Citations

Abstract The transition from internship to residency represents an important period for trainees. However, little is known about self-assessed preparedness among physiatry trainees. This national cross-sectional exploratory survey of United States postgraduate year 2–4 physiatry residents aimed to examine self-reported preparedness at the start of postgraduate year 2. A total of 109 postgraduate year 2–4 residents completed this survey, with 57.8% (63/109) reporting feeling prepared to assume patient care responsibilities at the start of postgraduate year 2 and 42.2% (46/109) reporting feeling unprepared to do so. Specific internship experiences (e.g., developing comfort handling overnight calls and rapid responses), but not type of intern year (e.g., transitional year, preliminary internal medicine or surgery year, intern year included in a categorical physiatry residency program) may be associated with self-reported clinical preparedness. Further research is warranted to explore in more detail factors identified as potentially associated with self-assessed clinical preparedness, as well as opportunities to identify and address physiatry trainee needs.

Abstract Aggressive B-cell non-Hodgkin lymphomas represent a clinically heterogeneous group of malignancies characterized by rapid progression and varied molecular features. Diffuse large B-cell lymphoma (DLBCL) is the most common aggressive B-cell non-Hodgkin lymphoma and encompasses a biologically diverse group of diseases, now classified into 18 molecular subtypes (Alaggio et al. Leukemia, 2022). While first-line R-CHOP therapy cures approximately 60% of patients (Coiffier et al. N Engl J Med. 2002), those with relapsed or refractory (R/R) disease face poor outcomes. Although CAR T-cell therapies (e.g. axicabtagene ciloleucel, tisagenlecleucel, lisocabtagene maraleucel) have improved outcomes, access remains limited due to logistical and disease-related constraints (Locke et al. N Engl J Med. 2022). More recently, bispecific CD20xCD3 antibodies such as epcoritamab and glofitamab have shown clinical activity in the R/R setting after ≥2 prior lines, with complete response (CR) rates of ~40% (Dickinson et al. N Engl J Med. 2022; Thieblemont et al. J Clin Oncol. 2023). However, treatment sequencing and mechanisms of resistance to CD20-targeted therapies remain areas of active investigation. One emerging resistance mechanism to CD20 bispecific antibodies is the downregulation or loss of CD20 expression, which has been associated with treatment failure and disease progression (Bannard et al. Clin. Cancer Research, 2022). This highlights the need for novel strategies to overcome CD20 resistance. Dapolsertib (MEN1703) is a first-in-class dual PIM/FLT3 kinase inhibitor that targets key oncogenic and survival pathways in hematologic malignancies. PIM kinases (PIM1, PIM2, PIM3) regulate translation, metabolism, apoptosis, and immune modulation. Overexpression and mutations in PIM genes are associated with poor prognosis in DLBCL, particularly in the ABC subtype, and are known to cooperate with MYC and BCL6 (Szydłowski et al. Cancer Res. 2021). Simultaneous inhibition of all three PIMs downregulates MYC and induces marked cytotoxicity in preclinical models. In AML, dapolsertib has demonstrated preliminary clinical single-agent activity, with ~10% CR/CRi reported in the DIAMOND study (NCT03008187; Martinelli et al. Blood Neoplasia, in press). Dapolsertib has also shown strong antitumor activity in lymphoma models, both in vitro and in vivo (Bellon et al. Mol Cancer. 2023). Notably, dapolsertib demonstrated synergy with anti-CD20 antibody, rituximab, providing a rationale for combination strategies (Szydłowski et al. Cancer Res. 2021). The rationale for combining dapolsertib with a CD20 bispecific antibody lies in its potential to modulate survival pathways, sensitize malignant B-cells to immunotherapy, and circumvent resistance mechanisms such as CD20 loss by inducing CD20 expression. JASPIS-01 (NCT06534437) is an ongoing, international multicenter, Phase 2 study evaluating dapolsertib as monotherapy or in combination with glofitamab in patients with R/R aggressive B-cell lymphoma after ≥2 prior lines of therapy. The trial consists of three parts: a safety run-in (Part 1), optional enrichment (Part 2), and a potential randomized comparison vs. glofitamab (Part 3). Part 1 will include 2 groups of patients. Group 1 comprises bispecific-naïve patients randomized to a prospective dose-optimization evaluation of the combination with dapolsertib. Patients receive either 125 mg on a 2 weeks on / 1 week off schedule or 150 mg on a 1 week on / 2 weeks off schedule for up to 12 cycles to investigate optimal therapeutic window. Group 2 comprises patients who exhausted therapeutic standard options and who will receive dapolsertib monotherapy at 125 mg on a 2 weeks on / 1 week off schedule until intolerable toxicity or disease progression. The initial safety run-in (Parts 1 of both groups) informs dose selection for Part 2. Dose continuation in Part 2 will be guided by Data and Safety Monitoring Board safety assessments after ≥2 completed treatment cycles. The primary objectives are to assess safety, tolerability, and preliminary anti-lymphoma activity. Key endpoints include incidence of adverse events, overall/complete response rates, and duration of response. As of July 11, 2025, Part 1 is enrolling in France, Poland, Spain and the UK with additional sites activation ongoing.

Purpose To describe injury epidemiology in U.S. adolescent tennis players between 2014 and 2018 via the High School Reporting Information Online (HS RIO) database. Methods The HS RIO database was queried for injury data on high school tennis players as reported by athletic trainers between 2014 and 2018. Injuries were analyzed according to athlete demographics, injury type, location, and context. Variables of interest between male and female athletes were compared using Pearson χ 2 test or Fisher exact test. Results In total, 176 injuries in high school tennis players between 2014 and 2018 were identified in the HS RIO database. Overall, 25.6% (45/176) occurred in the ankle, 12.5% (22/176) in the knee, and 9.7% (17/176) in the wrist. The most common types of injuries were ligament sprains and muscle strains at 35.2% (62/176) and 17.6% (31/176) of injuries, respectively. Although most injuries were unrelated to contact, such as overuse and heat exertion or stroke, 28.7% (47/176) of injuries were the result of rotation around a planted foot/inversion of the foot. We found no difference in injury patterns between male and female high school tennis athletes. Conclusions We found no difference in injury patterns between male and female U.S. high school tennis athletes. The ankles, knees, and wrists were the most commonly injured areas in this population. The most common types of injuries were ligament sprains and muscle strains. Although many injuries were new, athletes rarely required surgery and returned to play. Finally, we found no difference in injury patterns between male and female high school tennis athletes. Clinical Relevance The epidemiology of injuries among high school tennis players is poorly understood. The information from this study will help us to understand these injuries and how we may be able to better prevent them.

AbstractHow to deliver best care in various clinical settings remains a vexing problem. All pertinent healthcare-related questions have not, cannot, and will not be addressable with costly time- and resource-consuming controlled clinical trials. At present, evidence-based guidelines can address only a small fraction of the types of care that clinicians deliver. Furthermore, underserved areas rarely can access state-of-the-art evidence-based guidelines in real-time, and often lack the wherewithal to implement advanced guidelines. Care providers in such settings frequently do not have sufficient training to undertake advanced guideline implementation. Nevertheless, in advanced modern healthcare delivery environments, use of eActions (validated clinical decision support systems) could help overcome the cognitive limitations of overburdened clinicians. Widespread use of eActions will require surmounting current healthcare technical and cultural barriers and installing clinical evidence/data curation systems. The authors expect that increased numbers of evidence-based guidelines will result from future comparative effectiveness clinical research carried out during routine healthcare delivery within learning healthcare systems.

Background: Ablation of ventricular tachycardia (VT) is limited by the inability to create penetrating lesions to reach intramyocardial origins. Intramural needle ablation using in-catheter, heated saline-enhanced radio frequency (SERF) energy uses convective heating to increase heat transfer and produce deeper, controllable lesions at intramural targets. This first-in-human trial was designed to evaluate the safety and efficacy of SERF needle ablation in patients with refractory VT. Methods: Thirty-two subjects from 6 centers underwent needle electrode ablation. Each had recurrent drug-refractory monomorphic VT after implantable cardioverter defibrillator implantation and prior standard ablation. During the SERF study procedure, one or more VTs were induced and mapped. The SERF needle catheter was used to create intramural lesions at targeted VT site(s). Acute procedural success was defined as noninducibility of the clinical VT after the procedure. Patients underwent follow-up at 30 days, and 3 and 6 months, with implantable cardioverter defibrillator interrogation at follow-up to determine VT recurrence. Results: These refractory VT patients (91% male, 66±10 years, ejection fraction 35±11%; 56% ischemic, and 44% nonischemic) had a median of 45 device therapies (shock/antitachycardia pacing) for VT in the 3 to 6 months pre-SERF ablation. The study catheter was used to deliver an average of 10±5 lesions per case, with an average of 430±295 seconds of radiofrequency time, 122±65 minute of catheter use time, and a procedural duration of 4.3±1.3 hours. Acute procedural success was 97% for eliminating the clinical VT. At average follow-up of 5 months (n=32), device therapies were reduced by 89%. Complications included 2 periprocedural deaths: an embolic mesenteric infarct and cardiogenic shock, 2 mild strokes, and a pericardial effusion treated with pericardiocentesis (n=1). Conclusions: Intramural heated saline needle ablation showed complete acute and satisfactory mid-term control of difficult VTs failing 1 to 5 prior ablations and drug therapy. Further study is warranted to define safety and longer-term efficacy. Registration: URL: https://www.clinicaltrials.gov ; Unique Identifier: NCT03628534 and NCT02994446.

Introduction: Unstable scar related ventricular tachycardia (VT) is a common problem after myocardial infarction. Aggressive ablation may be limited, however, by incomplete scar penetration with available RF energy delivery technologies. The purpose of this study was to test the feasibility of full thickness linear ablation of infarcted ventricular substrate with a high penetration virtual electrode needle based electrode system. Methods: Chronic infarcted (> 2months) mongrel dogs (35–40 kg) underwent percutaneous catheter ablation of the LV with a saline-injection needle catheter employing an 8 mm 20-GA tip. Constant power at 40W was delivered for 90 sec via the virtual electrode needle during infusion of saline 10 ml/h at 50°C. The lines were created under electroanatomic map guidance and intracardiac ultrasound (ICE). The ejection fraction was monitored immediately before and after the ablation. One week after ablation, the dogs where restudied using CARTO epicardial and endocardial voltage mapping and hemodynamic testing. Results: The ablation lines created by a virtual electrode energy delivery made in the antero-lateral wall showed mean length of 4.4±1.4 cm. The mean area of ablation per lesion in the endocardium, mid myocardium and epicardium was 1.1±1.0, 2.6±1.3 and 1.9±1.3 cm 2 (p<0.05) respectively, with a mean ablation depth of 1.5±0.5 cm. Sixty-four percent of the length of lesions were transmural and in non-transmural areas had an average depth of 90±16% of wall thickness. The mean number of gaps/line was 0.5±0.7 with a length of 0.6 cm. Ejection fraction was 50±14, 52±17 and 52±13% before, after and 1 week post ablation respectively. At one week the epicardial and endocardial areas of low bipolar voltage < 1.5mV and dense scar < 0.5mV in the Carto map were 11.4±1.2 and 7.9±6.1cm 2 respectively which measurements were confirmed at necropsy by macroscopic scar in the epicardium and endocardium of 11.8±4.3 and 6.6±4.1 cm 2 respectively. Conclusion: This new novel saline-injection needle catheter effectively creates continuous long transmural lines in the infarcted LV. These data also confirm that the macroscopic ablation lesions can be consistently and accurately monitored by 3D electroanatomical mapping in both endocardium and epicardium.

Abstract Aims With the implementation of saline-enhanced radiofrequency (SERF) needle-tip ablation, real-time validation of lesion formation is needed for the controllable creation of transmural lesions. The aim of the study was to analyse the ability of two-dimensional intracardiac echocardiography (2D-ICE) to guide and validate SERF ablation in real-time. Methods and results Fifty-six SERF energy deliveries at left ventricular sites of 11 dogs guided by 2D-ICE were analysed (power: 15–50 W; time: 25–120 s; irrigation saline: 60°C with 10 mL/min flow rate). Catheter tip/tissue orientation and lesion formation could be well detected by 2D-ICE in 49 (87.5%) energy deliveries. Gross pathology analysis confirmed excellent 2D-ICE lesion localization, the ability to detect transmural lesions (70% sensitivity, 47% specificity) and positive correlation between 2D-ICE and the corresponding gross pathology measurements of ‘maximal lesion depth’; (repeated measures correlation: rrm = 0.43, P = 0.012) and ‘depth at maximal lesion width’ (D@MW; rrm = 0.51, P = 0.003). The median angle between SERF catheter tip and endocardium was 76° [interquartile range (IQR) 58–83°]. The more perpendicular the catheter tip/tissue orientation was the deeper D@MW (rrm = 0.32, P = 0.045). Grade 3 microbubbles on 2D-ICE during ablation, indicating inadequate catheter tip/tissue contact, was associated with smaller lesion volumes than with Grade 1 microbubbles (284.8 mm3 [IQR 151.3–343.1] vs. 2114.1 mm3 [IQR 1437.0–3026.3], P &lt; 0.001). Conclusion With excellent lesion localization and a 70% detection rate of transmural lesions, 2D-ICE is well suited to validate SERF ablation lesion formation in real-time. The catheter tip/tissue angle impacts the lesion formation and through perpendicular catheter positioning, deeper intramural areas of the myocardium can be reached.

OBJECTIVE The authors aimed to demonstrate the feasibility and advantages of carbon fiber–reinforced PEEK (CFRP) composite implants in patients with both primary and secondary osseous spinal tumors. METHODS Twenty-eight spinal tumor patients who underwent fixation with CFRP hardware were retrospectively identified in a Spine Tumor Quality Database at a single institution. Demographic, procedural, and follow-up data were retrospectively collected. RESULTS The study population included 14 females and 14 males with a mean age of 60 years (range 30–86 years). Five patients had primary bone tumors, and the remaining patients had metastatic tumors. Breast cancer was the most common metastatic tumor. The most common presenting symptom was axial spine pain (25 patients, 89%), and the most common Spine Instability Neoplastic Score was 7 (range 6–14). Two patients in this series had anterior cervical procedures. The remaining patients underwent posterior thoracolumbar fixation. The average fusion length included 4.6 vertebral segments (range 3–8). The mean clinical follow-up time with surgical or oncology teams was 6.5 months (range 1–23 months), and the mean interval for last follow-up imaging (CT or MRI) was 6.5 months (range 1–22 months). Eighteen patients received postoperative radiation at the authors’ institution (16 with photon therapy, 2 with proton therapy). Eleven of the patients (39%) in this series died. At the last clinical follow-up, 26 patients (93%) had stable or improved neurological function compared with their preoperative status. At the last imaging follow-up, local disease control was observed in 25 patients (89%). Two patients required reoperation in the immediate postoperative period, one for surgical site infection and the other for compressive epidural hematoma. One patient was noted to have lucencies around the most cephalad screws 3 months after surgery. No hardware fracture or malfunction occurred intraoperatively. No patients required delayed surgery for hardware loosening, fracture, or other failure. Early tumor recurrence was detected in 3 patients. Early detection was attributed to the imaging characteristics of the CFRP hardware. CONCLUSIONS CFRP spinal implants appear to be safe and comparable to conventional titanium implants in terms of functionality. The imaging characteristics of CFRP hardware facilitate radiation planning and assessment of surveillance imaging. CFRP hardware may enhance safety and efficacy, particularly with particle therapy dosimetry. Larger patient populations with longer-term follow-up are needed to confirm the various valuable aspects of CFRP spinal implants.

BACKGROUND Intramedullary spinal cord tumors represent a minority of intradural tumors. Among intramedullary spinal cord tumors, hemangioblastomas are uncommon, and schwannomas are extremely rare. Collision tumors are histologically distinct tumors that are intermingled and growing together. OBSERVATIONS In this report, the authors describe a patient with a cervical intramedullary collision tumor involving a hemangioblastoma and schwannoma. To the authors’ knowledge, no prior spinal intramedullary collision tumor involving multiple neoplasms has been described. The patient’s presentation and management are described. LESSONS Clinicians should consider the possibility of collision tumors when evaluating intramedullary spinal cord tumors, especially when patient presentation and radiographic findings are atypical. When tumors with similar radiographic characteristics form collision tumors, distinction using preoperative imaging can be extremely challenging. In addition, surgical management of intramedullary collision tumors, like that for all intramedullary spinal cord tumors, should involve meticulous perioperative care and a methodical surgical technique. Maximal safe resection will depend upon histopathological diagnosis, anatomical location of the tumor, presence of distinct dissection planes, and stability of neuromonitoring. Finally, ongoing research on the genetics of intramedullary spinal cord tumors may identify underlying genetic links for intramedullary hemangioblastomas and schwannomas.

BACKGROUND Anterior lumbar fusion procedures have many benefits and continue to grow in popularity. The technique has many potential approach- and procedure-related complications. Symptomatic retroperitoneal fluid collections are uncommon but potentially serious complications after anterior lumbar procedures. Collection types include hematomas, urinomas, chyloperitoneum, cerebrospinal fluid collections, and deep infections. OBSERVATIONS The authors present an unusual case of a patient with persistent symptoms related to a retroperitoneal collection over a 5-year period following anterior lumbar fusion surgery. To the authors’ knowledge, no similar case with such extensive symptom duration has been described. The patient had an infected encapsulated fluid collection. The collection was presumed to be a postoperative lymphocele that was secondarily infected after serial percutaneous drainage procedures. LESSONS When retroperitoneal collections occur after anterior retroperitoneal approaches, clinical clues, such as timing of symptoms, hypotension, acute anemia, urinary tract infection, hydronephrosis, elevated serum creatinine and blood urea nitrogen, low-pressure headaches, anorexia, or systemic signs of infection, can help narrow the differential. Retroperitoneal collections may continue to be symptomatic many years after anterior lumbar surgery. The collections may become infected after serial percutaneous drainage or prolonged continuous drainage. Encapsulated, infected fluid collections typically require surgical debridement of the capsule and its contents.