Faculty Bibliography

Cystic degeneration of thymoma can occur, although rarely to the extent that the lesion appears entirely cystic. We present a case of a 26-year-old man with a large anterior mediastinal cyst that was resected with histopathologic examination revealing a cystic thymoma.

Cortical networks for the production of spoken language in humans are organized by phonetic features^1,2, such as articulatory parameters^3,4 and vocal pitch^5,6. Previous research has failed to find an equivalent forebrain representation in other species^7-11. To investigate whether this functional organization is unique to humans, here we performed population recordings in the vocal production circuitry of the budgerigar (Melopsittacus undulatus), a small parrot that can generate flexible vocal output^12-15, including mimicked speech sounds¹⁶. Using high-density silicon probes¹⁷, we measured the song-related activity of a forebrain region, the central nucleus of the anterior arcopallium (AAC), which directly projects to brainstem phonatory motor neurons^18-20. We found that AAC neurons form a functional vocal motor map that reflects the spectral properties of ongoing vocalizations. We did not observe this organizing principle in the corresponding forebrain circuitry of the zebra finch, a songbird capable of more limited vocal learning²¹. We further demonstrated that the AAC represents the production of distinct vocal features (for example, harmonic structure and broadband energy). Furthermore, we discovered an orderly representation of vocal pitch at the population level, with single neurons systematically selective for different frequency values. Taken together, we have uncovered a functional representation in a vertebrate brain that displays unprecedented commonalities with speech-related motor cortices in humans. This work therefore establishes the parrot as an important animal model for investigating speech motor control and for developing therapeutic solutions for addressing a range of communication disorders^22,23.

Minoxidil has become an increasingly popular treatment option for hair loss disorders including androgenetic alopecia, cicatricial alopecia, and alopecia areata. There are various minoxidil formulations available including topical, oral, and injectable minoxidil. While injectable minoxidil may offer certain advantages, potential risks and costs should also be considered. First, we explore the enhanced bioavailability of injectable minoxidil in comparison to topical and oral formulations, as well as the variability in sulfotransferase enzyme levels and its role in the activation of minoxidil at hair follicles. Furthermore, we expand upon the potential adverse effects associated with injectable minoxidil given its widespread systemic distribution. We also highlight the importance of considering cost, access, and availability of injectable minoxidil given that injections are significantly more expensive than oral minoxidil tablets and involve the additional obstacle of frequent dermatology visits. Depending on geographic region and socioeconomic status, many patients may not live in sufficiently close proximity to a dermatologist for this level of care. Finally, we emphasize the need for ongoing research efforts to compare the efficacy, access, and tolerability of injectable minoxidil, alternative minoxidil formulations, and other alopecia medications.

BACKGROUND/UNASSIGNED:With the introduction of sirolimus as medical therapy for lymphangioleiomyomatosis (LAM), an updated evaluation of LAM lung transplant (LT) outcomes and characterization of peritransplant sirolimus use is needed. METHODS/UNASSIGNED:We identified adult LT recipients from 2005-2021 using the Scientific Registry of Transplant Recipients database and stratified by diagnosis (LAM vs other). Multivariable Cox regression was performed to calculate the adjusted hazard ratio for LAM vs other diagnoses. A pharmacy claims database was linked to provide sirolimus prescription information, and a subgroup analysis comparing outcomes with pre- vs posttransplant sirolimus use was performed. RESULTS/UNASSIGNED: = .003). CONCLUSIONS/UNASSIGNED:This study supports lung transplant as a treatment for severe pulmonary LAM and identifies increased mortality associated with pre-LT sirolimus, though this may be due to uncharacterized baseline differences.

MRI is widely used for the diagnosis and management of various abdominal diseases involving organs such as the liver, pancreas, and kidneys. However, one major limitation of MRI is its relatively slow imaging speed compared to other modalities. In addition, respiratory motion poses a significant challenge in abdominal MRI, often requiring patients to hold their breath multiple times during an exam. This requirement can be particularly challenging for sick, elderly, and pediatric patients, who may have reduced breath-holding capacity. As a result, rapid imaging plays an important role in routine clinical abdominal MRI exams. Accelerated data acquisition not only reduces overall exam time but also shortens breath-hold durations, thereby improving patient comfort and compliance. Over the past decade, significant advancements in rapid MRI have led to the development of various accelerated imaging techniques for routine clinical use. These methods improve abdominal MRI by enhancing imaging speed, motion compensation, and overall image quality. Integrating these techniques into clinical practice also enables new applications that were previously challenging. This paper provides a concise yet comprehensive overview of rapid imaging techniques applicable to abdominal MRI and discusses their advantages, limitations, and potential clinical applications. By the end of this review, readers are expected to learn the latest advances in accelerated abdominal MRI and explore new frontiers in this evolving field. Evidence Level: N/A Technical Efficacy: Stage 5.

IMPORTANCE/UNASSIGNED:Cutaneous squamous cell carcinoma (CSCC) risk stratification is central to management, and physicians rely on tumor staging systems to estimate risk. The Brigham and Women's Hospital (BWH) T staging system predicts risk based on 4 tumor risk factors (RFs). However, stage is not precisely associated with the number of RFs, as BWH stage T2b includes CSCCs with 2 and 3 RFs. OBJECTIVE/UNASSIGNED:To determine how RF number is associated with the risk of recurrence, metastasis, and disease-related death. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This retrospective multination cohort study of CSCCs diagnosed between October 1, 1991, and July 19, 2023, was conducted at 12 centers in the US (10), Spain (1), and Brazil (1). Invasive CSCCs with confirmed negative margins longer than 14 days were included. Tumors were excluded if they were metastatic at presentation or received adjuvant therapy. Data were analyzed from October 2023 to August 2024. INTERVENTIONS OR EXPOSURES/UNASSIGNED:CSCCs were stratified by the number of the following RFs (0, 1, 2, 3, or 4): a diameter of 2 cm or larger, poorly differentiated histology, tumor extension beyond subcutaneous fat, and large caliber nerve invasion. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Five-year cumulative incidences of local recurrence, nodal metastasis, distant metastasis, and disease-specific death. RESULTS/UNASSIGNED:A total of 16 844 CSCCs were included (5978 female individuals [35.5%]; median [IQR] age, 73.9 [65.7-81.8] years), with 0 (12 657 [75.1%]), 1 (2892 [17.2%]), 2 (1015 [6.0%]), 3 ( 225 [1.3%]) or 4 (55 [0.3%]) RFs. Median (IQ) follow up time was 33.6 (14.5-60.3) months. For local recurrence, the risk increased as the number of RF increased from 0 (1.7%; 95% CI, 1.5%-2.0%) to 1 (5.0%; 95% CI, 4.1%-5.9%) to 2 (8.8%; 95% CI, 7.0%-11.0%) to 3 (16.0%; 95% CI, 11.0%-22.0%) to 4 (33.0%; 95% CI, 19.0%-47.0%; P < .001 for between-group differences). This increase was also observed for nodal metastasis (0.6% [95% CI, 0.4%-0.7%] vs 3.6% [95% CI, 2.9%-4.4%] vs 11.0% [95% CI, 9.2%-13.0%] vs 20.0% [95% CI, 15.0%-26.0%] vs 28.0% [95% CI, 15.0%-42.0%], respectively; P < .001), distant metastasis (0.2% [95% CI, 0.1%-0.3%] vs 1.1% [95% CI, 0.7%-1.6%] vs 2.3% [95% CI, 1.4%-3.4%] vs 7.9% [95% CI, 4.6%-12.0%] vs 8.4% [95% CI, 2.6%-19.0%], respectively; P < .001), and disease-specific death (0.3% [95% CI, 0.2%-0.4%] vs 1.9% [95% CI, 1.4%-2.7%] vs 5.4% [95% CI, 4.0%-7.0%] vs 11.0% [95% CI, 6.7%-16.0%] vs 25% [95% CI, 12%-39%], respectively; P < .001). CSCCs with 3 RFs had higher cumulative incidences of local recurrence (1.6-fold), nodal metastasis (1.9-fold), distant metastasis (4.3-fold), and disease-specific death (1.9-fold) compared with those with 2 RFs. CONCLUSIONS AND RELEVANCE/UNASSIGNED:The results of this cohort study suggest that the number of RFs is an indicator of risk, and among BWH T2b tumors, those with 3 RFs represent a higher risk subset.

People with HIV are at increased risk of cardiovascular events; thus, care delivery strategies that increase access to comprehensive cardiovascular disease (CVD) risk management are a priority. We report the results of a multi-component telemedicine-based strategy to improve blood pressure control among people with HIV-Assess and Adapt to the Impact of COVID-19 on CVD Self-Management and Prevention Care in Adults Living with HIV (AAIM-High). The AAIM High strategy is a virtual adaptation of our previously published EXTRA-CVD strategy and consisted of hypertension education and six components: nurse-led care coordination (delivered by teleconference or telephone), home systolic blood pressure (SBP) monitoring, evidence-based treatment algorithms, electronic health records tools, technology coach, and communication preferences assessment. People with HIV (n = 74) with comorbid hypertension at three academic medical centers were enrolled in a single arm implementation study from January 2021 to December 2022. Over 12 months, the average patient-performed home SBP decreased by 7.7 mmHg (95% CI -11.5, -3.9). The percentage of patients at treatment goal, defined as average SBP <130 mmHg, increased from 46.0% to 72.5% at 12 months. By adapting to the growing use of telemedicine in healthcare delivery, our study effectively improved hypertension control in people with HIV through a virtual, nurse-led intervention.

Acute respiratory distress syndrome (ARDS) is a heterogeneous group of disease entities that are associated with acute hypoxic respiratory failure and significant morbidity and mortality. With a better understanding and phenotyping of lung injury, novel pathophysiologic mechanisms demonstrate the impact of a patient's excessive spontaneous breathing effort on perpetuating lung injury. Patient self-inflicted lung injury (P-SILI) is a recently identified phenomenon that delves into the impact of spontaneous breathing on respiratory mechanics in patients with lung injury. While the studies are hypothesis-generating and have been demonstrated in animal and human studies, further clinical trials are needed to identify its impact on ARDS management. The purpose of this review article is to highlight the physiologic mechanisms of P-SILI, novel tools and methods to detect P-SILI, and to review the current literature on non-invasive and invasive respiratory management in patients with ARDS.

OBJECTIVES/UNASSIGNED:We conducted a scoping review to identify barriers to telehealth use and uptake from the perspective of patient, provider, and system that were documented in the literature. In addition to identifying and categorizing the barriers, we aimed to assess how barriers differed for studies conducted during the COVID-19 pandemic, as well as how barriers differed between the United States vs internationally based studies. MATERIALS AND METHODS/UNASSIGNED:Comprehensive searches of the PubMed/MEDLINE, CINAHL, and Scopus databases conducted on December 29, 2021 yielded 17 887 results, with 11 221 potentially eligible documents after duplicates were removed. The team conducted an initial title and abstract review, followed by full text review. Data from the included sources were extracted and summarized into primary themes. RESULTS/UNASSIGNED:We identified 395 articles specifically related to barriers of telehealth use. The top 5 barriers, in order of frequency, were: lack of skills or ability (55%), lack of interest (49%), lack of access to technology (45%), limitations of technology infrastructure (45%), and lack of quality of care (42%). Roughly one-third (39%) of studies were related to the COVID-19 pandemic and 54% were US-based studies. The rank order of barriers between COVID-19 vs non-COVID-19 studies and US vs non-US studies was the same; however, patients in the United States and those using telehealth during COVID-19 were more likely to cite barriers related to the lack of access to technology (COVID = 56% vs 38%; United States = 51% vs 38%). DISCUSSION/UNASSIGNED:Interventions to address barriers need to consider the unique needs of specific populations and the ways in which different barriers may intersect. CONCLUSION/UNASSIGNED:This review found that barriers to telehealth uptake and use are multilayered and occur at several levels (individual, structural, technological).

BackgroundAdvances in STN-DBS technology, among which directional stimulation, improved Parkinson's disease (PD) treatment efficacy, while increasing the clinical programming complexity. Lead localization software may aid the stimulation contact selection process.ObjectiveWe aimed to assess the concordance between imaging-suggested (IGP) and conventional-programming (CP) selected stimulation contacts one year after surgery and its impact on motor outcomes.MethodsSixty-four PD patients with bilateral STN-DBS were enrolled. Lead localization was reconstructed with Brainlab^TM software. For each electrode, the vertical contact level and, when applicable, the directionality predicted by the lead reconstruction software to be the most effective were established and compared to the stimulation parameters clinically activated one-year post-surgery. IGP/CP concordance ratio was calculated for both stimulation level and directional contacts. Post-operative modifications of PD motor symptoms severity were compared among groups of concordant and discordant IGP/CP programming.ResultsOne-year post-surgery, IGP/CP concordance was 80% for active stimulation vertical contact level and 51% for directionality. No significant difference in motor outcomes was found between IGP/CP concordant and discordant patients for contact level activation, whereas patients with concordant IGP/CP active directional stimulation (c-Direction) showed superior motor outcomes at one-year follow-up than those discordant (d-Direction) (UPDRS-III stimulation-induced improvement: c-Direction = -25.66 ± 13.74 vs. d-Direction = -12.54 ± 11.86; p = 0.011).ConclusionsVisual reconstruction software correctly predicted the most clinically effective stimulation contact levels in most patients. Imaging therefore facilitates classic STN-DBS clinical programming while assuring similar outcomes. Moreover, better motor outcomes were reached by patients with concordant IGP/CP directional parameters, suggesting that visualization can represent an added value in particular for directional stimulation programming.