United States

BACKGROUND/PURPOSE: Post-traumatic osteoarthritis is a degenerative joint disease that leads to the exposure of type II collagen (CII) fibers and increased matrix metalloproteinase (MMP) activity. Injection of adipose-derived stem cells (ADSCs) into the diseased joint has been explored as a promising treatment option due to its strong potential to repair damaged cartilage tissue through immunomodulation and chondrogenic differentiation. However, clinical translation of stem cell therapy has been limited by poor retention and targeting within the joint cavity. This study aims to evaluate the effectiveness of an injectable type I collagen (Col I) scaffold conjugated with a monoclonal antibody against CII (MabCII) for targeted delivery of ADSCs to damaged cartilage in a murine PTOA model.

GOALS: To determine whether MabCII-Col I scaffolds enhance the localization and therapeutic potential of ADSCs in reducing cartilage degradation and inflammatory markers in PTOA.

METHODS/DESIGNS: PTOA was induced in 10-week-old female CBA mice via non-invasive mechanical knee overloading. At 6 weeks post-loading, the subjects were divided into five groups of 6 mice: 1) normal mice (no mechanical loading), 2) PBS injection, 3) treatment with ADSCs only, 4) treatment with non-targeted CI scaffolds containing embedded ADSC or 5) treatment with Col I scaffolds linked to MabCII and containing embedded ADSC. ADSCs were integrated into scaffolds using EDC/NHS crosslinking. Functional assessment of pain-related behavior using dynamic weight bearing was done at 9 weeks post-treatment. IVIS imaging for free CII exposure and MMP activity was done at 12 weeks post-treatment.

RESULTS/FINDINGS: Mice treated with MabCII-targeted ADSC scaffolds showed significantly reduced IVIS fluorescence for MMP activity and exposed CII fibers compared to untreated PTOA controls, indicating decreased inflammation and cartilage degradation. Dynamic weight-bearing analysis revealed improved limb loading in the treated group. Non-targeted scaffold and ADSC-only groups showed intermediate results. Untreated PTOA controls had the poorest outcomes.

CONCLUSIONS/IMPLICATIONS: The results from this study demonstrate that targeted delivery of ADSCs using MabCII-linked Col I scaffolds in vivo improves localization to damaged cartilage tissue and reduces cartilage degradation, inflammation, and pain-related behavior. This strategy represents a promising platform for the development of targeted ADSC therapies for osteoarthritis.


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In Vivo Analysis of Stem Cell Loaded Scaffolds Targeted with Antibodies to Type-II Collagen for Treatment of Post-Traumatic Osteoarthritis

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Background
Cesarean section (C-section) is the most common surgical procedure performed in the United States and a known contributor to initial opioid exposure among women of reproductive age. While neuraxial (epidural) anesthesia is the preferred technique for cesarean delivery, general anesthesia is still used in select clinical scenarios. Given the ongoing opioid crisis, it is critical to understand how anesthesia modality influences postoperative opioid prescribing patterns.

Methods
We conducted a retrospective cohort study using the TriNetX Global Collaborative
Network, a federated health research platform of electronic medical records from 148 healthcare organizations. Women aged 18–50 who underwent cesarean delivery between 2005 and 2025 were identified. Patients were grouped based on anesthesia type using CPT codes: general anesthesia (01961 only) and epidural anesthesia (01967 or 01968). Propensity score matching was performed on demographics, comorbidities, and prior medication exposures, resulting in two balanced cohorts each containing 78,572 patients. The primary outcome was receipt of an opioid prescription (morphine, oxycodone, hydromorphone, codeine, or tramadol) from day 1 to day 90 after surgery. Risk and survival analyses were conducted using TriNetX tools.

Results
Opioid prescriptions were more common in the general anesthesia group (74.3%)
compared to the epidural group (64.2%), with a risk difference of 10.1% and an odds ratio of 1.616. Kaplan-Meier survival analysis showed a significantly lower probability of remaining opioid-free at 90 days in the general anesthesia group (25.4% vs. 35.5%, log-rank p < 0.001). The hazard ratio for opioid use was 1.264 (95% CI: 1.249–1.279).

Conclusion
Women receiving general anesthesia for cesarean section were more likely to receive postoperative opioids and had a higher overall risk of opioid use within 90 days compared to those receiving epidural anesthesia. These findings underscore the importance of anesthesia choice in minimizing opioid exposure and guiding perioperative pain management strategies.

Association of Anesthesia Modality with Opioid Prescriptions After Cesarean Delivery: A Comparative Study of General and Epidural Techniques

Background
Non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) mutations constitutes a significant subset of lung cancer cases, particularly among non-smoking women of Asian descent. Brain metastases (BM) and leptomeningeal disease (LMD) occur more frequently in this disease, highlighting the unique biology of EGFR-mut NSCLC. Osimertinib, a third-generation oral tyrosine kinase inhibitor (TKI), has excellent central nervous system (CNS) penetration. However, there is a notable lack of guidelines regarding its use in combination with or sequentially with radiation therapy. This gap is particularly significant given the elevated rates of both CNS disease and LMD, highlighting an important unmet need in this population.
Methods
We retrospectively evaluated patients diagnosed with EGFR-mutated NSCLC with CNS disease over a 19-year period (2004-2023).
Results
Demographics: Our study included 158 patients with a median diagnosis age of 66 years. 68% were
female and 48% self-identified as Asian. Most patients did not have a smoking history (63%). Disease Characteristics: 80% of patients were diagnosed at stage IV, with 69% having CNS involvement. 23% of patients had LMD throughout their disease course. 23% of patients had poorly differentiated disease, and 85% had an exon 19 deletion or an L858R mutation.
Ó 2025 American Medical Association. All rights reserved.
Response: Among the evaluated patients, 48% received first-line Osimertinib, achieving a response rate (RR) of 79%. In comparison, 35% of patients were treated with non-Osimertinib TKI, demonstrating a RR of 85%. Focusing on the 55 patients who presented with CNS disease and received first-line Osimertinib, the CNS response rate was 67%, with a median duration of response (mDoR) of 44 months. For patients requiring subsequent therapy due to CNS progression, 73% received high-dose Osimertinib (120mg or 160mg), resulting in CNS RR of 44% and mDoR of 15 months. Meanwhile, 6 patients received chemotherapy, achieving an RR of 33%.
Conclusion
EGFR-mutated NSCLC with CNS disease mainly affects Asian females and is often diagnosed at stage IV with BMs. Osimertinib demonstrates significant and durable efficacy, outperforming earlier generation TKIs in systemic and CNS disease control. At CNS progression, high-dose Osimertinib was the preferred treatment strategy and showed superior efficacy in controlling CNS disease compared to chemotherapy. These results underscore Osimertinib’s critical role in frontline treatment and highlight the need for continued research to optimize CNS progression strategies. Data from our institution regarding outcomes in LMD and combination strategies with cranial local therapy across different EGFR mutations are forthcoming.

Osimertinib in EGFR-Mutant NSCLC with CNS Metastases: A 19-Year Single-Institution Retrospective Study

Abstract Title: Unmasking Tuberculosis: A Case of Pericardial Effusion in a Young Adult with Recurrent Pneumonia
Background
Tuberculosis (TB) remains a major global health concern. While pulmonary TB is the most common manifestation, extrapulmonary tuberculosis (EPTB), particularly involving the pericardium, can lead to life-threatening complications such as cardiac tamponade. TB pericarditis accounts for 1–2% of TB cases and is a leading cause of large pericardial effusions and constrictive pericarditis in developing countries. Diagnosis can be challenging in immunocompetent patients without classic TB symptoms.
Case Presentation
A 25-year-old Indian male with no significant past medical history presented to the emergency department (ED) with a two-week history of productive cough and pleuritic chest pain. He had previously presented to the ED five days prior and was discharged against medical advice with azithromycin, which offered minimal relief. On readmission, he was diagnosed with multifocal pneumonia and started on intravenous antibiotics before being discharged on oral therapy. He returned one month later with worsening respiratory symptoms. Imaging revealed a left-sided pleural effusion and a large pericardial effusion. Echocardiogram confirmed tamponade physiology. A CT chest also demonstrated cavitary lesions in the left upper lobe. Pericardial window was performed, yielding 1 liter of clear pericardial fluid. Sputum acid-fast bacilli (AFB) smear was strongly positive, confirming Mycobacterium tuberculosis infection. The patient was started on RIPE therapy and TB control authorities were notified.
Discussion
This case illustrates a rare but critical presentation of extrapulmonary tuberculosis as pericardial effusion with tamponade physiology in a young, immunocompetent adult without classic constitutional symptoms. Initial misdiagnosis as community-acquired pneumonia delayed TB-specific testing and treatment. This highlights the need to maintain high clinical suspicion for TB in patients with recurrent pneumonia, pleural or pericardial effusions, especially those with epidemiologic risk factors such as prior travel to endemic areas. Early chest CT and echocardiography were key in identifying extrapulmonary involvement, prompting timely intervention. Pericardial TB, though rare, carries significant morbidity if undiagnosed and should be considered in patients with unexplained pericardial effusions. Comprehensive evaluation including imaging and microbiological studies is crucial for timely diagnosis and management to prevent complications and reduce disease transmission.

Unmasking Tuberculosis: A Case of Pericardial Effusion in a Young Adult With Recurrent Pneumonia

A mild traumatic brain injury (mTBI) is defined as an injury to the brain due to sudden changes in velocity or blunt force trauma to the head, such as during a motor vehicle accident (MVA). Common sequelae include headaches, cognitive deficits, fatigue, and behavioral changes. The temperature of brain tissue during the time of injury has shown to affect outcomes of mTBI. Prior studies have found that the thalamus, hippocampus, cerebellum, and amygdala are particularly susceptible to heat damage. We investigated possible relationships between average temperature and humidity in relation to size values of the amygdala, hippocampus, cerebellum, and thalamus of patients with a history of mTBI. NeuroQuant software was used to analyze MRIs from 430 participants who experienced an mTBI from an MVA in the Las Vegas area. Historic temperature and humidity data was then sourced from the NCDC online database and the Visual Crossing weather database. Data was then compared across categorized temperature and humidity levels for the hippocampus, amygdala, thalamus, and cerebellum using Mood’s median test. Significant differences in total percent of ICV between temperature ranges were not observed for the brain regions of interest. Moderate statistical evidence for an effect was found between the hippocampus and humidity levels (Ꭓ2 = 7.06, p-value = 0.07). The results of our analysis suggests that temperature and humidity at the time of injury may not have a significant impact on post mTBI brain region size.


Exploratory Analysis of Environmental Factors and NeuroQuant MRI Data in Patients With History of mTBI From MVAs


Background: Although thousands of clinical trials are underway in cell and gene therapy (CGT), clinical adoption remains limited due to insufficient cell tracking data. Here, we are developing a novel genetically encoded (GE) reporter system that uses hyperpolarized (HP) magnetic resonance spectroscopic imaging (MRSI) to image metabolically active CGT. HP-MRSI allows for a 10^6-fold increase in signal intensity over traditional MR, while also enabling longitudinal detection of viable cells.
Methods: We engineered a system that includes a MR-compatible, highly specific enzyme-substrate pairing incorporating porcine liver esterase (PLE) and a 1-methyl-cyclopropyl protecting group on an ester. PLE cleaves these substrates without background hydrolysis by endogenous esterases. We genetically modified three hepatocellular carcinoma (HCC) cell lines (SNU-398, SNU-449, Huh7) and HEK293t controls to constitutively express PLE with dTomato. A PLE-flank tumor model of HCC was established using subcutaneous implantations of the GE cells. Toxicity was assessed with chemiluminescent viability assays, and in vitro enzyme kinetics were evaluated using UV-Visible spectroscopy, mass spectrometry, and HP-NMR for several PLE substrates. Natural abundance HP-NMR was used to determine which carbons are suitable for isotopic labeling based on polarizability with dynamic nuclear polarization MRSI, long T1 relaxation times, and sufficient metabolism.
Results: GE HCC and control cell lines tolerated substrate concentrations up to 10mM in cellulo without cytotoxic effects. The cell lines grew phenotypically normal flank tumors, and IVIS imaging confirmed dTomato expression. Michaelis-Menten analysis indicated sufficient PLE hydrolysis of all four substrates. Natural abundance HP-NMR revealed that substrate #4 had the fastest hydrolysis by PLE and is amenable to isotopic labeling, with sufficient T1 relaxation times and metabolism at both the carbonyl and quaternary cyclopropyl carbon. Substrate #4 also demonstrated in vivo compatibility with mouse plasma, as plasma solutes did not interfere with the compound’s T1 relaxation time.
Conclusion: Using kinetic evaluation and natural abundance HP-NMR, the proof of concept was validated that small cyclopropane ester molecules can serve as metabolic HP reporters in a system with PLE. The in vivo functionality of the system will be determined in the murine flank tumor model to demonstrate the potential of using this HP reporter system as a means of monitoring CGT. We plan to employ a functional HP reporter system to monitor delivery efficacy and therapeutic impact of an electroporation-based suicide gene delivery to HCC tumors. When administered as a prodrug, the HP reporter will facilitate tracking of enzymatic activity by the suicide gene and approximation of levels of intra-tumoral cell death.

Hyperpolarized MRI reporter for improved tracking of hepatocellular carcinoma gene therapy

Background: The combination of xanomeline, a central/peripheral muscarinic agonist, and trospium chloride, a peripheral muscarinic antagonist, (X/T) was FDA approved in September 2024 for schizophrenia in adults. X/T is the first medication indicated for schizophrenia psychosis that is not classified an “antipsychotic” by FDA as it reduces presynaptic dopamine without blocking or partially blocking postsynaptic dopamine receptors. FDA trial subjects with schizophrenia and no comorbidities experiencing an exacerbation or relapse of psychosis, who were neither treatment-resistant nor had taken clozapine, were tapered off previous antipsychotics, or were treatment-naive, prior to a rapid X/T titration in the hospital as monotherapy. Xanomeline is an intestinal CYP3A4 inhibitor that can transiently elevate 3A4 substrates, and CYP2D6 inhibitors can raise xanomeline levels and duration. However, for outpatient practitioners, the generalizability of the studied population and the treatment protocol is limited, leaving many real-world clinical questions about how to use X/T when comorbidities with schizophrenia are the rule, polypharmacy is commonplace, and discontinuing antipsychotics prior to X/T initiation is often infeasible due to safety concerns, such as psychotic relapse with potential risks to self or to others, in less supervised community settings.
Case Presentation: Based upon our early experience treating 40 adult outpatients with schizophrenia and comorbidities using X/T to date, we present 3 representative cases that are reflective of this cohort to illustrate clinical pearls we have uncovered through applying extant pharmacokinetic and pharmacodynamic preclinical and clinical data. Case 1 is an 18-year-old male with autism spectrum disorder and recent onset of schizophrenia, refractory to risperidone and aripiprazole plus benztropine for akathisia. Case 2 is a 45-year-old female with treatment-resistant schizophrenia on olanzapine with cardiometabolic side effects, gastroparesis, and tardive dyskinesia. Case 3 is a 75-year old female with clozapine-resistant schizophrenia, Alzheimer’s dementia, and obsessive compulsive disorder (OCD) on fluoxetine.
Discussion: To maximize efficacy while ensuring tolerability, it is important to track cholinergic (e.g. nausea, vomiting, diarrhea) versus anticholinergic (e.g. gastroesophageal reflux, constipation, urinary retention) side effects, and to adjust X/T dose, titration, administration, and concomitant medications accordingly. In addition to addressing positive, negative, and cognitive symptoms of schizophrenia, X/T holds potential to improve cognitive deficits in comorbid autism or dementia, OCD, tics, addictions, and ameliorate cardiometabolic side effects, gastroparesis and tardive dyskinesia symptoms associated with antipsychotic medications.

Xanomeline and trospium chloride for schizophrenia in adults: early outpatient experience

Background: Nailfold capillaroscopy (NFC) is an essential tool for evaluating microvascular abnormalities in patients with Raynaud’s phenomenon (RP), especially in United States (U.S.) Veterans. While dermatoscopy is an acceptable and cost-effective screening method for nailfold assessment in systemic sclerosis (SSc), published guidelines highlight the importance of clear image acquisition for appropriate interpretation. The objective of this project was assessment of NFC in patients with concern for connective tissue disease (CTD)-related RP to determine whether pigmentation of the skin impacts the interpretability of dermatoscopy screening.

Methods: Patients undergoing evaluation for CTD-related RP were consented for participation in Institutional Review Board approved research at the time of care at the Veterans Affairs (VA) Hospital (No. 1618579-17). Patients were prepared for NFC per published protocols. Images were obtained with two devices available at the VA Hospital, a dermatoscope attached to a smartphone (200X magnification, smart phone focus) and Smart G-Scope (250X magnification, USB automatic focus). Each image was classified for the clarity of image by two capillaroscopy experts. Microvascular findings for capillary density, apical enlargement, hemorrhages, and abnormal shapes were determined by the capillarscopy.io software application.

Results: A total of 38 U.S. Veterans were assessed for RP by NFC using clinically available two devices. Among these, 28% (n=11) of subjects were classified as African American. Dermatoscopy produced blurry images in 63.6% (7/11) of patients with Fitzpatrick skin type IV and V and 37% (10/31) in Fitzpatrick skin type I, II, and III. In 45.5% (5/11) of dermatoscopy exams in Fitzpatrick skin type IV and V skin were deemed uninterpretable compared to 37% (10/31) of Fitzpatrick skin type I, II, and III (kappa statistic >0.9). Smart G-Scope improved interpretability across the cohort of patients, especially in Fitzpatrick Skin Types IV and V. A scleroderma (SD)-pattern characteristic of scleroderma microangiopathy was detected by the Smart-G-scope in 3 of those 5 uninterpretable dermatoscope acquired images.

Conclusion:In patients with CTD-related RP, particularly among African American Veterans, a dermatoscopy device led to a high rate of uninterpretable examinations. The Smart-G USB device improved diagnosis of abnormal NFC. These results highlight that reliance on dermatoscopy alone as a screening tool may risk underdiagnosing microvascular involvement in SSc.

Dermatoscopy Limitation and the Critical Role of Capillaroscopy in Systemic Sclerosis and Raynaud’s Phenomenon among African American Veterans

ABSTRACT Background: Managing complex coronary artery disease in post-CABG patients remains challenging due to diffuse calcification, prior graft failure, and high surgical risk. Calcium modification with rotational atherectomy (RA) and intravascular lithotripsy (IVL) offers a novel hybrid approach to achieve optimal stent expansion and durable outcomes.
Case Summary: A 68-year-old male with prior CABG (LIMA–LAD patent, SVG–OM occluded) presented with CCS Class III angina. Coronary CTA demonstrated extensive multivessel calcific CAD (Agatston score 3120). Angiography revealed 80% distal LM stenosis extending into the ramus and LCx ostia, and an LCx ostial CTO (Syntax score 31). The patient underwent IVUS-guided PCI using a combination of RA (1.5 mm, 1.75 mm burrs) and IVL (3.5 × 12 mm balloon) to treat the LM bifurcation, followed by sequential DES implantation via the mini-crush technique. Post-PCI, TIMI 3 flow was achieved in all vessels with no procedural complications.
Outcome: The patient had an uneventful recovery and was discharged on dual antiplatelet and guideline-directed medical therapy. At one-month follow-up, he remained asymptomatic with preserved LV function.
Conclusion: This case highlights the efficacy of combined RA and IVL for calcium modification in complex LM bifurcation PCI and demonstrates that IVUS-guided multivessel PCI can be safely and effectively performed in post-CABG patients where surgical re-intervention carries prohibitive risk.
Keywords: Rotational Atherectomy, Intravascular Lithotripsy, Left Main PCI, Chronic Total Occlusion, Post-CABG, Intravascular Ultrasound

Triple Triumph-Multivessel PCI with RA and IVL for LM, Ramus & LCxCTO in Post-CABG Patient

INTRODUCTION: GLP-1 receptor agonists have gained widespread use in recent years due to their efficacy in managing type 2 diabetes and promoting weight loss. However, their association with acute pancreatitis remains a concern, particularly in patients with complex comorbidities. This case report describes a 74-year-old male with a significant medical history—including chronic lymphocytic leukemia, breast cancer, and multivessel coronary artery disease—who developed acute pancreatitis attributed to the GLP-1 agonist combination therapy, Soliqua (lixisenatide and insulin glargine).
CASE PRESENTATION: We followed this patient during his hospitalization at Medical City Fort Worth and subsequent follow-up visit. Informed consent was obtained, and relevant clinical data and imaging were collected from his medical chart. The patient initially presented to Medical City Weatherford with acute epigastric pain. CT imaging confirmed a diagnosis of acute pancreatitis, suspected to be induced by Soliqua. He was admitted for three days and treated supportively.
One week later, during a routine preoperative evaluation for coronary artery bypass grafting (CABG) at Medical City Fort Worth, the patient reported new-onset fatigue. Concern for gastrointestinal bleeding prompted an emergency department evaluation. Upper endoscopy revealed hemosuccus pancreaticus (HS), characterized by blood in the duodenum—a rare complication of pancreatitis. Although CTA did not show evidence of a pseudoaneurysm, active ampullary bleeding consistent with HS was observed.
RESULTS: Soliqua was discontinued following the pancreatitis diagnosis. At his post-discharge follow-up, the patient reported improved energy levels, a return of appetite, and resolution of gastrointestinal symptoms. His clinical course underscores the potential for serious gastrointestinal complications related to GLP-1 agonist therapy, particularly in medically complex individuals.
CONCLUSION: This case highlights the importance of careful risk-benefit assessment when prescribing GLP-1 agonists, especially in patients with significant comorbid conditions. Clinicians should remain vigilant for signs of pancreatitis and its rare but severe complications, such as hemosuccus pancreaticus. Early recognition and appropriate management are essential to preventing morbidity in this growing population of patients treated with incretin-based therapies.

Hemosuccus Pancreaticus: Acute Pancreatitis Caused by GLP-1 Agonism


Nepal continues to face problems with the migration of its medical graduates both abroad and into major urban centers like Kathmandu Valley, worsening the already uneven distribution of doctors across the country. Despite years of expanding medical education with the goal of improving rural healthcare access, many graduates choose opportunities overseas or in cities, leaving rural and remote areas underserved. Understanding where Nepali medical graduates are practicing, and why, is essential for developing effective strategies to retain them and strengthen
Nepal’s healthcare system. A descriptive cross-sectional survey was conducted from June 2023 to January 2025 among 1,208 Nepali medical graduates (both undergraduate and postgraduate levels) using a self-constructed electronic questionnaire. Participants were recruited through online platforms and alumni networks across all medical colleges in Nepal. Among the 1,208 respondents, 75.3% were male and 24.7% female, with a steady rise in female representation over
time from 8.1% before 2000 to 37.4% after 2020. The majority (67.8%) graduated from Tribhuvan University. Overall, 66.8% were practicing in Nepal, while 33.2% worked abroad, predominantly in the United States (74.31% of those abroad). Within Nepal, 62.3% of graduates were working in Kathmandu Valley, with Bagmati Province hosting the highest number of doctors. Male graduates were more likely than females to work outside Kathmandu Valley. A significant association was found between graduation year and current practice location (p <0.0001), with post-2020 graduates showing the highest retention in Nepal. Gender disparities, university affiliation, and graduation year significantly influenced practice location. Addressing these challenges will require targeted policies that improve rural incentives, expand postgraduate opportunities outside urban centers, and create supportive, gender-sensitive work environments.

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Association of Anesthesia Modality with Opioid Prescriptions After Cesarean Delivery: A Comparative Study of General and Epidural Techniques

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