (MOUD) options, psychosocial services, and housing supports across OTPs operating in states with different levels of OTP policy restrictions. METHODS:We conducted a cross-sectional study of 1501 opioid treatment programs (OTPs) in the United States. Exposures included 11 state-level OTP policies that impose legal or administrative barriers to opening or operating OTPs or to patients' receipt of care (e.g., pharmacy licensure requirements, zoning restrictions, government identification requirements, and administrative discharge for positive drug screenings). Data on OTP service offerings-including buprenorphine, naltrexone, all three medications for opioid use disorder, mental health services, contingency management, trauma-informed counseling, and housing services-and organizational characteristics were obtained from the 2023 Mental Health and Addiction Treatment Tracking Repository, a national longitudinal database of licensed substance use disorder treatment facilities. These data were linked to a previously developed state policy typology using latent class analysis, which categorized states as having low or high OTP restrictiveness. Regression models adjusted for state- and organizational-level characteristics and accounted for clustering within states. RESULTS:In descriptive analyses, OTPs in highly restrictive states were significantly less likely (p < 0.05) to offer all three MOUDs and behavioral health services, including mental health services, trauma-informed counseling, and contingency management, compared with OTPs in low-restrictiveness states. In adjusted Poisson regression models, facilities in highly restrictive states were significantly less likely to offer naltrexone (ARR: 0.73; 95% CI: 0.54-0.97) and all three MOUDs (ARR: 0.70; 95% CI: 0.53-0.92). CONCLUSIONS:Given that OTPs are the only facilities in which methadone can be legally dispensed, these facilities are a critical point of access for individuals in need of evidence-based OUD treatment. However, our findings suggest that states that place additional restrictions on OTPs also offer less services within their OTPs.

OBJECTIVE/UNASSIGNED:To evaluate the safety of alopecia treatments during pregnancy, in-vitro fertilization (IVF), and polycystic ovary syndrome (PCOS) workup, with a focus on potential maternal and fetal risks. DATA SOURCES/UNASSIGNED:A comprehensive literature search was conducted across PubMed, Web of Science, and Scopus from November 2024 to December 2024. Search terms included medication names in combination with "pregnancy," "IVF," "in-vitro fertilization," and "PCOS." STUDY SELECTION/UNASSIGNED:Peer-reviewed studies addressing the use of therapies for androgenetic alopecia, alopecia areata, and scarring alopecias in the contexts of pregnancy, IVF, and PCOS were included. Articles evaluating maternal safety, fetal risks, and treatment timing were prioritized. Only English-language publications were reviewed. RESULTS/UNASSIGNED:Despite increasing therapeutic options for alopecia, significant knowledge gaps remain regarding their safety during pregnancy. Pregnant women are often excluded from clinical trials, leading to a reliance on older treatments with limited data on dosing or pharmacokinetics in the pregnant population. Unfortunately, there are few alopecia medications with robust safety data in pregnancy, and many medications are contraindicated during this period. Some medications may be used with caution, while others require additional investigation. During IVF, there are alopecia medications with potential benefit in women experiencing implantation failure or PCOS. For patients undergoing PCOS workup, some alopecia medications may impact hormonal labs or mask PCOS symptoms. CONCLUSION/UNASSIGNED:There is a critical need for more targeted research on alopecia treatments in pregnancy, IVF, and PCOS contexts. This review provides current evidence to guide clinicians and support informed, individualized treatment decisions during this vulnerable period.

BACKGROUND:Chronic axial spinal pain is one of the leading causes of disability. The literature demonstrates that expenditures for low back and neck pain continue to rise, not only in parallel with increasing disability, but also with escalating healthcare costs, accounting for the highest spending among multiple disease categories. Based on current evidence utilizing controlled diagnostic blocks, facet joints, nerve root dura, and sacroiliac joints have been identified as potential sources of spinal pain. STUDY DESIGN/METHODS:A systematic review of the diagnostic accuracy of spinal facet joint nerve blocks. OBJECTIVE:To determine the diagnostic accuracy of spinal facet joint nerve blocks in chronic spinal pain. METHODS:Methodological quality of the included studies was assessed using the Quality Appraisal of Reliability Studies (QAREL) instrument. Only diagnostic accuracy studies meeting at least 50% of the predefined inclusion criteria were included in the analysis.The strength of evidence was graded using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. Levels of evidence were classified using a modified best evidence synthesis, ranging from Level I to Level V.Data sources included relevant literature identified through PubMed and other electronic searches published from 1966 through September 2025, Cochrane reviews, and manual searches of the bibliographies of primary and review articles. OUTCOME MEASURES/METHODS:Eligible studies were required to use placebo-controlled or comparative local anesthetic blocks. A positive diagnostic standard was defined as at least 50% pain relief from baseline scores along with the ability to perform previously painful movements. RESULTS:The available evidence demonstrated Level I for lumbar facet joint nerve blocks, based on 18 studies employing dual diagnostic blocks, demonstrating 75% to 80% pain relief, with an average prevalence of 16% to 45% and estimated or presumed false-positive rates of 25% to 50%.Evidence for the diagnosis of cervical facet joint pain using cervical facet joint nerve blocks is Level II, derived from 12 controlled diagnostic accuracy studies, showing substantial heterogeneity and internal inconsistency. Reported prevalence ranged from 36% to 67% with ≥ 80% pain relief and estimated or presumed false-positive rates of 26% to 63%.The level of evidence for the diagnostic accuracy of thoracic facet joint nerve blocks is Level II, based on 3 studies using dual diagnostic blocks, demonstrating 80% or greater pain relief, with prevalence ranging from 34% to 48% and estimated or presumed false-positive rates ranging from 42% to 58%. LIMITATIONS/CONCLUSIONS:Limitations of this systematic review include the limited number of studies involving the thoracic spine, ongoing debate regarding the appropriate reference standard, challenges in determining false-positive rates, concerns regarding the appropriateness of diagnostic blocks, the scarcity of recent publications, and issues related to clinical utility. CONCLUSION/CONCLUSIONS:There is Level I evidence for the diagnostic accuracy of lumbar facet joint nerve blocks and Level II evidence for cervical and thoracic facet joint nerve blocks in the evaluation of chronic spinal pain.

OBJECTIVES/OBJECTIVE:Medicare-funded home health (HH) provides short-term nursing, physical therapy, and other services to over 3.5 million older adults each year. Currently, half of HH episodes are "community-entry," meaning the patient was referred without an immediately preceding hospitalization. The 2020 implementation of a new payment system-the Patient-Driven Groupings Model (PDGM)-reduced traditional Medicare reimbursement for community-entry HH (CEHH). We investigated shifts in CEHH care delivery following PDGM implementation. DESIGN/METHODS:Cross-sectional study of national 2019 and 2021 linked HH claims, assessment, HH agency, and geographic data. SETTING AND PARTICIPANTS/METHODS:Traditional Medicare beneficiaries receiving a CEHH episode in 2019 or 2021 (n = 577,602). METHODS:HH is provided through clinician visits to the patient's home; therefore, visits are the primary unit of care delivery. We modeled the number of visits overall and by service type (eg, nursing, physical therapy) using national data for CEHH patients pre-PDGM (ie, 2019) and post-PDGM (ie, 2021). Models adjust for relevant patient, HH agency, and geographic characteristics (including monthly county-level COVID-19 infection rates). RESULTS:Following PDGM, there was an 18% decrease in total visits received, with the largest decreases in the number of physical therapy (-13%), occupational therapy (-17%), and aide (-16%) visits. Reductions in visits were greatest at HH agencies with lower Medicare Advantage penetration (and thus, greater exposure to PDGM) and for-profit agencies. CONCLUSIONS AND IMPLICATIONS/CONCLUSIONS:Findings raise questions about HH agencies' ongoing ability to meet the needs of patients with complex, overlapping clinical and social needs following PDGM implementation. Ongoing monitoring of how these care delivery changes impact outcomes for CEHH patients is essential to ensure that HH can continue to help high-need older adults safely age in place.

BACKGROUND:Prediction of treatment outcomes is essential for improving clinical management, particularly in patients with soft tissue sarcoma, where treatment options remain suboptimal. Given the limitations of current therapies, there is increasing interest in combining neoadjuvant radiotherapy with immunotherapy, referred to as neoadjuvant radioimmunotherapy (NRIT). We aim to develop a predictive model for assessing pathologic treatment response in patients undergoing NRIT or chemoradiotherapy, integrating radiomic features with radiologist assessments, clinical data, and pathology findings. MATERIALS AND METHODS/METHODS:Radiomic and semantic features were extracted from pre- and post-treatment MRI scans. The XGBoost algorithm was used for feature selection and model development. Models included a model based on clinical variables and semantic features, a model based on radiomic features and clinical features and a model using all available features. RESULTS:Study cohort included 213 patients (mean age of 54 years, male/female of 1.6). There were 17 patients in the prospective arm. The best model used all radiomic, clinical, and semantics features. It achieved an area under the receiver operating characteristic curve (AUC) of 0.72 (95% CI = 0.51-0.89) on the hold-out testing set. CONCLUSION/CONCLUSIONS:Multi-modal radiomic-based models are effective in identifying patients at higher risk of non-response to neoadjuvant therapy. Furthermore, the performance of multi-modal radiomics-based models exceeded those based solely on radiologist evaluations. Our findings underscore the potential of radiomics in enhancing precision medicine by enabling identification of treatment response in STS patients undergoing NRIT before surgical excision of the tumor.

OBJECTIVES/UNASSIGNED:To develop and study a novel means of imaging auditory brainstem implant (ABI) paddle placement utilizing postoperative MRI images to determine correlation between ABI performance and ideal paddle placement properties. DESIGN/UNASSIGNED:Single-center retrospective review and image analysis. SETTING/UNASSIGNED:Tertiary referral center. PARTICIPANTS/UNASSIGNED:Patients >18 years old who received an ABI from 2009 to 2023 and had subsequent MRI and auditory performance testing completed. MAIN OUTCOME MEASURES/UNASSIGNED:ABI paddle angulation and insertion depth measure, in addition to categories of auditory performance (CAP) score. RESULTS/UNASSIGNED: = 0.049) once patients with large tumor burden were excluded. Insertion depth and axial angulation showed a negative correlation, in which higher insertion depth was associated with a decrease in axial angulation value, although not statistically significant. CONCLUSION/UNASSIGNED:We present a novel means of measuring ABI paddle placement utilizing MRI to improve the objectivity of paddle placements assessments. Multicenter collaboration to increase the number of patients studied with this new measurement scheme will be required before stronger measurement associations can be determined.

Pediatric autoimmune hemolytic anemia (AIHA) is a heterogeneous disease with significant morbidity due to the underlying condition and its treatment. Evidence-based guidelines for evaluation and management are lacking. Data from 399 patients with AIHA followed at 15 pediatric centers were collected to identify factors associated with secondary diagnoses, recurrent/chronic course, therapeutic efficacy, and mortality. Most had AIHA associated with secondary diagnoses including Evans syndrome (37%, 142/385), other autoimmunity (22%, 86/392), and inborn errors of immunity (IEI, 18%, 68/379). Of 305 patients tested, 82% had abnormal functional immune results. Genetic testing for an IEI was sent in 31% (109/348) with pathogenic findings identified in 32% of those tested. Patients with IEI or other autoimmunity more frequently had abnormal immunoglobulin and complement testing. Prevalence of IEI was not different between those presenting with or without infection. The median number of treatments for the first AIHA episode was 2 (range: 0-17). Of those with warm AIHA, 31% received steroid-sparing therapy during the first episode. Patients with recurrent AIHA (42%) had a higher rate of abnormal immune tests (OR=2.29, p=0.012), Evans syndrome (OR= 4.85; p<0.001), IEI (OR=3.88, p<0.001), and other autoimmune disorders (OR=3.29; p<0.001). With median follow up of 4.9 years (range: 0-19.4 years), 72/257 (28%) with warm AIHA continued to have active disease on treatment. Of the 399 patients, 10 died, all of whom had secondary diagnoses. Expansive immune evaluation, monitoring, and targeted treatments directed at immune diagnoses are needed for pediatric AIHA, highlighting the need for evidence-based pediatric AIHA guidelines.

PURPOSE/OBJECTIVE:To evaluate the effects of extracorporeal ultra-high-fluence corneal cross-linking (ECO-CAIRS) on the dehydration and rehydration behavior of porcine corneal stromal ring segments in an experimental model simulating the preparation of corneal allogenic intrastromal ring segments. SETTING/METHODS:ELZA Institute, Zurich, Switzerland. METHODS:Corneal ring segments (two per cornea) were prepared from freshly enucleated porcine corneas (n=48) and randomly divided into three groups: controls (no CXL, Jerky technique), extracorporeal ultra-high-fluence CXL at 30 J/cm2, and 60 J/cm2 (n=32 each). After epithelial removal and ring preparation, segments in the control group were soaked in balanced salt solution (BSS), while those in the experimental groups were soaked in riboflavin solution (Ribo-Ker, EMAGine AG, Zug, Switzerland) for 10 minutes. Each group subsequently underwent a total dehydration period of 45 minutes, which included both UV-A irradiation and waiting phases for the CXL-treated groups, followed by a 10-minute rehydration phase using BSS. Segment thickness was measured by calibrated imaging at baseline, after dehydration, and after rehydration. RESULTS:Baseline structural thickness values did not differ significantly between groups. Both CXL-treated groups demonstrated significantly greater dehydration (p<0.01) and reduced rehydration (p<0.01) when compared to controls. No significant differences were found between the two CXL-treated groups. Ultra-high-fluence cross-linking enhanced segment dehydration and slowed rehydration. CONCLUSIONS:ECO-CAIRS effectively modulates the dehydration and rehydration of corneal ring segments, which may improve handling and implantation characteristics during surgery. These findings support the potential clinical benefit of CXL in CAIRS procedures. Further in vivo studies are required to confirm long-term behavior and biomechanical impact.