Citations

Background: Hip decompression effectively treats early-stage osteonecrosis of the femoral head (ONFH) by slowing disease progression and potentially delaying joint replacement. Biological adjuvants like bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP) support bone regeneration and improve outcomes 1–7 . The present video article demonstrates a simple, coreless hip decompression technique with BMAC and PRP injection for early-stage ONFH. Description: The procedure is performed in the same operating room setting as traditional core decompression, with the patient supine on a radiolucent table for fluoroscopic guidance. One or both legs are draped free for access to the iliac crests. Bone marrow is harvested percutaneously from the anterior superior iliac crest with a trocar needle kit, centrifuged, and prepared for injection. We recommend precoating needles and syringes with 1:1,000 heparin to prevent clotting. The BioCUE System (Zimmer Biomet) is typically utilized for centrifugation. Hip decompression is performed with use of a trocar and cannula (PerFuse System; Zimmer Biomet), with subsequent injection through the cannula into the femoral head. A 0.5-cm skin incision is made. The trocar is placed lateral to the femur and advanced percutaneously through the lateral femoral cortex, with a starting point proximal to the lesser trochanter. The trocar is then advanced along the femoral neck into the necrotic region by performing mallet strikes on the instrument’s strike cap. Anteroposterior and frog-leg lateral views assist in positioning the trocar within the necrotic area. Internal leg rotation, which aligns the patella upward, helps position the trocar horizontally parallel to the floor. Positioning is adjusted using repeated imaging as needed. Once the patient is positioned, the trocar is removed, leaving the cannula in place. With the cannula retracted 1 cm, a 30-mL syringe is utilized to inject BMAC and PRP into the necrotic lesion. Because of sclerotic resistance, substantial pressure is needed, but retraction of the cannula helps. Following injection, the cannula is withdrawn another 1 cm, and demineralized bone matrix is injected to prevent escape of the BMAC. Alternatives: Alternative treatments for ONFH include traditional core decompression with a sliding hip screw drill or an X-REAM device (Stryker), both of which carry a higher risk of fracture because of the larger diameter of the tract and require limited weightbearing postoperatively. Bone-cement injection can stabilize the femoral head but lacks regenerative properties. Core decompression with either BMAC or PRP alone, rather than in combination, also serves as an alternative treatment strategy. Open approaches, like osteotomy, are more invasive, have longer recovery times, and may complicate future hip arthroplasty if unsuccessful. Rationale: This technique enables minimally invasive hip decompression and delivery of adjuvant cell therapy or grafting, typically without the use of power instruments. This approach avoids the risk of injuring the bone due to the heat from power tools, protecting the BMAC injection site. Patients are generally discharged the same day and permitted full weight-bearing immediately, even in bilateral surgeries. Expected Outcomes: Hip decompression for ONFH has shown variable rates of success 8,9 , but adding BMAC or PRP may improve outcomes 1–3 . Houdek et al. reported that among 35 hips treated with decompression plus BMAC and PRP for corticosteroid-induced ONFH, 88% avoided THA at 3 years 2 and 70%, at 7 years 3 . Patients with grade-1 or 2 Kerboul angles had a 90% survivorship rate, underscoring the benefits of BMAC and PRP. Important Tips: Insert the trocar into the lateral cortex, positioned distal to the vastus ridge and proximal to the lesser trochanter, to reduce iatrogenic subtrochanteric fracture risk. Avoid advancing closer than 5 mm to the subchondral cortex to prevent joint-surface disruption or collapse, especially with eccentric lesions. If resistance occurs during injection, retract the cannula a few millimeters laterally to increase delivery space and reduce pressure. Acronyms and Abbreviations: BMAC = bone marrow aspirate concentrate ONFH = osteonecrosis of the femoral head PRP = platelet-rich plasma AP = anteroposterior THA = total hip arthroplasty ARCO = Association Research Circulation Osseous classification MRI = magnetic resonance imaging

Abstract Objective: Reading is a complex cognitive process requiring the integration of orthographic, phonological, and semantic information. The visual word form area, located in the ventral occipitotemporal cortex, is critically involved in orthographic decoding, and damage to this region is known to cause alexia. In contrast, the contributions of white matter pathways supporting reading are less well understood. Method: We present a unique neurosurgical case undergoing awake brain surgery for resection of a metastasis in the left occipitotemporal cortex. A tubular retractor was used to access the lesion and during the insertion of the retractor the patient underwent careful, continuous neuropsychological testing, including evaluation of reading. fMRI language mapping and diffusion MRI were performed preoperatively. Postoperative neuropsychological testing was completed two weeks after surgery to assess cognitive outcome. Results: The patient developed an alexia with letter-by-letter reading in real time during insertion of the tubular retractor. Stealth imaging enabled localization of the tubular retractor at the exact onset of the alexia and, by correlating this with tractography, showed that the tubular retractor was in the vertical occipital fasciculus (VOF). Conclusions: We present the first detailed case report linking the VOF to the acute onset of alexia observed intraoperatively during awake brain surgery. We discuss the connectomics of reading and possible contributions of the VOF in reading.

Background: Lung cancer is classified into small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC – including adenocarcinoma, squamous cell, and large cell carcinoma). The incidence of major adverse cardiovascular events (MACE)—defined as acute myocardial infarction, acute coronary syndrome/ischemic heart disease requiring revascularization, stroke, and cardiovascular death—have not been well defined in lung cancer patients following treatment. Coronary artery calcifications (CAC) and aortic calcifications (CA) are known cardiovascular risk markers in non-cancer populations. Purpose: To determine whether the presence of CAC or CA, as identified on baseline PET-CT (Positron Emission Tomography–Computed Tomography) or chest CT imaging, is predictive of MACE and all-cause mortality (ACM) in patients with lung cancer. Methods: We conducted a retrospective cohort study of patients diagnosed with SCLC or NSCLC who received chemotherapy, between January 1, 2010, and December 31, 2024. The baseline PET-CT or chest CT scans were reviewed for the presence of CAC and/or CA. Patients were excluded if they lacked baseline imaging or had experienced a MACE before treatment. Univariate and multivariate adjusted Cox regression models were employed to assess associations between CAC/CA and MACE or ACM. The Kaplan-Meier survival analyses was performed to evaluate event-free survival. Results: A total of 385 patients were included (mean age: 74 years, IQR: 67–79), predominantly female (158 [55%]) and white (279 [96.2%]). NSCLC was found in 255 (88%) and SCLC in 35 (12%). CAC was identified in 172 (60%) and CA in 87 (30%). Among patients with NSCLC, the presence of CAC was significantly associated with MACE (HR: 2.84 [95% CI: 1.6–4.8], p=0.0001) (Fig. a), particularly in those with adenocarcinoma (Fig. b). In SCLC, (HR: 1.56 [95% CI: 0.1–14.0], p=ns). On multivariable analysis, CAC remained the strongest predictor of MACE after adjusting for age, hypertension, diabetes, dyslipidemia, and smoking status (HR: 2.6 [95% CI: 1.5–4.4], p=0.0008) (Fig. d). No significant association was found between CA and MACE in either group (p>0.05). ACM was similar for SCLC, squamous cell, and NSCLC (Fig. c). Conclusion: In patients with NSCLC especially lung adenocarcinoma, the presence of CAC in the baseline PET/CT was an independent predictor of MACE. This finding supports the value of CAC as a non-invasive cardiovascular risk marker.

Introduction: Anthracycline-induced left ventricular dysfunction is well documented in lymphoma patients. However, the impact of cardiovascular risk factors (CVRF) and obesity on the right ventricle (RV) remains poorly characterized. Hypothesis: How does baseline CVRF burden—including obesity—affect RV structure and function over time in lymphoma patients treated with doxorubicin-based chemotherapy? Methods: A prospective cohort of patients with Hodgkin or non-Hodgkin lymphoma treated with doxorubicin-based chemotherapy at Mayo Clinic between March 1, 2013, and December 31, 2024, underwent echocardiography prior to chemotherapy initiation (T0), at 3–6 months (T1) and 6-18 months (T2) after treatment completion. A dedicated RV 4-Chamber view was used for all measurements. Patients were stratified into five groups: BMI>30, BMI>35, no CVRF, 1 CVRF (hypertension, diabetes, dyslipidemia, or smoking status), and ≥2 CVRF. RV parameters included end-diastolic/systolic area, FAC, TAPSE, S′ velocity, TRV, RVSP, and RV free wall strain. Group and time differences were analyzed using the Kruskal–Walli’s test due to non-normal distribution. Results: Among of 356 lymphoma patients (mean age 59.2 years, IQR:46-69) predominantly male (63.7%), 39.3% met criteria for obesity. At T0, patients with BMI >35 had greater RV end-diastolic (20.4 ± 4.4 vs. 18.7 ± 3.5 mm; p=0.009) and end-systolic diameters (11.0 ± 2.1 vs. 9.9 ± 2.6 mm; p=0.024), higher TRV (2.5 ± 0.4 vs. 2.2 ± 0.3 m/s; p<0.001) vs. no CVRFs. TAPSE was reduced vs. >2 CVRF group (23.7 ± 4.2 vs. 22.1 ± 4.8 mm; p=0.032). At T1, BMI >35 patients showed increased RV end-diastolic (22.3 ± 3.6 mm; p<0.001) and end-systolic areas (12.8 ± 2.9 mm; p<0.001), and worsened RVFWS (−24.0 ± 4.7% vs. −26.1 ± 2.98%; p=0.001) vs. no CVRF. RVSP was higher in those with >2 CVRFs (32.3 ± 5.4 mmHg; p=0.001). At T2, RVFWS was reduced in obese patients (−22.9 ± 3.5% vs. −27.1 ± 4.0%; p<0.001). RVSP stayed elevated in BMI >35 (33.0 mmHg) and >2 CVRFs (30.7 mmHg) vs. no CVRFs (23.7 mmHg; p<0.001). FAC and S′ did not differ significantly. Conclusion: In lymphoma patients treated with anthracyclines, isolated obesity was associated with the most pronounced RV changes—greater than those seen in non-obese patients with other CVRFs. These early and persistent alterations underscore the need for dedicated cardio-oncology care regardless of additional risk factors.

Background: Left atrial (LA) strain, measured by two-dimensional speckle tracking (2D-STE), has not been explored in lymphoma patients before anthracycline treatment as a prognostic marker for predicting future major adverse cardiovascular effects (MACE), heart failure, cardiotoxicity, and all-cause mortality after treatment. Hypothesis: Can an abnormal baseline LA peak reservoir strain (LA RS) measured before anthracycline chemotherapy predict MACE, heart failure, cardiotoxicity, and all-cause mortality in lymphoma patients? Methods: A retrospective cohort study was conducted including 104 patients diagnosed with Hodgkin and non-Hodgkin lymphoma, enrolled and followed from January 1, 2013, to June 30, 2023. LA RS was measured in a dedicated 4 chamber view (TomTec Imaging Systems, Unterschleissheim, Germany), abnormal values defined as less than 35%. Univariate Cox regression analyses were performed to assess whether the LA RS was associated with the development of MACE, cardiotoxicity, heart failure, and all-cause mortality. Multivariable Cox regression models were used to adjust for comorbidities. Associations with outcomes were evaluated using the Kaplan-Meier method and Cox regression. Results: Among 104 patients (mean age of 59 years; [IQR], 49–70), 69 (66.3%) were male and 102 (98.1%) were white. MACE occurred in 19 patients, heart failure in 14 patients, and cardiotoxicity was observed in 4 patients. Additionally, all-cause mortality was found in 19 patients (18.3%). Abnormal LA RS was significantly associated with increased all-cause mortality (HR 3.12, 95% CI 1.02–9.53, p=0.0454) (Figure c), even after adjusting for hypertension, dyslipidemia, smoking status, gender and age (Figure d). No significant associations were found between LA RS and MACE (HR 1.42, 95% CI 0.56-3.62, p=0.4604) (Figure a), heart failure (HR 1.12, 95% CI 0.38-3.24, p=0.8299), or cardiotoxicity (HR 3.23, 95% CI 0.33-31.47, p=0.3128) (Figure b). Conclusions: Abnormal baseline LA strain measured by echocardiography is an independent predictor of all-cause mortality in lymphoma patients. These findings support the use of LA strain assessment into initial risk stratification protocols, providing particular value in identifying patients at increased risk of mortality.

ABSTRACT Suicidality contributes substantially to global morbidity and mortality, yet despite its heritability, its biological etiology remains largely elusive. We conducted multi-ancestry genome-wide association study meta-analyses of suicidal ideation (259,747 cases), suicide attempt (64,993 cases), suicide death (9,197 cases), and suicidal behavior (suicide attempt/ death, 75,300 cases), across 54 cohorts (e.g., the Psychiatric Genomics Consortium, Million Veteran Program, UK Biobank). We identified 77 significant loci across meta-analyses, including 59 previously unreported for suicidality. SNP-based heritability ranged from 2.0-6.7% and there were strong, yet incomplete, genetic correlations between suicidality phenotypes (0.70-0.88). Fine-mapping prioritized putative causal SNPs and 20 credible genes. Enrichment analyses implicated synaptic pathways and neuronal populations predominantly in subcortical brain regions (e.g., amygdala excitatory, medium spiny, hippocampal CA1-3). Together, these findings establish suicidality as a polygenic set of traits with both shared and distinct genetic influences, providing a foundation for future studies of suicide biology and etiology.

Abstract Context Thyroid nodules are common in clinical practice, and inappropriate selection of patients for thyroid biopsy can contribute to thyroid cancer overdiagnosis or delayed diagnosis. Objective This work aimed to evaluate the frequency of inappropriate thyroid biopsies in practice, following a framework that integrates thyroid nodule ultrasound (US) features and patient-specific clinical factors. Methods This cross-sectional study was conducted at a single academic center in the United States. Participants included adult patients who underwent their first thyroid fine-needle aspiration (FNA) biopsy between January 1, 2016, and December 31, 2023, at the University of Florida. Data collection included thyroid US characteristics, clinical factors (eg, comorbidities, patient preferences), and context for biopsy decision-making. Main outcome measures included the appropriateness of thyroid biopsy assessed using a tiered framework incorporating US features and additional clinical factors. Results A total of 899 patients were evaluated, with 441 meeting the inclusion criteria and undergoing 481 thyroid biopsies. Of these, 388 of 481 (80.7%) were classified as likely appropriate (L-APP) based on the American College of Radiology Thyroid Imaging Reporting and Data System criteria. In 34 of 481 (7%) of cases, clinical factors such as thyroid cancer risk features, comorbidities, symptoms, or patient preferences led to reclassification from likely inappropriate (L-INAP) to L-APP. In 50 of 481 (10%) of cases, limited life expectancy (eg, chemotherapy, end-stage disease) led to reclassification from L-APP to possibly or extremely inappropriate (EXT-INAP). EXT-INAP biopsies occurred in only 0.8% (4/481) of cases. Conclusion This study underscores the value of integrating US findings with clinical context to guide thyroid biopsy decisions and enhance patient-centered care.

Abstract Increased demand to make medical linear accelerator acceptance testing procedures (ATP) more efficient exists while the technology being evaluated for clinical use has become increasingly complex. The most recent American Association of Physicists in Medicine (AAPM) task group giving guidelines to medical physicists on ATP was Task Group report 45, published in 1994. Several new technologies, enhanced machine performance, and possible future changes to ATP since that time require updated guidance from the AAPM. The goal of this task group is to empower the medical physicist to be meaningfully involved with the design and execution of comprehensive and effective linear accelerator ATP beginning with the purchasing contract negotiation to the contractual handover of the linear accelerator to the department for clinical use. Additionally, we discussed aspects related to beam matching, ATP at the time of replacing major linear accelerator's components as well as what we perceive as the future of the ATP process given the trends of standardizing linear accelerators.