Faculty Bibliography

INTRODUCTION/BACKGROUND:Biliary strictures (BS) are a significant challenge, with malignant strictures frequently diagnosed at advanced stages, limiting curative options. Digital single-operator cholangioscopy (D-SOC) enables high-resolution, direct visualization of the bile duct, yet with suboptimal accuracy. Artificial intelligence (AI) has shown promise for detection and differentiation of BS in frame-level analysis and small clinical series. This study aimed to validate a deep learning model for AI-assisted D-SOC image analysis. METHODS:This multicenter study included 135 D-SOC exams from 129 patients (61 with malignant BS) across 14 centers in the United States, Brazil, Spain, Colombia, Australia, and Saudi Arabia. For each exam, up to 25 clinically relevant frames were selected and uploaded to a web-based platform for AI analysis. The model performed both detection and differentiation of BS: detection was assessed by comparing AI-generated bounding boxes with expert-defined annotations using intersection-over-union (IoU), while differentiation was benchmarked against histopathology. Performance metrics included accuracy, sensitivity, specificity, and positive and negative predictive values (PPV and NPV). RESULTS:At the patient level, malignant BS were identified with 86.0% accuracy, 84.1% sensitivity and 85.7% specificity, with an AUC of 0.904. The model demonstrated robust detection performance, achieving a mean IoU of 70.3%. Performance was maintained across demographic variables and centers. DISCUSSION/CONCLUSIONS:This first multicentric validation study demonstrates real-world performance of AI-assisted D-SOC analysis across multiples continents and devices, with robust accuracy for BS detection and differentiation. These findings support AI as an adjunctive tool in D-SOC, enhancing a more accurate evaluation of patients with indeterminate BS.

BACKGROUND AND AIMS/OBJECTIVE:The TRISCEND II trial demonstrated superior clinical benefits for patients with ≥severe tricuspid regurgitation (TR) treated with the EVOQUE transcatheter tricuspid valve replacement (TTVR) system plus medical therapy versus medical therapy alone. This work reports 1-year and 18-month outcomes in patients stratified by baseline TR severity. METHODS:The multicentre, prospective TRISCEND II trial enrolled 400 patients with symptomatic, ≥severe TR and randomised 2:1 to TTVR (n=267) or control (n=133). In a post-hoc analysis, patients were stratified into severe TR (n=172) and massive/torrential TR (n=220) cohorts. Clinical and quality-of-life outcomes were reported at 1 year, with Kaplan-Meier estimates for all-cause mortality and heart failure (HF) hospitalisation assessed at 18 months. Study oversight included an independent echocardiographic core laboratory, clinical events committee, and data safety monitoring board. RESULTS:One year after TTVR, TR was ≤mild in 95.2% of severe TR and 95.3% of massive/torrential TR patients. The primary safety and effectiveness endpoint (win ratio) favoured TTVR over control regardless of baseline TR severity: severe (1.64 [95% CI: 1.11, 2.43]) and massive/torrential (2.20 [1.55, 3.14]). At 18 months, TTVR patients had similar mortality to controls (rate difference: severe 0.2% [-11.6, 11.9], massive/torrential -5.8% [-17.6, 6.0], whereas HF hospitalisation rates favoured TTVR in the massive/torrential cohort (vs. control, severe 9.8% [-3.0, 22.7], massive/torrential -15.2% [-28.9, -1.5]). CONCLUSIONS:Patients with ≥severe TR benefit from TTVR, experiencing improvements in TR severity, functional capacity, and quality of life regardless of baseline TR severity, with a signal for greater benefit in patients with more advanced disease.

This AM Last Page provides a visual depiction of how to best implement successful hybrid learning practices in academic -medicine using the Community of Inquiry conceptual framework.

OBJECTIVES/OBJECTIVE:Most pediatric residency programs introduce PICU rotations in postgraduate year (PGY) 2, although it is unclear whether this timing best supports trainees' skill development. Introduction during PGY1 may pose challenges due to clinical intensity, but could also have benefits in uniquely preparing residents for PGY2 responsibilities and autonomy. To address this question, this study explored the experiences and self-perceived impacts of a PGY1 PICU rotation among senior pediatric residents. DESIGN/METHODS:A multi-institutional qualitative study was conducted using semi-structured interviews of senior (PGY2 and PGY3) residents who completed a PGY1 PICU rotation. Stratified purposive sampling was used at both institutional and resident levels. Data were coded using constant comparison and analyzed thematically. SETTING/METHODS:Seven institutions requiring a 4-week PGY1 PICU rotation. PARTICIPANTS/METHODS:Senior pediatric residents at participating institutions. INTERVENTIONS/METHODS:None. MEASUREMENTS AND MAIN RESULTS/RESULTS:Twenty-one interviews across seven institutions identified three key themes: 1) PGY1s can succeed in the PICU setting when supervisors actively cultivate a learning environment of inclusion, support, and appropriate autonomy; 2) PGY1 PICU rotations can foster self-perceived competence in skills that translate to the PGY2 year; and 3) Participants generally believed the benefits of early PICU exposure outweighed the challenges. CONCLUSIONS:PGY1 PICU rotations can fall within the Zone of Proximal Development when the experience includes strong supervisory support. Findings highlighted the importance of psychologic safety for optimal learning, suggesting that strengthening psychologic safety may enhance the educational experience and outcomes. Further research exploring the impact of PGY1s on team dynamics and patient care, and comparing the effects of PGY1 vs. PGY2 introduction, could guide evidence-based recommendations on the optimal sequencing of PICU rotations for pediatric residents.

Recent advances in biological therapies, small molecules and allergen-specific immunotherapy are reshaping the management of immunoallergic diseases, progressively shifting therapeutic goals from short-term disease control toward the possibility of achieving sustained clinical remission. Despite increasing evidence across multiple conditions, a universally accepted and disease-transversal definition of clinical remission (CR) remains lacking. In this review we propose a comprehensive framework for defining clinical remission across a broad spectrum of immune-mediated diseases traditionally managed in Allergy and Clinical Immunology practice, including asthma, allergic rhinitis, chronic rhinosinusitis with nasal polyps, chronic urticaria, atopic dermatitis, mastocytosis, food allergy, and eosinophilic esophagitis. Clinical remission is defined as a sustained state of absence of clinically relevant disease manifestations, independently of underlying biological activity; suppression of inflammatory pathways and normalization of biomarkers define biological remission, which may coexist with, but is not required for, clinical remission. We introduce the 3D-CR model, a pragmatic, disease-adaptable framework integrating 3 complementary domains - clinical, biological, and functional - to characterize remission states as complete, partial, or absent. Building on this model, we propose the Allergic Disease Remission Score (ADReS) as a modular tool designed to support standardized assessment, longitudinal follow-up, and cross-disease comparison in clinical trials and real-world settings. These tools are intended as conceptual and research instruments rather than prescriptive algorithms for individual therapeutic decision-making. Finally, we outline a World Allergy Organization call to action advocating for a harmonized global approach to defining, measuring, and implementing clinical remission as a meaningful treatment target. Establishing standardized remission endpoints has the potential to improve patient outcomes, facilitate precision medicine strategies, enhance comparability across studies, and reduce heterogeneity in clinical research and practice worldwide.

BACKGROUND:Nondiagnostic cytology for thyroid nodules, consistent with The Bethesda System for Reporting Thyroid Cytopathology category I (B1) poses a management dilemma for clinicians. The objective of this study was to define the malignancy risk of nodules with B1 cytology using American College of Radiology Thyroid Imaging Reporting & Data System (TI-RADS) and to assess whether TI-RADS can help guide the decision to perform a repeat biopsy of these nodules. MATERIALS AND METHODS/METHODS:This retrospective cohort study evaluated 139 B1 nodules that had a definitive diagnosis on repeat biopsy or surgical excision. Sonographic features were evaluated and classified according to TI-RADS. TI-RADS category and total points were compared to the final diagnosis to determine the malignancy risk of B1 thyroid nodules. RESULTS:Of the 139 nodules, 11 (7.9%) were malignant. The malignancy risk of nodules assigned TI-RADS category 1 and 2 were both 0%, TI-RADS 3 was 2.9%, whereas TI-RADS 4 and 5 were 5.9% and 46.2%, respectively. The optimal cutoff for TI-RADS points predicting malignancy was 5 points. CONCLUSION/CONCLUSIONS:B1 thyroid nodules in TI-RADS categories 1-3 may not require repeat biopsy given low malignancy risk. However, B1 nodules in TI-RADS categories 4 and 5 have a higher malignancy risk and thus should undergo repeat biopsy.

Labetalol and nifedipine are first-line antihypertensives for hypertensive disorders of pregnancy. However, there is limited research comparing their effectiveness based on hemodynamic profiles seen in preeclampsia, such as high cardiac output (CO) and high systemic vascular resistance (SVR). This study assesses whether concordance of antihypertensive treatment with the hemodynamic status on echocardiogram reduces time to achieve target postpartum blood pressure (BP) before discharge.This retrospective cohort study included patients with preeclampsia with severe features who received a postpartum echocardiography, excluding patients with cardiac etiology. Antihypertensive choices were provider-dependent. The CO and SVR were calculated retrospectively from the echocardiogram in collaboration with cardiology. Concordance was defined as patients with high CO (>6 L/min) started on labetalol and high SVR (>1,200 dynes·sec·cm⁵) started on nifedipine; opposite pairings were discordant. The primary outcome was time to achieve target BP, defined as the period from the start of antihypertensive therapy to when no titration was needed to sustain BPs of less than 140/90 mm Hg. Chi-square and Fisher's tests were used for categorical variables, and Mann-Whitney U test for continuous variables.Of 298 patients, 155 (52%) received concordant therapy and 143 (48%) discordant. Of the cohort, 229 (76.8%) had high SVR and 69 (23.2%) had high CO. Median time to target BP was not significantly different (concordant: 32 hours [interquartile range, IQR: 0-61], discordant: 41 hours [IQR: 4-75], p = 0.13). The concordant group needed fewer titrations to achieve target BP (1 [IQR: 0-2] vs. 2 [IQR: 1-3]; p = 0.008) and were less likely to be discharged home on multiple antihypertensive medications compared with the discordant group (28.9 vs. 42.7%, p = 0.014). Maternal demographics were similar between groups.While time to target BP did not differ, concordance of antihypertensive therapy to postpartum hemodynamics in patients with severe preeclampsia reduced medication adjustments and increased the likelihood of discharge on a single-agent regimen. · Echocardiography can be used to assess maternal hemodynamics.. · Aligning BP meds to hemodynamics cuts the need for a second agent.. · Aligning BP meds to hemodynamics reduces dose adjustments..

BACKGROUND:Glioblastoma intramedullary spinal cord metastasis (GISCM) is a rare sequela of high-grade astrocytoma and glioblastoma multiforme (GBM). Discrete intramedullary spinal cord metastases are less common than spinal leptomeningeal spread and may follow a more indolent course. Once identified as GISCM, palliative maximal safe resection of the tumor may be considered to alleviate neurological symptoms. Reports describing the surgical management of these rare lesions, including the use of emerging technologies that may aid in maximal safe resection, are sparse. A further understanding is also required regarding the course of disease and factors contributing to mortality in GISCM. METHODS:We reviewed the intraoperative management and clinical course of three patients treated for GISCM at our institution between 2015 and 2024. We additionally conducted a PRISMA-guided systematic literature review of PubMed Central, MEDLINE, and Bookshelf databases through May 26th, 2025, including original patient reports of GISCM from cranial astrocytoma or GBM. The disease course, management strategies, and causes of mortality in previously reported cases were analyzed. RESULTS:Our institutional cohort had a mean time to spinal metastasis of 26.2 months from diagnosis of cranial disease (range 17.5-40.5 months), with a mean survival of 9.2 months following maximal safe resection of extramedullary components (range 7-12 months). In two cases, intraoperative Stimulated Raman Histology (SRH) was employed to facilitate the rapid identification of metastatic GBM, thereby influencing surgical strategy. In one case, 5-aminolevulinic acid (5-ALA) was used to differentiate between tumor and spinal cord parenchyma, facilitating maximal safe debulking without neurological injury. Literature review identified 38 prior reported cases of GISCM, with a median time to spinal diagnosis of 11.0 months and a median survival of 3.5 months thereafter. The cause of death in the review cohort often involved multiple factors, and when analyzed for contributing factors to death, 38.7% involved cranial progression, 38.7% involved progression of spinal disease, and 29.0% involved medical complications. Gait ataxia at presentation was associated with shorter survival in review patients, potentially reflecting advanced disease with extramedullary cord compression. CONCLUSION/CONCLUSIONS:GISCM represents an entity distinct from leptomeningeal disease and may be managed in conjunction with recurrent cranial disease. Surgical debulking is a technically feasible strategy that can be safely facilitated using tools employed in the management of intracranial GBM, facilitating maximal safe resection without compromising survival.