Hello and welcome to noon conference hosted by MRI online. We created noon conference when the pandemic hit as a way to connect the global radiology community through free live educational conferences that are accessible for all. It's become an amazing weekly opportunity to learn alongside radiologists from around the world, and we encourage you to ask questions and share ideas to help the community learning grow. You can access the recording of today's conference and previous noon conferences by creating a free MRI online account. You can also sign up for a free trial of our premium membership to get access to hundreds of case based micro learning courses across all key radiology sub specialties. Learn more at MRI online.com. Today we're honored to welcome Dr. Majid Khan for a lecture on vertebral augmentation past present and future. Dr. Khan presented completed his radiology residence residency at NUMC Stony Brook University and his sub specialty training and neuro radiology at Johns Hopkins University. He is at present on the neuro radiology and interventional radiology staff at Johns Hopkins University. Dr. Khan is a nationally and internationally recognized expert and spine tumor ablation and spine cement augmentation procedures. He's published extensively on these areas and has been invited to lecture preside over panels, run workshops and moderate sessions at many national and international conferences. At the end of the lecture, join Dr. Khan in a Q&A session where he will address questions you may have on today's topic. Please remember to use the Q&A feature to submit your questions so we can get to as many as we can before our time is up. With that, we're ready to begin today's lecture. Dr. Khan, please take it from here. Thank you Ashley for your kind introduction. Good morning, good afternoon wherever you are in the country. So let's get started about vertebral augmentation where we were and where we are and where we are hopefully going to be in future. These are my disclosures. Okay, what I'm going to talk about is mostly going to be relevant with in regards to benign compression fractures. We do vertebral augmentation for pathological fractures for traumatic fractures, but overwhelmingly what I'm going to talk today will be with in relation with the benign fractures and we know osteoporosis is perhaps the most important cause of vertebral fractures. Normal bone as you can see this is the healthy bone with sinusoidal cavities and the trabecular pattern. Osteoporosis literally means porous bones or bone that is full of holes and when you look at the picture you can see that the sinusoidal cavities have enlarged and the trabecular pattern has significantly turned out giving the typical appearance of the bone that we are used to seeing. This is another microscopic picture of the trabecular cavities in normal bone and compared to the osteoporotic bone you can see in the picture below how enlarged the sinusoidal cavities within the trabecular bones are. And if you look at the cortical bone also that also shows similar loss of the osteos material and you can see porous looking cortical margins of the bone. Overall 700,000 vertebral compression fractures happen in the US 70,000 of these patients with vertebral compression fractures will end up getting hospitalized with an average length of stay for about eight days so you can imagine. Just a fracture we normally don't think about vertebral fractures leading to such extensive length of stay in the hospitals, but it happens. Now we know previously we used to think that it is diagnosis of females only but now we know that 25% of the males will also sustain osteoporosis and can develop. Compression fractures due to osteoporosis. So, looking at the silver tsunami that once osteoporosis was called and still is if you look at the numbers back in 2010. Americans age 50 and more made up about 54% 99% of the population back in 2010 and more than half of that population had osteoporosis and osteopenia which total was about 17% of the entire population. So now we have will be increasing this number by about 27% of up to about 2030 and it will go even higher. So this is a big elephant that is that is sitting in the room for us. If you are a numbers person and really want to know the dollar amount that is being spent on this diagnosis. This is a very alarming slide, at least to me that I saw that the total amount of money that is spent on patients with osteoporosis that's that's total care of osteoporosis hospitalization in patient outpatient care. You can see it's about 4.8 billion dollars compared it to myocardial infarctions and stroke. So it's much higher than even typically what we think about are the biggest money guzzlers when it comes to patient care and inpatient and spending dollar amount on these on specific diagnosis. This is one of my patients I just wanted to show you the sequence of events that happened in this patient's life. So 51 year old female back in 2009 had a low DEXA score, so had a mild osteopenia. Nothing was done for this patient. In 2016 she sustained an L1 and L2 fracture she had an upper respiratory tract infection had a bout of coughing and fractured her bones. She was 58 then nothing was really done to address her problem at that point also. In 2018 she develops two more fractures of T10 and a T11 fracture and you had to be cognizant of the fact that each fracture is a sentinel event in this diagnosis and can be definitely prevented if specific care is given to the patient at specific points. And then finally in 2019 when I saw her she had another fracture of T12 abortibra. So multiple compression fractures which really could have been avoided had she had proper care diagnostic tests would have been done. No recent DEXA comparing the numbers to her previous DEXA scan and nothing was really done to reduce her fracture risks. So we really all of us get old but we shouldn't be really getting like older older and osteoporosis and fractures definitely make us old. This is literally the comments that I have heard in my clinic from patients that I have seen over the years. Most importantly especially with female you hear this a lot that I'm losing height. Talking to elderly patients either who live alone or as a couple and losing the ability to drive to do all these different chores that they are used to do has will have a devastating effect on their life. Because they are they're doing everything by by themselves without getting any help from anywhere. I have heard this many many many times in this day and age. Osteoporosis should be known to every person especially people over 50 years of age. But I tell you this is this is something that's that's consistently heard from our patients day in and day out that I have no idea about osteoporosis. Nobody told me to be on calcium or other treatment modalities and if I had known it earlier this everything would not have happened to me. Very very consistent symptom that I hear from these patients. Okay, imaging of osteoporosis we know we get plain radiographs we have these ghost vertebras I literally tell my patients that I can see through your vertebras they are so thinned out. This is just an example of that it's not much difference looking at soft tissues, compared to these auspicious bones in this patient. Hell the bone on a CT should look like this it should be quite dense and this is the appearance of osteoporosis on CT with a compression fracture these are this is your typical ghost vertebra you can see some these fatty content of the vertebral bodies thickened to back away also at times and loss of triangular pattern in some parts of the vertebral bodies. So we can make a diagnosis of osteoporosis on CT but it's not consistent. Differentiating normal bone from osteopenia slash osteoporosis is can be done reliably most of the times but differentiating osteopenia from osteoporosis can be hard on grayscale CT imaging. So back in 2019 we came up with this colored enhanced detection where we did a retrospective study by putting this CD on abdominal CTs that are done routinely, and to see if we can compare it to the patient's and what results we get. And it had really good results and we were able to put colors on the bone on CT and able to make a diagnosis of osteopenia osteoporosis or normal bone within two seconds. And so these are the grayscale imaging and this is the color detection images that have been poured with red being osteoporosis and green being normal bone. We followed it up actually with a prospective study validating the colored enhanced detection and again it had very very good correlation with the DEXA scan. Especially for an interventionalist who is treating these osteoporotic compression fractures can be very very useful. If you have your own clinic you're looking at your patient examining the patient, really we do not need an MRI if I have point tenderness at a particular location. My x-ray is showing a compression fracture and my patient is also telling me that the pain is maximum at this location. We don't but unfortunately some of the insurance companies really will want you to get an MRI before you intervene on a patient's fracture. So most of the practices will have some cross-sectional imaging either CT or preferably MRI that you will have to get. And really MRI helps you to age a fracture if you see in edema you know it's a subacute or acute fracture and helps you differentiate in a patient with multi-level fractures, a chronic fracture from more acute fractures. But really you're not treating an MRI. Many many times I have had patients who had just subtle changes on a star image on an MRI right next to a vertebra that had big time edema in the body. And the patient when I saw the patient in the clinic they were complaining of more localized pain in that subacute fracture rather than in the acute fracture. So you're really treating the patient and not always the MRI. MRI helps of course I'm not saying that you should not get it but it's very helpful but more helpful is when you examine the patient and when you know what the patient is telling you. So we do get lots and lots of MRI in these patients. So we came up with this vertebral bone quality score which is the VBQ score based on MRI and we compared this to DEXA scan and wanted to see how this VBQ score will be able to predict the fragility fractures independent of the bone mineral density. We actually published few papers based on the VBQ scores. It was actually one of the outstanding papers that was in NASA in 2020. And it showed really good correlation with the DEXA scan and predicting patients with osteopenia and osteoporosis. So basically, we just did a signal intensity from L1 to L4. We divided it by signal intensity of the CSF and came up with the VBQ score. And as I said, it really helped us because we get MRI right left and center in most patients. So this is something that can be very easily quickly done in patients and you will come up with a score if the patient doesn't have a DEXA scan and all that. So now we have a patient who has an established fracture. We have imaged the patient, whatever imaging you have obtained on that patient. And now we have to take care of the patient. So there are multiple services that are involved in treatment of these patients, right from primary care. You have the medicine guys, you have the nursing staff, the physical therapists. They usually come up from the ED, orthopedic surgeon, neurosurgeons. And then we have the interventional radiologist also getting involved in the treatment of such patients. So in intervention radiology, we treat the vertebral compression fractures by doing vertebral augmentation. I just wanted to touch on the research that has been done in this realm, because most of the people will come up with some controversial papers that came out in 2009 in an EJM journal, which is probably the biggest impact factor journal. And it had a huge implication on the practice of doing vertebral augmentation. Two trials actually came out Bush binder from published in 2009 and invest trial and also 2009 pop were published saying that more people plastic specifically more people plastic compared to a sham procedure and they said that the plastic had no benefit. Over a sham procedure. Looking at this graph, you know, the numbers of vertebral plastic or augmentation that was done before the 2009 paper. There was a humongous dip about 35% dip in the number of procedures that were done post 2009 up to almost 2012 2014. When the numbers started to pick back up again. And that's the literature since those two landmark trials that that got published in the any jam. Just to give you an idea about 4000 articles have been published on vertebral plastic in about 2000 on kyphoplasty. Two mega meta meta analysis have been done off 2500 patients included 52 level one and level two articles. There were actually certain things that were found in the bush binder study that came out in 2009. And it has been downgraded now from a level one to a level two based on certain flaws in the in the setup of those of those trials. And this is the few, few examples of few papers that came out. And this this the conclusion here is really alarming that about 35% reduction in mortality risk at up to four years for patient undergoing kyphoplasty when compared on and on an emergent basis and Zampini also found the same exact almost 48% lower risk in patients so big implication papers like this. The conclusion of some of the papers was that the because of the decrease in the number of augmentations that were done it in turn the five year period following 2009 was associated with elevated mortality in patients with vertical compression fractures slash osteoporosis. So the mortality actually went up post those 2009 papers. So these were the two papers that were published in 2009, comparing multiple plastic with sham. These are the three papers that were published later on using the same sham procedures and all three of them. And it proved that vertebral plastic had better results pain paliation, compared to a sham procedure. And just this was a free trial that was statistically significant in almost all the parameters that were used in 2019. These are very high impact papers just I just wanted you guys to take a look, look at the number of patients that were involved from the Medicare data. One million, one million, almost all of them showed that doing augmentation was better than non surgical management of these patients so much has been done since 2009 I know some of some of the some of the other over surgical colleagues still are referencing those 2009 papers but those of you who want to set up spine practice should really read up on these new papers that have come out which are clearly showing a benefit of doing augmentation or non surgical management. This is a landmark paper from my good friend Joshua Hirsch from Mass General that came out, which, which really showed that you need to do 15 word table augmentation procedures to save one life, and about 12 procedures to save one life at five and compared it to almost 22 management patients non surgically to save one life and 24 so almost double in the non surgical arm compared to the augmentation arm. So this is a really landmark people that that because no other people really shows the mortality benefit, long term mortality benefit of these procedures and this this paper clearly showed that there is significant mortality benefit by doing this these augmentations. Okay, so now we we we get the patient in our clinic and we start to discuss with our patients about word table augmentation so so what do I tell my patient when they first come up in my clinic about when I have assessed them. What am I what am I offering to my patient so we are either doing word table plastic we are either doing balloon kyphoplasty or we can do an implant kyphoplasty for such patients and the patient always. They tend to ask a what's the difference why am I why are you telling me that I will get Kyfo over word Hebrew or an implant over balloon kyphoplasty. So we all know that when you inject cement directly into the word table body, whether you're doing it through one pedicle or you're doing it from both pedicles. If you put a balloon in create a cavity and then put the cement in a pre created cavity is a balloon kyphoplasty. And then the implant is where you put a titanium implant in the word table body and then you inflate that implant in the body to restore the fracture height that's the implant kyphoplasty personally I if the vertebra has just lost minimal I will do word table plastic. If it's a mild to moderate fracture. I may do balloon kyphoplasty versus an implant kyphoplasty, but if it's a moderate to severe fracture and I can fit an implant in that word to I will do an implant kyphoplasty because you want to raise the height of the word table body also. But having said that the main aim of doing this is pain paliation so almost all of these have shown to decrease your your pain by at least four to five if not more points on visual analog pain scale. So going back into the percutaneous final procedures in 1934 actually ball or this ball was the first person who started to do image guided procedures so pretty much this is exactly what we do to this day. He actually if you look at these diagram. He is coming in for a particular and coming along the inferior aspect of that neural for I'm and I just avoid the nerve. And what we do now we mostly we try to come trans particular but this was back in 1934. And pretty much the technique is still the same exactly the same. We did back then. Next, we came up with what to put in the word table body or in the bossious structures and that was because what happened in the acrylic acid was used back in 1843. In 1877 we had German chemist look at the polymerization of the methyl methacrylate to poly methyl methacrylate and the solidification of that. And that's what was used later on in plastic sheet and plexiglass that we don't normally now see in our cars and some of our musical instruments in our in our we used to see that in our planes also the plexiglass that was used. Two, because of all the injuries that happened to especially the craniofacial injuries that happened to patients with deformities and all that actually cranial plastic with these acrylic plates where we're used for this facial deformities back then. People have also use PMMA cast for corpectomy these days now we see these big fancy corpectomy cages once you do a vertebraectomy, but back then they used to put a cast of PMMA in the in the vertebraectomy side, and it was used for those surgical maneuvers also. So the first word deeper plastic if you look at the history was actually done done in France in 1984. And there are more than the two guys who performed this. This was actually a guy who had aggressive C2 hemangioma and the surgeons did not want to operate on the patient. The patient was having excruciating pain. So that's when they thought of doing this percutaneously they went in through the trans oral route. And these are these are actually the original images you can see the needle coming in through the trans oral route into the C2 vertebrae and then they have filled it with PMMA and the patient had dramatic relief. And then after they injected about three ccs of cement into the C2 vertebra. They did seven cases of aggressive hemangiomas after that with protein, proteinous vertebral plastic. These are just some notes from their original paper and it was it was really fascinating to read them that they said that radiotherapy is the usual treatment for such patients but it couldn't be done because it was close to the spinal cord. And now these days with SBRT and all the other things we take everything for granted. But this was this was in their original paper how they how they came up with this. So what they were plastic coming to us was actually in 1993. A paper was presented at a SNR by the Dermont group from France. And then three of these our greats, John Mathis Lee Jensen. They actually went to France and they learned vertebral plastic from the Dermont group. And then they came back to University of Virginia in 1993 and started doing vertebral plastic and reported case series was reported in 1997 actually about vertebral plastic. They used to make the cement on their own. So you can imagine these days again we take it so much for granted. We have really good cement take whiskers cement and back then they had to mix everything right on the table. People who do this a lot day in and day out can can can realize how much of a pain it would have been back then but so and we all a lot these guys of what we're doing today. All the fancy things was because of what they did back then and and they were they else came up with this idea of adding barium to the cement so that the cement can actually be seen. Very nicely as the cement goes into the vertical body. Okay, so now going talking a little bit about the indications of doing the vertebral plastic. So if you have a painful osteoporotic or a traumatic fracture, which is refractory to medical therapy. It is indicated. If you have a pathological fracture be it from metastasis from any solid tumor multiple myeloma we do cement augmentation. Vertebral hemangiomas more so aggressive hemangiomas we do it if patient has cumulus phenomenon Austrian across as this is a really good procedure to do. And sometimes patients with chronic fractures who have ongoing compression and have a painful back, we tend to do this procedure. Traumatic fractures were are done more so by our European colleagues, but now spine Jack has gotten FDA approval in US also, because most of the insurance companies would not cover vertebral augmentation and traumatic fractures in US but hopefully that will change now with with the implant kyphoplasty. So this is just few examples of bipedicular approach for deep replacity as I said that when you do a word even plastic you just get the needles in and start putting the cement in straight away in that compressed bone and so this is an example of a bipedicular two needles have gone in, and that cement going into that compressed vertebra. So, it's it's as I said it's it's done very commonly very routinely. One of the things about what people plastic is that because you have not created a cavity so if there is good bit of impedance in the bone the pressure inside the bone is very high you may not be able to get a whole lot of cement into that vertebra. So, so you have to keep that in mind. Also, this is a unipedicular access now. Many instruments have come from many companies, which will let you get in from only one pedicle. And then you have a curved needle that you can cross over to the control lateral side and start putting cement in the vertebral body. And here you can see we have vertebra planar almost here, and we're coming in we just threaded this curve needle right across that planar. We started putting cement starting at the control lateral side and then we keep on pulling our curve needle back so that you spread the contrast completely from one pedicle to the epsilon pedicle filling up the vertebra. And this is something that these curve needles really help you with is that I put the curve needle in I've crossed the midline here, then I went, I can, I can curve it up I can curve it down so here I started putting cement by curving the needle up so I put the cement underneath the superior plate, which is the end plate that is fractured probably nine out of 10 times, and then I curved it down and put cement along the inferior aspect also, and completely filling up the vertebra would cement with the unipedicular access. If you're doing multiple level contiguous levels, I usually do three or at the most four levels in one setting. You can see very nicely that you can alternate the entry of the needles into the vertical bodies if you were doing by pedicular. You will not have been possible because the needles touch each other and you will not be able to put four needles, perhaps at the same time if the fractures are moderate to severe and very close to each other so that's another distinct advantage that you get by doing a unipedicular access by pedicular kyphoplasty very similar to the excess is the same just like you do the vertebral plastic but here now you put a balloon in the vertebra. You can inflate the balloon create a cavity in the vertebra deflate the balloon and then you put the cement in that pre created cavity so the advantage that kyphoplasty gives you is that you can put more cement more cement goes into the vertebra under less pressure so the chances of cement deflation are less theoretically compared to a vertebral plastic at times. So here you can see the balloons are going in here I have inflated the balloons the balloon. Touch the midline this is called the kissing balloon technique that's typically how it should be. And then you deflate the balloon and then you put the cement in crossing the midline you have to cross the midline you cannot put cement only on one side of the vertebra because that probably did more disservice to the patient than helping the patient if you have cement only on one side. Similarly now companies have come up with this unipedicular kyphoplasty so it's very useful because if you can get away with doing anything from one pedicle why do you want to puncture the patient twice. So it's been it decreases the table time it decreases the radiation to the patient to the operator. Table time is decreased and it's it's it's these days a lot depends on the table time so it's it's definitely helpful and and the results are pretty much the same. Comparing a unipedicular to a bipedicular kyphoplasty. So here you can see that come in. This is the balloon that has crossed the midline again you have to make sure that your cement and balloon go into the midline so that's very important because you don't want to be on the epsilon or the contralateral half of the vertebra you have to be in the midline. So that's what we have done this is how it looks on the lateral view. The balloon should be in the interior middle third of the vertebra that's another important thing because you don't want your cement coming into the posterior column because posterior column doesn't take any part in the axial dissipation of force. And here we have inflated the balloon right in the middle of the vertebra we are in the interior third of the vertebral body on the lateral and then we start deflated the balloon and started putting cement in as as we did in that unipedicular If for some reason you wanted to do this with CT guidance you can absolutely do that this is one of my patients who had frozen shoulders so we tried to do it under fluoroscopy but her arms where she could not lift her arms up. So we had to do her in CT and you can see that this is this was actually a pathologic fracture you can see this lytic lesion involving the vertebra. Here we are coming in we have put the balloon right across their head balloons getting inflated cement going in cement going in and this is the post picture on the same patient with the cement well and truly in place within the vertical body without any evidence of extra. Okay, so the first generation when we started all this of course medical management and vertebral plastic then the second generation is when we when Kyphon came up with this balloons and we started to think about balloon Kyphoplasty but all along we were thinking that how can we raise the height of a fractured vertebra that was the hard process and And those of us who have been doing this for many, many years we have we have used many, many devices over over the years just with this part of we need to restore the height of the vertebra rather than just getting in there and putting some cement so that the vertebra doesn't compress any further than it already has. There are many devices have come into the market and some did not survive the test of time and kind of went away, but definitely there are many devices that are still on the market. I think the, the biggest one of them now at present is this spine jack that is consistently being used to restore the height in the vertical bodies. This is an ossifix device that we use like literally like almost portable stents that we put in here you can see that inflating the stent underneath the superior end plate, and then putting cement in that stand it's not available in the market now. OptiMesh was another one that we used the cement used to come out from the mesh itself and really is not used in practice. Kiva device is still in practice, it's still available and we still use it. The good thing about Kiva is that you put these the introducer wire in and then you thread this peak over the wire. And when you have that in the vertical body the cement actually only comes out from the inside of this peak, rather than coming from the outside so all the cement is contained within this peak. And this can be used for patients with pathological fractures and completely broken vertical bodies. So here you can see that a Kiva device has been used very nicely. And after we put the cement, a good fill is considered to be end plate to end plate and from the inside of the pedicle from one side to the inside of the pedicle to the other side and you can see very nicely. The cement is in place there with the use of the Kiva device. This is a patient with severe pain, visual analogue plane score of 10 on 10. And just few steps you want to be again, very close to the speeder end plate because the device is going to open in a cordial fashion so you have to give yourself room and the device room to open cordially. So this is what we are doing now the the wires are use of wires have been put in. So this is the wire, all the way in. And then we put the peak or the sheet or the wire. Make sure that it is sitting snugly on both AP and lateral views and then you put cement in and this is the post CT in that patient. The back of the implant type of plastic is being done now to consistently being used in patients to restore vertical body height of course as I said pain palliation is number one goal in the in such patients but this device is used to restore height. And you can see what these videos when we put them in how nicely you can elevate the fractured end plates and restore the height of the vertebra and in some cases we have almost restored it back to pre fracture heights and and the patient has had really good relief. So this is these are just few examples this is a fracture right here this is the jack that has been put in place and completely inflated in the vertebra. And this is the post picture so if you compare the pre and the post there has been significant height gain. This is a patient 88 year old with osteoporosis MRI was done here really you can't even see where the fracture is but this was actually a T 12 fracture. This shows it a little better than the MRI here you can see a little bit of a retropulsion of the posterior cortex patient was managed to conservatively. But, or after a week you could see an ongoing compression and the patient was complaining of significant pain, which had improved a little bit compared to a week ago so patient was again put in a, in a, in a corset, and this is a narcotic analgesia and was sent home. The brace and the narcotics for three weeks patients pain did not get any better but the patient was now almost completely immobile was living and sleeping in his recliner. And this is two weeks after you can see where the fracture was barely seen now you can see at least a moderate compression fracture so at that point patient was sent over to me and this is when I put the patient on the table so it's almost a planar now by the time patient was on my table. So I usually like in the in a case such as this, we want to restore some height for this word so I decided to put in this implant. So this is just the steps of putting the implant in. And you can see the implants are going in and now we are inflating the implants in the patient and this is the pre image of the patient and this is the post image or almost almost double triple the height of the word that was compressed and the patient had complete pain relief within 48 hours and was very happy with the results. So, typically, as I said, for me if there's a moderate to severe compression fracture, I will use these implants because the aim is a pain palliation and be to restore as much height of that those compressed vertebras as as as much as we can. Another example osteoporotic fracture 10 on 10 pain, they were not that bad. We decided to go because these are junctional level fractures T 12 L 1 fractures we went in with spine jacks. And you can see right there so this is the pre picture and this is the post picture you can see almost normal normal height restoration prefractured level at both the levels and the patient did very well with his pain and with a vast score of zero. So I've talked a lot about the height restoration why it's not only that we want the images that we do post procedural to look pretty with good height restoration and everybody say how you give so much of height to the patient and blah blah blah. It definitely has a basis to this and the basis to that is when we talk about what people fractures we really talk and concentrate only on the bone, we forget a very, very important other factor or constant of the spine that is the disk. And research has shown us that you need normal vertebral height to maintain your normal intradiscal pressure. And as long as your intradiscal pressure and your vertebral body height is normal. You transfer your axial load from one vertebra into the other vertebra. Across the disk at the level of the nucleus nucleus is really spongy. That's the job of the nucleus that it transmits the weight very easily to the next level. So when you fracture so so so that's that's your blue line with the normal fracture. When you fracture a vertebra that has an indirect bearing on the intradiscal pressure and, and we know that the intradiscal pressure falls a lot when you develop portable compression fractures. And that's the intradiscal pressure. So what happens with this is that once you do that the fulcrum of the axial load transforms from the middle of the vertebra to the from the nucleus into the annulus and the annulus is not made to transmit that axial load from one vertebra into the other vertebra. And that's what predisposes the adjacent vertebral level for fracture. A lot of people will will will say that hey by putting cement in one vertebra, are we not putting the other adjacent vertebra at risk. Absolutely. There's no denying that fact that post cementation you have, you can develop adjacent level fractures but there's no denying the fact also that if you don't do anything your adjacent vertebra is also at risk for developing fracture just because of this factor that I told you that the fulcrum moves from the middle column to the interior column from the nucleus to the annulus fibrosis and and the predisposition of interior level fracture based on this is higher than the predisposition after cement injection. And the third line the yellow line that you're seeing is that after the height has been restored, the intradiscal pressure really comes up doesn't go all the way to normal, but it's still much much better than when the fracture had happened with the intradiscal pressure plummeting almost to zero baseline here. So that's that's the whole evidence behind and and and the thought process behind height restoration in these in these fractured vertebras. We actually did a study on spine jack and compared it to the safety profile and everything pain, palliation adjacent level fractures, and it was published in 21 and and we found that spine jack definitely did much better than the other. Vertebral plastic and kyphoplasty in regards to pain, palliation and in regards to development of adjacent level fractures. Vertebral body stents are also there and this is this is a prime example of that here you can see again the stents have been put in you inflate the stents very nicely in the vertebra, and then you put the cement in those stents, which is the thing. So why we do this, say for example, comparing this stand to balloon kyphoplasty you would say that it's it's no different from balloon kyphoplasty you showed balloon kyphoplasty and it was very similar. But remember when we do the balloon kyphoplasty you inflate the balloons, you kind of push the superior and plate up, but then you have to deflate the balloons to get the balloons out. And when you deflate the balloon so any good bit of height restoration that you have obtained by inflating those balloon the end plates really come back to rest at their original height. And then you put the cement in and you do get elevation of the end plate depending upon how much cement you're able to put in. But it's not as consistent as you see with these implant kyphoplasty is because the implants are used to attain the height restoration and they're kept in place there, and then the cement is put within these implants. And so the height restoration definitely is met much better and because it's better sustained by the implants rather than getting the height restoration with the cement that is the concept of balloon kyphoplasty. Now new new devices are coming in the market in which you can stabilize the vertebral body by putting cement in and then you have these peak implants and almost like pedicle screws that you can keep in place so that you argument both the the interior column as well as augment the posterior column. And one such is this we strut that that we are using now, and in a normal spine 60% of the axial load is the interior column and 40% is by the posterior column in older age group. The more pressure is is is along the interior vertebral body hence increase incidence of fracturing the the vertebral body rather than the posterior element so with the idea is that with the use of these struts, you can you can pretty much balance it out back to the normal spine of the younger days in such creations and that you started to use this more in patients with pathological fractures where the pedicles are involved so that you have some element of structural stability within that involved pedicle. And this is just an example of we strut here you can see augmentation of the vertebral body and then these dots they're seeing this is the struts that have been left in place in the posterior column right here. So what are the future directions where are we heading now so now a lot of research is being done because we have been using PMMA cement for like decades and decades. Nothing has changed really much in regards to what type of cement we use from our PMMA cement, but now a lot of research is being done in which we are thinking of impregnating our cement with anti mitotic agents. These titanium microspheres bisphosphonates locally for treatment of pathological fractures. So a lot is being done in this realm now and hopefully one day we will have these drug eluding cement that we will use rather than our simple PMMA cement. Bone cement with radio isotopes is being taught about also and research that can be used especially in certain cancers. There are certain chemotherapeutic agents that can be used with bone cement because few studies have shown that bone cement actually eludes out from the cement for about three weeks. So there are certain chemotherapeutic agents that make a radio resistant tumor, more radio sensitive so we're thinking about mixing those with our cement and hopefully hopefully so that SBRT or other radiation use can be much better in patients with the radio resistant tumors also. This is also being researched now. There are companies that have come up who are more thinking in terms of osteo integration of the bone cement and putting in bone grafts in that integrate into the osteo structures and help in healing of the vertebral body and this is one such case where you can see this Schmottos-Nord fractured vertebrae patient was having pain and this is the after these beads were put in. This is 12 months later you're seeing this osteopoil 100% allograft bone implant that was put in and you can see nice osteo integration at about 12 months of the bone with these beads so that's hopefully the future in this area. As I said, titanium microspheres have been put in, they've been also in the research world and still being researched but that's something hopefully we'll get to see in future with our augmentations. And with that I think we are, we have five, seven minutes for any question answers. Thank you for your attention. And if you have any questions, please go ahead. Dr. Khan, you can go ahead and open up that Q&A box, there's a couple in there for you. Okay, so the first question is how can we differentiate between pathologic fracture and osteoporotic fracture in an old lady. So, sometimes it can be hard on your routine anatomic imaging. We know that on routine anatomic imaging, be it CT or be it MRI, we have certain characteristics of pathologic fracture convex bulging of the posterior cortex is something that goes with malignant pathologic fracture if you have involvement of the pedicles that on especially on MRI if you have signal changes that go into the pedicles bilaterally that is something that favors pathologic fractures. If you have a pedispinal mass, be it in the ventral epidural space or the entrolateral aspect of the vertebral bodies, all of those favor pathological compression fractures. But having said that, at times it is extremely hard to differentiate if you don't have these features and you just have mild moderate compression fracture. It is very hard on routine anatomical imaging. But if we do have some suspicion of patient has a remote history of cancer or something like that. Here at our practice we have incorporated advanced spinal imaging where we do diffusion and profusion imaging now, and that really helps us better understand what anatomical imaging really does not. And that's something that should be incorporated in clinical practice now, especially in academic centers, I think that's something that needs to be done. If you're not able to do that then the only way to answer that question is by doing a biopsy and most of the time I do send a biopsy if I'm treating a new fracture and there is some history of remote history of cancer or the history is not clear cut we always send up the biopsy. The next one is what shall be done to reduce occurrence of osteoporosis or osteopenia before happening. Very, very good question and that's why if you are in intervention list and you are if you're wanting to become a spine intervention list. The days of treating a patient and then shoving the patient back to their referrals is long gone. So you have to have your own clinic where you see these patients. And so when I assess these patients we have a discussion with these patients about osteoporosis and if they have their PCP or they are have an endocrinologist or a rheumatologist who can take care of their osteoporosis. I had multiple occasions where the patient never even had a dexa scan done so we make sure that we tell the patient to get a dexa scan and then based on the results and all we make referral to either an endocrinologist or rheumatologist or talk to their PCP so that these patients are started on bone strengthening agents for treatment of their osteoporosis otherwise you'll be just chasing one fracture to the next fracture as I showed in the timeline on one of my patients. My patients we've developed like five fractures in six, seven years. So yeah, look at these patients treat these patients in your clinic, refer them to the appropriate physicians who can take care of osteoporosis is the spine jet MRI compatible if so at what time interval. So the company will says that it is it is conditional approval of spine jet. But we have dot MRI for this study that I showed I pretty much did MRI within 24 to 48 hours after putting the Jackson. So they are completely MR compatible and you can, you can image them right away after placement if need be. There shouldn't be a problem with that but but they come up with this disclaimer that they are conditional. What is your comment about using plates to fix a portable fracture. Using plates like quite don't understand plates is is are you talking about the ACDF or because typically, if it's a surgical fracture they they they put in trans practical screws or they do laminectomies. They can elaborate more on what you mean by surgical plates so I can probably answer that question much better. Why does word table augmentation increase the risk of adjacent level fracture. Great question. Again, one of the reasons is because as I said, we till now pretty much we have been putting in PMMA, and the PMMA has a very high tensile resistant. It is much, much stronger than the inherent bone especially if you're doing an osteoporotic weak bone. So that's that's when, because of the difference in the tensile strength of the bone in a in a severely osteoporotic patient that that may put the adjacent level at at risk. Sometimes you may have cases where there has been extra position of cement into the disk space and that's when I tell my fellows that you had to be very careful not extra visiting contrast into the disk space because if the contrast goes into the disk space touches the inferior end plate or the superior end plate of the adjacent vertebra. Obviously those those vertebras will be at at a higher risk for fracture than the normal bone. What is the treatment policy in US regarding extensive osteoporosis in female symptomatic only at one level. How do you, how do you follow up in view of stress on the adjacent vertebra. So, as I said, usually refer over patients either to endocrinologists or rheumatologists who can take care of, but most of the time patients will will get the bone bisphosphonates. So now you can get monthly six monthly and you can get yearly injections. We tend to follow these patients with a dexa scan and see overall improvement over time with these scans but most of the time, of course you have you have you're taking your vitamin D is your calcium, but in severe osteoporosis you end up taking these bone strengthening bisphosphonates. And then being managed either six monthly on a yearly basis now. Can these procedures be used to correct a scoliosis. No, scoliosis definitely needs to be created. I mean treated surgically, especially if it's a moderate to severe you need to put rods and screws. And these need need to be done. So this is this is that's not an indication for doing working a lot of notation. I guess that's it. That's it. Dr Khan Thank you so much for your lecture today and thanks to everybody for participating in new conference. You can access the recording of today's conference and all of our previous new conferences by creating a free MRI online account. Join us next Thursday, January 12 at 12pm Eastern for a special new conference co sponsored by the American Association for women in radiology for a lecture entitled the fountain of youth pediatric GU ultrasound. This lecture will be given by Dr Barbara Pauley, past president of the awr and associate professor of the ER and pediatric radiology at University of Kentucky. You can register for this lecture at MRI online calm and follow us on social media for updates on future new conferences. Thanks again and have a great day.


Ahoy-hoi and welcome to the video. I'm Dr. Sumerian, not a real daughter, and today we are going to go over the dank memes from the dank memes of Site 19 subreddit. Let's get started. This one is by underscore underscore zeal underscore. Maybe I could just say zeal, I don't know. Other people have only 69 and 420 for funny numbers. The SCP fandom. Pathetic. You know, we got 173 for funny numbers though. If we're thinking about the numbers that remind us of something, I mean you've got 682, you've got 999, but funny numbers? I mean there's a lot of jokes made about 173. That's kind of it. I don't know. If there's something I'm missing, anything can be made a joke out of, but I'm talking about when you hear the number you don't immediately think that's a joke. I can't think of anything other than 173. So I don't know where you're coming from zeal. I mean correct me in the comments if you could think of something else. There are some funny SCPs, but I don't recognize them by number. This one's by a Joey boy. I believe the title of this was when you post your first SCP. I mean not everyone fails the first time. That's not going to make you feel better, but it's true. And that's actually not true. And I know that you're probably not meaning it in a literal sense. I'm going to take this way too seriously because I think it's important for new authors. Just because your article is downvoted doesn't have any kind of commentary on you as a person.  They don't even hate your article. Most of the time they're pretty ambivalent about it, but it's a signal that your article isn't either isn't good enough for the site or something about it isn't appropriate for the site. I don't mean inappropriate as in to adult or to something. What I mean is that the site is sort of expecting a particular type of content and even very good content doesn't succeed extremely well on the SCP wiki if it kind of breaks the mold. But then again, there are articles that do that and do well. And I don't think most of the time it leads to them getting downvoted. It does lead to a lot of neutral votes and a lot of difficulty getting people to read it in the first place. But just if you fail, take it as not evidence, but take it as a lesson for the future. Look at what you did wrong. Usually there's comments that will tell you because everybody is an expert when it comes to downvoting stuff. But look at the comments, see what people are telling you, and use that to improve your article for the next time. And if for some join the community and be like, Hey, I wrote this article here. And I kind of would like to know what I'm doing wrong. Or so I saw this feedback from such and such. And I'd like to kind of get a better handle on what they were trying to say. I wouldn't do a wiki.pm. And I definitely because that's a little bit less. It's a little bit more formal. But definitely, you know, look into what you did wrong and or what you did that didn't work and work on correcting it for the next time. Marshall Carter in dark during an XK into the world scenario. I actually and this is by bitter gr for 613. I saw this and it gave me an idea immediately because I go through the full list of memes and then I curate out the ones that I think I can have something to talk about. And this one gave me an idea the first time I saw and that's that each group of interests sort of has their own certainly has their own versions of the end of the world. And while Marshall Carter and dark probably have, you know, protocols in place for actual ends of the world, like, you know, an asteroid strike or some sort of reality altering phenomenon that destroys the world, or even when daybreak sort of stuff. They also probably have a couple extra like, Oh, I don't know, what if money stopped working? What if money stopped being worth anything? And I was thinking about like what the other GOIs might have to, but mostly my brain was focused on Marshall Carter and dark when the idea hit. But I mean, like each GOI would have their own things, right? Like what kind of stuff do you think the chaos insurgency or the GOC would be looking at the GOC for the GOC like the end of the veil would be like the end of the world. They don't just care about like the veil in a serious way. They're like, Oh, no, the world a world without normalcy is is no longer the world for them. So they know everyone has their own every one of the GOIs has their own little version of that. This one is by C 21 Arthur, finally now bright is allowed to do.  I talked about censorship. I talked about people with mental illnesses who were attached to bright the character and in extremely destructive ways and the removal of bright from the SCP Wiki is causing them actual like psychological harm. And then I realized that this is a meme video and I probably should save that for its own video if I'm going to do talk about that kind of stuff. So yeah, I guess I'm just moving on now. This meme is by Clare Lestrange, me enjoying a what written tale 056 writing 682 like some kind of megalomaniac megalomaniac cowboy.  So, you know, gosh, there are fun stories on the SCP Wiki, right? Like, and there's nothing wrong with that. Something can be fun and well written. And maybe that tale that you're referencing. The only time I remember 682 being written is from is Duke Till Dawn. So I'm not sure if that's what you're referencing here, if it's something else, because it was about the Ouroboros cycle. So I don't think Duke Till Dawn's in the Ouroboros cycle. But the same thing must happen there, I guess, question mark. Yeah, no, it's fine. If it's well written, it's well written. Who cares if it's funny and or silly. This one is by Dimon Bright. Oh boy, time to read more SCP articles, object class, safes, strike through Euclid. What did you do this time foundation? All right, I have I have two things to say about this. First of all, strike throughs in digital documents are kind of ridiculous. You could just say like this was this used to if it's is is it safe anymore? No, then why does it still say safe? You don't strike through digital documents, you just backspace backspace backspace backspace and then type Euclid you. Second of all, that's a stylistic thing. But second of all, you know, sometimes it's not the foundation's fault. Sometimes it's the anomalies fault. Sometimes, not always. This is the last one by Frivash one, a nice short article offsets and collapsibles. Yeah.  I really feel like word count should be like it should be normalized to put word count in the little informational blurb you put at the top if you put the informational blurb at the top. But even if not put at the top and be like this this article in total but nobody but not nobody but some people don't want to do that because they know that people don't want to but you're not a good enough writer. That's the problem. Okay. If you were a good enough writer, this is the thing. I'm going to say this is the thing again, probably because I want to say a thing, but I also know that it could be very offensive to certain people and I want to try and dial that back because I want to be fair. Here's the thing. The writing on the SCP Wiki is not always amazing. If you're a good enough writer, people will read your stuff no matter how long it is. DJ Cactus has proven that. It's not just because of name recognition. It's not just because he's DJ Cactus. It's because he's written stuff before long stuff before that people have read and enjoyed enough to continue and finish. Okay. You don't get to end run around that by tricking people. If you think that putting in collapsibles and putting in offsets is the only way to get someone to read your article in its full length entirety, maybe you've written too long of an article or maybe you're just not as good enough of a writer as you think you are because what you think is and I'm going to say this isn't for everybody. Some people do this accidentally. There are people who do it deliberately.  Well, respect that or be a better writer. That's the option. You could just respect people's wishes. That's also a possibility. It annoys me because I prefer short stuff too. I mean, I'll read a long story every once in a while, but if I want to read a novel, I'll go read a novel by better writers. Anyway, that's it. Thank you very much for watching. If you enjoyed the video, hit the subscribe button and then hit the notification bell next to that so you're notified when I upload new videos. And then head on over to patreon.com forward slash decimarian and pledge at any level like everybody here on the screen already has including Sinjeriki who's pledged at $100. It is nice to know that I'm not alone out here and I will see you all again on Thursday.


In this presentation, we will record a cash donation into our not-for-profit organization.  Here we are in our not-for-profit organization dashboard. We're going to go on over to our Excel sheet to see what our objective will be. So let's jump into Excel. We're going to be in the second tab, so tab number two, where we have a cash donation. Now we're going to record this all as like one lump sum donation, but you can imagine multiple different donations of cash, which would be resulting in a similar transaction. This possibly being one of our more current or frequent type of transactions, the cash donation. So what's going to happen? Well, cash is going to be increasing. So from a journal entry or account perspective, cash would then be going up. The other side's going to go to kind of like what would be our revenue type of account. We're going to call it the contributions account. And it's going to be a contributions without restrictions, the assumption being here that there has been no restrictions on the cash donation that has been given to us. Obviously, we are not for profit organization, which has two programs. That's our primary goal for the cash donations, but there's been no further restrictions other than to do our objective as the not-for-profit organization. Therefore, it goes into contributions without restrictions. If we take a look at our accounts then, in a trial balance format, the cash would then be increasing. The other side would be down here on the income statement side of things. So this is income. So this is a revenue account. Revenue is going up in the credit direction. And that would mean that net income would be increasing. Net income is increasing as well as we could see down below. So net income increases here. That's an increase. That's a credit increase in the credit direction. That's going to be our objective. Note, of course, as we see these income statement accounts on the statement of activities, we're going to want to start to break this information out into the statement of activities, those with donor restrictions and those without donor restrictions. But as of this point in time, we have no items without donor restrictions. So we're fairly straightforward here within our statement of activities with this added kind of dimension on it. Okay. So let's go back over to our journal entry and then we'll jump on into zero. Let's go back into zero here and we're going to use our standard form. So someone gave us money. We're going to go to our standard type of form. We're going to say plus button go down and we're going to say they receive money form. So we got the receive money type of form. We're going to be choosing the account this time, of course, being the checking account. Now here, do want to note that if you're, for example, receiving having some kind of thing going on where you're receiving many donations at one time and like, let's say they're cash donations and then you expect to go to the bank at the end of the day. You may then want to put them into the clearing account or some kind of clearing account, undeposited funds, let's say, and then transfer them into the checking account at the point of time that you take those deposits into the bank. Why? Because you want your system here in zero to be deposited in the same format as they will be shown on the bank statement and that will make your reconciliation comparing our checking account to the, to the bank statement easier to do. And that's going to be your objective. So just keep that in mind whenever you're entering deposits here, how can you group them in such a way that there will be the same format of grouping that will be shown on the bank statement so that you can compare those two, reconcile them very easily. But for purposes of this problem, we're going to go in and just put it right into the checking account. And then we're going to say next. And then here's going to be our receive payment form. So I'm going to just say this came from donor two. So this is a person. So we're imagining this is a person or organization that's giving us money. So donor two, because we're not for profit organization. So donor two, I'm going to say that this happens on the second. So I'm going to bring this back to January number two, January second. Then we're going to use our item. Now our items are straightforward. Now it's just going to be a donation. So I'm just going to say donation. So there's our item for the donation and then the amount. We can imagine multiple different amounts or multiple different donations of a similar transaction that would add up to the $189,700 for our practice problems. We're putting them all in one group sum. All donations we could see would be in this format. So then we have the contributions. That's correct because that's the revenue account being driven by this item. No sales tax, of course. And then restricted or unrestricted. This is going to be unrestricted. And then I'm going to start off by just putting them all into the fundraising. And then later on, we're going to go, we're going to go back in and make any adjustments we need to fundraising, probably fine with the revenue side of things. But with the expense side of things, we'll, we'll make an adjustment in accordance with our percentages. So we'll do that later. No restricted item here. So that looks like it. What's going to happen when we record this, it's going to increase the cash account this time, the checking account. The other side is going to be going to our contribution unrestricted in essence, our revenue accounts. We can also print this form out as some evidence of the contribution to our donor of the cash contribution if we so choose. And we can track this information by basically customer or donor to see what these donations have been. Let's go ahead and look at it. We're going to say save then going to go ahead and save this thing. And then we'll open up our reports. Let's go to the accounting drop down then we're going to go to the accounting drop down up top, we'll then open up the balance sheet will be opening up the balance sheet report one of our primary reports here. The dates let's change the dates to January 2020. So bringing this out to January 31, 2020, updating that report. Then we have now in the checking account that 189 700 on the equity side of things. We got the 189 700 because that's in the current earnings, which we'll also see on the income statement. So let's go back up top and let's let's go to the tab up top, right click on that tab duplicate that tab. It then is the balance sheet is on the right, we're going to go back to the left so that we can then open the income statement or other favorite report accounting drop down going down to the income statements. You may otherwise know it as the profit and loss or the P and L the not for profit name being the statement of activities, which will rename it later. That won't be a problem. The renaming won't be a problem of it. So we're going to say, all right, now we have the contributions unrestricted with the 225 500 and then the rent we had last time. Let's go into that 225 500 and drill down on it. So we'll zoom in on that number. See the activity within it to believe we have two items up at this point. So there's the donation one donation to we can obviously then go into that donation form. If we want to see the actual form, if we wanted to print this form, we can go to the options up top. We can go and view it as a PDF and print it as a PDF if we so choose going to go back out of it.  Let's duplicate this form then I'm going to right click on the income statement up top. I'm on the tab. I'm on the tab up top. I'm up here and I'm going to go ahead and duplicate that again. So we're going to go ahead and duplicate. Go back to the tab to the left. Let's go back to the accounting drop down. Let's then look at our reports again. Let's look at another report and then I'm going to go into the sales items hit the drop down and then we have our income by contact income by contact actually a better name than something like income by customer for our not for profit right income by contact because they're donors instead of customers and whatever. So here we have our income by by customer and then again this is another useful report for us to track the income by contact. Now we're going to jump back over to the income statement here and just note that we do have the groupings here and you might be saying well what are we doing with those categories we don't have anything broken out yet between the categories but just note that some of the filtering options we will see shortly is if we go to the report options down below this is where we have those two categories the restricted and the unrestricted. Now currently we're saying hey I'd like to see all of it you know all of the restricted and unrestricted what this means is like I want all of it included in in the income line so it's all included in this income line here it's all included here now if we have multiple columns if we want to set up multiple columns we can do so and we're going to do so by editing the report and it's zero is actually really nice to be able to do this it's a little bit more complicated to kind of edit the reports because they're not just fixed reports that are going to be broken out you know in a certain a few couple ways you have more customization it's a little bit more difficult to set up but once set up we can have more reflex ability because you'll recall what our objective will be of course is once we have this stuff on the income statement we want to we want to be able to present this in such a way that it's going to be easy for people to to pick up the information so if I scroll down we have these statement of activities has the two columns so we'd like to have something that's kind of broken out like this if we can customize it within the software and then be able to break out more detail such as the expenses being broken out by both nature and by function the flexibility with zero will allow us to do that because what we want to do is give something that's going to be a little bit more simplified at first to the board so they can make decisions on it and then add more detail with more detailed reports as we go so we'll get into that later once we start to break this information out into more categories than just simply the unrestricted which we have at this point that's going to be it for now let's get out of here


Well, George, first to put this in perspective, and as some of your correspondence just said, this is the worst attack on Israel since 1973, the Yom Kippur War, almost exactly 50 years ago. But there's a fundamental difference. That was a war that was state to state, country to country, army to army. This is a massive terrorist attack that is gunning down Israeli civilians in their towns, in their homes. And as we've seen so graphically, literally dragging people across the border with Gaza, including a Holocaust survivor and a wheelchair, women and children. So you can imagine the impact this is having throughout Israel and the world should be revolted at what it's seen. We have immediately engaged our Israeli partners and allies. President Biden was on the phone with Prime Minister Netanyahu early yesterday. To assure him of our full support, I was on the phone with the Israeli president, the foreign minister. The entire government has been engaged throughout the region and well beyond. George, it's no surprise that those opposed to the efforts to normalize relations between Saudi Arabia and Israel, and more broadly to normalize Israel's relations with countries throughout the region and beyond, who opposes it, Hezbollah, Hamas, and Iran. So to the extent that this was designed to try to derail the efforts that were being made, that speaks volumes. Right now the focus is on dealing with this attack, dealing with Hamas. And we'll come to the normalization efforts, which, by the way, are incredibly difficult when it comes to Saudi Arabia and Israel, lots of hard issues to work through. But if we could get there, that would significantly advance stability in the region. It would offer so many greater prospects for people in all of these countries. And there are basically two paths that are before the region right now. One is the path of normalization, of integration, of people working together. And by the way, in that and on that path, it's not a substitute for resolving the differences between Israelis and Palestinians. On the contrary, it needs to be used to advance that effort as well. But that's one path. The other path is what we've seen from Hamas, terrorism, horror, and something that offers not only nothing to people throughout the region, it offers nothing to the Palestinians. On the contrary, everything that Hamas does makes their situation, their plight, even worse. They bring nothing but death and destruction not only to Israelis, but to Palestinians. So there's a long relationship between Iran and Hamas. In fact, Hamas wouldn't be Hamas without the support that it's gotten over many years from Iran. We haven't yet seen direct evidence that Iran was behind this particular attack or involved, but the support over many years is clear. The challenge for Israel and the challenge for all who support Israel and oppose horrific acts of terrorism is again to take measures that provide for accountability for what's happened and also to do our best to ensure that this doesn't happen again. And that is likely to take some time. And it's fraught with very difficult decisions for the Israelis to make. I don't want to speculate, get ahead, get into hypotheticals. But this is now we're 24 hours or so into this. As I said, there remains intense fighting in the Gaza area. And the focus has to be on helping Israel recover the territory that has been taken briefly by Hamas, protecting its citizens, and taking whatever measures are necessary to avoid this repeating itself.


This scoping review is the first to examine the use of decision impact studies, DIS, in genomic medicine and cancer care. It found that these studies are used to evaluate the impact of a genomic test on decision making and report on a variety of clinical utility outcomes such as provider slash team decision making, provider confidence, patient psychological impacts, and costing or savings impacts. This review suggests that DIS may provide evidence of clinical utility and impact clinical practice and reimbursement decision making in cancer care. This article was authored by Jillian Parker, Sarah Hunter, Samar Ghazi, and others.