Faculty Bibliography

BACKGROUND:Prior studies comparing virtual and in-person OSCEs have focused mainly on overall performance scores, with less attention to whether specific communication skills function differently across modalities. OBJECTIVE:To compare the level of communication proficiency required to achieve specific checklist ratings in virtual versus in-person OSCEs. DESIGN/METHODS:We identified Internal Medicine case (IM) OSCE cases conducted in both modalities. In each case, standardized patients (SP) rated resident performance in three communication domains (information gathering, relationship development, and patient education), using a behaviorally anchored scale of "not," "partially," or "well done." We compared overall communication scores and rating distributions across modalities and used a graded response Item Response Theory model to estimate item-level thresholds, representing the communication proficiency needed to move from one rating category to the next. Virtual and in-person threshold estimates were compared using Wald tests. PARTICIPANTS/METHODS:126 PGY-1 IM residents participated across six cases between 2019 and 2023 (in-person = 82, virtual = 54). MAIN MEASURES/METHODS:Mean communication domain scores, rating distributions, and item-level threshold estimates for each checklist item across modalities. KEY RESULTS/RESULTS:Most residents demonstrated sufficient skill to receive "partly" or "well" done ratings on most communication items. Overall communication performance appeared broadly similar across modalities. At the item level, one behavior-"using words patient understood and explaining jargon"-showed a statistically significant difference: residents required a lower level of proficiency to receive a "partly done" rating in virtual versus in-person encounters (z = 3.92, p_adj = 0.001). CONCLUSIONS:Overall communication scores may be comparable across modalities, but some individual communication items may function differently in virtual versus in-person formats. Such differences may reflect modality-related variation in item proficiency, differences in rater scoring, or both. Threshold analysis offers a nuanced approach to evaluating comparability of OSCE formats by examining whether an observed rating reflects the same level of underlying communication proficiency across modalities.

Depolarizing current injections produced a rhythmic bursting of action potentials, a bursting oscillation, in a set of local interneurons in the lateral geniculate nucleus (LGN) of rats. The current dynamics underlying this firing pattern have not been determined, though this cell type constitutes an important cellular component of thalamocortical circuitry and contributes to both pathologic and nonpathologic brain states. We thus investigated the source of the bursting oscillation using pharmacological manipulations in LGN slices in vitro and in silico. We found that selective blockade of calcium channel subtypes revealed that high-threshold calcium currents IL and IP contributed strongly to the oscillation. In addition, increased extracellular K+ concentration (decreased K+ currents) eliminated the oscillation. In addition, selective blockade of K+ channel subtypes demonstrated that the calcium-sensitive potassium current (IAHP) was of primary importance. A morphologically simplified, multicompartment model of the thalamic interneuron characterized the oscillation as follows, First, the low-threshold calcium current (IT) provided the strong initial burst characteristic of the oscillation. In addition, alternating fluxes through high-threshold calcium channels and IAHP then provided the continuing oscillation's burst and interburst periods, respectively. This interplay between IL and IAHP contrasts with the current dynamics underlying oscillations in thalamocortical and reticularis neurons, which primarily involve IT and hyperpolarization-activated cation current IH, or IT and IAHP, respectively. These findings thus point to a novel electrophysiological mechanism for generating intrinsic oscillations in a major thalamic cell type. Because local interneurons can sculpt the behavior of thalamocortical circuits, these results suggest new targets for the manipulation of ascending thalamocortical network activity.

Glucagonomas are a rare hormone-producing pancreatic neuroendocrine tumor (panNET), with an estimated incidence of 1 to 2 cases per million persons. They typically present at diagnosis as large, metastatic panNET and are characterized clinically by diabetes mellitus, weight loss, thromboembolic complications and necrolytic migratory erythema. The diagnosis of glucagonoma syndrome requires the presence of both elevated fasting plasma glucagon levels and glucagonoma symptoms. Staging relies on cross-sectional imaging with computed tomography (CT) or magnetic resonance imaging (MRI), complemented by somatostatin receptor positron emission tomography (PET) imaging. Initial management of glucagonoma includes supportive therapy with supplementation of amino acids, essential fatty acids, zinc, and other micronutrients as well as glycemic control and anticoagulation. Surgical resection is the only curative treatment. For unresectable or metastatic disease, palliative management parallels that of nonfunctioning panNET and includes somatostatin analogues, targeted therapies, peptide receptor radionuclide therapy with radiolabeled somatostatin analogues, and cytotoxic chemotherapy. Prognosis depends on tumor stage and grade, with reported 10-year survival rates approaching 100% for localized disease and approximately 50% for metastatic glucagonoma. A rare hereditary cause of hyperglucagonemia due to glucagon receptor mutations is glucagon cell hyperplasia and neoplasia, also termed Mahvash disease. These patients develop alpha cell hyperplasia and panNET but lack the classical glucagonoma symptoms. In conclusion, fasting glucagon levels should be measured in patients with typical features such as necrolytic migratory erythema, an advanced panNET associated with cachexia and new-onset or worsening diabetes mellitus or diffuse alpha cell hyperplasia.

Aggression is an innate behavior conserved across species, serving as a critical means to compete for food, mating opportunities, and other essential resources. A central question in aggression research is the extent to which inter-individual variability in aggression is shaped by genetic factors. Here, we examine aggressive behaviors in naïve male mice across seven genetically defined strains and find large cross-strain differences. We find a tight correlation between aggressiveness and anxiety levels across strains, but not within the same strain, suggesting strong genetic control of both traits. Pharmacologically elevating anxiety in high-aggression strains reduces aggression, revealing a causal relationship between these behaviors. We further demonstrate that differences in the synaptic and cellular properties of neurons in the ventrolateral ventromedial hypothalamus (VMHvl) largely account for cross-strain variability in male aggression, and that chemogenetically increasing VMHvl excitability enhances attack behavior in a low-aggression strain. Together, these findings reveal the neuronal implementation of the genetic control of innate aggression level.

The da Vinci 5 (DV5) system has purported advantages over existing platforms, including forced feedback. We compare perioperative safety, operative efficiency and early oncologic quality between DV5 and Xi robotic platforms for anatomic lung resection. A total of 419 robotic lung resections were performed between January 2025 and August 2026. Propensity-score overlap weighting balanced and matched 294 patients (47 DV5, 247 Xi) for age, sex, ASA class, BMI, forced expiratory volume in 1 s, tumor size, clinical T and N category, resection type and laterality. Effects were reported with robust and bootstrap 95% confidence intervals. Sensitivity analyses included 1:1 and 1:3 propensity matching comparisons and E-value assessment. From January 2025 to August 2026, 294 patients (47 DV5, 247 Xi) had balanced baseline characteristics (SMD < 0.01). Operative time was shorter with DV5 (96.4 vs. 118.7 min; 95% CI, - 36.2 to - 8.5). Lymph node yield was comparable (DV5 29.9 vs. Xi 31.6; [- 7.2 to + 3.7]). Blood loss (p < 0.01), length of stay (1.05 vs. 1.28 days; [- 0.53, + 0.06]) and stapler loads (8.5 vs. 9.6; [- 2.81 to + 0.55]) were numerically lower with DV5. Major complications were numerically lower with DV5 (1/47 [2.0%] vs. 20/247 [8.2%]; -16.0 to + 3.6). Both had 100% R0 resections and no conversion. There was no 30- or 90-day mortality. In this first clinical comparison of da Vinci 5 and Xi for robotic anatomic lung resection, DV5 preserved the safety and oncologic quality of Xi while being associated with shorter operative times. Prospective multi-institutional studies are required to confirm these findings.

STUDY DESIGN/METHODS:Retrospective analysis of a multicenter series of deformity patients undergoing thoracolumbar instrumentation to the pelvis. OBJECTIVE:Introduce the C2 coronal angle (C2C) as a novel metric, assess its association with quality-of-life and neck-specific outcomes, and compare the strength of this association with the traditional linear C7-CSVL offset. SUMMARY OF BACKGROUND DATA/BACKGROUND:While assessment of the sagittal plane incorporates vertebropelvic angles for surgical planning, angular coronal measurements have not been evaluated as predictors of patient-reported outcomes following adult spinal deformity (ASD) surgery. METHODS:Demographics, comorbidities, and radiographic parameters were collected preoperatively and at 2-year follow-up. Coronal angles were measured between CSVL and the center of the C2 body (C2C). Primary endpoints were patient‑reported outcomes at two years (SRS‑22, SF‑36, NDI) and whether patients achieved the minimal clinically important difference (MCID). Univariable and multivariable regression models examined the relationship between C2C and PROMs. An ROC analysis with Youden's Index identified optimal C2C thresholds for predicting NDI >20. RESULTS:Among 328 patients (mean age 64.0 years, 12.6 levels fused), postoperative absolute C2C was independently associated with PROMs. Each 1° increase in C2C was associated with decreased 2-yr SRS-Total (P=0.014) and activity (P=0.024), pain (P=0.033), and mental health (P=0.029) subdomains. Each 1° increase reduced odds of achieving NDI MCID by 34% (OR=0.66, P=0.022). ROC identified an optimal C2C threshold of 3.5°. Patients exceeding this had nearly twice the odds of neck disability (OR=1.90, P=0.049) and significantly lower SF-36 Physical Component (P=0.004) and Physical Functioning (P=0.011) scores. C2C was more strongly associated with SRS-Total than C7-CSVL (AIC=657 vs. 660; adj. R²=0.058 vs.0.048). CONCLUSIONS:Achieving postoperative C2C ≤3.5° is independently associated with reduced neck disability and optimized quality of life after ASD surgery. C2C was more strongly associated with SRS-Total than C7-CSVL and could be considered as a complementary measure of coronal alignment.

BACKGROUND:The majority of postoperative morbidity and mortality after partial pancreatectomy is attributable to postoperative pancreatic fistula. Several interventions to prevent postoperative pancreatic fistula have been assessed in randomized clinical trials but consensus on their efficacy is lacking. This is the first systematic review and meta-analysis of randomized trials focusing on strategies to prevent postoperative pancreatic fistula after all types of partial pancreatectomy. METHODS:Eligible randomized clinical trials assessing postoperative pancreatic fistula following partial pancreatectomy were included from the Evidence Map of Pancreatic Surgery database (2005-2025). As primary endpoint, both the 2005 and 2016 International Study Group for Pancreatic Surgery definitions of grade B/C postoperative pancreatic fistula were accepted. Interventions shown to reduce postoperative pancreatic fistula in at least one randomized trial were identified, and meta-analysis undertaken for those with at least three available trials, irrespective of their outcome. RESULTS:Overall, 193 RCTs were included with 29 408 patients from 24 countries. The pooled rate of postoperative pancreatic fistula grade B/C was 15.1%: 14.2% after pancreatoduodenectomy and 19.1% after left pancreatectomy. Overall, 24 trials identified 18 interventions as effective in reducing the rate of postoperative pancreatic fistula: 11 intraoperative and 7 postoperative. Eight interventions were eligible for meta-analysis, involving 46 trials. Following meta-analysis, three interventions remained effective: drain omission in left pancreatectomy, perioperative use of somatostatin analogues, and administration of perioperative corticosteroids. The certainty of evidence was high for drain omission, moderate for somatostatin analogues, and low for corticosteroids. Eleven trials focused specifically on high-risk patients and four on ongoing postoperative pancreatic fistula. No trial combined interventions. CONCLUSION/CONCLUSIONS:Omission of drains in left pancreatectomy, perioperative use of somatostatin analogues, and administration of perioperative corticosteroids are effective strategies to prevent postoperative pancreatic fistula after partial pancreatectomy. However, current evidence remains immature and further RCTs evaluating these interventions are warranted, as they are likely to change the conclusions of subsequent meta-analyses. Such trials could potentially focus on high-risk patient cohorts and/or assess combinations of interventions.

Cell motility, characterized by random walk and exploratory search movement, enables effector CD8+ T cells to search for sparse antigen-specific cancer targets within a tumor. This is of special relevance for treatment of solid cancers with adoptive T-cell receptor (TCR) T-cell therapy, where administered effector CD8+ T cells recognize specific MHC-I-presented antigens. Cell motility requires cytoskeleton remodeling to facilitate shape changes and movement. Herein, we show that increased mitochondrial Ca2+ levels are essential to reduce cytoskeleton stiffness of effector CD8+ T cells, leading to acquisition of a polarized shape and high motility. IL-21, but not IL-7 or IL-15, was able to raise mitochondrial Ca2+ levels in effector CD8+ T cells and increase their motility without affecting survival and proliferation. This increase in mitochondrial Ca2+ levels triggered by IL-21 was driven by sustaining mitochondrial membrane potential through mitochondrial STAT3, independently of its transcriptional activity. Enhanced motility of effector CD8+ T cells led to a superior killing efficacy of antigen-specific melanoma cells in vitro. Furthermore, enhanced mitochondrial Ca2+-mediated motility of adoptive TCR-specific effector CD8+ T cells resulted in a superior antitumor efficacy of this treatment against solid tumors in vivo. Thus, enhancing effector CD8+ T-cell motility is a promising strategy to boost efficacy of adoptive T-cell therapies against solid tumors.

BACKGROUND:Robotic surgery is increasingly used in emergency general surgery (EGS), but its adoption and outcomes after interhospital transfer remain unclear. We evaluated robotic adoption, hospital-level variation, predictors of use, and comparative outcomes among transferred EGS patients. STUDY DESIGN/METHODS:Using the Nationwide Readmissions Database (2016-2019), we identified adults transferred from acute-care hospitals who underwent EGS procedures. Mixed-effects models evaluated predictors and between-hospital variation in robotic use, summarized by intraclass correlation coefficients (ICC) and median odds ratios (MOR). Multivariable logistic and generalized linear models compared cost, length of stay (LOS), non-home discharge, complications, mortality, and 30-day readmission across robotic, laparoscopic, and open approaches. RESULTS:Robotics was used for ≥1 transferred patient in 8.5% of transfer-receiving hospital-years and 13.7% of robot-capable transfer-receiving hospital-years. Hospital-level variation was substantial for robotic vs laparoscopic selection (MOR 3.59; ICC 35.3%) but modest for robotic vs open selection (MOR 1.31; ICC 2.3%). Investor-owned hospitals and later years were associated with greater odds of robotic use, whereas extreme illness severity and rural residence were associated with lower odds. Compared with laparoscopy, robotics was associated with shorter LOS and higher cost, without statistically significant differences in adjusted clinical outcomes. Compared with open surgery, robotics was associated with shorter LOS, lower cost, and lower odds of non-home discharge and surgical complications. CONCLUSIONS:Robotic surgery after interhospital transfer was uncommon, with substantial hospital-level variation relative to laparoscopy despite similar adjusted clinical outcomes. These findings support defining selection criteria and evaluating equitable access to minimally invasive platforms.

OBJECTIVE:To quantify the operational burden of motion-related repeat MRI sequences across a high-volume health system and evaluate whether repeat acquisitions improve image quality and confidence in brain MRI and magnetic resonance cholangiopancreatography (MRCP). METHODS:This retrospective study analyzed six months of MRI examinations on scanners with sequence-level analytics. Examinations with technologist-labeled repeated sequences were identified. Brain MRI and MRCP baseline-repeat pairs were evaluated by four and two readers, respectively. Readers scored image quality and diagnostic confidence and indicated whether another repeat would be requested. Scores were compared using linear mixed-effects models with patient-level random intercepts. RESULTS:Among 85,349 MRI examinations, 4,072 (4.8%) included at least one repeated sequence. Repeat frequency was highest in pediatrics (9.9%) and lowest in breast MRI (3.5%). In the brain MRI study, 87 baseline-repeat pairs from 77 patients were evaluated. Repeat acquisition significantly improved image quality and diagnostic confidence across all metrics (all p<0.001). 19.5% of repeat sequences did not improve. Improvement declined with greater elapsed examination time. In the MRCP study, 30 baseline-repeat pairs from 27 patients were evaluated. Repeat acquisition did not significantly improve image quality or diagnostic confidence, and both readers would have requested another repeat for half of repeated acquisitions. DISCUSSION/CONCLUSIONS:Motion-driven repeat MRI sequences impose measurable operational burden, but diagnostic yield varies substantially by anatomic region and sequence type. Brain MRI repeats generally improved image quality and diagnostic confidence, whereas MRCP repeats showed limited benefit. These findings support sequence-level tracking to guide targeted motion-mitigation strategies and reduce low-value repeat imaging.