Faculty Bibliography

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.

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.

OBJECTIVE:To evaluate the relationship between the Global Budget Revenue (GBR) model and surgical outcomes. SUMMARY BACKGROUND DATA/BACKGROUND:Medicare tested GBR in Maryland, wherein hospitals received a fixed annual revenue to cover healthcare delivery for their population. The relationship between GBR implementation and outcomes after cancer surgery is unclear. METHODS:Observational difference-in-differences analysis using 100% national Medicare data to compare changes in outcomes between GBR hospitals and matched control hospitals before (2011-2013) and after (2014-2018) policy implementation in Traditional Medicare beneficiaries undergoing cystectomy, prostatectomy, or nephrectomy for cancer. The primary outcome was achievement of a textbook outcome, defined as the absence of in-hospital and 30-day mortality, postoperative complications, a prolonged length of stay (i.e., above the 75th percentile by procedure and year) and readmission within 30 days of discharge. The secondary outcome was Medicare inpatient spending. RESULTS:This study included 23 Maryland hospitals with 4,910 beneficiaries and 371 control hospitals with 57,456 beneficiaries. Textbook outcomes increased from 72.8% to 76.1% in GBR hospitals and from 70.2% to 70.5% in matched controls, a differential increase of 2.9 percentage points (95% CI, 0.5 to 5.3; P=0.02). The greater improvement at GBR hospitals was a result of reducing complications (-1.5 percentage points; 95% CI, -2.9 to -0.1) and limiting prolonged lengths of stay (-1.8 percentage points; 95% CI, -2.9 to -0.7). Medicare inpatient spending declined by $771 (95% CI, -$1,275 to -$267) more at GBR hospitals. CONCLUSIONS:The GBR was associated with improved surgical outcomes and lower Medicare inpatient spending.

BACKGROUND:Poor documentation quality can significantly affect healthcare operations, but the feedback process for clinicians to improve clinical notes is time-consuming and often insufficient. Large language models (LLMs) such as Generative Pre-trained Transformer 4 (GPT-4) have the potential to streamline this process. OBJECTIVES/OBJECTIVE:To determine whether an LLM can generate feedback to improve the medical contingency and discharge planning (MCDP) component of clinical documentation that is non-inferior to feedback by physicians. METHODS:A cross-sectional study of GPT-4 feedback and physician feedback on inpatient progress notes was conducted. A random sample of 64 inpatient progress notes identified by the validated AI Audit Tool as having a low likelihood of containing MCDP was included from adult general medicine patients hospitalized at New York University Langone Health (NYULH) in December 2023. Both GPT-4 model and attending physicians generated feedback on these inpatient progress notes. A/B testing was then conducted on the measures of understandability, usefulness, acceptability, and impartiality. Evaluations employed 5-point Likert scales that were converted to 10-point bidirectional interval scales for interpretability, ranging from -10 (human suggestions significantly better) to +10 (GPT-4 suggestions significantly better), with a non-inferiority threshold set to -1 for the primary endpoint. RESULTS:64 inpatient progress notes were included, representing 55% female patients with a median age of 73. GPT-4 feedback was non-inferior to physician feedback in all measures: understandability (mean 1.27, 95% CI 0.73 to 1.8, P < 0.001), usefulness (mean 2.09, 95% CI 1.27 to 2.91, P < 0.001), acceptability (mean 2.07, 95% CI 1.33 to 2.81, P < 0.001), and impartiality (mean -0.20, 95% CI -0.52 to 0.12, P < 0.001). CONCLUSIONS:This study shows that an LLM can be leveraged to generate note quality feedback that is non-inferior to expert clinician feedback.

IMPORTANCE/UNASSIGNED:Transcatheter tricuspid valve replacement (TTVR) demonstrated superior outcomes over medical therapy in patients with severe tricuspid regurgitation (TR) in the Edwards EVOQUE Transcatheter Tricuspid Valve Replacement: Pivotal Clinical Investigation of Safety and Clinical Efficacy Using a Novel Device II (TRISCEND II) randomized clinical trial, and received regulatory approval in the US in 2024. Contemporary real-world data on its effectiveness and safety remain limited. OBJECTIVE/UNASSIGNED:To evaluate 30-day clinical, echocardiographic, and health status outcomes of TTVR in real-world use. DESIGN, SETTING, AND POPULATION/UNASSIGNED:Retrospective cohort study of all consecutive patients who underwent TTVR in the US from February 2024 through March 2025 in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Patients had symptomatic, severe TR despite optimal medical therapy and TTVR was deemed appropriate by a heart team. Statistical analysis was conducted from September 2025 to February 2026. EXPOSURE/UNASSIGNED:Device-enabled TTVR. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Thirty-day event rates (all-cause death, stroke, bleeding, new cardiac implantable electronic device [CIED] implantation, heart failure hospitalizations), TR reduction, and changes in health status (New York Heart Association [NYHA] functional class and Kansas City Cardiomyopathy Questionnaire Overall Summary [KCCQ-OS] score) are reported. Subgroup analyses examined the impact of baseline CIED status on outcomes. RESULTS/UNASSIGNED:Among 1034 attempted procedures at 82 centers (mean [SD] age, 77.1 [10.6] years; 69.1% female; 73.2% NYHA functional class III/IV), a valve was successfully implanted in 1017 patients (98.4%). Mild or less TR was achieved in 98.4% of patients post procedure and in 97.7% at 30 days. At 30 days, all-cause mortality was 3.1%; stroke, 0.2%; bleeding, 7.9%; new CIED, 15.9% in CIED-naive patients; and heart failure hospitalization, 3.1%. There were significant improvements in NYHA functional class (class I/II, 82.7%; P < .001) and mean KCCQ-OS score (22.4 points; P < .001) from baseline to 30 days. There were no significant differences in 30-day mortality (P = .47), heart failure hospitalization (P > .99), and functional outcomes (P = .55) when patients were stratified by baseline CIED status. CONCLUSIONS AND RELEVANCE/UNASSIGNED:Early US real-world experience with TTVR confirms safety and effectiveness in patients with severe TR. Thirty-day outcomes are consistent with the TRISCEND II pivotal trial, demonstrating acceptable safety, near-complete TR elimination, and significant health status improvements in an older, comorbid population. Rates of new CIED implantation and bleeding were lower than randomized clinical trial experience.

PURPOSE/OBJECTIVE:Secondary brain injury is a common cause of poor outcome after trauma, subarachnoid hemorrhage, and intracerebral hemorrhage, and optimizing treatment requires real-time insight into cerebral metabolism. Cerebral microdialysis (CMD) uniquely provides key related information, yet consensus on its use has not been updated since publication of the consensus statement from the 2014 International Microdialysis Forum. We aimed to assess expert consensus on the use of CMD in critical care and provide contemporary guidance to standardize practice and advance clinical implementation. METHODS:We conducted a 3-round modified Delphi study with international experts in CMD and neurocritical care. Consensus was defined as ≥ 75% agreement among non-abstaining respondents, with a minimum of 30 non-abstaining respondents required per statement. Statements not reaching consensus were iteratively revised based on panelist feedback. RESULTS:Forty of 67 invited experts (60%) from 9 countries participated. Sixty of 62 individual items achieved consensus (97%) across 9 domains: indications and patient selection, technical and procedural considerations, detecting deterioration and secondary injury, metabolic interpretation, treatment algorithms, glucose management, sampling frequency, core reporting items, and barriers to clinical implementation. CONCLUSION/CONCLUSIONS:This consensus statement provides updated, evidence-informed recommendations for the use of CMD in critical care. The panel reaffirmed many core recommendations from the 2014 consensus while making targeted advances: cautious extension of guidance to intracerebral hemorrhage, comprehensive reporting guidance addressing frequently omitted elements (19 items vs. 6 in 2014), and identification of 10 key barriers to routine clinical adoption.

BACKGROUND AND OBJECTIVE/OBJECTIVE:Most patients with high-risk localized prostate cancer (HRLPC) do not undergo stereotactic body radiotherapy (SBRT) in part because of the limited evidence of long-term outcomes. We report long-term efficacy and toxicity outcomes for men treated with SBRT for HRLPC. METHODS:Individual patient data from ten prospective clinical studies evaluating SBRT for HRLPC across nine institutions were pooled in the Stereotactic Body Radiotherapy for High-Risk Localized Carcinoma of the Prostate consortium. The Kaplan-Meier method was used to estimate 5-yr biochemical recurrence (BCR) and distant metastasis (DM), stratified by receipt of intensified treatment (≥12 mo of androgen deprivation therapy [ADT] with extremely dose-escalated [≥8 Gy/fraction] prostate-directed SBRT). The impact of intensified treatment on BCR-free survival and DM-free survival was evaluated using multivariable Cox proportional hazards models. Late Common Terminology Criteria for Adverse Events grade ≥2 gastrointestinal (GI) and genitourinary (GU) toxicity was analyzed using time-to-event models. KEY FINDINGS AND LIMITATIONS/UNASSIGNED:In 440 patients with a median follow-up time of 60.4 mo, 5-yr BCR and DM rates were 22% (95% confidence interval [CI] = 17-26%] and 9.2% (95% CI = 6.2-12%), respectively. In the 93 patients (21%) who received intensified treatment, 5-yr BCR and DM rates were 7.4% (95% CI = 1.7-13%) and 3.7% (95% CI = 0-7.9%), respectively. Receipt of intensified therapy was associated with a significant reduction in both BCR (hazard ratio [HR] = 0.38 [95% CI = 0.20-0.74], p = 0.005) and DM (HR = 0.43 [95% CI = 0.18-0.99], p = 0.049). For the overall cohort, 5-yr rates of grade ≥2 GU and GI toxicity were 23% (95% CI = 19-27%) and 10% (95% CI = 7-13%), respectively. Limitations include heterogeneous treatment techniques and the nonrandomized nature of the study. CONCLUSIONS AND CLINICAL IMPLICATIONS/CONCLUSIONS:The safety and efficacy profile of SBRT for HRLPC remains favorable at long-term follow-up, and SBRT should be integrated into shared decision-making for treatment of HRLPC.

BACKGROUND:The objectives of this study were to determine if financial considerations affect reconstructive decision-making, and conversely if reconstructive choice affects downstream financial burden. METHODS:We conducted mixed-methods study with a convergent design. Patients undergoing mastectomy with or without reconstruction were administered the Comprehensive Score for Financial Toxicity (COST) questionnaire before and after surgical treatment, where COST ≤20 indicated financial toxicity (FT). Multivariable regression models were used to identify predictors of FT and changes in COST score. Additionally, we conducted semi-structured interviews with patients who screened positive for FT to comprehensively capture experiences with financial burden. RESULTS:There were 1,029 patients with a COST score prior to mastectomy, with a 30.6% rate of FT. Significant predictors of FT included age (OR 0.97), race (Asian OR 2.12, Black OR 2.66, compared to White), marital status (divorced/separated OR 2.70, single OR 2.43, compared to partnered), and neighborhood-level socioeconomic deprivation (OR 1.15) (p<0.02). Receipt of reconstruction was not significantly associated with baseline FT, nor were type and timing among those who underwent reconstruction (N=739). Additionally, receipt, type, and/or timing of reconstruction were not significantly associated with a change in COST score (full cohort N=446, reconstruction cohort N=297). Interviews yielded 3 themes: prioritizing outcomes over financial implications, difficulties navigating and maintaining insurance coverage, and a need for greater transparency and access to financial resources. CONCLUSION/CONCLUSIONS:Bidirectional relationships between FT and receipt, type, and timing of reconstruction did not reach statistical significance. Additional patient-centric financial navigation and price transparency are warranted to mitigate financial burden.

Urologic oncologic emergencies represent a relatively narrow yet diverse group of critical conditions that require prompt recognition and intervention to prevent potentially life-threatening complications. These oncologic emergencies may arise as direct consequences of a malignancy, including local invasion, or as sequelae of surgical or therapeutic interventions. Common urologic emergencies include malignant obstructive uropathy or ureteral obstruction, which may lead to urosepsis or acute kidney injury; large volume hematuria and hemorrhagic cystitis, which both can result in substantial blood loss; renal hemorrhage, which can lead to hemodynamic instability; fistula formation; and postsurgical urinary leaks. Radiologists play a key role in promptly detecting and evaluating such emergencies and can help differentiate expected post-treatment findings from urgent or potentially life-threatening complications. Imaging not only helps to diagnose these emergencies but can also guide subsequent management strategies and thus is essential for optimizing patient outcomes. This review article aims to highlight the clinical and multi-modality imaging manifestations of urologic oncologic emergencies and their potential management strategies.

IMPORTANCE/OBJECTIVE:Pelvic floor physical therapy (PFPT) is a first-line treatment for pelvic floor disorders, though it is frequently an uncovered benefit. Data on insurance acceptance among PFPT offices is limited; therefore, its true accessibility is unknown. OBJECTIVES/OBJECTIVE:Our primary objective was to characterize the effect of insurance coverage on access to PFPT in a national sample. Our secondary objective was to identify factors associated with Medicaid acceptance. STUDY DESIGN/METHODS:This cross-sectional analysis utilized a "secret shopper" methodology. Investigators contacted 200 PFPT offices across 8 states, 4 with expanded Medicaid access, using a script to evaluate insurance acceptance, wait times, and cost. The agreement between Medicaid and commercial insurance acceptance was tested using the McNemar test. Logistic regression identified factors associated with Medicaid acceptance. RESULTS:Of 200 PFPT offices, 141 (70%) accepted commercial insurance and 94 (47%) accepted Medicaid (χ2=35.8, P<0.001); 53 accepted neither (26.6%). Factors associated with Medicaid acceptance included location in nonexpansion states (adjusted odds ratio [aOR], 2.0; 95% CI, 1.02-4.00, P=0.045), acceptance of commercial insurance (aOR, 6.72, 95% CI; 2.22-20.38, P<0.001), academic affiliation (aOR, 17.54; 95% CI, 6.93-44.36, P<0.001), and nonurban location (aOR, 3.10, 1.23-7.18, P=0.016). Mean wait time for Medicaid was 4.6 weeks versus 3.1 weeks for non-Medicaid offices (P=0.004). In all, 117 PFPTs (58.5%) reported a cash cost for an initial visit: median cost was $190.62 (SD=73.77), range $70-$450. CONCLUSIONS:Our analysis reveals significant PFPT disparities for Medicaid beneficiaries, underscores barriers to access for Medicaid patients, and highlights opportunities for policy interventions to promote equity.