Faculty Bibliography

OBJECTIVE:Texture analysis extracts high-order mathematical features from an image with the potential to reveal subtle image differences. Although racial variations have been demonstrated in traditional optical coherence tomography angiography (OCTA) parameters, texture analysis has not been well explored. METHODS:This is a retrospective, cross-sectional study of 226 eyes from 127 nondiabetic subjects (60 Black, 67 White). We collected 3 × 3 mm en face OCTA images of the superficial choriocapillaris (CC), which were processed using computerized texture analysis to extract the following features: average grey level, grey level 30% threshold, grey level 70% threshold, balance, skewness, energy, entropy, contrast, mean gradient, root-mean-square (RMS) variation, and first moment of power spectrum. RESULTS:There were no significant baseline differences in the demographics and clinical characteristics of the 2 racial groups, other than a higher rate of diagnosed hypertension in Black subjects (20% in Black vs 6% in White subjects; p = 0.017). Using a mixed-effects linear regression model, we found statistically significant differences in the absolute value of the grey level, skewness, and root-mean-square variation, which remained significant in a subgroup of nonhypertensive patients (p < 0.001 for all). CONCLUSIONS:These findings demonstrate racial variation in CC texture features, underscoring the importance of diversity when building clinical datasets. Future studies may better explore how these differences correlate with underlying chorioretinal pathogenesis.

Pancreatic ductal adenocarcinoma (PDAC) is a devastating cancer with increasing incidence and a dismal prognosis. Here, we uncover serine protease inhibitor Kazal type 1 (SPINK1) as a putative determinant of PDAC progression with a previously unrecognized role in epigenomic regulation. We show that SPINK1 expression, which is highly dynamic across PDAC progression, is associated with key aggressive cancer phenotypic states and regulates cancer cell stemness and plasticity in both in vitro and patient samples. Mechanistically, our results suggest a new signaling axis where SPINK1 interacts with COL18A1 to promote its cleavage into endostatin, which then induces histone H3 modifications. These results reveal a new function of SPINK1 in PDAC and highlight the SPINK1-COL18A1-endostatin signaling axis as a potential therapeutic target to combat PDAC aggressiveness.

BACKGROUND:Agitation is a common clinical presentation associated with up to 2.6% of emergency department (ED) visits per year. The science of identifying, predicting, and managing agitation has rapidly progressed over the past decade, leading to broad recommendations about initial approaches and management strategies. OBJECTIVE:The purpose of this clinical review is to review existing literature on the etiology, recognition, and management of agitation to help clinicians and staff who care for these patients. METHODS:A narrative review was performed of articles published from 1984 to 2026. DISCUSSION/CONCLUSIONS:Standardized approaches to agitation management are discussed, highlighting both existing literature and research gaps. There is broad agreement on 5 main objectives of the approach to the agitated patient in the ED: address safety issues for the patient and ED staff, an expedited clinical assessment, identifying a presumptive etiology of agitation in order to guide treatment, verbal de-escalation as an initial management strategy, and judicious medication administration. CONCLUSIONS:This review shows that practices like verbal de-escalation, therapeutically-indicated medication administration, and multidisciplinary teamwork are imperative to improving care and reducing mistrust, longer hospital stays, use of restraints, and physical assaults on ED staff and ultimately, workplace violence. In particular, verbal de-escalation should be a first-line treatment. There is agreement that the etiology of agitation should guide management, but less agreement on particular drug combinations if medication is needed. Recommendations are given but further research is necessary.

Global imaging demand now exceeds capacity due to an aging population, rising comorbidities, expanded indications for imaging, and workforce shortages. These pressures are reshaping national health care policy. At the same time, the competing demands to expand access to imaging services while reducing costs are creating momentum to reimagine imaging delivery through the integration of transformative technologies like artificial intelligence (AI). This consensus statement from the International Society for Strategic Studies in Radiology (IS3R) is a call to action, outlining promising AI solutions that increase workflow efficiency and align radiology with health system and payer priorities. Reflecting expert consensus from the IS3R meeting in Dublin, Ireland, in August 2025, this statement defines strategic directions for radiology amid accelerating digitalization, rapid innovation, and data-driven patient care. This article covers four domains: image interpretation, capacity building, data governance, and systemic digital transformation. This article examines how AI can address rising imaging demand and costs while addressing challenges related to improving data quality, standardization, and interoperability. It also highlights the need to re-engineer workflows and adapt to new care models while maintaining high-quality services. Finally, it presents consensus recommendations outlining how AI can enable multimodal health data integration and advance alignment with value-based care.

BACKGROUND/UNASSIGNED:Psychotherapy training is difficult to scale because manual rating of motivational interviewing (MI) and cognitive behavioral therapy (CBT) sessions is time-intensive, requires trained raters, and is subject to rater variability. Large language models (LLMs) may support simulation-based training and rubric-guided scoring, but early-stage evidence is needed before such systems can be applied to real learners. OBJECTIVE/UNASSIGNED:This study aimed to conduct a simulation-based evaluation of a multiagent LLM framework for generating and scoring stylized MI and CBT training encounters. METHODS/UNASSIGNED:<0.05. Agreement analyses used intraclass correlation coefficients (ICCs) with bootstrap 95% CIs. A secondary prompt-augmentation sensitivity analysis tested whether appending criterion-referenced feedback text to the novice Student-agent prompt shifted subsequent Evaluator-assigned scores. RESULTS/UNASSIGNED:Evaluator scores increased across prompt-defined Student-agent competence levels. For MI, overall mean scores increased from 1.18 (95% CI 1.16-1.20) for novice profiles to 1.75 (95% CI 1.69-1.81) for intermediate profiles and to 3.57 (95% CI 3.48-3.66) for expert profiles. For CBT, overall mean scores increased from 0.83 (95% CI 0.78-0.88) to 2.18 (95% CI 2.10-2.26) and 4.38 (95% CI 4.28-4.48), respectively. Criterion-level planned contrasts were significant after false discovery rate correction. On AnnoMI transcripts, Evaluator scores aligned with metadata-derived high/low session labels, with 91.7% classification accuracy at the prespecified threshold. Human interrater reliability was an ICC(2,1) of 0.866 for MI and 0.769 for CBT. Evaluator-vs-human-consensus agreement was an ICC(2,1) of 0.959 for MI and 0.934 for CBT. In the secondary prompt-augmentation analysis, overall MI scores shifted from 1.18 to 1.44, and CBT scores shifted from 0.83 to 1.01. CONCLUSIONS/UNASSIGNED:This proof-of-concept study suggests that a rubric-guided multiagent LLM framework can score stylized synthetic MI and CBT transcripts along expected prompt-defined competence gradients and align with preliminary external and human-rater benchmarks. The study is innovative in separating synthetic learner, patient, scoring, and feedback-generation roles within a single simulation workflow, extending prior LLM work from plausible dialogue generation toward rubric-linked scoring. The findings support further development of scalable simulation tools for psychotherapy training research. Prospective studies with human trainees, standardized or real patients, and formal psychometric testing are required.

BACKGROUND:Evidence supporting platelet-rich plasma (PRP) injection for plantar plate injuries remains limited. PURPOSE/OBJECTIVE:To evaluate patient-reported outcomes, return to activity, complications, and failures at midterm follow-up in patients with plantar plate injuries treated with PRP injection. STUDY DESIGN/METHODS:Retrospective case series evaluating outcomes following PRP injection for plantar plate injuries. METHODS:Patients with plantar plate injuries were treated with ultrasound-guided PRP injection following failure of nonoperative management. Clinical outcomes evaluated were Foot and Ankle Outcome Score (FAOS) and Visual Analog Scale (VAS). Complications and failures were also reported. RESULTS:Twenty patients (23 feet) with a mean age of 51.0 ± 14.5 years and mean follow-up time of 58.0 ± 28.4 months were included. Mean FAOS scores improved 32.2 points (p < 0.001), with 20 of 23 (87%) feet achieving the minimal clinically important difference (MCID). Mean VAS scores improved 4.5 points (p < 0.001), with 19 of 23 (83%) feet achieving the MCID. Among 10 athletes, 7 (70%) returned to sport at a mean time of 3.1 ± 1.1 months. Complications occurred in 1 of 23 (4%) feet, and 3 of 23 (13%) feet required subsequent surgical intervention. CONCLUSIONS:At midterm follow-up, PRP injection for plantar plate injuries was associated with significant clinical improvement and a favorable safety profile, suggesting a potential role as an intermediary treatment option between conservative management and surgery. Female sex, smoking history, and higher-grade injuries were associated with inferior outcomes, underscoring the importance of individualized patient counseling and injury severity assessment. LEVEL OF CLINICAL EVIDENCE/METHODS:IV, retrospective case series.

The United States continues to grapple with the shifting substance use landscape among the emerging concurrent use of opioids and stimulants. Polysubstance use (PSU) of opioids and stimulants, whether intentionally or unintentionally, has increased substance use related morbidity and mortality. Changes at the policy level are needed to effectively curb overdose and other adverse outcomes. This article outlines 3 policy changes that are particularly relevant to opioid-stimulant PSU: (1) reforms in opioid agonist treatment policy, (2) reforms in payment for evidence-based treatment, and (3) reforms of drug paraphernalia laws. The current overdose crisis requires a multidimensional paradigm shift toward patient-centered and harm reduction focused policies that will expand access to comprehensive evidence-based treatments and services for individuals engaged in opioid and stimulant PSU.

Presurgical lip, alveolus, and nose approximation (PLANA) is a form of presurgical infant orthopedics designed to reduce cleft severity without an intraoral molding plate. This study compared nasolabial outcomes and the burden of care in patients with a bilateral cleft treated with PLANA in relation to nasoalveolar molding (NAM). A single-institution retrospective review was conducted of all patients with bilateral cleft lip treated with NAM (2016-2019) or PLANA (2023-2025). Clinical data were collected, including treatment timing, number of visits, and number of unscheduled appointments. Anthropometric measurements for nasolabial angle (NLA), columella length, pronasale to subnasale distance, and alar base width at initiation and completion of therapy were collected. Paired-samples t tests were used for intragroup changes, and independent-samples t tests were used for intergroup comparisons. Across 24 patients (11 PLANA and 13 NAM), the PLANA cohort required fewer visits (6 versus 17, P<0.05) and unscheduled appointments (0 versus 1, P=0.01). Treatment initiation occurred earlier in the PLANA group (11 versus 35 d, P<0.05), as did the insertion of the nasal appliance or stent (19 versus 72 d, P<0.05). Primary surgery was performed earlier in the PLANA group (107 versus 150 d, P<0.05). Both groups exhibited improvements in NLA, columella length, and the pronasale-to-subnasale difference, with no intergroup differences. The PLANA group exhibited greater improvement in alar base width (3.3 versus 0.4 mm, P=0.01). Patients treated with PLANA exhibit favorable nasolabial outcomes, as well as reduced treatment durations, scheduled visits, unscheduled appointments, and overall burden of care.

BACKGROUND:Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas present a broad spectrum of biological behavior, ranging from benign to malignant. Their management poses significant ethical dilemmas, particularly concerning diagnostic uncertainty, the risk of overdiagnosis and overtreatment, and resource allocation. METHODS:This qualitative study employed a constructivist approach to explore the ethical challenges faced by surgeons in managing IPMNs. Data were collected through focus group meetings (FGMs) with members of an expert working group at the Verona Evidence-Based Meeting on IPMNs (2020). Discussions were analyzed to identify key ethical concerns. RESULTS:The analysis highlighted several major ethical concerns: (1) decision-making under diagnostic uncertainty, (2) ethical challenges in patient communication, (3) overdiagnosis and over-surveillance due to defensive medicine and patient anxiety, (4) overtreatment through unnecessary surgery, and (5) issues of distributive justice in access to care and healthcare resource utilization. Participants emphasized the difficulty of balancing transparency with the need to minimize psychological distress in patients, as well as the challenge of applying international guidelines in diverse healthcare settings. CONCLUSIONS:Ethical decision-making in IPMN management requires balancing the risks of malignancy with the potential harms of overtreatment, while also considering patient autonomy and resource limitations. Enhancing decision-support tools, improving surgeon training in communication, and refining clinical guidelines to incorporate ethical considerations may help address these challenges. Further research is needed to develop strategies for more individualized and patient-centered care.

Sellar region neurocytoma (SELN) is a rare neoplasm whose relationship to other neurocytomas within the central nervous system (CNS) has remained unclear. Prior reports have variably classified SELN as a variant of extraventricular neurocytoma (EVN), while immunohistochemical and ultrastructural studies have suggested a hypothalamic origin. Here, we performed unsupervised clustering of DNA methylation data across a large pan-cancer reference set and identified SELN (n = 20) as distinct from other neurocytomas and regional mimics, as well as clustering with neuroendocrine tumors from other organ sites. SELN exhibited a CIMP-like phenotype, TTF1 negativity (0/8), and AVP (vasopressin) promoter hypomethylation, implicating a magnocellular hypothalamic cell of origin. In evaluable cases, a neuronal/neuroendocrine immunophenotype was observed (synaptophysin 8/8, chromogranin A 5/5) with absent pituitary transcription factor expression (PIT1 and TPIT negative 0/4). DNA sequencing (n = 5) and RNA-based fusion profiling (n = 4) did not detect recurrent mutations or gene fusions, respectively. Patients often presented with visual disturbances or headaches and spanned pediatric and older age groups (median 42 years, range 12.5-75), with no sex predilection. Despite locally aggressive imaging features in some cases (cavernous sinus invasion, carotid encasement, hydrocephalus), disease-free survival (n = 13) was comparable to central neurocytoma, with no disease-related deaths during the limited follow-up. Together, these findings support SELN as a molecularly distinct hypermethylated neuroendocrine-like epitype and clinicopathologic entity.