Citations

Abstract Objectives/Background Our objectives were to characterize the geographic distribution and local availability of United Council for Neurologic Subspecialties‐certified headache specialists across US counties, hospital referral regions, and states, and to examine associations with socioeconomic deprivation, social vulnerability, and urbanicity. Headache disorders are highly prevalent and disabling, yet local availability of certified headache subspecialty care in the United States remains uneven. Although prior studies have described national and state‐level distributions of United Council for Neurologic Subspecialties‐certified headache specialists, important gaps remain in understanding county‐level availability and disparities in access. Prior state‐level summaries may mask within‐state differences in access to United Council for Neurologic Subspecialties‐certified headache specialists. Methods We conducted a cross‐sectional geospatial workforce analysis of United Council for Neurologic Subspecialties‐certified headache specialists in the United States as of January 7, 2026. Practice locations were mapped to counties, hospital referral regions, and states, and compared with general neurologist supply from the National Provider Identifier registry. Estimated population need was calculated by applying a national migraine prevalence to adult population denominators. We examined associations between specialist distribution and county‐level socioeconomic vulnerability, urbanicity, and region. Results Among 3144 US counties, 2870 (91.3%) had no United Council for Neurologic Subspecialties‐certified headache specialists, and 2085 (66.3%) had no neurologists. Headache specialists were entirely absent from counties without neurologists. Median county‐level headache specialist density was 0 per 100,000 adults, reflecting the absence of local subspecialty care in most US counties. Accounting for county adult population, neurologist density, urbanicity, and region, higher Area Deprivation Index and Social Vulnerability Index scores were associated with lower headache specialist rates. Each 10‐point increase in Area Deprivation Index was associated with lower expected headache specialist rate (adjusted incidence rate ratio = 0.87, 95% confidence interval = 0.82–0.93), and each 0.1‐unit increase in Social Vulnerability Index was also associated with lower expected rate (adjusted incidence rate ratio = 0.94, 95% confidence interval = 0.90–0.98). Headache specialist availability relative to estimated population need varied markedly across counties, with substantial estimated local differences between migraine burden and certified subspecialty supply that were not apparent in state‐level summaries. Conclusion United Council for Neurologic Subspecialties‐certified headache specialists are unevenly distributed across the United States, with limited local availability of certified headache subspecialty care in socioeconomically disadvantaged and nonmetropolitan counties. County‐level analyses identified substantial local gaps in certified headache subspecialty availability that were not apparent in state‐level summaries.

Abstract Background Single-stage management of choledocholithiasis with intraoperative cholangiography (IOC) and concomitant common bile duct exploration (CBDE) is supported by reduced length of stay, fewer anesthetic events, and high stone-clearance rates. However, broad adoption is limited by surgeon experience and the technical demands of transcystic exploration. The fourth-generation da Vinci 5 (DV5) surgical platform (Intuitive Surgical, Sunnyvale, CA) integrates a native Telepresence module that enables a remote expert to view the operative field and the surgeon console feed in real time and to communicate with the operating surgeon through bidirectional audio and video. We describe what we believe to be the first reported use of DV5 Telepresence to assist intraoperative decision-making and execution during robotic CBDE for choledocholithiasis discovered on IOC. Methods A surgeon with early experience in common bile duct exploration while performing a robotic cholecystectomy with routine fluoroscopic IOC encountered a filling defect at the distal common bile duct consistent with an obstructing stone. A DV5 Telepresence session was activated, connecting an experienced surgeon in common bile duct exploration. The picture-in-picture (PiP) feature on the surgeon console displayed the intraoperative view and the live fluoroscopic image simultaneously, allowing both surgeons to review the cholangiogram in real time. Verbal-only guidance was provided through bidirectional audio while the operating surgeon performed transcystic flushing, balloon sweep, and sphincteroplasty. Results Total Telepresence connection time was 19 minutes. Complete duct clearance was achieved during the index operation, confirmed by completion cholangiogram. The patient was discharged from the post-anesthesia care unit with no complications. The PiP feature was identified as the technical enabler that allowed simultaneous interpretation of the cholangiogram and operative anatomy without exiting the console or duplicating monitors. Conclusions Native robotic Telepresence on the DV5 is feasible, safe, and clinically useful for time-sensitive intraoperative consultation during CBDE. By collapsing the latency between identification of choledocholithiasis and expert-guided definitive management, this approach may broaden access to single-stage biliary clearance for surgeons earlier in their learning curve and warrants prospective evaluation. This feature may allow for surgical advice/mentoring in a variety of settings/cases.

ABSTRACT Endoluminal flow diverters are increasingly used to treat cerebral aneurysms. Despite good aneurysm occlusion efficacy, delayed ischemic complications due to side branch or perforator occlusion remain a serious concern. However, the mechanisms leading to side branch occlusion are poorly understood. To investigate these mechanisms, a combination of animal and computational models was utilized. Flow diverters were deployed in four rabbit superior mesenteric artery (SMA) and studied with computational fluid dynamics (CFD) and a previously developed fibrin dynamics model. Subject‐specific vascular models were reconstructed from 3D rotational angiography images and flow conditions were derived from Doppler ultrasound velocity measurements. Flow diverting devices were virtually deployed within the vascular models under guidance from angiography images. Coupled flow and fibrin production, transport, and adhesion simulations were carried out and the effects of fibrin accumulation at the origin of jailed side branches after flow diverter implantation were analyzed. The results of the computational models suggest significant fibrin accumulation across the struts of all flow diverting devices jailing side branches. Larger accumulation was observed at the more distal branches. However, minor flow alterations were produced which were not detectable in angiography sequences. These results were in agreement with experimental observations. On the other hand, fibrin accumulation alone did not explain complete side branch occlusions, which are likely the result of the interaction between initial fibrin accumulation and subsequent cell migration from the peripheral parent artery.

Abstract INTRODUCTION Plasma p‐tau217 and p‐tau217/Aβ42 reliably identify non‐Hispanic White individuals with symptomatic and pre‐clinical AD. However, performance across ethnoracially diverse groups remains unknown. METHODS Cognitively normal Black, Hispanic, and non‐Hispanic White participants completed cognitive evaluations, brain magnetic resonance imaging (MRI), amyloid and tau positron emission tomography (PET), and measures of kidney function. Plasma p‐tau217 and Aβ42 were measured using Fujirebio Lumipulse assays. Pre‐clinical AD detection was evaluated using symptomatic and cohort‐derived optimized cutoffs. RESULTS Among 191 participants (57 Black, 46 Hispanic White, 88 non‐Hispanic White), age‐adjusted plasma p‐tau217 and p‐tau217/Aβ42 performed similarly in detecting amyloid‐positive individuals (≥ 25 Centiloids), regardless of race/ethnicity. Both measures independently correlated with amyloid deposition, whereas estimated glomerular filtration rate (eGFR) correlated solely with p‐tau217. Pre‐clinical AD optimized cutoffs (p‐tau217 ≥ 0.132 pg/ml; p‐tau217/Aβ42 ≥ 0.0059) outperformed cutoffs established in symptomatic individuals (sensitivity: 83% vs. 57%; 77% vs. 63%; negative predictive value [NPV] > 93%). DISCUSSION Plasma biomarkers performed similarly across ethnoracially diverse cohorts. Optimized cutoffs may improve early detection and trial enrollment.

ABSTRACT We report the case of a 38‐year‐old recreational female runner with anterior and lateral chronic exertional compartment syndrome treated with ultrasound‐guided fasciotomy using a V‐shaped meniscotome. She began her return‐to‐run protocol 8 days postprocedure and achieved full symptom resolution. At 6 months, ultrasound revealed persistent fascial separation without complications, representing the first report of long‐term sonographic outcomes following fasciotomy for chronic exertional compartment syndrome. These findings support further prospective studies to evaluate the clinical and sonographic outcomes of this technique.

Background: Increased posterior tibial slope (PTS) has been associated with higher revision rates after anterior cruciate ligament reconstruction (ACLR). Whether the addition of lateral extra-articular tenodesis (LET) mitigates the risk associated with increased PTS is unclear. Purpose: To determine the prevalence of increased PTS (≥12°) in a young high-risk primary ACLR population and evaluate whether LET is associated with lower revision rates in patients with increased PTS. Study Design: Cohort study; Level of evidence, 3. Methods: This study included patients aged ≤25 years undergoing primary ACLR across 3 high-volume centers with ≥2 years between surgery and data collection. PTS was measured on lateral radiographs for medial and lateral plateaus. Primary analyses consisted of 4 prespecified multivariable logistic regression models with different PTS operationalizations as continuous predictors per 1° increase (medial PTS, lateral PTS, the maximum [PTSmax], and the lateral-medial difference), adjusted for patient and surgical covariates including graft type, with surgical center as a fixed effect. Secondary analyses used PTS dichotomized at 12°; revision rates were compared between isolated ACLR and ACLR with LET, with the treatment effect quantified as absolute risk reduction and number needed to treat. Results: A total of 780 patients were included; 84 (10.8%) underwent revision ACLR. Increased PTS (≥12°) was present in 28.2% of patients and more common in those requiring revision (38.6% vs 27.0%; P = .03). In patients with PTSmax ≥12°, revision occurred in 21.0% without LET and 9.2% with LET (absolute risk reduction, 11.8% [95% CI, 2.3%-21.3%]; number needed to treat, 9); in patients with PTSmax <12°, revision occurred in 13.2% without LET and 5.4% with LET (absolute risk reduction, 7.8% [95% CI, 3.0%-12.6%]; number needed to treat, 13). In the 4 prespecified multivariable models with PTS as a continuous predictor, LET was independently associated with substantially lower odds of revision ACLR (odds ratio [OR], 0.37; 95% CI, 0.22-0.62; P < .001). Lateral PTS (OR, 1.09 per 1° increase; 95% CI, 1.00-1.18; P = .04) and PTSmax (OR, 1.09; 95% CI, 1.00-1.19; P = .04) were independently associated with revision ACLR. The lateral-medial PTS difference was not associated with revision ACLR. Conclusion: In a young high-risk primary ACLR population, increased PTS was present in nearly 30% of patients. LET was associated with a lower risk of revision irrespective of PTS, while increased PTS was independently associated with revision ACLR.

Obesity is common among critically ill adults, but its association with outcomes during venovenous extracorporeal membrane oxygenation (VV ECMO) remains controversial. We evaluated associations of body mass index (BMI) with mortality and Extracorporeal Life Support Organization (ELSO)–defined complications in adults supported with VV ECMO. We conducted a retrospective multicenter cohort study of adults receiving VV ECMO at four centers (2017–2025). The primary outcome was in-hospital mortality; secondary outcomes were ELSO-defined complications. Multivariable logistic regression was adjusted for age, sex, and hospital site; BMI was evaluated as continuous, dichotomized (≥30 vs . <30 kg/m 2 ), and World Health Organization (WHO) obesity class exposures, with interaction testing by coronavirus disease 2019 (COVID-19) status. Among 420 patients (median BMI, 31 kg/m 2 ), in-hospital mortality was 62%. Higher BMI was associated with mortality in non–COVID-19 acute respiratory distress syndrome (ARDS; odds ratio [OR] = 1.06 per 1 kg/m 2 , 95% confidence interval [CI] = 1.02–1.10, p = 0.003) but not in COVID-19 ARDS (OR = 1.00, 95% CI = 0.94–1.05); there was insufficient evidence of interaction between BMI and COVID-19 ( p = 0.07). Higher BMI was associated with renal complications in both groups and infectious complications in non–COVID-19 ARDS (OR = 1.05, 95% CI = 1.02–1.09, p = 0.003). No significant BMI × COVID-19 interaction was detected for any outcomes. These findings do not support an obesity survival paradox during VV ECMO.