Faculty Bibliography

BACKGROUND:The therapeutic landscape of acute ischemic stroke (AIS) has been transformed by expanding endovascular therapy (EVT) criteria. With the incorporation of MR perfusion imaging in the 2026 AHA/ASA Guidelines for the early management of patients with AIS to support EVT patient selection, there is renewed energy and focus on the clinical applications of different MR perfusion techniques in AIS. A reliable, contrast-free perfusion technique with acceptable acquisition time and capability to identify salvageable tissue and assess collateral status may be utilized in certain clinical contexts. Arterial spin labeling (ASL) is a clinically feasible technique that can be considered as a valuable modality within stroke workflows and MRI-based EVT selection protocols, particularly in patients with renal insufficiency, contrast allergy, and contrast-limited settings. Although ASL has been investigated in multiple previous studies, its systematic integration into contemporary acute stroke clinical workflows has yet to be routinely adopted and standardized practical guidance in this regard is lacking. Furthermore, ASL is not yet validated in prospective EVT-selection trials to support timely reperfusion decisions. METHODS AND PURPOSE/UNASSIGNED:This state-of-practice paper was developed on behalf of the American Society of Functional Neuroradiology (ASFNR) by an expert panel of neuroradiologists with expertise in cerebrovascular imaging and MR perfusion. We appraise the current evidence, clinical applications, implications for therapeutic decision-making, and translational barriers of ASL in AIS triage and EVT patient selection. We also discuss ASL challenges related to workforce capacity and reimbursement, and propose recommendations for future clinical validation and implementation. CONCLUSION/CONCLUSIONS:ASL may serve as a valuable adjunct within MRI-based stroke workflows by providing complementary information on ischemic penumbra and collateral status. However, validation through multicenter prospective studies for EVT patient selection, standardized acquisition protocols, and automated postprocessing quantification pipelines are needed before ASL can be routinely integrated into time-sensitive stroke workflows.

OBJECTIVE:We assessed the underlying etiology of MMR deficiency (dMMR), genetic (germline/somatic) versus epigenetic hMLH1, and associations between response rate, and survival outcomes in patients with advanced and recurrent dMMR endometrial adenocarcinoma treated with immune checkpoint inhibitors. METHODS:The Endometrial Cancer Molecularly Targeted Therapy Consortium (ECMT2) database was used to identify patients with mismatch repair deficient (dMMR) tumors treated with pembrolizumab or dostarlimab from 2016 to 2023. Cases were categorized into two groups- germline Lynch Syndrome mutation (gLS) and somatic Lynch Syndrome mutation (sLS), or MLH1 promoter hypermethylation (hMLH1). Clinical and pathologic data included patient demographics, tumor characteristics, recurrence date, survival, and treatment. RESULTS:A total of 133 patients were included: gLS/sLS (n = 34, 25.6%) or hMLH1 (n = 99, 74.4%). Demographic and tumor characteristics, including stage at diagnosis and histology were similar between groups. The response rate was 57.1% for the entire cohort [55.9% gLS/sLS, 57.6% hMLH1; (p = 0.90)]. The survival outcomes were not significantly different in the gLS/sLS and hMLH1 groups [2-year progression-free survival: 68.0% and 59.0% (p = 0.77); 2-year overall survival: 70.9% and 62.2% (p = 0.55)], respectively. CONCLUSION/CONCLUSIONS:Our findings suggest that response to immune checkpoint inhibitors and survival outcomes are not associated with different mechanisms of dMMR.

BACKGROUND/UNASSIGNED:Vascularized composite allotransplantation (VCA) restores complex defects when conventional reconstruction is not feasible. However, lifelong immunosuppression introduces substantial risks, including posttransplant malignancies. This study aims to characterize the incidence, timing, management, and outcomes of posttransplant malignancies in VCA recipients to inform future surveillance and management guidelines. METHODS/UNASSIGNED:A systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines using PubMed, Scopus, Web of Science, and Cochrane. Eligible studies included patients who underwent VCA and developed a subsequent malignancy. Collected data included demographics, transplant and malignancy details, and survival. RESULTS/UNASSIGNED:Fifteen studies comprising 15 unique VCA recipients were included. Transplants involved the face (37.5%), upper extremity (37.5%), scalp (12.5%), lower extremity (6.25%), and abdominal wall (6.25%). Median time to first malignancy was 1.89 years posttransplant. Across all cases, 24 malignancies were reported, most commonly nonmelanoma skin cancer (60%) and posttransplant lymphoproliferative disorder (33%). Notably, 85% of skin cancers developed at nonallograft sites. Overall survival was 53.3%. All patients with skin cancer alone survived, whereas posttransplant lymphoproliferative disorder carried a 50% mortality rate. Median time from malignancy to death was 5.5 years, and from transplant to death, 10.1 years. CONCLUSIONS/UNASSIGNED:Recipients of VCA demonstrate increased malignancy risk, particularly nonmelanoma skin cancers and lymphoma, with a typical onset of 2 years posttransplant. Dermatologic surveillance focusing on native skin, Epstein-Barr virus viral load monitoring in high-risk recipients, and regular follow-up are essential and may aid early detection.

OBJECTIVE:To describe the evidence- and practice-based processes that led to the International Olympic Committee Sport Mental Health Assessment Tool 2 (IOC SMHAT2). METHODS:Seven stages were conducted including: (1) reviewing the scientific literature related to the use (eg, uptake by physicians) of the IOC SMHAT-1; (2) gathering the view (eg, experience with the tool, advice for improvements) of IOC SMHAT-1 users; (3) exploring the misclassification and measurement properties of the IOC SMHAT-1; (4) performing misclassification analysis of available IOC SMHAT-1 data; (5) designing the initial IOC SMHAT2; (6) evaluating the content validity and feasibility of the initial IOC SMHAT2; and (7) finalising the IOC SMHAT2. RESULTS:The IOC SMHAT2 was developed for sports medicine physicians and other licensed/registered health professionals with the objective of identifying elite athletes (defined as professional, Olympic, Paralympic or collegiate level; 16 years of age and older) potentially experiencing mental health symptoms and disorders. The IOC SMHAT2 is comprised of a three-step approach: (1) universal screening as step 1, including five disorder-specific screening questionnaires and two single questions; (2) conditional screening as step 2, including two disorder-specific screening questionnaires; and (3) an aid to clinical assessment and treatment as step 3 that should be conducted by sports medicine physicians or licensed/registered mental health professionals. CONCLUSION/CONCLUSIONS:Based on scientific and anecdotal reflections on its first version, we developed the IOC SMHAT2 as a second updated version of the tool to identify elite athletes potentially experiencing mental health symptoms and disorders.

BACKGROUND/UNASSIGNED:Skilled nursing facilities (SNFs) play a critical role in postacute recovery for older adults with heart failure (HF), yet the transition from SNF to home remains a vulnerable and understudied phase of care. Although discharge guidelines emphasize clear communication, HF-specific self-care education, medication management, and follow-up coordination, little is known about how these practices are implemented during SNF-to-home transitions. METHODS/UNASSIGNED:We conducted a convergent mixed-methods study across 4 nonprofit SNFs, integrating data from postdischarge patient and caregiver surveys, structured medical record abstraction of discharge instructions, and semi-structured staff interviews. Eligible patients were Medicare beneficiaries aged ≥65 years discharged from SNF to home following HF hospitalization, with SNF stays ≤60 days. Quantitative data were analyzed using descriptive statistics, while qualitative data underwent thematic and directed content analysis. Findings were triangulated across data sources to identify key challenges and actionable strategies. RESULTS/UNASSIGNED:Among 150 respondents, 59% reported receiving written discharge instructions; however, HF-specific self-care elements (eg, daily weight monitoring, low salt diet) were documented in only 15% to 41% of instructions. Although 87% reported receiving a medication list, only 53% had it reflected in the discharge instructions, and adherence support was infrequently addressed (24%). Follow-up coordination was similarly discordant: 37% of respondents reported a scheduled primary care appointment, compared with 13% documented in discharge instructions. Staff interviews revealed nonstandardized discharge workflows, workforce constraints, and reliance on verbal education, contributing to variability in patient preparation and communication across care settings. CONCLUSIONS/UNASSIGNED:SNF-to-home transitions after HF hospitalization are marked by discordance between patient-reported education and written documentation, as well as inconsistent medication and follow-up coordination. These gaps represent modifiable vulnerabilities during a high-risk recovery period. Standardized HF-focused discharge workflows and strengthened cross-setting communication may improve transitional care, while long-term solutions must address structural and workforce constraints.

BACKGROUND/UNASSIGNED:Concomitant ocular and facial trauma (COFT) can result in devastating functional, aesthetic, and psychosocial consequences, including vision loss. Standard reconstructive techniques often fall short in addressing the intricate needs of these injuries, making advanced techniques, such as combined facial transplantation and whole-eye transplantation (FT-WET), promising solutions. This study characterizes COFT patients to define a population that may benefit from FT-WET. METHODS/UNASSIGNED:A retrospective analysis of the National Trauma Data Bank (2018-2022) was conducted to identify COFT patients using International Classification of Diseases, Tenth Revision diagnosis codes. Patients were stratified into surgical and nonsurgical cohorts based on the presence of major surgical interventions targeting the face or eye. Characteristics of each group were compared. RESULTS/UNASSIGNED:< 0.001) were also more common in this group. CONCLUSIONS/UNASSIGNED:Surgical COFT patients represent a younger population with more complex injuries, aligning with favorable characteristics for potential FT-WET candidates. This study identified a distinct population of COFT patients who may benefit from FT-WET, providing critical insights into candidate selection and injury patterns.

BACKGROUND:Among high-bleeding risk (HBR) patients undergoing coronary stenting, abbreviated dual antiplatelet therapy (DAPT) reduces bleeding without ischemic risk trade-off; whether these benefits persist across the entire spectrum of bleeding risk has not been investigated. OBJECTIVES/OBJECTIVE:The aim of this study is to explore the value of the novel PRECISE-HBR score as a risk stratification tool to guide DAPT duration in patients at high bleeding risk. METHODS:The XIENCE Short DAPT program combined 3 international single-arm studies of HBR patients treated with cobalt-chromium everolimus-eluting stents who discontinued DAPT at 1 month (XIENCE 28 USA/Global) or 3 months (XIENCE 90), if event free and treatment adherent. Bleeding risk was classified as nonhigh (PRECISE-HBR score ≤22), high (score 23-26), or very high (score ≥27). Clinical outcomes were assessed between 1 and 12 months using propensity score stratification. RESULTS:Among 3,364 patients, the PRECISE-HBR score was ≤22, 23-26, and ≥27 in 359 (10.7%), 744 (22.1%), and 2,261 (67.2%), respectively. Rates of BARC (Bleeding Academic Research Consortium) type 3-5 bleeding (0.3%, 2.5%, 5.6%) and death or myocardial infarction (2.9%, 4.6%, 9.8%) increased progressively across risk categories. One- versus 3-month DAPT was associated with a significant reduction in BARC type 3-5 bleeding in patients with a score ≥27 (HR: 0.59, 95% CI: 0.39-0.88) but not in those <27 (HR: 2.31, 95% CI: 0.89-5.99; P-interaction = 0.012). Ischemic risk was similar between 1- and 3-month DAPT, irrespective of the PRECISE-HBR score (P-interaction = 0.40). CONCLUSIONS:The PRECISE-HBR score identified patients at increased risk for both bleeding and ischemic events who seemed to derive greater benefit from 1-month DAPT after stent implantation.

BACKGROUND:Benefits from clinical guidelines often only exceed harms after 10 years (payoff time). Based on population norms, guidelines are often discontinued at 75 years of age, but survival likely differs for those with complex chronic disease. We compare estimates based on age alone versus the physiologically based Veterans Ageing Cohort Study-Charlson Comorbidity Index (VACS-CCI) among all patients in care, and among patients with diabetes or HIV. METHODS:Estimates for patients in care within the US Veterans Health Administration (VHA) with a clinic visit in 2007-17 (followed thru 2021) were compared using C-statistics, Brier Scores, and calibration curves. "Physiological age" was defined as the chronological age at which median VACS-CCI matched US population survival estimates. Among those with 10-year follow-up, we compared percent correctly classified using age ≥75 years vs. VACS-CCI score of ≥42. FINDINGS/RESULTS:Among 6.6 million (51.4% ≥ 65 years; 25.2% with diabetes; 0.5% with HIV) VACS-CCI improved discrimination over age (Overall C-statistic: 0.81 vs. 0.74; Brier Score 0.239 vs. 0.262). Among 65-year-old males-females, "physiological age" exceeded chronological age by 4.6-3.1 years overall; 8.6-7.8 years for diabetes; and 13.5-11.6 years for HIV. Compared to age ≥75 years, VACS-CCI improved correct classification of survival for 1 in 13.3 overall; 1 in 7.8 with diabetes; and 1 in 6.4 with HIV. INTERPRETATION/CONCLUSIONS:Compared to chronological age alone, VACS-CCI offers an improved method to identify those likely to reach minimum payoff time, especially for those with complex chronic diseases. Use of clinical data to assess "physiological age" could improve healthcare value. FUNDING/BACKGROUND:This work was supported by National Institutes of Health NIAAA: P01 AA029545, U24 AA020794 and the Emory Center for AIDS Research (P30AI050409).