Citations

Background: Radiologically Isolated Syndrome (RIS) is defined as incidentally found MRI abnormalities that are radiographically indistinguishable from multiple sclerosis (MS) and is considered a presymptomatic disease state of MS. Age <37 years, infratentorial or spinal cord lesions, gadolinium-enhancing lesions on index imaging, and positive cerebrospinal fluid oligoclonal bands have been identified as risk factors for conversion to MS. There are no existing guidelines regarding the role of disease-modifying therapy (DMT) in RIS patients. Objective: The objective of this study was to critically assess the current evidence regarding the impact of initiating DMT for patients with RIS on the time to first clinical attack of MS. Methods: The objective was addressed through the development of a structured critically appraised topic. This included a clinical scenario with a clinical question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, medical librarian, and content experts in the field of neuroimmunology. Results: A multicenter, prospective, randomized, double-blind, placebo-controlled trial was chosen for critical appraisal. This trial examined the impact of treatment with dimethyl fumarate (DMF) versus placebo on the risk of conversion from RIS to MS over a 96-week study period. Patients in the DMF arm were found to have an 82% reduction in risk of clinical attack. DMF patients also had a smaller number of new/newly enlarging T2 hyperintense lesions compared with placebo. No subgroup analyses were performed to elucidate risk factors for conversion. Conclusions: While initiation of DMT in RIS does appear to reduce the time to first clinical attack of MS, the risk factors that should prompt initiation of DMT in this patient population require further study.

ABSTRACT Genital lymphedema presents significant challenges in surgical management, with limited effective interventions. This case report explores the use of contrast‐enhanced ultrasound (CEUS) with microbubble injection as an alternative adjunct technique for lymphatic mapping in lymphaticovenous anastomosis (LVA) surgery for genital lymphedema. A retrospective chart review approved by our institutional review board was performed for patients with genital lymphedema undergoing LVA surgery between 2020 and 2024. Intraoperative CEUS for lymphatic mapping was used with intradermal injection of microbubble suspension Lumason (Bracco Suisse, Monroe Township, NJ, USA). Data regarding demographics, comorbidities, clinical and operative characteristics, complications, and surgical outcomes were retrieved. Three patients with genital lymphedema who underwent LVA were identified. The first patient was a 34‐year‐old female with recurrent lymphangioma circumscriptum and vesicular drainage. She successfully underwent CEUS‐guided LVA followed by two debulking procedures. The second patient was a 16‐year‐old male with congenital scrotal and lower extremity lymphedema. He had two CEUS‐guided LVAs and subsequent debulking for anterior scrotal swelling, with long‐term reduction in edema. The third patient was a 31‐year‐old female with primary lymphedema of the right lower extremity and genital region. She underwent seven CEUS and indocyanine green lymphography (ICG) guided anastomoses targeting the mons and lower abdomen, resulting in substantial symptomatic and volumetric improvement. CEUS detected target lymphatic vessels in all cases, including cases where ICG imaging failed to identify candidate lymphatic vessels. CEUS with intradermal microbubble injection successfully identified target lymphatic vessels in the preoperative planning for LVA surgery in patients with genital lymphedema.

Abstract Background Alcohol biomarkers including ethyl glucuronide (EtG) and phosphatidylethanol (PEth) are ordered frequently in clinical and forensic settings including solid organ transplantation. PEth provides a long detection window but can be insensitive to light drinking. In contrast, EtG and ethyl sulfate (EtS) can be elevated after light alcohol consumption and might complement PEth testing. Methods Urine EtG/EtS and whole blood PEth results were evaluated from all clinically-ordered testing between 2014 and 2024. PEth and EtG/EtS confirmation were performed by liquid chromatography tandem mass spectrometry at two reference laboratories, using cutoffs: Lab A, PEth 20 ng/ml, EtG and EtS 500 and 250 ng/ml; Lab B, PEth 10 ng/ml, EtG and EtS 250 and 100 ng/ml. Only Lab B performed EtG screening by immunoassay, using a 500 ng/ml cutoff. Results Phosphatidylethanol was positive in 1269 (15.6%) of 8131 samples, compared to 769 (6.7%) confirmed EtG/EtS positives from 11 555 samples. EtG screening (n = 9668) was positive in 743 (7.7%) samples, of which 30 (4.0%) confirmed negative (false positives); the screen was indeterminate in 267 (2.8%) samples, 66 of which confirmed positive and 172 negative. Of 3132 paired PEth and EtG samples, 2887 (92.2%) were concordant, 224 (7.2%) were PEth-positive, and 21 (0.7%) were EtG-positive. PEth was significantly more sensitive in paired samples (P &lt; .001), even after accounting for potential confounders such as transfusion. Limiting testing to PEth would have correctly identified alcohol consumption in 331 of 373 (88.7%) instances versus EtG/EtS in 149 (39.9%), and reduced charges by &gt;$720 000 USD. Discussion Phosphatidylethanol outperformed EtG/EtS in detecting alcohol consumption in a predominantly abstinent transplant population. Compared to PEth, EtG/EtS had lower overall positivity and poorer sensitivity in paired samples; additionally, EtG screening demonstrated false positives and indeterminate results. EtG testing provided little added value beyond PEth in this population, and did not warrant the increased cost of performing both tests.

Background: Right atrial thrombus (RAT), though rare, carries a high risk of pulmonary or systemic embolism and a 25–44% mortality rate. In LVAD candidates, coexisting RAT significantly complicates perioperative management due to their critical condition and high risk of decompensation during surgery. Percutaneous thrombectomy offers a less invasive, lower-risk alternative to open surgery, enabling faster recovery. Case Presentation: We present a case of a 76-year-old male with ischemic cardiomyopathy and heart failure secondary to Adriamycin chemotherapy with an ejection fraction (EF) of 26%, diabetes mellitus, and stage 3 chronic kidney disease, scheduled for left ventricular assist device (LVAD) implantation. Preoperative echocardiography revealed a large, multilobulated, mobile thrombus in the right atrium. Given the high surgical risk and thrombus mobility, percutaneous thrombectomy using the AngioVac system (Angiodynamics, Latham, NY, USA) was performed. The thrombus was successfully removed, and the patient was discharged on apixaban for long-term anticoagulation. Advanced medical therapy and transplant/durable LVAD evaluation were delayed by 35 days to allow for the stabilization of any postoperative effects. Conclusions: This case underscores the efficacy of percutaneous thrombectomy as a bridge to LVAD in high-risk patients, reducing thromboembolic complications and supporting safe LVAD implantation.

Coronary anomalies, although rare, should be considered when young patients present with angina. Clinical suspicion and multi-modality imaging including coronary angiography and tomographic imaging should be pursued for symptomatic patients such as the one we are presenting with anomalous right coronary artery from the pulmonary artery. She was promptly referred for surgical intervention with re-implantation of the right coronary artery onto the aorta.

Abstract Background: Spatial Reasoning AI (SRAI) systems are reshaping clinical practice by enabling real-time interpretation of complex anatomical structures in medical imaging, surgery, and chronic disease management (Lin et al., 2023, Qiao et al., 2021; Song et al., 2024) . Unlike traditional AI approaches that rely on tabular or 2D data, SRAI models incorporate geometric priors, multimodal fusion, and 3D anatomical reasoning to support high-impact tasks such as volumetric segmentation, disease localization, and intraoperative guidance (Milletari et al., 2016; Hatamizadeh et al., 2022; Zhang et al., 2022) . Objective: This scoping review aimed to (1) characterize the emerging landscape of spatial reasoning models in healthcare, (2) evaluate their clinical performance across diagnostic and prognostic applications, and (3) identify architectural trends that underpin successful translation into practice. Methods: Following PRISMA guidelines, we systematically screened PubMed to identify studies that implemented spatially aware AI models with real-time or clinically validated outcomes (Page et al., 2021) . Data extraction captured model architecture, modality, anatomical scope, clinical application, and performance metrics. Results: We identified 124 eligible studies across the clinical domains of oncology, neurology, cardiology, orthopedic surgery, and infectious diseases (Nie et al., 2019; Hao et al., 2020; Tasken et al., 2023) . SRAI systems consistently outperformed conventional methods in segmentation, lesion classification, and risk stratification. (Lin et al., 2023; Qiao et al., 2021; Mahootiha et al., 2024) . A paradigm shift from task-specific CNNs to foundation models that reason across spatial structures has emerged, beginning with adaptations of generalist models such as MedSAM and MedCLIP for zero-shot segmentation and cross-modal retrieval, and NeRF-based reconstruction for anatomically faithful 3D modeling (Ma et al., 2024; Mildenhall et al., 2020; Radford et al., 2021). Beyond technical performance, randomized evidence shows that SRAI systems can improve workflow efficiency without compromising outcomes (Lang et al., 2023) . Conclusion: SRAI models hold promise for enhancing diagnostic accuracy, prognostic precision, and clinical efficiency across diverse applications. Their successful integration will depend on standardized evaluation metrics, robust validation, and interpretable outputs. As foundation models evolve to better encode spatial priors, SRAI is poised to become a cornerstone of personalized and procedural medicine.