Faculty Bibliography

Radiofrequency ablation (RFA) has been gaining traction for treating benign thyroid nodules, but its use for papillary thyroid carcinomas (PTCs) remains uncommon. We conducted a single institution prospective cohort study of patients who underwent RFA for biopsy-proven PTC(s) 1.5 ​cm in greatest diameter. Primary outcomes included volume reduction ratio (VRR) at 1, 3, 6, and 12 months and rate of complications. We performed RFA on 46 ​PTCs in 41 patients. With a median follow-up of 8 months (IQR:6-12.3), we achieved complete sonographic disappearance of 85 ​% of tumors. Median VRR was -107.5 ​% (IQR: 322.3 - 6.0), 18.8 ​% (IQR: 75 - 54.12), and 100 ​% (IQR:70.7-100) at 1, 3, and 12- months follow-up. Four patients (9.8 ​%) experienced minor complications. Preliminary findings suggest that RFA is a safe and effective treatment modality for patients with PTCs. Additional enrollment and further surveillance are necessary to assess the long-term efficacy of RFA for PTCs.

PURPOSE/OBJECTIVE:Both MRI and PSMA PET/CT are often utilized for staging of intermediate-risk (IR) and high-risk (HR) prostate cancer (PCa). Recent studies found that PSMA PET/CT was superior to MRI in correctly identifying final pathological tumor stage, dominant nodule, extraprostatic extension (EPE), and small areas of clinically significant PCa. We sought to determine if PSMA PET/CT was superior to MRI in both locoregional staging of PCa and potential focal therapy planning. METHODS:We retrospectively analyzed our prospectively collected, IRB-approved database of all patients who underwent prostatectomy at one institution between 10/1/2019-2/29/2024. Patients were excluded if they did not pre-operatively undergo both MRI and PSMA PET/CT. 2 × 2 tables were used to compare each modality to the "gold standard" of prostatectomy specimen in both the proper detection of laterality and presence of EPE. Sensitivities and specificities were compared using a chi-squared test. HR v. IR groups were compared using a Wilcoxon rank sum test for continuous variables and Fisher's exact test for categorical variables. Results were considered significant at p < 0.05. RESULTS:580 patients underwent prostatectomy within the specified timeframe. 78 patients met inclusion criteria. MRI was more sensitive in the detection of EPE than PSMA PET/CT (23.5% v. 7.8%, p = 0.0294). MRI and PSMA PET/CT were similar in the specificity of EPE detection. In the identification of laterality, MRI was more specific (86.7% v. 56.7%, p = 0.0099), while sensitivities were similar between the modalities. CONCLUSIONS:MRI was superior to PSMA PET/CT in the proper detection of both EPE and laterality in patients with IR and HR PCa.

BACKGROUND:The gracilis flap is a versatile muscle flap that can be utilized as a muscle only or myocutaneous flap for soft tissue coverage, as well as for reconstruction of facial animation or extremity function. Few studies have compared donor site complications of free and pedicled gracilis flaps, including the effect of skin paddle harvest on donor site morbidity. METHODS:We performed a retrospective review of patients who underwent a free or pedicled gracilis flap at our institution from 2013-2023. Gracilis flaps were categorized as: pedicled gracilis muscle flaps used for vaginectomy in gender reaffirming surgery, free gracilis muscle flaps, and free gracilis myocutaneous flaps. Outcome variables were duration of drain placement and complications including seroma, hematoma, infection, dehiscence, and persistent numbness. RESULTS:We identified 128 gracilis flaps including 19 free myocutaneous flaps, 35 free muscle flaps, and 74 pedicled muscle flaps. Free myocutaneous flaps required longer drain placement as compared to free muscle flaps or pedicled flaps (13.6 vs 8.4 vs 7.4 days, respectively, p=0.002). Free myocutaneous flaps displayed a higher complication rate (36.8%) as compared to pedicled muscle flaps (10.8%), or free muscle flaps (11.4%, p=0.020). After adjusting for age, BMI, and ASA status, free myocutaneous flaps demonstrated higher odds of major donor site complication as compared to pedicled muscle flaps (OR 1.23, p<0.001), while free muscle flaps were not associated with increased odds of major complication (OR 1.08, p=0.117). Of the documented complications, the most common were surgical site infection (36.8%), hematoma (21.1%) and seroma (21.1%). CONCLUSION/CONCLUSIONS:The inclusion of a skin paddle during gracilis flap harvest is associated with increased duration of drain placement and donor site complications including surgical site infection, hematoma, and seroma. These factors should be carefully considered in the context of patients' reconstructive needs and other risk factors.

CONTEXT/BACKGROUND:Traumatic musculoskeletal injuries may result in chronic pain and mobility limitations, decreasing quality of life, and increasing predisposition to comorbid disorders. Osteopathic manipulative treatment (OMT) utilizes palpatory assessment and application of manual forces as an adjunct intervention for musculoskeletal disease. Multiple studies have demonstrated OMT's potential benefits for a range of disease states, but data on osteopathic OMT are limited. OBJECTIVES/OBJECTIVE:The objective of our study was to understand the potential benefits of a novel OMT for trauma outpatient program for the care of injured patients suffering chronic pain and mobility limitations. METHODS:In 2021, the New York University (NYU) Langone Hospital - Long Island Level 1 Trauma Center established a novel outpatient OMT for Trauma Program (OTP). We performed a retrospective analysis of OTP patients seen from January 1, 2021 to December 31, 2022 with the chief complaint of refractory chronic (persistent ≥3 months since inciting injury) postinjury pain and mobility limitations (inclusion criterion). We excluded patients missing follow-up, then extracted and analyzed patient demographic, injury-specific, and OMT data. Data are presented as frequencies (percentages) or medians (interquartile range [IQR]). RESULTS:Forty-three patients (75.4 % of patients treated at the outpatient OTP) reported a mechanism of injury (MOI). Of these, 30 (69.8 %) met the inclusion criteria, and seven met the exclusion criterion, yielding 23 total patients for the analysis (40.3 % of the total OTP population). 73.9 % were female aged 46 (39-59) years old. Patients presented 3.00 (0.58-20) years since etiologic injury. MOIs included 56.5 % motor vehicle collisions (MVC), 21.7 % falls, 8.7 % penetrating, and 13.0 % sports-related or lifting injuries. Patients reported 3 (2-4) treatment modalities tried and 2 (1-3) medications attempted prior to the OTP. After the first OMT session, 95.7 % of patients reported subjective improvement in pain with a decrease in pain score 3 (3-7) out of 10. After OMT, patients also self-reported ease of activities of daily living (ADLs, 82.6 %), improved sleep hygiene (26.1 %), improved anxiety/mood (65.2 %), and decreased use of analgesic medication (13.0 %). Four (17.4 %) reported post-OMT complication of 2-3 days of self-limited, mild musculoskeletal pain. Univariate logistic regression models demonstrate that OMT benefited patients regardless of time since inciting injury. CONCLUSIONS:OMT may benefit refractory chronic traumatic pain and mobility limitations regardless of the time since inciting the injury. This is the first major publication from the OTP and bolsters proof-of-concept for an organized OMT program at a level 1 trauma center. Further study, including comparative analysis with more formalized pain assessments utilizing validated tools as well as standardized OMT session surveys, is warranted.

BackgroundMalignant bowel obstruction (MBO) is a complex clinical entity and there remains a relative lack of high-quality comparative trials on surgical management, in part due to a heterogeneous patient population and different treatment modalities which contribute to challenges in trial design and completion. SWOG S1316 is the only prospective randomized trial evaluating surgical vs non-surgical management of MBO and involved a trial framework in which patients were recruited for a randomization pathway as well as a patient choice pathway. Importantly, successful completion of S1316 required numerous amendment modifications to the trial during its course. We aimed to highlight aspects of S1316 trial design, execution, and modification that potentially contributed to trial completion.MethodsIterative qualitative content analysis of trial modification amendments through the course of the trial from 2015 to 2020.Results133 unique amendments were made to S1316 from 2015 to 2020. We found four dominant domains for the amendments: Accrual Barriers, Study Design Changes, Data Collection Issues, and Clarifications. Accrual amendments were essential to completing the trial and included increasing participating sites from six to 30 (including international sites) and the inclusion of Spanish-speaking participants (11% of final study population).ConclusionsContent analysis of S1316 trial amendments highlighted that Accrual amendments were important in trial completion. Future investigators may benefit from better anticipating trial modifications as they design their studies. It is likely that rapid initiation of trial amendments can lead to improved accrual and study completion.

INTRODUCTION/BACKGROUND:Redo hypospadias repairs present significant challenges due to tissue scarring and hypovascularity, substantially increasing the risk of complications. Previous literature document complication rates above 40 % after three or more previous urethroplasties, highlighting the need for strategies that enhance tissue quality. Postoperative hyperbaric oxygen therapy (HBOT) can improve healing outcomes. However, the role of perioperative HBOT in enhancing tissue quality through neovascularization remains unclear. This study aims to evaluate whether perioperative HBOT (both pre- and postoperative) instead of the senior author's standard of care (SOC) topical nitroglycerin reduces complication rates and improves surgical outcomes in redo hypospadias repair. METHODS:We retrospectively reviewed 47 patients (aged 3-18 years) who underwent redo hypospadias repairs between January 2019 and January 2022, following 2-4 prior failed procedures. Inclusion criteria included patients with failed primary repairs, while exclusion criteria included patients with contraindications to HBOT or incomplete follow-up data. Patients were allocated to treatment groups (i.e. perioperative HBOT v. SOC) based on insurance coverage for HBOT rather than randomization. Group 1 (n = 31) received perioperative HBOT while Group 2 (n = 16) received SOC, consisting of topical nitroglycerin ointment. Additionally, BMG patients in both groups received topical vitamin E for 2-3 weeks post-operatively. HBOT protocol consisted of 20 preoperative sessions and 5-10 postoperative sessions at 2.0 ATA. RESULTS:The two groups did not differ significantly in hypospadias locations (Group 1: 22 distal, 9 proximal; Group 2: 10 distal, 6 proximal; P = 0.795) or operative technique (Group 1: 21 one-stage dorsal inlay grafts [DIG], 10 staged buccal mucosa grafts [BMG]; Group 2: 10 one-stage DIG, 6 staged BMG; P = 0.972). The HBOT group demonstrated a reduction in postoperative complications compared to SOC group (6.4 % vs. 25 %; P = 0.179 95 % CI 0.05-1.26), though this difference did not reach the level of statistical significance. Specifically, the HBOT group experienced only two cases of fistula formation, while the SOC group had four total complications: one case of graft contracture and three fistulas. All complications were successfully corrected surgically one year postoperatively using the perioperative HBOT protocol. Subjective clinical assessment also suggested improved tissue quality and pliability in HBOT-treated patients. CONCLUSIONS:This study suggests that perioperative HBOT was associated with a lower, but not statistically significant, complication rate in redo hypospadias repairs. The findings support the potential use of perioperative HBOT in promoting tissue healing and justify further investigation through prospective randomized controlled trials to establish definitive efficacy and optimize treatment protocols for this challenging patient population.

BACKGROUND:Despite decreased mortality over the past several decades, the prognosis of brain abscesses remains dependent on intracranial location and causative organism. Deep-seated brain abscesses carry a risk of intraventricular rupture, an event with reported mortality near 80%. Coccidioidomycosis from the fungus Coccidioides immitis, endemic to the American Southwest, is growing in incidence but uncommonly produces deep brain abscesses, making management unclear.The authors report the diagnosis and management of a solitary thalamic Coccidioides abscess without meningitis. OBSERVATIONS/METHODS:A 59-year-old female presented with 1 week of gait instability, left facial weakness, dysarthria, and intermittent headache, but no meningismus. Cranial imaging was consistent with abscess or, less likely, a neoplasm, and a stereotactic brain biopsy was pursued. Despite negative fungal cultures and lack of serum antibody detection, findings of pathognomonic spherules in pathology tissue with confirmatory polymerase chain reaction testing helped diagnose coccidioidomycosis. The patient's symptoms resolved 3 weeks postoperatively with a dexamethasone taper and, due to relapse risk, planned lifelong fluconazole therapy. The patient self-discontinued fluconazole at 11 months postoperatively but remained disease free at 1 year. LESSONS/CONCLUSIONS:C. immitis can present as solitary brain abscesses despite negative fungal cultures. Postoperative dexamethasone and long-term fluconazole can clear the pathogen and suppress recurrence. https://thejns.org/doi/10.3171/CASE25381.

Machine translation supported by artificial intelligence (AI) may enhance linguistically-concordant care for patients speaking languages other than English. This assessment of free-text inpatient discharge instructions in Arabic, Armenian, Bengali, simplified Chinese, Somali, and Spanish compared linguist, clinician, and family caregiver evaluations of translations generated by (1) ChatGPT-4o, (2) professional linguists, and (3) human-in-the-loop (AI-generated, professional linguist post-edited). Likert scales (1-5; higher is better) evaluated linguistic and clinical characteristics of each translation. ChatGPT-4o exhibited variable performance relative to professional translations, with poorest ratings for digitally underrepresented languages (Armenian and Somali). Conversely, human-in-the-loop translations achieved comparable, often better, outcomes to professional translations for all languages, (e.g., Armenian mean overall quality: 3.9 [95% CI 3.7-4.2] vs. professional 3.6 [3.4-3.9], p = 0.01), were most frequently preferred (46.5% vs. 28.4%) and had shorter mean translation time (7.1 [5.4-8.8] vs. 16.8 [13.7-19.9] min, p < 0.001). Human-in-the-loop strategies may enable safe, efficient, equitable machine translation application in clinical practice.