Faculty Bibliography

BACKGROUND:Left main (LM) and multivessel coronary disease (MVD) are high-risk conditions in which surgical revascularization may be preferred over medical or percutaneous therapies, yet may be missed by conventional imaging. Vasodilator stress perfusion cardiac magnetic resonance (CMR) appeared promising in resolving endocardial ischemia, but large multicenter data are lacking. OBJECTIVES/OBJECTIVE:This study aims to assess whether stress perfusion CMR reliably rules out LM/MVD and predicts adverse cardiac outcomes. METHODS:Consecutive patients from the expanded cohort of the 13-center SPINS (Stress CMR Perfusion Imaging in the United States Study) were included. Study outcomes were composites of angiographic new diagnosis of LM disease (>50% stenosis), high-risk MVD (significant 3-vessel disease or MVD treated with surgical revascularization), acute nonfatal myocardial infarction (MI), and cardiovascular death. RESULTS:: 4.31; 95% CI: 3.08-6.05; P < 0.001), adjusted for clinical risk factors and late gadolinium enhancement. The presence of abnormal stress perfusion portended a 10-fold increase in the annualized primary event rate compared with those without ischemia (10.6% vs 0.9%), whereas annual event rates were 0.9% vs 0.08% for LM disease, and 5.6% vs 0.3% for high-risk MVD, respectively. CONCLUSIONS:The absence of ischemia on vasodilator stress perfusion CMR was associated with a very low likelihood of angiographically verified high-risk coronary artery disease and its associated events.

OBJECTIVE:Patients with stage IV non-small cell lung cancer (NSCLC) often present with substantial symptom burden that impairs quality of life and tolerance of systemic therapy. Quad Shot (QS), a cyclical hypofractionated radiotherapy (RT) regimen, could provide effective symptom palliation while allowing concurrent systemic therapy. We evaluated the safety, feasibility, and patient-reported outcomes (PROs) of delivering up to three cycles of QS concurrently with systemic therapy. METHODS:This prospective phase I dose-escalation trial enrolled patients with stage IV NSCLC from June 2020 to February 2024. Allowable systemic therapy included immunotherapy alone, immunotherapy plus chemotherapy, or chemotherapy alone at the treating medical oncologist's discretion. Each QS cycle consisted of 14.8 Gy in 4 fractions delivered twice daily over 2 consecutive days within 1 week of systemic therapy. The primary endpoint was to determine the maximum tolerated number of QS cycles (MTD) using a modified 3+3 design, defined as a dose-limiting toxicity (DLT) rate ≤17% (1 of 6 patients). Secondary endpoints included feasibility, systemic therapy disruptions, RT-related toxicities, and PROs. RESULTS:Forty-five patients were enrolled in this study. One DLT occurred in the two-cycle cohort, and none occurred with three cycles, establishing three cycles as the MTD. In the expansion cohort, three patients developed grade 3 RT-related toxicities. All systemic therapies were administered without any interruptions. Among symptomatic patients, PROs demonstrated improvement in dyspnea (67%), cough (62%), and hemoptysis (100%). CONCLUSIONS:Three cycles of QS were associated with limited high-grade toxicities, no disruption of systemic therapy, and high rates of patient-reported symptom improvement, supporting its use as a palliative option within multidisciplinary care for advanced NSCLC.

PURPOSE OF REVIEW/OBJECTIVE:Gastrointestinal symptoms are common and often severe in patients with hypermobile Ehlers-Danlos syndrome/hypermobility spectrum disorders (hEDS/HSD), postural orthostatic tachycardia syndrome (POTS), and mast cell activation syndrome (MCAS). This review provides a structured, practical framework for evaluation of gastrointestinal symptoms and appropriate use of nutrition support in this population, where clinical practice remains variable and escalation to non-oral nutrition support may occur prematurely. RECENT FINDINGS/RESULTS:Emerging data highlight the high prevalence of disorders of gut-brain interaction, avoidant/restrictive food intake disorder, and malnutrition in these overlapping conditions. Evidence suggests that enteral and parenteral nutrition are frequently initiated without adequate trials of conservative and behavioral interventions, and that de-escalation once advanced nutrition support is established remains challenging. A coordinated evaluation integrating validated tools should precede escalation to non-oral nutrition support. Enteral nutrition is preferred when oral strategies fail, and parenteral nutrition should be reserved for intestinal failure. A multidisciplinary, biopsychosocial care model is essential to optimize outcomes and reduce unnecessary harm in this complex population.

Lung cancer is the leading cause of cancer-related deaths globally, and early diagnosis and treatment are important for improving prognosis. Pulmonary nodules (PNs) are small pulmonary lesions frequently identified during clinical practice, with incidental detection increasing due to advances in imaging techniques and the expanded use of computed tomography scans for thoracic evaluation. The majority of incidental PNs (IPNs) are benign, however some represent early-stage lung cancer, therefore distinguishing benign from malignant IPNs is key to improving lung cancer outcomes. Current management guidelines differ by nodule type and involve biopsy to determine the malignancy status of the nodule. Here, we review current knowledge on the classification, prevalence, and detection of PNs, as well as the current management and risk stratification of PNs. We outline the role of oncogenic driver mutations in the pathobiology of PNs and assess current literature on targeted treatment of oncogene-driven PNs. Finally, we discuss evidence gaps and areas for future research.

PURPOSE OF REVIEW/OBJECTIVE:Aberrant activation of the RAS-RAF-MEK-ERK signaling pathway contributes to numerous malignancies, congenital syndromes, and cardiovascular disorders, establishing MEK inhibitors (MEKi) as crucial therapeutic agents. MEKi demonstrate substantial clinical benefit as monotherapy (e.g., NF1-associated tumors) or combination therapy (e.g., melanoma, glioma, congenital RASopathies). Cardiovascular adverse events, primarily asymptomatic reductions in left ventricular ejection fraction (LVEF), have prompted intensive echocardiographic monitoring. RECENT FINDINGS/RESULTS:Emerging evidence indicates that isolated mild LVEF decreases rarely progress to symptomatic heart failure, raising concerns about unnecessary treatment interruptions driven by overly rigorous imaging protocols. Integrating cardiac biomarkers into monitoring strategies could offer a more pragmatic approach, guiding echocardiographic evaluations based on biomarker elevation or symptoms. Expert recommendations advocate personalized, risk-adapted surveillance frameworks. High-risk patients include those with baseline cardiovascular conditions, abnormal biomarker profiles, or significant clinical symptoms. Normal-risk patients can be safely monitored clinically, reserving imaging for biomarker changes or symptom onset. Prospective studies should seek to validate these recommendations.

STUDY DESIGN/METHODS:Retrospective review of multicenter, prospective cervical deformity database. OBJECTIVE:To compare outcomes of extension of fusion to the cervical spine versus the upper thoracic (UT) spine. SUMMARY OF BACKGROUND DATA/BACKGROUND:Proximal junctional kyphosis (PJK) management after thoracolumbar fusion requires extension of fusion to the proximal spinal segments. Unlike extensions to the less mobile thoracic segments, crossing the cervicothoracic junction (CTJ) involves more mobile cervical segments and creates different biomechanical influences and clinical outcomes. No study has compared the outcomes of extending fusion to the cervical versus the UT spine. METHODS:Patients with thoracic PJK who underwent revision with extension of fusion to either the cervical or UT (T1 or T2) spine were identified in a multicenter, prospective cervical deformity database. Patients with cervical upper instrumented vertebra (UIV) were subdivided into lower cervical (LC; C4-7) and upper cervical (UC; and occiput-C3) groups. Baseline demographics, surgical variables, radiographic outcomes, 2-year health-related quality-of-life scores, complications, and revision rates were analyzed. RESULTS:Fifty-one patients (mean age: 60.4±12.9 y; 91% female) with at least 2 years of follow-up were included. Twelve had extension to the UT, 20 to the LC, and 19 to the UC spine. Demographic data, Charlson Comorbidity Index, follow-up duration, surgical parameters, radiographic measurements, recurrent PJK and reoperation rates, and 2-year patient-reported outcome scores were similar across groups. The instrumentation failure rate was higher in the LC (25%) than in the UT (0%) and UC (8%) groups (P=0.03). CONCLUSIONS:Stopping fusion at T1 or T2 did not result in greater complication or reoperation rates than extending to the cervical spine. The instrumentation-related complication rate was higher for extension to the LC than to the UC or UT spine. Crossing the CTJ should be individualized, but may not prevent additional proximal junctional-level problems in the management of thoracolumbar fusion PJK. LEVEL OF EVIDENCE/METHODS:Level IV.

BACKGROUND:Large-bore aspiration catheters are integral to mechanical thrombectomy (MT) for large vessel occlusions (LVOs), offering potential for improved first pass success and faster recanalization. OBJECTIVE:To assess the clinical performance, efficacy, and safety profile of the Broadway 8 system as a primary aspiration device in MT of LVOs. METHODS:This is a multicenter observational study conducted across 8 US comprehensive stroke centers. Efficacy outcomes included first pass effect (FPE), defined as a single-pass modified Treatment In Cerebral Infarction (mTICI) score ≥2c, and successful reperfusion (final mTICI ≥2b). Safety outcomes included device-related complications, symptomatic intracranial hemorrhage (sICH), and inpatient mortality. Functional outcomes included modified Rankin Scale (mRS) at discharge and delta National Institutes of Health Stroke Scale (NIHSS) score. Logistic regression was used to assess predictors of thrombus access and intermediate catheter use. RESULTS:49 patients were included. The Broadway 8 system reached the thrombus in 44 (89.8%). Median puncture-to-thrombus and puncture-to-reperfusion times were 11 min (IQR 9-18) and 20 min (14-31), respectively. FPE was achieved in 20 (40.8%). Successful reperfusion was achieved in 46/49 (93.8%), with 35 (71.4%) using Broadway 8. sICH occurred in 2 patients (4.1%). Median mRS at discharge was 3.0 (IQR 1.0-4.0); delta NIHSS was 8 (IQR 5-12). Regression analysis showed faster reperfusion when Broadway 8 was used without an intermediate catheter. CONCLUSION/CONCLUSIONS:The Broadway 8 system appears to be a safe and effective frontline aspiration device, demonstrating a safety and efficacy profile comparable to other large-bore aspiration systems that incorporate delivery-assist technology.

ObjectivesEvidence suggests individuals with a laryngectomy (IWL) face multiple challenges accessing the necessary multidisciplinary healthcare professionals (HCPs) needed to provide optimal care. This study examined the perceptions of HCPs regarding current laryngectomy care models to identify and prioritize opportunities for service improvement.MethodsA concept mapping methodology was utilized, which combines both qualitative and quantitative data, enabling HCPs to identify and then prioritize critical elements of care that require refinement to improve the current care pathway. Twenty HCPs were recruited from 2 services within the United States (10 per site) including participants from medical, nursing and allied health disciplines. Considering differences in services, separate analysis was conducted by site.ResultsParticipants generated 31 and 36 unique statements from each site respectively. Both sites identified highly similar issues. Go-Zone analysis revealed 49% of Site 1 statements and 33% of Site 2 rated highest for both importance and changeability. Prioritized issues related to the importance of education, access to skilled HCPs, coordinated services, the need for a post-acute care pathway and improving financial supports.ConclusionsHCPs identified multiple actionable changes to help optimize the care pathway for IWLs which can be used by services to direct improvements in care.