Citations

Klippel-Trénaunay syndrome (KTS) is a rare congenital vascular-overgrowth disorder within the broader spectrum of PIK3CA -related overgrowth syndromes. Although clinical, radiologic, and orthopedic manifestations are well described, the histologic spectrum of KTS-associated pathology remains under-characterized. Clinicopathologic findings from 21 patients with clinically established KTS were reviewed, including 18 with longitudinal clinical follow-up and 3 consultation cases of rare malignant mesenchymal neoplasms. Cases were identified from institutional pathology and clinical databases, and available hematoxylin and eosin-stained sections and ancillary studies were reviewed. The cohort included 11 males and 10 females. Among the 18 clinically followed patients, 12 had limb length discrepancy or asymmetric limb overgrowth, 9 had documented deep vascular malformations, 4 had intra-articular/synovial malformations, and 10 underwent initial orthopedic evaluation or intervention before age 18. Orthopedic morbidity clustered into mechanical overgrowth-related, vascular malformation-related, and soft tissue/wound-related complications. Histologic findings included superficial and/or deep slow-flow vascular malformations, ulceration and granulation tissue, hemosiderin-laden reactive synovium, and destructive hemorrhagic arthropathy. Intra-articular disease recapitulated a hemophilic arthropathy-like pattern, with hemosiderotic synovitis, papillary synovial hyperplasia, and progressive joint destruction with loss of articular cartilage, exposed subchondral bone destruction and remodeling, all attributable to long-standing intra-articular hemorrhage. Three consultation cases showed malignant mesenchymal neoplasia, including 2 angiosarcomas. Recognition of these patterns is important for pathologists evaluating specimens from patients with known or suspected KTS, particularly when findings mimic hemophilic arthropathy, diffuse-type tenosynovial giant cell tumor, nonsyndromic vascular malformation, and/or end-stage destructive arthropathy.

Abstract Objective Otolaryngology–Head and Neck Surgery (OHNS) residency remains highly competitive, with persistent disparities in applicant representation. This study presents a cross‐sectional analysis of OHNS residency and faculty demographics using 2025 program rosters, evaluating degree type (MD vs DO), geographic distribution, and leadership influence. Study Design A cross‐sectional review. Setting All US ACGME‐accredited OHNS residency programs, with data collected in 2024 to 2025. Methods Demographic data were collected on OHNS faculty and residents, including post‐graduate year (PGY) 1 through PGY5 trainees at the time of data collection, corresponding to entry years from 2020 to 2024 across all US ACGME‐accredited residency programs. Data was extracted from official program websites, FREIDA, ACGME, NRMP, and social media. Programs with incomplete data, those using the military match, and non‐accredited sites were excluded. Descriptive statistics, χ 2 tests, and correlation analyses were performed ( p < .05). Results Of 131 programs, 125 were analyzed at the program level and 121 at the faculty level. DO residents were concentrated in Michigan (59%), Ohio (50%), and Oklahoma (50%). DO representation correlated with DO faculty ( r = .82, p < .0001), DO program director ( r = .95, p < .0001), and former AOA program designation ( r = .92, p < .0001). A negative correlation existed between program size and DO resident ( r = –.4, p < .0001). Conclusion Despite growing diversity following the single accreditation system, disparities persist in OHNS. DO residents remain underrepresented and geographically concentrated, with representation strongly associated with osteopathic faculty presence, program leadership, and prior AOA affiliation.

Introduction The World Health Organization (WHO) endorses male circumcision as an effective human immunodeficiency virus (HIV) prevention intervention in settings where the expected impact is greatest, including Sub-Saharan Africa. Data on cost implications of early infant male circumcision (EIMC) are limited. The ShangRing (SR) is a WHO pre-qualified device for circumcision. We sought to perform a comprehensive cost assessment alongside a randomized controlled trial (RCT) of the SR versus the standard of care Mogen clamp (MoC) for EIMC to enable future scale-up towards a cost-effective HIV prevention strategy. Methods We collected resource utilization and economic data as part of an RCT of infants aged 0–60 days old undergoing EIMC in Kenya, Tanzania, and Uganda. Cost data for both the SR and MoC included baseline facility costs, direct costs, and indirect costs. The Decision Makers Program Planning Tool v1.0 was used to perform a direct cost comparison of these two devices. The Goals model was used to compare the costs of EIMC in 2023 using the present value of money to circumcise an adolescent male 15 years from now. Results A total of 1,378 infant males underwent circumcision, 689 via SR and 689 via MoC. The overall cost of a single EIMC in Kenya, Tanzania, and Uganda were 61.30 United States Dollars ($), $47.14, and $64.59 respectively for the SR, and $56.38, $50.43, and $58.57 respectively for the MoC. In Kenya, EIMC would be less expensive based on nominal present costs in 2023 compared to waiting for adolescent circumcision at age 15 years in 2038. This finding is reversed in Tanzania and Uganda. Conclusions The overall cost of EIMC via SR versus MoC is comparable in an RCT. With scale-up utilizing lower level personnel, the cost of SR may be further reduced. The SR is an attractive alternative for future EIMC initiatives in Sub-Saharan Africa to further reduce HIV burden.

Abstract Background Lower extremity compression therapy has been proposed as an adjunct to mitigate diuretic resistance during acute decompensation of heart failure (ADHF). We evaluated the effect of lower leg compression with elastic bandages on diuretic efficiency in patients with diuretic-resistant ADHF. Methods Historical cohort study enrolling adult cardiac ICU admissions with ADHF who used elastic bandages (EB) at Mayo Clinic in Minnesota from 2007 to 2017. The diuretic efficiency before and after applying EB was the primary outcome. Results A total of 176 patients with heart failure who received elastic bandages were included. The in-hospital mortality rate, the median hospital length of stay, and 30-day hospital readmission were 9.7%, 11.4 days (IQR 7.1–19.0), and 11%, respectively. When EB was applied, the average daily loop diuretic dosage was decreased by a mean difference of 1.19 mg per 40 mg furosemide equivalent (95% CI: 0.22 to 2.2; p = 0.016). The average post-EB diuretic efficiency was 1,355 mL (IQR 1,119, 1,590) per 40-mg furosemide, which was significantly higher than before EB application, with a mean difference of 340 mL per 40-mg furosemide equivalent (95% CI: -554, -125; p = 0.002). A higher diuretic efficiency led to lower diuretic doses. Average daily urine output before and after EB application was not different (2,642 pre-EB vs. 2,792 post-EB mL/day; 95% CI: -455 to 154; p = 0.33). Conclusion EB use enhances diuretic efficacy during ADHF. Further studies are needed to determine the potential clinical benefits and risks of applying EB compression treatment in ADHF.

Précis: In this randomized multicenter trial, both TRAB and CPC lowered IOP at 12 months as primary glaucoma surgeries, with TRAB yielding lower final IOP with fewer medications, while both procedures demonstrated meaningful clinical effectiveness. Purpose: To compare the efficacy and safety of trabeculectomy (TRAB) and slow-burn transscleral cyclophotocoagulation (CPC) as primary surgical treatments for glaucoma. Methods: Prospective, randomized, multicenter trial including one eye per patient from July 2020 to July 2023, with 12-month follow-up. Participants were allocated to TRAB (GI) or CPC (GII). The primary endpoint was surgical success at 12 months, defined by intraocular pressure (IOP) between 6 and 18 mm Hg without non-protocol glaucoma surgery or serious complications. Results: Eighty-six eyes were included; nine were excluded (four in GI; five in GII). Baseline demographics were similar between groups. Both significantly reduced IOP at 12 months (GI: 22.97±8.23 mm Hg to 10.14±2.89 mm Hg; GII: 23.47±6.34 mm Hg to 14.58±3.66 mm Hg; P <0.001 for both). Medication use decreased significantly in both groups, with a lower mean number of medications per year in GI ( P <0.001). An IOP of 6–14 mm Hg was achieved in 91.4% of GI and 39.4% of GII ( P =0.007). Final IOP between 6 and 18 mm Hg was reached by 97.1% of GI and 90.9% of GII ( P =0.708). Qualified success rates were high and comparable (GI: 97.4%; GII: 86.8%; P =0.08), while complications were infrequent (four in GI; one in GII; P =0.3). Quality of life improved after TRAB (EQ-5D: 0.71±0.19 to 0.78±0.14; P =0.031) but remained unchanged after CPC ( P =0.424). Conclusions: Both procedures reduced IOP at 12 months as primary glaucoma surgeries. TRAB achieved lower final IOP, required fewer medications, and was associated with improved quality of life, whereas CPC required more adjunctive medication and retreatment in some eyes.

Abstract Objective Untreated obstructive sleep apnea (OSA) in the perioperative period confers significant cardiopulmonary risk. However, many otolaryngologists defer restarting positive airway pressure (PAP) therapy following functional endoscopic sinus surgery (FESS) due to perceived risk of epistaxis, mucosal injury, and wound healing. Thus, the objective of this study was to evaluate the immediate resumption of PAP therapy in OSA patients undergoing FESS. Study Design Multicenter prospective controlled study. Setting Academic medical centers. Methods Patients with a history of OSA on PAP therapy scheduled for FESS were prospectively enrolled (OSA/PAP group) along with a control group of non‐OSA FESS patients (non‐OSA group). Patients in the OSA/PAP group restarted PAP therapy on post‐operative Day #0 or #1. The primary outcome was change in Lund‐Kennedy endoscopic scores (LKES); secondary outcomes of interest included change in post‐operative SNOT‐22 scores, Pittsburgh Sleep Quality Index (PSQI) scores, complications, and epistaxis severity scores. Results A total of 100 patients were enrolled, of whom 49 were in the OSA/PAP group, and 51 were in the non‐OSA group. In multivariate adjusted models, early PAP resumption was not independently associated with higher LKES compared to the control group at POV1 or POV2, higher SNOT‐22 compared to the control group at POV1 or POV2, or higher postoperative epistaxis scores compared to the control group. There were no PAP‐related complications such as orbital emphysema or pneumocephalus. Conclusion Early resumption of PAP in OSA patients undergoing FESS does not appear to be associated with worsened post‐operative endoscopic scores, quality‐of‐life scores, or an increased risk of post‐operative epistaxis.

Background Caregiver burden assessments lack clinical uniformity in palliative care. Existing evidence-based interventions often impose resource demands that are prohibitive for smaller programs. Objectives (1) Demonstrate the practical utility of routine caregiver screening paired with an interdisciplinary team (IDT) response protocol. (2) Identify patient and caregiver factors influencing burden. Design Setting: Cross-sectional study in a US outpatient palliative care clinic. Measure ments: The 12-item Zarit Burden Interview (ZBI-12) was administered by a nurse or social worker. Scores guided immediate, point-of-care IDT interventions. Results Of 81 approached caregivers, 74 completed the ZBI-12 (72% female; median age 56). Burden was stratified into mild (n = 37), mild-moderate (n = 22), and high (n = 15) tiers, with median scores increasing significantly (6 vs 16 vs 28; P < 0.001). General counseling was consistent across tiers (∼54%). However, high-intensity supportive interventions rose significantly with burden severity: social work telephone follow-ups increased (0% vs 13.6% vs 33.3%; P < 0.001), support group referrals rose (2.7% vs 31.8% vs 46.7%; P < 0.001), and psychotherapy referrals increased (0% vs 4.5% vs 13.3%; P = 0.030). Multivariable linear regression showed lower patient Palliative Performance Scale (PPS) scores independently predicted higher caregiver burden. Each 10-point decrease in PPS correlated with a 2.4-point increase in total ZBI-12 score (β = −0.240; 95% CI, −0.433 to −0.048; P = 0.015). Conclusion This workflow provides a replicable roadmap to transition caregivers from “invisible patients” to actively supported extensions of the care unit, reinforcing dyadic assessments as standard practice in outpatient palliative medicine.

Introduction There is uncertainty about the number of shark bites on humans in Florida (FL). Methods The International Shark Attack File (ISAF) and Global Shark Attack File (GSAF) databases (2016–2024) were compared with the non-inpatient FL Ambulatory and Emergency Department Patient Data database (AHCA) (2018–2023) and the National Emergency Medical Services (EMS) Information System (NEMSIS) (2016–2024). Results Between 2016–2024 there were 244 FL shark encounters reported in ISAF (mean 27.1 per year), 214 in GSAF (mean 23.8 per year), and 293 in a merged ISAF and GSAF (mean 32.6 per year). Between 2020–2023, there were 373 FL shark encounters reported in AHCA (mean 62.2 per year) compared with 114 encounters reported in NEMSIS (mean 22.8 per year) for 2020–2024. The rate ratio for AHCA FL shark encounters compared to the merged ISAF and GSAF was 1.91 (95% CI 1.64–2.23); p < .001. The percentage of shark encounters in Volusia County, FL, compared with all of FL shark encounters showed no significant differences between the ISAF and GSAF (40.2% and 33.6%, respectively) ( p = .16) and between the AHCA and NEMSIS (7.2% and 7.5%, respectively) ( p = 1.0). However, when comparing either ISAF or GSAF with either AHCA or NEMSIS, there were significant differences ( p < .001 for all). Discussion The AHCA dataset identified about twice as many shark bites as either the ISAF or GSAF. Many FL shark encounters did not require EMS or admission to the hospital. The discrepancy in the number of shark encounters attributed to Volusia County, FL, varied based on the dataset being examined.

Abstract Objective In 2024, the US News and World Report (USNWR)'s Best Hospitals began reporting complications following elective outpatient otolaryngology procedures in its ears, nose, and throat (ENT) ranking. However, this methodology has not been clinically adjudicated in a peer‐reviewed domain. We aimed to conduct manual health record adjudication to assess whether the USNWR methodology accurately attributes complications following elective outpatient otolaryngology procedures. Study Design Case‐cohort. Setting A case‐cohort of n = 80 elective, outpatient otolaryngology procedure/complication pairings from January 2019 to October 2023 across four academic medical centers using the 2024 USNWR otolaryngology procedure subgroups and Solventum Ambulatory Potentially Preventable Complications (AM‐PPC) software. Methods We used the AM‐PPC‐defined complication types as our standard of comparison for our clinical adjudication. Using the electronic health record, we adjudicated: (1) Was there agreement (yes/no) on complication type between our clinical adjudication and the Solventum AM‐PPC software? (2) Was the complication clinically related to, or a sequela of, the index otolaryngology procedure (yes/no)? Results The clinical adjudication agreed on complication type in 59/80 (74%) of patients, and 63/80 (79%) were judged to be clinically related to the index otolaryngology procedure. In total, 50/80 (63%) complications were adjudicated to be in agreement on both the complication type and clinical relatedness to the index procedure, while 9/80 (11%) complications did not agree with the complication type nor were clinically related to the index procedure. Conclusion Outpatient complications reported in the USNWR ENT rating lack the specificity to exclude patients whose complications are sequelae of chronic underlying conditions or related to concurrent, non‐otolaryngology procedures.

ABSTRACT Objective Pituitary carcinoma (PC) is defined by the presence of metastasis from a pituitary tumour. PC is rare, therefore information regarding survival and factors influencing survival are limited. We sought to assess overall survival following the diagnosis of PC and to determine factors associated with outcome. Design Retrospective case series. Patients Patients with PC who attended the Mayo clinic between 1997 and 2025. Measurements Information regarding patient demographics, tumour characteristics, management and outcomes were extracted. Results In total 25 patients (11 women, 44%) were diagnosed with PC (median age 56 years, range, 44–78). The most common cell type was a corticotroph tumour ( n = 15, 60%). All but one patient had pituitary directed surgery and all received pituitary adenoma (PA) directed radiation therapy. Metastases were identified a median 6 years (range, 1–32) after initial PA diagnosis. At last follow‐up, 10 (40%) patients were alive, 12 (48%) died of PC, and 3 (12%) died from other causes. The median survival time of patients from PC diagnosis was 3 years. The 1‐, 5‐ and 10‐year survival rates were 59%, 37% and 15%, respectively. Increased survival probability was associated with temozolomide treatment ( n = 9) at some point in treatment plan ( p = 0.026), the use of systemic therapy vs locoregional treatment ( p = 0.045), female sex ( p = 0.011), and in nonfunctional tumours ( p = 0.023). Conclusion PC carries a poor prognosis, with a median survival of only 3 years. Improved survival was associated with temozolomide exposure, female sex, and nonfunctional tumour subtype and underscores the prognostic relevance of tumour biology and treatment approach.