Publications by Year: 2026

BACKGROUND: Patients with cerebellar disorders often experience fatigue and the cerebellar cognitive affective syndrome (CCAS), both of which impair quality of life (QoL). There are no approved treatments.

OBJECTIVE: To test the hypothesis that stimulant medications improve fatigue and CCAS in patients with cerebellar disorders.

METHODS: We administered a questionnaire to 20 patients with cerebellar disorders, assessing the impact of stimulant medications on nine domains: QoL, fatigue, alertness, verbal expression, thinking clearly, and multitasking, as well as emotional state, social interactions, and physical symptoms. Patients also completed the Patient-Reported Outcome Measure of Ataxia, Mental section (PROM-Ataxia MEN), rating symptoms before and during treatment.

RESULTS: Patients perceived improvements in all domains, with 95% reporting improved alertness, 90% fatigue, and 80% executive control. PROM-Ataxia MEN scores improved by 26%.

CONCLUSIONS: These preliminary findings suggest that stimulants may be associated with perceived symptom improvements in cerebellar disorders. Given the small, heterogeneous sample and reliance on retrospective patient-report, further exploration is warranted.

OBJECTIVES: Individuals with both avoidant/restrictive food intake disorder (ARFID) and pediatric acute-onset neuropsychiatric syndrome (PANS) report restrictive eating. Inflammatory and immunological alterations may drive the onset of restrictive eating and comorbid obsessive-compulsive (OC) symptoms in PANS, while the etiology of restrictive eating in ARFID is unknown. Nevertheless, few studies have explored PANS and related OC symptoms among individuals with ARFID. We aimed to identify the frequency and nature of PANS and OC symptoms among those with full or subthreshold ARFID. We also explored associations between OC severity, ARFID profiles, and infection history.

METHODS: The study included 37 adolescents and young adults with subthreshold or full ARFID. We quantified the frequency of PANS/pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection symptoms and diagnoses, as well as OC symptoms and severity, in our ARFID sample. We analyzed associations between ARFID profiles and OC severity, along with the relationship between infection history and OC severity.

RESULTS: Two individuals (5%) met PANS criteria, and 17 (46%) reported lifetime mild-severe OC severity. The fear of aversive consequences profile was associated with a significant increase in log-transformed OC severity (β = 1.2, p = 0.04, adjusted R2 = 0.10) after adjusting for sensory sensitivity, lack of interest, and body mass index z-score. We did not find any associations between OC severity and infection history.

DISCUSSION: In the first study to examine PANS and related symptoms among individuals with ARFID, we demonstrated salient overlap between PANS, OC symptoms, and ARFID. Further research is needed to examine the relationship between ARFID and PANS.

INTRODUCTION: The value of esophageal baseline impedance (BI) in assessing proximal reflux and laryngopharyngeal symptoms (LPSs) is unclear.

METHODS: Two hundred eighteen patients with LPS underwent 24-hour combined hypopharyngeal-esophageal impedance-pH monitoring. Proximal/distal BI was obtained, and a slope-and-intercept model of proximal BI contour was constructed.

RESULTS: Proximal BI correlated with proximal/pharyngeal reflux (r = -0.21, P < 0.01) and reflux symptom index (r = -0.14, P = 0.08). The proximal BI contour model incorporating both the BI change (slope) and BI just below upper esophageal sphincter (intercept) outperformed models using individual BI measures in predicting proximal (Akaike information criterion: 110 vs 251-253) or pharyngeal (akaike information criterion: 32 vs 141-148) reflux.

DISCUSSION: Proximal esophageal impedance contour predicts proximal reflux in patients with LPS.

BACKGROUND: Patellofemoral instability is a difficult problem to assess because of its dynamic nature, which is not easily quantified using physical examination techniques. This study aimed to describe and evaluate a novel examination method using stress ultrasonography to quantify patellar instability. The secondary aim was to assess the relationship of stress ultrasonography measurements with clinical and morphologic risk factors for patellar instability.

METHODS: Knees with symptomatic patellar instability underwent the ultrasound-assisted patellar glide test. In this test, the patella was translated laterally from its resting position during ultrasound visualization until an endpoint was reached. The medial patellofemoral distance (MPFD) was used to quantify the gap between the medial boundary of the patella and the trochlea, and the difference in MPFD between the resting (unloaded) and loaded conditions was defined as the delta MPFD. Measurements were compared with those in asymptomatic contralateral knees of patients with unilateral instability, asymptomatic knees after patellar stabilization surgery, and control knees. Regression analyses assessed for relationships of MPFD with morphological and clinical risk factors. Receiver operating characteristic (ROC) curve analysis assessed the ability of stress ultrasonography measurements to discriminate between knees with and without symptomatic patellar instability.

RESULTS: Four hundred and seventy-seven knees in 277 patients were included in this study; 173 of the knees had patellar instability (patient age, 24 ± 8 years; 72% female). Delta MPFD was 3 times greater in knees with patellar instability (median, 3.3 mm [95% confidence interval, 3.1 to 3.4 mm]) than in the contralateral asymptomatic (1.1 mm [0.9 to 1.3 mm]), postoperative (1.0 mm [0.8 to 1.2 mm]), and control knees (1.4 mm [1.1 to 1.6 mm]). ROC analysis demonstrated an optimal threshold value for delta MPFD of 2.0 mm, which had an area under the curve (AUC) of 0.97 (0.94 to 0.99), demonstrating excellent discrimination in identifying knees with patellar instability. No relationships of clinical or morphologic risk factors with delta MPFD were found.

CONCLUSIONS: A delta MPFD of ≥2 mm on the ultrasound-assisted patellar glide test had an AUC of 0.97 for identifying knees with symptomatic patellar instability, indicating excellent discriminatory ability. Additional studies utilizing this method are recommended to standardize and quantify assessments of patellar instability.

LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

PURPOSE: Given varying preference signal numbers and structures across residency specialties, this study investigates the impact of preference signaling on match outcomes in highly competitive medical specialties.

METHOD: Data were from University of Texas Southwestern Medical School's Texas Seeking Transparency in Application to Residency survey of applicants to the top 10 most competitive specialties using signaling between 2021 and 2024. Bivariate statistical testing compared groups across categorical and continuous variables. Multivariate logistic regression compared outcomes between 10 or fewer and 20 or more signals.

RESULTS: The dataset contained 4,469 applications from 4,391 unique students. Number of signals used did not affect number of overall matches (2,458 of 2,908 [84.5%] for 3-5 signals, 94 of 112 [93.9%] for 6-10 signals, 178 of 203 [86.7%] for 21-25 signals, and 585 of 662 [88.4%] for 26-30 signals; P = .08). Higher signal numbers were associated with significantly higher matching rates at signaled institutions (916 of 2,098 [37.2%] vs 525 of 662 [89.6%], P < .001). Away rotations (odds ratio [OR], 9.25; 95% CI, 6.37-13.43; P < .001), signaling gold (OR, 7.74; 95% CI, 3.85-15.55; P < .001), geographic connections (OR, 4.12; 95% CI, 3.01-5.64; P < .001), and signaling programs (OR, 3.38; 95% CI, 2.43-4.68; P < .001) were significantly associated with matching. Away rotations were ranked as most important (β = 2.23) followed by gold signals (β = 2.05), geographic connection (β = 1.42), and program signals (β = 1.22). Program signals had a stronger impact for applicants with 10 signals or fewer vs 20 signals or more (OR, 5.99 [95% CI, 3.96-9.08] vs 3.00 [95% CI, 1.33-6.77]; P < .001).

CONCLUSIONS: Specialties with more signals favor successful matching to signaled programs, but signal effectiveness diminishes as quantity increases. Applicants should prioritize impactful strategies to improve their chances of matching.

BACKGROUND: Lateral locked plating remains an important treatment strategy for distal femoral fractures but has been associated with nonunion rates ranging from 6% to 20%. The objective of this study was to identify factors associated with nonunion following lateral locked plating of distal femoral fractures with use of a Bayesian analysis.

METHODS: All consecutive patients ≥18 years of age who were treated with lateral locked plating for a distal femoral fracture at 2 Level-I trauma centers between 2006 and 2024 and who had ≥3 months of follow-up were included. Multivariable Bayesian logistic regression analysis was performed to identify factors associated with nonunion, which was defined as a reoperation to promote healing, and the results are reported as odds ratios (ORs) with 95% credible intervals (CrIs). Probabilities of >95% were considered very strong evidence of an association with nonunion, and probabilities of 90% to 95% were considered strong evidence.

RESULTS: A total of 560 patients (median age, 68 years; 29% male; 90% White; 97% non-Hispanic; 41% with distal periprosthetic fractures) were included. Fifty-four patients (9.6%) underwent reoperation to promote healing. There was very strong evidence that multifragmentary comminution of the metaphysis (versus simple fracture: OR, 2.60; 95% CrI, 0.91 to 8.06), medial cortical comminution of >0 to 25 mm (versus 0 mm: OR, 3.11; 95% CrI, 1.35 to 7.48), and varus (lateral distal femoral angle [LDFA] of ≥84°: OR, 3.04; 95% CrI, 1.46 to 6.51) or valgus (LDFA of ≤78°: OR, 2.42; 95% CrI, 0.96 to 5.99) malalignment increased the odds of nonunion. A screw density of ≤0.60 proximal to the working length reduced the odds of nonunion (versus ≥0.81: OR, 0.40; 95% CrI, 0.16 to 0.95), although the size and certainty of this effect varied in the sensitivity analysis that utilized alternative thresholds. There was strong evidence that obesity increased the odds of nonunion (OR, 1.64; 95% CrI, 0.86 to 3.13) and that intact wedge fractures reduced the odds of nonunion (versus simple fracture: OR, 0.35; 95% CrI, 0.05 to 1.74).

CONCLUSIONS: One in 10 patients developed nonunion and underwent reoperation to promote healing. Surgeons should restore coronal plane alignment and may consider augmenting fixation in the presence of multifragmentary comminution. Constructs in which all screw holes proximal to the working length are filled should be avoided, although the optimal configuration remains unclear and depends on other construct characteristics influencing biomechanics. Overall, the small to moderate effect sizes highlight the multifactorial etiology of nonunion following lateral locked plating of distal femoral fractures.

LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.