Faculty Bibliography

BACKGROUND:Robotic hiatal hernia repair (RHHR) has emerged as an innovative alternative to conventional laparoscopic techniques, offering potential advantages in visualization, dexterity, and ergonomics. However, predictors of revision surgery following RHHR remain incompletely understood. This systematic review investigates key surgical and patient factors associated with revision within 5 years following RHHR. METHODS:We systematically searched PubMed/MEDLINE, Embase, the Cochrane Library, and Web of Science from inception through July 2025 for studies reporting revision or recurrence after RHHR, following PRISMA 2020 guidance. Eligible studies enrolled adults undergoing primary RHHR (≥ 10 patients) and reported revision or recurrence with at least 12 months of follow-up. Two reviewers independently screened records and extracted data, with disagreements resolved by a third reviewer; methodological quality was appraised using the Newcastle-Ottawa Scale. Because of substantial clinical and methodological heterogeneity (variable hernia size criteria, fundoplication and crural closure techniques, outcome definitions, and follow-up duration), a formal quantitative meta-analysis was judged inappropriate; we therefore performed a structured descriptive synthesis with sample size-weighted pooled estimates where data permitted. RESULTS:), advanced age (> 70 years), and comorbidities (diabetes, chronic steroid use) showed inconsistent associations with revision risk, with only 6 of 14 cohorts performing multivariate analysis to control for confounding variables. CONCLUSION/CONCLUSIONS:Hernia size consistently emerges as the primary determinant of revision following RHHR, with larger hernias demonstrating substantially higher revision rates regardless of surgical approach. Based on available data, the 5-year revision rate for RHHR ranges from 0 to 5.7%, with an estimated weighted average of 3.2%. Technical considerations including mesh reinforcement and reconstruction methods remain incompletely understood due to significant reporting variations across studies. Patient-specific factors require further investigation through adequately powered prospective studies. Future research demands rigorous prospective designs with standardized documentation of surgical techniques, hernia characteristics, and patient profiles to better identify and stratify revision risk factors after RHHR. The development of consensus guidelines for reporting outcomes in hiatal hernia surgery would facilitate meaningful comparison across studies and improve our understanding of optimal surgical approaches.

BACKGROUND/OBJECTIVES/OBJECTIVE:Peritoneal metastases (PMs) arise from gastrointestinal, gynecologic, hepatobiliary, and colorectal origins and are associated with poor outcomes. Cytoreductive surgery (CRS) with intraperitoneal (IP) chemotherapy offers benefit for select patients, but survival remains limited. This review aims to summarize recent insights into the molecular and tumor microenvironmental (TME) changes characteristic of PMs and the impact of IP chemotherapy. METHODS:A literature review was performed using recent clinical, translational, and preclinical studies examining alterations in molecular signaling, DNA repair alterations, metabolic pathways, and angiogenic factors in PMs before and after IP therapy. RESULTS:Peritoneal metastases exhibit distinct biology after being treated with IP chemotherapy. Treatment induces alterations in gene expression, mutational patterns, and immune infiltrates. Heated intraperitoneal chemotherapy (HIPEC) has been associated with increased CD8+ T-cell activity, macrophage and NK cell shifts, and modulation of PD-1/PD-L1 signaling, which correlate with treatment response and survival. Emerging data on PIPAC similarly suggests induction of favorable gene expression changes with repeated treatment, though supporting evidence remains more limited than for HIPEC. Angiogenic pathways-particularly VEGF and HIF1α-remain key drivers of PM progression and predictors of post-operative outcomes. Early findings suggest potential synergy between IP chemotherapy and immunotherapy though clinical trials are ongoing. CONCLUSIONS:IP chemotherapy induces tumor microenvironmental changes that have potential to shape therapeutic response. Characterizing these measurable biologic changes may allow clinicians to improve patient selection and support the development of combination therapies to enhance outcomes.

Psychological distress among persons living with HIV (PLWH) can negatively impact behavioral and clinical outcomes. There is need for additional data surrounding mental health status in resource-constrained settings to inform intervention. We assessed social and economic factors associated with symptoms of depression and anxiety among PLWH in western Kenya. Baseline data from the Harambee cluster randomized trial were collected from May 2021 through March 2022 among 1040 PLWH (≥ 18 years of age) receiving care through the Academic Model Providing Access to Healthcare program. Self-reported physiological distress (defined as non-specific symptoms of depression, anxiety and stress) was measured via the four-item Patient Health Questionnaire for Anxiety and Depression (PHQ-4). Multivariable logistic regression analysis was used to identify factors associated with psychological distress. At study baseline, 24% of participants reported severe psychological distress (PHQ-4 summary score ≥ 6). Compared to participants earning <$7 USD per month, those with a monthly income of ≥$35 USD had reduced odds of reporting severe psychological distress (adjusted Odds Ratio (aOR): 0.50; 95% Confidence Interval (CI): 0.27-0.93). Participants in the highest (versus lowest) wealth quintile (aOR: 0.36; 95% CI: 0.18-0.70), and those reporting moderate or high (versus low) levels of social support (aOR: 0.46; 95% CI: 0.46-0.98) were less likely to report severe psychological distress. Among PLWH in rural Kenya, higher monthly income, greater household wealth, and higher levels of social support were negatively associated with severe psychological distress. Multilevel interventions that provide both economic and social support may be essential for improving their mental health.Trial Registry ClinicalTrials.gov Identifier: NCT04417127.

BACKGROUND:Gastroparesis is a chronic disorder characterized by delayed gastric emptying without mechanical obstruction, significantly impacting patient quality of life. Management of refractory gastroparesis remains challenging, with both gastric electrical stimulation (GES) and prokinetic medications used as treatment options. This systematic review synthesizes the available evidence on GES clinical outcomes, the role of continued prokinetic therapy after GES, and indirect comparative data relevant to symptom management in adult patients with refractory gastroparesis. METHODS:A comprehensive systematic review was conducted following PRISMA guidelines. Multiple databases were searched for studies published between 2000 and 2011 focusing on GES for gastroparesis. This window was selected to capture the period from initial FDA Humanitarian Device Exemption approval of the Enterra system (2000) through publication of cohorts with mature, multi-year follow-up (up to 10 years), maximizing the durability evidence available for analysis. Inclusion criteria required adult patients with refractory gastroparesis, GES as primary intervention, symptom-related outcomes, and minimum 6-week follow-up. Eight studies met eligibility criteria with follow-up periods ranging from 6 weeks to 10 years. Quality assessment utilized the Newcastle-Ottawa Scale for cohort studies and Cochrane risk-of-bias tools for controlled trials. RESULTS:Gastric electrical stimulation (GES) demonstrated significant symptom improvement in patients with treatment-resistant gastroparesis. Controlled studies showed vomiting frequency reduction of 57% at 6 weeks, improving to 67.8% after one year (p < 0.001). Long-term data revealed ≥ 50% reduction in Total Symptom Scores in 58% of diabetic gastroparesis patients, 53% of post-surgical cases, and 48% of idiopathic gastroparesis patients (p < 0.05) (Fig. 3; Table 2). Combination therapy (GES plus prokinetics) yielded significantly better symptom scores (1.35) compared to GES alone (2.20, p = 0.02). Device-related infection requiring removal occurred in approximately 7% of cases. No direct head-to-head comparisons between GES and prokinetic medications alone were identified. CONCLUSION/CONCLUSIONS:GES provides substantial symptom relief for treatment-resistant gastroparesis, particularly in diabetic gastroparesis. Combination therapy with GES plus prokinetics appears superior to GES monotherapy. However, the absence of direct comparative studies limits definitive conclusions regarding relative effectiveness versus prokinetic medications alone. Future randomized controlled trials are needed to establish optimal treatment protocols and patient selection criteria along with the role of other surgical approaches. Planned next steps include direct comparisons of GES with pyloric-directed interventions - namely gastric per-oral endoscopic myotomy (G-POEM) and surgical pyloroplasty - to clarify the optimal positioning of GES within the contemporary treatment algorithm for refractory gastroparesis.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Accelerated 3-year programs (A3YPs) for an MD degree offer a condensed medical education pathway to residency, often with directed pathways in primary care. Many programs aim to address workforce shortages and decrease debt. As these programs expand, assessing whether A3YP graduates are as prepared for residency as their peers from traditional 4 year programs is critical. This study evaluates milestone attainment of A3YP postgraduates in Year 1 (PGY-1s) compared to non-A3YP PGY-1s within family medicine residency programs. METHODS:We analyzed the Accreditation Council for Graduate Medical Education milestone ratings for family medicine PGY-1s from 2021 to 2023. The study included 109 A3YP graduates across 51 family medicine programs and 1,638 non-A3YP PGY-1s (MD, DO, international medical graduate) in those same programs. PGY-1s were compared across milestone competency domains using mixed-effects regression that accounted for clustering by program and subcompetency. RESULTS:At midyear, A3YP PGY-1s scored significantly higher in medical knowledge, systems-based practice, and practice-based learning and improvement. Differences were statistically significant but modest. Coefficients ranged from 0.05 for patient care and medical knowledge to 0.10 for practice-based learning and improvement (PBLI; P&lt;0.01). At end-year, A3YP PGY-1s maintained slightly higher scores in medical knowledge, professionalism, PBLI, and communication (coefficients ranged from 0.07 to 0.10; P&lt;0.01). CONCLUSIONS:A3YP graduates demonstrate equal or minimally higher milestone attainment compared to non-A3YP peers during PGY-1, supporting the viability of accelerated pathways. These findings reassure residency programs of A3YP readiness and highlight their potential to address workforce shortages and reduce student debt without compromising educational outcomes.

BACKGROUND:Chronic axial spinal pain is a major contributor to disability and healthcare expenditures, with facet joints recognized as one of the established sources of pain. OBJECTIVE:To provide evidence-based guidance in performing diagnostic and therapeutic facet joint interventions. METHODS:A multidisciplinary panel of experts from various medical and pharmaceutical disciplines, convened by the American Society of Interventional Pain Physicians (ASIPP), reviewed the available evidence, considered patient perspectives, and formulated recommendations for facet joint interventions in the management of chronic pain.The methodology included the development of key questions with evidence-based statements and recommendations. Grading of the evidence and recommendations followed a modified approach described by ASIPP, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and the Agency for Healthcare Research and Quality (AHRQ) methods for grading strength of recommendations. The evidence review included existing guidelines, systematic reviews, comprehensive reviews, randomized controlled trials (RCTs), and observational studies evaluating the effectiveness and safety of facet joint interventions in chronic pain management.In the development of consensus statements and guidelines, a modified Delphi technique was utilized to minimize bias related to group interactions. Panelists without a primary conflict of interest voted on approval of specific guideline statements. Each panelist was permitted to suggest revisions to guideline wording and provide additional qualifying remarks or comments regarding implementation of the guidelines in clinical practice. To achieve consensus and inclusion in the final guidelines, each guideline statement required at least 80% agreement among eligible panel members without a primary conflict of interest. RESULTS:A total of 48 authors participated in the development of these guidelines, of whom 39 participated in the voting process. A total of 37 recommendations were developed, with 100% acceptance for all items. The Summary of Recommendations is presented separately. These recommendations addressed diagnostic, therapeutic, and special considerations related to facet joint interventions. For diagnostic and therapeutic interventions, the level of evidence ranged from II to III, with moderate to strong recommendations. For special considerations and safety assessments, the level of evidence ranged from II to V. The evidence provided recommendations regarding diagnosis, treatment, sedation, concurrent antithrombotic therapy, and precautions required in special clinical circumstances. LIMITATIONS/CONCLUSIONS:The limitations of these guidelines include a paucity of high-quality studies in some aspects of diagnosis and therapy. CONCLUSION/CONCLUSIONS:These guidelines for facet joint interventions were developed through a comprehensive review of the literature, including methodologic quality assessment and determination of the level of evidence and strength of recommendations. DISCLAIMER/CONCLUSIONS:These guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a "standard of care."

BACKGROUND/UNASSIGNED:Retained foreign bodies (RFB), or those left behind following spine surgery, are considered "Never Events (NE < 1/1000: they should never happen)," or "Near Never Events (NNE < 1/100; they should nearly never happen)", but are not just "Adverse Events (AE >/= 1/100)." The vast majority of NE/NNE are due to cotton sponges, cottonoids, or residual cotton strands (i.e., collectively called Textilomas or Gossypibomas). However, RFB additionally included; fractured needles, guidewires, fractured screws/implants/drains, and/or broken instruments (i.e., scalpels). Notably, the spine surgeon of record, as captain of the ship, is primarily liable for RFB and is central to ensuing medicolegal suits. However, secondarily liable are the adjunctive surgical/medical personnel, (i.e., physicians, Physician Assistants, Nurses, Nurse Practitioners, Physical Therapists, Occupational Therapists), and others who are independent or work full-time for hospitals. METHODS/UNASSIGNED:Patients with RFB may present with acute, subacute, or chronic/delayed pain and suffering. Additional complaints include; lost wages, sustained physical disability and/or injury attributed to these objects. Most RFB are diagnosed on plain X-rays, followed by MR and/or CT studies. RESULTS/UNASSIGNED:RBS's may include; retained drain fragments, broken needles, fractured guidewires, broken scalpel blades, fractured screws, and/or instruments. Retrieval procedures warrant a wide variety of different techniques, some of which fail. Notably, RFB's largely occur due to the performance of; emergent procedures, doing an unfamiliar operation, encountering anatomical variants, or operating on patients with elevated body mass indexes (BMI). Additionally these include; surgeons' failure to order and/or radiologists' failure to correctly read intraoperative X-rays/fluoroscopic images, and/or nurses' failures to correctly perform end of surgery counts. CONCLUSION/UNASSIGNED:RFBs, or foreign bodies left behind following spine surgery, are considered "Never Events (< 1/1000)" or "Near Never Events (< 1/100)," and are not just "Adverse Events (> 1/100)". When they do occur, the operating surgeon bears primary responsibility, but the nursing/adjunctive staff and hospital are also liable.

PURPOSE/UNASSIGNED:We report long-term follow-up on participants in the QUILT-3.032 study in BCG-unresponsive non-muscle-invasive bladder cancer (NMIBC) carcinoma in situ (CIS) +/- papillary disease utilizing nogapendekin alfa inbakicept (NAI) approved by the FDA (ANKTIVA) in combination with BCG. MATERIALS AND METHODS/UNASSIGNED:Participants received 400 mcg NAI in combination with 50 mg BCG via intravesical instillation weekly for six weeks, with optional re-induction if complete response (CR) was not achieved at month 3. Primary endpoints were CR rate at any time; secondary endpoints were duration of CR (DOR), progression-free survival (PFS), overall survival (OS), disease-specific survival (DSS), and time to cystectomy. RESULTS/UNASSIGNED:The CR rate (n=100) was 71% (95% CI, 61.1, 79.6) with a median DOR of 26.6 months (range, 0.03-53.62). The cystectomy-free rate (CFR) in the 71 responders at 24- and 36-months was 90.3% (95% CI 79.7, 95.6) and 84.2% (95% CI 69.6, 92.1), respectively. DSS was 100% (95% CI 100.0, 100.0) at 12-months, and 98.2% (95% CI 88.2, 99.8) at 36-months. Treatment-related adverse events (TRAE) were largely grade 1 to 2 (61%), with 3% grade 3 and no grade 4 or 5 TRAE observed with this biological combination. CONCLUSIONS/UNASSIGNED:The CR rate and durability of responses that surpass 53 months reveal the efficacy of NAI in combination with BCG for treating BCG-unresponsive NMIBC with CIS +/- Ta/T1 disease. The high CFR of 84% and DSS of 98% at 36-months suggest that NAI plus BCG is a safe and efficacious option for NMIBC with CIS +/- Ta/T1 disease.

Artificial intelligence (AI) has rapidly emerged as a transformative force in radiology, offering enhanced diagnostic accuracy, workflow optimization, and the potential to alleviate rising imaging demands. As radiology remains inherently dependent on pattern recognition and high-volume data interpretation, it represents an ideal domain for AI integration. This narrative review synthesizes current evidence on the clinical impact of AI across multiple dimensions of radiologic practice, including diagnostic performance, workflow efficiency, patient perspectives, and trainee education. AI systems have demonstrated performance approaching or exceeding that of radiologists in high-prevalence tasks, particularly in chest imaging and breast cancer screening, while also improving triage and reducing report turnaround times. However, these benefits are accompanied by significant challenges. Automation bias, over-reliance on algorithmic output, and anthropomorphic framing may compromise clinical judgment. Additionally, AI integration may paradoxically increase workload and contribute to radiologist burnout when poorly implemented. Patient-centered studies consistently indicate a preference for AI-augmented, rather than autonomous, diagnostic models, underscoring the enduring importance of physician oversight and communication. Among trainees, concerns regarding job security persist, though these are mitigated by increased AI literacy and structured educational initiatives. Ultimately, AI is best conceptualized not as a replacement for radiologists, but as a complementary tool. Thoughtful integration, combined with robust training, validation, and human oversight, will be essential to ensure that AI enhances rather than diminishes the quality of radiologic care.