Citations

Health care–related out‐of‐pocket and indirect costs may create financial barriers to initial and/or continued receipt of care among patients with cancer, and subsequent financial toxicity is associated with worse oncologic and quality of life outcomes. Recognition and mitigation of risk factors for financial toxicity are essential to the provision of equitable, high‐quality care.

BACKGROUND: Accurate assessment of left ventricular outflow tract (LVOT) gradients is critical for hypertrophic cardiomyopathy management, yet Doppler-based measurements are technically demanding and require expertise. The objective of this work was to develop a multi-view deep learning model capable of classifying LVOT obstruction (>20 mm Hg) using routine 2-dimensional echocardiographic windows without reliance on Doppler imaging. METHODS: We trained and externally validated a cross-attention-based video-to-video fusion framework that integrated EchoPrime-derived video representations from 3 standard transthoracic echocardiographic views to classify LVOT gradients. RESULTS: Training was performed on a derivation cohort (N=1833) from a tertiary care system in the United States, with model performance evaluated on an internally held-out test set (N=275) and a Korean external validation cohort (N=46). Single-view baselines showed limited discrimination (external area under the receiver operating curves, 0.47–0.70). Conversely, the domain-specific foundational model (EchoPrime) achieved superior single-view performance (area under the receiver operating curves, 0.75–0.80 internal; 0.79–0.83 external), highlighting the importance of echo-specific pretraining and temporal modeling. The proposed multi-view fusion further enhanced predictive performance, with the late fusion model reaching an area under the receiver operating curve of 0.84 on the external cohort with significant population-shift. CONCLUSIONS: These results suggest LVOT physiology is encoded in routine 2-dimensional imaging and can be leveraged for clinically relevant gradient classification without Doppler input. The proposed artificial intelligence-guided strategy demonstrates substantial cost savings compared with the screen-all approach. By integrating complementary spatial-temporal information across multiple views, our approach generalizes robustly across populations and may enable real-time decision support, extend LVOT assessment to portable or resource-limited settings, and complement Doppler-based evaluation for longitudinal hypertrophic cardiomyopathy management.

ABSTRACT Background and Objectives Pancreatic neuroendocrine tumors (pNETs) account for 1%–2% of pancreatic tumors, with an increasing incidence. The safety of concurrent pancreas‐liver resections remains uncertain. This study evaluated the national outcomes of concurrent pancreatectomy and liver‐directed surgery for pNETs. Methods ACS‐NSQIP (2019–2023) was queried for adult patients who underwent pancreatectomy for pNETs. Concurrent liver‐directed procedures were identified by CPT code and classified as hepatectomy or ablation alone; patients were grouped as isolated pancreatectomy, concurrent hepatectomy, or concurrent ablation alone. Pre‐, intra‐, and postoperative characteristics were compared using inferential statistics. Multivariable logistic regression identified predictors of 30‐day morbidity, readmission, reoperation, and mortality, with Firth penalized likelihood used for rare outcomes. Results Of 4794 patients, 4587 (95.7%) underwent isolated pancreatectomy, 172 (3.6%) underwent concurrent hepatectomy, and 35 (0.7%) underwent concurrent ablation alone. Concurrent hepatectomy was parenchymal‐sparing in 163 of 172 patients (94.8%); only nine patients underwent a major hepatectomy. Overall morbidity was similar across groups (38.8%, 45.9%, and 42.9%; p = 0.154), as was serious morbidity (28.7%, 27.9%, 22.9%; p = 0.730) and 30‐day mortality (1.0%, 0.6%, 0%). On multivariable analysis, neither concurrent hepatectomy (OR 1.02, 95% CI 0.71–1.48) nor concurrent ablation (OR 0.94, 95% CI 0.46–1.93) was associated with morbidity. Pancreatoduodenectomy was associated with morbidity (OR 2.38, 95% CI 2.05–2.76), reoperation (OR 2.16, 95% CI 1.52–3.08), and mortality (OR 2.50, 95% CI 1.39–4.50), and a minimally invasive approach was associated with lower morbidity (OR 0.69, 95% CI 0.60–0.80). Conclusions Concurrent liver‐directed surgery was not associated with an increase in 30‐day morbidity or mortality after pancreatectomy for pNETs. These findings support the safety of concurrent hepatic resection in appropriately selected pNET patients.

Abstract Primary angiitis of the central nervous system is an extremely rare diagnosis, with an incidence of 2.4 cases per 1,000,000 person-years. The exact cause of PACNS remains unknown, and typically cases present with a long prodrome. It is a diagnosis of exclusion, and various infectious, autoimmune, and malignant processes must be excluded prior to final diagnosis. Given the rarity of this condition, there is often a delay in diagnosis that can range from 6 to 23 months. It is imperative that all clinical providers be aware of this diagnosis when managing patients who present with insidious and non-specific neurological symptoms. We present a case of PACNS that responded well to a therapeutic regimen of high-dose steroids and cyclophosphamide.

Sex and gender influence disease mechanisms and outcomes, yet their integration into medical curricula remains limited. Faculty knowledge and confidence are essential for effective incorporation. This study assessed baseline sex- and gender-specific health (SGSH) knowledge, attitudes, and comfort among medical school educators and delivered a multi-format faculty development intervention. A survey adapted from prior SGSH assessments was distributed to medical school block leaders before the intervention, measuring SGSH knowledge, comfort differentiating sex and gender, awareness of SGSH resources, and readiness to integrate SGSH content. The intervention included virtual and in-person grand rounds, distribution of How Sex and Gender Impact Clinical Practice , and a screening of Ms. Diagnosed . Of the 103 invited to participate, 68 educators (66% response rate) completed the baseline survey. Forty percent reported no prior SGSH training, and only 13.2% felt very comfortable with SGSH concepts. Although 94.1% correctly identified gender as a social construct and sex assignment at birth, 22% remained uncomfortable distinguishing the two. More than 80% were neutral or uncomfortable identifying SGSH resources. Comfort with curriculum integration varied: 45.6% felt comfortable, 32.4% neutral, and 22.1% uncomfortable, with differences observed across specialties. These findings reveal significant gaps in medical educators’ SGSH knowledge and comfort regardless of experience, with SGSH content narrowly confined to reproductive health topics. Simply providing resources is insufficient; educators need structured guidance on integration. By outlining baseline gaps and an intervention model, this study offers a framework for institutions seeking to enhance SGSH integration through interactive, longitudinal, multi-format faculty development approaches.

Abstract Objective. Proton minibeam radiation therapy (pMBRT) is a novel spatially fractionated radiation therapy technique that offers improved tumor control and reduced normal tissue toxicity. However, its clinical translation has been hindered in part by limited field sizes, low dose rates, and complex manufacturing. This work describes the design, manufacturing, and commissioning of a novel divergent pMBRT collimator along with accessory components to maximize its versatility and facilitate clinical implementation. Approach. The dosimetric outcomes for pMBRT collimator geometry, including slit width, center-to-center (CTC) spacing, thickness, divergence, and field size, were evaluated using TOPAS Monte Carlo (MC) to maximize surface peak-to-valley dose ratio (PVDR) while maintaining uniform target coverage. The collimator was constructed using brass plates held by aluminum side holders. Commissioning measurements with a PTW Bragg peak chamber and EBT4 radiochromic film were compared to TOPAS and an in-house fast GPU-based MC simulation. Ancillary equipment consisting of lead foils, range shifters, custom apertures, and secondary pMBRT collimators were characterized in tandem. Main results. An optimized divergent pMBRT collimator with 0.5 mm slit width, 2.0 mm CTC distance, and 40 mm thickness produced a surface PVDR of 4.8 while preserving quasi-homogeneous dose in the 6–14 cm depth region. Measured dose profiles demonstrated valley dose agreement within 3% for both TOPAS and GPU-based MC predictions after the simulated collimator geometry was refined to match Bragg-peak chamber average dose measurements. The onset of the quasi-homogeneous dose region was shifted toward shallower depths by using thin lead foils, without significantly impacting entrance PVDR. Apertures sharpened penumbra and enhanced peripheral PVDR. A dual collimator approach produced 2D pinhole dose arrays that resulted in valley doses from MC simulations and film measurements agreeing within ∼5%. Significance. We demonstrated a practical low-cost, large-area divergent physical pMBRT collimation system with validated MC modeling. In addition, we introduce complementary accessories that substantially expand system versatility to facilitate clinical implementation.

Abstract Background Vagally mediated syncope and functional bradyarrhythmias can cause recurrent symptoms, injury and a need for permanent pacing, yet standard therapies do not address the underlying autonomic reflex. Cardioneuroablation (CNA) targets this mechanism, but adoption has been limited by uncertainty about patient selection, procedural endpoints and durable outcomes. Methods We studied 95 consecutive patients with vagally mediated syncope (n=78) or functional bradyarrhythmia (n=17) who underwent CNA at a single center by a single lead operator under a uniform, prospectively maintained protocol. Extracardiac vagal stimulation (ECVS) was performed before and after ablation to confirm vagally mediated sinus or atrioventricular (AV) nodal responses and to verify their attenuation. Outcomes through 1 year included clinical recurrence, quality of life, pacing burden and pacemaker extraction. Results Before ablation, ECVS provoked sinus pauses in 95.8% of patients and AV block in 91.6%; after ablation, sinus pauses were abolished in every patient and residual AV block was present in 4.2%. One-year freedom from recurrent syncope and from bradyarrhythmia-related events was 93.8% and 94.1%. Syncope burden fell from a median of 2.7 episodes per year to none, and disease-specific quality of life improved substantially (P<0.001). Among patients with pre-existing devices, atrial pacing burden fell from a median of 22% to 0%. There were no strokes, deaths or myocardial infarctions. Conclusions In this single-center cohort, physiology-guided CNA was associated with durable symptom control, improved quality of life and reduced pacing across vagally mediated bradyarrhythmia syndromes. Multicenter controlled studies are needed to confirm these findings.

Juvenile Parkinson's disease (JPD) is a rare condition characterized by the onset of parkinsonian motor symptoms before the age of 21. Sixteen patients with JPD who presented to the Mayo Clinic between 1990-2020 were included. The median age of symptoms onset was 18.5 years, and six cases had pathogenic PRKN mutations. Resting tremor was the most frequent initial symptom (81.3%), and non-motor symptoms were notably common, including mild cognitive impairment (56.3%), anxiety (62.5%), and depression (56.3%). Levodopa responsiveness was suboptimal in 9 patients and 14 exhibited motor fluctuations. JPD demonstrates distinct clinical characteristics compared with early-onset and late-onset PD.