Faculty Bibliography

BACKGROUND AND AIMS/OBJECTIVE:Radial access site for percutaneous coronary intervention (PCI) is recommended by clinical practice guidelines because of superior outcomes compared with femoral access site. Historically, the adoption of radial access site in the USA has lagged behind much of the rest of the world, but contemporary data on access site selection across the spectrum of clinical presentations and its association with outcomes are lacking. METHODS:A retrospective cohort study from the National Cardiovascular Data Registry's CathPCI Registry was conducted including PCIs performed between 1 January 2013 and 30 June 2022. The comparative safety of radial vs femoral access site for PCI was evaluated with instrumental variable analysis, a technique that can be used to support causal inference, exploiting operator variation in access site preferences as the instrumental variable. RESULTS:Overall, 6 658 479 PCI procedures were performed during the study period, of which 40.4% (n = 2 690 355) were performed via radial access site, increasing from 20.3% in 2013 to 57.5% in 2022. This increase was seen in all geographic regions and across the full spectrum of presentations, with the largest relative increase seen in patients with ST-elevation myocardial infarction. Overall, 2 420 805 PCIs met inclusion criteria for the comparative safety analysis. In instrumental variable analyses, radial access site was associated with lower in-hospital mortality [absolute risk difference (ARD) -.15%, 95% confidence interval (CI) -.20 to -.10], major access site bleeding (ARD -.64%, 95% CI -.68 to -.60), and other major vascular complications (ARD -.21%, 95% CI -.23 to -.18) but a higher risk of ischaemic stroke (ARD .05%, 95% CI .03-.08). There was no association with the falsification endpoint of gastrointestinal or genitourinary bleeding (ARD .00%, 95% CI -.03-.03). CONCLUSIONS:Over the past decade, use of radial access site for PCI has increased 2.8-fold in the USA and now represents the dominant form of access site across all procedural indications. Based on instrumental variable analyses, PCI with radial access site had lower rates of in-hospital mortality, major access site bleeding, and other major vascular complications compared with femoral access site but a slightly higher risk of ischaemic stroke in contemporary practice.

Post-radiotherapy erectile dysfunction (ED) can significantly impact the quality of life of patients with prostate cancer (PCa). Critical anatomical structures, such as the neurovascular bundle (NVB), internal pudendal arteries (IPA), penile bulb, and corporal tissues track in close proximity to the prostate, making them susceptible to radiation-related damage. This study aimed to evaluate the anatomical patterns of these structures and their relationship with the prostate, and to provide comprehensive illustrative examples on MRI. Consecutive patients with PCa who underwent MRI-linear accelerator (LINAC)-based stereotactic body radiotherapy (SBRT) in January-December 2024 were included. NVB patterns were classified into 3 categories: (1) "classical" with discrete NVB elements, (2) "adherent", dispersed and adherent to prostatic capsule, and (3) "absent". The smallest distance between the IPA and the prostate capsule and membranous urethral length (MUL), serving as a surrogate for distance between corporal tissue and prostatic apex, were also measured. These MRI findings were compared between prostate volumes >40 and <40 ml and between MRI/pathological features of the dominant intraprostatic lesion. A total of 160 men (median age 70 years, interquartile range [IQR] 64-76) were included. The most common NVB pattern was "classic" (80.0-85.0%), followed by the "adherent" NVB pattern (13.8-18.1%). The median smallest distance between the IPA and prostate was 2.3 cm (IQR 1.8-2.8 cm), with 3.1-3.8% less than 1.0 cm. The median MUL was 1.5 cm (IQR, 1.2-1.8 cm), with 2.5% of patients less than 1.0 cm. No significant association was found between these MRI features and prostate volume or other variables (p = 0.09-0.99). In conclusion, most PCa patients demonstrated favorable anatomy for potential dose sparing of critical structures. Comprehensive MRI illustrations are provided to help radiation oncologists recognize the location, trajectory, and relationship of these structures, facilitating their contouring and ultimately aiding in achieving meaningful dose reductions to these erectile function structures.

STUDY DESIGN/METHODS:A national prospective cervical spine surgery registry was developed to archive radiographic studies, patient-reported outcome measures (PROMs), and surgical implant data to assess long-term safety. OBJECTIVE:To describe the design, development, funding, and implementation of a cervical spine data registry for 1000 patients with myelopathy and radiculopathy. SUMMARY OF BACKGROUND DATA/BACKGROUND:While surgery for cervical radiculopathy and myelopathy is safe and effective, there is significant practice variation among spine surgeons. While randomized clinical trials (RCTs) can provide high-quality comparative effectiveness data, RCTs lack the ability to evaluate the safety and effectiveness of various surgical procedures and implants among heterogenous real-world patient populations. The CSRS Registry was designed to collect patient demographics, outcomes, radiographic imaging, surgical approach, and implant data for the purpose of conducting high-quality research. METHODS:Patients with cervical myelopathy or radiculopathy were enrolled in the CSRS National Registry. De-identified patient data, validated PROMs, radiographic data, and implant data were collected from multiple clinical sites across the United States. RESULTS:One thousand patients [mean age, 58 y; 456 (46%) women] were enrolled, with 31% follow-up at 1 year. Five hundred ninety-two patients were diagnosed with radiculopathy, 252 with myelopathy, and 156 with radiculopathy and myelopathy. Patients had significant improvements in their PROMs after surgery. At 1 year, the mean NDI score improved from 37.2 to 20.9 (P<0.001). The mean self-reported P-mJOA score at baseline was 14.2 and improved to 15.2 by 1 year (P<0.001). Baseline CSDI score was 23.6 and improved with a 1-year decrease to an average score of 13.6 (P<0.001). There was significant improvement in PROMIS-10 Physical Health score from 41.0 to 45.9 (n=311; P<0.001) at 1-year follow-up. CONCLUSIONS:The CSRS Registry has successfully collected clinical outcomes data that is being leveraged for comparative effectiveness research and evaluations of the long-term safety and effectiveness of spinal implants.

OBJECTIVE:The CDC recommends initiating opioids for pain treatment at the lowest effective dose and duration. We examine how interactions between dose, duration, and other medication factors (e.g., drug type) influence opioid use disorder (OUD) risk-a gap not considered by CDC guidelines. SUBJECTS/METHODS:Using Medicaid claims data (2016-2019) from 25 states, we analyzed opioid-naïve adults, newly diagnosed with musculoskeletal pain who initiated opioids within three months of diagnosis. A 6-month washout confirmed no prior opioid exposure or musculoskeletal diagnosis. METHODS:Initial opioids were categorized by "dose-days supplied" (low [>0-20 mg MME] to very high [>90 mg MME] dose, and short [1-7 days] to moderate [>7-30 days] supply), and by opioid type; physical therapy (PT) sessions were also recorded. Using Poisson regression models, we estimated the OUD risk associated with dose-days categories, adjusting for baseline demographics, clinical characteristics, and medications. We separately examined opioid dose-days and PT, and assessed PT's moderating effect on dose-days' impact. RESULTS:Among 30,536 patients, half initiated opioids at 20-50 MME for 1-7 days, and 20% received PT. OUD risk was 2-3 times higher for opioids initiated for >7-30 days compared to 1-7 days across doses, and 5.5 times higher for opioids initiated for >7-30 days at > 90 MME versus 1-7 days at < 20 MME. PT alone, neither affected OUD risk nor mitigated the increased risk from longer or higher-dose opioids. CONCLUSIONS:Our findings support the need for careful opioid prescribing and alternative pain management strategies, as the observed associations between initial prescription characteristics and OUD were not mitigated by adjunctive PT. PERSPECTIVE/CONCLUSIONS:This study demonstrated that initial opioid prescriptions of 7-30 days, especially above 90 MME/day, increased OUD risk in opioid-naïve patients with musculoskeletal pain; physical therapy did not mitigate the risk. Different opioids posed varied risks, even at the same dose and duration. Careful prescribing and alternative pain management are essential.

OBJECTIVE:To assess photon counting CT iodine density as a marker of histopathologic treatment response after neoadjuvant chemotherapy in patients with pancreatic ductal adenocarcinoma. MATERIALS AND METHODS/METHODS:A retrospective PACS search identified 21 pancreatic ductal adenocarcinoma patients [14 men; mean (SD) age: 64 (10) y] who underwent neoadjuvant chemotherapy and pancreatic photon counting CT 2 months before resection from April 11, 2022 to February 2, 2024. The histopathologic treatment response grade was the reference standard. Freehand regions-of-interest measurements were drawn independently by 2 radiologists as large as possible within the mass on pancreatic parenchymal phase images. Attenuation, iodine density, and iodine density normalized to the aorta were recorded. Mann-Whitney U test was used to compare attenuation, iodine density, and normalized iodine density for responders (pathologic grade 1, 2) versus nonresponders (grade 3). Receiver operating characteristic curves were created, and optimal thresholds were determined with Youden's index. A P<0.05 indicated statistical significance. RESULTS:Thirteen of 21 (61.9%) patients showed pathologic treatment response. Iodine density for nonresponders and responders was mean (SD) 0.47 (0.23) mg/mL and 1.20 (0.75) mg/mL, respectively (P=0.005). Normalized iodine density for nonresponders and responders was 7.6 (5.5)% and 22.5 (16.0)%, (P=0.006). Attenuation for nonresponders and responders was 56.5 (10.9) HU and 70.6 (17.7) HU, (P=0.04). Upon receiver operating characteristic analysis, an iodine density threshold of 0.65 mg/mL had 77% sensitivity and 88% specificity (AUC=0.86), and a normalized iodine density threshold of 10.1% had 77% sensitivity and 88% specificity (AUC=0.86) for treatment response. A 61.8 HU threshold had 77% sensitivity and 75% specificity (AUC=0.78). CONCLUSIONS:Elevated iodine density correlates with pancreatic ductal adenocarcinoma histopathologic treatment response with high specificity. Photon counting CT iodine density may be used as a marker of histopathologic treatment response.

Obesity is a chronic disease associated with increased morbidity and mortality and reduced quality of life. Pharmacotherapy can be associated with life style interventions aiming at increasing and maintaining weight loss and ameliorating obesity-related medical conditions. In patients affected by obesity and uncontrolled obesity-associated complications or high degree of BMI (> 40 kg/m²), metabolic bariatric surgery (MBS) can be a feasible therapeutic option. Many different types of surgical procedures have been developed in last decades, mainly performed via laparoscopic approaches. However, clinical indications for MBS and the selection of the most appropriate type of procedure have not been clarified so far. The Italian Society of Bariatric and Metabolic Surgery for Obesity (Società Italiana di Chirurgia dell'Obesità e delle Malattie Metaboliche-SICOB) decided to design and develop the updated version of the Italian guidelines aimed at assisting healthcare professionals in the choice of the surgical option for the treatment of obesity and related medical conditions. Between June and October 2022, a panel of 24 experts and an evidence review team (ERT, 10 members), participated in the definition of clinical questions, outcomes, and recommendations and collected and analyzed all the available evidence on the basis of pre-specified search strategies. GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology and PICO (Patient, Intervention, Comparison, Outcome) conceptual framework have been adopted for the development of the present guidelines. The aim of the present guideline is to verify indications to bariatric surgical endoscopy with respect to the presence of comorbid conditions, evaluate the different types of endoscopic bariatric procedure and revise indication to revisional bariatric endoscopy and postoperative procedures.