United States

Background: Hypoglossal nerve stimulation (HGNS) is an effective therapy for Obstructive Sleep Apnea (OSA) in patients intolerant to CPAP. However, concerns about its efficacy in patients with elevated body mass index (BMI) have led to restrictive insurance coverage, often using a threshold of 32 kg/m². This creates a critical treatment gap for a significant patient population. This systematic review and meta-analysis aimed to evaluate how a BMI ≥32 kg/m² influences HGNS surgical outcomes, challenging the evidence basis for current BMI-based restrictions.

Methods: Following PRISMA guidelines, a systematic literature search was conducted across PubMed, Embase, and Scopus for studies published between January 2014 and April 2025. Eligible studies included prospective/retrospective cohorts or case-control studies that reported HGNS outcomes in adult OSA patients, stratified by a BMI of 32 kg/m². Data on study design, patient demographics, and postoperative outcomes were extracted. A random-effects meta-analysis was performed on qualifying studies to estimate the pooled odds ratio (OR) for treatment success, primarily defined by the Sher criteria, comparing patients with BMI ≥32 kg/m² to those below this threshold.

Results: Seven studies comprising 1,572 patients were included in the qualitative synthesis, with four studies (n=1,507) qualifying for the meta-analysis. While individual study findings were mixed, the meta-analysis revealed that patients with a BMI ≥32 kg/m² had a trend toward reduced odds of achieving surgical success (pooled OR = 0.87, 95% CI: 0.68–1.11), though this result was not statistically significant. Notably, many patients in the higher BMI groups who did not meet formal success criteria still experienced clinically meaningful reductions in Apnea-Hypopnea Index (AHI) and reported high rates of satisfaction and subjective improvement on validated scales like the Epworth Sleepiness Scale and the Clinical Global Impression Index scale.

Conclusion: The assertion that a BMI ≥32 kg/m² uniformly predicts HGNS failure is not supported by this meta-analysis. The lack of statistical significance, coupled with consistent reports of objective and subjective benefits, suggests that many patients with elevated BMI derive substantial value from HGNS. These findings challenge the rigid application of BMI-based cutoffs in payer policies and advocate for a more individualized, patient-centered approach to determining HGNS candidacy, which could expand access for a population with limited treatment alternatives.

AMA Research Challenge 2025 

Body Mass Index and Hypoglossal Nerve Stimulation Outcomes: A Systematic Review and Meta-Analysis

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Precise genome engineering of primary human T cells is critical for the development of adoptive immunotherapies. However, conventional Cas9 homology-directed repair (HDR) strategies are inefficient in naïve T cells and carry risks associated with double-strand break toxicity, limiting their therapeutic utility. To address this challenge, we explored Cas9D10A, a double-nickase variant, as an HDR-independent knock-in platform, successfully creating a construct. Guide RNAs were designed, cloned, and electroporated into both naïve and activated human T cells. Knock-in efficiency was quantified using flow cytometry to detect GFP and tNGFR expression. Editing was achieved with 1 of 6 gRNAs tested, and IS2(9) supported dual reporter expression in both activated and naïve subsets. These results provide proof-of-concept that Cas9D10A nickase can effectively edit naïve T cells, a population notoriously resistant to efficient modification. By bypassing HDR dependence, this platform offers a safer and more versatile approach for genome engineering, with potential to expand the scope of adoptive T-cell therapies.

Creating an HDR Independent Cas9D10A Nickase to Induce Knock-In
Mutations in T-Cells

Advances in neuro-oncology have transformed the diagnosis and management of brain tumors, which are among the most challenging malignancies due to their high mortality rates and complex neurological effects. Despite advancements in surgery and chemoradiotherapy, the prognosis for glioblastoma multiforme (GBM) and brain metastases remains poor, underscoring the need for innovative diagnostic strategies. This review highlights recent advancements in imaging techniques, liquid biopsies, and artificial intelligence (AI) applications addressing current diagnostic challenges. Advanced imaging techniques improve the differentiation of tumor progression from treatment-related changes. Additionally, novel positron emission tomography (PET) radiotracers, such as 18F-fluoropivalate, 18F-fluoroethyltyrosine, and 18F-fluluciclovine, facilitate metabolic profiling of high-grade gliomas. Liquid biopsy, a minimally invasive technique, enables real-time monitoring of biomarkers enhancing diagnostic precision. AI-driven algorithms improve accuracy, reduce interobserver variability, and accelerate clinical decision-making.

Modernizing Neuro-Oncology: Impact of Imaging, Liquid Biopsies, and AI on Diagnosis and Treatment

Background
The tibia is known to be the main weight-bearing bone of the leg, with the fibula supporting this function and providing an attachment point for various muscles. However, the precise biomechanical consequences of this functional specialization are poorly understood. We conducted a three-dimensional analysis to quantify the cross-sectional geometry of the central diaphyses in paired tibiae and fibulae to determine if proximodistal variation in mechanical stiffness is correlated between these bones. We hypothesize that the fibula compensates for resistance to bending in areas where the tibia is particularly weak and/or thin. This information can help to explain certain fracture patterns that are commonly seen by orthopedic physicians.

Methods
The CT data from 10 deceased individuals were obtained with permission from the New Mexico Descendent Image Database. CT data from the left leg of each donor were cropped, and the cortical bone was segmented to generate digitized periosteal and endosteal surfaces of both the tibia and fibula. We used these to quantify cross-sectional parameters across 30 equidistant slices taken from the central diaphysis of each bone. This data was then analyzed using the Morphomap cross-sectional geometry package in R. Non-parametric correlations were measured between resistances to mediolateral and anteroposterior bending, longitudinal twisting, and mean diaphyseal thickness and cortical area. 

Results
We found that tibial cortical area was weakly positively correlated with body mass and height, and strongly negatively correlated with age. Comparing the cross-sectional properties of coplanar sections of the tibia and fibula, we found that all second moment of area measurements in the tibia were negatively correlated with cortical area and mean thickness of the fibula. Resistances to mediolateral bending and axial torsion were also found to be inversely proportional between both bones. Generally, the diaphyseal cortical bone of the tibia becomes thinner distally, while the diaphysis of the fibula is thickest in the middle and is at its thinnest proximally and distally. 

Conclusion
These results support the hypothesis that the fibula partially compensates for the reduced bending resistance of the tibia in regions where the tibial cortical bone is particularly thin and/or weak. These data inform functional hypotheses of the fibula and can help explain the mechanism of certain breakage patterns in fractures involving the distal lower limb.

Analysis and Clinical Interpretation of Correlated Cross-sectional Properties of the Tibia and Fibula

BACKGROUND: Approximately 7-25% of grade 1 meningiomas recur, indicating a need for additional criteria for appropriate risk stratification. The growth and development of meningioma are closely linked to its molecular profile. Notably, homozygous CDKN2A/B deletions are associated with shorter time to progression and increased recurrence. Additionally, the rising incidence of meningioma in pregnant patients has suggested an important role of hormone receptors commonly expressed in meningiomas; however, the prognostic value of hormone receptor status remains unclear. This study investigates patient stratification by molecular and hormonal markers to guide clinical management.

METHODS: We identified patients aged 18 and older with histologically confirmed meningioma, stratified by WHO grade, hormone receptor status, and molecular alterations. Primary outcomes were overall survival and progression-free survival.

RESULTS: Of 99 patients, 70 were grade 1 (70.7%), 25 were grade 2 (25.3%), and 4 were grade 3 (4.04%). PR-positivity was seen in 72 patients (72.7%), AR-positivity in 39 (39.4%), and ER-positivity in 1 (1.01%). Among PR-positive patients, 57 were grade 1 (79.2%) and 15 were grade 2 (20.8%). In AR-positive patients, 31 were grade 1 (79.5%), 7 were grade 2 (17.9%), and 1 was grade 3 (2.56%). The ER-positive patient was grade 2. In the PR-positive group, 16 (22.2%) progressed and 56 (77.8%) did not. In the AR-positive group, 5 (12.8%) progressed and 34 (87.2%) did not. The ER-positive patient showed no progression. Molecularly, 27 patients were NF2 mutant (27.3%), 2 had CDKN2A/B deletions (2.02%), 2 had AKT mutations (2.02%), and 2 had SMO mutations (2.02%).

CONCLUSION: Preliminary findings suggest PR-positivity may be a favorable prognostic marker, whereas AR-positivity may be unfavorable. Due to the rarity of ER-positivity, prognostic conclusions could not be made. Hormone receptor status may aid in risk stratification and guide treatment planning and surveillance intervals in meningioma patients.


Risk Stratification of Meningioma Based on Molecular & Hormone Receptor Status

Introduction 
Fibrostenotic complications of Crohn’s disease (CD) affect up to 50% of patients and often require surgery due to a lack of antifibrotic therapies. The renin-angiotensin-aldosterone system (RAAS) has been implicated in intestinal fibrosis, and RAAS inhibitors, such as angiotensin receptor blockers (ARBs), improve outcomes in animal models, but clinical validation is limited.

Methods
We performed a retrospective study using the multi-institutional database TriNetX to compare rates of endoscopic balloon dilation or surgery—proxies for fibrotic complications—in CD patients taking ARBs versus those not taking ARBs through July 8, 2025. One-to-one propensity score matching (PSM) balanced cohorts by age, sex, race, and smoking status. Outcome risk was expressed with hazard ratios (HRs) and Kaplan-Meier curves.

Results
After PSM, 7,708 CD patients taking ARBs (mean age 60.5 ± 13 years; 54% female; 75% White) were compared to an equal number not taking ARBs. Any ARB use was associated with a 27% lower risk of intervention (HR: 0.73, 95% CI: 0.66–0.80, P<0.01). Losartan (N=5,480) and olmesartan (N=586) reduced risk by 32% and 44%, respectively (HR: 0.68, 95% CI: 0.61–0.77; HR: 0.56, 95% CI: 0.39–0.80; P=0.01). Valsartan (N=1,698) showed no significant effect (HR: 0.88, 95% CI: 0.72–1.09, P=0.24). Higher ARB doses conferred greater benefit (losartan ≥50 mg: HR 0.59; olmesartan ≥20 mg: HR 0.44; valsartan ≥160 mg: HR 0.42; all P≤0.02).

Discussion
ARB use is associated with reduced endoscopic or surgical interventions for CD-related fibrosis, with evidence of dose dependence, supporting a potential antifibrotic mechanism and the need for prospective clinical evaluation.

Angiotensin Receptor Blockers are Associated with Reduced Risk of Fibrostenotic Complications in Crohn’s Disease

Background

Idiopathic sudden sensorineural hearing loss (ISSNHL) is a rapid decrease in hearing ability, typically occurring in one ear. Treatments for ISSNHL are difficult to study as patients can recover hearing spontaneously, making it difficult to separate treatment effects from the natural course of the disease. Current first-line therapies are oral and intratympanic corticosteroids, yet the mechanisms underlying their benefit remain poorly understood. Hyperbaric oxygen therapy (HBOT) has also emerged as a potential ISSNHL treatment, yet it is not clear if it offers benefits beyond steroids. This study assessed the effect of HBOT, in combination with corticosteroids, on hearing improvement following ISSNHL.

Methods

We analyzed data from the HBOT Registry, a global, multicenter collaboration that tracks outcomes of ISSNHL patients treated with HBOT across 33 institutions. In addition, we conducted a retrospective case series of selected ISSNHL patients at Dartmouth-Hitchcock Medical Center, who received HBOT following corticosteroid therapy, to determine if there were cases that showed a benefit beyond steroids.

Results

HBOT Registry data showed that HBOT was associated with overall improvement in measured hearing thresholds (i.e., pure tone average across frequencies 500Hz, 1000Hz, 2000Hz, and 4000Hz) among ISSNHL patients (n=256). Specifically, 41.02% of patients were found to have achieved clinically significant hearing recovery, defined as a ≥15 dB improvement in pure tone

average. The mean improvement in pure tone average following HBOT was 14.4 dB. Since most patients typically receive steroids prior to HBOT, this suggests an additional benefit from HBOT. In a retrospective case series conducted at Dartmouth-Hitchcock, we highlight 10 patients with complete audiometric data in which HBOT was associated with additional hearing recovery beyond that achieved with steroid treatment alone. This recovery was particularly apparent amongst low frequencies (i.e., 500-1000 Hz). This is a limited case series and additional study on the interaction between corticosteroid therapy and HBOT is warranted.

Conclusion

Our findings suggest HBOT improves hearing beyond what is achieved with corticosteroids in some individuals. Further controlled studies are needed to delineate the effects of spontaneous recovery, corticosteroids, and HBOT in ISSNHL.

Hyperbaric Oxygen Therapy for Sudden Sensorineural Hearing Loss

Background
Hyper IgE Syndrome (HIES) is a rare primary immunodeficiency characterized by elevated IgE levels, recurrent infections, and eczema. Diagnostic delays are common due to phenotypic variability and overlap with other inflammatory conditions. This case report aims to highlight diagnostic challenges in atypical HIES presentations and explore potential connections with hidradenitis suppurativa.

Case Presentation
We report a 30-year-old Caucasian female with Type I HIES who experienced a 12-year diagnostic delay from symptom onset to definitive diagnosis. Her clinical presentation began in infancy with oral thrush, chronic diarrhea, and severe eczema, progressing to recurrent skin abscesses during adolescence. She required multiple hospitalizations for incision and drainage of abscesses predominantly affecting bilateral breasts and right lower extremity. Significant complications included pneumonia with osteomyelitis (2020), ocular candidiasis with choroidal
involvement (2022), and a recent Candida glabrata lower extremity abscess (February 2025). The patient also experienced chronic perioral and periorbital dermatitis and approximately 30 episodes of otitis media throughout childhood. Initially misattributed to recurrent cellulitis (2008- 2018), the patient was later evaluated for hidradenitis suppurativa due to the anatomical distribution of abscesses in apocrine gland-rich areas. Immunological evaluation was finally initiated in 2020 following pneumonia with osteomyelitis. Laboratory investigations revealed
markedly elevated IgE levels (4,200 IU/mL; normal <100 IU/mL), while other immunoglobulin levels remained within normal limits. Genetic testing confirmed a heterozygous pathogenic STAT3 mutation (c.1144C>T, p.Arg382Trp), consistent with autosomal dominant HIES.

Discussion
Recent research suggests that some patients diagnosed with hidradenitis suppurativa may have underlying primary immunodeficiencies. This case provides evidence for this emerging connection through shared characteristics including anatomical predilection for apocrine gland- rich areas, chronic inflammatory processes with bacterial colonization, predominance of Staphylococcus aureus infections, and frequent treatment resistance. However, distinguishing
features include onset timing (HIES typically begins in infancy vs. HS post-puberty), systemic involvement (multisystem in HIES vs. primarily cutaneous in HS), and laboratory findings (markedly elevated IgE in HIES vs. normal in typical HS). The patient's STAT3 mutation affects the DNA-binding domain, resulting in dominant-negative effects on STAT3 function. This leads to impaired T-helper 17 cell differentiation, reduced IL-17 production, defective neutrophil
chemotaxis, and increased susceptibility to bacterial and fungal infections. The immune dysfunction involves multiple pathways including defective Th17 responses, impaired neutrophil function, regulatory T-cell abnormalities, and defective antimicrobial peptide production. This case demonstrates that HIES presentations can be highly variable, and the absence of classical features should not preclude diagnosis.

Hyper IgE Syndrome with Atypical Presentation: Diagnostic Challenges and
Potential Links to Hidradenitis Suppurativa

Background
Non-alcoholic fatty liver disease (NAFLD) and type 2 Diabetes Mellitus are the major causes of significant mortality and morbidity. NAFLD and type 2 diabetes have common risk factors. SGLT-2 inhibitors are believed to have a beneficial effect on liver fat in patients with NAFLD and type 2 diabetes. However, there are limited data available on this aspect of empagliflozin use. Thus, we aimed to compare the impact of empagliflozin on liver fat reduction in type 2 diabetes and NAFLD.
Methods
A comprehensive search of databases like PubMed, Google Scholar, and Cochrane Library was done. In the end, a detailed analysis was performed on a total of 6 finalized studies, all of which were randomized controlled trials. This comprehensive analysis consisted of a cohort of 806 Individuals.
Results
Participants in the Empagliflozin group had an average change of -29.57 (SD = 19), while those in the placebo group showed a smaller improvement of -16.41 (SD = 24.1). The standardized mean difference (SMD) was -0.60, with a 95% CI, Z = 2.48, P = 0.01. AST studies showed a statistically significant benefit of empagliflozin over placebo with an SMD of -0.41 (95% CI: -0.66 to -0.16, p = 0.001). Heterogeneity among the studies was low (I² = 34%). The SMD is -0.43 with a 95% CI and a p-value of 0.03, indicating a statistically significant effect favoring empagliflozin. The heterogeneity is low (I² = 0%, P = 0.37). The results for 30 % liver fat reduction show an odds ratio of 14.08 with a 95% CI of 2.74 to 72.48. The test for overall effect is statistically significant (p = 0.002).
Conclusion
The analysis found that with the use of empagliflozin, different variables significantly decreased. These include Liver Steatosis (CAP) Score, AST, MRI-PDFF, 30% LVEF Reduction, and liver fat content (LFC).
Keywords: 
Empagliflozin, NAFLD, Type 2 diabetes, liver fat reduction


Empagliflozin and liver fat reduction in T2DM & NAFLD

Introduction: Smoking is a major modifiable risk factor for age-related macular degeneration (AMD), but its influence on disease progression after early dry AMD is uncertain. The purpose of this study is to quantify the association between smoking and progression from early or intermediate nonexudative AMD to (1) advanced nonexudative AMD and (2) exudative AMD. 
Method: Retrospective cohort study using de-identified electronic health records from the TriNetX US Collaborative Network (68 health care organizations). Smokers were identified by nicotine dependence ICD 10 codes or varenicline prescriptions; nonsmokers had no such records. Propensity score matching (1:1) for age, sex, race/ethnicity, diabetes, hypertension, and obesity yielded balanced cohorts of 8,978 smokers and 8,978 nonsmokers—incident diagnosis of advanced nonexudative AMD or exudative AMD captured by ICD-10 codes. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated.
Results: Among 22 490 adults aged ≥50 years with early or intermediate non exudative AMD (11,225 smokers [mean (SD) age, 73.1 (8.9) years; 52.5% female] and 11,265 nonsmokers [73.1 (9.1) years; 52.8% female]), smoking was associated with a higher risk of progression to advanced non exudative AMD (580/11225 [5.2%] vs 486/11265 [4.3%]; risk difference, 0.9%; RR 1.20; 95% CI, 1.07 1.35). Among 19,766 patients without prior exudative AMD (9,702 smokers, 10,064 nonsmokers), progression to exudative AMD occurred in 710/9702 (7.3%) vs 678/10,064 (6.7%); risk difference, 0.6%; RR 1.09; 95% CI, 0.98- 1.20.
Conclusions: Smoking was independently associated with a modest but statistically significant 20% relative increase in risk of progression to advanced nonexudative AMD, whereas its association with exudative AMD progression was not substantial. These findings reinforce smoking cessation as a key preventive strategy for patients with early dry AMD and refine risk stratification in clinical practice.


Evaluating the Impact of Smoking on Early Dry Age-related Macular Degeneration Outcome: A Large-Scale Matched Cohort Analysis

Racial Disparities in End-of-Life Care Among ICU Patients: A Multi-Center Retrospective Study

Background
Palliative care consultation (PCC) improves symptom management, facilitates advance care planning (ACP), and promotes care aligned with patient values. National guidelines recommend timely inpatient PCC. However, PCC remains underutilized and is often delivered late. Racial disparities further exacerbate this; Black patients are consistently less likely than White patients to receive PCC or have documented do-not-resuscitate (DNR) orders. 

Although prior studies have examined these disparities in general inpatient or terminal populations, fewer large-scale analyses have focused specifically on ICU patients with high predicted mortality, who are most likely to benefit from early end-of-life (EOL) interventions. The ICU setting, characterized by high symptom burden, complex decision-making, and elevated mortality risk, represents a critical environment. To build on existing literature and address this specific context, we conducted a retrospective cohort study to evaluate racial differences in PCC and DNR status among ICU patients using a large, multicenter database.

Methods
This study utilized the TriNetX Research Network, a database of de-identified electronic health records. Inclusion criteria consisted of patients admitted to the ICU with conditions commonly associated with higher mortality rates. Patients with prior cancer diagnoses were excluded. The primary exposure was race (Black vs White). Outcomes included receipt of any end-of-life (EOL) care encounter (defined as PCC and/or DNR order), PCC alone, and DNR status alone. Propensity score matching (1:1) was performed on covariates including age, sex, comorbidities, and hospital characteristics. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

Results
A total of 496,109 ICU patients met inclusion criteria, with 98,241 remaining in each group after matching.
• Black patients had a significantly lower likelihood of any EOL encounter compared to White patients (HR 0.887, 95% CI 0.863–0.911; p<0.0001).
• DNR status was also significantly less frequent among Black patients (HR 0.726, 95% CI 0.699–0.753; p<0.0001).
• Receipt of PCC was lower among Black patients (HR 0.961, 95% CI 0.935–0.988; p=0.0047).

Conclusion
Among ICU patients with high predicted mortality, Black individuals were significantly less likely than White individuals to receive EOL interventions, even after adjusting for clinical factors. These disparities highlight the need for targeted system-level strategies to ensure equitable access to goal-concordant care. Future work should explore institutional practices and structural drivers underlying these patterns and evaluate interventions to promote timely PCC in critical care settings.

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Creating an HDR Independent Cas9D10A Nickase to Induce Knock-In Mutations in T-Cells

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