Publications

Clear cell morphology is an uncommon finding in human tumors and reflects the distinctive appearance of the cytoplasm under standard histopathologic examination. Granular cell morphology appears to be a closely related phenomenon and reflects an abundant eosinophilic cytoplasm. Accumulating evidence suggests a central role for the MITF/TFE family of transcription factors in diverse clear cell and granular cell neoplasms. A principal function of these transcription factors concerns cytoplasmic organellar biogenesis: TFEB is the master regulator of lysosome biogenesis while MITF controls the biogenesis of lysosome-related organelles known as melanosomes, which are responsible for melanin pigment production. This article reviews the role of MITF/TFE pathway activation in a variety of benign and malignant tumors, with an emphasis on the diverse oncogenic mechanisms that activate this pathway and the resulting altered cell biology that contributes to the distinctive histomorphologic features.

OBJECTIVES: To examine whether unionized nursing homes in New York State show different levels of resident voice-measured through formal complaints-and how ownership relates to these patterns.

DESIGN: Cross-sectional analysis of 2022 facility-level data.

SETTING AND PARTICIPANTS: A total of 511 New York State nursing homes categorized by union status and ownership type.

METHODS: Resident voice was defined as complaints per 100 residents submitted to the New York State Department of Health Complaint Hotline. Key predictors were union status and ownership, with covariates including facility size, payer mix, occupancy, hospital admissions, and quality rating.

RESULTS: Of the 511 facilities, 361 (70.6%) were unionized. Unionized homes had fewer complaints on average (57.9 vs 64.4 per 100 residents; P = .04). Among unionized facilities, higher Medicaid (β = 0.885; P < .001) and Medicare shares (β = 0.567; P = .003) were positively associated with complaints and higher overall quality ratings were inversely associated (β = -6.77; P < .001).

CONCLUSIONS AND IMPLICATIONS: Nursing homes with unionized workforces display distinct patterns of resident voice. These findings suggest that workforce organization may influence the institutional environment in ways that either facilitate or constrain residents' ability to advocate for improved care. Understanding how labor structures intersect with ownership and quality conditions can inform future policy efforts aimed at strengthening resident-centered care and guide research on mechanisms linking workforce organization to resident advocacy behaviors.

CONTEXT: Oncocytic cells can occur in benign and malignant thyroid nodules, posing a diagnostic challenge. This has reduced the diagnostic performance of molecular testing for indeterminate oncocytic thyroid nodules.

OBJECTIVE: To evaluate the performance of Afirma Genomic Sequencing Classifier (GSC) in thyroid nodules with Bethesda III or IV cytology and oncocytic predominance.

DESIGN, SETTING, PATIENTS, AND INTERVENTION: A multicenter retrospective study was conducted in adults with Bethesda III and IV thyroid nodules showing oncocytic predominance who underwent a fine-needle aspiration biopsy and Afirma GSC testing between July 2017 and December 2023. Variables included presence of Hashimoto's thyroiditis and Thyroid Imaging Reporting and Data System (TIRADS) classification.

MAIN OUTCOME MEASURES: Outcomes included benign call rate (BCR), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of Afirma GSC testing.

RESULTS: Of 359 nodules (57% Bethesda III, 43% Bethesda IV) tested with Afirma GSC, the mean nodule size was 2.0 cm. BCR was 81% and 74% for Bethesda III and IV nodules, respectively. GSC sensitivity, specificity, PPV, and NPV were 89%, 86%, 24%, and 99% for Bethesda III nodules and 94%, 87%, 50%, and 99% for Bethesda IV nodules, respectively. A concurrent diagnosis of Hashimoto's thyroiditis significantly reduced the specificity and PPV in Bethesda III nodules. TIRADS classification did not affect the BCR or PPV in Bethesda III or IV nodules.

CONCLUSIONS: Afirma GSC has a high BCR and improved performance over earlier generation molecular tests in oncocytic thyroid nodules, particularly for Bethesda IV. However, the PPV in Bethesda III nodules remains low, especially in the presence of Hashimoto's thyroiditis.

OBJECTIVE: To determine whether frailty, as quantified using the Five-Item Modified Frailty Index (mFI-5), independently predicts postoperative complications in patients undergoing surgery for diabetic foot ulcers (DFUs), and to assess its utility as a clinical risk stratification tool.

APPROACH: A retrospective cohort analysis was conducted using the American College of Surgeons National Surgical Quality Improvement Program database (2015-2021). Adults with type 2 diabetes and International Classification of Diseases, 10th Revision-coded DFUs (E11.621) undergoing elective surgery were identified and stratified into frail (mFI-5 >2) and prefrail (mFI-5 ≤2) groups. Preoperative variables, perioperative characteristics, and 30-day postoperative outcomes were compared using univariate tests, followed by multivariable logistic regression adjusting for clinically relevant confounders. The study design, reporting, and analysis followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for observational cohort studies.

RESULTS: Among 2,819 patients, 714 (25.3%) were classified as frail. Frail patients had significantly higher rates of overall complications (50.6% vs. 32.9%), mortality (4.1% vs. 1.6%), and medical complications, including reintubation and urinary tract infection. In adjusted models, frailty independently predicted any postoperative complication (odds ratio [OR] = 1.34, 95% confidence interval [CI] 1.05-1.70, p = 0.02) and medical complications (OR = 1.53, 95% CI: 1.12-2.07, p = 0.007).

INNOVATION: This is the first large-scale study applying the mFI-5 to DFU surgery, demonstrating that frailty provides prognostic information beyond traditional comorbidity-based assessments and offers a rapid, objective tool for perioperative risk evaluation.

CONCLUSION: Frailty, as measured by the mFI-5, independently predicts postoperative morbidity and mortality after DFU surgery. Incorporating preoperative frailty screening may improve surgical decision making, resource allocation, and enhance outcomes in this high-risk population.

Myelin-weighted imaging with inversion-recovery ultrashort-echo-time (IR-UTE) is highly motion-sensitive, yet extra hardware or longer scans are impractical. We evaluated whether a 1D superior–inferior (SI) navigator with bit-reversed spoke-angles mitigates motion artifacts without extending acquisition. Dual-echo IR-UTE was implemented at 3T. After an adiabatic inversion pulse, 21 spokes were acquired per segment around the white-matter null point, and dual-echo subtraction suppressed residual long-T2 signals. Adding SI-navigators at the end of each segment allows motion detection without lengthening TR. And bit-reversal is used to pseudo-randomize the spoke-angles. Bloch simulations of a 2D synthetic brain removed 10% of spokes to mimic gating. Three volunteers were scanned: (i) sequential-ordering, no-motion; (ii) bit-reversed, no-motion; (iii) bit-reversed with deliberate head nods. The navigator rejected 1,280 of 12,000 spokes (10.7%) during nodding, and the same gating was reconstructed on motion-free data. Simulation showed coherent streaks for sequential ordering but an isotropic point-spread function for bit-reversal. In vivo, gating degraded only the sequential dataset. bit-reversal preserved subcortical and deep-white-matter detail. During intentional nodding, gating with bit-reversal enhanced myelin contrast, outperforming the image reconstructed from the ungated data. The SI-navigator plus bit-reversal enables effective motion gating without hardware or time penalty, supporting routine motion-robust myelin mapping.

PURPOSE OF REVIEW: Prehabilitation constitutes a multidisciplinary strategy aimed at improving physiological and psychological readiness prior to surgery. Within pain medicine, prehabilitation provides an opportunity to address modifiable pain-related and functional risk factors prior to major procedures. This narrative review synthesizes contemporary evidence on prehabilitation modalities, their impact on surgical and pain-relevant outcomes, and persistent knowledge gaps limiting integration into perioperative pain pathways.

RECENT FINDINGS: A targeted PubMed search was performed on June 25, 2025. Supplementary exploratory searches in Web of Science and Scopus did not identify unique eligible studies beyond those already captured in PubMed. After excluding non-original reports and studies lacking outcome data, 153 clinical studies were included. The most frequently represented surgical specialties were general surgery (43%), orthopedic surgery (21%), and cardiothoracic surgery (18%). Single-modality prehabilitation was reported in 43% of studies, whereas multimodal approaches varied by specialty, occurring in 36% of general surgery studies and 13% of cardiothoracic surgery studies. Five principal prehabilitation modalities were identified: exercise, nutrition, psychological intervention, substance cessation, and medical optimization. Exercise-based interventions were the most common, incorporated in 84.7% of studies, followed by nutritional interventions in 29.5%. Overall, 82% reported improvements in at least one postoperative or functional outcome, although pain-specific endpoints were inconsistently reported.

SUMMARY: Prehabilitation appears beneficial across surgical specialties; however, pain outcomes remain underreported, and multimodal programs remain limited. Future work should standardize pain endpoints and evaluate multimodal interventions to guide integration of prehabilitation into perioperative pain management pathways.

SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11916-025-01464-2.

BACKGROUND: This study aimed to demonstrate the feasibility of using computer vision (CV) to unobtrusively extract body motion metrics from videos of emergency medicine (EM) clinicians, and gather validity evidence of these metrics to differentiate POCUS skills between novice and experts, as well as to capture skills gained over time.

METHODS: Prospective cohort study including novice and expert EM clinicians performing echocardiogram (ECHO) and focused assessment with sonography for trauma (FAST) exams on a live simulated patient. Expert observers provided objective structured clinical examination (OSCE) scores (numerical ratings on a scale from 1 to 100), and sonographers' hands and head motion metrics (path length, speed, acceleration, jerk, and smoothness) were extracted via CV using 2-dimensional videos. Data points were captured at baseline, and for novices at baseline and after 12-15 months of residency training.

RESULTS: CV achieved high detection rates (99.52% ECHO, 98.70% FAST). At baseline, experts demonstrated superior OSCE scores (ECHO: 98.6 ± 2.1 vs 63.4 ± 17.0; FAST: 99.2 ± 1.5 vs 68.9 ± 17.7, p < 0.001) and faster task completion (101.8 ± 44.7 vs 240.3 ± 84.1 s, p < 0.001). Experts exhibited smoother hand movements (left hand smoothness: -129.3 ± 47.6 vs -241.3 ± 64.6, p < 0.001) and reduced total path lengths. After 12-15 months of training, novices showed significant improvements in OSCE scores (ECHO: 85.3 ± 10.3; FAST: 84.8 ± 6.5) and task efficiency (134.0 ± 35.6 s), with improvements in motion smoothness and reduced path lengths (p < 0.001). Motion metrics strongly correlated with OSCE scores (r = 0.455-0.783) and task completion time (r = 0.491-0.951).

CONCLUSIONS: CV successfully extracted objective motion metrics that differentiated POCUS skill levels between novices and experts and captured skill development over time. This approach offers a scalable, unobtrusive method for objective POCUS assessment, while supporting competency-based medical education frameworks.

Pancreatic ductal adenocarcinoma (PDAC) is a leading cause of cancer-related deaths, accounting for over 90 % of pancreatic cancer cases. Accurate diagnosis is crucial, but often challenging. It typically relies on minimally invasive procedures, such as endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and small biopsy samples. These small biopsies may be the only tissue diagnosis made before embarking on neoadjuvant therapy, major surgery, or transition to comfort care, depending on clinicoradiologic factors. This paper reviews important diagnostic strategies and criteria for cytologic and small biopsy samples, highlighting cytomorphologic characteristics, histologic patterns, and the role of immunohistochemical and molecular diagnostics. PDAC cytology often shows hypercellular aspirates with disorganized glandular fragments, significant nuclear atypia, prominent nucleoli, and a necrotic background. In contrast, small biopsy samples typically reveal invasive glandular structures surrounded by desmoplastic stroma and nuclear pleomorphism. However, biopsies are often scant and there are a variety of difficult histologic subtypes and mimics that complicate these cases. Although there is a lack of sensitive or specific markers for PDAC, immunohistochemical markers, such as P53, and SMAD4, can be useful for supporting a diagnosis of PDAC over chronic pancreatitis/tumor mimics. Molecular alterations in KRAS, TP53, BRCA1/2, and others may aid in diagnosis, prognostication, and the selection of targeted therapeutic options. By systematically integrating clinicoradiologic, cytological, histological, immunophenotypic, and molecular data, pathologists can effectively differentiate PDAC from benign or reactive lesions and metastatic neoplasms, ensuring accurate diagnoses that are essential for optimal patient management.

Animals produce diverse motor actions that enable expression of context-appropriate behaviors. Neuromodulators facilitate behavioral flexibility by altering the output of neural circuits. Discrete populations of serotonergic (5-HT) neurons target circuits in the brainstem and spinal cord, but their roles in motor behavior are unclear. Here, we define the pre- and post-synaptic organization of spinal-projecting serotonergic neurons in mice and identify a role in locomotor control. While forebrain-targeting 5-HT neurons decrease their activity during locomotion, spinal-projecting neurons increase their activity in a context-dependent manner. Optogenetic activation of ventrally projecting 5-HT neurons does not initiate movement, but rather enhances the speed and duration of ongoing locomotion. Serotonergic neurons can influence motor output beyond periods of increased activity, indicating that neuromodulators can act over extended timescales. These findings indicate that the descending serotonergic system potentiates locomotor output and demonstrate a role for serotonergic neurons in modulating the temporal dynamics of motor circuits.