United States

Background: Surgical resection of thalamic lesions poses significant challenges due to the deep location of the thalamus, complex architecture, and proximity to critical white matter tracts and vascular structures. Over the past several decades, multiple surgical and anatomical taxonomies of the thalamus have been proposed to improve operative orientation, ranging from four- to eight-region classifications based on sulcal, ventricular, or vascular relationships. These evolving schemes underscore ongoing efforts to standardize thalamic subdivision for both anatomical study and surgical planning. Despite extensive knowledge of thalamic neurophysiology, a unified surface-based framework linking these subregions to specific surgical access routes is lacking. While the concept of safe entry zones (SEZs) revolutionized brainstem surgery, its application to thalamic lesions remains limited and inconsistently defined. This study synthesizes cadaveric and clinical evidence to delineate the anatomical organization of thalamic subregions and their corresponding surgical approaches, aiming to clarify potential region-specific SEZs.
Methods: A systematic review of PubMed, Scopus, Embase, and the Cochrane Library was conducted to identify original articles that proposed or modified thalamic regional subdivisions, emphasizing studies that detailed the anatomical organization, white matter relationships, and operative accessibility of each region.
Results: Eight studies met inclusion criteria, comprising anatomical dissections and retrospective case series. The included studies organized the thalamus into subregions (anterior, medial, lateral, geniculate/thalamopeduncular junction, pulvinar/posterior, and choroidal) with distinct approach patterns and tract associations across subregions. Pulvinar and posterior lesions demonstrated the greatest approach diversity, while anterior and medial regions were constrained by proximity to critical tracts such as the mammillothalamic, fornical, and internal capsule fibers. Lateral and thalamopeduncular junction lesions were reported as more amenable to resection through transparietal or subtemporal routes with preservation of neurological function in selected cases. Only a limited subset of studies explicitly proposed relatively safe surgical corridors or preferential approach trajectories, and these were largely restricted to posterior lesions.
Conclusion: Comprehensive and standardized assessment of thalamic surgery remains exceptionally challenging due to anatomical complexity. While certain thalamic areas may be more surgically accessible and permit reproducible approaches, overall strategies remain heterogeneous, and region-specific SEZs are inconsistently characterized. Future efforts should focus on developing standardized anatomical-surgical maps, integrating advanced imaging modalities, and conducting prospective studies to validate the existence and utility of region-specific SEZs to improve surgical planning and patient outcomes.

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Exploring Region-Specific Surgical Approaches to the Thalamus: Defining Safe Entry Zones

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Background: Pseudomonas aeruginosa continues to be a significant opportunistic pathogen, with growing antibiotic resistance and no available vaccine. Previous work showed that the P. aeruginosa type III secretion system (T3SS) protein, PopB, elicits a protective Th17 response after intranasal immunization using the Th17 adjuvant curdlan, but the protection is of low potency. In those studies, PopB was co-purified with its chaperone PcrH. In the current studies, we tested whether fusing or mixing PopB with PcrV, a T3SS protein known to elicit protective antibodies, would enhance protective efficacy. We also hypothesized that adding a Th17 antigen (PopB) to PcrV would improve mucosal IgA responses to PcrV.


Methods: Fusion proteins to the avidin homolog rhizavidin (Rhavi) were constructed to achieve multimeric antigen presentation as dimers and also for future coupling to biotinylated polysaccharides. A fusion protein of Rhavi to full-length PcrV and PopB (denoted RVB) was purified from E. coli using a pACYCDuet-1 vector co-expressing His-PcrH, where untagged RVB bound to His-PcrH was pulled down by nickel affinity resin, followed by ion exchange chromatography and then negative affinity chromatography with nickel resin using elution with 0.1% LDAO to dissociate RVB from His-PcrH. Recombinant His-tagged Rhavi-PcrV, PcrV, and PopB/PcrH were prepared by published methods. Mice were immunized intranasally using curdlan as adjuvant. IgA titers in bronchoalveolar lavage fluid (BALF) were assayed by ELISA, and Th17 responses were assessed by measuring IL-17 (ELISA) in supernatants of splenocytes stimulated with antigens in vitro. Protective efficacy was evaluated in a murine acute pneumonia model using P. aeruginosa strain N13.


Results: Our results show significantly higher IgA titers to PcrV in BALF of mice immunized with RVB when compared to mice immunized with either PcrV or Rhavi-PcrV, where IgA titers were undetectable. Th17 responses to PopB were significantly higher in RVB-immunized mice compared to mice immunized with PopB/PcrH. In the P. aeruginosa acute pneumonia model, RVB-immunized mice displayed 100% survival, whereas PcrV- and Rhavi-PcrV-immunized mice had approximately 60% survival (logrank P=0.06 compared to RVB), all significantly higher than curdlan-immunized mice (0% survival).


Conclusion: These results suggest that integrating PopB with PcrV into the same rhizavidin fusion protein elicits improved IgA titers to PcrV while maintaining a robust Th17 response to PopB, ultimately conferring broad and potent protection against P. aeruginosa lung infection.

Pseudomonas aeruginosa Fusion Protein Vaccines Containing the Th17-stimulating Antigen PopB Improve Mucosal IgA Responses and Protective Efficacy in Mice After Intranasal Immunization

Background: Crohn’s disease and ulcerative colitis are the two primary forms of inflammatory bowel disease (IBD) which are chronic autoimmune conditions that require timely diagnosis and appropriate lifelong management to prevent severe complications and preserve quality of life. Social Determinants of Health (SDOH), including economic stability, healthcare access, and social context, are known to impact chronic disease outcomes, yet their role in IBD remains underexplored. 

Methods: Existing studies on the relationship between SDOH and IBD often lack secondary layers of analysis, limiting deeper exploration of the structural or systemic drivers behind disparities in access. To build on this gap, we conducted a cross-sectional analysis using All-Payer Claims Databases (APCD) from the state of New York and the nationally representative Medical Expenditure Panel Survey (MEPS). APCD data was analyzed to assess associations between race, ethnicity, and hospital utilization metrics. MEPS analysis focused on SDOH impacting emergency room usage among IBD patients. We constructed a composite binary variable—“Underserved”—flagging individuals with one or more indicators of structural disadvantage.

Results: Analysis revealed that race had a modest but significant effect on length of stay (p = 0.044), with illness severity exerting a stronger influence (p < 0.001). Race and insurance type both significantly impacted total charges (p < 0.001), while ethnicity was associated with higher emergency and lower elective admissions (p < 0.001), though not with length of stay or cost. In the MEPS dataset, the composite Underserved variable was a statistically significant predictor of ER utilization among IBD patients. Individual components were not significant when entered together into multivariable models, likely due to multicollinearity. These findings suggest that cumulative social disadvantage is more predictive of healthcare access disparities than any single factor alone.

Conclusion: Economic stability and healthcare access emerged as the most influential and frequently co-occurring SDOH domains, particularly in relation to insurance and financial barriers. However, social and cultural drivers remain under examined in the current literature. Our results underscore the need for multidimensional analyses that reflect the compounding effects of disadvantage. Future directions include a geospatial analysis of IBD care access in marginalized populations and development of a public-facing, searchable disparities database to support patient and policymaker decision-making.


Social Determinants of Health and Adverse Outcomes in Inflammatory Bowel Disease

Purpose: To demonstrate an open-source global nomogram platform for SMILE surgery that combines individual surgeon nomograms with collective data, utilizing deep learning to predict optimal laser correction values.

Methods: A proof-of-concept web platform was developed with a neural network trained on 136 eyes requiring post-operative care. The platform generates personalized and global nomograms for outcome benchmarking and predicts VisuMax laser parameters from preoperative measurements.

Results: The platform successfully generated dual-view nomograms and demonstrated promising prediction accuracy (R-squared=0.956 sphere, 0.952 cylinder, 0.999 axis, 0.966 spherical equivalent, RMSE = 0.274D sphere, 0.084D cylinder, 0.258D spherical equivalent, MAE = 1.2 degrees axis) despite using a limited dataset of primarily follow-up cases.

Conclusion: This study demonstrates the feasibility of combining personalized and global SMILE nomograms with deep learning prediction, though current accuracy is limited by dataset size and selection bias.

Shallow Neural Network for Multi-Parameter Prediction and Nomogram Optimization for SMILE Surgery

Background: Chronic pain, particularly fibromyalgia, has a sizable prevalence of 0.2 to 5% in the adult population. Previous research indicates fibromyalgia is more common in patients with comorbidities like diabetes mellitus (DM). However, fewer studies discuss the impact of DM on fibromyalgia symptomology. Our study hypothesized that adult fibromyalgia patients with DM will have increased fibromyalgia symptom severity.
Methods: This retrospective TriNetX study included queries from adults (>18 years old) with a fibromyalgia diagnosis (ICD-10: M79.7). Patients were divided into cohorts with DM (ICD-10: E10-E11) and without DM. We then examined the presence of symptoms relevant to the severity of fibromyalgia with record of relevant ICD-10 codes after the index date. Measures of association, including odds ratios (OR) and 95% confidence intervals (CI), were calculated to evaluate the strength of relationships. The study was IRB exempt.
Results: A total of 1,450,715 patients were diagnosed with fibromyalgia in the TriNetX database, and 24% (350,883 patients) were also diagnosed with DM. Fibromyalgia occurred in a population that was 75% female, 67.6% white, and 13.1% Black/AA. After matching to minimize any confounding variables (both cohort N=293,490), across all six analyzed outcomes, fibromyalgia patients with DM are significantly more likely to report the presence of fibromyalgia symptoms (p<0.001). The highest difference was in sleep disturbances and mood disorders, with 46.9% of patients with DM reporting sleep disturbances and 60.9% reporting mood disorders, compared to 36.9% and 55.6% respectively without DM. Patients with DM were 51% more likely to have sleep disturbances (OR: 1.51, 95% CI: 1.50-1.53) and 24% more likely to have mood disorders (OR: 1.24, 95% CI: 1.23-1.26). These associations were statistically significant.
Conclusion: Fibromyalgia patients with DM have a significantly higher association of severe fibromyalgia symptoms, specifically sleep disorders and mood disorders. This demonstrates an importance for clinicians to consider comorbidities such as DM, when evaluating fibromyalgia patients, as they are at greater risk for developing severe symptoms, impacting their treatment needs and quality of life.


Exploring the Impact of Diabetes Mellitus on Severity of Symptoms Among Patients with Fibromyalgia

Background
Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors affecting the gastrointestinal tract, most often localized to the stomach (50-60%), small intestine (30-35%), and colon or rectum (5%). GISTs typically present with vague symptoms, contributing to diagnostic delays1. Global incidence of GIST is 10-22 per million persons, with prevalence of 135-155 cases per million people2 and median age of presentation between 60-65 years. 
Early detection is crucial, as approximately 40% of localized GISTs metastasize, and 10%-20% patients have overt metastases at presentation. Nine-year survival rate is 35% in patients with advanced GIST receiving chemotherapy. Larger tumors (>5cm) are more likely to metastasize so detection is crucial.
We present a case of a high-grade GIST presenting with syncope and anemia.

Case Presentation
A 58-year-old male with past medical history of hypertension, hyperlipidemia, and type II diabetes mellitus presented to emergency department with dizziness and a syncopal episode. He reported melena over few days following travel. Examination revealed pallor and non-tender palpable lump in left lumbar region but otherwise unremarkable. Laboratory investigations revealed severe anemia with hemoglobin of 6.9 g/dL. Further investigation of the suspicious mass with an upper endoscopy revealed a 3 mm non-bleeding gastric ulcer and chronic active gastritis with biopsies positive for Helicobacter pylori. CT of abdomen and pelvis identified a colossal mass, 13×12×14cm, in left mid-abdomen specifically in proximal duodenum near lower border of pancreas. Percutaneous biopsy and histopathological evaluation confirmed a high-grade GIST with immunohistochemistry positive for CD117, DOG-1, CD34, caldesmon, SMA and negative for S100 and SOX-10.
Patient underwent an open exploratory laparotomy with partial small bowel resection, partial omentectomy, and excision of GIST, followed by small bowel anastomosis and drainage of peritoneal cavity. Postoperatively, he developed intra-abdominal bleeding requiring transfusions. Mesenteric angiography revealed no contrast extravasation, so no embolization was performed. Patient was discharged in stable condition with plans to follow up with oncology. 

Discussion
This case highlights importance of considering GIST in patients with unexplained anemia and gastrointestinal bleeding. 
High-grade GISTs are aggressive, often presenting with complications such as bleeding and rapid growth. Early surgical resection remains the cornerstone of treatment, offering a favorable prognosis, particularly when combined with adjuvant therapy. GISTs vary in size and location and are often incidental findings on imaging, as demonstrated in our patient. 
Timely diagnosis, surgical resection, and multidisciplinary coordination are essential to optimize outcomes. Clinicians should maintain a high index of suspicion for GIST with similar clinical presentations.


A Colossal Surprise: The Case of a Massive 19-cm High-Grade Gastrointestinal Stromal Tumor (GIST)

Background
Secondary iron overload is a common complication in patients with chronically transfused sickle cell disease (SCD) and can lead to multi-organ dysfunction and increased mortality. Extrahepatic iron deposition is rare in SCD, and pancreatic involvement has not been well described. Here, we present a unique case of a patient with SCD who developed pancreatitis in the setting of severe iron overload, with further workup also revealing multiple endocrinopathies also related to iron overload. 

Case Presentation
A 56-year-old woman with SCD requiring chronic blood transfusions was admitted to the hospital with worsening weakness, fatigue, and poor oral intake for three months. Her labs demonstrated a hemoglobin of 6.2, white blood cell count of 21, total bilirubin of 3.3 (direct 2.1, indirect 1.3), AST 91, ALT 70, alkaline phosphatase 119, lipase 71, and a ferritin of 9,395. An MRCP revealed pancreatitis with acute to subacute peripancreatic fluid collections, an auto-infarcted spleen, and iron deposition in the liver, kidneys, bone marrow, and pancreas. Multiple etiologies of pancreatitis in a patient with SCD were ruled out, including microvascular ischemia, infection, gallstones, drug-related causes, autoimmune disease, alcohol use, and hypertriglyceridemia. Her pancreatitis was therefore suspected to be secondary to direct pancreatic inflammation and injury from excessive iron accumulation. A follow up MRI using T2 weighted images specific for liver iron quantification demonstrated 460 micromoles/g of liver iron, consistent with severe iron overload. She also underwent a workup for endocrine dysfunction due to ongoing hypotension and fatigue, which revealed hypothyroidism, hyperparathyroidism, hypogonadism, and central adrenal insufficiency suspected to be a result of iron deposition in multiple endocrine organs. She was started on chelation therapy, levothyroxine, and hydrocortisone, and was discharged in stable condition. 

Discussion
Secondary iron overload can involve multiple organ systems and may lead to life-threatening consequences. There are a few reported cases of pancreatitis in the setting of severe iron overload due to hereditary hemochromatosis, as well as animal models showing that chronic transfusion-related iron overload can lead to pancreatitis. However, to our knowledge, this is the first reported case of pancreatitis due to iron overload in a chronically transfused patient with SCD. Diagnosis includes serum ferritin levels and MRI, particularly using noninvasive techniques to quantify iron overload. This case underscores the need for greater clinical awareness of this rare pancreatitis etiology to enable timely recognition of iron overload, evaluation of associated complications such as endocrinopathies, and prompt initiation of chelation therapy.


Severe Iron Overload Presenting as Pancreatitis in a Patient with Chronically Transfused Sickle Cell Disease

Background
Giant cell tumors of bone (GCTB) are generally benign but locally aggressive neoplasms composed of multinucleated osteoclastic giant cells within a fibrous stromal background. Malignant transformation is rare, reported in approximately 4 - 5% of cases. Even less frequently described are cases of GCTB with soft tissue recurrence or distant metastases. We present a case of a proximal femoral neck giant cell tumor (GCT) with secondary aneurysmal bone cyst features that underwent rapid progression and widespread metastasis following initial resection.

Methods
Our patient is now deceased. We received IRB exemption (HSC-MS-24-0387) to obtain patient consent for this case report.

Case Report
A 46-year-old woman presented with a 5 cm cystic lesion of the right femoral neck, diagnosed as a benign giant cell tumor of bone. Surgical biopsy was complicated by a pathologic fracture, necessitating proximal femoral resection and total hip arthroplasty, followed by adjuvant Denosumab therapy. Three months postoperatively, a local recurrence was identified. She underwent repeat resection, including partial excision of adjacent gluteal and quadriceps musculature. Histopathology revealed GCT with extensive aneurysmal bone cyst changes, focal necrosis, osteoid formation, and cytologic atypia. Immunohistochemistry was negative for S100, p53, and CD99, and MDM2 amplification was not detected. Diagnosis of atypical GCT was confirmed on extramural review.

Eighteen months later, the patient developed a 30 cm soft tissue recurrence involving the ipsilateral thigh and pelvis. She declined further systemic therapy and underwent pelvic resection with positive margins. Postoperatively, she developed persistent leukocytosis and anemia. Within three months, she developed pulmonary and spinal metastases. Despite undergoing a palliative hemipelvectomy, her disease progressed rapidly. She died six weeks postoperatively, approximately three years after the initial diagnosis.

Conclusion 
Giant cell tumor of bone (GCTB) can rarely undergo malignant transformation, resulting in pulmonary, skeletal, or soft tissue metastases despite an initially benign histologic appearance. 

This case illustrates the potential for aggressive clinical behavior in GCTB with atypical histological features. Although the initial diagnosis was benign, the tumor rapidly progressed following surgery, culminating in massive soft tissue recurrence and systemic metastases. Histologic findings of necrosis, osteoid formation, cytologic atypia, and aneurysmal changes raised concern for malignant transformation. Clinicians should maintain vigilance for malignant progression in GCTB, especially in cases with atypical pathology or rapid local recurrence.


Beware of “Atypical” or “Aneurysmal” Giant Cell Tumors of Bone: A Case Report

Vitamin B6 has been linked to neuropathy in patients who over-supplement. Current understanding suggests that high-dose vitamin B6 saturates the liver function in hepatic conversion, leading to accumulation in peripheral neurons, particularly in the dorsal root ganglia. This may lead to neuropathy seen in patients presenting as axonopathy or degeneration of neurons altogether. Unfortunately, vitamin B6 toxicity is frequently overlooked in general clinical practice, and especially in patients who have other comorbidities, such as diabetes mellitus, hypertension, and cardiovascular diseases. Going unnoticed, vitamin B6 toxicity may progress to a worsened neuropathy for the patient, such as irreversible nerve damage; it can also lead to unnecessary diagnostic testing and medical interventions. Here, we present a case of bilateral peripheral neuropathy in a patient with a past medical history of type II diabetes mellitus whose baseline plasma vitamin B6 level was twice the upper limit of the normal range. We provide justification for providers to obtain patients’ supplementation history and the importance of considering vitamin B6 toxicity when evaluating patients with sensory neuropathy.

Vitamin B6 Related Peripheral Neuropathy in a Diabetic Patient: A Case Study


Background
Osteoarthritis (OA) of the hip and knee are very common pathologies that affect thousands of people worldwide. Large database retrospective studies suggest that Hispanics and Blacks significantly underutilize joint replacement procedures compared to non-Hispanic Whites (NHW), even when health insurance access is controlled. Improvements in utilization require an understanding of the barriers to and attitudes of these minority populations. We assessed attitudes towards medical care and lower extremity joint replacement procedures in a predominantly Hispanic community in San Antonio, Texas.

Methods
Subjects had to be 50-89 years of age and residents of Bexar County, TX. The assessment included three answer blocks about demographics, financial and insurance status, education, attitudes towards seeking healthcare, faith, and opinions about total hip and knee replacement procedures. Respondents who self-identified as Hispanic or NHW were included in the primary
analysis (n = 315). 157 subjects who reported daily knee or hip pain completed the joint replacement attitudes section. Group differences were assessed using Wilcoxon rank-sum tests. Correlations with fear of surgery were analyzed using Spearman’s rho. An ordinal logistic regression model was used to assess multivariate predictors of surgical fear.

Results
Approximately 61% Hispanic and 35% NHW subjects were included. 61% of the subjects were male. Compared to NHW subjects, Hispanic subjects reported significantly greater fear of surgery (p = 0.0001) and indicated that the surgical experiences of others influenced their decision to seek treatment for OA (p = 0.02). Moreover, Hispanic subjects more strongly disagreed that total joint replacement was a successful treatments for OA (p = 0.03) compared to
NHW subjects. Fear of surgery negatively correlated with income (ρ = −0.199) and the regularity of primary care visits (ρ = −0.168). It also positively correlated with the belief that a doctor’s cultural background matters (ρ = 0.168).

Conclusion
Evidence consistently suggests that Hispanic individuals have worse post-operative outcomes after hip and knee joint replacement procedures, and they underutilize these procedures as a treatment for OA. Ameliorating underutilization will be difficult because Hispanic individuals are more greatly affected by the poor surgical outcomes experienced by acquaintances than NHW individuals. Unlike previously published reports, no ethnic differences were found in the
relationship between education level, insurance coverage, coping strategies, and fear of joint replacement surgery. Efforts to address orthopedic surgery utilization disparities must be tailored towards local attitudes that are shaped by ethnic and regional customs as well as personal experiences.

Community Attitudes Towards Lower Extremity Joint Replacement – Insights from South Texas

Background
Following the COVID-19 pandemic, public health dashboards have become an increasingly popular visualization tool. Public health dashboards display information in an understandable manner, allowing stakeholders from medicine and government to quickly identify pertinent information. This ease of access and translation is particularly useful for evolving public health issues such as the opioid epidemic. Many dashboards pertaining to opioid use and opioid-related harm have been developed by national and local organizations, but limited research exists examining their utility. The purpose of this narrative review is to describe how existing public health dashboards are being used to mitigate opioid-related harm.

Methods
We performed a narrative review of peer reviewed articles describing public health dashboards in the context of opioid use and opioid related harm using the PubMed, Cochrane Library, and Embase databases. Articles were identified using a search string with various combinations of “dashboard,” “public health,” “opioid,” and “opioid overdose,” as well as MeSH terms such as “public health surveillance,” “public health,” and “opioid epidemic.” 

Results
Nine studies met the inclusion criteria and were reviewed for common themes. Principal findings include that opioid dashboards are used to address opioid-related harm at both the state and community level, and to visualize changes in opioid trends following policy changes. However, there is limited evidence demonstrating how opioid specific dashboards influence public health policy. Dashboards utilize different local and national data sources, and have different target audiences including clinicians, public health professionals, policy makers and more. In addition, dashboards may be used in conjunction with other informatic tools to improve efficacy and delivery of opioid trends and information. No standard metric for dashboard development was identified. 

Conclusion
In conclusion, public health dashboards are currently being used in a variety of different contexts to reduce opioid overdose and abuse. Although dashboards help examine the impact of policy changes, their effectiveness in directly shaping public health policy remains unclear. The lack of consistency between public health dashboards makes evaluation difficult but also hinders user interpretation. Standardization of public health dashboards could greatly improve user experience and lead to more targeted evaluation of existing dashboards. Future studies evaluating the efficacy of public health dashboards in the context of the opioid epidemic may provide strong insights as to how informatics may improve public health outcomes.

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Pseudomonas aeruginosa Fusion Protein Vaccines Containing the Th17-stimulating Antigen PopB Improve Mucosal IgA Responses and Protective Efficacy in Mice After Intranasal Immunization

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