Faculty Bibliography

OBJECTIVE:The quality of discharge processes impacts adverse outcomes post hospitalization for children with medical complexity (CMC). Perspectives of caregivers at risk for communication challenges (eg, non-English speakers, those with limited health literacy, immigrants) on understandability and feasibility of discharge instructions for CMC are understudied. Our objective was to explore their perspectives on barriers and facilitators to comprehension and implementation of discharge instructions for CMC. PATIENTS AND METHODS/METHODS:In this qualitative, descriptive study, we used maximum variation sampling to enroll caregivers of CMC (N = 40) discharged from acute or intensive care units of 2 urban hospitals. English- and Spanish-speaking caregivers of CMC (Pediatric Medical Complexity Algorithm) aged 18 years or older and discharged on 1 or more daily medications were eligible. We conducted semistructured interviews, audio-recorded and transcribed interviews, and performed content analysis. Two team members applied codes from a codebook (developed based on prior literature and preliminary analyses) and identified emerging themes. RESULTS:Equal numbers of participants spoke English and Spanish (n = 20 per language) and were recruited from each hospital (n = 20 per hospital). Half (47.5%) had low health literacy; 85% were of non-US birth. Themes emerged across 4 categories: (1) clinician and medication access; (2) patient- and family-centered approaches to discharge planning and education; (3) caregiver prior experience; and (4) resources and support systems. CONCLUSIONS:Caregivers identified barriers and facilitators affecting discharge plan comprehension and implementation. Optimizing postdischarge care for CMC is complex and requires family-centered, language-concordant, and health literacy-informed processes. Future interventions should focus on systems-level changes that enhance access and account for caregiver perspectives.

Study DesignConsensus-based classification development utilizing a modified Delphi process.ObjectivesTo develop a practical, standardized classification system to quantify surgical invasiveness in minimally invasive degenerative lumbar spine procedures.MethodsAn international panel of 45 spine surgeons from the AO Spine Knowledge Forum - Degenerative participated in a three-stage, modified Delphi consensus process. First, candidate determinants of invasiveness were identified through evaluation of existing indices and literature review, then refined through iterative expert rounds. The scale was applied to standardized case scenarios, with internal review by the AO Spine Knowledge Forum - Degenerative and external review by the AO Spine MISS Task Force. Finally, a consensus survey reached ≥75% agreement on all final factors for inclusion in the grading scale.ResultsThe final classification system included nine factors: operative time, number of approaches, blood loss, instrumentation, muscle dissection/access, anesthesia, number of levels, fusion technique, and revision status. Consensus was achieved on all components of the scale following iterative refinement. Each factor was scored from 0 (least invasive) to 2 (most invasive), generating a cumulative invasiveness score. Application of the scale across representative procedures demonstrated a spectrum ranging from least invasive (endoscopic 1-level discectomy) to most invasive (thoracic-to-pelvis fixation). Procedures were stratified into minimally invasive, less invasive, and more invasive categories.ConclusionsMISS-INC (L) is a proposed, consensus-based classification that quantifies surgical invasiveness among minimally invasive lumbar spine procedures. It offers a user-friendly framework for communication, research, and patient counseling, with further validation against clinical outcomes representing an important next step.

BACKGROUND:Ureteroenteric strictures (UES) are a challenging complication after urinary diversion and may lead to infection, renal dysfunction, and the need for reintervention. Robotic repair has emerged as an effective minimally invasive option, but data remain limited, particularly in complex and heterogeneous cohorts. METHODS:We conducted a retrospective review of 40 patients who underwent robotic UES repair at a single tertiary center between July 2014 and May 2024. Seventeen patients were treated with the Xi system and 23 with the single-port (SP) platform, all by a single experienced surgeon. Patient demographics, stricture characteristics, operative details, perioperative outcomes, and follow-up data were analyzed. Surgical success was defined by symptom resolution, stent- or nephrostomy-free status, radiological patency, and stable renal function. RESULTS:A total of 40 patients representing 50 ureteral units were included. The cohort included a range of stricture characteristics and reconstructive approaches. Primary anastomosis was most commonly performed for shorter strictures, whereas flap, graft, and interposition techniques were used for longer or more complex disease. Overall, robotic repair was associated with high success rates (95%) and acceptable morbidity (12.5% major complications). Perioperative outcomes improved over time, with reductions in operative time, blood loss, and length of stay, likely reflecting increasing surgical experience and technical refinement. CONCLUSIONS:Robotic repair of UES is safe and effective across both multiport and SP platforms. This series reflects a decade of evolving technique and highlights practical refinements that facilitate reconstruction in complex postdiversion cases.

IMPORTANCE/UNASSIGNED:Black women have twice the endometrial cancer mortality of White women, and studies suggest that differences in ultrasound diagnostic accuracy partially contribute to this disparity. OBJECTIVE/UNASSIGNED:To evaluate racial and ethnic differences in the diagnostic performance of transvaginal ultrasound for detecting endometrial neoplasia. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:A prospective cohort study of 1833 women aged 50 years or older at risk of endometrial neoplasia, conducted at a large urban academic medical center from February 2014 to August 2022, with follow-up through March 2023. The statistical analyses were conducted from March 2024 to December 2025. INTERVENTIONS/UNASSIGNED:Women underwent endometrial assessment via transvaginal ultrasound followed by sonohysterogram-directed biopsy and follow-up observation to establish final outcome. MAIN OUTCOME AND MEASURES/UNASSIGNED:Assessment of transvaginal ultrasound diagnostic performance for detecting endometrial cancer and hyperplasia across racial and ethnic groups, measured by: (1) completion rate (endometrial accessibility) and (2) accuracy of completed scans. To assess any association with fibroids, analyses were repeated after excluding women with fibroids. Subgroup analyses were conducted among women with endometrial cancer, those with postmenopausal bleeding, and those without prior exposure to estrogen or tamoxifen. RESULTS/UNASSIGNED:A total of 1833 women met inclusion criteria (mean [SD] age, 60.3 [8.1] years). Most were postmenopausal (1218 women [87.4%]), and 832 (45.4%) were Black, 705 (38.5%) were Hispanic, and 253 (13.8%) were White. Black women had significantly lower completion rates (adequate endometrial visibility) for transvaginal ultrasound compared with White women (75.7% vs 88.9%; relative risk, 0.85; 95% CI, 0.80-0.90; P < .001). Accuracy of completed transvaginal ultrasound was slightly lower among Black women compared with White women (sensitivity, 96.3%; 95% CI, 91.3%-100% vs 100%; negative predictive value, 97.9%; 95% CI, 95.0%-100% vs 100%). After excluding women with fibroids, differences in completion and accuracy between Black and White women disappeared. Similar findings were observed in subgroup analyses of women with a final diagnosis of endometrial cancer, those presenting with postmenopausal bleeding, and those without prior exposure to estrogen or tamoxifen. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this cohort study of a diverse population of women, ultrasound completion rates were lower among Black women, primarily due to fibroids impairing endometrial visibility. Nevertheless, transvaginal sonography demonstrated a 76% completion rate and retained excellent ability to exclude cancer in Black women, regardless of fibroid presence.

PURPOSE/UNASSIGNED:Eosinophil-related cutaneous adverse events (ercAE) are common after systemic cancer therapies and often affect health-related quality of life (HRQoL). In this study, we investigate the efficacy and safety of benralizumab for ercAE following systemic cancer therapies. PATIENTS AND METHODS/UNASSIGNED:This single-arm, single-center, open-label, phase II trial (NCT04552288) in patients with cancer and systemic therapy-associated ercAE was performed from September 2020 to October 2023. Benralizumab 30 mg was administered subcutaneously according to the approved dosing schedule, with 3 doses given every 4 weeks followed by 3 doses given every 8 weeks. The primary endpoint was clinical response (reduction in ercAE to Common Terminology Criteria for Adverse Events grade ≤ 1 by week 4). Secondary endpoints included HRQoL, rash body surface area (rash-BSA), eosinophil levels, and AE. RESULTS/UNASSIGNED:At baseline (N = 47), ercAE were attributed to phosphoinositide 3-kinase inhibitors in 47%, checkpoint inhibitors in 21%, tyrosine kinase inhibitors in 9%, and antibody-drug conjugates in 9%; ercAE were grade 2 and 3 in 49% and 51% of patients, respectively. Of the 42 patients evaluable for the primary endpoint, 76% of patients (n = 32/42) responded to treatment by week 4; median ercAE grade decreased from 2 to 1 (P < 0.0001). Patients exhibited improved HRQoL, reduced mean rash-BSA, and decreased peripheral eosinophils. All patients with ercAE following alpelisib (n = 18) or enfortumab vedotin (n = 4) responded by week 4 (both P < 0.05). Most AE were mild to moderate and likely unrelated to benralizumab. CONCLUSIONS/UNASSIGNED:Benralizumab demonstrated favorable efficacy and safety against grade 2/3 ercAE related to novel cancer therapies. Further investigation in larger placebo-controlled trials is warranted.

Since the introduction of the Vesical Imaging-Reporting and Data System (VI-RADS), MRI has become an important imaging modality in the management of patients with bladder cancer. Its excellent diagnostic performance for determining muscle invasion in bladder cancer has been supported by numerous prospective and retrospective studies. Nevertheless, there needs to be continued improvement of the diagnostic performance of VI-RADS and sustained efforts to address remaining unmet clinical needs within the field of bladder cancer. In this paper, we highlight several such areas, some of which are actively being investigated. These include (1) whether to use intravenous contrast media or not (multiparametric vs. biparametric MRI), (2) quantitative metrics to enhance assessment of muscle invasion, (3) anatomic locations that come with pitfalls in staging, (4) introduction of bladder MRI image quality, (5) neoadjuvant chemotherapy VI-RADS (nacVI-RADS) and other considerations needed in the treatment response assessment after systemic therapies, (6) need for wider adoption, training, and implementation, and (7) application of artificial intelligence.

BACKGROUND:The Essentials in Minimally Invasive Gynecologic Surgery (EMIGS) is a new assessment employed by the American Board of Obstetrics and Gynecology to evaluate physicians' surgical skills for certification. The program assesses the minimal laparoscopic skills needed to qualify for the certifying exam. We aimed to use checklist assessments to predict performance on the Running Stitch task of EMIGS OBJECTIVES: We strove to develop and evaluate a novel metric to predict competency in the EMIGS Running Stitch task. Secondarily to assess resident PGY year, prior laparoscopic suturing experience, and prior laparoscopic simulation experience correlation with passage. STUDY DESIGN/METHODS:A novel task specific checklist was developed by expert teaching surgeons to assess the Running Stitch task of EMIG. The checklist was tested for inter-rater reliability. Settings Residency programs at four participating academic centers PARTICIPANTS: 71 participants completed 97 videotaped trials Interventions participants completed a pre-study survey prior to each video-taped laparoscopic skills session (one to four sessions over four months of study). The video and the completed EMIGS task Penrose were evaluated both by the study team with checklists and later by EMIGs MEASUREMENT: The two scores were correlated using linear regression and Bland-Altman plots for agreement. RESULTS:53% of trials received a passing score by AAGL. AAGL and study team checklist scores were moderately correlated (0.73) however study team metrics consistently overrated performance. Laparoscopic case numbers and PGY level correlated with passing score. CONCLUSIONS:Scoring using our novel metric correlated with passing scores but overrated performance. This tool may aid educators in assessment during resident preparation for the EMIGS skills exam, but metrics for grading of this examination remain poorly understood.

Humans are the only species with the ability to systematically combine words to convey an unbounded number of complex meanings. This process is guided by combinatorial processes whose underlying neural mechanisms remain obscured by inherent limitations of noninvasive brain measures and a near-total focus on comprehension paradigms. Here, we address these limitations with high-resolution neurosurgical recordings (electrocorticography) and a controlled sentence production experiment. We uncover distinct cortical networks encoding word-level and higher-order information. These networks exhibited a hybrid spatial organization: broadly distributed across traditional language areas but with focal concentrations of sensitivity to semantic and structural contrasts in canonical language regions. In contrast to previous comprehension-based findings, we find that these networks are largely nonoverlapping. Most notably, higher-order linguistic information showed an unexpected dissociation from local activity magnitude. This result establishes an operational dissociation between activity magnitude and information content, pointing toward a potentially distinct neural coding scheme for higher-order language, with important implications for the neurobiology of language.