Collision tumors, defined as the simultaneous occurrence of two distinct neoplasms within the same anatomical location, are exceptionally rare in the clivus. The coexistence of chordoma and chronic lymphocytic leukemia (CLL) within the clivus has not been previously reported, making this case particularly noteworthy.We present the case of a 69-year-old woman with a known history of stable CLL who presented with a 3-month history of progressive right-sided horizontal diplopia and hemianopsia. Imaging revealed a large sellar/suprasellar lesion with significant involvement of both cavernous sinuses, prompting surgical intervention. An endoscopic endonasal transsphenoidal and transclival approach was utilized to achieve near-total mass resection, with a small remnant left in the right cavernous sinus due to its proximity to the internal carotid artery. Histopathological examination confirmed the presence of a collision tumor composed of chordoma and CLL.This case represents the first reported instance of a collision tumor involving a chordoma and CLL within the clivus. The patient's postoperative course was uneventful, and she remains stable at 3-month follow-up after receiving adjuvant radiotherapy. The rarity of such a collision tumor underscores the need for heightened clinical suspicion and thorough pathological evaluation in cases presenting with atypical skull base lesions. The involvement of a multidisciplinary team was crucial in the management and favorable outcome of this complex case.

Rationale: Extrusion 3D bioprinting is an additive manufacturing tissue engineering technique that uses cell-laden viscous biomaterials known as bioinks. Manually mixing cell suspensions into viscous biomaterials can be challenging due to the high viscosity ratio between the two fluids. Static mixers are an attractive approach as they can quickly and reproducibly mix two fluids, including those with a high viscosity ratio. However, static mixers intended for viscous applications have not been comprehensively investigated for bioink preparation. This work evaluates the mixing performance, shear stress, and cell viability using four different types of static mixers intended for high viscosity mixing. Methods: Three static mixers intended for mixing viscous solutions were designed based on the Sulzer SMX, Ross ISG, and serpentine mixers and fabricated using resin 3D printing. CELLMIXER, a Kenics-style static mixer commercially available through CELLINK, was used as a comparator. Two biomaterial inks based on PEGDA and methacrylated gelatin were used to characterize each mixer's performance. Shear stress was estimated via fluid dynamics simulations using shear-thinning attributes measured experimentally through rheology. Mixing effectiveness was evaluated using fluorescent beads, from which the most effective design was chosen for live cell mixing experiments. Viability of cell lines (A549 and NIH-3T3) and primary human lung fibroblasts was evaluated postmixing. A demonstration of extrusion bioprinting was performed using the mixed bioinks. Results: The SMX-style mixer provided the most uniform mixing and yielded the lowest simulated shear stresses among the designs investigated. A549, NIH-3T3, and primary human lung fibroblasts maintained viabilities above 96% postmixing using the SMX-style mixer with a more homogeneous cell distribution compared to the CELLMIXER. The bioprinting demonstration validated our mixing system for producing viable tissue constructs with evenly distributed cells. Conclusions: We present a simple, reproducible, and flexible system for mixing cells into viscous biomaterial inks. Our approach facilitates standardized fabrication of cell-laden tissue constructs to ensure consistency in the growing field of extrusion 3D bioprinting.

ABSTRACT Experiencing rejection from a romantic partner can be painful, and sexual rejection may have a lasting impact on satisfaction. However, some ways of communicating sexual rejection may elicit more constructive responses from the rejected partner, fostering continued connection in the face of rejection. Across three studies—a cross-sectional study of individuals in romantic relationships (Study 1; N = 315) and two dyadic daily diary studies (Studies 2–3; total N = 219 couples contributing 9,287 daily reports)—we tested whether specific ways of communicating sexual rejection are associated with the rejected partner’s emotional and behavioral responses. Across studies, perceived hostile rejection (e.g. the partner displayed criticism) was associated with more negative responses (i.e. resentment) from the rejected partner. In contrast, perceived reassuring rejection (e.g. the partner expressed warmth or future interest in sex) elicited more positive responses to rejection (i.e. understanding) and maintained the rejected partner’s sexual desire. The findings extend relationship theories to understand sexual conflict, and provide a framework of specific, observable behaviors that researchers and clinicians can incorporate to help couples navigate the challenges of sexual rejection.

Fall prevention recommendations include mobility or balance testing to identify older adults with high fall risk who require further intervention. However, there is no consensus on the best tests or optimal cut-off values. The Initial Test for Fall RIsk Assessment in The Elderly (INITIATE) study was designed to determine the optimal screening test(s) for predicting falls among community-dwelling older adults. Here we describe the study protocol, sample characteristics, and baseline differences between participants with and without a history of falling. We undertook a 1-year prospective cohort study of community-dwelling older adults (≥ 65 years) able to walk 10m without assistance at baseline and living in Ontario, Canada. Participants underwent a 2-hour baseline visit where 7 validated balance and mobility tests (Timed up and go (TUG) usual pace, TUG fast pace, TUG with a cognitive dual task, Brief Balance Evaluation Systems Test (BESTest), 5 times sit-to-stand (5TSTS), single leg stance, gait speed) were administered. Falls were tracked for 12 months using monthly diaries and follow-up calls for context. Participants received quarterly calls to monitor general wellbeing, healthcare utilization, and changes to mobility. Descriptive statistics were calculated and differences by 12-month fall history were tested using t-tests, chi square tests, and Wilcox Rank Sum tests as appropriate. From 3211 contacted older adults, 514 (19%) consented. The mean age was 76.4 years (SD 6.7), 64% were female, 68% had a postsecondary degree/diploma, and 231(45%) reported a fall in the last 12 months. Means(SD) for the performance-based tests were as follows: TUG = 11.8s(4.0), TUG fast pace = 9.2s(3.4), TUG cog = 14.2s(5.9), Brief BESTest = 15.9 score(5.3), 5TSTS = 12.5s(4.3), single leg stance = 14.1s(16.3), gait speed = 1.14m/s(0.28). Comparisons between baseline fallers and non-fallers showed no differences in age, sex, income, or education(p > 0.05) but did show differences in all 7 tests(p < 0.05). Participants are representative of community-dwelling older adults with fall risk. Balance and mobility test differences between fallers and non-fallers support the need for prospective comparisons of their predictive validity. Follow-up results, expected in late 2025, will help inform future updates to fall risk assessment and prevention guidelines.

In patients with cryptogenic stroke, the characteristics of multiterritory brain infarcts, the recurrent stroke risk, and the response to anticoagulation remain unclear. The ARCADIA trial (Atrial Cardiopathy and Antithrombotic Drugs in Prevention After Cryptogenic Stroke) screened patients with cryptogenic stroke for atrial cardiopathy at 185 centers in the United States and Canada from 2018 to 2022. Investigators reported baseline acute brain infarction in the left anterior, right anterior, and posterior circulation. Atrial cardiopathy was defined as P-wave terminal force in ECG lead V1s >5000 μV·ms, NT-proBNP (N-terminal pro-B-type natriuretic peptide) >250 pg/mL, or left atrial diameter index ≥3 cm/m2. Site echocardiography laboratories determined left atrial diameter index and a central echocardiography laboratory determined LVEF. We used ANCOVA to examine whether atrial cardiopathy biomarkers or LVEF were associated with the number of territories with infarction. Cox regression was used to examine whether the number of infarct territories was associated with recurrent stroke or modified the effect of apixaban compared with aspirin. Among 3464 patients with reported baseline magnetic resonance imaging data, 220 (6.4%) had no visible acute infarct and 2794 (80.7%) had acute infarction in 1, 374 (10.8%) in 2, and 76 (2.2%) in 3 territories. Atrial cardiopathy biomarkers and LVEF were not associated with the number of infarct territories. Among 937 of these 3464 patients who were randomized, we found higher risks of recurrent stroke associated with infarcts in 2 territories (hazard ratio, 2.4 [95% CI, 1.3-4.2]) or 3 territories (hazard ratio, 3.7 [95% CI, 1.5-9.3]) relative to single-territory infarction, whereas the absence of visible infarction was not associated with recurrence (hazard ratio, 1.8 [95% CI, 0.6-4.9]). The number of infarct territories did not modify the effect of apixaban versus aspirin in relation to recurrent stroke (P for interaction, 0.71). Multiterritory brain infarction was not associated with atrial cardiopathy biomarkers or LVEF in the ARCADIA trial. Multiterritory infarction was associated with a significantly higher risk of recurrent stroke, but this heightened risk was not reduced by apixaban relative to aspirin.

Immune thrombocytopenia (ITP) often presents for the first time in pregnancy, or, in patients with a history of ITP, pregnancy can trigger a relapse. ITP in pregnancy is often mild, leading to minimal or no symptoms; however, treatment may be needed if thrombocytopenia becomes severe, if bleeding occurs, or in anticipation of delivery and neuraxial analgesia. To facilitate the diagnosis of ITP in pregnancy, we present a systematic approach that allows clinicians to first consider urgent pregnancy-related thrombocytopenic conditions such as hypertensive disorders of pregnancy or thrombotic thrombocytopenic purpura; exclude other causes of thrombocytopenia; and determine the need for treatment. We review options for first-line therapies for ITP in pregnancy, including corticosteroids (prednisone or methylprednisolone) and intravenous immune globulin, which has a favorable safety profile in pregnancy, and second-line therapy options that have been used in pregnancy including thrombopoietin receptor agonists, rituximab, and certain immunosuppressant medications such as azathioprine. We summarize the recommendations for platelet targets for delivery, recognizing that the evidence is limited, including a platelet count of 50 × 109/L or higher for caesarean delivery and 70 × 109/L or higher for neuraxial anesthesia. Treatment decisions for ITP in pregnancy should be informed by patients' values and preferences along with a multidisciplinary team that includes hematologists, obstetricians, and anesthesiologists.

We performed a systematic review and meta-analysis comparing patient-important outcomes among different surgical approaches to total mesorectal excision (TME) for patients with rectal cancer. We searched PubMed, Embase, and Cochrane Central to identify articles of interest published prior to October 17th, 2024, to identify RCTs and observational studies comparing outcomes between transanal TME (taTME), laparoscopic TME (laTME), and robotic TME (roTME) for patients with low- and mid-rectal cancers. The multidisciplinary panel prioritized outcomes and established objective decision thresholds a priori. Two reviewers completed article screening, data extraction, and risk of bias appraisal. We performed a random effects meta-analysis. We conducted a sensitivity analysis to compare the durability of results between studies at low/moderate versus high risk of bias. We identified 35 reports of 32 studies from 8,228 articles. Patients had a mean age ± standard deviation (SD) of 62.6 ± 14.0, 62.6 ± 14.1, and 63.2 ± 12.7years for patients that underwent taTME, laTME, and roTME, respectively. Most patients were diagnosed with stage II (36.5%, 38.6%, and 33.5%) or stage III (43.5%, 44.1%, and 55.8%) rectal cancer. There were 43 fewer [95% CI 71 fewer to 18 more] 30-day major complications per 1000 patients undergoing taTME compared to laTME. There were 34 fewer disease recurrences at two years [95% CI 53 fewer to 11 fewer] per 1000 patients undergoing taTME compared to laTME. There were either no clinically important differences or high uncertainty in all outcomes between those undergoing taTME versus roTME for low- and mid-rectal cancer. Patients with low- and mid-rectal cancer undergoing taTME may confer a lower likelihood of 30-day major complications and disease recurrence at 2years compared to laTME. Additional comparative studies are needed between taTME and roTME in patients with rectal cancer.

Background:The role of research personnel (e.g., research assistants, research coordinators, research managers, etc.) is critical to the success of clinical trials in orthopaedic surgery. Retention of research personnel is a challenge faced by many academic surgical researchers. Limited investigation has been conducted to identify and quantify factors that lead to low retention rates, especially in the field of orthopaedic surgery clinical research.Methods:We developed an electronic survey, containing the validated Job Satisfaction Survey (JSS), to evaluate job satisfaction, career path, and educational pathways in the context of long-term retention of research personnel working in orthopaedic surgery. We distributed the anonymized survey to research personnel who currently or had previously participated in at least 1 orthopaedic trauma clinical trial coordinated by a university-affiliated surgical methods center.Results:Seventy-two research personnel working on clinical orthopaedic studies completed the survey (43%). Using the JSS, overall respondent scores (mean 143.8, SD 26.6) fell on the border of the ambivalent and satisfaction categories. The lowest mean scores, representing dissatisfaction (scores <12), were seen within the promotion (11.4, SD 4.9) and pay (11.9, SD 5.1) subscales. Higher pay was the most common factor that would increase respondents’ satisfaction in their current position (72%). Almost half (46%) expressed funding being a barrier to accessing continuing education, and 54% were unsure or considered clinical research in orthopaedic trauma a temporary position. Four main themes arose from the qualitative portion of the survey: (1) appreciation and involvement, (2) institutional barriers, (3) training, and (4) support from the principal investigator.Conclusions:Research personnel in clinical orthopaedic trauma surgery are a highly motivated group with job satisfaction bordering ambivalence into satisfaction. Despite the desire to grow in their positions, pay and inadequate funding to support continuing education opportunities are barriers. The qualitative findings provide additional insights into how job satisfaction and retention can be improved among clinical research personnel in orthopaedic trauma surgery.Level of Evidence:Level III. See Instructions for Authors for a complete description of levels of evidence.