Citations

Background Stereotactic body radiotherapy (SBRT) is increasingly used for patients with oligometastatic prostate cancer, yet the optimal target definition, dose, and toxicity profile for rib metastases remain uncertain. Objectives We assessed local control (LC), toxicity, and the risk of radiation-induced rib fracture (RF) after SBRT for rib metastases. Design Retrospective multicenter cohort study. Methods We analyzed prostate cancer patients with radiologically diagnosed rib metastases treated with SBRT and >=12 months of follow-up. Outcomes were descriptively compared between gross tumor volume (GTV)-only and GTV plus an intraosseous clinical target volume (CTV) margin. Analyses included Kaplan-Meier survival estimates, cumulative incidence functions, and exploratory univariable Cox and logistic regression; no formal equivalence testing or multivariable validation was attempted because event numbers were very low. Results We included 102 patients with a median follow-up of 20 months. The 1- and 2-year LC rates were 97.9% and 96.3%, respectively. At 3 years, local progression was 2.1% in the GTV-only group, absent in patients treated with >=10 mm margins, and numerically highest with 3-5 mm CTV margins (13.5%, p=0.022). Among 13 symptomatic patients, pain control was excellent, with complete or partial response in all patients within 6 months. No grade >=3 toxicities occurred. RFs were rare (n=3, 2.9%), comprising one symptomatic Grade 2 event (0.9%) and two asymptomatic Grade 1 events (2.0%). Baseline symptoms and extraosseous infiltration were associated with RF in exploratory univariable analysis, but confidence intervals were wide. Higher PTV dose exposure, particularly PTV D50% (36.9 vs. 31.1 Gy, p=0.041), was also observed among RF cases. Conclusions SBRT for rib metastases from prostate cancer was associated with high LC, pain relief, and low observed toxicity in this retrospective real-world cohort. GTV-only contouring may be feasible in carefully selected patients staged and planned with PSMA-PET/CT, but the non-randomized design, baseline imbalances, short follow-up, and very low event count preclude drawing conclusions about equivalence or independent validation. RF predictor analyses should be considered exploratory and hypothesis-generating.

Abstract Objective To evaluate the connection between symptom burden and sexual quality of life in women with idiopathic subglottic stenosis (iSGS). iSGS is a rare fibroinflammatory disorder involving progressive airway narrowing and respiratory distress. While the impact on physical functioning is well‐established, the influence of iSGS on sexual health, a key component of quality of life, remains unexplored. Study Design Anonymized cross‐sectional survey using validated questionnaires. Setting Online international iSGS support group (Living with Idiopathic Subglottic Stenosis). Methods The Dyspnea Index (DI), the Female Sexual Quality of Life (SQOL‐F) questionnaire, and the Medical Outcomes Health Survey (SF‐36) were distributed to an iSGS support group. Only complete responses were analyzed. Associations between DI and sexual quality of life were evaluated using correlation and linear regression. Median‐based symptom burden groupings were used for secondary descriptive comparisons. Results 682 completed all items in the assigned questionnaires and met inclusion criteria. DI scores were inversely correlated with SQOL‐F (Rho = −0.305, P < .001). SQOL‐F was consistently lower among those with high symptom burden across nearly all items; only partner communication showed no difference. Each one‐point increase in DI predicted a 0.61‐point decrease in SQOL‐F ( B = −0.609, P < .001). High‐burden patients also reported significantly lower SF‐36 Physical (PCS) and Mental (MCS) Component Scores. Conclusions Greater airway symptom burden in iSGS is associated with significantly diminished sexual and general health‐related quality of life. These findings reinforce a need for patient‐centered care that considers both physical and psychosocial well‐being.

Abstract General anesthesia increasingly facilitates asleep deep brain stimulation (DBS) surgery but suppresses spontaneous electrophysiological signals used to guide lead placement. Here, we investigated whether evoked resonant neural activity (ERNA), a stimulation-evoked biomarker of basal ganglia circuitry, remains informative during asleep DBS. We analyzed intraoperative recordings from a multisite cohort of 45 patients (86 hemispheres) undergoing subthalamic nucleus or globus pallidus internus DBS under awake and anesthetized conditions. Anesthesia markedly attenuated spontaneous beta and high-frequency oscillatory activity. Although ERNA amplitude was reduced at matched stimulation intensities, increasing stimulation current restored high-amplitude, spatially localized responses while preserving anatomical specificity. Across both targets, ERNA spatial distributions remained stable across awake and anesthetized states, co-localized with established motor-network biomarkers, and retrospectively identified electrode levels associated with the greatest postoperative therapeutic window. These retrospective findings position stimulation-evoked circuit interrogation as a complement to imaging for physiology-guided asleep DBS and as a candidate signal for contact prioritization. Prospective studies are warranted to determine whether ERNA-guided decisions improve placement, programming efficiency and clinical outcomes.

Background Cerebellar tonsillar ectopia may arise from altered cerebrospinal fluid (CSF) dynamics and can mimic Chiari I malformation. Differentiating between pressure-induced tonsillar descent and congenital malformations is essential. We present an interesting case that visualizes variable tonsillar displacement levels as an indicator of CSF dynamics. Case A 3-year-old boy presented with headache and sixth nerve palsy and was diagnosed with idiopathic intracranial hypertension. Initial magnetic resonance imaging (MRI) revealed a 5 mm descent of the cerebellar tonsils. During hospitalization, the patient underwent mastoidectomy for an incidental T2 hyperintense lesion. Subsequent MRI scans demonstrated the resolution of tonsillar displacement. At age 5, the patient experienced worsening headache. Brain MRI revealed a 13 mm descent of the cerebellar tonsils below the foramen magnum and pachymeningeal enhancement. Further evaluation revealed transtemporal CSF leakage through the previous mastoidectomy site into the soft neck tissues. Conclusion This case exemplifies cerebellar tonsillar displacement associated with both intracranial hypertension (push) and hypotension (pull), illustrating opposite causal directions of CSF dynamics in the same patient. Understanding the phenomenon as a result of dynamic CSF balance rather than unidirectional force or fixed pathophysiology can enhance monitoring of patients.

ABSTRACT Objective Idiopathic subglottic stenosis (iSGS) is a rare, fibroinflammatory airway disorder with non‐standardized management. This study aimed to quantify the global clinical variation in surgical strategies for iSGS and identify barriers and facilitators to the adoption of both established and novel techniques. Methods An international cross‐sectional online survey was responded to by 193 clinicians (otolaryngologists, thoracic surgeons, and interventional pulmonologists) across 42 countries. Data on demographics, technique execution, treatment algorithms, clinician satisfaction (7‐point Likert scale), and adoption barriers were collected. Both statistical analysis and thematic analysis were performed. Results Otolaryngologists constituted the majority of respondents (84%), predominantly from Europe (52%) and North America (28%). Endoscopic dilation was nearly universal (95%), but execution was heterogeneous (85% used occlusive balloons, 56% used CO 2 laser). Newer techniques showed varied adoption: In‐office serial intralesional steroid injections were used by 57% of clinicians and the Maddern procedure by 17%. Overall satisfaction with current treatment strategies was moderate (mean Likert score: 5.07; SD = 1.15). Significant variation was found in the definition of treatment failure. Fellowship‐trained surgeons managed higher case volumes and were more likely to perform complex open surgery ( p = 0.019). Key barriers to adoption included lack of experience and insufficient supporting evidence. Conclusion Significant global clinical variation exists in the management of iSGS, affecting surgical technique, adjuvant therapy, and the definition of treatment failure. Standardization of clinical outcomes, continued large‐scale comparative effectiveness trials, and newer efforts aimed at implementing emerging evidence are needed to reduce variability, establish evidence‐based guidelines, and improve global patient care for this complex disease. Level of Evidence 5.

Cardiovascular disease causes the largest number of deaths across the world. The weak regenerative ability of adult hearts originates from limited cell proliferation and polyploidization of postnatal cardiomyocytes, which severely hinders tissue repair after myocardial injury. Fetal development represents a critical window during which maternal physiological and metabolic status can shape long-term offspring cardiac structure and function. Maternal exercise represents a safe nonpharmacological prenatal intervention that confers long-term benefits to offspring health. Available evidence indicates that maternal exercise enhances placental apelin secretion and elevates α-ketoglutarate (α-KG) levels in fetal brown adipose tissue, liver, and skeletal muscle. The apelin and α-KG signaling cascade participates in epigenetic regulation and confers protective effects on offspring metabolic health. Independent animal experiments have further validated that supplementation with either apelin or α-KG alleviates myocardial infarction (MI)-induced cardiac injury in adult mice, with α-KG showing direct evidence of reactivating cardiomyocyte proliferation. Nevertheless, it remains poorly elucidated whether maternal exercise could modulate fetal cardiomyocyte proliferative capacity in offspring through apelin- or α-KG-associated signaling. This narrative review integrates current evidence and proposes a testable framework in which maternal exercise influences fetal cardiac growth and regenerative potential through placental, metabolic, and epigenetic signaling. Because direct evidence remains limited, this model should be regarded as a hypothesis that requires further experimental validation.

Abstract Objective To evaluate the clinical value of breast MRI in radiation-associated angiosarcoma of the breast (RAASB) for assessing disease extent at diagnosis and after neoadjuvant therapy compared with clinical examination and surgical pathology. Methods This IRB-approved retrospective study included 25 patients with breast MRIs between1995 and 2020. MRI estimated disease extent was compared to clinical exam and surgical pathology. MRI findings were evaluated for additional disease and impact on clinical management. Agreement between MRI and clinical assessment of disease was evaluated using Cohen’s kappa statistic. Results Baseline MRI demonstrated moderate agreement with clinical disease extent (Cohen’s κ = 0.44; 95% CI, 0.14-0.75). Thirteen of 24 (54%) of MRIs reflected clinical exam, 4/24 (17%) MRIs underestimated disease, and 5/24 (21%) MRIs overestimated disease. Baseline MRI changed surgical management in 4/24 (17%). In 8 patients who proceeded directly to surgery, MRI reflected pathology in 6/8 (75%). In 10 patients with post-neoadjuvant MRI, 4/10 (40%) pathology and MRI extent were similar, 5/10 (50%) MRI overestimated disease, and 1/10 (10%) MRI underestimated disease. Conclusion MRI has clinical value in assessing RAASB with the potential for significantly altering surgical management. In this small cohort, post-neoadjuvant MRI demonstrated limited additional clinical value. Larger studies are needed to define the optimal role and timing of post-neoadjuvant MRI. Advances in knowledge Baseline MRI detected additional disease not identified on initial clinical exam in 5/24 (21%) and changed surgical management in 4/24 (17%). Although baseline MRI demonstrated moderate agreement with clinical examination, post-neoadjuvant MRI frequently overestimated residual disease when compared with final pathology.

Background: The Accreditation Council for Graduate Medical Education (ACGME) case log system establishes minimum clinical experiences for anesthesiology residency. While core program requirements were last updated in 2016, case log minimums themselves have not undergone a major revision in approximately two decades. Consequently, current requirements may not fully reflect changes in anesthetic practice and the evolving scope of perioperative medicine. In anticipation of major ACGME revisions in 2027, this study aimed to develop consensus-driven recommendations for modernizing residency case logs. Methods: A three-round modified Delphi study was conducted with a nationally representative panel of 60 stakeholders, including anesthesiology residency program directors and academic and private practice anesthesiologists. Panelists evaluated a comprehensive list of potential case categories across three domains: technical skills, surgical case characteristics, and patient demographics. In Round 1, panelists proposed minimum numbers or suggested that no requirement was necessary. Rounds 2 and 3 utilized iterative feedback to determine consensus on the necessity of requirements and specific minimum thresholds. Consensus was defined as at least two-thirds agreement. Results: Sixty invited experts completed all three rounds (100% response rate). The panel reached consensus to recommend new minimum requirements across several areas not currently tracked with minimums, including arterial lines (40), central lines (20), fiberoptic intubation (10), one-lung ventilation (10), neuromonitoring (10), POCUS (10 Cardiac, 10 Lung), and NORA (20 cases). Regarding existing requirements, consensus was reached to recommend increasing total peripheral nerve blocks from 40 to 60, with added requirements for anatomic specificity, and cardiac case minimums from 20 to 25. The panel also established consensus definitions for life-threatening pathologies to standardize reporting. The panel did not achieve consensus on several areas, including, for example, whether a minimum requirement for patients younger than 3 months should be maintained. Conclusion: These findings provide stakeholder-validated recommendations to inform upcoming ACGME requirement revisions.