Weill Cornell Medicine

Background The treatment of traumatic carotid injuries has evolved over time, particularly with advancements in endovascular techniques. We analyze contemporary management of blunt and penetrating carotid injuries, and compare outcomes following endovascular and open repair. Methods The National Trauma Data Bank (NTDB) (2017–2023) was queried for carotid injuries in patients aged ≥16 managed with endovascular or open repair. Baseline characteristics, associated injuries, and in-hospital outcomes were compared between groups, and further stratified by blunt versus penetrating mechanism. Additional subgroup analysis was performed for patients with concomitant traumatic brain injury (TBI). Primary outcomes were stroke and mortality, and multivariable analysis was performed to identify independent predictors of stroke and composite stroke mortality. Results Of 3,339 carotid injuries, 54.5% were treated endovascular and 45.5% open. Patients who underwent endovascular repair of carotid injuries (ENDO) suffered from predominantly blunt trauma (81%), and those who underwent open repair (OPEN) had mostly penetrating trauma (66%; P < 0.001). ENDO patients were more likely to have high injury severity score (ISS ≥15; 74% vs. 69%; P < 0.001), longer time to intervention (41h vs. 3h; P < 0.001), and interfacility transfer (30% vs. 23%; P < 0.0001). The most common ENDO modalities were stenting (60%), embolization (18%), and angioplasty (5.6%); OPEN patients were managed with primary repair (31%), interposition/bypass (27%), ligation (9.7%), and patch angioplasty (4.7%). On unadjusted analysis, ENDO patients were more likely to suffer stroke (31% vs. 26%; P = 0.025), with no mortality difference (14% vs. 12%; P = 0.2). Among penetrating injuries, there was no difference between ENDO versus OPEN groups for stroke (24% vs. 25%; P = 0.9) or mortality (14% vs. 14%; P = 0.9). For blunt injuries, ENDO patients had greater mortality (14% vs. 9.0%; P = 0.004) but not stroke (33% vs. 29%; P = 0.2). On multivariable analysis, neither operative approach nor injury mechanism was independently associated with stroke or stroke mortality. Predictors of stroke were male gender (odds ratio [OR] 0.67; 0.49–0.92; P = 0.012), smoking (OR, 1.50; 1.09–2.06; P = 0.012), and hypertension (OR, 1.74; 1.20–2.52; P = 0.004). Predictors of stroke-mortality included concomitant TBI (OR, 2.49; 1.69–3.68; P < 0.001), hypertension (OR, 1.71; 1.20–2.44; P = 0.003), cardiac complication (OR, 2.43; 1.52–3.91; P < 0.001), and ISS ≥15 (OR, 2.03; 1.43–2.90; P < 0.001). Conclusion Carotid trauma carries significant morbidity, with over a quarter of patients experiencing stroke and 12–14% dying during hospital admission. Mechanism or operative approach do not seem to predict stroke or stroke mortality, which appears to be driven by overall injury burden.

Background Metabolic dysfunction–associated steatotic liver disease (MASLD) is highly prevalent and frequently undiagnosed, despite liver fibrosis being the strongest predictor of liver-related morbidity and mortality. We aimed to quantify Fibrosis-4 (FIB-4) index-based fibrosis risk and to evaluate guideline-recommended follow-up—FIB-4 documentation, confirmatory testing, and specialist referral—in a large US cohort. Methods We conducted a retrospective study of electronic health record data from the US All of Us Research Program. Among adults aged 35 years or older with sufficient laboratory data, FIB-4 scores were calculated from routinely captured biomarkers, classified as low (<1.3), indeterminate (1.3–2.67; 2.0–2.67 if aged ≥65 years), or high risk (>2.67), and described across sociodemographic and metabolic subgroups; associations with incident major adverse liver outcomes (MALO) were assessed with Cox proportional-hazards regression. We examined FIB-4 documentation, confirmatory testing, and specialty referrals within 365 days of the index FIB-4 date. Findings Among 136,004 participants (mean age 60.8 years [SD 13.5]; 79,365 [58.4%] female; 81,420 [59.9%] White, 21,779 [16.0%] Hispanic or Latino, 20,076 [14.8%] Black), 26,971 (19.8%, 95% CI 19.6–20.0) had indeterminate and 11,217 (8.2%, 8.1–8.4) high FIB-4–based fibrosis risk. Elevated risk was more frequent with cardiovascular disease (41.7% vs 25.6%), hypertension (30.7% vs 23.4%), and type 2 diabetes (29.7% vs 27.4%), rising from 25.6% with no metabolic comorbidities to 36.6% with four. FIB-4 documentation was rare, and fewer than 1% of high-risk participants underwent confirmatory testing or referral; referral was low across risk categories (0.19% high, 0.19% indeterminate, 0.25% low risk). MALO occurred in 1308 (11.7%) high-risk vs 830 (0.8%) low-risk participants (adjusted hazard ratio 19.68, 95% CI 17.88–21.67). Interpretation Routinely collected laboratory data identify substantial liver fibrosis risk in this volunteer US cohort, yet guideline-recommended follow-up is uncommon. Implementation strategies such as automated risk calculation and reflex-based testing pathways could reduce missed opportunities for earlier diagnosis and intervention. Funding No specific funding was received for this study.

AbstractTypically developing children start using words around age 1 and develop conversational ability by 18 to 24 months. In autism, these communicative behaviors are delayed and impaired to varying degrees. Affected areas of language development include articulation, word use, syntax and morphology, echolalia (repetition with similar intonation of words/phrases someone else has said), and confusion of personal pronouns. Further research must address deficits in ability to process information about social situations, as this is most likely behind the communication disorders in autism.

Differentiated thyroid carcinomas (DTC), including papillary thyroid carcinoma (PTC) and follicular carcinoma (FC), account for most thyroid malignancies and are generally associated with excellent prognosis. However, a subset of DTC demonstrate aggressive clinical behavior characterized by increased recurrence, distant metastasis (DM), radioactive iodine (RAI) resistance, and reduced survival. Identification of these tumors is critical for appropriate risk stratification and management. A number of pathologic features have been shown to predict aggressive behavior, including vascular invasion (VI), capsular invasion (CI), and extrathyroidal extension (ETE), as well as high-grade histologic features such as increased mitotic activity and tumor necrosis. In the 2022 World Health Organization (WHO) Classification for Endocrine and Neuroendocrine Tumours, high-grade features are acknowledged as prognostically significant, and DTC meeting these criteria are classified as high grade differentiated thyroid carcinoma (HGDTC), a category with a prognosis similar to PDTC. In addition, certain histologic subtypes of PTC, including the tall cell, hobnail, and columnar cell subtypes, have traditionally been associated with more aggressive clinical outcomes. However, the prognostic significance of histologic subtype alone remains debated, as tumor behavior is often influenced by the presence of invasive features and high-grade morphology. Recent advances in molecular profiling have further refined risk stratification. While the independent prognostic significance of the BRAFV600E mutation remains controversial, TERT promoter mutations have consistently been associated with aggressive tumor biology, including DM, RAI resistance, and decreased survival. Importantly, the coexistence of BRAFV600E and TERT promoter mutations identifies a subset of thyroid carcinomas with particularly poor outcomes. This review summarizes the key pathologic and molecular features associated with aggressive behavior in DTC, highlighting their diagnostic criteria, prognostic significance, and implications for clinical management. Comprehensive pathologic evaluation integrating morphologic and molecular findings remains essential for accurate risk stratification and multidisciplinary care of patients with thyroid carcinoma.