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.

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.

IMPORTANCE/UNASSIGNED:The management of infectious and inflammatory lesions of the breast remains controversial. The expert panel focused on management recommendations for 3 of the most common infectious breast conditions, as very few evidence-based guidelines for the management of these conditions exist. OBSERVATIONS/UNASSIGNED:Clinicians should distinguish between infectious and noninfectious lactational mastitis (LM) because the former often requires interventions whereas the latter requires supportive care only. Patients with infectious LM often have thick fluid collections that are not amenable to aspiration and usually require a stab incision with drain placement (but no packing) to resolve the infection. Operative drainage is only required if the patient cannot tolerate an office procedure. If a phlegmon is present, antibiotics should be prescribed for at least 10 days. The diagnosis of granulomatous mastitis (GM) requires pathology confirmation with characteristic findings on core biopsy. Cystic neutrophilic granulomatous mastitis (CNGM) is a specific form of GM associated with a granulomatous reaction to Corynebacterium infection and should be empirically treated with doxycycline. For patients without findings characteristic of CNGM and no other associated bacterium identified, there is no role for empiric antibiotic use. Granulomatous mastitis cases often recur and can take up to 18 months to resolve. Patients who have GM cases with worsening symptoms should be treated with repeated intralesional steroid injections; surgical excision or repeated aspirations should be avoided. Cases refractory to intralesional steroid injection may require oral steroids or even advanced biologic agents such as methotrexate or azathioprine. Periductal mastitis with squamous metaplasia of lactiferous ducts (PDM-SMOLD) is a distinct entity from other periductal mastitis cases that can present with recurrent abscesses and should be treated with antibiotics and aspiration for fluid collections. Operative excision for PDM-SMOLD is required for those patients who present with a fistula or recurrent episodes typically using a radial incision to remove the diseased ducts within and below the nipple. CONCLUSIONS AND RELEVANCE/UNASSIGNED:Evidence-informed, consensus-, and expert opinion-based guidelines for the management of infectious and inflammatory conditions of the breast were developed. Clinicians can use these guidelines to appropriately manage these conditions for which clinical care often varied in the past.

While many parasitic and vector-borne infections have traditionally been considered to have geographically limited distribution, factors including climate change, the immigration and world travel of individuals, and the importing and exporting of goods continue to shift ecosystems and expand the geographic distributions of parasites and insect vectors and the infections they transmit. Because they may be unexpected, cases emerging in regions of nonendemicity can result in a medical mystery, and because appropriate management relies on an accurate diagnosis, identification of these diseases is vital. Radiologists should be aware of these infections and their potential sequelae to help limit the delays in diagnoses and potentially lifesaving treatment that can occur if the diagnosis is not promptly suggested and investigated. Although some imaging findings are nonspecific, a knowledgeable radiologist can play a crucial role in correlating imaging features or patterns of features with laboratory findings and available clinical information to reveal the diagnosis and/or develop a differential diagnosis. The authors describe a variety of parasitic and vector-borne infections that affect humans, with a specific focus on those that manifest in the head, neck, and spine. A brief introduction to these infections is provided and includes relevant epidemiologic factors, clinical presentations, and potential complications, with the sequelae associated with head, neck, and nervous system infections more thoroughly described. Case examples are included to demonstrate the imaging features associated with acute and chronic and common and uncommon sequelae of these infections across multiple imaging modalities. ^©RSNA, 2026 Supplemental material is available for this article.

PURPOSE/OBJECTIVE:The purpose of this study was to evaluate the effect that associated glenohumeral dislocations have on outcomes following surgical treatment of proximal humerus fractures. METHODS:This IRB-approved study reports on 301 patients, who underwent operative treatment for proximal humerus fractures at an academic medical center from January 2006 to January 2023. Fractures were classified according to the Neer system. Patients were separated into two cohorts based on whether a glenohumeral dislocation was present at the time of initial injury. Outcomes measured included the Disabilities of the Arm, Shoulder, and Hand (DASH) score, shoulder range of motion (forward elevation, external rotation, internal rotation), readmission rates, complications, hardware removal, and need for revision surgery. Independent samples t-tests and chi-squared analysis were used for continuous and categorical variables, respectively. A binary logistic regression was performed to analyze the influence of these factors on complication rate. RESULTS:230 patients sustained an isolated fracture (PHF) and 71 sustained a fracture-dislocation (FD). Significant differences were observed between the FD and PHF groups in all measured outcomes. The FD group had a poorer DASH score (24.38 ± 19.09 vs 10.54 ± 13.67; P < 0.001) and reduced range of shoulder motion in forward elevation (114° ± 40° vs 162° ± 19°; P < 0.001), external rotation (40° ± 19° vs 66° ± 19°; P < 0.001), and internal rotation (57° ± 26° vs 82° ± 21°; P < 0.001). Readmission rates were higher in the FD group (0.28 ± 0.85 vs 0.05 ± 0.28; P < 0.001). The FD cohort also had a higher rate of complications (25.35% vs 6.52%; P < 0.001), need for removal of hardware (14.08% vs 3.04%; P = 0.002), and overall revision surgery (11.27% vs 1.30%; P < 0.001). The FD cohort demonstrated a greater incidence of AVN (12.68% vs 4.35%; P = 0.012). No significant difference was observed regarding rates of fracture healing and recurrent dislocation. Multivariate analysis in the form of binary logistic regression indicated that fracture-dislocation significantly increased the complication risk (OR = 3.310, 95% CI = 1.42-7.70; P = 0.005). CONCLUSION/CONCLUSIONS:Proximal humerus fracture-dislocations are associated with worse functional outcomes and higher complication rates compared to those without dislocations. These findings highlight the potential need for specialized treatment strategies to mitigate the impact of dislocation on recovery.

A pilot online, video-based abortion care curriculum nationally positively affected obstetrics-gynecology residents' clinical knowledge, providing residency programs with a useful, centralized educational resource.

PURPOSE/UNASSIGNED:Recent publications have renewed interest in prophylactic pelvic radiation therapy for higher-risk prostate cancer, as well as dose escalation for magnetic resonance imaging (MRI)-defined intraprostatic lesions. Here, we explore the use of pelvic nodal irradiation with a 3-fraction stereotactic body radiation therapy (SBRT) boost to the prostate and seminal vesicles, with a simultaneous MRI-directed focal intraprostatic lesion-ablative microboost (MIB). METHODS AND MATERIALS/UNASSIGNED:We evaluated an institutional registry of patients undergoing pelvic nodal radiation followed by an SBRT boost to the prostate and seminal vesicles from April 2021 to March 2023. The study was approved by the local institutional review board (study #00001269). All patients were treated with pelvic nodal irradiation followed by a 3-fraction SBRT boost. The prostate SBRT boost dose was primarily 2100 cGy in 3 fractions (an accommodated range of 1800-2100 cGy). A subgroup of 15 patients received an MIB to an additional dose of 2300 cGy in 3 fractions (range, 2100-2400 cGy). The distribution of adverse event grades for acute and late gastrointestinal (GI) and genitourinary (GU) toxicity was assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events, version 5.0. RESULTS/UNASSIGNED:Fifty-eight patients underwent pelvic nodal irradiation followed by an SBRT boost to the prostate, with the distribution of risk groups as follows: patients were either in the high (36.2%, n = 21) or very high (34.5% n = 20) risk groups, whereas those with known nodal disease (19.0%, n = 11) or intermediate risk (10.3%, n = 6) comprised the rest of the study population. Most patients received androgen-deprivation therapy. The prostate SBRT boost dose was primarily 2100 cGy in 3 fractions. Fifteen patients received an MIB to an additional dose of 2300 cGy in 3 fractions. A median follow-up of 8.7 months was used to document the incidence of GU and GI toxicity. The distribution of GI and GU toxicity showed no significant difference between the MIB and non-MIB subcohorts at either the acute (<90 days) or late (>90 days) time points. Two grade 3 toxicities were observed, both in the non-MIB cohort. Grade 2+ GI and GU toxicities were not significantly different between the 2 groups, as assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events, version 5.0. CONCLUSIONS/UNASSIGNED:In the early follow-up period, we observed no significant difference in GI or GU toxicity between those who underwent MIB and those who did not. These results suggest that MRI-directed SBRT MIB did not increase GI toxicity and may even reduce GU toxicity compared with standard treatment. Future research should explore long-term side effects, with attention to the Expanded Prostate Cancer Index Composite (EPIC) scores and oncologic outcomes of this novel method of dose escalation.

INTRODUCTION/BACKGROUND:Children with immune thrombocytopenia (ITP) may have an increased risk of perioperative bleeding. However, current pediatric ITP guidelines do not address this management setting. We aimed to describe perioperative management and outcomes in pediatric patients with ITP by platelet count, type of surgery, and ITP-directed treatment strategies. METHODS:We conducted a retrospective analysis of patients with ITP ages 0-24 years who underwent tooth extraction, tonsillectomy and adenoidectomy, appendectomy, and/or splenectomy at six centers in the United States and Canada between 2019 and 2024. RESULTS:/L where hematology was not involved in perioperative management. Medication side effects were reported in 7% (3/43) of patients receiving ITP-directed therapies. CONCLUSIONS:/L. Perioperative bleeding risk appears to be low in pediatric ITP under current management practices.

IMPORTANCE/UNASSIGNED:Pancreatic ductal adenocarcinoma (PDAC) is a leading cause of cancer deaths in the US. Although early detection improves survival, the rarity of the disease has rendered population screening a difficult approach. OBJECTIVE/UNASSIGNED:To develop and validate a parsimonious, interpretable, and generalizable model predicting incident PDAC-termed PRIME (PDAC Risk Model for Earlier Detection)-using routinely available electronic health record (EHR) data. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This cohort study used the Optum Labs Data Warehouse, a longitudinal, deidentified US EHR and claims database. Adults 40 years or older with an outpatient clinical encounter between 2016 and 2018 were included. Participants from 23 health systems (n = 4 859 833) comprised the training cohort; 31 additional systems (n = 5 619 091) served as validation. International validation was conducted in the UK Biobank (n = 498 754). Data analysis occurred July 2025 to January 2026. EXPOSURES/UNASSIGNED:Demographics, diagnosis codes, and routinely measured laboratory values were evaluated. Elastic-net regularization with 10-fold cross-validation selected the predictor set. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Incident PDAC was identified by International Classification of Diseases, Ninth and Tenth Revisions (ICD-9/10) codes. Model performance was assessed using time-dependent area under the curve (AUC) and calibration metrics. RESULTS/UNASSIGNED:Overall, the study included more than 11 million adults (2.1% Asian individuals, 8.4% Black individuals, 4.3% Hispanic/Latino individuals, 82.7% White individuals, and 2.4% other race/ethnicity by EHR reporting). In the training cohort (mean [SD] age, 60.4 [11] years), 14 405 individuals were diagnosed with PDAC (incidence 55 per 100 000 person-years) over a mean (SD) of 5.4 (2.5) years; in the validation cohort, 11 693 individuals were diagnosed with PDAC (54 per 100 000 person-years) over a mean (SD) of 3.9 (2.5) years. PRIME retained 19 predictors including history of pancreatitis, gastrointestinal disorders, prior cancers, type 2 diabetes, elevated aspartate aminotransferase levels, smoking, non-type-O blood, and male sex. Discrimination was strong at the 36-month time horizon (AUC = 0.75 in both the training and validation cohorts) with good calibration. In the validation cohort, patients in the top 1% of predicted risk had substantially higher PDAC risk (HR, 7.63; 95% CI, 6.85-8.49) compared with average-risk patients. In the UK Biobank, PRIME achieved a 36-month AUC of 0.71 with good calibration. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this validation cohort study, PRIME was a transparent EHR-based model that effectively stratified PDAC risk across diverse US health systems and generalized internationally. Prospective studies should evaluate for EHR-guided PDAC case-finding and integration with blood-based early-detection assays.