Bony Sites Research Articles

Advances in Bioceramics for Bone Regeneration: A Narrative Review.

Large osseous defects resulting from trauma, tumor resection, or fracture render the inherent ability of the body to repair inadequate and necessitate the use of bone grafts to facilitate the recovery of both form and function of the bony defect sites. In the United States alone, a large number of bone graft procedures are performed yearly, making it an essential area of investigation and research. Synthetic grafts represent a potential alterative to autografts due to their patient-specific customizability, but currently lack widespread acceptance in the clinical space. Early in their development, non-autologous bone grafts composed of metals such as stainless steel and titanium alloys were favorable due to their biocompatibility, resistance to corrosion, mechanical strength, and durability. However, since their inception, bioceramics have also evolved as viable alternatives. This review aims to present an overview of the fundamental prerequisites for tissue engineering devices using bioceramics as well as to provide a comprehensive account of their historical usage and significant advancements over time. This review includes a summary of commonly used manufacturing techniques and an evaluation of their use as drug carriers and bioactive coatings-for therapeutic ion/drug release, and potential avenues to further enhance hard tissue regeneration.

Immediate single-tooth implant placement in bony defect sites: A 10-year randomized controlled trial.

It is unclear whether an intact buccal bony plate is a prerequisite for immediate implant placement in postextraction sockets. The aim of this 10-year randomized controlled trial was to compare peri-implant soft and hard tissue parameters, esthetic ratings of, and patient-reported satisfaction with immediate implant placement in postextraction sockets with buccal bony defects ≥5mm in the esthetic zone versus delayed implant placement after alveolar ridge preservation. Patients presenting a failing tooth in the esthetic region and a buccal bony defect ≥5mm after an extraction were randomly assigned to immediate (Immediate Group, n=20) or delayed (Delayed Group, n=20) implant placement. The second-stage surgery and provisional restoration placement occurred 3months after implant placement in both groups, followed by definitive restorations 3months thereafter. During a 10-year follow-up period, marginal bone levels (primary outcome), buccal bone thickness, soft tissue parameters, esthetics, and patient-reported satisfaction were recorded. The mean marginal bone level change was -0.71±0.59mm and -0.36±0.39mm in the Immediate Group and the Delayed Group after 10years (p=0.063), respectively. The secondary outcomes were not significantly different between both groups. Marginal bone level changes, buccal bone thickness, clinical outcomes, esthetics, and patients' satisfaction following immediate implant placement, in combination with bone augmentation in postextraction sockets with buccal bony defects ≥5mm, were not statistically different to those following delayed implant placement after ridge preservation in the esthetic zone. Immediate implant placement in case of a failing tooth is a favorable treatment option for patients because it considerably shortens treatment time and the number of surgical treatments. The question is if an intact buccal bone wall is necessary for immediate implant placement. A 10-year study was performed in which 20 patients with a failing tooth in the frontal region of the upper jaw were treated with immediate implant placement and were compared with 20 patients in whom a more conventional treatment strategy was followed in which the failing tooth was first removed and the bone gap restored and the implant placed in a second step. After a 10-year follow-up period, it appeared that the bone around the implant was very stable, gums were healthy, and patients were very satisfied with the result. There was no difference between the two treatment procedures. Such results mean that professionals can discuss the procedure with the patient and apply the individual's preference.

Role of [18F]FDG – PET/CT Scan in Cervical Tuberculosis

Background: Distribution and quantification of extra-pulmonary tuberculosis and elicitation of response antitubercular therapy via F18–Fluorodeoxyglucose Positron Emission-based Tomography/ Computed Tomography(F18–FDG PET/CT). Materials and Methods: This was a prospective Pilot study. In this study 30 patients of age between 15 to 36 years(mean 26.8±6.13years) were included. PET/CT scan was performed at the time of presentation(baseline) and after 2 months of anti-tubercular therapy to evaluate bacterial activity in different levels of cervical lymph nodes and changes in various parameters of lymph nodes such as size, conglomeration and abscess formation were included in the evaluation. Result: In this study, 18 patients were of 18 to 30 years(60.0%), 3 patients were below 18 years(10.0%) and 9 patients above 30 years(30%). The female proportion was higher in our study population(53.3%). Node-positive status, conglomeration, and abscess were evaluated clinically. Maximum percentages were found in level II and level V groups. While minimum percentage was found in level I and level VI. We also found that in all patients of tubercular cervical lymphadenopathy, tubercular bacterial activity was found at some distant sites also the common sites were the lung(56.7%), mediastinum(53.3%), abdomen(36.7%) and bone(23.3%). The response of antitubercular therapy by F18 - FDG PET/CT scan after 2 months of treatment was checked. There was a significant change in standardized uptake value(SUV-max) pre-treatment and post-treatment at all distant sites except the bony site. Conclusion: F18-FDG PET/CT scan is a non-invasive tool in monitoring the response of antitubercular chemotherapy in patients of extrapulmonary and multiorgan lymphadenopathy.

Osteotomy wedge angle - Aiming to achieve perfection with new device: Pre-clinical stage

IntroductionThe surgical execution of osteotomy requires precision in measuring the wedge angle. The pre-operative planning methods are plenty and so are few devices for high tibial osteotomy. But struggle happens for those bony areas other than proximal tibia where alignment correction is needed. The new device is proposed to address this surgical problem. The ease of measuring angle for bony wedge angle, in any bone, independent of its width and in any plane, is the question being solved with the proposed devices. MethodsTwo jig instruments have been shown in the study. First one the curved with direct angle measuring marking in degrees on the body. K wire is accepted through the tower exactly showing the desired angle. The second jig instrument is flat design with marking in millimeters. This device works on trigonometric principle of sum of angles of any triangle is equal to 180°. The jig can be removed leaving the k wires in place to complete the final osteotomy once confirmed. ResultsIt's a pre-clinical stage study. The saw bone models show encouraging measurements and perfect execution of angle at the osteotomy site. DiscussionHTO has been researched a lot with many options of surgical devices. The criticism of using known devices is the variable accuracy, especially for the smaller width of tibial metaphysis. One major limitation of these available instruments is they can be used only for proximal tibial metaphysis. For any other surgical sites like distal femur, distal tibia, distal humerus or tibial slope correction neither these HTO jigs will work nor there is any available universal instrument as such. The common misconception of one degree equal to 1 mm does not stand true at all bony sites. Hence there was a need to solve this problem with universal jig. I have designed two new devices which are currently at pre-clinical stage. The curve device has limitations which get corrected in straight device. The philosophy changes from one direct measurement with two tips of wires forming the angle in a curved device to indirect measurement by simple trigonometric calculation in a straight device. The proposed new device would work in any bone, for any trapezoidal wedge shape osteotomy using simple user-friendly k wires.

ASSESSING RISK FACTORS FOR OSTEOPOROSIS AND FRACTURES AT DIFFERENT SITES: LUMBAR VERTEBRAE VERSUS NECK OF FEMURS IN A LARGE COHORT. A CROSS-SECTIONAL STUDY

Osteoporosis can cause significant disability and cost to health services globally. We aim to compare risk fractures for both osteoporosis and fractures at the L1-L4 vertebrae (LV) and the neck of femurs (NOFs) in patients referred for DEXA scan in the North-West of England.Data was obtained from 31546 patients referred for DEXA scan in the North-West of England between 2004 and 2011. Demographic data was retrospectively analysed using STATA, utilising chi-squared and t-tests. Logistical models were used to report odds ratios for risk factors included in the FRAX tool looking for differences between osteoporosis and fracture risk at the LV and NOFs.In a study involving 2530 cases of LV fractures and 1363 of NOF fractures, age was significantly linked to fractures and osteoporosis at both sites, with a higher risk of osteoporosis at NOFs compared to LV. Height provided protection against fractures and osteoporosis at both sites, with a more pronounced protective effect against osteoporosis at NOFs. Weight was more protective for NOF fractures, while smoking increased osteoporosis risk with no site-specific difference. Steroids were unexpectedly protective for fractures at both sites, with no significant difference, while alcohol consumption was protective against osteoporosis at both sites and associated with increased LV fracture risk. Rheumatoid arthritis increased osteoporosis risk in NOFs and implied a higher fracture risk, though not statistically significant compared to LV. Results summarised in Table 1.Our study reveals that established osteoporosis and fracture risk factors impact distinct bony sites differently. Age and rheumatoid arthritis increase osteoporosis risk more at NOFs than LV, while height and steroids provide greater protection at NOFs. Height significantly protects LV fractures, with alcohol predicting them. Further research is needed to explore risk factors’ impact on additional bony sites and understand the observed differences’ pathophysiology.For any figures or tables, please contact the authors directly.

Atypical Metatarsal Fractures: Report of Five Clinical Cases.

Atypical fractures are well elucidated when they occur in the femur and are related to the use of bisphosphonates. Prolonged therapy with this drug leads to excessive suppression of bone remodeling, which makes the bone more brittle. In general, they are caused by minimal trauma or are atraumatic. This type of fracture is also reported in other bony sites, such as the metatarsus. Some reports and studies on atypical metatarsal fractures have been published, but further investigations are required to better understand this type of fracture and establish the proper diagnosis, treatment and conduct. The present study is a report of five cases of patients who presented metatarsal fractures during therapy with bisphosphonates. All patients were female, had osteoporosis as a preexisting disease, were taking bisphosphonates, presented fractures that were either atraumatic or caused by minimal trauma, and the imaging examination showed a transverse meta-diaphyseal fracture of the fifth metatarsal shaft with thickening of the lateral cortex, image characteristics similar to the criteria used by the American Society for Bone and Mineral Research (ASMBR) to define atypical femur fractures.

A Wireless and Wearable Body-Pressure-Monitoring System for the Prevention of Pressure-Induced Skin Injuries.

This article presents a wireless and wearable body-pressure-monitoring system for the on-site, real-time prevention of pressure injuries for immobilized patients. For the prevention of pressure-induced skin injuries, a wearable pressure sensor system is designed to monitor the pressure at multiple sites on the skin and to alert the danger of prolonged application of pressure on the skin with a pressure-time integral (PTI) algorithm. The wearable sensor unit is developed using a pressure sensor based on a liquid metal microchannel and integrated with a flexible printed circuit board that includes a thermistor-type temperature sensor. The wearable sensor unit array is connected to the readout system board for the transmission of measured signals to a mobile device or PC via Bluetooth communication. We evaluate the pressure-sensing performances of the sensor unit and the feasibility of the wireless and wearable body-pressure-monitoring system through an indoor test and a preliminary clinical test at the hospital. It is shown that the presented pressure sensor has high-quality performance with excellent sensitivity to detect both high and low pressure. The proposed system measures the pressure at bony sites on the skin for about six hours continuously without any disconnection or failure, and the PTI-based alarming system operates successfully in the clinical setup. The system measures the pressure applied to the patient and provides meaningful information from the measured data for early diagnosis and prevention of bedsores to doctors, nurses, and healthcare workers.

COVID-19 induced remission of biliary and renal cell carcinomas.

e14598 Background: Clear cell renal carcinoma and cholangiocarcinoma are resistant to standard therapy. Complete remissions are rare. SARS-CoV-2 (COVID-19) boosts anti-viral immune responses but effects on cancers are unknown. Case reports of hematologic cancer remissions after COVID infection are emerging. Anti PD1/PD-L1 antibody therapy have prolonged remission in 20% of solid tumor patients. mRNA COVID-19 vaccines and COVID-19 active infections create anti-viral immune responses - increased IgG titers, SARS-CoV-2-specific antibodies, and boost T-cell response. Anti PD-1/PD-L1 antibodies immune responses, are presumed independent of the immune response to COVID vaccination/infection. Two previous case reports of hematologic remission were seen after COVID infection. (Hodgkins, multiple myeloma). There are no cases of solid cancer remission after COVID-19 exposure. Methods: Three patients with solid cancers and complete/near complete radiographic remissions after COVID-19 exposure. Two on low carbohydrate diets. History, dietary course and clinical outcomes are presented. Results: Case 1: 58 year old male diagnosed with stage IV clear cell renal carcinoma (lung nodules, mediastinal nodes). After 5 years he progressed on Sunitinib and began Nivolumab. His cancer stabilized but hypophysitis, diarrhea, severe jaw pain ended his treatment. After COVID-19 booster vaccine, he became anorexic, lost 50 lbs over 8 weeks (267 to 211 lb). Relapse was suspected but PET CT showed complete resolution of his lung nodules and adenopathy. Asymptomatic and in remission over 9 months post vaccine. Case 2: 51 year old male heavily pretreated stage 4 renal cell cancer, bone, liver, nodal metastases. On Nivolumab with stable disease but after COVID booster vaccine had high fever, fatigue, myalgia. PET CT scans later showed near complete resolution of his bony, hepatic and nodal metastatic sites. Case 3: 75 year old male with unresectable cholangiocarcinoma on second line Atezolizumab. COVID-19 infection was followed by complete radiographic remission. Conclusions: Effects of SARS-CoV-2 (COVID-19) on cancers remain unknown. Few case reports of cancer remissions after infections are emerging. These are two cases of renal cell cancers in complete remission after COVID-19 vaccination while on immunotherapy. Both followed low glycemic diets. Third case was a complete remission of biliary cancer after an acute COVID-19 infection. Proposed anti-cancer mechanisms - pathogen specific T cell action, anti-inflammatory effects against COVID-19 infection, cross-reactivity against tumor antigens, natural killer cell activation. COVID-19 proteins have oncolytic properties - HIV related B cell apoptosis and Coxsackievirus A21 oncolytic effects on myeloma and CD138+ plasma cells via intercellular adhesion molecule interaction. COVID-19’s effects plus the anti PD-1/PD-L1 antibodies immune response may be synergistic and merits further research.

Arthroscopic debridement of the extensor carpi radialis brevis

Surgical treatment of lateral epicondylitis is reserved for patients who, despite extensive conservative therapy, do not experience satisfactory relief of symptoms. As an alternative to the open procedure, arthroscopic debridement of the extensor carpi radialis brevis (ECRB) muscle is asimple and standardized procedure. The arthroscopic approach also enables the additional treatment of intra-articular pathologies such as loose bodies or osteochondral lesions. After diagnostic arthroscopy, the attachment of the ECRB is visualized via the anteromedial portal, so that under visual control the debridement of the tendon fibers of the ECRB and its bony insertion site can be performed via the anterolateral portal. Postoperatively, there is no restriction of movement of the elbow joint. The outcome after arthroscopic ECRB debridement described in the literature is equivalent to that of other surgical techniques.

Assessment of exercise-induced hypoalgesia in chronic low back pain and potential associations with psychological factors and central sensitization symptoms: A case-control study.

Exercise is the most recommended treatment for chronic low back pain (CLBP) and is effective in reducing pain, but the mechanisms underlying its effects remain poorly understood. Exercise-induced hypoalgesia (EIH) may play a role and is thought to be driven by central pain modulation mechanisms. However, EIH appears to be disrupted in many chronic pain conditions and its presence in people with CLBP remains unclear. As people suffering from chronic pain often exhibit psychological factors and central sensitization symptoms influencing pain perception, EIH might be associated with these factors. The aim of this study is to compare the level of EIH between participants with and without CLBP following back and wrist exercises and to assess the associations between EIH, psychological factors, and symptoms of central sensitization (using the central sensitization inventory - CSI) in CLBP. Twenty-eight participants with CLBP and 23 without pain were recruited. Pressure pain thresholds (PPT) were measured at 4 sites (2 bony sites=capitate, S1|2 muscle sites=wrist flexors, lumbar erector spinae) before and after each of two exercises (wrist flexion and lumbar extension). Exercise-induced hypoalgesia was defined as percent change in PPT from pre- to post-exercise. Participants with CLBP also completed questionnaires to measure psychological factors (e.g., kinesiophobia, catastrophizing, anxiety, and self-efficacy) and symptoms of central sensitization (CSI), and correlations with EIH were calculated. After wrist exercise, EIH measured at the muscle sites was lower in the CLBP group compared with the pain-free group (p=0.047) but no differences were found at bony sites (p=0.49). No significant differences for EIH were observed following back exercise at muscle sites (p=0.14) or at bony sites (p=0.65). Exercise-induced hypoalgesia was not correlated with any psychological factors or with the CSI score. The lower EIH following wrist exercises may represent an alteration in pain modulation control in CLBP. However, psychological factors and central sensitization symptoms may not explain the differences observed.

Paired bone marrow and peripheral blood samples demonstrate lack of widespread dissemination of some CH clones.

Clonal hematopoiesis (CH) represents clonal expansion of mutated hematopoietic stem cells detectable in the peripheral blood or bone marrow through next generation sequencing. The current prevailing model posits that CH mutations detected in the peripheral blood mirror bone marrow mutations with clones widely disseminated across hematopoietic compartments. We sought to test the hypothesis that all clones are disseminated throughout hematopoietic tissues by comparing CH in hip vs peripheral blood specimens collected at the time of hip replacement surgery. Here, we show that patients with osteoarthritis have a high prevalence of CH, which involve genes encoding epigenetic modifiers and DNA damage repair pathway proteins. Importantly, we illustrate that CH, including clones with variant allele frequencies >10%, can be confined to specific bone marrow spaces and may be eliminated through surgical excision. Future work will define whether clones with somatic mutations in particular genes or clonal fractions of certain sizes are either more likely to be localized or are slower to disseminate into the peripheral blood and other bony sites.

Hormone Positive HER2 Negative Breast Cancer Metastatic to the Rectum: A Case Report

Background: The rectum is an uncommon site for metastases from Invasive Ductal Carcinoma (IDC) of the breast, and it poses risks such as perforation and obstruction.
 Case Report: A 50-year-old non-diabetic, non-alcoholic, and nonsmoker premenopausal female patient diagnosed with rectal metastasis primarily originating from breast cancer.
 In 2009, the patient was diagnosed with stage IV hormone positive, Her-2 (+2) negative, FISH positive right breast cancer with cervical (C6) vertebrae metastasis seen on PET scan. As she had oligo metastasis with a single bony focus, she was treated with intent to cure. For this purpose, she received radiation therapy to the cervical vertebrae, resulting in a complete response. This was followed by pseudo-neoadjuvant chemotherapy with six cycles of Docetaxel and trastuzumab. The patient then underwent a right-modified radical mastectomy. The pathology showed no complete response with residual 2.5 cm invasive carcinoma (PT2), and 4 out of 25 Axillary lymph nodes were positive for metastases (PN2). She was given (pseudo) adjuvant radiotherapy to the chest wall and lymphatics and was started on (pseudo) adjuvant tamoxifen. Trastuzumab was completed for one year as a (pseudo) adjuvant setting.
 Her disease seemed to be cleared up as no new cancer signs were reported by follow-up full body scans (CT/PET). After seven years, in May 2016, her PET-CT scan showed multiple new hypermetabolic osseous lesions, in keeping with metastasis involving the right shoulder, mid-thoracic spine, left aspect of L5, right sacrum, and the greater trochanteric region of the left femur and left ischium. She also presented a new hypermetabolic retroperitoneal paracaval lymph node, in keeping with metastasis. The new ill-defined hypodensity in the left hepatic lobe was associated with increased FDG uptake, which is suspicious for early metastasis. She also presented a tiny right lung peri-fissural nodularity that was too small to be characterized by PET.
 She was treated with Zoladex 3.6 mg injection monthly, Femara 2.5 mg daily, Palbociclib 125 mg PO daily for 21 days over a 28-day cycle, and Denosumab 120 mg monthly. The treatment was initiated in Singapore. As previously stated, Her-2 testing was reported as negative. The patient went into complete remission for more than six years, as documented by the PET scan conducted on January 19, 2022. Later, in June 2022, the patient developed signs and symptoms of intestinal obstruction (abdominal pain, nausea, and vomiting) and was diagnosed with rectal cancer metastases of breast origin.
 Conclusion: As the patient first developed breast cancer with oligo-bony metastasis, which was successfully treated with chemotherapy and radiotherapy, but later relapsed in the lung, liver, lymph nodes, and multiple bony sites. She was treated successfully via hormonal and targeted therapy. Finally, she relapsed in the form of rectal metastasis.

Hypofractionated Palliative Radiotherapy for Relapsed and Refractory High-Risk Neuroblastoma

<h3>Purpose/Objective(s)</h3> While palliative radiation therapy (RT) is frequently used in the management of relapsed/refractory high-risk neuroblastoma (HR-NBL) in pediatric patients, few studies have examined the role of palliative hypofractionated RT (hypo-RT) in HR-NBL. We sought to characterize outcomes after palliative-intent RT using conventionally fractionated (conv-RT) and hypo-RT regimens for patients with relapsed/refractory HR-NBL. <h3>Materials/Methods</h3> The Institutional Review Board approved a retrospective study of 37 patients who were diagnosed with HR-NBL between 1997-2021 and received palliative RT at two institutions. Patients receiving RT for central nervous system and liver metastases were excluded. Hypo-RT was defined as treatment courses using dose >2 Gy per fraction. Clinical and treatment characteristics and outcomes, including dates and locations of progression, were recorded. Fisher exact tests were used for categorical variables. Follow-up time was defined from start of RT. Cumulative incidence of in-field progression was analyzed using Gray's test with death as competing risk. Univariate analyses (UVA) were performed using Cox proportional-hazards regression. <h3>Results</h3> When analyzing by first course of palliative RT, there were 16 courses of conv-RT (43.2%) and 21 courses of hypo-RT (56.8%). The distribution of patients having further progression of disease before palliative RT, receiving palliative RT to bony and soft tissue sites, and undergoing chemotherapy before, during, and after palliative RT were not different between the two groups. With median follow-up of 10.3 months (range: 0.3-104.0), cumulative incidence of in-field progression at 10 months was not different between hypo-RT and conv-RT (30.0% vs 20.1%, p=0.80). After RT, patients had similar clinical benefit, defined as symptomatic relief or decrease in size of lesion (92.3% conv-RT vs. 90.0% hypo-RT, p=1.00). On UVA, further progression of disease before palliative RT, bony vs. soft tissue sites, receipt of chemotherapy before RT, receipt of concurrent chemotherapy with RT, and receipt of chemotherapy after RT were not associated with time to in-field progression. In addition, hypo-RT (Hazard ratio [HR]: 1.50, 95% confidence interval [CI]: 0.47-4.76, p=0.49) and biologically equivalent dose (BED) ≥29 Gy (HR: 1.44, 95% CI: 0.43-4.82, p=0.55) were not associated with time to in-field progression. <h3>Conclusion</h3> We found no difference in cumulative incidence of in-field progression and clinical outcomes between the conv-RT and hypo-RT groups. On UVA, hypo-RT and BED ≥29 Gy were not associated with longer time to in-field recurrence. Palliative hypo-RT can be considered for relapsed/refractory HR-NBL, especially when quality of life from shorter treatments may be of benefit.

Stability of dental implants placed in healed bony sites of hyperlipidemic patients

Background: The effect of elevated levels of serum fats ­­-hyperlipidemia- on the long-term implant stability and bone quality has been heavily examined in animal-model studies. This human-based case series is the first clinical study which aimed at clinical and radiographic evaluation of dental implant stability and the changes in bone density in patients with high lipid profile. Materials and Methods: Twelve female patients, each had a single healed bony site which indicated for implantation together with high serum fasting (Low-density lipoprotein) LDL level (≥160 mg/dl) were included in this study. The clinical implant stability values (ISQ) which were measured using the Resonance Frequency Analysis (RFA) method, and CBCT changes were recorded at baseline and six months post-implant insertion. Results: All patients showed implant success after six months. There was a significant increase of implant stability after 6 months from (65.92 ± 6.39 ISQ) to (74.42±6.20 ISQ) (p&lt;0.001).

69-Year-Old Man With Dysuria and Right Lower Abdominal Pain

69-Year-Old Man With Dysuria and Right Lower Abdominal Pain

Osteosarcoma/Ewing Sarcoma

Osteosarcoma/Ewing Sarcoma

Intraosseous angiolipoma of the mandible: case report of a rare entity

<h3>Background</h3> Intraosseous angiolipoma is a benign adipocytic lesion that may occur at any bony site, with predilec- tion for the long bones, ribs, vertebrae, and the head and neck region. As the name suggests, the lesion is character- ized by the presence of mature adipocytes associated with increased vascularity. Intraosseous angiolipoma of the mandible is an exceedingly rare condition first described by Polte in 1976. Until the present date, only four cases were documented in the English literature. Case description: We report a case of a 58 year-old woman presenting with an asymptomatic lesion of the mandible. CBCT examination shows a hypodense area extending from the api- cal region of the mandibular first molar to the mid portion of the mandibular ramus, right side. Lesion is localized, multilocular, with scalloped borders and partially corticated. There is thinning of the facial and lingual cortices, with focal areas of expansion and bone discontinuity. The cortices of the inferior alveolar canal are not visual- ized in some portions. No root resorption is identified. The clinical impression was ameloblastoma. Enucleation and curettage was performed. Microscopic examination reveals the presence of mature adipocytes surrounded by fibrous connective tissue septa featuring numerous vascular channels. Scattered chronic inflammatory cells includ- ing mast cells are seen. No cellular atypia or increased mitotic activity are identified. <h3>Conclusion</h3> We present the fifth case of an intraosseous angiolipoma involving the mandible. The lesion has been classified as either a hyper- plastic process or a benign neoplasm. The differential diagnosis often includes vascular lesions, benign odontogenic entities, central giant cell granuloma, or low-grade intraosseous malignancies. Due to the scarcity of case reports, the nature of the lesion as well as its preferred treatment method are still to be determined.

The Association between Lead Exposure and Bone Mineral Density in Childhood and Adolescence: Results from NHANES 1999-2006 and 2011-2018.

There are few studies on lead’s effect on bone mineral density (BMD) in childhood. In this study, we examined the association between lead exposure and BMD among 13,951 children and adolescents aged 8–19 years from NHANES 1999–2006 and 2011–2018. The whole blood lead levels (BLLs) were used as lead exposure biomarkers, and total BMD, subtotal BMD, lumbar spine BMD and limb BMD were used as outcome variables. The survey weighted multivariable generalized additive models (GAMs) with smoothing terms were used to explore the association between blood lead levels and BMDs, adjusted for age, sex, race/ethnicity, height, weight, family-income-to-poverty ratio and blood cadmium. Subgroup analyses stratified by sex and bony sites were further performed. We found an N-shaped curve association between BLLs and total BMD, subtotal BMD and limb BMD for males and females, whereas the association between BLLs and lumbar spine BMD was only significantly negative for females. The findings suggested that lead exposure had different effects on BMD of different bony sites (highly cortical or trabecular regions) in childhood and adolescence and had different effects on the same bone among different ages population and/or at different levels.

Device-related pressure ulcers: SECURE prevention. Second edition.

Device-related pressure ulcers: SECURE prevention. Second edition.

Salvage Radiosurgery for Recurrent Cardiac Sarcoma: A Case Report

<h3>Purpose/Objective(s)</h3> Primary cardiac sarcoma is a rare malignant tumor that arises from the cardiac myocardium. Surgical resection is the standard of care and median survival after a R0 resection is typically 6 to 12 months. However, after local recurrence, patients are frequently inoperable with a poor prognosis. The role of salvage chemotherapy and radiation is not well defined. A few case reports have described local control for up to eight months after hypo-fractionated radiosurgery. <h3>Materials/Methods</h3> A 53 year old female presented in October 2017 with acute congestive heart failure and underwent complete surgical resection of undifferentiated pleomorphic sarcoma of the left atrium followed by 6 cycles of adjuvant doxorubicin/hydroxydaunorubicin and ifosfamide. An MRI scan demonstrated an asymptomatic, 24 mm, recurrent atrial mass. The patient elected to proceed with salvage frameless robotic radiosurgery system stereotactic body radiosurgery. We fused CT, MRI, and PET imaging modalities in order to determine the target volume. The tumor was treated with a dose of 7200 cGy in 15 fractions to the 84% isodose line utilizing spine tracking with 4D CT to determine the ITV. Fractionation was used in order to achieve acceptable maximal doses to the main stem bronchus and esophagus. Repeat cardiac MRI at four weeks showed in-field local progression with greater protrusion into the left atrium. The tumor volume doubled in size with invasion of the left ventricle. The patient elected to proceed with salvage frameless robotic radiosurgery system treatment. 2500 cGy in 1 fraction was prescribed to the 76% isodose line in June of 2019. <h3>Results</h3> She tolerated treatment well without any acute toxicity. The patient was subsequently treated with a variety of chemotherapy regimens including TKIs and immunotherapy. Unfortunately, the patient relapsed in December with metastases in the spine and the pelvis. She underwent palliative radiation therapy to multiple bony sites with a partial response. She resumed chemotherapy treatment with TKIs but passed away in June 2020 due to septic shock without evidence of local failure. <h3>Conclusion</h3> Fractionated SBRT was ineffective at controlling our patient's cardiac sarcoma. Our patient demonstrated local control of disease at twelve months after salvage 25 Gy in one fraction radiosurgery without any evidence of cardiac toxicity. High dose single fraction radiosurgery is a reasonable palliative option for long term local control of unresectable cardiac sarcomas.