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.

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.

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.

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.

BACKGROUND:Comparative trials evaluating surgical outcomes are critical in guiding treatment for hallux valgus. However, the statistical stability of these outcomes is not well documented. Purpose The purpose of this study was to evaluate the statistical fragility of comparative studies analyzing minimally invasive surgery (MIS) versus open techniques for hallux valgus correction. STUDY/METHODS:Design A systematic review identified comparative studies assessing MIS versus open hallux valgus correction. METHODS:Outcome data were extracted with Fragility Index (FI) and Continuous Fragility Index (CFI) calculated for significant outcomes, and reverse FI (rFI) and reverse CFI (rCFI) for nonsignificant outcomes. Fragility Quotient (FQ) was calculated for each and compared to the number of patients lost to follow-up (LTFU). RESULTS:Of 628 studies screened, 18 met inclusion criteria, totaling 1,369 patients. Among 88 dichotomous outcomes, the median FI was 2, FQ was 0.021, rFI was 4, and rFQ was 0.072. For 236 continuous outcomes, the median CFI was 8, CFQ was 0.116, rCFI was 19, and rCFQ was 0.280. CONCLUSION/CONCLUSIONS:This is the first study to evaluate fragility in comparative trials on MIS versus open hallux valgus correction and among the first to assess reverse fragility in continuous outcomes. Significant results were more fragile than nonsignificant data and dichotomous outcomes were more fragile than continuous ones with nearly a quarter having an FI lower than the number of patients LTFU. Both outcome types demonstrated considerable statistical fragility supporting the cautious interpretation of MIS vs open hallux valgus findings and the reporting of statistical fragility data alongside P-values to better contextualize the robustness of clinical research.

BACKGROUND:Epigenetic regulators represent a novel strategy to modulate the tumor immune microenvironment in pancreatic ductal adenocarcinoma (PDAC). In preclinical models, DNA hypomethylating agents enhance cytotoxic T-cell infiltration, synergize with PD-1 blockade, and improve survival when combined with immune checkpoint blockade. This single-institution, phase II study evaluated the safety, efficacy, and biomarkers of azacitidine plus pembrolizumab in patients with previously treated PDAC. METHODS:Patients with locally advanced or metastatic PDAC after one prior regimen received 50 mg/m2 subcutaneous azacitidine on days 1-5 of a 28-day cycle, starting week 1, and pembrolizumab 200 mg intravenously every 3 weeks starting week 3. Baseline and on-treatment blood and tumor was collected for exploratory biomarker analysis. RESULTS:Thirty-six patients enrolled between October 2017 and September 2021 (median age: 62.5 years); 34 were evaluable for safety; 31 for efficacy. Treatment was generally well-tolerated, with Grade 1-2 fatigue and diarrhea most common AEs. Three patients (9.7%) had a partial response, and the disease control rate was 35.5%. Median progression-free and overall survival was 1.51 and 4.83 months, respectively. Exploratory analysis suggested higher baseline CD8+ T cells and lower tumor Ki-67 was associated with response, whereas low baseline CD8+ T cell and Granzyme B infiltration correlated with higher exponential tumor growth rate. PD-L1 and CD68 expression were not predictive of benefit. CONCLUSION/CONCLUSIONS:Azacitidine plus pembrolizumab demonstrated limited clinical activity in second line, locally advanced or metastatic PDAC. Biomarker analysis suggests higher baseline CD8+ T-cell infiltration and lower proliferative index may identify patients more likely to benefit. (NCT03264404).

BACKGROUND:The number of graduates from accelerated 3-year MD (A3YP) programs has increased over the past decade. Previous work showed that A3YP graduates perform comparably to non-accelerated (4-year) graduates from the same medical schools on mid-year and end-year Accreditation Council of Graduate Medical Education (ACGME) harmonized milestones. In shifting to the residency program perspective, it remains unclear how the performance of A3YP graduates compares to non-accelerated graduates including traditional 4-year, international, and osteopathic medical school graduates. OBJECTIVE:To compare the intern performance of A3YP graduates compared with non-accelerated graduates using mid-year and end-year ACGME milestones in Internal Medicine (IM) residency programs. DESIGN/METHODS:The study employed a retrospective cohort design, hypothesizing that graduates from A3YPs were comparable to non-accelerated graduates in the same program. PARTICIPANTS/METHODS:108 interns who graduated from A3YP were compared to 3,542 interns from non-accelerated programs at the same 34 IM residency programs. MAIN MEASURES/METHODS:Descriptive statistics were provided for ACGME milestone performance. Cross-classified random-effects regression was used to account for residency program effects and estimate group differences. KEY RESULTS/RESULTS:After controlling for residency programs, the milestone ratings of A3YP graduates were higher in all competency domains at mid-year except practice-based learning and improvement (PBLI) at .04 (P = .089) (coefficients ranged from 0.08 for medical knowledge (MK) (P < .001) to 0.23 in professionalism (PROF) (P < .001)). These differences persisted at the end-year period (coefficients ranged from 0.05 in PBLI (P = .039) to 0.17 in PROF (P < .001)) except MK at .02 (P = .656). Patient care differences were 0.15 (P < .001) at mid- and 0.14 (P = .005) at end-year. CONCLUSIONS:This study contributes to the literature demonstrating that interns graduating from A3YP are at least equivalent in terms of milestone assessment and possibly better in the competencies of PC and PROF than their non-accelerated counterparts.

OBJECTIVE:Exposure to antidepressants, particularly agents that work through serotonin-reuptake inhibition, may increase potential for bleeding, especially among patients with other bleeding risk factors. There is limited guidance for clinicians in the use of serotonin reuptake inhibitors (SRIs) and other antidepressants in the setting of increased bleeding risk. METHODS:A PubMed literature search was conducted for English-language articles (1992-2024) examining the bleeding risk associated with antidepressants. Physicians from the Association of Medicine and Psychiatry then convened to develop consensus recommendations. RESULTS:Consensus recommendations were established for managing antidepressant use in patients with medical and psychiatric comorbidities. Additionally, a clinical decision algorithm was created to assist clinicians in assessing the appropriateness of antidepressant prescribing in patients at risk for bleeding. CONCLUSIONS:The proposed algorithm can aid clinicians in determining whether antidepressant (including SRI) initiation, discontinuation, or dose adjustment should be considered for patients susceptible to bleeding. These guidelines preserve a role for clinical judgment in selection of treatments that balance the risks and benefits, which may be particularly relevant for patients with complex medical and psychiatric comorbidities. Additional studies are needed to better guide clinical decision making.

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.