Citations

Expert consensus recommendations from 21 academic centers were established for appropriate radiography utilization at 12 potentially low-yield anatomic sites through a multidisciplinary process endorsed by six major American medical societies.

Summary Achalasia is a motility condition defined by failure of relaxation of the lower esophageal sphincter and loss of peristalsis in the distal esophagus. Per-oral endoscopic myotomy (POEM) is a technique to reduce lower esophageal sphincter pressure. We performed a systematic review and meta-analysis to assess the association between POEM and the clinical outcomes. We performed a systematic review and a meta-analysis (CRD420251052240). Literature search was done on PubMed and Embase (up to 8 June 2025). Original studies involving achalasia patients who underwent esophageal POEM with impedance planimetry using 8-cm balloon at 30 or 40 mL filling volumes with 325 catheter only (not the 322-N catheter) were included. The outcomes of interest were the clinical response groups (responders’ Eckardt score [ES] < 3 and non-responders’ ES > 3), reflux esophagitis, cross-sectional area (CSA), distensibility index (DI), and diameter. Nineteen studies with 1215 patients were included. The responders (ES < 3) showed a statistically significantly greater increase in DI due to POEM (post-op minus pre-op) (mean difference [MD] = 1.92 mm2/mmHg [0.32, 3.53], P = 0.02) as well as a higher postoperative DI (MD = 1.87 mm2/mmHg [0.04, 3.70], P = 0.05) (40 mL). Reflux esophagitis group had statistically significantly higher CSA and diameter values (CSA MD = 15.68 mm2 [6.91, 24.24], P = 0.0005) (diameter MD = 0.96 mm [0.58, 1.33], P < 0.00001) but no statistically significant difference for DI as compared to the non-reflux esophagitis group (DI MD = 0.19 mm2/mmHg [−0.51, 0.89], P = 0.59). In achalasia patients undergoing esophageal POEM, a greater interval increase in the DI as well as a higher post-procedural DI absolute value predicts a favorable clinical response. Higher postoperative CSA and diameter were linked to reflux esophagitis.

Abstract INTRODUCTION Research into cognitive dispersion – a cognitive process score measuring the intra‐individual variability (IIV) across a single testing session – suggests utility in neurodegenerative populations. Given widespread deficits observed in sporadic early‐onset Alzheimer's disease (EOAD), however, it is unclear if examining cognitive dispersion shows benefit in this condition. METHODS A total of 309 participants (188 amyloid‐positive EOAD, 43 amyloid‐negative early‐onset dementia [EOnonAD], 78 cognitively normal [CN]) completed neuropsychological testing twice over 12 months. Dispersion‐related differences among groups were assessed, as was cognitive dispersion's capacity to predict domain‐specific cognitive trajectories, and its convergence with imaging biomarkers. RESULTS EOAD participants displayed higher cognitive dispersion than EOnonAD participants, and associations with EOAD‐specific biomarkers. Additionally, cognitive dispersion was associated with 12‐month reliable change across several cognitive domains. DISCUSSION These preliminary results examine cognitive dispersion in sporadic EOAD. When used with baseline cognitive performance, cognitive dispersion measures may enrich future clinical trials in EOAD by enhancing treatment monitoring over time.

Abstract Inflammatory bowel diseases (IBD), principally Crohn’s disease (CD) and ulcerative colitis (UC), are common chronic disorders involving inflammation and often progressive tissue damage. Genome-wide association studies have mapped many risk signals, but the causal variants, effector genes and relevant cellular contexts remain difficult to resolve, limiting mechanistic interpretation and therapeutic translation. Here we performed a multi-ancestry GWAS meta-analysis of 125,992 individuals with IBD and more than 1.2 million controls, identifying 619 independent association signals (374 novel) at 420 IBD regions that account for 77–80% of SNP-based heritability. Fine-mapping resolved 81 high-confidence variants, 41 not previously reported. Although most signals were shared between CD and UC, 39% showed IBD subtype specificity, with UC signals showing stronger enrichment in functional annotations from intestinal epithelial, secretory and enteroendocrine cells, and CD showing stronger genetic correlations with circulating inflammatory biomarkers, including C-reactive protein and glycoprotein acetylation. Latent causal modelling supported a causal effect of decreased high-density lipoprotein on CD risk. By integrating bulk and single-cell eQTL and pQTL resources using colocalisation and Mendelian randomisation, together with coding-variant evidence from exome sequencing, we prioritised 664 candidate effector genes across 341 signals, including 390 newly implicated IBD genes, revealing new biological mechanisms and candidate therapeutic targets supported by human genetics.

Abstract Rationale Prior studies demonstrate pulmonary artery (PA) enlargement on computed tomography (CT) in pulmonary hypertension (PH). Some patients exhibit markedly enlarged or “aneurysmal” PA dilation, but its clinical relevance remains unclear. We aimed to characterize clinical characteristics, hemodynamics, and survival probability of patients with aneurysmal PA size. Methods Demographics, clinical characteristics, and CT imaging were obtained for individuals with group 1 or 2 PH and matched controls in the Pulmonary Vascular Disease Phenomics cohort. PA diameter was measured using Osirix software. PA diameter was categorized based on previously reported values as normal (<27 mm [females], <29 mm [males]), enlarged (27-39 mm [females], 29-39 mm [males]), or aneurysmal (≥40 mm). Outcomes included mean PA pressure (mPAP) on right heart catheterization (RHC) and time to death or heart/lung transplant. Associations with mortality and mPAP were evaluated using multivariable Cox and linear regression models, adjusting for age, sex, and BMI. Descriptive statistics are presented as median [IQR]. Results 690 subjects met the inclusion criteria for survival analysis (364 WSPH group 1 or matched comparator, 241 group 2 or comparator, 85 healthy control), with 594 undergoing RHC. PA diameter was normal in 163 participants, enlarged in 414, and aneurysmal in 113. Aneurysmal PA, compared with normal or enlarged PA, was associated with younger age (53 ± 14 vs 55 ± 16 and 59 ± 15 years, respectively; p < 0.001), non-White race (18.9% vs 8% and 17.2%; p = 0.034), pro-BNP (1950 ± 5708 vs 531 ±1651 and 110 ± 2258 pg/mL; p < 0.001), PH duration (6.78 ± 6.86 vs 2.24 ± 4.39 and 3.82 ± 5.47 years; p < 0.001), group 1 disease (77% vs 37% and 61%), and congenital heart disease (CHD)-PAH (10.6% vs 0.0% and 4.8%, p < 0.001). Aneurysmal PA subjects had higher mPAP (46 [36-57] vs 19 [16- 25] and 35 [28-47] mmHg, p < 0.001), pulmonary vascular resistance (PVR) (5.5 [3.6-9.4] vs 1.7 [1.0-2.3] and 4.1 [2.4-7.1] Woods units, p < 0.001), cardiac index (CI; 2.73 [2.34-3.29] vs 2.55 [2.13-2.98] and 2.52 [2.12-3.10] L/min/m2, p < 0.02) and likelihood of death or transplant (p < 0.001; Figure 1). Conclusion “Aneurysmal” PA was more common in younger, non-White subjects with longer WSPH group 1 disease duration, CHD, and higher pro-BNP levels. Aneurysmal PA was associated with elevated mPAP, PVR, and CI, and reduced likelihood of survival. These findings highlight the need to further elucidate the pathophysiology and prognostic implications of aneurysmal PA remodeling in PH. This abstract is funded by: NHLBI and the Pulmonary Hypertension Association

Abstract Background We recently reported a strong association between CT markers of pulmonary artery (PA) dilation and mean PA pressure (mPAP) in subjects with World Symposium on Pulmonary Hypertension (WSPH) group 1 and 2 pulmonary hypertension (PH). The relationship between PA size and mPAP in subjects with WSPH group 3 PH, in which parenchymal changes may influence PA dilation, remains uncertain. We sought to investigate this relationship in subjects with and without PH who have significant parenchymal pulmonary disease or hypoxia. Methods We measured PA diameter and PA:aorta (PA:A) ratio on CT for all subjects with WSPH group 3 PH, matched disease comparators, and healthy controls in the Pulmonary Vascular Disease Phenomics (PVDOMICS) cohort. PH and comparator subjects were categorized by group 3 etiology into obstructive (including chronic obstructive pulmonary disease [COPD] and cystic fibrosis), interstitial (including idiopathic pulmonary fibrosis, unspecified interstitial lung disease, combined pulmonary fibrosis and emphysema, and chronic hypersensitivity pneumonitis), and non-parenchymal (including obesity hypoventilation syndrome, obstructive sleep apnea, and extrinsic restrictive disease) subgroups. Primary outcome was mPAP on right heart catheterization (RHC). Association with mPAP was evaluated using multivariable linear regression adjusted for age, sex, and BMI. Results 339 subjects met inclusion criteria (101 WSPH group 3 PH, 153 disease comparators, 85 healthy controls). 83 subjects had obstructive disease, 125 had interstitial disease, and 46 had non-parenchymal disease. PA diameter and PA:A were associated with mPAP in all subjects and in each subgroup (p < 0.001; see figure 1). The association was notably stronger in the non-parenchymal group (ρ = 0.707 for diameter, 0.750 for PA:A) compared to obstructive (ρ = 0.566 for diameter, 0.529 for PA:A) and interstitial (ρ = 0.432 for diameter, 0.373 for PA:A) groups. Change in PA size between 25th and 75th percentile mPAP was lower in the interstitial group (3.88 mm, ratio 0.12) than in the obstructive (4.88 mm, ratio 0.17) and non-parenchymal (4.80 mm, ratio 0.19) groups (see figure 1). Conclusions PA size on CT is associated with mPAP in subjects with chronic lung disease with and without PH. This association is strongest in subjects without parenchymal lung disease but with features of hypercarbia or hypoxia alone. These data suggest that features of parenchymal lung disease in certain patients may limit expected PA dilation in response to elevated PA pressures. Further study is needed regarding the implications of these findings for early identification of PH in patients with chronic lung disease. This abstract is funded by: The NHLBI and Pulmonary Hypertension Association

Abstract Introduction The diagnosis of fungal lung infections remains challenging as standard tests, such as bronchoalveolar lavage (BAL) antigen testing, often yield variable or inconclusive results. These limitations can delay appropriate therapy and may require additional tissue sampling for definitive diagnosis. Robotic-assisted bronchoscopy (RAB) biopsy has been primarily used as a minimally invasive technique for assessing suspicious peripheral pulmonary lesions (PPL). This case series highlights the diagnostic utility of RAB for identifying fungal infections within PPL when conventional BAL antigen analysis is non-diagnostic. Case Description Four patients with suspected infectious or malignant PPL underwent RAB-guided biopsy for diagnostic clarification, all yielding histopathologic confirmation of fungal disease. The first, a 73-year-old bilateral lung-transplant recipient with hemoptysis, had a negative BAL Aspergillus antigen despite RAB biopsy confirming Aspergillus infection. Similarly, a second 73-year-old man with chronic obstructive pulmonary disease (COPD) and esophageal adenocarcinoma had a negative BAL antigen, while RAB biopsy of bilateral cavitary lesions confirmed Aspergillus. Additionally, a 39-year-old woman with a nodule being evaluated for malignancy, had negative BAL Histoplasma antigen and PCR, whereas RAB biopsy confirmed Histoplasma capsulatum. In contrast, a 56-year-old woman with a right-lower-lobe nodule had a positive BAL Aspergillus antigen that aligned with the histopathologic biopsy findings. Discussion BAL-based antigen testing demonstrates variable diagnostic accuracy in fungal lung disease. Reported sensitivities for Aspergillus detection are typically high in meta-analysis, approximately 80%-90%, but clinical performance in the immunocompromised or high-risk patients is often substantially lower. Similarly, while BAL antigen testing for Histoplasma performs well in disseminated infections, it often fails to detect localized pulmonary disease. In this series, three out of four patients had negative BAL results in the presence of histopathologic confirmation of fungal infection. While current guidelines consider BAL positivity supportive of a “probable” diagnosis, tissue histopathology remains the gold standard for a “proven” infection. These findings emphasize the value and capability of RAB in obtaining direct tissue confirmation when conventional testing, such as BAL antigen analysis, is non-diagnostic. Conclusion RAB-guided biopsy of PPLs offers the opportunity for histopathologic confirmation of fungal infection when BAL testing is non-diagnostic. This approach can enhance upfront diagnostic yield in patients with suspected fungal pulmonary infections, avoiding delays in diagnosis and treatment initiation. This abstract is funded by: None

Abstract Rationale Advances in bronchoscopic technology, including robotic-assisted bronchoscopy (RaB) and cone-beam CT (CBCT), have enabled biopsy of multiple nodules in a single procedure. Here we present the procedural characteristics, safety, diagnostic yield, and use of linear endobronchial ultrasound (EBUS) staging in patients with multifocal pulmonary nodules biopsied under a single anesthesia event. Methods This multi-center, retrospective observational study included adults undergoing RaB biopsy of multifocal peripheral pulmonary lesions and lymph node assessment under a single anesthesia event at six U.S. centers from 11/2019 - 8/2025. Procedures utilized either the Ion (Intuitive) or Monarch (Ethicon) systems under general anesthesia. De-identified demographic, radiologic, procedural, pathologic, and safety data were collected in a secure centralized database. Safety outcomes included pneumothorax and its sequelae, hypoxia, and infectious complications. Diagnostic yield was determined using the 2024 ATS/ACCP consensus statement. NGS adequacy was reported from two health systems with well-defined criteria for sufficiency and standard institutional practices for sending NGS testing on both nodules. Statistical analyses utilized included descriptive statistics, t-tests, chi-squared/Fisher’s tests where appropriate, and logistic regression. Results Among 191 patients, 177 underwent biopsy of two and 14 of three nodules. Lymph nodes were sampled in 167 (87.4%), with 18 (10.8%) positive for malignancy; notably, 17 of 18 (94%) patients with nodal metastases had at least one fully solid nodule. Complications occurred in 20 patients (10.5%), including pneumothorax in 14 (7.3%), with 4 (2.1%) requiring tube thoracostomy. There were no cases of bilateral pneumothorax. Transient hypoxia occurred in 3 patients (1.6%) and 3 developed outpatient-managed bronchitis. Seven patients (3.7%) required unplanned admission. Overall diagnostic yield was 72.2%, with 122 (63.9%) patients having two diagnostic nodules and 33 (17.4%) having two non-diagnostic nodules. Bronchus sign (OR 2.9, p = 0.003), radial EBUS use (OR 2.6, p = 0.025), and CBCT use (OR 2.4, p = 0.021) were associated with procedures having two diagnostic nodules. At sites with standardized NGS adequacy reporting, 74 of 81 malignant nodules (91%) provided sufficient tissue for NGS. Conclusions •Single-procedure biopsy of multifocal pulmonary nodules is feasible, safe, and achieves industry-standard strict diagnostic yield. •Complications are slightly higher than single-nodule procedures. Serious events were rare. •17 of 18 patients with malignant nodal disease had at least one fully solid nodule; no patients with two pure ground glass nodules had nodal metastasis. •NGS testing was feasible and adequate on the majority of samples, aiding clinicians in staging multifocal nodules. This abstract is funded by: None

Abstract Introduction Large Language Models (LLMs) have proven effective at analyzing unstructured and structured data from electronic health records (EHR). Their reliance on static EHR data means they miss the dynamic, high-resolution physiological signals that are the first indicators of patient decline, creating a fundamental data lag as clinical documentation of an event may occur hours after its onset. This represents a critical gap in the ability to develop truly effective triage tools. Furthermore, while LLMs can synthesize multi-source data for acuity assessment, they exhibit known limitations, including hallucinations that constrain autonomous use in safety-critical settings. In contrast, a Vision-Language Model (VLM) with strong image-grounded clinical reasoning can interpret vital sign trend images, surpassing the limitations of current EHR-based models. This approach provides immediate triage evaluations that lead to earlier detection of patient deterioration. Methods This mixed-methods study deployed a VLM (Gemini 2.5) integrated within the eICU dashboard. We used near-real-time two-hour trends in heart rate, blood pressure, respiratory rate, and oxygen saturation from consecutive patient cases during alerts in hospital floor units monitored by eICU that admit acute medical and surgical patients. To increase the diversity of the sample, we sought routine cases from patients without alerts and emergent cases from patients admitted to the medical, surgical, trauma, and mixed ICUs. A structured context prompt was used to generate a standardized summary including clinical interpretation, data quality and artifact assessment, triage recommendation, and the model’s chain-of-thought reasoning. Results We included patients from Mayo Clinic Rochester, MN, using an 800-patient cohort for prompt development and a 100-patient cohort for validation against clinically adjudicated results. In the validation cohort the VLM achieved 80% accuracy (80/100). An analysis of the 20 incorrect predictions revealed a clear pattern of conservative over-triage: 80% (16/20) of errors were clinically acceptable adjacent-class discrepancies (routine↔urgent or urgent↔emergent). Only 4/20 discrepancies represented a substantive misclassification. Most errors therefore reflected conservative prioritization rather than incorrect assessment. The model demonstrated a perfect safety profile, underestimating patient acuity in 0% of cases, and thus avoiding the most clinically dangerous error. These results confirm the feasibility of VLM-based approach and provide a strong foundation for the proposed work. Conclusion This VLM performs cross-modal reasoning by fusing deep visual perception with broad clinical context. The result is a fully contextualized and explainable triage prioritization, which provides direct decision support and integrates into the clinical workflow, allowing for faster and more confident acute care assessments. This abstract is funded by: none

Abstract Rationale Patients with idiopathic pulmonary fibrosis (IPF) living in disadvantaged neighborhoods have worse composite outcomes and pulmonary function. Although the current FDA approved drugs reduce lung function decline and may improve mortality for this progressive and fatal disease, equitable access to therapy remains a challenge, which may be contributing to low antifibrotic uptake. Existing understanding of social determinants of health in IPF is derived from local registries and special subpopulations, such as Veterans. The aim of our study is to investigate the association between neighborhood-level deprivation indicators and both the distribution of patients with IPF and outcomes in a large national database. Methods We performed a retrospective cohort analysis between October 1st, 2014, and December 31st 2022, using the Optum Labs Data Warehouse, a large de-identified administrative claims database. We used claims data from commercial, Medicare Advantage, and Medicare Fee-for-Service enrollees across the United States. Diagnosis of IPF was defined using ICD-9 and ICD-10 codes. Social deprivation index (SDI), assessed at the zip code tabulation area level, was determined based on 7 demographic characteristics from the 2015-2019 American Community Survey. Patients were grouped in quintiles based on SDI at diagnosis, where higher values reflect greater deprivation. Hazard ratios (HR) were calculated for all-cause mortality as primary and hospitalization as secondary outcome. Results A total of 96,143 patients (mean age 75.1 years ± 6.9 years) were included in the study, 23.5% received antifibrotics. As area deprivation increased, proportion of female, Black, and Hispanic patients increased, whereas, proportion of male, White, and Asian patients decreased. Similarly, antifibrotic use declined slightly, while prescription of steroids and oxygen increased with SDI. Residing in most disadvantaged neighborhoods increased risk of hospitalization (HR, 1.13 [95% CI 1.09 - 1.17] and all-cause mortality (HR, 1.15 [95% CI 1.11 - 1.19]) after adjusting for covariates over median follow-up of 301 days and 680 days, respectively. Conclusion Gender and racial disparities were evident among IPF patients who live in resource-limited areas. Our study shows that greater proportion of female, Black, and Hispanic IPF patients were disproportionately represented in more socioeconomically deprived areas. Furthermore, as area-level disadvantage increased, fewer patients received antifibrotics, while more patients were on steroids and oxygen therapy potentially indicating more advanced disease. Moreover, living in disadvantaged neighborhoods was associated with worse all-cause mortality and hospitalizations. Identifying individuals who live in socioeconomically disadvantaged areas is essential to provide equitable care and improve outcomes for this life-threatening disease. This abstract is funded by: None