Citations

Objectives: There are few studies that have closely evaluated the outcomes of ulnar collateral ligament repair and reconstruction (UCLR) in position players (PP). The objective of this study was to determine the outcome of UCLR in professional baseball players who play in non-pitcher positions, i.e. PP. Methods: The approval of the Major League Baseball (MLB) Research Committee was obtained. All PP who underwent surgery for their UCL while active on an MLB or Minor League Baseball (MiLB) team were identified using The MLB Health and Injury Tracking System. PP who underwent UCLR from 2010 to 2023 were analyzes, however for data that concerned PP time to return to professional play, only players who underwent UCL surgery from 2010 to 2021 were evaluated in order to ensure the presence of a minimum of 2-year follow-up data. Return to play (RTP) was defined as a player who played in at least 1 game at any professional level (A, AA, AAA, or MLB). Players were deemed to return to the same level of play (RTSLP) if they played in at least 1 game at the same competition level or higher that they played in prior to their UCL surgery. PP who had a time to RTP or a time to RTSLP that exceeded 800 days were excluded from any analysis that concerned the time to return to play. PPs were also compared to a cohort of professional baseball pitchers who had also undergone UCL surgery. Results: From 2010 to 2023, 241 PP underwent surgery for their UCL at a mean age of 23.4 ± 4.3 years old (Table 1). Overall, PP had their UCL surgery at approximately a mean of 3.7 ± 3.3 years after the start of their professional career (Table 1). Further, apart from the year 2020, the annual number of UCL surgeries performed in MLB and MiLB PP demonstrated an upward trend from 2010 to 2023, although no trends in the distribution of UCL surgeries across position type or between major and minor players exist. No statistically significant differences in RTP nor RTSLP rates following UCL surgery in PP existed when comparing across position type (catcher vs. infielder vs. outfielder) and across surgery type (repair vs. reconstruction vs. reconstruction with augmentation) (Table 2). PP who underwent repairs were able to RTP at a median of 221 days (IQR: 81), which was sooner than PP who underwent reconstruction surgery (median: 383 days, IQR: 316) or reconstructions with augmentation (median: 456 days, IQR: 219) (P = 0.002) (Table 3). PP with UCL repairs were also able to RTSLP sooner (median: 234 days, IQR: 64) than PP who underwent reconstructions (median: 394 days, IQR: 305) or reconstructions with augmentation (median: 462 days, IQR: 242) ( P = 0.003) (Table 3). Further, infielders RTP sooner (median: 335 days, IQR: 157) than catchers (median: 396 days, IQR: 283) and outfielders (median: 412 days, IQR: 366) ( P = 0.036) (Table 3). Similarly, infielders RTSLP sooner (median: 334 days, IQR: 162) than catchers (median: 470 days, IQR: 281) and outfielders (median: 426 days, IQR: 354) ( P = 0.016) (Table 3). Following UCL surgery, PP were able to RTSLP, on average, more than 2 months sooner than pitchers (429 ± 177 days for PP vs 499 ± 153 days for pitchers, P < 0.001). PP who underwent repair of their UCL were able to RTSLP over 4.5 months, on average, sooner than pitchers who underwent UCL repair (269 ± 125 days for PPs vs 405 ± 153 days for pitchers, P < 0.001) and PP who underwent reconstruction of their UCL were able to RTSLP just under 50 days sooner than pitchers who had their UCLs reconstructed (450 ± 175 days for PPs vs 498 ± 151 days for pitchers, P < 0.001) (Figure 1). Conclusions: Few studies have examined PP outcome data following UCLR surgery. As such, there is little understanding as to the differences in return to game rates between various baseball non-pitcher positions as well as the differences in the time it takes to RTP and RTSLP. This study highlights that the annual number of UCLR surgeries demonstrates an upward trend. This retrospective analysis also highlights that PP with UCL repairs were able to RTP and RTSLP sooner than PP who underwent UCL reconstructions and UCL reconstructions with augmentation. Furthermore, infielders were able to RTP and RTSLP sooner than catchers as well as outfielders. The results of this study demonstrate that the type of UCL surgery as well as the player’s position does not seem to significantly impact whether or not a player actually returns to playing professional baseball, however it does impact the speed at whichthey are able to return (provided they do return to playing baseball). As such, the results of this study may be used to counsel PP regarding speed at which a return to playing baseball can be expected.

Objectives: The medial ulnar collateral ligament (MUCL) is the primary stabilizer of valgus forces across the elbow. Injury to the MUCL has a large impact on the throwing athlete, particularly in baseball. The incidence of MUCL injury in baseball pitchers is on the rise. Surgical treatment and rehabilitation is evolving to improve outcomes and improve return to sport time frames. The purpose of this study was to highlight the trends in MUCL repair and reconstruction in professional baseball pitchers, describe relevant outcomes such as return to any level of play (RTP) for surgical repair and reconstruction, and distinguish what factors might impact these outcomes. The authors hypothesize that primary and revision MUCL surgery is increasing with revision surgery requiring the greatest time to RTP. Methods: The Major League Baseball (MLB) Health and Injury Tracking System (MLB HITS) database was used to procure data during the targeted study period (2010 – 2023). All professional pitchers who underwent MUCL surgery within the study period were included. Variables analyzed included age, career length, and level of play. Surgical variables included date and type of procedure, RTP status, time required to RTP, return to same level of play (RTSL), career length before and after surgery, number of revision surgeries, and time between surgeries. Successful RTP was designated if a pitcher had returned in at least one professional game after index surgery. Analyses of trends over time were performed. The year 2020 was considered an outlier and omitted from the analysis of trends due to the coronavirus pandemic which limited games played. Results: A total of 2,287 pitchers underwent MUCL surgery during the study period (Table 1). The annual number of MUCL surgeries on all pitchers increased year over year (R 2 = 0.821, p < 0.001), as did the annual number of reconstructions with internal brace (IB) augmentation (R 2 = 0.896, p < 0.001) (Figure 1). The RTP rate (93%) for MLB pitchers was significantly higher compared to the RTSL rate (71%, P < 0.001). This difference was not observed in Minor League Baseball (MiLB) (RTP 76% vs. RTSL 74%, P = 0.142) (Figure 2). The percentage of players who RTP after revision surgery was significantly lower compared to primary surgery (71%vs. 80% respectively, P = 0.020). Mean time to RTP is significantly shorter (470 ± 135 days) compared to the mean time to RTSL (499 ± 153 days, P < 0.001) (Figure 3). The annual number of revision MUCL surgeries on all pitchers increased year over year as well (R 2 = 0.322, p = 0.043). Conclusions: MUCL surgery continues to increase, also leading to increasing numbers of revisions in professional pitchers. Overall, 80% of pitchers were able to RTP at a mean of 470 days (15.5 months), while only 71% were able to RTSL at a mean of 499 days (16.5 months), but this varied based on level of play. Surgical techniques continue to evolve as MUCL repairs and reconstructions with IB augmentation have increased significantly in recent years. This study will help guide athlete expectations and surgeon decision-making.

Abstract Background Delirium is often underdiagnosed in clinical practice and is not routinely coded for billing. While manual chart review can identify delirium, it is labor-intensive and impractical for large-scale studies. Natural language processing (NLP) can analyze unstructured text in electronic health records (EHRs) to extract meaningful clinical information. Methods To support national integration of NLP for EHR-based delirium identification across different institutions, we launched the Delirium Interest Group within the national Evolve to Next-Gen Accrual to Clinical Trials (ENACT) NLP Working Group. This paper outlines our initial efforts to standardize, evaluate, and translate an NLP-based delirium detection model into the i2b2/ENACT platform. Results Multisite contextual inquiry identified several key challenges, including variations in local screening practices (eg, tools used, documentation frequency, and quality control), the need for harmonized definitions in the context of EHRs, and the complexity of modeling temporal logic. Multisite NLP evaluation revealed variable performance degradation driven by differences in delirium screening practices, clinical documentation patterns and semantics, and note syntactic structures. Conclusion Our work represents an important first step toward enabling scalable and standardized NLP-based delirium detection across institutions. By engaging diverse institutions through the ENACT NLP Working Group, we identified shared challenges and site-specific variations that impact model implementation and performance. Our collaborative approach enabled the development of a more robust framework for delirium identification across heterogeneous EHR systems. Future efforts will build on this foundation to enhance the validity, usability, and translational impact of delirium detection.

ABSTRACT Objectives To characterize practice patterns and outcomes in the management of low‐ and intermediate‐grade salivary gland carcinoma prior to the existence of treatment guidelines. Methods Analysis of a registry of patients who underwent parotid and submandibular gland resections for low‐and intermediate‐grade carcinomas between 2010 and 2019. Results Of all 786 patients included in the study, 726 (92%) had preoperative imaging and 653 (83%) had preoperative biopsy. Of the 729 patients with parotid gland cancer, the majority underwent superficial ( n = 384, 53%) or total ( n = 254, 35%) parotidectomy. In patients with facial nerve preservation, total parotidectomy was associated with a significant increase in transient facial weakness (72/177 (41%) vs. 82/311 (26%), RR 0.65, 95% CI 0.50–0.84, p < 0.05) and permanent facial nerve weakness (23/176 (13%) vs. 16/301 (5%), RR 0.41, 95% CI 0.22–0.75, p < 0.05) compared to superficial parotidectomy. Adjuvant radiation therapy ( RT ) was delivered to 285 (36%) patients. The proportion of patients receiving adjuvant RT declined significantly over the time period from 2015 to 2019 compared to 2010 to 2014 at 162/504 (32%) and 123/282 (44%), respectively ( RR 0.74, 95% CI 0.61–0.89, p < 0.05). When comparing the time periods from 2015 to 2019 and 2010 to 2014, there was no significant difference in local control rates ( RR 0.52, 95% CI 0.26–1.04, p = 0.06) or regional control rates ( RR 0.75, 95% CI 0.26–2.13, p = 0.58). Conclusions Management of low‐ and intermediate‐grade salivary cancer from 2010 to 2019 was variable, which is expected given the rarity and heterogeneity of the disease and the lack of treatment guidelines prior to 2021. Most patients with parotid malignancies underwent superficial or total parotidectomy. The extent of parotidectomy had an impact on facial nerve function outcomes. Delivery of adjuvant radiation trended down with time. The data presented here will support dissemination of the guidelines and provide data that could inform future trials. Level of Evidence 2b.

Background: The COVID-19 pandemic brought profound changes to health care systems worldwide. This study examines the adaptive responses of a sleep medicine practice that successfully pivoted to telemedicine, remote diagnostics, and agile operations, resulting in sustained growth and improved patient accessibility. Methods: We analyzed organizational and cultural elements enabling responsiveness, including telemedicine infrastructure, adaptive leadership, quality-focused processes, and effective communication. Objective outcomes were assessed by analyzing patient demographics, telemedicine visits, and sleep testing patterns during three phases: pre-pandemic (June 1, 2018 to March 8, 2020), acute COVID-19 (March 9, 2020 to April 19, 2020), and post-acute COVID-19 (April 20, 2020 to December 31, 2021). Results: Across 105,199 encounters, monthly sleep medicine visits and testing declined ∼50% during acute COVID-19, but rebounded to surpass baseline in the post-acute phase. Virtual visits increased significantly, replacing many face-to-face encounters. Home sleep apnea test use rose sharply, driven by disposable WatchPAT tests, while polysomnography use decreased. Testing volumes increased overall post-acute compared with pre-pandemic. Patients served during acute and post-acute phases were younger, more often female, non-White, and postgraduate-educated (all p < 0.001). Nonlocal patients increased during the post-acute phase, reflecting telemedicine expansion. Conclusions: Proactive telemedicine investments, adaptive leadership, quality-focused processes, and effective communication enabled this practice to adapt successfully during the pandemic. These resilience strategies provide a model for navigating future health care challenges, underscoring telemedicine and e-health’s critical roles in maintaining care delivery during crises.

Abstract Small cell carcinoma of the ovary, hypercalcemic type (SCCOHT) is a rare, deadly form of ovarian cancer that uniformly harbors mutations in SMARCA4, a member of the SWI/SNF chromatin remodeling complex. SWI/SNF impacts RNA splicing, and dysregulation of splicing can generate immunogenic tumor antigens. Here, we explored the relationship between SMARCA4 loss and RNA splicing dysregulation. SCCOHT primary tumors harbored tumor-associated outlier splicing events compared to normal tissues. Many of the tumor events were retained introns encoding novel peptides predicted to bind to MHC-I complexes. Immune cells were observed in primary SCCOHT tumors, suggesting a potentially immune reactive tumor microenvironment. Mutations in several SWI/SNF subunits were associated with higher rates of outlier retained introns across tumor types in TCGA data. Interestingly, RNA sequencing of isogenic SCCOHT cell lines demonstrated a role for SMARCA4 in intron retention. Distinct protein-protein interactions between splicing factors identified in SCCOHT cell lines supported a role for SMARCA4 in splicing regulation. Further, SWI/SNF localized to genes which were differentially spliced. Mass spectrometry analyses confirmed expression of some of these novel peptides and a subset of these are predicted to bind to MHC-I complexes. A pool of these novel peptides derived from retained introns in SCCOHT triggered proliferation and expression of TNFa and INFb in primary human T cells. Together, these data suggest that SMARCA4 loss in SCCOHT leads to intron retention. Furthermore, T cell activation by novel peptides encoded by these tumor-specific splicing events suggests intron retention could be a source of tumor-associated antigens in SCCOHT. Citation Format: Elizabeth Raupach, Apurva Hegde, Krystine Garcia-Masnfield, Marice Alcantara, David Rose, Rebecca Halperin, Krystal Orlando, Jessica Lang, Ritin Sharma, Victoria David-Dirgo, Salvatore Facista, Rayvon Moore, Rochelle Kofman, Zoe Jensen, Victoria Zismann, Anthony Karnezis, Yemin Wang, Lynda Bennett, Timothy Whitsett, Marcin Kortylewski, William Hendricks, David Huntsman, Lorna Rodriguez-Rodriguez, Bernard Weissman, Jeffrey Trent, Patrick Pirrotte. Loss of SMARCA4 leads to intron retention and generation of tumor-associated antigens in small cell carcinoma of the ovary, hypercalcemic type [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Advances in Ovarian Cancer Research; 2025 Sep 19-21; Denver, CO. Philadelphia (PA): AACR; Cancer Res 2025;85(18_Suppl):Abstract nr B065.

Abstract Background The past two decades have witnessed tremendous growth in the appreciation and treatment of sacroiliac joint (SIJ) complex pain, including anatomical dissections that shed light on innervation, an appreciation for the contribution of extra-articular components to SIJ complex pain, the advent of radiofrequency ablation (RFA) and a host of minimally invasive surgical techniques. Yet, there is no standardization on diagnosis and treatment paradigms. Methods In February 2023, the Boards of Directors for the American Academy of Pain Medicine (AAPM) and American Society of Regional Anesthesia & Pain Medicine (ASRA-PM) approved the development of multispecialty guidelines on SIJ complex pain. Thirty partner organizations with clinical and scientific interests in SIJ complex pain were identified, and formal letters of request-for-participation were sent to each, along with a request for nominees to serve on the committee. Twenty five organizations agreed to participate in addition to the Departments of Defense and Veterans Affairs. A steering committee developed 21 questions, which spanned criteria for diagnosis, non-interventional and interventional treatments including surgery, technical parameters on how to optimize results, and what constitutes positive outcomes. Questions were methodically assigned to specialized modules comprising 4-5 members with complementary expertise, who collaborated with the Subcommittee Lead and one of three Committee Chairs to develop preliminary drafts. Following thorough revisions, these drafts were subsequently submitted to the full committee for comprehensive review. A modified Delphi method was used in which the answers to questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was achieved. During a committee meeting before commencement, it was agreed that recommendations would be noted when there was &gt;50% agreement among committee members, but that a formal recommendation would require ≥75% consensus. Results Twenty-one organizations formally endorsed the guidelines. The American Society of Anesthesiologists, and American Academy of Physical Medicine & Rehabilitation, and the North American Spine Society affirmed the benefit of the guidelines but did not officially endorse them. The American Academy of Neurology declined to affirm the benefit of the guidelines citing “lack of relevance to their membership.” Per policies, while the Departments of Defense and Veterans Affairs did not formally review the guidelines for endorsement, their representatives approved them. In addition to being endorsed or the benefit affirmed by all voting organizations, complete consensus from committee members was obtained on all 21 questions. On 2 recommendations, there were dissensions from 3 societies who thought that selecting patients for sacral lateral branch RFA and minimally invasive fusion should be based on ≥75% relief from 2 blocks instead of at least 50% relief from a single block before RFA, and greater than 50% pain relief with documented functional improvement after a single block before fusion. One additional society (Latin American Society of Regional Anesthesia) abstained on the statement that the evidence is stronger for extra-articular than intra-articular injections. The committee found that a battery of physical exam tests has reasonable sensitivity, but lower specificity, for identifying intra-articular but not extra-articular pathology, with negative tests having greater predictive value than positive ones. Intra-articular injections have diagnostic validity for SIJ intra-articular, but not extra-articular pain. There is unclear or negative evidence for imaging. The prevalence rates of intra-articular and extra-articular pathology are comparable, with both intra- and extra-articular steroid injections providing at least 4 weeks of relief in well-selected patients. However, the evidence is slightly stronger for extra-articular corticosteroid injections to provide short-term relief. The evidence base for non-interventional therapies is indirect, extrapolated mostly from low back pain studies. There is weak evidence supporting dextrose-based prolotherapy and platelet-rich plasma to provide at least 3 months of pain relief. There is strong evidence for sacral lateral branch RFA to provide relief for at least 6 months in individuals with extra-articular pathology, with face validity and indirect evidence from randomized trials supporting sacral lateral branch blocks as a prognostic tool. There is stronger evidence for larger lesions or more aggressive lesioning strategies than for less stringent techniques. There is weak evidence to support non-steroidal anti-inflammatory drugs to prevent neuritis after RFA, and in most cases anticoagulation does not require cessation in the periprocedural perioid. With an aggressive lesioning strategy, sensory stimulation provides minimal therapeutic benefit, with weak, extrapolated evidence that motor stimulation can provide safety benefit. The cutoff to designate diagnostic or prognostic blocks as positive is most commonly set at 50%, with higher values not shown to improve outcomes for more definitive procedures; for therapeutic treatment outcomes, the evidence supports a lower threshold of ≥30% pain relief or meaningful benefit on non-pain outcomes (eg, opioid cessation) for designation of a positive response. For carefully selected patients with intra-articular SIJ complex pain based on controlled blocks who have failed conservative therapies, there is weak or very weak evidence that minimally invasive SIJ fusion can provide benefit for at least one year. Conclusions SIJ complex pain remains an underappreciated source of chronic low back pain, affecting between 15% and 30% of patients with axial pain predominantly below L5. Answers to many questions were limited by low-quality evidence, indicating the need for better research. SIJ complex pain is a multifarious condition (ie, pain can be from different portions of both the intra- and extra-articular components of the joint) for which an interdisciplinary, multimodal treatment plan can optimize treatment outcomes.

Abstract Radiological protocol selection is a critical but time-consuming step in clinical workflow, requiring radiologists to match patient indications with the appropriate MRI or CT protocol. Manual selection can be prone to delays or potential errors, and automated approaches must contend with substantial data imbalance, site-specific variation, and evolving nomenclature. We investigated whether a large language model (LLM) can support reliable protocol selection at scale and whether retrieval-augmented generation (RAG) offers operational advantages over direct fine-tuning. Using 498,228 patient reports collected across three Mayo Clinic sites (Arizona, Florida, and Rochester) spanning six radiological divisions, we trained site-specific Llama 3.2 3B models for use with and without retrieval augmentation. Division-scoped Facebook AI Similarity Search (FAISS) indexes constructed from procedure and diagnosis text were used to supply contextual evidence in the RAG framework. Both fine-tuned and RAG-augmented models achieved strong performance across sites, with F1 scores of 0.88–0.90. RAG matched or modestly trailed direct fine-tuning overall but delivered consistent gains in specific divisions (e.g., musculoskeletal imaging). Importantly, the RAG model introduced abstention behavior (Not Enough Information), which concentrated in linguistically diverse divisions and provided an interpretable signal of uncertainty. These findings suggest that RAG-based models are viable for division-scoped protocol selection and offer practical advantages. Retrieval indexes can be refreshed far more easily and with fewer resources than retraining LLMs, enabling continual adaptation to evolving clinical workflows. Future prospective deployment will evaluate real-time accuracy, agreement with practitioners, and the role of abstention as a safety mechanism in clinical decision support.

This study evaluated the efficacy of the multiple sclerosis disease-modifying therapies, intramuscular interferon beta-1a (Avonex) and subcutaneous peginterferon beta-1a (Plegridy), using data from the United States Network of Pediatric Multiple Sclerosis Centers. In this retrospective analysis, 154 patients with multiple sclerosis were included who were treated with Avonex (n = 130), Plegridy (n = 23), or both treatments (n = 1) before the age of 18 years. After 3 months’ sustained use acclimation (“wash-in”), the probability of being relapse-free during the first year was 68.3% for Avonex-treated patients and 69.9% for Plegridy-treated patients; annualized relapse rates were 0.50 and 0.59, respectively. Both disease-modifying therapies demonstrated efficacy similar to that reported in adult populations. Despite the lack of formal approval for pediatric multiple sclerosis, these outcomes indicate that patients may benefit from treatment with Avonex or Plegridy. Understanding efficacy of specific disease-modifying therapies in pediatric multiple sclerosis is essential to making informed treatment decisions.