Faculty Bibliography

Perianal fistulas are abnormal epithelialized connections between the anal canal to the perineal skin. Magnetic resonance imaging (MRI) has become the gold standard for both pre- and postoperative evaluation, offering excellent soft tissue contrast and superior delineation of fistulous tracts, sphincteric involvement, tract extensions, abscesses, and associated complications. Despite its diagnostic value, interpretation of perianal fistula MRI can be challenging, particularly for radiology trainees, as it requires detailed understanding of complex perianal anatomy, as well as familiarity with optimized MRI acquisition planes and interpretation techniques. This pictorial review aims to provide a structured and practical approach to perianal fistulous disease on MRI. It highlights key imaging features of fistulas, illustrates essential anatomic landmarks of the anal canal and surrounding spaces, and reviews current pathogenesis theories of fistula formation to serve as foundational knowledge. The Parks classification system will be systematically reviewed with case examples and illustrations. Finally, key reporting considerations are presented using a stepwise, trainee-oriented approach, providing a structured MRI interpretation framework to promote accurate and consistent assessment, improve communication with surgeons, and support standardized reporting in clinical practice.

BACKGROUND:Soft tissue sarcoma (STS) is a rare and heterogeneous malignancy with more than 100 histologic subtypes that can arise in virtually any part of the body. Although surgical resection is the standard of care, complete surgical resection is often limited by involvement of critical anatomy, and most subtypes are resistant to systemic therapies. Histotripsy uses microsecond length, high-pressure ultrasound (US) pulses delivered externally to generate cavitation inside the target tumor to mechanically liquefy tissue to acellular homogenate. This study tested the effect of histotripsy in a variety of soft tissue tumors (STTs) including benign tumors and sarcomas. METHODS:Histotripsy was delivered to 45 surgically excised ex vivo human samples with a custom 1 MHz 8-element US transducer guided by US imaging. RESULTS:Histotripsy was successful in creating an identifiable treatment effect across all subtypes including adipocytic tumors, benign myxoid and nerve sheath tumors, aggressive fibrous sarcomas, and high-grade sarcomas. Immediately after histotripsy, B-mode and shear-wave elastography US imaging was shown to effectively evaluate the treatment. Tissue structure heterogeneity among the tumor subtypes dictated the variation in histologic treatment effects. CONCLUSIONS:The data demonstrate effective US-guided histotripsy ablation on a robust cohort of ex vivo STTs. The variable treatment effects observed across tumor subtypes highlight the need for histotripsy parameter optimization, with support for its potential as a promising non-invasive treatment modality for sarcoma patients who currently have limited therapeutic options.

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.

BACKGROUND/UNASSIGNED:Patients with end-stage renal disease (ESRD) and atrial fibrillation (AF) face paradoxical risks of both thrombosis and bleeding, creating uncertainty regarding stroke risk and optimal anticoagulation (AC) strategies. OBJECTIVES/UNASSIGNED:This study evaluated the impact of ESRD on stroke risk and mortality in patients with AF using a large national cohort. METHODS/UNASSIGNED:A retrospective cohort study was conducted using the National Inpatient Sample database for 2018-2019. Adult patients (≥18 years) with AF were stratified by ESRD status. Propensity score matching (1:1) was performed using baseline demographic and comorbidity variables. Primary outcomes included ischemic stroke, hemorrhagic stroke, transient ischemic attack (TIA), and all-cause mortality. RESULTS/UNASSIGNED:< .001; OR, 1.95; 95% CI, 1.87-2.04). CONCLUSION/UNASSIGNED:Patients with AF with ESRD had lower cerebrovascular event rates despite lower AC use, suggesting that uremic platelet dysfunction and intradialytic heparin exposure may confer protective AC effects. These findings challenge traditional stroke risk assumptions and highlight the need for ESRD-specific risk-stratification tools and individualized shared decision making.

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.

Social support systems, particularly caregivers, play a critical role in the evaluation, treatment, and recovery of patients undergoing heart or lung transplantation or left ventricular assist device (LVAD) implantation. However, definitions, assessment practices, and expectations for social support vary considerably across programs, and evidence guiding optimal caregiver engagement remains limited. This International Society for Heart and Lung Transplantation expert consensus statement summarizes current evidence and provides recommendations for assessing, engaging, and supporting social support systems across adult and pediatric populations. A multidisciplinary international writing committee reviewed the literature and developed recommendations through a structured consensus process. Social support encompasses medical management, logistical, emotional, informational, psychological, and companionship assistance, with caregiver needs and responsibilities evolving across the treatment trajectory. Existing assessment approaches and interventions are heterogeneous, with limited longitudinal evidence. Consensus recommendations emphasize early caregiver identification and engagement, structured and tailored education and skills training, longitudinal assessment of caregiver needs and burden, integration of caregivers into clinical workflows, access to psychosocial and palliative care resources, and peer support. A strengths-based, individualized approach that recognizes social and structural barriers is recommended to promote equitable access and optimize patient and caregiver outcomes.

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.

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:Culturally effective care for dual-language learners (DLLs) should incorporate evidence-based guidance on bilingual language development. This study assessed pediatric providers' knowledge of bilingualism and provision of culturally effective language promotion and developmental surveillance for DLLs. We also investigated provider-level factors related to these practices. METHODS:Pediatric providers (N=349) who conduct birth-five well-child visits completed an online survey that asked about: knowledge of bilingual language development, self-reported language promotion with DLLs, difficulty identifying language delays, and application of culturally effective language promotion and developmental surveillance in clinical vignettes. RESULTS:The percent of providers who agreed with the evidence-based statements testing knowledge of bilingual language development ranged from 26% to 98% depending on the statement. The percent of providers who self-reported frequently providing culturally effective language promotion to DLLs ranged from 36% to 93% depending on the item. Most (79%) providers reported difficulty identifying language delays in DLLs in cases of language non-concordance, compared to 38% in cases of language concordance and 7% for monolinguals. The percent of providers who responded correctly to hypothetical clinical vignettes ranged from 29% to 95% depending on the vignette. Providers who were bilingual, had received bilingualism training, encountered more DLL patients, and were more knowledgeable about bilingualism reported engaging in more culturally effective care. CONCLUSION/CONCLUSIONS:This study revealed gaps in pediatric providers' knowledge and provision of culturally effective language promotion and developmental surveillance for DLLs. Promoting a linguistically diverse workforce and providing training on bilingualism may be important ways to support families of DLLs.