Faculty Bibliography

BACKGROUND:Respiratory failure frequently complicates cardiogenic shock (CS), yet the optimal initial ventilatory strategy remains uncertain. Whether a noninvasive ventilation (NIV)-first approach is associated with worse outcomes compared to direct invasive mechanical ventilation (IMV) is unclear. METHODS:We performed a cohort study using a multicenter, nationally representative database including adults with CS who received NIV or IMV on the first hospital day. Patients were categorized as NIV only, direct IMV, or NIV before IMV. Inverse probability of treatment weighting balanced baseline characteristics. The primary outcome was in-hospital mortality. Sensitivity analyses excluded mechanical circulatory support and out-of-hospital cardiac arrest and additionally incorporated lactate adjustment and entropy weighting. RESULTS:Among 81,892 patients with CS, 13.7% received NIV alone, 81.9% direct IMV, and 4.4% NIV before IMV on the first day of admission. In-hospital mortality was 37.2%, 57.7%, and 52.1%, respectively. After adjustment, IMV and NIV before IMV had higher mortality than NIV (absolute risk difference 11.8%, 95% CI 10.4-13.3, and 12.9%, 95% CI 10.6-15.1; both p<0.001). Mortality did not differ between direct IMV and NIV before IMV (risk difference 1.0%, 95% CI -1.0-3.0; p=0.279). Notably, sensitivity analyses including lactate and when stratified by SCAI D shock showed higher mortality with NIV before IMV compared to direct IMV. CONCLUSIONS:Direct IMV and NIV before IMV were associated with worse outcomes than NIV alone. Results for direct IMV compared to NIV before IMV were not consistent between analyses and support the urgent need for a prospective study of respiratory support strategies.

PURPOSE/OBJECTIVE:To develop Trainee Attributable & Automatable Care Evaluations in Real‑Time (TRACERs) for inpatient diabetes management, collect validity evidence for their use in formative assessment, and explore performance variation across residents and institutions. METHOD/METHODS:In 2023, a multi‑institutional team created two TRACERs based on type 2 diabetes guidelines-discourage bolus‑only insulin (TRACER #1) and encourage basal (± bolus) insulin (TRACER #2)-for internal medicine residents at three large residency programs. Residents were attributed to inpatient admissions based on placing the most medication orders in the first 12 hours. Structured queries extracted 35 discrete variables from the electronic health record (EHR). Two experts per institution reviewed random admissions (July-August 2022) to establish criterion validity. A retrospective cohort (July 2020-June 2023) added validity evidence. RESULTS:Automated extraction achieved ≥96% sensitivity and ≥95% specificity when compared to manual review. Among 615 residents attributed to 6,192 admissions of patients with type 2 diabetes at high risk for hyperglycemia, TRACER #1 occurred in 42.6% (1,689/3,965) of admissions at Program A, 28.9% (408/1,410) at Program B, and 26.7% (218/817) at Program C. TRACER #2 occurred in 44.9% (367/817) of Program C admissions versus 24.2% (959/3,965) at Program A and 28.2% (397/1,410) at Program B (all P < .001). Four resident-level insulin‑ordering profiles were identified-consistent basal-bolus insulin use (most guideline-concordant), basal-predominant, bolus-predominant, and bolus-only (most guideline-discordant)-with between‑resident variation exceeding between‑program differences. Longitudinally, cohort-level trends masked opposing individual trajectories-some residents improved with exposure while others worsened-and performance tertiles were distinguishable early in training. CONCLUSIONS:TRACERs revealed substantial institution‑ and resident‑level variation in insulin‑ordering practices, including guideline deviations, demonstrating potential for real‑time formative feedback. Multi‑institutional implementation highlighted scalability barriers, including EHR heterogeneity and workflow‑dependent attribution, underscoring the need for continued refinement and broader validation.

BACKGROUND:Women have been underrepresented in peripheral artery disease revascularization trials. We aimed to analyze sex-specific outcomes after endovascular therapy (EVT) with stent implantation versus bypass surgery (BSx) in patients with symptomatic femoropopliteal peripheral artery disease, leveraging data from the REVIVE (Revascularization Strategies in Patients With Peripheral Arterial Disease Involving the Femoropopliteal Arteries) study. METHODS:The REVIVE study pooled individual patient data from 5 randomized controlled trials comparing EVT with stent implantation versus BSx. The primary end point was major adverse limb events, a composite of all-cause death, major amputation, or reintervention. Secondary end points included amputation-free survival, the individual components of major adverse limb events, and primary patency at 2 years. Early complications were defined as a composite of any bleeding, infection, or all-cause death within 30 days. RESULTS:<0.001 in men). CONCLUSIONS:Our analysis supports the efficacy and safety of EVT with stent implantation as an alternative to BSx in patients with symptomatic peripheral artery disease involving the femoropopliteal segment, regardless of sex.

Conventional imaging techniques lack the resolution and sensitivity to adequately characterize cerebral small-vessel abnormalities (CSVA) in vivo. This study aimed to overcome these limitations and evaluate the feasibility of a novel MRI technique called Microvascular In-vivo Contrast Revealed Origins (MICRO), which uses an ultrasmall superparamagnetic iron oxide (USPIO) contrast agent (Ferumoxytol) to resolve the cerebral microvascular architecture with a level of anatomical and physiological detail not previously achievable in vivo. Fifty-nine Parkinson's disease (PD) patients underwent MICRO MRI based on susceptibility-weighted imaging (SWI). Three independent raters identified and categorized CSVAs as large developmental venous anomalies (DVAs), micro DVAs, engorged vessels, and diminished vessels. The location of each CSVAs was documented, and its association with white matter hyperintensities (WMHs) was assessed. The MICRO imaging protocol demonstrated excellent inter-rater agreement for identifying these CSVAs. Our findings show a high prevalence of CSVAs in PD patients, with engorged vessels being the most common type (49.06% of subjects). Both engorged vessels (72.41%) and micro DVAs (81.82%) were highly associated with WMHs. CSVAs were most frequently observed in the periventricular white matter (n=28), deep white matter (n=32), and putamen (n=14), suggesting regional distribution pattern of detectable CSVAs. This work establishes MICRO as a feasible, reliable platform for in vivo microvascular mapping with potential applications in neurovascular research.

OBJECTIVE:To estimate the cumulative probability of achieving at least one live birth (LB) after up to six sequential single euploid embryo transfers (euploid SET) and characterize per-transfer outcomes to inform evidence-based counseling for patients undergoing in vitro fertilization (IVF) with preimplantation genetic testing for aneuploidy (PGT-A). DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:University-affiliated fertility center. SUBJECTS/METHODS:Patients who underwent IVF with PGT-A followed by euploid SET between January 2014 and December 2024. EXPOSURE/METHODS:Up to six sequential euploid SETs until a live birth was achieved, or the patient discontinued additional transfers. MAIN OUTCOME MEASURES/METHODS:Estimated cumulative probability of achieving ≥1 LB and per-transfer rates of live birth, spontaneous abortion, biochemical pregnancy, and non-pregnant. RESULTS:Among 5811 patients undergoing 7763 euploid SETs attempts, the estimated cumulative probability of a LB increased from 63.1% after one SET to 92.0% after three, 98.3% after five, and 98.8% after six SETs. Per-transfer live birth rate declined from 63.1% at the first euploid SET to 54.0% at the second, then remained stable across subsequent attempts. Rates of spontaneous abortion, biochemical pregnancy, and non-pregnant followed a similar trend. Fewer than 5% of patients met criteria for recurrent implantation failure after three euploid SETs, and fewer than 2% remained without live birth after five SETs. CONCLUSION/CONCLUSIONS:Continued sequential transfer of euploid embryos is supported as the primary management strategy after early transfer failure. For patients able to generate an adequate euploid embryo inventory aligned with their individual risk tolerance, persistence with treatment is associated with a high likelihood of achieving a live birth.

PURPOSE/UNASSIGNED:This study aims to characterize demographic characteristics of transgender and nonbinary (trans) medical students and their training experiences. METHODS/UNASSIGNED:We conducted cross-sectional analyses of responses to the Association of American Medical Colleges Graduation Questionnaire (2016-2023) to characterize trans medical students using measures of race, ethnicity, age, and medical school region; assess overall satisfaction with medical training; and evaluate time to graduation, all compared to cisgender peers. RESULTS/UNASSIGNED:< 0.001). CONCLUSION/UNASSIGNED:With higher odds of being unsatisfied with their education, additional research must identify and develop interventions to improve their training experience.

AIM/OBJECTIVE:The "2026 HRS Expert Consensus Statement Update on Cardiovascular Implantable Electronic Device Lead Management and Extraction" provides updated recommendations to guide clinicians in the management of cardiovascular implantable electronic device (CIED) leads. BACKGROUND:Since the publication of the "2017 HRS Expert Consensus Statement on Cardiovascular Implantable Electronic Device Lead Management and Extraction," the field has evolved quickly. New evidence on CIED lead management and the blooming development of new CIED technologies, including leadless pacing and implantable cardioverter-defibrillator leads implanted outside the vascular system and new lumenless pacing leads and lead extraction tools, have contributed to the field's rapid evolution. METHODS AND RESULTS/RESULTS:A comprehensive literature search was conducted in accordance with the Institute of Medicine standards. The writing committee reviewed evidence gathered through electronic literature searches encompassing clinical trials, original studies, and meta-analyses conducted on human subjects published in English from MEDLINE, PubMed, Embase, and the Cochrane Library up to December 2024. The comprehensive literature review supports each evidence-based recommendation and is compiled in the evidence tables. A predefined threshold of >70% approval for each recommendation was required, with a quorum of two-thirds of the writing committee. The final mean consensus of 108 recommendations was 93.61%. DISCUSSION/CONCLUSIONS:The recommendations from the "2017 Expert Consensus Statement on Cardiovascular Implantable Electronic Device Lead Management and Extraction" have been updated with new evidence to guide clinicians. The new recommendations address the latest CIED technologies with the advantages over transvenous leads; new evidence supporting diagnosis, treatment, and prevention for CIED infection; appropriate lead management in transcatheter tricuspid valve replacement for tricuspid regurgitation; and standardization of transvenous lead extraction approach, protocol, and facilities to improve the outcomes of CIED lead management and extraction.

Primary liver and biliary tract cancers remain major causes of global cancer mortality, with liver and intrahepatic bile duct cancers accounting for 866,136 new cases and 758,725 deaths worldwide in 2022. Curative surgery, transplantation, ablation, embolotherapy, and systemic therapy have improved outcomes, but many patients remain limited by cirrhosis, liver reserve, vascular invasion, biliary obstruction, anatomic constraints, or advanced presentation; population-level survival remains poor for both liver and bile duct cancers. Modern radiation therapy has emerged as an important local and regional modality for hepatocellular carcinoma, intrahepatic cholangiocarcinoma, extrahepatic cholangiocarcinoma, and gallbladder cancer.

Alston's singing mouse has emerged as an intriguing model for the comparative study of vocal control. New work on the species sets the stage to understand the proximate mechanisms and evolutionary roots of novel acoustic communication traits.

PURPOSE/OBJECTIVE:The role of ureteral access sheath (UAS) during flexible ureteroscopy (fURS) remains undecided in the era of direct in-scope suction (DISS), which subserves dust and debris removal with active intrarenal pressure control. This study aims to evaluate the utility of UAS on perioperative outcomes in patients undergoing DISS-assisted fURS. METHODS:This prospective, multicentre study analysed data from an international registry of patients who underwent successful fURS with DISS at 16 centres across 14 countries between May and December 2025. Patients were grouped based on whether UAS was used. All participants had one non-contrast CT scans (NCCT) before and at 30 days post operatively. 100% Stone-free rate (SFR) was defined as zero residual fragment (ZFR) on NCCT in bone window (Grade A) or overall stone free (OSF) was Grade A + B where grade B reported a single RF of 2 mm. The study recorded perioperative outcomes, immediate Clavien-Dindo complications and new anatomical anomalies on 3 month imaging. Multivariable logistic regression identified factors that predicted SFR and complications. RESULTS:A total of 540 patients were divided into Group1 undergoing DISS without UAS 296 (54.8%), and Group2 had DISS with UAS 244 (45.2%). ZRF Grade A (Group1vs Group2) was 72.6% vs. 70% and OSF (grade A + B) was 95.9% vs. 88.9% (p = 0.011) respectively but no significant differences in planned re-intervention. Group2 cohort including larger stone burden (12.0 vs. 10.0 mm, p = 0.016), multiplicity higher pre-stenting (57.0% vs. 15.2%, p < 0.001) and more complex cases, operative time was significantly longer in this cohort (64 vs. 39 min, p < 0.001). Although OSF (Grade A + B) rates were high in both groups, they were significantly higher in the non-UAS cohort compared with the UAS cohort (95.9% vs. 88.9%, p = 0.011). Fever > 38.C was significantly higher in Group 2(11.5 vs. 2.7%, p < 0.001) as was 30 day any cause re-admission (7% vs. 15, p < 0.001) with zero sepsis case. Multivariate analysis did not reveal any specific association for ZRF but the use of UAS (OR 6.52, 3.52-12.41, p < 0.001) and pre-stenting (OR 2.63, 1.44-4.90, p,0.002) increases the odds for 30 day complications. CONCLUSIONS:DISS with UAS (conventional or Flexible and Navigable Suction access sheath FANS) is preferred in fURS for larger, multiple, or complex stones. Non-UAS DISS is a safe, effective option for smaller, simpler cases, showing high ZRF and OSF rates with fewer low grade complications. Dusting with simultaneous aspiration removes fragments efficiently, may extend operative times, and can reduce post-operative stenting without increasing readmissions or infection risk. These results support tailoring DISS management to individual cases.