International Journal of Medical Students
The International Journal of Medical Students (IJMS) is an open-access, peer-reviewed scientific journal (ISSN 2076-6327) that publishes original research and experiences in all fields of medicine. The IJMS was created in 2009 to share scientific production and experiences where there is at least one author enrolled as a medical student (including MBBS students, MD students, DO students, MD/MSc students, and MD/PhD students) in any medical school in the world or a recently graduated physician. These early-career scientists must be accompanied by a senior researcher that must be also responsible for the research, guaranteeing the quality of the work. The IJMS aims to be the leading publication platform for early-career scientists' medical research. Read more in the About the Journal section.
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Ease of Nasogastric Intubation using a Frozen Nasogastric Tube by a Novice Intern in Anaesthetized, Intubated Adult Patients. A Randomized, Controlled Parallel Assignment Study
Ease of Nasogastric Intubation using a Frozen Nasogastric Tube by a Novice Intern in Anaesthetized, Intubated Adult Patients. A Randomized, Controlled Parallel Assignment Study Background: Frozen nasogastric tube insertion has a higher first attempt success rate compared to normal nasogastric tube insertion in many previous clinical trials. However, the insertion in these studies were done by an expert or the familiarity with nasogastric intubation is not commented about. Success rate of the skilled techniques differ based on the expertise level. We observed that the primary contact physician to be the first responder to nasogastric intubation call in majority of the hospitals is a novice intern. AIM: Our study aims to determine the success rate and associated complications when a novice intern attempt to introduce a frozen or a conventional nasogastric tube under supervision. Methods: A total of 200 anesthetized, tracheally intubated patients were randomized to receive either a frozen nasogastric tube (n=100) or a normal nasogastric tube (n=100) as a part of routine care. The first attempt success, overall success, duration of insertion, number of attempts and complications were noted. Results: Frozen nasogastric tube group had higher first attempt success (74 versus 51) and overall success (82 versus 57). It also had fewer attempts for successful nasogastric tube insertion as well as lesser time for the successful procedure (35.8 s versus 42.1 s). Overall complications were fewer with Frozen nasogastric tube (34 versus 61) compared to conventional nasogastric tube except bleeding (21 in both) and kinking (5 and 1). Conclusion: Our study demonstrated that in the hand of novice intern a frozen nasogastric tube results in higher first attempt success rate, overall success rate, reduced number of attempts, reduced coiling and shorten intubation time with a comparable mucosal bleeding in comparison to conventional nasogastric tube intubation.
Copyright (c) 2025 MADHURI DOMMARAJU, Shameem s, Aloka Samantaray https://creativecommons.org/licenses/by/4.0
Evaluation of Anxiolytic Effect of Pantoprazole on Swiss Albino Mice – An Experimental Study
Background: Anxiety disorders, affecting over 7% of the global population, are among the most common psychiatric disorders significantly impairing daily life, productivity, and social functioning. Current treatments, such as SSRIs and benzodiazepines, provide only partial relief and are often limited by side effects including sedation, sexual dysfunction, and dependence. This has created a pressing need for safer and more effective therapeutic options. Pantoprazole, a commonly used proton pump inhibitor, has demonstrated neuroprotective and anti-inflammatory properties in preclinical studies. These findings raise the possibility that pantoprazole may also exert anxiolytic effects, which have not yet been systematically explored. Methods: Thirty female Swiss albino mice were divided into five groups, each consisting of 6 animals each- control (saline), standard (diazepam 5 mg/kg i.p.), and pantoprazole-treated groups (10, 15, 20 mg/kg orally). Drugs were administered daily for 14 days. Mice were then assessed using the Elevated Plus Maze (EPM) which measures time spent and entries into open arms, and Actophotometer which records locomotor activity to determine whether pantoprazole produced sedative effects. Results: Pantoprazole treatment significantly reduced anxiety-like behavior in a dose-dependent manner. In the EPM, mice treated with pantoprazole spent more time and made more entries into open arms compared to controls, with the 20 mg/kg dose producing the strongest effect (p<0.001), comparable to diazepam. Importantly, locomotor activity remained unchanged across pantoprazole groups, indicating that its anxiolytic effect was not confounded by sedation. Statistical analysis confirmed that the 20 mg/kg dose of pantoprazole produced significant improvements in anxiety-related measures without altering overall activity levels. Conclusion: This experimental study provides the first evidence that pantoprazole, at higher doses, exerts significant anxiolytic effects in Swiss albino mice. Unlike diazepam, pantoprazole did not reduce locomotor activity, suggesting a favorable safety profile without sedative side effects. These results highlight pantoprazole’s potential as a novel or adjunctive therapeutic agent for anxiety disorders. While further mechanistic studies and clinical trials are required, the findings open an exciting avenue for repurposing an established and well-tolerated drug in the management of anxiety. Group EPM: Time in Open Arms (sec) EPM: Open Arm Entries Locomotor Activity (Counts) Control (Saline) 89.00 ± 14.07 3.67 ± 1.15 241.67 ± 35.13 Diazepam 5 mg/kg (i.p.) 213.17 ± 29.93 10.33 ± 2.08 295.17 ± 28.07** Pantoprazole 10 mg/kg (p.o.) 121.83 ± 16.53 5.83 ± 1.47* 228.33 ± 25.75 (ns) Pantoprazole 15 mg/kg (p.o.) 131.67 ± 13.79 7.50 ± 1.87 216.17 ± 28.28 (ns) Pantoprazole 20 mg/kg (p.o.) 155.67 ± 22.44 8.17 ± 1.60 225.83 ± 29.45 (ns) Table 1. Effects of Pantoprazole on Anxiety-Like Behavior in the Elevated Plus Maze and Locomotor Activity Legend: Values are expressed as mean ± SEM (n = 6 per group). Statistical significance was analyzed against control group: *p < 0.05, **p < 0.01, **p < 0.001; ns = not significant.
Copyright (c) 2025 Farheen Kooliyattayil, Shwetha Oommen, Jacob Abraham https://creativecommons.org/licenses/by/4.0
Assessing the Precision of AI-Generated Medical Answers: An Evaluation of LLaMA-3 Powered Meta AI
Background & Objective: Meta AI is being used frequently by medical students to clear the queries or to solve the questions, due to its easy availability. The purpose of this study is to assess the correctness of the Meta AI-generated answers to medical questions, and the reproducibility of the results. Method: The study employs an Evaluation Research Design aimed to assess the quality and effectiveness of Meta AI. A total of 240 MCQs were included in the questionnaire, 30 MCQs from each subject. Out of these, 108 were case-based (Category: A), whereas 132 were fact-based (Category: B). Meta AI was re-queried with the previously failed questions 14 days later. Results were analyzed manually and accuracies were evaluated using IBM SPSS version 27. Results: In initial analysis, Meta AI correctly answered 187 out of 240 questions (average accuracy = 77.9%). The most accurately responded category was Category-A with an average accuracy of 82.4%. The accuracy of Category-B was noted to be 74.2%. In re-scored analysis, Meta AI reproduced correct answers for only 12 out of 53 previously failed questions leading to an average reproducibility of 22.6%. The accuracy of Category A was 47.3% and that of Category B was 8.8%. Conclusion: The integration of AI in the field of medicine is advancing rapidly, and models like Meta AI represent significant strides in making medical information more accessible and accurate. Despite these promising results, there are notable limitations, such as the scope of questions, the subjects covered, and potential selection biases. Table 1. Overview of Total and Categorical Validation from Initial Analysis Subject Correct Answers Wrong Answers Category – A n (total) Category – B n (total) Accuracy % Anatomy 20 10 1 (8) 9 (22) 66.6 Biochemistry 26 4 3 (16) 1 (14) 86.6 Community Medicine 20 10 5 (10) 5 (20) 66.6 Forensic Medicine 18 12 0 (0) 12 (30) 60.0 Microbiology 27 3 1 (16) 2 (14) 90.0 Pathology 29 1 1 (29) 0 (1) 96.6 Pharmacology 26 4 3 (15) 1 (15) 86.6 Physiology 21 9 5 (14) 4 (16) 70.0 Total = 187 53 19 (108) 34 (132) 77.9 Table 2. Overview of Total and Categorical Validation from Re-scored Analysis Subject Total Questions* Correct Answers Wrong Answers Category – A n (total) Category – B n (total) Accuracy % Anatomy 10 1 9 0 (1) 9 (9) 10.0 Biochemistry 4 1 3 2 (3) 1 (1) 25.0 Community Medicine 10 3 7 3 (5) 4 (5) 30.0 Forensic Medicine 12 1 11 0 (0) 11 (12) 8.3 Microbiology 3 2 1 0 (1) 1 (2) 66.6 Pathology 1 0 1 1 (1) 0 (0) 0.0 Pharmacology 4 3 1 0 (3) 1 (1) 75.0 Physiology 9 1 8 4 (5) 4 (4) 11.1 Total = 53 12 41 10 (19) 31 (34) 22.6 Legend: Total questions refer to the questions that were answered incorrectly in first (initial) attempt
Copyright (c) 2025 Areeba Khan, Muhammad Talha Khan https://creativecommons.org/licenses/by/4.0
National Trends Reveal Hypertension as the Dominant Driver of Cardiovascular Readmissions
Introduction: Cardiovascular (CV) hospital readmissions significantly burden the U.S. healthcare system, particularly among patients with heart failure. While previous studies have evaluated all-cause readmission, there is limited understanding of the specific CV diagnoses responsible for short- and long-term hospital returns. This study aimed to identify the leading CV-specific diagnoses contributing to 30-day and 1-year readmissions following an index hospitalization for heart failure to inform targeted interventions and reduce repeat hospitalizations. Methods: We conducted a retrospective cohort analysis using the Nationwide Readmissions Database (NRD) from 2016 to 2022. A total of 31,886,859 weighted hospitalizations were included. Adult patients (≥18 years) admitted with a primary diagnosis of heart failure were included. The primary outcome was CV-specific readmission within 30 days and 1 year, based on ICD-10 codes for heart failure/pulmonary edema, hypertension and hypertensive crisis, myocardial infarction, arrhythmias/conduction disorders, stroke, pulmonary circulation disorders, and venous thromboembolism. Survey-weighted descriptive statistics, stratified by 30-day and 1-year CV-specific readmission status, identified leading diagnoses. Adjusted models accounted for demographics, comorbidity burden (Charlson Comorbidity Index), and hospital characteristics. Chi-square tests and phi-coefficients (φ) quantified associations, with statistical significance set at p < 0.001. Results: Among patients initially hospitalized for heart failure, hypertension or hypertensive crisis accounted for the majority of CV-specific readmissions at both 30 days (64.8%) and 1 year (65.1%). Recurrent heart failure or pulmonary edema was the second most common cause, followed by arrhythmias, acute myocardial infarction, and stroke. All comparisons versus hypertension or hypertensive crisis were statistically significant (p < 0.001; φ = 0.53–0.69). These diagnostic patterns remained consistent over time. Conclusion: Hypertension-related complications and recurrent decompensated heart failure are the predominant causes of early and late CV-specific readmissions. These findings emphasize the need for robust post-discharge blood pressure control and longitudinal heart failure management. By identifying high-yield targets for intervention, this study supports the development of more effective care models aimed at reducing the CV readmission burden in this vulnerable population. Table 1. Thirty-Day and One-Year Readmission Rates Across Cardiovascular Conditions Compared with Hypertension N = 31,886,859 30-Day Readmission % (N) SE χ²(1) vs. HTN p-values vs. HTN φ-coefficient vs. HTN Acute Myocardial Infarction 5.90 (1,881,325) 0.024 24,202,174 < 0.001 0.62 Arrhythmias / Conduction 9.24 (2,946,346) 0.030 21,108,975 < 0.001 0.58 Heart Failure / Pulmonary Edema 12.90 (4,113,504) 0.035 18,076,867 < 0.001 0.53 Hypertension / Hypertensive Crisis (HTN) 64.80 (20,662,685) 0.049 Pulmonary Circulation 0.62 (197,699) 0.008 29,836,652 < 0.001 0.68 Stroke / Transient Ischemic Attack 5.61 (1,788,853) 0.024 24,486,831 < 0.001 0.62 Venous Thromboembolism 0.84 (267,850) 0.009 29,581,492 < 0.001 0.68 1-Year Readmission Acute Myocardial Infarction 6.37 (2,031,193) 0.017 23,946,025 < 0.001 0.61 Arrhythmias / Conduction 8.79 (2,802,855) 0.020 21,700,892 < 0.001 0.58 Heart Failure / Pulmonary Edema 12.10 (3,858,310) 0.023 18,896,344 < 0.001 0.54 Hypertension / Hypertensive Crisis 65.10 (20,758,345) 0.034 Pulmonary Circulation 0.61 (194,510) 0.006 30,057,395 < 0.001 0.69 Stroke / Transient Ischemic Attack 6.14 (1,957,853) 0.017 24,168,617 < 0.001 0.62 Venous Thromboembolism 0.79 (251,906) 0.006 29,848,196 < 0.001 0.68
Copyright (c) 2025 Kyle E. Thurmann, MS, Trisha G. Mukherjee, Joseph G. Dantin, MS, JD, Paul T. Kang, PhD, Michael D. White, MD https://creativecommons.org/licenses/by/4.0
Sleep Solutions or Sleepless Nights? Adverse Events in Mandibular Adjustment Devices and Hypoglossal Nerve Stimulator Treatment of Obstructive Sleep Apnea
Background: Novel therapies for patients with obstructive sleep apnea (OSA) are gaining popularity as many turn away from traditional continuous positive airway pressure (CPAP) treatment. This study aims to analyze and compare the adverse events (AEs) associated with two alternative therapies to CPAP, mandibular adjustment devices (MADs) and hypoglossal nerve stimulators (HGNs). Methods: A retrospective database analysis was conducted of the adverse event (AE) reports extracted from The Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database. Devices included MADs (SomnoMed Herbst Advance, Sydney, Australia, product codes DYJ, LRK, ECN, and EJF) and HGNs (Inspire Implant, Golden Valley, Minnesota, USA, product code MNQ) for all years reported. Duplicate entries and reports related to device malfunction were excluded. AEs were analyzed for severity of the adverse event and classified using the Clavien-Dindo scale. AEs were classified based on the severity of harm, type of harm (Allergic Reaction, Choking, Numbness, Pain, Trauma, Paralysis, Dystonia, Hemorrhage, Dysphagia/Odynophagia), and patient outcomes (Hospitalization, Surgical Management). Results: A total of 24 MADs and 60 HGNs met the inclusion criteria for analysis. Trauma was the most frequently reported AE for MADs (n=8, 33.333%) while pain was most frequently reported for HGNs (n=29, 48.333%). Allergic reactions were significantly more prevalent in MADs compared to HGNs (n=6, 25.000% vs n=1, 1.667%, p=0.002). On the other hand, pain was significantly more prevalent with the use of HGNs compared to MADs (n=4, 16.667% vs n=29, 48.33%, p=0.012). The mean severity of the AE was higher in HGNs compared to MADs (3.000 vs 2.375, p=0.005) indicating a higher level of intervention was required and increased risk of life-threatening outcomes. No statistically significant difference in association was observed between MADs and HGNs for hospitalization, surgical management, choking, numbness, trauma, paralysis, dystonia, hemorrhage, dysphagia/odynophagia. Several outcomes and AE types approached statistical significance but did not meet the threshold for significance (p<0.05). Conclusion: Mandibular adjustment devices and hypoglossal nerve stimulators have distinct differences in their adverse event profile. Hypoglossal nerve stimulators demonstrate higher severity burden and association with pain while mandibular adjustment devices showed higher association with allergic reactions. Given that both mandibular adjustment devices and hypoglossal nerve stimulators have the capacity to pose significant harm to patients, comprehensive investigation is needed to identify the causes and risk factors for complications to advance patient safety. Additionally, novel treatments for obstructive sleep apnea are needed to meet the increasing demand for alternatives to CPAP.
Copyright (c) 2025 Jacob Bauer, Chloe Carrington, Sana Khan https://creativecommons.org/licenses/by/4.0
Exploring Careers in Healthcare & Onward (ECHO): A Community Outreach Program to Promote Healthcare Career Interest in K-8 Students Surrounding the CU Anschutz Medical Campus
Background: Early exploration can strongly influence children’s career development. Past research suggests that children of low socioeconomic status (SES) have a relative lack of exposure to the healthcare environment, which has been adversely associated with healthcare career interest. Many have examined the importance of promoting early interest in healthcare careers, particularly as a strategy to address shortages of healthcare professionals practicing in low socioeconomic areas. While most research examines career interventions in teenage adolescents, there is a relative lack of such interventions geared towards the elementary and middle-aged population. Our community outreach program is designed to introduce basic physiological concepts and explore careers in healthcare through hands-on experiments. The aim is to increase exposure and interest in healthcare careers in elementary- and middle-aged students. Methods: From December 2024 to October 2025, ECHO organized four career fairs at libraries and elementary schools in Aurora County. Participants were recruited through advertising at partnering schools and libraries, most of which have a large population of students who qualify for free or reduced-price lunches. The event offered four activities: “Build Your Own Stethoscope” (Cardiology), “Learn About Lungs” (Pulmonology), “Make a Surgeon’s Bracelet” (Surgery), and “All About Reflexes” (Neurology). Each activity was led by 2-4 volunteer medical students or physicians from the CU Anschutz medical campus. Following completion of the fair, participants completed anonymous post-event surveys that evaluated interest in the activities offered and medical professions before and after the career fair. Results: Between December 2024 and October 2025, 71 elementary and middle school students participated and completed post-event surveys at three ECHO career fairs. There was a 175% increase in “Yes” responses to the question “I am interested in a career where I grow up to be a doctor” following the event. This increase in reported healthcare career interest was statistically significant (p=0.0045). Relative popularity of activities followed the same pattern as reported interest in specific careers in medicine, with the surgery activity and profession being the most popular activity table and career, followed by cardiology, neurology, and pulmonology. The most frequently cited reason for why a favorite activity was chosen was “The activity was the most fun.” Conclusions: Our post-survey results demonstrate a significant increase in healthcare career interest following completion of the ECHO career fair curriculum. By offering opportunities for students surrounding the CU Anschutz medical campus to engage in healthcare career-oriented learning experiences, ECHO can empower youth to pursue careers in healthcare in their professional futures.
Copyright (c) 2025 Ariel Davydov, Rebecca Altshuler, Zoe Van De Voorde, Aimme Pugh Bernard https://creativecommons.org/licenses/by/4.0
Sleep Quality in First- to Third-Year Medical Students at Universidad de San Carlos de Guatemala: Prevalence and Associations with Daytime Sleepiness and Perceived Stress
Background: Sleep quality is fundamental for learning, emotional regulation, and long-term health. Medical students often face heavy workloads and irregular schedules that can disrupt sleep and increase stress and daytime sleepiness. Based on our literature search, we found no previous reports examining sleep quality and its associations with daytime sleepiness and perceived stress among Guatemalan medical students; therefore, this study represents an initial contribution to this field. Establishing the magnitude of sleep problems in this context is essential to guide student well-being initiatives and institutional policies. Aim: To determine the prevalence of poor sleep quality among first- to third-year medical students at the Universidad de San Carlos de Guatemala and to evaluate its association with daytime sleepiness and perceived stress. Methods: We conducted a cross-sectional survey of first- to third-year medical students at the Universidad de San Carlos de Guatemala during June-July 2024. Participants filled out an online questionnaire that included the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and the Spanish Perceived Stress Scale (EEP). Poor sleep was defined as PSQI > 5. Demographic data included sex, age, and academic year. Categorical variables were compared with chi-square tests, and associations among PSQI, ESS, and EEP scores were assessed with Spearman correlations. Analyses were performed in R with α = 0.05. Results: A total of 100 students participated (mean age 21.7 ± 1.6 years; 61% women), who reported an average nightly sleep duration of 4.9 ± 1.05 hours (mode = 5 hours) over the previous month. The mean PSQI score was 9.2 ± 2.8, with 90.0% (95% CI 83.5–94.6) classified as having poor sleep quality (PSQI > 5). Excessive daytime sleepiness (ESS ≥ 10) was found in 49% of students (mean ESS 8.8 ± 3.6). High perceived stress was present in 87% of participants, with a mean score 32.1 ± 6.8 which corresponds to the high-stress category (27–40) on the 0–56 PSS/EEP scale. Poor sleep was not significantly associated with sex (χ² = 0.17, p = 0.68) or academic year (χ² = 3.33, p = 0.19). PSQI scores correlated positively with daytime sleepiness (ρ = 0.31, p = 0.0017) and perceived stress (ρ = 0.31, p = 0.0020). Conclusion: Poor sleep quality is highly prevalent among early-year medical students at the Universidad de San Carlos de Guatemala and is associated with greater daytime sleepiness and perceived stress. These findings point to the need for both institutional and individual interventions—such as sleep-hygiene education, stress-management programs, and structural measures to reduce chronic sleep restriction—to help protect students’ health and academic performance. .
Copyright (c) 2025 Victor Rivero, Ana Palomo https://creativecommons.org/licenses/by/4.0
Mobile Phone Use and Hand Grip and Pinch Strength in the SCAMP Study
Background: Use of smartphones demands small, repetitive movements of the thumb and digits on small screens with prolonged hand grip and awkward wrist movement, which may result in fatigue, discomfort, weakness or musculoskeletal impairment. The relationship between phone use and grip and pinch strength in adolescents is poorly understood. Existing research is limited to small, cross-sectional studies predominantly in young adults with little adjustment for confounders, limiting causal inference. Yet hand and wrist injuries pose a huge economic burden to the NHS, costing c£1.3 billion annually with an average 2.8 days of workdays lost. High quality, longitudinal research with appropriate adjustment of confounders is required to resolve this research question, given the high levels of smartphone use in UK adolescents. Methods: The aim of this study is to investigate the longitudinal association between smartphone use and hand grip and pinch strength, and to explore if any observed associations differ between dominant and non-dominant hands, or between biological sexes, in the Study of Cognition, Adolescents and Mobile Phones (SCAMP), a prospective school-based cohort in Greater London, UK. 647 SCAMP participants with baseline (11-12 years) and follow-up (13-15 years) data were included in the analysis. Hand grip strength was measured for both hands, using standardised technique, with a hand-held Jamar dynamometer (kg), and tip pinch, key pinch and palmar pinch with a Jamar pinch gauge (kg). Mobile phone use variables were daily duration of calls, daily duration of social network use, daily duration of internet use, daily frequency of text messaging and daily frequency of instant messaging. Self-reporting via questionnaire at baseline and follow-up were undertaken. Analyses were adjusted a priori for potential confounders (age, sex, socioeconomic status, ethnicity, other device use, time difference between baseline and follow-up, and school cluster effects). Results: Preliminary results showed no evidence of a relationship between any mobile phone use activity at baseline and hand grip or pinch strength in either hand at follow-up. However, when examining change over time in mobile phone use, preliminary results indicated that increases in instant messaging, text messaging, and social network site use on a mobile phone between baseline and follow-up were associated with stronger hand grip, key pinch and palmar pinch measures at follow-up. For example, an IQR increase in instant messaging frequency over the two-year follow-up period was associated with a 0.72kg (95% CI: 0.06,1.39) increase in grip strength in the dominant hand at follow-up. Conclusions: This is the first longitudinal study to examine the relationship between mobile phone use and hand grip or pinch strength. Our preliminary results oppose previous small-scale cross-sectional research findings, as we find no evidence of any negative impacts of mobile phone use on grip or pinch strength in adolescents, with some specific activities e.g., messaging, actually associated with stronger grip and pinch strength.
Copyright (c) 2025 Rachel B. Smith, Lan Cheng, Catherine James, Chen Shen, Mireille B. Toledano https://creativecommons.org/licenses/by/4.0
Cognitive Impairment and Its Influencing Factors Among Elderly at Residential Homes in Western Tamil Nadu -A Cross-sectional Study
Background: The global population is experiencing rapid aging, with projections indicating that the number of older adults will double by 2050. In India, it is anticipated that one in every five individuals will be aged 60 years or above in the near future. This demographic transition brings with it an increasing prevalence of cognitive impairment (CI), characterized by declines in memory, attention, or executive functioning that are more severe than typical age-related changes but do not meet criteria for dementia. Elderly individuals living in old age homes face additional vulnerabilities due to social isolation, weakened family support, and adjustments to institutional care. Despite these challenges, cognitive health within residential care settings has received limited attention in the Indian context. Identifying the prevalence and contributing factors of CI is essential for promoting appropriate healthcare interventions and safeguarding the autonomy and well-being of older adults. Aim: The present study was designed to evaluate the prevalence of cognitive impairment and to examine the factors associated with it among elderly residents of old age homes in Coimbatore. Methods: A cross-sectional study was carried out between November 2024 and February 2025 across selected old age homes in Coimbatore. Using multistage random sampling, 200 individuals aged ≥60 years were recruited. Cognitive function was assessed with the Montreal Cognitive Assessment (MoCA). A pretested semi-structured questionnaire collected data on demographic and socioeconomic characteristics, financial dependence, and past occupations, as well as health conditions and lifestyle factors. Anthropometric measurements and clinical parameters such as blood pressure and pulse were recorded. Data were analysed using SPSS v25.0, and associations were tested at a significance level of p<0.05. Results: Among 200 elderly participants (mean (± SD) age 69.8 ± 9.8 years; 57% men, 43% women), one-third were illiterate and only 10.5% received a pension. The mean MoCA score was 15.2 ± 5.6, with 30.5% showing mild, 49% moderate, and 18% severe cognitive impairment, and it was notably higher among women (figure 1). Cognitive impairment was significantly associated with sex (p = 0.03), education (p < 0.001), past occupation (p = 0.020), pension status (p < 0.001), and financial dependence (p < 0.001). Hypertension (34%), diabetes (16.5%), and sleep disturbances (28.5%) were the common comorbidities. These findings indicate a high burden of cognitive impairment among institutionalized older adults, with socioeconomic and health factors playing a critical role. Conclusion: Cognitive impairment was highly prevalent among elderly residents of old age homes and was associated with socioeconomic factors. These findings highlight the urgent need for the annual cognitive screening in the institutional settings and its integration into the existing national geriatric health program in the country. Addressing modifiable risk factors including financial dependence, limited social interaction, and sleep problems can improve the overall quality of life, reduce the caregiver burden, and promote cognitive health as a cornerstone of dignity and healthy aging.
Copyright (c) 2025 Sri Thabasni S K https://creativecommons.org/licenses/by/4.0
Association Between Diabetes Mellitus and Intraoperative Awareness During General Anesthesia: A Retrospective Cohort Study
Background: Despite advancements in anesthetic techniques, specific patient populations remain vulnerable to intraoperative awareness. Diabetes mellitus (DM), increasingly prevalent and often accompanied by significant comorbidities, may complicate anesthetic management and mask signs of inadequate anesthetic depth. This study investigates whether DM is independently associated with an increased risk of unintended intraoperative awareness. Methods: A retrospective cohort analysis was conducted using the TriNetX research platform, a federated health database. Two cohorts were identified: patients with DM and a control group without DM undergoing surgery under general anesthesia. Propensity-score matching (1:1) was used to control for confounders, including cognitive impairment, chronic obstructive pulmonary disease, substance use, cardiovascular disease, and anesthesia type. The incidence of intraoperative awareness was compared between groups. Results: After matching, 193,868 patients were included in each cohort (total n=387,736). The incidence of intraoperative awareness was significantly higher in the DM group (0.027%, n=52) compared to the non-DM group (0.015%, n=29). DM was associated with a statistically significant increased risk (absolute risk difference: 0.012%, 95% CI: 0.003–0.021%, p=0.0106). Diabetic patients had nearly twice the risk of intraoperative awareness (RR=1.793, 95% CI: 1.139–2.824; OR=1.793, 95% CI: 1.139–2.825). Conclusion: DM significantly increases the risk of intraoperative awareness during general anesthesia. These findings underscore the importance of heightened anesthetic vigilance and personalized monitoring strategies in diabetic patients to mitigate this risk. Table 1. Comparison of Intraoperative Awareness Incidence Between Diabetic and non-Diabetic Cohorts. Cohort Patients in Cohort Patients with Outcome Risk Diabetes Cohort 193,868 52 0.027% Non-Diabetic Control Cohort 193,868 29 0.015% Risk Difference 95% CI (Risk Diff) z p Risk Ratio 95% CI (Risk Ratio) Odds Ratio 95% CI (Odds Ratio) 0.012% (0.003%, 0.021%) 2.556 0.0106 1.793 (1.139, 2.824) 1.793 (1.139, 2.825)
Copyright (c) 2025 Zhenghao Wang, Ngoc Bich Nguyen, Eduardo Espiridion https://creativecommons.org/licenses/by/4.0
The Effects of Community-Based Mental Health Interventions on Resettled Adult Refugees from Muslim-Majority Countries
Background: Although refugees from Muslim-majority countries represent a vast percentage of displaced populations globally, limited data exists on their resettlement into high-income nations. This gap has resulted in an inadequate and inequitable method of care when addressing their mental health needs, often overlooking relevant cultural and religious frameworks. The religious beliefs of these individuals, paired with the sociocultural assumptions placed upon them both internally and externally, affect help-seeking behavior and psychosocial resilience which ultimately manifests in poorer health outcomes. These issues are compounded because refugees often face significant stressors through discrimination, societal stigma, and trauma from forced migration which exacerbate disparities. Furthermore, the COVID-19 pandemic disproportionately affected refugee populations that struggled with limited access to treatment and healthcare information. The pandemic amplified epidemic hysteria fueled stigmatization of refugee populations which further increased their distrust in Western medicine and decreased compliance with healthcare systems. Aim: To identify the effects of community-based mental health interventions in resolving this population's unmet mental health disparities. Methods: We conducted an integrative review of the literature on this topic to illuminate the effectiveness of this healthcare model for resettled adult refugees from Muslim-majority countries. Data extracted from the literature included information on interrelated environmental systems that affect mental health, descriptions of the measures taken at each of the four ecological levels of influence, and reported outcomes in regards to effectiveness and challenges. Results: Interventions for depression, anxiety, and psychological distress were most prevalent, addressed most commonly through strengthened social-bondedness and interpersonal relationships among refugees and their communities. Programs which address cultural stigma through psychosocial support were suggested as developments which can reinforce Muslim refugee identity and thereby enhance healthcare delivery. Eligible publications suggest that mental health programs addressing social connectedness, early on-set community health intervention, and direct refugee engagement within program development improves overall psychosocial wellbeing. Common results included an increase in social encouragement among refugees, the implementation of communal healing practices, and a strengthened connection between refugees and their families overseas. Such family centered interventions have been shown to be feasible, accepted, and effective in reducing traumatic stress and depression in certain populations. Faith-informed interventions led by community members have likewise shown significant benefits for resettled Muslim refugees in terms of reducing PTSD and depression. The COVID-19 pandemic underscored virtual care as a promising potential tool for psychotherapy of refugee populations. However, telehealth must be properly integrated into telehealth systems to overcome technological and cultural barriers to provide meaningful care to refugee populations. Conclusion: The persisting mental health and intervention needs among these resettled refugees warrant high-quality, advanced studies to facilitate the equitable mobilization of resources and attention. Collaborative partnerships with the stakeholders, local communities, and refugees play a vital role in the successful implementation of equitable health care.
Copyright (c) 2025 Ahmad Elhaija, Ilia Talebi Dolouei https://creativecommons.org/licenses/by/4.0
Emotional and Psychological Dependence of Medical Students on Artificial Intelligence Chatbots: A Cross-Sectional Study
Background: Artificial Intelligence (AI) chatbots are programs designed to simulate human-like conversations to provide information and parasocial interaction. Even though these tools may provide a sense of companionship-like bonds, overreliance risks conflating support with dependence. This raises critical questions regarding whether the very features that enhance chatbot engagement may, through repeated or emotionally charged interactions, inadvertently promote emotional dependence. Our study aimed to evaluate the emotional and psychological dependence on AI chatbots among medical students, a population group at higher risk of adopting such coping strategies due to intense stress and limited avenues for emotional support. Methods: A national cross-sectional survey was conducted among medical students enrolled in various public and private institutions across Pakistan over a period from July to August 2025 through an online questionnaire with assured anonymity. The survey was voluntary, and all participants provided informed consent prior to enrollment. Ethical approval was obtained from Ethical Committee of Ameer-ud-Din Medical College. Data collectors were recruited from different provinces to ensure broad geographic representation, and the survey link was disseminated through institutional and student networks. The questionnaire comprised the following sections: demographics, chatbot usage patterns, emotional expression, psychological help, emotional and psychological dependence, relationship-style dependency, and satisfaction. Reverse coded items were included to minimize acquiescence bias. Dependence was classified as low, moderate, or high using mean ± SD thresholds. Data were analyzed in SPSS 27 using descriptive and inferential statistics, multivariable regression, and mediation–moderation analyses to address confounding and interaction effects, with significance set at p ≤ 0.05. The study complied with STROBE guidelines. Results: Of 1063 responses, 1045 were considered valid; 986 (94.4%) students reported using AI chatbots with 50.7% of users engaging with chatbots daily. The mean age was 21.7 ± 2.1 years, with 53.5% males. Most participants (≈68%) showed moderate overall dependence, while high emotional–psychological and relationship-style dependence were observed in 12.37% and 18.36%, respectively. Students with excellent academic performance reported significantly lower dependence scores than those with good performance (p = 0.037). A focused analysis on participants from Punjab revealed significant regional trend (p = 0.009), with private-institution students showing higher emotional dependence. All scales were strongly and positively intercorrelated (Spearman p < 0.001). Multiple regression identified satisfaction as the strongest predictor of both emotional (β = 0.65, p < 0.001) and relationship-style dependence (β = 0.66, p < 0.001), followed by psychological help-seeking and emotional expression. Mediation analysis confirmed an indirect effect of emotional expression on dependence via satisfaction (β = 0.22, p < 0.001), underscoring satisfaction as a central pathway in chatbot-related dependence. Conclusion: Medical students show moderate dependence on AI chatbots, driven by satisfaction. The mental well-being of medical students is closely related to both their academic performance and future clinical practice, underscoring the importance of understanding these dynamics. These findings call for education and institutional policies to promote balanced, responsible AI use and safeguard students’ mental well-being. Future research should explore the long-term impact of chatbot dependence on students’ learning, professional development, and psychological well-being.
Copyright (c) 2025 Sheraz Qasim, Ali Hassan, Fatima Saleemi , Shaheer, Ibrahim , Adeenah , Safia Bibi, Ali Sher, Ahsan https://creativecommons.org/licenses/by/4.0
Vagus Nerve Neuropathy in SARS-CoV-2 Infection: An Ultrasound Study
Background: The vagus nerve regulates systemic inflammation through the inflammatory reflex arc. Afferent fibers detect cytokines and relay signals to the brainstem, which activates parasympathetic pathways to suppress inflammation via acetylcholine release in the spleen. Disruption of this “brake system” can lead to cytokine storm, a driver of severe COVID-19. Beyond COVID-19, vagal dysfunction is also implicated in atherosclerosis, asthma, diabetes, Crohn’s disease, ulcerative colitis, and autoimmune thyroiditis. Aim: To determine whether vagus nerve neuropathy can be detected in SARS-CoV-2–infected patients using ultrasound, and to assess its contribution to COVID-19 pathophysiology and related inflammatory conditions. Methods: A prospective study was conducted between October 2021 and April 2022, including 68 patients (mean age 53.1 ± 14.3 years) with PCR-confirmed Delta variant infection and 50 healthy controls (mean age 22.7 ± 2.4 years). Exclusion criteria for controls included chronic illness or medication affecting autonomic function. Ultrasound was performed with a 10–18 MHz linear probe, with patients supine or in lateral decubitus position. The vagus nerve was examined bilaterally at two levels: X1 (carotid bifurcation) and X2 (cricoid cartilage). Cross-sectional area (CSA) was traced just outside the hyperechoic rim. Each measurement was repeated by two independent operators. Data were analyzed using Mann–Whitney U tests (IBM SPSS v26). Results: On the left side, X1 values did not differ, while X2 showed a borderline increase in the COVID group (p=0.05). On the right side, both X1 and X2 were nearly doubled in COVID-19 patients compared to controls (p<0.001). Median CSA values were consistently higher in patients (Left X1: 0.77 vs 0.70 mm²; Left X2: 0.87 vs 0.70 mm²; Right X1: 1.20 vs 0.60 mm²; Right X2: 1.30 vs 0.70 mm²). Importantly, this enlargement was observed despite the older age of the patient group, where smaller nerve dimensions would normally be expected. This contrast reinforces the likelihood of pathological involvement rather than age-related variation. Conclusion: Ultrasound revealed enlargement of the vagus nerve in COVID-19 patients, most prominently on the right side. Although ultrasound cannot fully distinguish edema from structural neuropathy, the consistent enlargement justifies use of the term neuropathy in a broad sense. These findings support the hypothesis that vagus nerve dysfunction contributes to cytokine storm and severe outcomes in SARS-CoV-2 infection. Moreover, ultrasound emerges as a simple, bedside, non-invasive tool to study cranial nerves in vivo. Given the role of the inflammatory reflex in many chronic diseases, these results may extend beyond COVID-19, offering opportunities for diagnostics, monitoring, and therapeutic interventions targeting vagal pathways.
Copyright (c) 2025 Jelena Mićić https://creativecommons.org/licenses/by/4.0
Occupational Exposure to Blood / Body Fluid and Anxiety Among Final-Year Medical Students: The Result of the Curricular Gaps in Medical Education
Background: Occupational exposure to blood and body fluids (BBF) remains a significant hazard globally, with medical students being particularly vulnerable during clinical training. These exposures pose direct blood-borne pathogen transmission risk and considerable psychological sequelae, including anxiety. This study aimed to determine BBF exposure prevalence and characteristics among final-year medical students and investigate their association with anxiety levels, while identifying key contributing factors. Methods: A cross-sectional study was conducted among 271 final-year medical students at Bursa Uludağ University Faculty of Medicine between January and February 2025, achieving a response rate of 74.9% (n=203). Data were collected via a structured online questionnaire comprising three sections: sociodemographic characteristics, a detailed assessment of occupational BBF exposure history (including frequency, route, procedure, clinical department, and contributing factors), and the Turkish version of the Generalized Anxiety Disorder-7 (GAD-7) scale, a validated self-report tool for anxiety screening. Statistical analysis involved descriptive statistics, bivariate comparisons (Chi-square, t-test), and multivariate Negative Binomial Regression. Results: More than half of the participants (56.2%, n=114) reported at least one BBF exposure during their clinical internships, with the majority (67.5%, n=77) experiencing multiple (≥2) incidents. Among the reported exposure routes, cutaneous contact was the most frequent (23.6%), followed by percutaneous injuries (12.8%). Exposures occurred most frequently during venous blood draws (50.0%) and arterial punctures (33.3%). Rotations in the Emergency Department were associated with the highest proportion of exposures (66.7%). While glove usage was universal during reported exposures (100%), adherence to other personal protective equipment (PPE) was low (masks: 58.8%, gowns: 16.7%). The leading self-reported contributing factors were intense working hours (31.6%), pressure from assistants (21.9%), and inexperience (20.2%). The overall prevalence of anxiety (GAD-7 score ≥5) was 50.2%. Students who experienced a BBF exposure had a significantly higher mean GAD-7 score (7.21±5.38) compared to their unexposed peers (5.39±5.15; p=0.016). Multivariate regression analysis confirmed that BBF exposure itself was a significant predictor of higher anxiety severity (p<0.001), equivalent to a 2.1-point increase in the mean GAD-7 score. Rotations in high-risk departments (Emergency Medicine and General Surgery) further amplified this risk (p<0.001). Notably, psychosocial factors such as performance anxiety (p<0.001) and pressure from assistants (p<0.001) demonstrated even stronger associations with anxiety severity than the physical exposure event. Conclusion: BBF exposure is highly prevalent among final-year medical students and is significantly associated with increased anxiety levels, creating a dual burden. The high rate of recurrent exposures and inadequate PPE use beyond gloves, especially in high-acuity settings like the Emergency Department, points to critical gaps in current occupational safety training and practice. The findings highlight that psychological factors, including hierarchical pressure and performance anxiety, are potent contributors to both the risk of exposure and subsequent anxiety, suggesting a stress-injury cycle. There is an urgent need to evolve beyond traditional didactic training towards integrated, resilient protocols that combine enhanced, stress-inoculated simulation-based procedural training, strict enforcement of comprehensive PPE use, and embedded psychological support systems within the medical curriculum to safeguard both the physical and mental well-being of future physicians.
Copyright (c) 2025 Levent Özdemir, Sena Sude Özyar, Sabrina İsrafilzade, Behrokh Khorasani https://creativecommons.org/licenses/by/4.0
Evaluation of HMBG1 serum levels and its involvement in depressive symptoms in Obstructive Sleep Apnea Patients (OSA)
Obstructive sleep apnea (OSA) is a chronic disorder marked by recurrent airway obstruction, leading to sleep fragmentation and intermittent hypoxia. It is associated with neuropsychiatric comorbidities, particularly depression. Both OSA and depression involve systemic inflammation. High-mobility group box 1 (HMGB1), a ligand of TLR4, promotes proinflammatory cytokine secretion and has been linked to depression. Its secretion can be induced by reactive oxygen species. This study aimed to assess HMGB1 concentrations in OSA patients and examine their relationships with polysomnography (PSG) parameters, hypoxia-inducible factor 1α (HIF-1α), and depressive symptoms. The study included 152 participants undergoing PSG. Based on apnea-hypopnea index (AHI), they were divided into OSA (AHI≥5; n=102) and non-OSA (n=50) groups. Depression was assessed with the Montgomery–Åsberg Depression Rating Scale (MADRS), and insomnia with the Insomnia Severity Index (ISI). Serum HMGB1 and HIF-1α levels were measured using ELISA. Participants were further categorized into control (n=21), depression only (n=29), OSA only (n=57), and OSA with depression (n=45) subgroups. HMGB1 levels differed between groups (p=0.014). Controls had lower concentrations (40.0 pg/ml) compared to depression (45.6 pg/ml, p=0.013) and OSA+depression (44.9 pg/ml, p=0.049). Across all participants, HMGB1 correlated with MADRS scores (R=0.178, p=0.028), but not within subgroups. HMGB1 and HIF-1α were correlated in the whole sample (R=0.278, p=0.011) and particularly in depression and OSA subgroups. No association was observed between OSA severity and HMGB1 levels. In conclusion, elevated HMGB1 is linked to depression, independent of OSA presence, and relates to depressive symptom severity. HMGB1 dysregulation may contribute to depression development, warranting further investigation.
Copyright (c) 2025 Julia Jaromirska, Agata Gabryelska, Marcin Sochal, Szymon Turkiewicz https://creativecommons.org/licenses/by/4.0
Characterisation of Morphological Changes and Retinal Decay in a Retinal Degeneration Murine Model of Retinitis Pigmentosa
Retinitis pigmentosa (RP) is a complex, incurable, polygenic retinal dystrophy that initially presents as loss of night vision in childhood, and progresses to severe, irreversible loss of vision in adult patients. The Pde6rd10mouse models a progressive retinal degeneration akin to RP seen in humans. These mice carry a spontaneous mutation in the rod-phosphodiesterase gene that leads to photoreceptor degeneration peaking between (P)20-25 postnatal days, with degenerative plastic changes of second- and third- order neurones becoming increasingly severe following this. RP is currently without cure, however one such idea for successful vision restoration relies on the intraocular injection of haematopoietic stem cells as rod and cone photoreceptor precursor cells. There is a requirement to determine at which points there is sufficient retinal degeneration to for there to be a treatment need, without compromising the integrity of the scaffolding neurones in the remaining retina as retinal disorganisation worsens. Early transplantation of differentiated photoreceptors could delay or even prevent remodelling of the second-order neurones and cell death by providing synaptic input to those circuits. The study aim was to determine the peak range of photoreceptor cell death and evaluate the structural modifications to retinal neurones following photoreceptor degeneration in the Pde6rd10 mouse model, documenting the sequence of changes of second- and third-order retinal cells and their synaptic terminals to an advanced stage of degeneration. This data can be used to inform the timespan within which transplanted photoreceptor precursor stem cells could effectively integrate with the retinal cells in the rd10 retina and function as normal, restoring normal vision. Immunohistochemistry and qualitative immunofluorescence microscopy were performed on retinal cryosections of rd10mice to detect and assess the presence of specific cellular markers across of wild-type and postnatal days 21-200 (P21-200) of the rd10 mouse retina. Antibodies against cell and synapse-specific markers were used for single- and multiple-labelling studies. Histological staining was performed to quantify the degradation of the photoreceptor-containing outer nuclear layer (ONL) of the retina. Immunofluorescence microscopy demonstrated a remarkable deterioration in the number of rods in the ONL and subsequent changes in the morphology of the retinal cells that synapse with the photoreceptors. No outer segments were distinguishable beyond postnatal day (P24). Synaptic connections were reduced in number, and second order amacrine cells and horizontal cells were reduced in size and complexity throughout the retinal layers in all rd10 postnatal day samples. Haematoxylin and eosin staining showed a statistically significant (p < 0.0001) reduction in the depth of the photoreceptor-containing ONL in all measured intervals from the wild-type to P200, most significantly between the WT and P23; 60.43um and 15.24um, respectively (more about P23-P24). Peak interval deterioration of photoreceptors was determined at P23-24 in addition to important findings about alterations in the surrounding retinal architecture. This study helps to inform the optimum timeline for the intraocular injection and transplantation of haematopoietic stem cells, and thus the replacement of degenerated photoreceptors ultimately for the
Copyright (c) 2025 Harriet Fallon https://creativecommons.org/licenses/by/4.0
Handgrip Strength Asymmetry in Middle-aged and Older Adults: Clinical Aspects
Background: Identifying early markers of neurodegeneration remains a key challenge. Recent studies (Zammit AR, 2021; Chen Z. et al., 2022; Wang et al., 2023) suggest an association between handgrip strength (HGS) asymmetry and cognitive decline. This study explores clinical characteristics of HGS asymmetry in middle-aged and elderly patients. Methods: Ninety patients (mean age 63.7±1.2 years; 58.9% men) were enrolled. Inclusion criteria: age >45, preserved hand function. HGS was measured using a KERN MAP 130K1 dynamometer. Asymmetry coefficient was defined as the ratio of non-dominant to dominant hand strength; values <0.9 or >1.1 indicated asymmetry. Cognitive function was assessed via the MoCA test; anxiety and depression via the HADS scale. Results: Mean HGS: dominant hand – 28.5±1.8 kg, non-dominant – 25.9±1.3 kg. HGS asymmetry was found in 54.4% of patients (dominant hand – 38 cases; non-dominant – 11). MoCA scores were lower in the asymmetry group (22.8±0.6) vs. the non-asymmetry group (24.8±0.4; p<0.05). Significant declines were observed in visuoconstructive skills (1.67±0.24 vs 2.58±0.30) and memory (1.61±0.39 vs 2.11±0.40). MoCA negatively correlated with age (r = -0.39) and anxiety (r = -0.32). In the asymmetry group, strong correlations were found between gender and muscle strength (r = -0.70), and between muscle strength and MoCA scores (r = 0.34). Conclusion: HGS asymmetry was present in over half of patients and was associated with lower cognitive scores. The asymmetry coefficient may serve as a clinical marker of early cognitive decline.
Copyright (c) 2025 Anastasiia Kolesnykova, Maksym Parii, Zoia Salii https://creativecommons.org/licenses/by/4.0
From Observation to Participation: Gender Differences and Surgical Exposure among Medical Students
Introduction: Surgical rotations are critical to the clinical education of medical students, bridging theoretical knowledge with practical experience. In many medical institutions, the transition from passive observation to active participation in surgical settings remains inconsistent and may be influenced by gender disparities. This study aimed to assess the extent of surgical exposure among clinical medical students in Georgia, with a particular focus on gender-based differences in opportunities to participate actively during general surgery rotations. Methods: A cross-sectional survey was conducted among undergraduate medical students from the University of Georgia, Ilia State University, European University, Caucasus University, and Caucasus International University in Tbilisi, following ethical approval. The survey was carried out from June 27 to July 18, 2025. Participants were asked about the duration of their general surgery rotation, the number and types of procedures they observed and assisted with, and their involvement in basic surgical tasks. Perceptions of supervisory support, feedback, and overall satisfaction were measured using a Likert scale. Gender-based comparisons were analyzed using independent sample t-tests, with statistical significance at p < 0.05. Results: Of the 96 respondents (mean age: 24.05 ± 2.65 years), 52 were female (54.2%) and 44 male (45.8%). Most students (58.3%) spent 2–4 weeks in general surgery rotations. Only 70.8% had the chance to perform basic surgical skills under supervision. Male students were more likely to have scrubbed in during surgeries compared to females. Males also reported significantly more opportunities to perform basic surgical tasks (p = 0.007) and assist in operations (p = 0.017). While both genders reported similar perceptions of supervisor approachability, female students rated their overall learning experience lower on average. 43.8% of all students strongly disagreed they had sufficient hands-on practice, and only 16.7% received regular constructive feedback. When asked whether the experience increased their interest in pursuing a surgical career, only about one-third agreed or strongly agreed, with a slight but not statistically significant male predominance. Conclusion: This study showed the presence of gender-based disparities, with male students receiving significantly more hands-on opportunities. Addressing these gaps through more structured and equitable training is essential to ensure that all students gain meaningful surgical experience. Table 1. Survey of Medical Students’ Surgical Exposure, Participation, and Satisfaction Exposure to Surgical Procedures Approximately how many weeks did your General Surgery rotation last? Less than 2 weeks 5 5.2 2–4 weeks 56 58.3 5–8 weeks 26 27.1 More than 8 weeks 9 9.4 How many surgeries did you observe during your rotation? Less than 2 weeks 22 22.9 1–5 47 49.0 6–10 17 17.7 More than 10 10 10.4 How many surgeries did you assist in (scrubbed in)? None 66 68.8 1–3 24 25.0 4–7 3 3.1 More than 7 3 3.1
Copyright (c) 2025 Nnaemeka Emmanuel Mgbedo, Jametta Ukpong, Alvin Turay , Orugbaoghene Mba , Oritsemimajemite Lori https://creativecommons.org/licenses/by/4.0
Antimicrobial Resistance Awareness and Antibiotic Prescribing Behavior Among Healthcare Workers
Background: Antimicrobial resistance (AMR) is on the rise worldwide and presents a significant threat in Iraq, where ongoing conflict and fragile health systems contribute to elevated levels of multi-drug-resistant (MDR) organisms. It is increasingly recognized as a public health challenge in Iraq, largely due to the prevalent misuse and over-prescription of antibiotics. Research indicates that numerous physicians in public hospitals often prescribe antibiotics based on empirical evidence while community pharmacists commonly dispense antibiotics without prescriptions, which exacerbates self-medication and misuse. Although national AMR control plans are in place, their implementation is still limited. Surveillance initiatives have uncovered high levels of multidrug-resistant bacteria, including Escherichia coli, Klebsiella pneumoniae, and Staphylococcus aureus, in both adult and pediatric populations. It is essential to raise awareness about AMR in Iraq. This necessitates coordinated efforts across healthcare, agriculture, and environmental sectors consistent with the One Health approach to encourage responsible antibiotic usage, enhance surveillance, and enforce regulatory measures. Objective: The current study conducted to evaluate healthcare workers’ (HCWs) awareness, practices, and institutional barriers to AMR control in a sample of Baghdad hospitals. Methods: A cross-sectional survey from July to September 2025 was designed. About 196 HCWs across five hospitals in Baghdad City were involved to assess perceptions of AMR, infection control practices, and stewardship awareness. Results: The largest proportion of participants were from Baghdad Medical City (64.3%), followed by Al-Yarmouk Teaching Hospital (16.8%), Al-Kindy Teaching Hospital (10.7%), Madain Hospital (7.7%), and Zafaraniyah General Hospital (0.5%). Most respondents were residents (39.8%) or pharmacists (35.7%); 86.2% considered AMR a major problem. Gram-negative (43.2%) and Gram-positive (42.1%) were almost equal. The most frequently reported Gram-positive bacteria were Staphylococcus aureus (12.6%) and Methicillin-resistant Staphylococcus aureus (MRSA) (6.6%). Other reported organisms included Vancomycin-resistant Enterococcus (2.2%) and Streptococcus (1.1%). For Gram-negative organisms, the most problematic species were Pseudomonas aeruginosa (14.2%), Acinetobacter baumannii (6.0%), Klebsiella pneumoniae (5.5%), and Escherichia coli (2.2%). Just over half (53.1%) of HCWs reported that their hospitals had infection control policies, while (36.2%) stated no such policies existed, and (10.7%) were unaware. Training on infection prevention and control was infrequent: the majority (62.8%) reported no training at all, while only (21.4%) received training every 6 months, (8.7%) every 3 months, and (7.1%) monthly. Awareness of stewardship programs was limited (45.4%). The internal medicine ward (12.8%), surgery wards (9.7%), and intensive care unit (9.4%) were significantly associated with MDR infections. The resuscitation care unit (7.7%), burn wards (2.0%), and respiratory wards (2.0%) were also reported, while other wards such as pediatrics, hematology, and infection control unit had fewer mentions. Conclusion: Despite widespread recognition of AMR, Iraqi hospitals face critical gaps in training, stewardship, and policy implementation. Nearly two-thirds of HCWs had never received infection prevention training. Pathogens such as Pseudomonas aeruginosa and Staphylococcus aureus were equally detected and were the most common. Multi drug-resistant infections were concentrated in internal medicine, surgery, and intensive care units, with Gram-negative organisms predominating. Urgent, system-wide interventions are needed to strengthen infection control and curb the growing burden of multi drug resistance.
Copyright (c) 2025 Abdalrhman Salah https://creativecommons.org/licenses/by/4.0
Publication Rate of Students and Graduates of the Program of Combined Studies in Medicine (PECEM), an MD/PhD Program of Mexico
Background: Clinician-scientists play a critical role in bridging biomedical research and clinical practice, offering innovative solutions to the complexity of health challenges worldwide. MD/PhD programs provide a structured pathway for students to simultaneously develop clinical expertise and research skills. While these programs are common in North America and Europe, there are a few in Latin America, like the Program of Combined Studies in Medicine (PECEM) of the National Autonomous University of Mexico (UNAM) that was established in 2011 as one of the first initiatives of its kind in Mexico to integrate undergraduate medical education with rigorous research training, aiming to graduate physicians with both clinical competence and doctoral-level expertise. Evaluating the scientific productivity of PECEM students is essential to understand its contribution to academic medicine and the development of physician-scientists in Mexico. Methods: A cross-sectional study was conducted, including all articles published by PECEM students and graduates between 2013 and the first half of 2025. The search was performed in the Scopus database to identify publications authored by program participants. Each publication was examined individually to extract the publication year, journal type (international or national), impact factor of the journal, number of citations, and research topic. Additional demographic data from PECEM enrollment and graduation records were also reviewed. A database was built using Microsoft Excel 2010, and descriptive analyses were conducted to determine publication trends, productivity by generation, thematic distribution, and average citations. Results: Between 2013 and 2025, PECEM students produced 790 original articles. Of these, 749 (94.8%) were published in international journals, while 41 (5.2%) appeared in national journals. The second generation of PECEM students contributed the largest proportion of publications (33.54%). Research topics were diverse, although endocrinology (13.42%) and applied statistics (12.28%) were the most frequent, followed by oncology, infectious diseases, and epidemiology. The average impact factor of journals where PECEM students published was 4.26, with an average of 17.92 citations per article, underscoring the visibility and academic relevance of their work. As of 2025, PECEM includes 110 students distributed across 14 cohorts, with 30 graduates who sum up 542 (68.57%) of the articles published. Among them, 9 women (8.18%) and 21 men (19.09%) have successfully obtained both degrees. The program has demonstrated steady growth in student enrollment, accompanied by an increase in research output, particularly notable after 2021, coinciding with the global scientific response to the COVID-19 pandemic. Conclusion: PECEM at UNAM represents an innovative model for integrating clinical training with scientific research at the undergraduate level in Mexico. Its experience demonstrates that it is possible to train physician-scientists capable of making significant contributions to biomedical knowledge and clinical practice. By promoting early scientific productivity, the program helps to reduce the gap in medical publications in Latin America and strengthens the training of professionals with national and international impact. PECEM serves as a reference model for other institutions seeking to expand the role of physician-scientists in Latin America, fostering a stronger future for healthcare systems and the advancement of modern medicine.
Copyright (c) 2025 Jennifer Eble Gaytán, Ana Flisser, Tanya Plett-Torres https://creativecommons.org/licenses/by/4.0
The Intersection of Rheumatology and Cardiology: Cardiac Disease in Rheumatic Disorders within Palestinian patients between 2022-2024, A Retrospective Cohort Study
Background: Rheumatologic and cardiovascular conditions are major causes of morbidity and mortality. Recent research has shown a close association between them. As cardiac manifestations in the Palestinian population remain uncharacterized, the current study aims to investigate the proportion of cardiac manifestations in rheumatologic disease patients from Palestine and to determine the factors associated with these manifestations. Methods: A retrospective cohort was conducted on rheumatology patients, at Al-Makassed Hospital from 2022 to 2024. Data was collected from electronic records for 296 patients. Cardiovascular manifestations were recognized through echocardiography and consultation reports. Analysis using SPSS version 26 was performed to determine the association between patients' characteristics and the cardiac manifestations. Data included demographics (age, gender), previous chronic diseases; especially regarding rheumatologic condition; age at diagnosis; cardiac manifestations; imaging reports, laboratory information, lipid profile, comorbidities and risk factors. Results: Of the 296 patients, 71.6% were females, with an average age of 49.2 ± 15.5 years. The most common rheumatic diseases were seronegative spondyloarthropathy (25.1%), rheumatoid arthritis (RA) (18.1%), and systemic lupus erythematosus (SLE) (11.1%). The proportion of clinically recognized cardiac disease was 17.9%; whereas 16.6 percent of participants had obesity and 9.8 percent had an addiction to cigarettes. Among comorbidities other than rheumatologic diseases, hypertension (30.4%) and diabetes mellitus (19.9%) were the most common. Cardiac disease was significantly associated with older age, diabetes mellitus, hypertension, coronary artery disease, positive troponin, and positive CK-MB (p < 0.05). Meanwhile, no significant associations with gender, specific rheumatic conditions, or lipid profile were observed. Conclusion: This is the first research from Palestine that studies cardiac involvement and its burden on rheumatology patients. The study identified seronegative spondyloarthropathy, rheumatoid arthritis, and systemic lupus erythematosus as the predominant rheumatological diseases, with an average age of diagnosis at 45 years. Hypertension, diabetes, and cardiac disease were commonly observed comorbidities. This population exhibits a heightened risk of subclinical myocardial injury with increasing age. Integrated cardio-rheumatology care is advocated to support screening, risk assessment, and management of these patients; as systemic inflammation, seropositivity, and long disease duration play a dominant role in cardiovascular risk, especially in populations with low proportion of traditional risk factors (e.g.: smoking). This underscores the importance of integrating inflammatory markers and serologic status into CVD risk assessment tools for rheumatology patients. Furthermore, given the potential for subclinical myocardial injury, incorporating biomarkers such as CK-MB and troponin into routine monitoring may enable earlier detection of cardiac involvement. Future research in regional populations should aim to refine screening protocols—potentially including periodic echocardiography, carotid ultrasound, and biomarker testing— and guide preventive interventions. There’s also a need for studies examining the effects of disease-modifying treatments on cardiovascular disease outcomes in patients with at-risk rheumatic diseases, studies employing early intervention techniques of anti-atherosclerotic drugs such as aspirin, statins, and angiotensin converting enzyme inhibitors in patients with diseases such as SLE and RA. And large-scale, population-based research is needed to specify the prevalence and patterns of cardiovascular manifestations in regional population.
Copyright (c) 2025 Malak R. Hroub https://creativecommons.org/licenses/by/4.0
Effectiveness of Haptic Feedback Devices in Reducing Pain Perception During Intra-Articular Corticosteroid Injections in Rural Guatemala and Kenya – A Randomized Controlled Trial
worldwide and a leading cause of disability, affecting most individuals by age 65 due to cartilage degradation, eburnation, osteophyte formation, and inflammation. Intra-articular corticosteroid injections (IACIs) are widely used for moderate to severe OA and are especially beneficial in low-resource areas where long-term medications and physical therapy may be inaccessible. However, IACIs can induce substantial pain and anxiety, particularly when anesthetics or imaging guidance are unavailable. Haptic feedback, such as tactile stimulation through handheld vibration devices, has demonstrated the ability to modulate pain perception in clinical settings. As a simple, low-cost method, it may offer a non-pharmacologic option to reduce procedural discomfort in environments where pain control measures are limited. This study evaluates the effectiveness of handheld vibration devices in reducing pain perception during IACIs in rural Guatemala and Kenya. Aim: To assess whether handheld vibration devices reduce pain perception during intra-articular corticosteroid injections in patients with osteoarthritis in resource-limited health settings. Methods: A randomized controlled study was conducted during Kansas City University's Global Health Outreach programs in Guatemala and Kenya. 37 adult patients with OA of the knee (89%), hand (8%), or shoulder (3%) scheduled for IACIs were enrolled; four were excluded due to protocol deviations or incomplete data, resulting in a final sample of 33 participants. Subjects were randomized 1:1 into a control group (standard care) or a haptic group that held a vibration device (Beurer MG10) in the contralateral hand during the injection. Pain perception was assessed using the Wong-Baker FACES Pain Rating Scale before and after the procedure. Statistical analysis was performed using Mann-Whitney and Wilcoxon Signed Rank tests. Results: No statistically significant difference was found between the control and haptic feedback groups in post-injection pain scores (p = 0.058). However, the majority of participants experienced significantly lower actual pain than expected (Haptic = 76.5%, Control = 62.5%), with only two reporting increased pain and seven reporting no change. Pain scores decreased by an average of 4.047 points overall (p < .001), with reductions of 3.217 in the control group (p = .001) and 2.727 in the haptic group (p = .006). The average post-injection pain score was 1.44 for the control group and 2.35 for the haptic group. Conclusion: Although handheld vibration devices did not significantly reduce pain perception compared to standard care during IACIs, a higher proportion of patients in the haptic group reported less pain than expected. Participants experienced significantly less pain than anticipated, suggesting that factors such as patient reassurance, procedural familiarity, or clinical environment may play a larger role in pain modulation. Limitations included communication barriers despite translator and language support, procedural variability among injectors, and an imbalance in joint types treated, with most injections administered to the knee. Nonetheless, this study highlights the feasibility of implementing low-cost, non-pharmacologic strategies like haptic feedback in resource-limited settings. Further investigation with a larger sample size and standardized technique is warranted to explore the role of haptic feedback in reducing procedural pain in low-resource environments.
Copyright (c) 2025 Tyler Perleberg, Alfeil Felipe, Carmen Tong, Jordan Konstanty, Gautam Desai https://creativecommons.org/licenses/by/4.0
Effectiveness of Trimethoprim-Sulfamethoxazole in Cyclosporiasis: A Meta-analysis of Randomized Clinical Trials
Introduction: Cyclosporiasis, caused by Cyclospora cayetanensis, is an intestinal infection transmitted via contaminated food and water and is responsible for at least 10% of diarrheal episodes in children aged 0-4 years in endemic regions. Clinically, it manifests as watery diarrhea, fever, and fatigue, posing significant public health challenges because of its association with foodborne outbreaks and the resultant healthcare costs. The primary treatment regimen involves trimethoprim-sulfamethoxazole (TMP/SMX); however, no meta-analysis has validated its use. Objective: We performed a meta-analysis to evaluate the efficacy of TMP/SMX compared to placebo for the eradication of oocysts and clinical resolution of cyclospora, drawing on data from randomized controlled trials (RCTs). Methods: A comprehensive search was performed in PubMed, Scopus, and Google Scholar until May 2025. The studies deemed eligible were randomized controlled trials (RCTs) that included confirmed diagnoses and clinical or laboratory assessments conducted seven days following treatment. The methodological quality of the studies was evaluated using Cochrane's Risk of Bias 2 (RoB 2) tool. Risk differences (RD) with 95% confidence intervals (CI) were calculated using a random-effects model. Results: Among the 19 studies identified, only three were randomized controlled trials, encompassing 88 patients. The oocyst eradication rates with TMP/SMX ranged from 83% to 100%, in contrast to the persistent infection observed in the placebo group. The reported risk difference (RD) values were −1.00 (Madico et al.), −0.78 (Hoge et al.), and −0.82 (Shim et al) The heterogeneity was moderate, with an I² value of 40%. The risk of bias was low for Hoge et al., moderate for Shim et al., and high for Madico et al. Conclusion: The present meta-analysis demonstrated that TMP/SMX exhibits significant efficacy in eradicating Cyclospora cayetanensis and improving clinical outcomes compared to placebo, thereby supporting its designation as the preferred treatment for Cyclosporainfection. However, the evidence is constrained by the limited number and variable quality of existing trials, underscoring the necessity for larger, high-quality randomized controlled trials (RCTs) to reinforce the therapeutic recommendations.
Copyright (c) 2025 Sofía Bermúdez Rodríguez, Luis Felipe Mosquera Solano, Daniela Agudelo Torres, Filippo Furlanetto, Jorge Enrique Gomez Marin https://creativecommons.org/licenses/by/4.0
Amyloidosis – A Rare Complication of Long-Evolving Rheumatoid Arthritis. A Case Report
Background: Amyloidosis consists of a diverse spectrum of medical conditions, defined by the accumulation of fibrillar proteins in a beta-sheet configuration in different tissues. Reactive amyloidosis (AA), previously known as secondary amyloidosis, can appear as a complication of chronic inflammatory diseases, such as rheumatoid arthritis. In present times, the use of biological therapies has decreased its prevalence, but it remains a considerable threat for patients, as its main target is the kidney, with progression towards renal failure. Light chain amyloidosis (AL) is a primary form of the disease, involving plasma cell clones in the bone marrow, and has been reported in patients with rheumatoid arthritis, constituting an important differential diagnosis. Herein, we present the case of AA amyloidosis in a patient with a long evolution of rheumatoid arthritis, highlighting its diagnostic difficulties. The Case: A 55-year-old woman presented to our clinic with mild arthritic pain in the hands, fatigue and hyperpigmentation on the dorsal side of her forearms, associated with itching. Rheumatoid arthritis is present in her medical history, having been diagnosed 15 years prior. Her medication included Metotrexate for three years, interrupted due to digestive intolerance, followed by Sulfasalazine to the current presentation. Physical exam highlighted obesity, the skin lesions on the forearms and a positive Gaenslen sign bilaterally. Biologically, an important inflammatory syndrome was discovered, alongside a very high rheumatoid factor (FR). These have been persisting for a number of years, prompting several past investigations to identify its cause. A serum protein electrophoresis with immunofixation was negative for monoclonal bands, but serum light chains kappa and lambda were slightly elevated. Histopathological analysis of a biopsy from abdominal fat revealed apple-green birefringence in polarized light with Congo red staining, leading to the diagnosis of amyloidosis. Infection and cancer were ruled out after extensive investigations. Taking into account the lack of renal manifestations, the relatively poorly controlled rheumatoid arthritis and the very slight elevation of serum light chains, this was interpreted as reactive amyloidosis. Treatment was promptly switched to Leflunomide and the patient will be evaluated for treatment with anti-TNF biological therapies. Conclusion: Amyloidosis can constitute a life-threatening complication to long-evolving chronic inflammatory diseases, such as rheumatoid arthritis. As no therapies that target amyloidosis specifically are available as of yet, management involves strict control of the underlying inflammatory condition, making early detection critical. This case highlights the diagnostic challenge this rare complication poses, as AL amyloidosis might also be considered, and the importance of controlling rheumatoid arthritis both clinically and biologically, in order to prevent its development. Parameters Unit Value Reference values C-reactive protein mg/dL 8.37 < 0,5 Rheumatoid Factor UI/mL 140.2 < 14 Erythrocyte sedimentation rate mm/h 67 < 30 Serum light chain lambda mg/L 28.4 5.71 - 26.3 Serum light chain kappa mg/L 34.62 3.3 – 19.4 Table 1: Laboratory Results at First Day of Hospitalization
Copyright (c) 2025 Irina Maria Rusu, Rebeca-Ioana Rus, Maria-Cristina Simian, Daria Șerbănescu, Laura Muntean https://creativecommons.org/licenses/by/4.0
Left Colo-renal Fistula in an Elderly Female: Case Report
Background: Colo-renal fistulas are rare entities, with very few cases reported worldwide and no established prevalence. Left-sided fistulas are the most frequent reno-intestinal communications. They usually result from chronic inflammation, diverticular disease, or necrotic processes. However, colo-renal fistulas caused by an abscessed renal cyst are exceptionally uncommon. This case highlights a rare presentation in an elderly female and underscores the importance of considering fistulous complications in patients with complicated renal cysts. The Case: An 82-year-old female, history of high blood pressure, diverticulitis, left renal cyst classified as Bosniak II F–III was admitted for a scheduled cystectomy. She presented with progressive low back pain, asthenia, unintentional weight loss, pneumaturia, fecaluria and sustained a fall from standing height during hospitalization. No additional medical history was noted. Follow-up abdominal CT revealed findings suggestive of emphysematous pyelonephritis, an infected left renal cyst, and a small communicating tract between the left kidney and the splenic flexure of the colon. Exploratory left lumbotomy confirmed the colo-renal fistula. The patient was managed by a fistulectomy, and drainage of the abscessed renal cyst was performed, followed by placement of a Jackson-Pratt drain. Postoperative recovery was favorable, with resolution of pain and no recurrence at 6 months-follow-up. Conclusion: This case illustrates an unusual cause of colo-renal fistula, secondary to rupture and infection of a renal cyst after trauma. Given its rarity and nonspecific presentation, early suspicion based on imaging and clinical findings is critical. Management requires a multidisciplinary surgical approach in a tertiary care setting. To our knowledge, this is one of the few reported cases of a colo-renal fistula associated with an abscessed renal cyst, contributing to the limited body of literature on this rare condition.
Copyright (c) 2025 Sebastian Penafiel, Juan Velez-Posada https://creativecommons.org/licenses/by/4.0
Primary Intestinal Lymphangiectasia Presenting as Chylous Ascites in a Young Female: A Rare Case
Background: Primary intestinal lymphangiectasia (PIL) is a rare condition that occurs due to the pathological dilation of intestinal lymphatics, characterized by protein losing enteropathy, and occurs more commonly in children. Adults’ occurrence is less common, and misdiagnoses with other gastrointestinal disease is prevalent because of the overlapping and nonspecific features. The Case: A 28-year-old female presented with recurrent abdominal distension and chylous ascites requiring therapeutic paracentesis over the past three years. Medical history was notable for 7 years of diffuse recurrent intermittent crampy abdominal pain more prominent periumbilical and at the right lower quadrant, bloating, loose stools, and weight loss, raising suspicion for Crohn’s disease, however, no supportive findings were noted on colonoscopy or histopathology, despite this, she was treated as a case of Crohn’s for a short period, but the absence of progression and the new-onset chylous ascites prompted reconsideration of the diagnosis and further investigation into alternative causes of protein-losing enteropathy and ascites. At presentation, the patient denied fever, night sweats, diarrhea, or overt gastrointestinal bleeding. An abdominal examination showed distention with shifting dullness, consistent with ascites. Without peripheral edema, lymphadenopathy, or hepatosplenomegaly. Laboratory investigations were significant for low serum albumin level of 2.3 g/dL. Ascitic fluid was sterile, and negative for malignant cells. A PET-CT scan was ordered to exclude occult malignancy, autoimmune, inflammatory, or metabolically active conditions. Abdominal CT imaging revealed diffuse thickening of the hepatic flexure of the colon, associated mesenteric fat stranding, and lymphadenopathy (largest node 1.5 cm), in addition to moderate-volume ascites, these findings alongside the clinical picture have raised suspicion for a lymphatic telangiectasia; the patient was started on budesonide and long-acting octreotide (Sandostatin LAR 20 mg intramuscularly every 28 days). She showed clinical improvement following therapy, with reduction in abdominal distension and decreased need for paracentesis. Endoscopic evaluation (Figure 1) demonstrated multiple white plaques in the duodenum on upper endoscopy. Histopathologic examination of the duodenum and ileum was most consistent with primary intestinal lymphangiectasia and revealed lymphatic dilation with preserved villous architecture. No parasites, granulomas, dysplasia, or malignancy were noted. Conclusion: PIL is rare in adults and can mimic other gastrointestinal disorders, leading to delayed diagnosis. Diagnosis relies on histopathologic confirmation and exclusion of secondary causes. Dietary management is the cornerstone of treatment, with adjunctive therapies reserved for refractory cases. Our patient’s diagnostic journey underscored several critical knowledge gaps that continue to challenge clinicians managing intestinal lymphangiectasia. Despite presenting clinical and biochemical features suggestive of the disease, the absence of standardized approaches to quantify lymphatic dysfunction made it difficult to objectively assess disease burden or monitor response to therapy. This case reflects broader gaps in our understanding of the disease’s natural history, particularly in adult-onset presentations, which remain poorly characterized. The clinical heterogeneity observed across patients suggests that individualized diagnostic and therapeutic strategies are urgently needed. Continued research is essential to uncover the underlying mechanisms driving variability in presentation and treatment response and ultimately guide the development of more targeted, personalized care.
Copyright (c) 2025 Basheer Babaa, Malak R. Hroub, Yousef Habes, Maha Ramzi, Omar H. Salloum https://creativecommons.org/licenses/by/4.0
Background: Rosai-Dorfman Disease (RDD) is a rare form of histiocytosis. We have observed extralymphatic involvement in about 43% of RDD cases in the literature, while dermatological symptoms manifest in only about 10% of cases. We present a case of RDD characterized by both nodal and extranodal involvement, initially presenting with bilateral ear nodules and dyspnea that closely resembled the clinical features of relapsing polychondritis; unfortunately, the diagnosis was missed at first. This case highlights the necessity for greater awareness and education among healthcare professionals regarding RDD to do diagnosis and treatment. Case Report: A 25-year-old lady had a one-year history of discomfort and swelling in the cartilaginous part of the ears, accompanied by dyspnea (MRC dyspnea scale 2). A clinical diagnosis of relapsing polychondritis was made by an ENT surgeon, and oral steroids and NSAIDs were given. An inhaler containing salbutamol was also prescribed. The symptoms progressively worsened, her left ear became more swollen, dyspnea worsened (MRC dyspnea scale 3), she also developed bilateral cervical lymphadenopathy, and she presented to the medicine OPD. The examination revealed bilateral enlargement of the ear helices, resembling a cauliflower-like appearance (Figure 1). This time, FNAC from the left ear and a biopsy of the cervical lymph node were done, and they showed proliferation of histiocytes. Most of the histiocytes have abundant foamy cytoplasm and prominent nucleoli. These cells were found admixed with plasma cells with Russell bodies, lymphocytes, and neutrophils. Histiocytes showed features of emperipolesis. Fibrosis with a vague storiform pattern is present. These morphologic features are compatible with RDD. Routine laboratory investigations were normal. Serologies for antinuclear antibody (ANA) were positive (16.5 U/mL), and anti-dsDNA was negative. Spirometry revealed an obstructive pattern with a forced expiratory volume in one second (FEV1) of 3.2 L (50% of the predicted value). Computed tomography of the chest revealed bilateral hilar lymphadenopathy. Investigations concerning sarcoidosis and tuberculosis were negative. A watchful waiting strategy was taken as a management plan with medications of oral methotrexate and a salbutamol inhaler. Conclusion: RDD is a rare non-Langerhans cell histiocytosis that commonly presents with significant lymphadenopathy and may or may not have systemic symptoms. The disease may affect almost every organ system, mimicking different clinical conditions. Frequently afflicted areas include the nasal cavity and sinuses, gastrointestinal, pulmonary, renal, musculoskeletal, and genitourinary systems, and, less frequently, the skin. FNAC or tissue biopsies are needed to diagnose RDD, and they commonly show extensive, pale histiocyte infiltrates with intact intracytoplasmic lymphocytes, which is known as emperipolesis. Histological features help diagnose this condition and separate it from other histiocytic illnesses. Medical literature inadequately describes the prognosis of RDD. In certain cases, a lengthy clinical course might lead to spontaneous remission. Multifocal illness, vital organ involvement, and a big mass worsen prognoses. No guideline on RDD management exists due to its rarity, making standardized therapy difficult. Knowing the clinical and histological presentations of RDD is crucial for accurate diagnosis, as it often mimics other disease conditions. Research is needed to determine the potential treatments.
Copyright (c) 2025 Montasir Ahmed, Karma, Forhad, Parvat, Nuyama Rai, Anushila https://creativecommons.org/licenses/by/4.0
One Step Forward, Two Steps Back: Functional Decline following Lisfranc Fracture-Dislocation
Background: What once was managed through foot amputations has now evolved from a surgical sentence to a joint-sparing breakthrough in modern orthopaedics. Though rare, Lisfranc injuries pose devastating consequences as they are associated with poor functional outcomes and high rates of disability. Lisfranc injuries continue to test clinicians with its subtlety and complex biomechanics. The Case 24-year-old male sustained a Lisfranc fracture-dislocation during Brazilian jiu-jitsu training when his left foot was held in plantarflexion and abruptly subjected to axial-load. Initial weight-bearing radiographs demonstrated classic widening between the 1stand 2nd metatarsal bases (“fleck sign”), lateral displacement of the 2nd metatarsal, and subluxation of the tarsometatarsal joints, confirming ligamentous disruption. CT scans further detailed the fracture-dislocation. The surgical team debated between primary arthrodesis versus open reduction and internal fixation (ORIF). Given the patient’s age and fitness, he underwent urgent closed reduction followed by ORIF using multiple cannulated screws and a dorsal bridge plate. A follow-up X-ray showed improved alignment, but the patient reported ongoing pain despite 12 months of physiotherapy. Everyday activities like walking and standing for extended periods became difficult, impacting his mental health. He later opted for a second surgery to remove the hardware. Though this offered partial relief, he continues to suffer from stiffness and pain. Conclusion: Even with timely surgical repair, Lisfranc injuries are physically taxing to recover from, often leading to life-altering functional limitations as they are associated with arch collapse and posttraumatic arthritis. Improving access to specialist care is essential to promote midfoot stability and prevent long-term disability.
Copyright (c) 2025 Nasrin Ahmed https://creativecommons.org/licenses/by/4.0
Aggressive Gallbladder Carcinoma in Down Syndrome Patient: A Rare Presentation
Background: Gallbladder carcinoma in individuals with Down syndrome (DS) is exceedingly rare, literature reports only a handful of cases. Risk factors include cholelithiasis, chronic inflammation, biliary helicobacter pylori colonization, chromosomal instability and cytogenetic abnormalities of chromosome 21. The Case : A 45-year-old male with a history of Down syndrome, presented to the emergency department complaining of moderate epigastric pain for 3 days, 5 days of yellowish skin discoloration, and 2-weeks of postprandial nausea and vomiting of undigested food. There was no history of dysphagia, anorexia, bowel habit changes, or gastrointestinal bleeding. Family and drug history is unremarkable. On examination, the patient had a distended abdomen, jaundice, mild epigastric tenderness, and a palpable bulge in the right upper quadrant. Laboratory findings over repeated evaluations revealed persistently elevated inflammatory markers, direct hyperbilirubinemia, hypocalcemia, mild anemia with decreased hematocrit level, and hypoalbuminemia. Liver and pancreatic enzymes were unremarkable. On ultrasound, moderate-to-severe ascites were noted. MRI abdomen showed a large exophytic hepatic mass (9 × 7.5 × 7.3 cm) in segment VI encasing and compressing the gallbladder, with multiple smaller hepatic lesions (0.2–2.3 cm) and enlarged multilobular speculated periportal/mesenteric lymph nodes measuring up to 4.3 cm in diameter, 3.3 cm right adrenal lesion and asymmetric thickening of the ascending colon. Findings were suspicious for metastatic malignancy with gallbladder involvement. Colonoscopy was performed and revealed grossly normal mucosa; histopathology was unremarkable. A triphasic CT scan confirmed metastatic disease; and hyperbilirubinemia was explained by hepatocellular invasion rather than obstructive cholestasis. Echocardiography was significant for moderate pulmonary hypertension. Histopathological exam of a core biopsy of the liver lesion revealed moderately differentiated adenocarcinoma, consistent with gallbladder carcinoma with hepatic metastases. The patient was admitted for supportive and symptomatic management. He was kept nil per os (NPO) and started on intravenous fluids, proton pump inhibitors, broad-spectrum antibiotics, analgesics, anticoagulation, and diuretics. Ursodeoxycholic acid and hydrocortisone were added later in the course. Despite escalation of therapy, the patient developed clinical deterioration with ascites and worsening jaundice, requiring transfer to the intensive care unit. During the ICU stay, the patient received supportive medications including ranitidine, famotidine, potassium chloride, calcium gluconate, and phytomenadione (vitamin K) as part of correction of electrolyte disturbances, gastric protection, and coagulopathy management, however, after few months, the patient died. Conclusion: Our report adds to the scarce evidence by documenting an older age at presentation, establishing histopathological confirmation, and demonstrating even more extensive systemic spread at diagnosis. This case highlights the tendency for late presentation with disseminated disease and limited therapeutic options, underscoring the aggressive course of gallbladder carcinoma in DS. Collectively, these observations reinforce the importance of maintaining a high index of suspicion in DS patients presenting with hepatobiliary symptoms and support the consideration of earlier imaging and potentially screening approaches in this high-risk population. The low number of reported cases may reflect underdiagnosis or early mortality from other conditions. Larger prospective studies are needed to clarify the true incidence, evaluate screening strategies, and improve outcomes.
Copyright (c) 2025 Basheer Babaa, Malak R. Hroub, Lana M.A Jamal, Salahaldeen Deeb, Khaled Alhashlamon, Izzeddin A. Bakri https://creativecommons.org/licenses/by/4.0
Avoiding Pacemaker: Resolution of Sinus Node Dysfunction through CPAP Therapy
yet underdiagnosed sleep-related breathing disorder with significant cardiovascular implications. Besides hypertension, heart failure, and ischemic disease, SAHS has been increasingly associated with arrhythmias and conduction abnormalities. Sinus node dysfunction (SND) is among the rhythm disturbances most frequently reported, with clinical manifestations ranging from bradycardia to prolonged sinus pauses. The pathophysiology involves recurrent nocturnal hypoxemia, sympathetic-vagal imbalance, and intrathoracic pressure fluctuations, which together promote electrical instability. Traditionally, pacemaker implantation has been considered the treatment of choice for symptomatic or severe SND. However, growing evidence suggests that adequate management of SAHS with continuous positive airway pressure (CPAP) may reverse rhythm disorders, highlighting the importance of identifying reversible causes before committing to invasive procedures. The Case: We report the case of a 34-year-old man with morbid obesity (BMI 43.6) and no cardiovascular history, who presented with severe daytime sleepiness (Epworth score 17). Physical examination was unremarkable, with no structural heart disease. Baseline electrocardiogram showed sinus bradycardia at 56 bpm. Holter monitoring revealed sinus node dysfunction with nocturnal pauses up to 6.8 seconds. Based on these findings, dual-chamber pacemaker implantation was initially considered. Simultaneous overnight polysomnography confirmed severe SAHS, with an apnea-hypopnea index (AHI) of 70 events/hour, oxygen desaturation index of 52/hour, and a nadir oxygen saturation of 56%. Given the temporal overlap between apneic events and sinus pauses, an alternative strategy was pursued. The patient was started on CPAP therapy and received weight loss counseling. At one-month follow-up, he reported complete resolution of daytime symptoms. Repeat polysomnography demonstrated significant improvement, with AHI reduced to 38/hour, desaturation index to 19/hour, and minimum O₂ saturation improved to 70%. Holter monitoring confirmed normalization of sinus rhythm, with a mean heart rate of 68 bpm and no further pauses. Pacemaker implantation was therefore avoided. Conclusion: This case highlights the complete reversibility of sinus node dysfunction after treatment of severe SAHS with CPAP therapy. It underscores the need to systematically consider sleep-disordered breathing in patients with unexplained bradyarrhythmias, particularly in younger individuals without cardiac comorbidities. Identifying SAHS as an underlying cause may dramatically alter the therapeutic strategy, preventing unnecessary device implantation and its long-term complications. Beyond improving quality of life, CPAP should be recognized as a potential disease-modifying therapy for rhythm disturbances. Early screening, accurate diagnosis, and prompt initiation of noninvasive ventilation may represent a decisive step in redefining the management of SND in the context of sleep apnea.
Copyright (c) 2025 Rebeca-Ioana Rus, Irina-Maria Rusu, Maria Cristina Simian, Bogdan Valentin Roznovan, Paula Cornelia Varga https://creativecommons.org/licenses/by/4.0
Silent Splenic Crisis in an Immunocompetent Adolescent: A Case Report of Multifocal Splenic Abscess with Subcapsular Extension and Paradoxical Leukopenia Managed Conservatively
Background: Primary splenic abscess is a rare clinical entity, with a reported incidence ranging from 0.05% to 0.70%, and is especially uncommon in immunocompetent individuals. The spleen’s robust phagocytic and immunological functions generally confer protection against microbial invasion. Most splenic abscesses are secondary to hematogenous seeding, frequently in the setting of infective endocarditis, immunosuppression, diabetes, trauma, or intravenous drug use. The clinical presentation is often vague, with the classic triad of fever, left upper quadrant (LUQ) pain, and leukocytosis present in only a minority of cases. The diagnostic challenge is compounded by nonspecific symptoms and frequently sterile blood cultures. Imaging modalities, particularly computed tomography, play a central role in diagnosis. Surgery has long been the main treatment for splenic abscesses, but there’s now a growing preference for less invasive options like targeted antibiotics and image-guided percutaneous drainage. However, the optimal treatment approach remains uncertain. Percutaneous drainage can be a useful option in selected cases, but studies have reported high failure rates, ranging from 14.3% to 75%. Moreover, even with advances in imaging and treatment, delayed diagnosis or inadequate treatment carries a high mortality risk. We report a rare case of primary multifocal splenic abscess in a previously healthy 15-year-old immunocompetent female. The Case: A previously healthy 15-year-old female presented with a 10-day history of high-grade fever and abdominal pain, which localized to the LUQ and became sharp and positional in nature. She had no history of recent infection, immunosuppression, trauma, or chronic illness. Notably, she experienced transient arthralgias and displayed no gastrointestinal or respiratory symptoms. Clinical examination revealed LUQ tenderness and splenomegaly. Laboratory investigations showed profound leukopenia (WBC 2,100/mm³) with neutropenia (ANC 800/mm³) and normocytic anemia (Hb 9.2 g/dL). Procalcitonin was markedly elevated at 8.2 ng/mL, while blood cultures remained sterile. Abdominal ultrasonography and computed tomography revealed an enlarged spleen with multiple hypodense, peripherally enhancing lesions, the largest measuring 53 × 39 × 58 mm, with subcapsular extension and perisplenic fat stranding. Initial empirical therapy with ceftriaxone and metronidazole was ineffective. Ultrasound-guided aspiration yielded 50 mL of pus. Culture of the aspirate grew Klebsiella pneumoniae, prompting escalation of antimicrobial therapy to intravenous meropenem and teicoplanin. Over the next two weeks, the patient showed complete resolution of fever and significant symptomatic relief. She was discharged in stable condition with no complications. Follow-up ultrasonography at one month showed normal splenic architecture and complete resolution of abscesses. Conclusion: This case emphasizes the importance of maintaining clinical vigilance and early imaging in febrile patients, even in the absence of typical risk factors for deep-seated infections. It demonstrates that conservative management, including image-guided aspiration and targeted antibiotic therapy can be a safe and effective alternative to surgery in selected cases. With timely diagnosis and an individualized treatment approach, it is possible to achieve complete resolution while preserving splenic function and minimizing procedural risks. This case supports the evolving paradigm toward less invasive strategies in managing splenic abscesses, particularly in stable, immunocompetent patients.
Copyright (c) 2025 Amit Kumar, Shweta Tanwar, Yogeshwaran Mohan, Aman Dubey https://creativecommons.org/licenses/by/4.0
Subcutaneous Panniculitis-like T-cell Non-Hodgkin Lymphoma Associated with Cushing Syndrome: An Introspection
Background: Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) accounts for less than 1% of non-Hodgkin lymphoma cases and is characterized by malignant lymphocyte infiltration into adipose tissues. The term “panniculitis-like T -cells” refers to the histological similarity of the lymphoma cells to the T-cells found in chronic or granulomatous panniculitis. This type of lymphoma is responsible for an ectopic ACTH secretion which leads to excessive cortisol secretion causing Cushing syndrome. Case: A 45-year-old patient diagnosed with SPTCL in 2022 underwent six cycles of cyclophosphamide, epirubicin, vincristine, and prednisone (CHOP regimen). Due to iatrogenic Cushing syndrome, CHOP was discontinued, and two cycles of rituximab-ifosphamide-carboplatin-etoposide (R-ICE) were administered. In 2023, the patient presented with scleral jaundice and dark urine. Laboratory findings revealed a total bilirubin of 11.2 mg/dL, leukopenia, thrombocytopenia, hyperfibrinogenemia, and elevated D-dimers. A CT scan showed hepatic and iliopsoas muscle lesions, indicating systemic dissemination and relapse of the lymphoma. Conclusion: Corticosteroid-based regimens are standard treatment options for SPTCL. However, paraneoplastic syndromes such as ectopic ACTH secretion by malignant cells may lead to excessive cortisol levels, exacerbated by corticosteroids. Due to iatrogenic Cushing syndrome induced by the first-line therapy and relapse following second-line options, off-label venetoclax, an apoptosis inducer, was initiated in combination with ropeginterferon alfa-2b. The patient achieved complete remission. No SPTCL cases treated with venetoclax have been published in the literature. We report high efficacy of off-label venetoclax in a relapsed SPTCL with no other available therapeutic option.
Copyright (c) 2025 Maria Palfi, Alexandra Zirbo, Cristina Simian, Dávid Kegyes, Anamaria Bancoș, Ciprian Tomuleasa https://creativecommons.org/licenses/by/4.0
Opportunities for Climate-Sensitive Work in the Health Sector - Kenya and Germany in Focus
Background: Healthcare systems around the world are facing unprecedented challenges as concerns about climate change and its widespread effects intensify. The healthcare sector has two big problems: it is very vulnerable to the health effects of climate change and yet it contributes significantly to greenhouse gas emissions. Therefore, transitioning to climate-sensitive healthcare is a top concern for the whole world. However, implementation differs significantly across various economic and geographical contexts. This study aimed to identify and compare opportunities for climate-sensitive work in the health sectors of Kenya and Germany. Methods: The study employed a qualitative approach, using a combination of field observations and expert interviews between July and September 2025. Data was collected over four-week periods at Kenyatta National Hospital (KNH) in Nairobi, Kenya, and Charité – Universitätsmedizin in Berlin, Germany. Methods included structured field observations across six key categories (energy, mobility, nutrition, supply chains, waste management, and digitalization) and in-depth, semi-structured expert interviews with medical students and hospital staff. Interview transcripts and observational notes were analyzed using thematic analysis. Results: KNH demonstrated inherent low-carbon practices like passive cooling, local food sourcing with minimal packaging, and high reuse of materials including food waste. It however, faced systemic barriers including heavy reliance on fossil fuels, budget constraints, and inadequate waste recycling. Charité utilized energy-efficient infrastructure and efficient public transport but struggled with high food waste from individual packaging and perceived inefficiencies in waste sorting. Both institutions were making efforts towards digitalization especially in patient records. A significant knowledge-attitude-practice gap was identified; healthcare professionals and students in both countries expressed strong interest but reported a lack of formal education on climate-health interlinkages. Conclusion: High-income healthcare systems can learn resource-efficient practices from low-income settings. Health care sectors in low and middle-income countries can adopt technological advancements from the former. Overcoming shared barriers such as educational gaps is crucial. These findings underscore the critical need for tailored interventions, cross-context learning, and integrating planetary health education into the core of medical training and hospital management.
Copyright (c) 2025 Cyrus Kimanthi, Juliette Clara Schreiber, Pamela Miloya Godia; Andrea Budnick https://creativecommons.org/licenses/by/4.0
Near-Peer Teaching of Laparoscopic Skills among Medical Students – A Randomized Feasibility Study
Background: Laparoscopic surgery is integral to modern surgical practice, with proficiency increasingly required across a range of specialties. However, many medical students graduate with limited exposure to essential skills. To address this, university surgical societies have adopted the “Near-peer” model to teach surgical skills. That is, senior or experienced medical students teach junior students basic surgical skills. However, the objective impact of this intervention remains under-evaluated. Furthermore, objective evaluation requires a comprehensive and validated assessment tool, which is currently lacking. The aims of this study were to develop a novel objective assessment tool, assess changes in students’ confidence and objective performance in laparoscopic tasks following near-peer versus self-directed training, and explore factors associated with performance outcomes. Methods: This single-blinded, randomised feasibility study enrolled 42 medical students without prior laparoscopic experience. Participants were assigned via computer randomisation to peer-taught (Group 1) or self-taught group (Group 2) and completed six weekly sessions across four laparoscopic stations: Ball Transfer, Circle Cutting, Peg Transfer, and String. Each of the peer-teachers had at least six months of peer-teaching experience and had completed an online teaching module. Performance was scored using a novel objective assessment tool developed through a Modified Delphi Method. In contrast to a traditional Delphi approach, a draft assessment tool was developed by the first author based on a literature review and preliminary framework. This was distributed to three experts in laparoscopic surgery and surgical education who provided structured feedback until unanimous consensus was achieved. The assessment domains of the novel assessment tool were unique for each station. Points were allocated for specific task anchors based on the performance quality of each step, alongside bonuses, deductions, and overall impression (Table 1). Two blinded surgical trainees independently assessed all performances. One-way Interclass Correlation was calculated for each station pre-intervention. Results: No significant differences were observed in pre-intervention objective performance between groups, except for the “Peg Transfer” station. Post-intervention, the novel assessment tool demonstrated that both groups improved significantly across all tasks (p<0.001). Similarly, both groups’ confidence improved significantly (p<0.001). The peer-taught group outperformed the self-directed group in “Circle Cutting” (p=0.02) and “String” (p=0.01). This study found no relationship between age, gender, or video game experience and performance outcomes. One-way Interclass Correlation was 0.845 for the pre-intervention “Ball Transfer” station, 0.897 for the “Circle Cutting”, 0.951 for the “Peg Transfer”, and 0.846 for the “String” station. Conclusion: This is the first study to demonstrate that near-peer teaching of laparoscopic skills significantly improved laparoscopic performance among medical students compared with a control group. While the feasibility design limited generalisability, the results support the broader integration of near-peer teaching of laparoscopic surgical skills within the undergraduate setting. A multi-centre randomised controlled trial, powered on the effect sizes generated in this feasibility study is the essential next step to confirm efficacy. Furthermore, the validation of our novel assessment tool may offer a new gold standard for evaluating laparoscopic performance in undergraduate surgical education.
Copyright (c) 2025 Martin Ho https://creativecommons.org/licenses/by/4.0
Managing Hyperphagia, Obesity, and Hyperglycemia in Prader-Willi Syndrome: A Meta-Analysis of GLP-1 Agonists and SGLT2 Inhibitors
Background: Prader-Willi Syndrome (PWS) is a genetic disorder caused by a deletion, mutation, or imprinting error of the paternal 15q11-13 region or by maternal uniparental disomy of chromosome 15. One of the disorder's most noticeable characteristics is the development of a constant insatiable appetite, which often results in hyperphagia, hyperglycemia and severe obesity. Hyperphagia related incidents and obesity complications are the leading cause of death for individuals with PWS. Effective treatments for hyperphagia, obesity, and hyperglycemia are needed to improve the quality of life and life expectancy for patients with PWS. Methods: This meta-analysis aims to assess changes in weight, HbA1c, and hyperphagia after the commencement of GLP-1 agonists and SGLT2 inhibitors in individuals with PWS. A review of the literature was conducted by searching Scopus, PubMed, clinicaltrials.gov, and Cochrane to identify relevant case studies, case series, retrospective studies, non-randomized clinical trials, and randomized clinical trials that involved treating PWS patients with any GLP-1 agonists or SGLT2 inhibitors. A total of 224 records were screened with 45 studies meeting inclusion criteria. Studies involving monotherapy and combination therapy regimens were included, and studies of all ages were included. Case and retrospective studies must have quantitative data on changes in weight, hyperphagia, BMI, or HbA1c to be included in the meta-analysis, and a meta-analysis of raw data extracted from these studies was conducted. For the studies involving trials, a fixed-effect meta-analytic model was used. Results: Preliminary analysis of the studies showed promising results that indicated that GLP-1 agonists and SGLT2 inhibitors could help PWS patients with weight management, reduction of hyperphagia, and glycemic control. However, most of the studies were retrospective case reviews rather than trials, and the trials had less favorable results. The two clinical trials, which looked at the GLP-1 agonists exenatide and liraglutide, showed limited improvement in HbA1c and hyperphagia, but there were no clinically significant changes in weight in either trial. Conclusions: Emerging evidence indicates that GLP-1 agonists and SGLT2 inhibitors may provide meaningful benefits for individuals with Prader-Willi Syndrome by reducing hyperphagia, improving glycemic control, and supporting weight management. Nonetheless, the current literature is limited primarily to case reports and small observational studies, and only two trials have been published. Future clinical trials are needed to assess the efficacy and safety of newer GLP-1 medications such as semaglutide and tirzepatide. In studies of the broader population, these newer drugs have demonstrated greater weight loss than older drugs in their class like liraglutide and exenatide. Additionally, further investigation into combination strategies, particularly pairing GLP-1 agonists or SGLT2 inhibitors with diazoxide choline, are needed. Diazoxide choline was recently approved for treating PWS-associated hyperphagia, but one adverse effect reported for this drug was hyperglycemia. Since GLP-1 agonists and SGLT2 inhibitors are effective glycemic control drugs, investigation into their interactions with diazoxide choline should be undertaken. These additional clinical trials are essential to improve the treatment options and ultimately improve both quality of life and long-term health outcomes in patients with PWS.
Copyright (c) 2025 Saumika Mulluri https://creativecommons.org/licenses/by/4.0
What Medical Students Can Learn from the 2024 Dengue Outbreak in Pakistan: Clinical Spectrum, Biochemical Abnormalities and Predictors of Severity
Background: To provide insights into the demographic profile, clinical manifestations, biochemical abnormalities, and outcomes of patients admitted with dengue fever (DF) during the 2024 outbreak in Pakistan. Methods: This prospective cohort hospital-based study was carried out at Fauji Foundation Hospital Rawalpindi from August to November 2024. DF was diagnosed on the basis of positive Dengue NS-1 antigen or IgM antibody or both. Patients under 12 years, having other causes of fever or chronic co-morbid diseases were excluded. Demographic data, symptoms, clinical examination signs and laboratory parameters were recorded on a proforma. Severity of dengue was based on WHO revised classification of 2009. Data were analyzed using SPSS, version 21.0. Results: A total of 198 patients were included and majority of them (83.8%) were from the Pothohar Plateau of Punjab comprising of Rawalpindi, Chakwal, Jhelum and Attock districts.Diagnosis was based on positive Dengue NS-1 antigen in 132 (66.6%), positive IgM antibody in 21 (10.6%) and both NS-1 and IgM positive in 45 (22.7%) patients. Mean age was 39.14±17.6 years and 173 (87.4%) were females. The mean duration of hospital stay was 4.98±2.42 days. Twenty six (13.1%) patients were categorized as “Dengue without warning signs” (DWoWS), 150 (76%) patients as “Dengue with warning sign”s (DWWS), and 22 (11%) patients as “Severe Dengue” (SD). Among this study cohort, 184 (92.9%) survived and improved clinically to be discharged, however, there were 14 (7.1%) mortalities. All these 14 patients had Severe Dengue. Compared with survivors the non-survivors&#39; age did not differ significantly; 38.6±17.7 vs 45.8±14.3 years respectively, p= 0.139. The proportion of non-survivors was significantly higher among males (24%) as compared to females (4.6%), p= 0.00. The OR (odds ratio) of a male dying was 10.8 time that of a female. All patients of both groups had a history of fever. The proportion of patients with myalgia, rash, vaginal bleed did not differ between the two groups. However, the presentation of abdominal pain, persistent vomiting, epistaxis, hematuria, gastrointestinal bleeding, third space fluid leak in the form of pleural effusion or ascites, tachypnea and shock were significantly more common among the non-survivors; p˂0.05. Moreover, very low platelet count below 10,000 cells/mm 3 , very high ALT above 500 IU/L, AKI as evidenced by serum creatinine above 2.0 mg/dL and coagulopathy as evidenced by prolonged APTT were all significantly more frequent among the non-survivors; p=0.00. Among these 14 fatal cases, 11 had a platelet count less than 10,000, all had evidence of third space fluid loss, 10 were in shock (systolic BP &lt; 90), 10 had major GI bleed, 11 had epistaxis, 10 had AKI, 6 had ALT &gt;500 IU/L, and 6 had a prolonged APTT. Conclusion: The 2024 dengue outbreak in Pothohar region of Pakistan was characterized by high rate of severe dengue and mortality. WHO 2009 classification of Dengue Severity should be used to stratify the dengue patients. Signs of severe dengue should alert the clinician to the heightened risk of mortality..
Copyright (c) 2025 Mahnoor Ahmed, Shahan Ahmed, Faizan Ahmed, Hamayun Ashraf https://creativecommons.org/licenses/by/4.0
Risk of Recurrence of Congenital Ocular Toxoplasmosis in Children: A Meta-Analysis Review of Studies With Long-Term Clinical Follow-up.
Background. Congenital toxoplasmosis, a vertical infection caused by Toxoplasma gondii, can result in neurological and ocular sequelae that may manifest even years postnatally. Although standardized postnatal treatments have been implemented, clinical recurrences, particularly ocular ones, are anticipated to persist during extended follow-up periods. Consequently, prenatal treatment may potentially mitigate these recurrences; however, the evidence supporting this is currently limited and dispersed. Aim: To conduct a meta-analysis on the recurrence rate in children with congenital toxoplasmosis, considering their history of prenatal and postnatal treatment (spanning at least one year), and incorporating long-term clinical follow-up (extending for a minimum of two years). Methods. The databases utilized for the study selection process included PubMed, Web of Science, and Google Scholar. The Medical Subject Headings (MeSH) terms employed were “Toxoplasmosis AND Congenital” and "Toxoplasmosis AND Ocular.” The search was refined using the filters “clinical trial” and “randomized controlled trial.” Additionally, the references of the identified articles were scrutinized to identify other pertinent studies, employing the snowball technique. Experts in the field were consulted to provide relevant published or unpublished data. Studies were included if they reported a minimum of two years of follow-up and presented the results of ophthalmological follow-up. Data concerning prenatal treatment were extracted and systematically organized in an Excel database. The recurrence rate was determined by dividing the number of relapses among untreated patients over the follow-up period by 100. Results. Following revision, only three studies documented the incidence of new retinochoroiditis episodes during extended ophthalmological follow-up. All children in these cohorts received a minimum of one year, with some receiving up to two years of postnatal anti-Toxoplasma treatment. The adjusted recurrence rate in prenatally treated children was 2.6 (n = 229), whereas in untreated children, it was 16.2 (n = 185). The overall adjusted risk of recurrence in prenatally treated children was 0.23 (95% CI: 0.09–0.56; p = 0.001). Conclusions. There is a paucity of research concerning the impact of prenatal treatment on the ocular recurrence of congenital toxoplasmosis. A meta-analysis of three studies revealed that the absence of prenatal treatment heightened the risk of new episodes, even after one year of comprehensive postnatal treatment.
Copyright (c) 2025 Juan David Duarte Arias, Geraldine Mesa Londoño, Nicolás León Parra, Jorge Enrique Gómez Marín https://creativecommons.org/licenses/by/4.0
Aging Patients, Changing Substances: Unexpected Demographic Shifts in Turkey’s Drug Treatment Admissions Over a Decade
Background: Substance use disorders (SUD) have undergone significant demographic and epidemiological shifts worldwide, with emerging substances and evolving patterns of use presenting new challenges for healthcare systems. In Türkiye, the past decade has been marked by increased policy efforts to expand treatment access and reduce drug-related harms. However, systematic evaluations of national-level data remain limited. This study retrospectively examines Türkiye’s national drug reports between 2013 and 2023 to identify critical trends in treatment admissions, substance prevalence, and health outcomes among individuals with SUD. Methods: We conducted a retrospective analysis of official data from the Turkish Ministry of Interior covering the period 2013–2023. A total of 362,560 documented cases were included. Key indicators assessed were annual treatment admissions, direct drug-related mortality, seized illicit substances, and infectious disease markers (including HIV) among people who inject drugs (PWID). Trends were further stratified by demographic variables such as age, sex, and primary substance of use. Results: Over the study period, treatment admissions for SUD rose by 60%, reflecting both increased prevalence and broader treatment availability. Direct drug-related mortality declined by 39.6% between 2017 and 2023, coinciding with the implementation of harm reduction policies. Notably, methamphetamine emerged as the dominant substance, with an average annual prevalence increase of 46.2%. This trend displaced opioids as the leading primary substance, with opioid-related admissions declining from 76.3% to 4.2%. Mortality patterns revealed that 75.2% of drug-related deaths in 2022 were linked to polydrug use. Demographic analysis highlighted substantial changes in the treatment population. The proportion of female participants increased from 5.6% to 9.7%, indicating a narrowing gender gap in treatment access. The mean age of treatment entrants rose from 24.3 to 27.6 years, demonstrating a gradual ageing trend. Educational profiles also shifted, with broader representation across different academic backgrounds. Despite gains in treatment expansion, infectious disease surveillance raised concerns. HIV seropositivity among PWID increased 6.7-fold, predominantly associated with methamphetamine injection, underscoring emerging public health risks tied to changing patterns of substance use. Conclusion: This analysis reveals profound demographic and epidemiological shifts in Türkiye’s substance use landscape over the past decade. Rising treatment admissions, declining opioid prevalence, and the rapid dominance of methamphetamine use highlight evolving drug-related challenges. Positive outcomes include reduced drug-related mortality and increased female engagement in treatment, suggesting partial success of harm reduction policies. However, the surge in methamphetamine-related harms, polydrug mortality, and HIV incidence among PWID signal urgent areas for intervention. These findings underscore the need for adaptive, evidence-based strategies that integrate harm reduction, infectious disease prevention, and targeted support for vulnerable populations.
Copyright (c) 2025 Ayça Sıla Kumtepe, Levent Özdemir, Serranur Sığındere, Derya Çağlayan https://creativecommons.org/licenses/by/4.0
Cross Sectional Study on Air Pollution and its Influence on Health Related Quality of Life in Coimbatore
Background: The air quality inside and outside of buildings and structures is referred to as indoor air quality (IAQ), particularly as it pertains to the comfort and health of building occupants. Since most individuals spend 90% of their time indoors, mostly at home or at work, indoor environment conditions have a significant impact on human wellbeing. Air quality is closely linked to global ecosystems and climate, and the impact of indoor air pollution on people's quality of life is an iceberg. Objectives: The study aim to assess the indoor air pollution and its influence on Health Related Quality of Life (HRQoL) in an urban population. Methods: A cross sectional study was conducted among 400 adults under an urban field practice area of a private college using systematic random sampling. The semi-structured questionnaire was designed for indoor air pollution along with EuroQol 5-Dimension 5-level (EQ-5D-5L); EuroQol Visual Analogue Scale (EQ VAS) was used. The data collected was entered in Microsoft Excel and analysed using SPSS software v.25. Descriptive statistics such as mean (SD), proportion has been done accordingly with inferential statistics chi-square test was used to see association between categorical variables. Cox proportional hazard model – hazard ratio and Kaplan Meier Curve – visualize life expectancy deterioration (LED) was done accordingly. Results: The prevalence of indoor air pollution was 72.5% in our study area. Based on EQ 5D 5L, the mean (±SD) score is 0.86 (±0.17), and the EQ VAS score is 76.3 (±11.1) of satisfactory life. There was a significant association between the presence of indoor air pollution and poor health based on EQ-5D-5L score (0.041) type of family (0.002), overcrowding (0.009), second-hand smoking (<0.01), and comorbidities (<0.01). Conclusion: The study highlighted that indoor air pollution negatively affects the quality of life in the study population, with a 4.56 years loss in Quality-Adjusted Life Expectancy (QALE). To improve the health and well-being of the population, we recommend to enhance the air quality monitoring with strict regulations, using alternate sources of energy in all possible fields, and early detection of the disease as well as health interventions to mitigate the impact of pollution-related health issues.
Copyright (c) 2025 Dhaarani Dharmaraj https://creativecommons.org/licenses/by/4.0
MALAT1 and MIAT as Emerging Biomarkers for Diabetic Retinopathy: A Systematic Review and Meta-Analysis
Background: Diabetic retinopathy (DR) is a leading cause of preventable blindness, affecting nearly one-fourth of diabetic patients worldwide. Early diagnosis remains a major challenge due to reliance on labour-intensive, clinician-dependent fundoscopy. Long non-coding RNAs (lncRNAs), particularly MALAT1 (Metastasis-Associated Lung Adenocarcinoma Transcript 1) and MIAT (Myocardial Infarction-Associated Transcript), have been implicated in the pathogenesis of DR through regulation of angiogenesis, inflammation, oxidative stress, and vascular dysfunction. Their measurable expression in accessible biofluids such as serum and tears make them promising candidates for non-invasive biomarkers. The objective of this systematic review and meta-analysis was to assess the utility of MALAT1 and MIAT as diagnostic biomarkers for diabetic retinopathy. Methods: The study methodology complied with PRISMA 2020 standards and was documented in the PROSPERO registry (CRD420250650000). Databases including PubMed, Embase, Scopus, and PubMed Central were systematically searched, without date restrictions. Eligible studies included original, full-length research articles, case-control studies, and clinical studies evaluating MALAT1 or MIAT as biomarkers in patients with DR compared to diabetics without DR or healthy controls. Data on sensitivity, specificity, and area under the curve (AUC) were extracted. Quality assessment employed the Newcastle-Ottawa Scale, and pooled diagnostic performance was derived using a random-effects model. Results: Out of 52 records screened, 5 studies (n = 795 participants) were included, comprising 3 studies on MALAT1, 2 on MIAT, and 1 assessing both. Study populations were drawn from China, Egypt, and Canada, with serum or plasma as the primary biological matrix. MALAT1 demonstrated AUC values ranging from 0.62 to 0.84, with a pooled AUC of 0.737 (95% CI: 0.607–0.868). MIAT showed AUC values between 0.75 and 0.82, with a pooled AUC of 0.786 (95% CI: 0.732–0.839). The overall pooled AUC for both biomarkers was 0.761 (95% CI: 0.697–0.825), indicating moderate-to-good diagnostic performance. (Figure) MIAT showed lower heterogeneity (I² = 0%, p=0.52) compared to MALAT1 (I² = 83%, p<0.01), suggesting more consistent diagnostic accuracy across studies. Risk of bias assessment indicated moderate methodological quality, with limitations in exposure ascertainment and control group definition. Conclusion: The study demonstrates that MALAT1 and MIAT hold promise as non-invasive biomarkers for early detection of diabetic retinopathy. Both lncRNAs were significantly upregulated in DR patients, with diagnostic performance supporting their potential incorporation into molecular diagnostic panels. MIAT showed slightly higher accuracy and consistency compared to MALAT1. However, current evidence is limited by small sample sizes, methodological heterogeneity, and a lack of standardized detection protocols. Larger, multicentre studies with standardized methodologies are required to validate these findings and facilitate translation into clinical practice.
Copyright (c) 2025 Saransh Gupta, Seerat Kular, Vandana Sharma, Anuradha Raj, Harmanpreet Singh Kapoor, Aklank Jain https://creativecommons.org/licenses/by/4.0
Health Anxiety Among Clinical Medical Students: A Cross-Sectional Study at Uludağ University Faculty of Medicine
Background: Health anxiety, characterized by persistent worry about having or developing serious illness due misinterpretation of bodily sensations, represents a significant concern in medical education. Medical Student Syndrome (MSS), a unique manifestation of health anxiety specific to medical trainees, involves the tendency to misinterpret benign bodily sensations as symptoms of diseases being studied. Turkish medical students demonstrate higher rates of anxiety and depression compared to non-medical peers due to academic pressures, emotional exposure to illness, and prolonged training demands. The heightened awareness of disease pathology, combined with educational stressors, may increase susceptibility to health anxiety among medical students. This study aimed to evaluate and compare health anxiety levels among clinical-year medical students across different academic stages. Methods: A cross-sectional study was conducted among 288 clinical medical students (4th, 5th, and 6th years) at Uludağ University Faculty of Medicine. The sample exceeded the minimum required size of 272 participants calculated using Cochran's finite population correction formula. Data collection utilized a two-part online survey following informed voluntary consent. Part one assessed sociodemographic variables and health anxiety-related factors, while part two employed the validated Turkish version of the Short Health Anxiety Inventory (SHAI), an 18-item self-report instrument evaluating current mental states and emotional responses to illness scenarios. Statistical analysis was performed using SPSS version 23, employing descriptive statistics, Chi-square tests, Student's t-tests, and multiple linear regression analysis to identify significant predictors of health anxiety. Ethics approval was obtained from Uludağ University Faculty of Medicine Clinical Research Ethics Committee. Results: The study population comprised 136 (47.2%) female and 152 (52.8%) male students, with proportional distribution across academic years: 92 (31.9%) fourth-year, 95 (33.0%) fifth-year, and 101 (35.1%) sixth-year students. The overall mean SHAI score was 19.2±9.3. Female students exhibited significantly higher health anxiety levels compared to males (21.3±9.0 vs. 16.8±9.0; t=4.20, p<0.05). Among participants, 64.2% reported experiencing distress and anxiety due to self-perceived illness attributed to medical education knowledge, with significantly higher SHAI scores (21.1±8.7 vs. 15.7±9.2; t=4.80, p<0.05). Notably, 54.2% sought medical consultation based on self-diagnosis from medical knowledge, showing significantly elevated anxiety scores (22.6±8.1 vs. 15.2±8.9; t=7.30, p<0.05). Among those seeking consultation, 53.8% received confirmation of their suspected diagnosis. Multiple linear regression analysis revealed female gender as a significant predictor of health anxiety (B=4.15, 95% CI [2.34, 5.96]). No significant differences were observed in health anxiety scores based on residence location or academic year level (p>0.05). Conclusions: This study demonstrates significant health anxiety prevalence among clinical medical students, with female gender and medical education-induced health concerns serving as primary risk factors. The finding that over half of students sought medical consultation based on self-diagnosis highlights the practical impact of health anxiety on healthcare utilization behaviors. The absence of significant differences across academic years suggests that health anxiety remains consistently elevated throughout clinical training phases. These findings emphasize the need for targeted mental health support and educational interventions addressing health anxiety in medical curricula. Early identification and management of health anxiety could improve student wellbeing and reduce inappropriate healthcare-seeking behaviors.
Copyright (c) 2025 Levent Özdemir, Ezgi Mühürcü, Oğuzhan Çalışkan https://creativecommons.org/licenses/by/4.0
Association Between the Presence of Palmaris Longus Muscle and Handwriting Performance in Medical Students: A Cross-Sectional Study
Background: The Palmaris Longus (PL) is a superficial muscle of the anterior compartment of forearm, contributing to wrist flexion but considered functionally dispensable. Anatomically, it shows significant variability, with agenesis reported in 1.5–63.9% of individuals worldwide. The functional significance of the PL has been studied primarily in sports; however, limited research has examined the role of PL in fine motor tasks, particularly handwriting, which demands both wrist stability and precise motor control. Given the PL’s contribution to wrist flexion and hand stabilisation, its absence may influence handwriting. With this background, this study was focused to assess the prevalence of the PL in North Indian medical students, analyze its variation with respect to laterality and gender and determine any possible association between the presence of the PL and handwriting performance. Understanding these relationships could provide insight into the functional relevance of the PL in fine motor activities and contribute to anatomical and clinical knowledge in the population studied. Methods: A cross-sectional observational study was conducted over two months among 200 first- and second-year MBBS students aged 18–25 years at AIIMS Bathinda. The presence of the PL muscle was assessed using Schaeffer’s, Pushpakumar’s, and Mishra’s tests. Handwriting performance was evaluated with the validated Handwriting Assessment Battery for Adults, which included dot writing, horizontal line drawing, and numeral writing, scored for speed, accuracy, and legibility. Descriptive statistics were computed, and associations were analyzed using regression models (negative-binomial, Poisson, and linear), adjusting for sex, handedness, and PL laterality. A p-value <0.05 was considered statistically significant. Results: Most participants were right-handed (189/200, 94.5%). PL absence was uncommon (11/200, 5.5%) and more frequent in females (7/73, 9.6%) than males (4/127, 3.1%). Dominant-hand PL was significantly more common in males (122/127, 96.1%) than females (60/73, 82.2%; p = 0.0016). Horizontal line scores were lower in males (IRR 0.85, 95% CI 0.76–0.96, p = 0.008) and in participants with dominant-hand PL (IRR 0.48, 95% CI 0.24–0.99, p = 0.046), but higher in right-handers (IRR 1.82, 95% CI 1.28–2.58, p = 0.0009). Dot-writing scores were not significantly associated with handedness or dominant-hand PL (IRR 0.52, 95% CI 0.08–3.22, p = 0.478). Numeral-writing scores also showed no statistically significant variation with PL presence. Conclusion: The findings of our study suggest that the PL muscle has minimal functional impact on fine motor tasks such as handwriting. Future studies with larger and more heterogeneous populations are needed to validate these findings and to investigate potential subtle functional effects.
Copyright (c) 2025 Seerat Kular, Anshika Gandhi, Anirudh, Saransh Gupta, Dr. Apurba Patra, Dr Priti Chaudhary https://creativecommons.org/licenses/by/4.0
Survival Factors in Lung Cancer Patients with Mutations in the PROS1, SERPINC1, F2, and F5 Genes
Background: Lung cancer remains a leading cause of cancer mortality globally, with poor 5-year survival rates largely due to late-stage detection. Small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) are distinguished by distinct growth patterns, metastatic potential, and genetic profiles. Genetic markers in coagulation pathways, including F2, F5, PROS1, and SERPINC1, are implicated in tumor progression, metastasis, and hypercoagulable states. This study investigates the association of these gene mutations with clinical outcomes, tumor location, stage, and demographic factors in lung cancer patients. Aim: The objective of this study was to characterize the prognostic significance of F2, F5, PROS1, and SERPINC1 mutations in lung cancer by analyzing clinical outcomes and survival patterns. Using TCGA-LUAD and TCGA-LUSC cohorts, we assessed how these mutations interact with patient age, race, tumor laterality, anatomic site, stage, and treatment strategies. The overarching aim was to determine whether thrombophilia mutations represent independent factors influencing survival and to explore their potential role in guiding personalized therapy. Methods: Primary lung cancer patients with mutations in F2, F5, PROS1, or SERPINC1 were identified from TCGA-LUAD and TCGA-LUSC datasets. STAR RNA gene expression quantification was obtained for each gene. Patients were divided into mutation (n = 569) and comparison (n = 850) groups. Univariate and multivariate Cox proportional hazards analyses were conducted to evaluate associations between overall survival and patient age, race, AJCC pathologic stage, tumor primary site, laterality, and treatment type (chemotherapy, ancillary, immunotherapy, pleurodesis, radiation, targeted therapy). Hazard ratios (HR) with 95% confidence intervals (CI) were calculated. Results: Across all mutations, higher pathologic stage and right-sided tumor location were consistently associated with worse survival. F5 mutations were significantly associated with improved outcomes in middle lobe (HR = 1.49, 95% CI [1.04–2.13], p = 0.028), pleura (HR = 1.33, 95% CI [1.08–1.64], p = 0.006), and upper lobe tumors (HR = 1.20, 95% CI [1.02–1.41], p = 0.025). PROS1 and SERPINC1 mutations conferred survival benefit in upper lobe tumors. In upper lobe cancers, African American patients harboring F5 mutations exhibited significantly worse survival (age at diagnosis HR = 1.01, 95% CI [1.00–1.02], p = 0.015; race HR = 1.33, 95% CI [1.04–1.71], p = 0.024). Gene counts were significant in the comparison group but not in mutation groups, potentially reflecting the averaging of gain- and loss-of-function mutations. Conclusion: Thrombophilia-associated mutations in F2, F5, PROS1, and SERPINC1 influence lung cancer survival outcomes in a site- and demography-specific manner. Higher pathologic stage consistently predicts worse outcomes. F5 mutations confer protective effects in middle lobe, pleura, and upper lobe tumors, while PROS1 and SERPINC1 mutations are protective in upper lobe tumors. Notably, African American patients with F5 mutations experience reduced survival, and right-sided tumors harboring F2, F5, PROS1, or SERPINC1 mutations are associated with worse outcomes. These findings underscore the importance of considering thrombophilia gene status in prognostication and support the development of targeted therapies aimed at optimizing survival in lung cancer patients
Copyright (c) 2025 Raniya Ahmad https://creativecommons.org/licenses/by/4.0
Leishmaniasis in a Patient with Congenital Neutropenia - A Rare Case Report
Background: Visceral leishmaniasis is a parasitic disease caused by Leishmania species and transmitted by sandflies. It typically presents with fever, hepatosplenomegaly, and cytopenias. Congenital neutropenia is a rare primary immunodeficiency characterized by recurrent infections due to persistently low neutrophil counts. To our knowledge, the coexistence of congenital neutropenia and visceral leishmaniasis has not previously been reported. The case: We describe an eight-year-old child with congenital neutropenia who presented with pallor and hepatosplenomegaly, notably in the absence of fever. Laboratory studies showed pancytopenia with severe neutropenia. Given this constellation of findings, several differential diagnoses were initially considered, with leukemia being strongly suspected. Bone marrow aspiration was performed to confirm the diagnosis. Unexpectedly, the marrow examination revealed numerous Leishmania amastigotes, establishing the diagnosis of visceral leishmaniasis. The patient was treated with liposomal amphotericin B, resulting in a gradual clinical recovery and normalization of blood counts. Conclusion: This report represents the first documented case of concurrent congenital neutropenia and visceral leishmaniasis. It highlights the importance of maintaining a broad differential diagnosis in immunocompromised patients presenting with cytopenias and organomegaly, even in the absence of fever. Early recognition of visceral leishmaniasis remains critical, as timely treatment can substantially improve outcomes.
Copyright (c) 2025 Karima Boughambouz, Sana Bouimout, Yasmine Bouferkas, Meriem Boueri https://creativecommons.org/licenses/by/4.0
Diabetic Striatopathy: A Forgotten Diagnosis in Clinical Neurology
Background: Diabetic striatopathy primarily affects individuals with type 2 DM, often controlled, and is more common in females from Asian regions; cases have been reported across diverse populations.1,2 The incidence is approximately 1/100,000.3 Biopsy of the striatum shows vasculopathy with reactive gliosis. Diabetic striatopathy, a rare complication of Diabetes Mellitus (DM), presents a clinical challenge due to its variable manifestations. It is primarily characterized by abnormal involuntary movements, such as chorea or ballismus, which may affect limbs and, as in our case, the oromandibular region.4 This atypical presentation highlights the need to include diabetic striatopathy in the differential diagnosis of unexplained movements in patients with diabetes. The Case A 73-year-old man presented to the emergency department with a 15-day history of involuntary movements involving his left leg and oromandibular region. The symptoms began with mild pain, followed by irregular jaw movements and later choreiform movements of the left leg. He had recently been diagnosed with type 2 diabetes and was on metformin, glyburide, and sitagliptin, with no family history of movement disorders, prior head or neck injuries, or fever. On examination, he was alert, oriented, and hemodynamically stable, with no focal neurological deficits. Laboratory evaluation revealed fasting glucose of 132 mg%, postprandial 148 mg%, HbA1c 7.3%, mild anemia, and elevated thyroid function (0.3 µIU/mL); renal and liver function tests were normal. Initial suspicion of right basal ganglia or subthalamic stroke was revised after MRI revealed right putaminal hyperintensity with preservation of the internal capsule (Figure 1). Endocrinology consultation and anti-chorea therapy with tetrabenazine and clonazepam led to complete resolution, and the patient remained well on follow-up while continuing oral hypoglycemic therapy. Conclusions: The pathophysiology remains incompletely understood. Evidence suggests a link between hyperglycemia and vascular changes in the striatum, with biopsy showing vasculopathy and reactive gliosis.1,5 These hyperglycemia-induced microangiopathic changes parallel those seen in diabetic retinopathy.6,7 Further research is required to elucidate the molecular mechanisms connecting striatal vasculopathy to abnormal movements. Diagnosis relies on hyperglycemia history, chorea or ballismus, and characteristic imaging findings, such as striatal hyperdensity on CT or T1 hyperintensity on MRI, with preservation of the internal capsule distinguishing it from stroke.8 Management focuses on glycemic control and symptomatic treatment with anti-chorea agents like tetrabenazine and clonazepam, which resulted in resolution in our patient. Prognosis is generally favorable, with clinical and radiologic improvement after controlling hyperglycemia.9 Despite increasing recognition, research gaps persist regarding pathophysiology, clinical variability, and optimal management strategies.10 Documenting and sharing cases, particularly from resource-limited regions, will enhance understanding and guide clinical care.
Copyright (c) 2025 Sajjad Ahmed Khan, Anish Luitel, Rasmita Poudel, Huma Kausar, Vivek K. Rauniyar https://creativecommons.org/licenses/by/4.0
Efficacy of Narrowband UVB Phototherapy in Mild to Moderate Psoriasis: A Case Series from Kharkiv, Ukraine
Background. Psoriasis is a genetically determined, chronic autoimmune disease of the skin and joints with a complex immunopathogenesis. Although topical corticosteroids remain the first-line treatment for mild to moderate forms, narrowband UVB (NB-UVB) phototherapy has emerged as an effective non-systemic alternative. AIM: To evaluate the clinical efficacy of NB-UVB phototherapy in patients with mild to moderate psoriasis using PASI and DLQI scores. Methods: Five patients were treated with NB-UVB phototherapy at the Dermatologic Centre “Chista shkira” (Kharkiv, Ukraine) between February and May 2025. PASI and DLQI were assessed before and after the course of treatment. All patients received adjunctive topical corticosteroids and antihistamines. Statistical analysis was performed using the Wilcoxon signed-rank test. Results: The mean PASI score decreased from 4.8 ± 3.78 to 0.56 ± 0.54 (p = 0.0625), and DLQI scores also improved, though statistical significance was not achieved (p = 0.0544). Clinical improvement, PASI75, was observed in 4 of 5 patients. All patients reported a reduction in pruritus. Conclusion: NB-UVB phototherapy combined with topical corticosteroids and antihistamines demonstrated clinical improvement in most patients with mild to moderate psoriasis. Although the results did not reach statistical significance due to the small sample size, the findings support further investigation of this therapeutic approach.
Copyright (c) 2025 Marharyta Khaustova, 2. Andrii Dashchuk https://creativecommons.org/licenses/by/4.0
Reconstruction of a Large Lumbar Carcinoma Defect Using a Subtype III Keystone Flap: Case Report
Background. Systemic inflammation is theorized to alter lipid metabolism through cytokine-driven suppression of hepatic synthesis, changes in lipoprotein clearance, and impaired reverse cholesterol transport. These theoretical changes include reductions in low-density lipoprotein (LDL), high-density lipoprotein (HDL), and total cholesterol (TC) with elevations in triglycerides (TG). While these mechanisms are biologically plausible and supported in experimental settings, large-scale inpatient data confirming these patterns remain limited. Clarifying how lipid profiles shift during acute inflammation is essential for accurate cardiovascular risk assessment and interpretation of lipid panels during illness. Methods. We conducted a retrospective analysis of electronic medical record data from a tertiary academic medical center between 2020 and 2024. A total of 5,060 hospitalized adult patients with C-reactive protein (CRP) >5 mg/L and at least one lipid panel were included. Patients were stratified into CRP categories: 5–20, 20–50, 50–100, and >100 mg/L. Mean values for TG, LDL, HDL, and TC were compared across groups using one-way ANOVA. Tukey HSD post-hoc testing was performed to evaluate between-group differences. Results. Among the 5,060 patients included, th mean age was 50.5 years, and 53.4% were female. As CRP increased, LDL declined from 105.53 mg/dL in the 5-20 mg/L group to 87.94 mg/dL in the >100 mg/L group, and TC declined from 187.04 to 157.28 mg/dL. HDL also showed a consistent inverse relationship with CRP, decreasing from 48.89 to 38.68 mg/dL across categories. ANOVA revealed significant group differences for LDL (F = 68.53, p < 0.0001), HDL (F = 94.83, p < 0.0001), TC (F = 99.39, p < 0.0001), and TG (F = 5.39, p = 0.0011). Tukey post-hoc tests showed significant LDL reductions between the 5-20 and >100 mg/L groups (mean difference = –17.60 mg/dL, p < 0.0001) and the 20-50 and >100 mg/L groups (mean difference = –9.72 mg/dL, p < 0.0001). For TC, the 5-20 and >100 mg/L comparison showed a statistically significant reduction (mean difference = –29.77 mg/dL, p < 0.0001). For HDL, significant reductions were observed between the 5-20 and >100 mg/L groups (mean difference = –10.21 mg/dL, p < 0.0001), 20-50 and >100 (mean difference = –7.58 mg/dL, p < 0.0001), and 50-100 and >100 (mean difference = –3.09 mg/dL, p = 0.0023). Conclusion. This study demonstrates a clear inverse association between CRP levels and lipid values, particularly LDL, HDL, and TC, in hospitalized patients. These patterns reflect inflammation-induced suppression of lipoprotein synthesis and metabolic remodeling. Lipid profiles obtained during inflammatory states may underestimate baseline atherosclerotic cardiovascular risk, highlighting the importance of contextual interpretation to avoid delayed or missed preventive interventions. Figure 1. Mean Lipid Levels by CRP Category in Hospitalized Patients (N = 5,060) CRP Category (mg/L) Triglycerides (mg/dL) LDL (mg/dL) HDL (mg/dL) Total Cholesterol (mg/dL) 5–20 174.31 105.53 48.89 187.04 20–50 163.55 97.66 46.26 174.11 50–100 169.16 89.57 41.78 160.45 >100 186.74 87.94 38.68 157.28 ANOVA F-value 5.39 68.53 94.83 99.39 ANOVA P-value 0.0011 <0.0001 <0.0001 <0.0001
Copyright (c) 2025 Wilson Sebastian Peñafiel-Pallares, Camila Brito-Balanzategui, Juan Velez-Posada, Jonathan Velasco https://creativecommons.org/licenses/by/4.0
The Lipid Paradox in 5,060 Hospitalized Patients: An Inverse Association Between C-Reactive Protein and Cholesterol in a Tertiary Care Cohort from 2020 to 2024
Background. Systemic inflammation is theorized to alter lipid metabolism through cytokine-driven suppression of hepatic synthesis, changes in lipoprotein clearance, and impaired reverse cholesterol transport. These theoretical changes include reductions in low-density lipoprotein (LDL), high-density lipoprotein (HDL), and total cholesterol (TC) with elevations in triglycerides (TG). While these mechanisms are biologically plausible and supported in experimental settings, large-scale inpatient data confirming these patterns remain limited. Clarifying how lipid profiles shift during acute inflammation is essential for accurate cardiovascular risk assessment and interpretation of lipid panels during illness. Methods. We conducted a retrospective analysis of electronic medical record data from a tertiary academic medical center between 2020 and 2024. A total of 5,060 hospitalized adult patients with C-reactive protein (CRP) >5 mg/L and at least one lipid panel were included. Patients were stratified into CRP categories: 5–20, 20–50, 50–100, and >100 mg/L. Mean values for TG, LDL, HDL, and TC were compared across groups using one-way ANOVA. Tukey HSD post-hoc testing was performed to evaluate between-group differences. Results. Among the 5,060 patients included, the mean age was 50.5 years, and 53.4% were female. As CRP increased, LDL declined from 105.53 mg/dL in the 5-20 mg/L group to 87.94 mg/dL in the >100 mg/L group, and TC declined from 187.04 to 157.28 mg/dL. HDL also showed a consistent inverse relationship with CRP, decreasing from 48.89 to 38.68 mg/dL across categories. ANOVA revealed significant group differences for LDL (F = 68.53, p < 0.0001), HDL (F = 94.83, p < 0.0001), TC (F = 99.39, p < 0.0001), and TG (F = 5.39, p = 0.0011). Tukey post-hoc tests showed significant LDL reductions between the 5-20 and >100 mg/L groups (mean difference = –17.60 mg/dL, p < 0.0001) and the 20-50 and >100 mg/L groups (mean difference = –9.72 mg/dL, p < 0.0001). For TC, the 5-20 and >100 mg/L comparison showed a statistically significant reduction (mean difference = –29.77 mg/dL, p < 0.0001). For HDL, significant reductions were observed between the 5-20 and >100 mg/L groups (mean difference = –10.21 mg/dL, p < 0.0001), 20-50 and >100 (mean difference = –7.58 mg/dL, p < 0.0001), and 50-100 and >100 (mean difference = –3.09 mg/dL, p = 0.0023). Conclusion. This study demonstrates a clear inverse association between CRP levels and lipid values, particularly LDL, HDL, and TC, in hospitalized patients. These patterns reflect inflammation-induced suppression of lipoprotein synthesis and metabolic remodeling. Lipid profiles obtained during inflammatory states may underestimate baseline atherosclerotic cardiovascular risk, highlighting the importance of contextual interpretation to avoid delayed or missed preventive interventions.
Copyright (c) 2025 Kyle Thurmann, Trisha G. Mukherjee, Michael D. White, MD https://creativecommons.org/licenses/by/4.0
Is Mental Health Contagious? Depression, Anxiety, Stress and Burnout among Mental health professionals in Sudan
Background: Mental health professionals are more likely to experience mental health problems due to their work environment, Poor management of this can lead to job dissatisfaction, low organizational commitment and high turnover. The goal of this cross-sectional study is to evaluate the mental health of health care professionals working in Khartoum state psychiatric hospitals in order to comprehend effective coping strategies. Methods: Data was collected through both online and paper questionnaires, and analyzed using SPSS version 25, using descriptive statistics for categorical and continuous data, and inferential tests like Mann Whitney U, Kruskal-Walllis, and Sperman’s correlation. P value < 0.05 was considered significant. Results: A total of 164 mental health workers participated, majority of participants were female, single, and worked in private institutions for an average of 36-48 hours per week. The study found that participants experienced high levels of stress and personal burnout, with depression and anxiety being negatively correlated with the age of respondents and work-related burnout. Conclusion: The study suggests that mental health professionals in Sudan are experiencing relatively high levels of depression, stress, anxiety, and burnout. This highlights the need for effective strategies to support the mental well-being of healthcare professionals in this setting. Table 1. Demographic and Occupational Profile of the Study Sample. Variable Total N % Gender Male 68 41.5 Female 96 58.5 Social status Single 77 47.0 Married 78 47.6 Divorced 7 4.3 Widowed 2 1.2
Copyright (c) 2025 Iyas Abdelhadi Ahmed Abdelhadi https://creativecommons.org/licenses/by/4.0
Healthcare Access Dimensions among ESRD Patients on Dialysis in Northern Sudan during Wartime 2024
Background: Patients with end-stage renal disease (ESRD) undergoing hemodialysis are among the most vulnerable groups in low-income and conflict-affected settings. Adequate access to healthcare is crucial for maintaining treatment continuity, preventing complications, and supporting nutritional health in this population. This study assesses healthcare access and its determinants among end-stage renal disease (ESRD) patients on hemodialysis in Northern Sudan and examines the relationship between access and malnutrition. Methods: This cross-sectional study involved secondary data analysis from 137 ESRD patients in four dialysis centers in Northern Sudan using cluster sampling. Healthcare access was measured using a structured questionnaire based on the modified Penchansky and Thomas model. Nutritional status was assessed usingthe Subjective Global Assessment (SGA). Descriptive statistics, bivariate analysis, and logistic regression were used to identify determinants and predictors of healthcare access using the Statistical Package for Social Science (SPSS) v21. Statistical significance was set at p-value < 0.05. Results: Overall, all patients showed moderate to high levels of healthcare access (mean index: 3.87 ± 0.51). Affordability scored the lowest among access dimensions. Higher income and age were significant predictors of better access (AOR=9.99 and AOR=3.87, respectively; p<0.05), while gender, displacement, and health insurance showed no significant contribution. Malnourished patients showed significantly lower scores on the affordability and awareness domains (p-value < 0.05). Conclusion: While patients in Northern Sudan had moderate to high access to healthcare, affordability was the most prominent barrier, being more prominent in malnourished patients, besides the low awareness. We recommend socioeconomic support, facilitating healthcare access for vulnerable patients, and nutritional educational programs.
Copyright (c) 2025 Iyas Abdelhadi https://creativecommons.org/licenses/by/4.0
Malnutrition among Patients with End-Stage Renal Disease in War 2024: The Role of Healthcare Access, Dialysis, Gender, and Economic Disparities
Background: Chronic kidney disease (CKD) involves a decline in kidney function for at least three months, often requiring renal replacement therapy at the end stage. Ende-stage renal disease (ESRD)patients on haemodialysis are at risk of malnutrition, leading to poor clinical outcomes. This complex and multifaceted issue, influenced by socioeconomic and clinical care, is expected to worsen due to the ongoing war and high displacement rates. This study aimed to provide evidence on the prevalence of and factors contributing to malnutrition among haemodialysis patients in northern Sudan. Methods: This cross-sectional study recruited 141 patients from four public haemodialysis centres in the northern state through cluster sampling. Socioeconomic and clinical data were collected via interviews with patients, caregivers, and healthcare providers. Nutritional status was assessed using Subjective Global Assessment, and healthcare access was evaluated using the Penchansky and Thomas model. Descriptive, bivariate, and multivariate analyses were performed using SPSS v21, with statistical significance set at P < 0.05. Results: Most patients were males (68.1%), and the mean age was 52 ± 14.5 years. Hypertensive renal damage was the most common aetiology of ESRD (36.9%), followed by hereditary kidney diseases (20.6%). Approximately one-fourth of patients were hospitalized in the last 6 months, primarily due to electrolyte disturbances. Mild to moderate malnutrition was observed in 44% of patients, and severe malnutrition in 4.3%. Female gender (OR=2.292, 95% CI= 1.037-5.066) and dialysis duration over 5 years (OR=2.945, 95% CI= 1.155-7.505) predicted malnutrition. Better healthcare access correlated with improved nutritional status (p<0.05). Lower income, urban residence, hypertension, and cardiopathy were linked to higher SGA scores. Conclusion: The study reveals a high prevalence of malnutrition in haemodialysis patients, with a significant contribution of iatrogenic factors, symptomatic burden, healthcare access, and socio-economic disparities. We recommend regular nutritional monitoring and an integrated healthcare approach addressing clinical factors, symptoms management, and socio-economic support. Table 1. Bivariate Analysis for the Clinical and Socioeconomic Determinants of Malnutrition Among Patients with ESKD on Hemodialysis at Northern state, Sudan 2024 Knowledge About OTC drugs: - Count Column Valid % All OTC (over the counter) drugs are safe and effective Yes 183 46.7% No 209 53.3% OTC drugs are used usually for treating diseases like I don’t know 68 17.3% Chronic Illnesses 44 11.2%
Cross-Sectional Descriptive Study of Comparative Accuracy of ChatGPT, Google Gemini, And Microsoft Copilot in Solving NEET PG Medical Entrance Test
Background: Artificial Intelligence (AI) is increasingly applied in healthcare and medical education, with tools capable of assisting in diagnosis, treatment planning, and exam preparation. The NEET-PG is India’s national entrance examination for postgraduate medical training, with case vignettes forming a major component of assessment. AI chatbots therefore hold potential as aids in exam preparation. Previous studies have reported variable accuracy of AI tools in medical licensing exams, but head-to-head comparisons across question types, subjects, and platforms are scarce. Given their rapidly growing use by students and educators, establishing the reliability of these tools is critical. This study directly compares three leading AI chatbots. The objective was to assess and compare the accuracy of ChatGPT-4, Google Gemini, and Microsoft Copilot in solving the NEET-PG 2023 examination and evaluate their performance across different question types and medical subjects. Methods: This cross-sectional descriptive study evaluated the performance of three AI chatbots using a validated set of 200 NEET-PG 2023 questions sourced from PrepLadder and verified against standard textbooks. These questions were presented verbatim to ChatGPT-4, Google Gemini, and Microsoft Copilot. Each chatbot received the questions independently in separate sessions to minimize memory bias. Responses were recorded correct or incorrect using the validated answer key, and accuracy was expressed the percentage of correct responses. Comparative analysis was performed for overall accuracy, subject distribution, and question type (recall, analytical, image-based, case-based). Differences were assessed using the chi-square test with p < 0.05 considered statistically significant. Results: Microsoft Copilot achieved the highest overall accuracy with 165/200 correct responses (82.5%), followed by ChatGPT-4 with 161/200 (80.5%) and Google Gemini with 155/200 (77.5%). The difference in overall performance was not statistically significant (χ² = 1.6, p = 0.4). All three chatbots achieved 100% accuracy in Microbiology, Anesthesia, and Psychiatry, whereas lower accuracy occurred in Community Medicine, Forensic Medicine, Internal Medicine, and Radiology. No significant variation was found across subjects (χ² = 2.7, p = 0.9). By question type, recall-based items showed the highest accuracy (85.5%), followed by case-based (82.4%) and analytical (77.3%), while image-based questions were the most challenging (mean accuracy 71.0%). Although Copilot performed slightly better on recall and image-based items, the differences across the three chatbots for question type were not statistically significant (χ² = 0.35, p = 0.9). These findings highlight variability by subject and question format but no significant difference among the three tools. Conclusion: All three AI chatbots demonstrated good accuracy in solving NEET-PG questions, performing better in recall-based subjects and less well with image-based items, reflecting current limitations in multimodal applications. They can complement exam preparation by serving as an accessible and interactive platform, offering an affordable alternative to expensive coaching. In healthcare, AI chatbots hold potential for assisting with diagnosis, treatment planning, triage, and referral, particularly in resource-limited settings. However, concerns regarding data privacy, patient confidentiality, lack of empathy, erosion of clinical decision-making limit their broader adoption. Future research should evaluate evolving versions of these models, larger exam datasets, and integration into structured educational frameworks.
Copyright (c) 2025 Manik Bhise, Kale Sachin Sadanand, Patil Anuradha Vishwanath, Jali Nandita Vivekanand https://creativecommons.org/licenses/by/4.0
Enhancing wash Practices and Health Outcomes in a Remote Community in the Peruvian Amazon: a Community-Based Intervention
Background: Florida International University Herbert Wertheim College of Medicine (FIU HWCOM) students initiated a community health and Water, Sanitation, and Hygiene (WASH) initiative in San Juan de Yanayaku, a remote Peruvian Amazon village of 105 individuals, from November 28 to December 2, 2024. The purpose of this project was to provide essential healthcare services and address critical WASH issues. The project was conducted in collaboration with Nevada Building Hope Foundation, which has provided support to the community for over a decade. Methods The team established and operated a temporary health clinic in a central community space to evaluate the overall health status of community members. Screenings included common acute and chronic health conditions, nutritional assessments, and vital sign monitoring. Each participant underwent a basic health assessment, with brief interviews to collect self-reported hygiene practices, water consumption, and prior illness history. Data were used to identify hygiene-related illness trends and inform future WASH interventions. New clothing was also distributed to community members. In addition, WASH education at the local primary school emphasized proper handwashing techniques and hygiene practices to reduce communicable disease spread. Results: The clinic provided health screenings for 40 individuals. Of these, sixty percent were female and most were between 20 and 60 years old. Eighty percent reported direct exposure to Amazon River water. While 65% reported no known medical conditions and 92.5% were not on medications, this may reflect limited healthcare access rather than absence of disease. Diarrhea was more common in river water consumers (50% vs. 12.5%). Stomachaches were also more frequent in river water users (37.5% vs. 25%). Higher glucose levels were observed in individuals drinking river water, suggesting a possible nutritional or metabolic impact linked to chronic infection or lack of food and care. Headaches and muscle aches were found in both groups, with no notable differences. The school-based intervention provided interactive handwashing demonstrations to instill hygiene practices. Conclusion: This project highlights the urgent need for targeted WASH interventions in San Juan de Yanayaku. The association between river water consumption and diarrheal disease indicates inadequate water sanitation as a major health risk. Elevated blood glucose levels and underdiagnosis of chronic illnesses further suggest limited healthcare access and health literacy. Community-based health screenings provided diagnostic and educational benefits, but a single intervention is insufficient. Ongoing follow-up, educational campaigns, and installation of a permanent water sanitation system are essential to improve long-term outcomes. This initiative demonstrates that community-driven health assessments can guide sustainable WASH programs and integrate medical outreach with public health advocacy in underserved regions.
Copyright (c) 2025 Rosemary Wright, Sakhi Shah, Venus Liu https://creativecommons.org/licenses/by/4.0
Human Immunodeficiency Virus Infection Among Women with Cervical Cancer: A Cross-Sectional Study
Background: Cervical Cancer remains a major public health concern worldwide, particularly in low- and middle-income countries. Women living with Human Immunodeficiency Virus (HIV) are at significantly higher risk for persistent Human Papilloma Virus (HPV) infection and progression to invasive cervical cancer due to immune suppression. This study aimed to determine the prevalence of HIV infection among women with cervical cancer and to assess demographic and clinical factors associated with HIV positivity. Methods: A prospective cross-sectional study was conducted among histologically confirmed cervical cancer patients after the approval of ethics committee. Demographic details, clinical history, HIV status, and treatment history were collected using a pre-validated structured questionnaire after obtaining informed consent. Data were analyzed using descriptive statistics, and subgroup analysis was performed for age, menopausal status, and place of residence. Results: Eighty patients were included, with a mean age of 47.86 ± 20.94 years; most were aged 45–64 years (51.25%) and presented with stage IIb disease (67.5%). Sixteen patients (20%) were HIV-positive. HIV prevalence was highest among women aged 45–64 years (41.17%) and among urban residents (62.5%). A majority of patients (65%) were premenopausal. Conclusion: A substantial proportion of cervical cancer patients were HIV-positive, underscoring the need for routine HIV screening, early diagnosis, and integrated management of HIV and cervical cancer to improve clinical outcomes. Table 1. HIV Status Distribution Among Cervical Cancer Patients HIV Status No.of cervical cancer patients Percentage Positive 16 20% Negative 64 80%
Copyright (c) 2025 Sai Sadhvika Kommuru https://creativecommons.org/licenses/by/4.0
Exploring the Relationship Between Students’ Academic Performance and Jungian Psychological Types: A Correlational Study
Introduction: The aim of this study is to explore the potential relationship between students' academic performance and their psychological types, as defined by Carl Jung's theory. The study also aims to highlight the relevance of Jung's theory of psychological types in understanding individual differences in academic performance. The key question is whether a person's psychological type influences their learning process, goal setting, and achievement. Methods: For theoretical information C. G. JUNG “THE COLLECTED WORKS” Edited by Sir Herbert Read was used. 50 students participated in the correlation study based on informed consent. The inclusion criteria are people with active student status aged 18 to 24 years. Questionnaires were used to collect data. The Myers-Briggs Type Indicator (MBTI) was used to determine the psychological types. SPSS Statistics Program was used to process the data. Four major variables were identified: 1. Gender, 2. University (Tbilisi State Medical University or other), 3. Psychological types, 4. Academic performance for the last 2 semesters (A, B, C, D). A correlation analysis was performed between these variables to determine the Pearson Correlation coefficient. Results: As a result of the pilot study the correlation between academic performance with student’s psychological type was not confirmed (Pearson Correlation -.132. Table1.). Given the small cohort, the results cannot be generalized of the general population. Conclusion: Aforementioned pilot correlation research shows that a person’s professional success, academic performance and the scale of the use of knowledge is not dependent on the psychological type. This calls for further studies with bigger and more diverse cohorts. Table 1. Pearson correlation coefficient Academic performance psychological type Academic performance 1 -.132 psychological type -.132 1
Copyright (c) 2025 Lizi Sarjveladze https://creativecommons.org/licenses/by/4.0
Prevalence of Anxiety Among Medical Students in River Nile Universities: A Cross-Sectional Study
Background: Despite the social prestige the medical profession gives, it is not without taxation. Because of the rigorous training curriculum and long-term clinical practice medical school is stressful and onerous for mental health. We aim to measure prevalence of anxiety among medical students in the River Nile state and its association with sociodemographic characteristics. Methods: A descriptive cross-sectional facility-based study involving 335 students from first to fifth academic years at River Nile State medical schools. conducted using the Hospital Anxiety and Depression Scale (HADS) in addition to questions about a demographic. Data analysis was done on STATA program. Results: In our study wefound a high prevalence of anxiety 71.4% (Anxiety 47.8% and borderline anxiety 23.6%). There was no significant association between different colleges and anxiety (p=0.85), and no significant association in different academic years (p=0.23), Nationality (p=0.64), smoking (p=0.59) and drug (p=0.3). There was a significant association between anxiety and gender (p=0.001) female has more anxious than male. Conclusions: The Level of anxiety among medical students at River Nile state was high (71.4%), there is an urgent need to focus on awareness about mental well-being and provide the necessary support services to reduce anxiety.
Copyright (c) 2025 Tarteel Abazer Musa, Alwathig Yahia https://creativecommons.org/licenses/by/4.0
The Impact of Lifestyle on Cardiovascular Health Among Medical Students at 6 October University
Background: Life-threatening cardiovascular conditions (CVDs) are one of the most important factors that affect peoples’ appetites and life expectancy on a global scale. Lifestyle factors such as diet, physical activity, sleep, and stress levels are important determinants of cardiovascular health. This research examines medical students’ lifestyle habits in relation to cardiovascular health indicators at 6 October University. Methods: This is a cross-sectional study of 100 medical students, and it was conducted via an online questionnaire in English and Arabic. The questionnaire contained demographic data, information about leisure activity, diet, smoking, sleep patterns, stress levels, and self-measured heart rate and blood pressure. Results: Of the participants, 62% were physically active more than 3 times weekly, only 28% of students reported eating fast food more than twice a week and 35% reported eating fruits and vegetables daily. 64% said they sleep for 6-8 hours a day. 42% reported feeling stressed. Among the responding students, 16% reported having elevated blood pressure and the majority of these students who reported poor lifestyle scores. Conclusion: These findings suggest that lifestyle behaviours including physical activity and dietary habits are associated with cardiovascular health indicators among medical students. It is necessary to promote healthy lifestyle changes to improve the wellbeing of future health professionals. Table 1. Summary of Health Behaviors Among Students Variable % of Students Physically active ≥3 times/week 62% Fast food consumption >2/week 28% Daily fruit/vegetable intake 35% Sleep duration 6–8 hours/night 64% Reported moderate/high stress 42% Elevated blood pressure reported 16%
Copyright (c) 2025 Naif A. Jaafari https://creativecommons.org/licenses/by/4.0
Emotional Well-Being, Anxiety, Depression, and Burnout Among First-Year Hospital Medical Students in Guatemala: A Pilot Study
Background: The transition into the first hospital year is a critical period in medical education, exposing students to new responsibilities, academic demands, and emotional stressors that increase vulnerability to anxiety, depression, and burnout. In Guatemala, evidence on students’ mental health at this stage is scarce. This pilot study examined emotional well-being, anxiety, depression, and burnout among Guatemalan medical students. Methods: A cross-sectional survey was conducted among 50 first-year hospital medical students from public and private universities in Guatemala using non-probabilistic convenience sampling. Data collection employed a Google Forms questionnaire with validated instruments: Patient Health Questionnaire (PHQ-9) for depression, Generalized Anxiety Disorder scale (GAD-7) for anxiety, and Oldenburg Burnout Inventory (OLBI) for exhaustion and disengagement. Sociodemographic data were also obtained. Descriptive statistics, Pearson correlations, and chi-square tests were performed with significance set at p < 0.05. Results: Mean OLBI scores were 16.3 ± 4.2 for exhaustion and 19.5 ± 2.9 for disengagement, with high levels in 40% and 84% of students, respectively. The mean PHQ-9 score was 6.0 ± 3.9, with 22% meeting criteria for moderate-to-severe depression. The mean GAD-7 score was 9.4 ± 5.5, with 42% screening positive for moderate or higher anxiety. Depression and anxiety were strongly correlated (r = 0.71, p < 0.001). Burnout was not significantly associated with depression or anxiety (p > 0.5). Conclusions: This pilot study revealed high rates of anxiety, depression, and burnout among Guatemalan medical students, underscoring the urgent need for institutional interventions to protect mental health.
Copyright (c) 2025 Ana Palomo, Victor Rivero, Luis Torres, MD https://creativecommons.org/licenses/by/4.0
Assessment Of Vision Impairments Among Licensed Drivers In Mathura: A Pilot Study
Background: Driving is a visually intensive task that requires the integration of multiple visual functions to ensure road safety. In India, vision screening protocols for obtaining a driving license are often inadequate or inconsistently enforced. This pilot study was conducted to assess the prevalence and types of vision impairments among licensed drivers in Mathura district. Objective: To evaluate key visual parameters—glare recovery, night vision, color vision, visual acuity, phoria, and horizontal visual field—among licensed male drivers and determine their potential impact on driving performance. Methods: A cross-sectional pilot study was conducted at Spexwear Optical & Physiotherapy Centre, Mandi chauraha, Sonkh Road, Mathura. A total of 198 male drivers aged 18–56 years participated. Standardized tests were conducted to assess visual acuity (Snellen chart), color vision (Ishihara plates), glare recovery, night vision, phoria, and horizontal field of vision. Data were analyzed using descriptive statistics and chi-square tests; p-values < 0.05 were considered statistically significant. Results: Visual acuity deficits were noted in 29% of participants (binocular), 33% (right eye), and 25% (left eye). Impairments in glare recovery and night vision were present in 15% and 12% of drivers, respectively. Color vision deficiency was found in 23% of participants, with an additional 13% requiring retesting. Phoria was abnormal in 24%, and 19–20% of drivers showed subnormal horizontal field vision in at least one eye. Most impairments showed statistically significant associations (p < 0.05) with driving fitness. Conclusion: A significant proportion of licensed drivers in Mathura have unrecognized visual impairments. Comprehensive vision screening should be made mandatory in the driver licensing process to enhance road safety and reduce accident risks. Table 1. Distribution of Visual Function Test Results Among Drivers Glare Recovery Test Grade Number of Drivers Percentage (%) P value Outstanding (10) 8 4% = 0.042 Excellent (9) 9 5% Very Good (8) 41 20% Good (7) 40 20% Reasonably Good (6) 30 15% Satisfactory (5) 29 15% Above Average (4) 9 5% Average (3) 8 4% Below Average (2) 14 7% Poor (1) 10 5%
Copyright (c) 2025 Dr Ragni Kumari, Jagdish Singh https://creativecommons.org/licenses/by/4.0
Factors Influencing Varicose Vein Amongst the Local Population of Namakkal - A Cross-Sectional Study
Background: Varicose veins are a part of the spectrum of chronic venous disease. Varicosity might be due to obstruction, valvular insufficiency and calf muscle pump malfunction. They are not only a cosmetic concern but can also lead to significant morbidity, including pain, edema, skin changes, and ulceration if left untreated. Globally, the prevalence of varicose veins varies between 10% and 30%, influenced by genetic, occupational, and lifestyle factors. Prolonged standing, elevated body mass index (BMI), and hereditary predisposition are among the most widely reported risk factors. Aim: To assess the estimation of factor that influence the occurrence of varicose veins. Methods:: This study will be conducted in the Department of General Surgery at Swamy Vivekanandha Medical CollegeHospital and Research Institute. Patients who are coming to the Out Patient Department(OPD) and are willing to be examined for research purposes will be a part of the study. A minimum of 50 cases will be included in this study. Patients with severe pain and complications like: DVT/associated atherosclerotic arterial diseases will be excluded from the study. Patients with varicose will be examined and interviewed physically. The parameters of the study Age,Gender,Hours of Standing (Occupation),BMI,Pregnancy,Hereditary} will be noted down and the findings will be analyzed statistically using Chi-Squared test, SPSS software to understand the prevalence of varicose vein depending on the factors influencing them. Conclusions: The study is conducted to analyze the risk factors associated with varicose vein among the local population of Namakkal. Further counselling will be given to reduce the prevalence of varicose vein among the general public
Copyright (c) 2025 vivek krishnaa https://creativecommons.org/licenses/by/4.0
Knowledge, Attitude, and Practice on Over-the-Counter Drugs among Medical Students University of Khartoum, 2022-2023
Background: Self-medication with over-the-counter (OTC) medications is common among medical students. It is influenced by many factors, such as age, sex, income, self-care orientation, and medical knowledge. A high level of education and professional status are predictive factors for self-medication. Unfortunately, especially in developing countries, professional health care is relatively expensive and in some cases not readily available making self-medication an obvious choice of healthcare service. Furthermore, it has been noted that purchase of drugs that can only be purchased with a doctor's prescription in developed countries are OTC in developing countries. Students are expected to have proper knowledge, attitude, and practice (KAP) towards OTC medications and subsequent adverse drug reactions (ADRs). Objective: This study aimed to assess the KAP of OTC medication use and related factors among medical students, Uofk 2022. Methods: A cross-sectional study was conducted. Data were collected using a self-administered questionnaire from 377 students from year 1 to year 6 University of Khartoum, Faculty of Medicine.Then the data was analyzed using Statistical Package for Social Sciences (SPSS) version 24. Chi-square analysis was conducted and multivariable logistic regression analysis was used to determine the association between KAP and OTC use and its related adverse effects. Result: A total of 393 students participated in the study. The majority of the respondents (75.2%) reported that they practice self-medication. Fever & headache (76%), cough & common cold (48.5%), and abdominal cramps (45.7%)) were the most common conditions for which the students go for self-medication while analgesics (85.2%) followed by antispasmodics (72.4%) were the most commonly used classes of drugs. Minor illnesses (55.9%) and a desire for quick relief 171 (25%) were the main reasons for the self-medication practice with OTC medications. Conclusion: Self-medication is widely practiced among medical students. Significant problems and malpractices were identified, such as sharing of OTC medications, the use of expired medicines, storage of OTC medications, and not reading expiry dates. Table 1: Knowledge of the Study Participants Towards OTC Medication Use; N=393 Knowledge About OTC drugs: - Count Column Valid % All OTC (over the counter) drugs are safe and effective Yes 183 46.7%
Students' Perspectives on the Educational Environment at the University of Khartoum, Faculty of Medicine (2023-2024)
Background: Educational Environment (EE) is a broad category of settings that engage students in learning activities and its plays a central role in shaping students’ learning, attitudes, and academic success..A positive EE promotes intellectual growth, cooperation, satisfaction, and achievement, while students’ perceptions guide improvement effort. In Sudan, however, medical education faces unique challenges, including limited resources, political instability and ongoing conflict, all of which negatively affect training, infrastructure, and student well-being, highlighting the urgent need for systematic evaluation. At the University of Khartoum’s Faculty of Medicine, understanding students’ views is vital for identifying strengths and areas requiring improvement. Despite the institution’s leading role, little research has examined how academic performance, motivation, and living conditions influence these perceptions. Methods: A cross-sectional study was conducted using a self-administered, online questionnaire. The Dundee Ready Educational Environment Measure (DREEM) was applied to assess the perceptions of 377 medical students across six academic batches. Stratified random sampling ensured adequate representation by gender and batch. Data were analyzed using SPSS version 22 to examine the influence of demographic and academic factors on five key domains of the educational environment: perceptions of teaching, perceptions of teachers, academic self-perception, perceptions of atmosphere, and social self-perception. Results: The overall DREEM score was 113.1 ± 19.62, indicating a generally positive perception of the educational environment. However, subgroup analyses revealed notable disparities. Male students reported lower perceptions of teaching quality (p = 0.036), while dormitory residents had a significantly lower perception of teachers (p = 0.011). Students with intrinsic motivation exhibited higher scores in teaching (p = 0.002) and social self-perception (p = 0.002), whereas students experiencing academic difficulties had significantly lower scores in teaching (p = 0.016) and atmosphere (p = 0.029). Conclusion: The findings indicate a generally favorable perception of the educational environment, yet subgroup differences highlight areas requiring targeted improvement. Male students’ lower ratings of teaching suggest the importance of incorporating gender-sensitive instructional strategies. Similarly, dormitory residents’ less favorable views of faculty may point to environmental or institutional barriers limiting student–faculty interaction. The higher scores among intrinsically motivated students underscore the value of fostering self-directed learning, while lower scores among academically struggling students emphasize the strong link between performance and perceptions of the learning environment. Together, these results call for evidence-based curricular reforms, strengthened student support services, and faculty development initiatives to create a more inclusive and effective environment that supports both academic achievement and professional growth. Student perceptions thus provide critical insights, with targeted interventions in teaching approaches, motivational support, and institutional systems offering pathways to enhance learning outcomes and student well-being.
Copyright (c) 2025 Malaz M. Abdalmotalib, Nihal Elmubarak A. Hussien, Eyad Kashif, Muaiad Adil A. Abdelmotalab, Hadiea Mosaab Ahmedelbashir Hassan https://creativecommons.org/licenses/by/4.0
Myeloid-Derived Suppressor Cells in HIV: A Marker Beyond CD4 Count?
Background: HIV infection causes profound immune dysregulation, primarily through CD4⁺ T lymphocyte depletion and persistent immune activation. Myeloid-derived suppressor cells (MDSCs) have recently been recognized as key immunoregulatory cells. They represent a heterogeneous population of immature myeloid cells with strong capacity to suppress T cell proliferation and cytokine production, often mediated via PD-L1 expression and arginase activity. While their role has been described in cancer and other chronic infections, their contribution to HIV pathogenesis, clinical manifestations, and therapy response remains insufficiently defined. Aim: The aim of this study was to investigate the role of MDSCs and PD-L1 expression in HIV-positive patients, in relation to clinical symptoms, CD4⁺ T cell count, and type of antiretroviral therapy (ART). Methods: Peripheral blood samples from 41 HIV-positive patients and 10 healthy controls were collected. Flow cytometry was performed to quantify MDSCs (absolute counts and percentage of CD45⁺ cells), PD-L1 expression on MDSCs, and CD4⁺ T cell counts. Patients were stratified by clinical status (symptomatic vs. asymptomatic), CD4⁺ stage (<200/µl, 200–500/µl, >500/µl), and ART regimen (PI+NRTI, PI+NNRTI, NRTI+NNRTI, or no therapy). Statistical analysis was carried out using IBM SPSS v26. Normality of data was evaluated with the Shapiro–Wilk test. Depending on distribution, comparisons were made using t-test, ANOVA, Mann–Whitney U, or Kruskal–Wallis test. Correlations between continuous variables were assessed using Spearman’s rho. Results: MDSC percentages were significantly higher in HIV patients compared to healthy controls (p = 0.007). Within the HIV group, symptomatic patients showed elevated MDSC levels (p = 0.045) and lower CD4⁺ counts (p = 0.032) than asymptomatic individuals. Stratification by CD4⁺ stage revealed a trend toward increasing MDSC percentages with advancing disease, though this did not reach significance (p = 0.077). No differences were observed between ART regimens in relation to MDSCs, CD4⁺ counts, or PD-L1 expression (all p > 0.5). Moreover, PD-L1 expression on MDSCs did not correlate with CD4⁺ counts or MDSC percentages (p > 0.1). Conclusion: Elevated MDSC levels distinguished HIV patients from healthy controls and were further increased in symptomatic cases, suggesting a contribution to clinical manifestations of immune imbalance. Although PD-L1 expression did not correlate with disease stage or therapy type, MDSCs provide insights beyond CD4⁺ counts in assessing immune status. These findings highlight the potential of MDSCs as early immunosuppressive markers in HIV. Larger studies incorporating functional assays are warranted to validate their diagnostic and therapeutic relevance and to explore whether therapeutic modulation of MDSCs could open new avenues in the management of chronic HIV infection.
Copyright (c) 2025 Jelena Mićić, Nikola Trifunović, Ivan Stanojević, Vesna Begović Kuprešanin, Danilo Vojvodić https://creativecommons.org/licenses/by/4.0
Early Clues, Early Cure: Evaluating the Utility of the Hematological Scoring System in the Early Diagnosis of Neonatal Sepsis.
Background: Neonatal sepsis is a clinical syndrome characterised by signs of circulatory compromise due to microbial invasion of the bloodstream in the first month of life. It is a leading cause of neonatal mortality and is a global health concern. Early identification is crucial. The “gold-standard”- blood culture - has low sensitivity and is time-consuming. In resource-limited settings, these factors frequently lead to empirical antibiotic use, contributing to antimicrobial resistance. Rodwell et al. introduced a Hematological Scoring System (HSS) as an adjunctive tool for early diagnosis of neonatal sepsis using various hematological parameters. This observational diagnostic accuracy study aims to establish the reliability of HSS as a diagnostic marker, with potential for global use in the early identification of neonatal sepsis. Methods: This study is set in a tertiary care centre in Kerala, India. 60 neonates admitted to the NICU were included. The Hematological Scoring proposed by Rodwell et al is given in the table. Sepsis likelihood was interpreted as follows: ≤2 (less likely), 3–5 (probable), and >5 (very likely). Sensitivity, Specificity, PPV and NPV of each HSS parameter as well as CRP was assessed using IBM SPSS Statistics, ver. 30. Results: The study included 60 cases divided into three groups. Definite sepsis (5/60): Blood culture is positive for sepsis. Probable sepsis (25/60): Blood culture is negative but signs or elevated CRP suggestive of infection. No sepsis (30/60): Negative blood culture, normal CRP levels and absence of any signs of infection. The most common organisms isolated from the definite sepsis group were Staphylococcus Aureus and Acinetobacter Baumanni. Performance of the hematological parameters were analysed by two different approaches: Definite sepsis group vs. No definite sepsis group (Probable sepsis and No sepsis). Definite and Probable sepsis groups vs. No sepsis group. In both the approaches, total neutrophil count was the most sensitive parameter with the highest NPV, while I:M ratio was the most specific with the highest PPV. Total leukocyte count, Total neutrophil count, Immature neutrophil count, I:M Ratio and Platelet Count were found to be statistically significant (p < 0.05). Furthermore, a significant association was found between CRP levels and HSS scores. Conclusion: The HSS is a simple, feasible and cost-effective tool which can be utilised for the early diagnosis of neonatal sepsis. It can also aid in preventing antibiotic resistance as a result of exposing infants to unnecessary antibiotics. On a broader scale, the HSS can contribute to lowering neonatal mortality rates. Table: The Hematological Scoring System proposed by Rodwell et al. Parameters Value HSS Total leucocyte count ≤5,000/μL ≥25,000/μL (at birth) ≥30,000/μL (12-24hrs) ≥21,000/μL (day 2 onwards) 1 Normal 0 Total neutrophil count No neutrophils 2 Increased/Decreased 1 Normal 0
Copyright (c) 2025 Fahed Mohammed, Farin Ashraf, Gayathri G Nair https://creativecommons.org/licenses/by/4.0
Perceived Knowledge, Perception and Readiness of University Students regarding Sustainability Education and Practice
Background: Education for Sustainable Development (ESD) empowers individuals to acquire the knowledge, skills, attitudes, and values necessary for fostering a sustainable future. As global concerns regarding climate change, resource depletion, and environmental degradation intensify, higher education institutions play a vital role in preparing students to adopt and champion sustainable practices. This study aims to assess perceived knowledge, perception, and readiness toward sustainability education and practice among IMU University students, with the goal of informing institutional strategies and designing impactful educational interventions. Methods: A cross-sectional study was conducted among students enrolled in foundation, undergraduate, and postgraduate programs in IMU University. Data were collected using a validated, self-administered online questionnaire disseminated through institutional emails and social media platforms. The online survey included a combination of closed-ended multiple-choice questions, Likert scale ratings, and open-ended questions. A minimum sample size of 426 students was calculated to ensure representativeness, factoring in a 20% non-response or attrition rate. The survey assessed students’ demographic characteristics, prior exposure to sustainability content, perceived knowledge of sustainability concepts, attitudes toward environmental and planetary health, and readiness to engage in sustainability initiatives. Data were analyzed descriptively to summarize trends and identify potential gaps in knowledge and participation. Results: A total of 427 respondents participated in the study; 328 were female, and 351 were Malaysian. The majority (83.6%) were enrolled in undergraduate programs, and 81% had not attended any course related to sustainability. In terms of environmental and planetary health, 92.3% and 87.2% of respondents, respectively, rated their knowledge as fair or good. Climate change, pollution, and deforestation were identified as the key sustainability challenges facing the planet. Over 89% of respondents were very concerned about climate change, while over 74% were concerned about biodiversity loss challenges. Nearly 64% of respondents agreed that sustainability education should be a required part of the university’s curriculum. Most preferred workshops or seminars to include sustainability education in the curriculum, while others preferred extracurricular activities or integration into existing courses. Approximately 83% of respondents expressed willingness to participate in sustainability initiatives. The most commonly suggested campus-level changes to promote sustainability were recycling improvements, reducing the use of single-use plastic, and energy conservation. The level of concern of the respondents about current sustainability challenges was measured. The maximum possible score was 24 and the median score was 13. Conclusion: The present study revealed that respondents demonstrated generally good knowledge and perceptions regarding environmental health and sustainability issues. However, fewer than 20% had undertaken formal courses on these topics. Hence, courses should be introduced and offered through workshops, symposia, or practical sessions to strengthen understanding and engagement. Student engagement in sustainability-related initiatives on campus should be actively promoted and further strengthened. Findings from this study can guide the university in integrating sustainability into its curriculum and fostering sustainable practices among students. By highlighting knowledge gaps and attitudes, the study will contribute to the development of targeted educational strategies and institutional policies.
Copyright (c) 2025 Pui Ee Seow, Ke Shuen Yeo https://creativecommons.org/licenses/by/4.0
Cross Sectional Study On Prevalence Of Insomnia And Factors Contributing To Insomnia In Adolescent School Students
Background: Insomnia- the unwelcome experience of difficulty in falling asleep, difficulty in maintaining sleep or early morning awakening with inability to resume sleep is common in all age groups and impairs quality of life. Untreated insomnia has severe impact on health and socioeconomy.These include subjective and objective daytime consequences like fatigue or malaise, poor attention and concentration, social and vocational dysfunction, mood disturbances, daytime sleepiness, reduced energy, tension etc. Insomnia is highly related to advancing age, family history of insomnia, female sex, lifestyle, emotional background, worry and stress; each of which is important to assess among the community, especially centering the adolescent age group. Since there are no known existing studies on the same topic in the authors setting and the available studies show wide variations in the prevalence of insomnia, they would like to investigate that. Objective: Primary objective: To study the prevalence of Insomnia in adolescent school children in Thiruvananthapuram Corporation, Kerala, India. Secondary objective: To find out the factors contributing to insomnia among the study population- Methodology: Study design: Cross sectional study. Study setting: Higher secondary schools of Thiruvananthapuram Corporation, Kerala, India. Study population: Adolescent students of two schools of Thiruvananthapuram Corporation. Data collection and analysis: Schools were approached through proper channels. Permissions were taken from school authorities before study. Questionnaires based on Insomnia Severity Index were distributed among the study population. The questionnaire consists of two sections, one based on a standard Insomnia severity assessment question and second one includes questions that are directed towards the establishment of relation between insomnia and certain factors, in which the researchers are interested in. A score based on all of this is determined and the demographic data is analyzed using spss software. The Chi square test is used to describe the relations. Results: 165 candidates took part in the study. On analysis 94 students had no clinically significant insomnia, 51 students had subthreshold insomnia, 20 students had clinical insomnia of moderate severity, and no students had severe clinical insomnia. On analysis, there was significant association between gender of students and insomnia. It was found to be more associated with females compared to males. From the study they also reached the conclusion that the following factors contribute to insomnia among adolescent school children: problems in family, academic stress (mainly, pressure from parents) and substance use (alcohol, cigarettes, drugs). Smart phone use showed no significance whereas occurrence of insomnia increased with increasing average screen time per day. Conclusion: Sleep symptoms often go under reported and under diagnosed and can have a significant impact on long term outcome. In some cases they are environmental or related to lifestyle factors. Therefore it is important to identify these factors. Early detection of insomnia and its symptoms is also an important step to avoid secondary psychiatric disorders. This study provides preliminary data on sleep quality and factors contributing to insomnia, which maybe used to guide sleep hygiene promotion and intervention among adolescent school students.
Copyright (c) 2025 Athul. A https://creativecommons.org/licenses/by/4.0
Impact of War on Burnout among Medical Students at Al-Neelain University in Sudan, 2024
Background: Burnout, characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment, is relatively frequent among medical students due to the demanding nature of medical education. In conflict zones, such as Sudan, the challenges are exacerbated by war, which disrupts training and increases psychological stress. Despite its potential long-term consequences on individuals and healthcare systems, burnout among medical students in these settings remains underexplored. Aim: This study aimed to assess the prevalence of burnout among medical students at Al-Neelain University in Sudan, with a focus on the impact of war on burnout levels. Additionally, it evaluated the students' coping mechanisms and resilience in overcoming the challenges posed by conflict and academic disruptions. Methods: A cross-sectional study was conducted among 259 medical students at Al-Neelain University, selected using a stratified sampling technique. Data were collected through an online, close-ended questionnaire comprising three sections: sociodemographic and training-related questions, a burnout assessment using the Maslach Burnout Inventory-Student Survey (MBI-SS), and an evaluation of resilience using the Brief Resilient Coping Scale (BRCS). The data collected were analyzed using Microsoft Excel and the Statistical Package for the Social Sciences (SPSS). Results: Of the total of 259 medical students at Al-Neelain University, the prevalence of burnout using the two-dimensional definition was 18.5%, while 8.1% met the criteria for three-dimensional burnout. High emotional exhaustion and cynicism were observed in 31.7% and 32.8% of students, respectively, whereas 30.1% had low academic efficacy. Burnout was significantly associated with poor academic performance, inadequate social support, and limited internet access (p < 0.001). The Brief Resilient Coping Scale (BRCS) showed that only 19.3% of students had high resilience coping, while 45.9% had low resilience coping. Resilience showed a statistically significant moderate positive correlation with academic efficacy (r = 0.487, p < 0.001) and a weak negative correlation with cynicism (r = -0.226, p < 0.001). While burnout had a limited direct impact on clinical training for fifth-year students, conflict-related disruptions, such as reduced access to hospitals and inconsistent mentorship, posed significant challenges to their educational experiences. Conclusion: Medical students at Al-Neelain University exhibited an alarming prevalence of burnout, compounded by academic and conflict-related challenges. It demonstrated the urgent need for interventions to reduce burnout, enhance resilience, and improve resource access, which are essential to support students' well-being and ensure training continuity, especially in conflict zones like Sudan. Table 1. Prevalence of Burnout, sub-scales, levels among medical students at Al-Neelain University (n=259). Frequency (n) Percent (%) Emotional Exhaustion (High) 82 31.70% Cynicism (High) 85 32.80%
Copyright (c) 2025 Enas Seyed, Mohammed Yhya, Ruaa El.Walid, Assma Gamie, Noha Sofyan https://creativecommons.org/licenses/by/4.0
Ochratoxin A and Citrinin Contamination in Rice, Oats and Wheat Flour in Michoacán, Mexico: an External Biomonitoring Study
Background: Ochratoxin A (OTA) and citrinin (CIT) are classified as nephrotoxic mycotoxins, compounds naturally produced by some saprophytic filamentous fungi of the Aspergillus and Penicillium genera. These two mycotoxins are of particular concern because of both their ability to contaminate a vast spectrum of foods and their thermal stability of up to 250º C, thus representing a concrete threat for human health. Progressive decline in kidney function, chronic kidney disease, interstitial nephritis and Balkan Endemic Nephropathy are listed as long-term health risks. Aim: Since Mexico does not have regulations on OTA and CIT contamination limits in food, an external biomonitoring study is needed. The main objective of this study is to determine whether and to which extent selected food matrices are contaminated with ochratoxin A and citrinin. Methods: Commercial rice, oats and wheat flour, purchased from large-scale retail stores in Morelia (Michoacán), were selected as food matrices. In order to assess mycotoxins’ concentration, extracts of these cereals were needed. The process of extraction began by finely grinding and sieving the cereals until a homogeneous powder was obtained. Three replicates of each cereal were prepared by mixing 20 grams of powder with 100 mL of 80% acetonitrile. To optimize extraction, samples were placed on a rotatory magnetic plate for 15 minutes, centrifuged at 1980 g for 5 minutes. The supernatant was then collected, concentrated by rotary evaporation, and stored at 4°C until analysis. For detection, sensitive and highly specific techniques were applied: thin-layer chromatography (TLC) and enzyme-linked immunosorbent assay (ELISA). TLC was employed for qualitative analysis, while ELISA was used for quantitative analysis. Results:TLC results showed considerable ochratoxin A and citrinin contamination in all the analyzed samples (rice, oats and wheat flour), as well as potential occurrence of other toxins. Further investigation is needed to assess other mycotoxins’ contamination. At the time of writing, ELISA has not been performed. Nevertheless, since TLC has already detected the investigated mycotoxins, we are confident about the positive results that ELISA will yield, allowing us to confirm both ochratoxin A and citrinin presence in the samples and to quantify their concentration. Conclusion: Overall, the experiment revealed ochratoxin A and citrinin contamination in commercial food (rice, oats and wheat flour) from Michoacán, Mexico, through thin-layer chromatography. When conducted, ELISA will provide more data regarding the specific concentrations of each mycotoxin in all the samples analyzed. Further investigation is needed to determine the impact of mycotoxins’ exposure to humans. Moreover, a biomonitoring external study for other contaminating mycotoxins should be conducted.
Copyright (c) 2025 Maria Elena Asdrubali, Alessandro Perera, José Ángel Patricio Abarca Figueroa https://creativecommons.org/licenses/by/4.0
Green Synthesis of Streptomycin-Conjugated Silver Nanoparticles and their Efficacy Against Multi Drug-Resistant Staphylococcus aureus
Background: The emergence of multidrug resistant (MDR) pathogenic microbes against typical antibiotics is a global problem. Novel and effective strategies are being explored to treat various disease causing MDR pathogens. In this study, we prepared and tested the efficacy of antibiotic-conjugated silver nanoparticles against MDR-pathogens. Methods: We used the plant extract for the green-synthesis of Silver nanoparticles (AgNPs) as well as Streptomycin-conjugated AgNPs. The aqueous Azadirachta indica (Neem) leaf extract was used for the synthesis of AgNPs. The synthesized nanoparticles were characterized by various techniques and the antimicrobial activity was determined by agar-well plate method. Results: The green synthesized Streptomycin-conjugated AgNPs were characterized by different analytical techniques to establish the nanoparticle formation, size, shape and the presence of functional groups. The UV-visible spectra indicating absorbance at 450 and 440nm confirmed the formation of AgNPs and St-AgNPs, respectively. The scanning electron microscopic images showed that AgNPs and St-AgNPs are spherical in shape and the size in the range of 21-30 nm and 29-43 nm, respectively. The X-ray diffraction pattern of AgNPs and St-AgNPs showed peaks establishing the crystalline nature of the particles with characteristic peaks of 2θ for (111), (200), (220) and (311) planes. The Fourier Transform Infrared spectrum of St-AgNPs shows distinct peaks at 2980.47 (C-H bond), 1723.37(C=O bond), 1606.89 (C=C bond), 1507.63 (N-O group), 1445.33 (C-H), 1269.02 (C-O bond),1019.19 (C-O bond), and 812.43 cm (C-C bond) which corresponds to the functional groups present in both AgNPs and the conjugated antibiotic streptomycin. Further, the antimicrobial activity of AgNPs and St-AgNPs was examined by using the agar-well plate method against MDR Staphylococcus aureus. The antimicrobial activity analysis showed that St-AgNPs exhibited ~50% higher activity as compared to streptomycin alone. Conclusion: The results of our study indicate that the green synthesized antibiotic conjugated AgNPs could be used to treat MDR Staphylococcus aureus and potentially other MDR pathogens as well. Further detailed studies are in progress to confirm the utility of these antibiotic conjugated AgNPs.
Copyright (c) 2025 Soura Rajeshwara, Raghu S. Holalkere, Raghavendra S. Nagaraju, Rajeshwara Achur, Halesh L.H. https://creativecommons.org/licenses/by/4.0
Modulatory Role of Pre-orthostatic Cold-Water Ingestions on the Electroencephalogram
Background: Literature is replete with the adverse outcomes of the cold impacts of climate change. The aim of the study was to investigate the effect of pre-orthostatic cold water ingestions on the electroencephalogram in male individuals. Methods: 35 apparently healthy young males averaging 19.5years satisfied the inclusion criteria and were selected for the study. Participants ingested 500militers of portable commercial water at 250c and 100c five minutes prior to sitting or orthostasis. Orthostasis lasted for minutes. Electroencephalogram (EEG) was recorded using PowerLab 26T with eye opened. On assumption of erect position, EEG recording was started and continued for 20 minutes during which the standing lasted. Results: Ingestion of 250c or 100c water prior to orthostasis has no significant effect on alpha wave frequency when compared to baseline. Beta wave frequency and alpha/beta ratio were significantly higher and lower in participants who ingested 250c prior to orthostasis when compared to those who ingested 250c prior to sitting respectively. Beta wave frequency and alpha/beta ratio also increased and decreased respectively in participants who ingested 100c prior to orthostasis when compared to those who ingested 100c prior to sitting. Ingestion of 250c prior to orthostasis caused higher beta wave frequency and lower alpha/beta ratio when compared to participants who ingested 100c prior to orthostasis. Conclusion: The findings of the study demonstrated that ingestion of 250c water prior to orthostasis was associated with relatively greater cortical activation.
Copyright (c) 2025 Mayowa Adeniyi, Ayoola Awosika https://creativecommons.org/licenses/by/4.0
Effects of Non-Nutritive Sweetener Mixers compared to Carbohydrate Mixers on Alcohol Pharmacokinetics and Patient-Reported Outcomes: A Systematic Review and Meta-Analysis
Background: Alcohol-associated accidents pose a major global health burden, accounting for 4.7% of all deaths and 4.6% of total disability-adjusted life years. Alcohol impairs psychomotor performance, driving ability, and risk perception. These acute outcomes are largely determined by alcohol absorption and metabolism, which in turn is influenced by gender, body composition, enzyme polymorphisms, drinking state, and co-consumed mixers. While carbonation and caffeinated mixers have shown to alter the pharmacodynamics of alcohol, the effects of non-nutritive sweetener (NNS) mixers remain underexplored. Given the increasing prevalence in the use of NNS mixers, clarifying their impact on alcohol pharmacokinetics and subjective intoxication and related outcomes is critical. Methods: A systematic review and meta-analysis of studies obtained from three databases (PubMed, EMBASE, Scopus) was conducted in accordance with PRISMA guidelines. Primary outcomes assessed were breath or blood alcohol concentration (BrAC/BAC) and gastric emptying (t1/2, tlag). Secondary outcomes included subjective ratings of intoxication and related psychomotor tests. Risk of bias was assessed using the RoB2 tool. Standardized mean differences (SMD) was calculated for BrAC Cmax. Subgroup analysis were performed separately for the breathalyzer used, standardized ethanol dosing, and non-nutritive sweetener composition. Heterogeneity was quantified using I² statistic, and sensitivity and publication bias analyses were performed when required adjusting for the small sample size. Results: Five studies were reviewed, of which four (34 NNS vs. 34 carbohydrate (CHO)) contributed to meta-analysis. All included studies were rated as having an overall risk of bias of “some concerns”. NNS mixers were associated with higher not statistically significant peak BrAC (SMD = +1.01, 95% CI = -0.44 to 2.46, p = 0.097; I² = 53%). Subgroup analyses done for the type of breathalyzer used (p=0.1), standardized ethanol dose (p=0.80), non-nutritive sweetener content (p= 0.17) were not significant. Sensitivity analysis showed that the study by Akca et al. had a strong influence on the overall results. Gastric half-emptying time (t½) with NNS mixers were observed to be shorter than with CHO mixers in two studies. Marczinski & Stamates found that alcohol with NNS mixers slowed reaction times and increased inhibition failures, indicating impaired cognitive control. Despite Brickley et al. observing no significant subjective differences between NNS and CHO mixers, there was a trend toward poorer vehicle control and greater risk-taking in men. Acka et al. reported expected alcohol-related changes in intoxication and alertness with no significant differences between mixer types. Conclusion: Current evidence suggests that NNS mixers may accelerate gastric emptying and raise peak alcohol levels compared to CHO mixers, without proportionally increasing subjective patient-reported or similarly reported intoxication levels. This mismatch between physiological and perceived impairment highlights potential safety risks and underscores the need for further research on diet mixer use.
Copyright (c) 2025 Shwetha Shenod, Dhanikha SV, Hari Sudhan S https://creativecommons.org/licenses/by/4.0
Evaluating SLC11A2 Expression in Stage III Colon Adenocarcinoma: No Prognostic Signal but Coordinated Expression with SLC40A1
Background: Colon cancer is characterized by the uncontrollable growth of abnormal epithelial cells and is a leading cause of cancer-related mortality worldwide. Stage 3 colon adenocarcinoma involves local lymph nodes and has a 5 year survival rate of about 65-75%. In diseases associated with marked inflammation, expression of iron regulating genes has been shown to experience significant alterations and predict worse prognosis in some patients. Notable genes involved in this pathway include SLC11A2, HAMP, FTH1, and SLC40A1. Aim: This study assessed SLC11A2’s significance for predicting overall survival in stage 3 colon adenocarcinoma followed by a gene expression correlational analysis with other iron regulating genes in patients from The Cancer Genomic Atlas COAD database. Methods: TCGA was queried for clinical and STAR counts RNA gene expression data within the TCGA-COAD project. 362 patients with AJCC stage 3 primary colon adenocarcinoma were selected. STAR RNA data was normalized using variance stabilizing transformation and patients were stratified by quartiles of expression into Q1, Q2, Q3, or Q4 groups. Additionally, patients were classified as early onset (EO) or late onset (LO) if age at diagnosis was before or after 50 years old, respectively. A Kaplan-Meier overall survival (OS) curve was created comparing survival across quartiles of SLC11A2 expression with log rank analysis assessing significance. Univariate and multivariate Cox Proportional Hazards Analysis was completed for SLC11A2 expression quartile, age, gender, and race. Linear regression testing was completed to assess colinearity of SLC11A2 expression with HAMP, FTH1, and SLC40A1. Results: On Kaplan-Meier analysis, SLC11A2 expression was not a significant predictor of survival at any quartile. Q2 experienced the worst survival, with all other quartiles displaying similar survival. On univariate analysis, quartiles of SLC11A2 expression were nonsignificant for OS. LO patients experienced significantly worsened survival compared to EO (7.23 HR, 1.76-29.7 95% CI, p=0.006). On multivariate analysis, SLC11A2 expression remained a nonsignificant predictor of OS. However, LO age group remained a significant predictor of worsened survival, moreso than on univariate analysis (13.3 HR, 3.04-58.2 95% CI, p<0.001). Race became a significant survival predictor with African American patients surviving worse than white patients (2.07 HR, 1.15-3.70 95% CI, p=0.015). On correlational analysis, SLC11A2 and SLC40A1 showed a significant positive expression correlation with no other genes showing significance (r=0.36, p<0.001). Conclusion: Regardless of SLC11A2 expression, overall survival in stage 3 colon adenocarcinoma is mediated by age and race. SLC11a2 does not appear to be a significant gene in predicting prognosis in stage 3 of this cancer. SLC40a1 and slc11a2 display a significant positive expression correlation. After accounting for SLC11A2 expression, age, and gender, African American and LO patients experience significantly worsened OS.
Copyright (c) 2025 Ryan Brownlee, Shagun Dolakia, Mashoor Al Ahammed, Aditya Birla, Raniya Ahmad, Girindra Raval https://creativecommons.org/licenses/by/4.0
Using pretreatment MRI perfusion to inform subsequent MRI perfusion
Purpose: Patients with brain metastases frequently require stereotactic radiosurgery (SRS), which offers effective local control while avoiding the neurocognitive toxicities of whole brain radiation therapy. Increasing enhancing lesions after SRS may represent recurrent metastasis or radiation necrosis. MR perfusion is commonly used to distinguish between these entities, with recent meta-analyses showing good correlations between hyperperfusion and recurrent metastasis. However, some metastases do not show hyperperfusion before SRS due to innate tumor properties rather than technical limitations. We hypothesize that pretreatment MR perfusion can improve perfusion interpretation at suspected progression, where absent hyperperfusion before treatment suggests perfusion is an unreliable marker for recurrent metastasis. Materials and Methods : We retrospectively reviewed patients with systemic cancers and brain metastases who underwent SRS, had MR perfusion scans ≤30 days before SRS, and later developed suspected progression (>30 days post-SRS) with repeat MR perfusion ≤30 days before surgical resection. Histopathology served as the reference standard for determining recurrent metastasis versus necrosis. One metastasis was evaluated per patient. We analyzed dynamic contrast enhanced T1-weighted MR perfusion images with automated arterial input function to calculate Ktrans maps (transfer constant coefficient) and VP maps (plasma volume). The entire enhancing lesion was segmented using a semi-automated tool, propagated onto Ktrans and VP maps, and used to calculate normalized ratios (rKtrans, rVP). Absent hyperperfusion was defined as ratio <1.5. Statistical analysis used t-test where p=0.05. Results: Initial perfusion results before SRS across the entire cohort showed median rKtrans=1.7 (range: 0.20-29.56) and median rVP=2.1 (range: 0.275-7.536). Median metastasis size was 3.0 cc (range: 0.369-10.431). We identified 22 patients with growing enhancing lesions and repeat perfusion a mean 283.7 days after SRS. Histopathology showed 14 (64%) recurrent tumors and 8 (36%) necrosis. Recurrent metastases showed median rKtrans=7.4 (range: 0.58-221.13) and median rVP=3.1 (range: 0.48-6.10), while necrosis showed lower median rKtrans=1.6 (range: 0.18-198.47) and median rVP=0.9 (range: 0-6.40), p=0.08. Among recurrent metastases without hyperperfusion (ratio <1.5) at repeat imaging (n=6), pre-SRS perfusion showed rKtrans=10.38 (range: 0.35-15.27) and rVP=2.81 (range: 0.71-5.22). The remaining recurrent metastases (ratio ≥1.5) showed pre-SRS rKtrans=6.17 (range: 0.49-13.04) and rVP=3.94 (range: 0.20-29.56). Conclusion: Our results confirmed MR perfusion utility in distinguishing recurrent metastasis from necrosis. Incorporating pre-SRS perfusion improved correlations and offers a novel approach for better informed management. Absent hyperperfusion in growing lesions that lacked hyperperfusion before treatment should be considered unreliable. Further patient incorporation and analysis are ongoing. Table 1: Initial Results Suggest Utility of MR Perfusion to Distinguish Between Recurrent Metastasis and Necrosis in Treated Patients. Pre-SRS MRI Ratios Entire Cohort Non-hyperperfused (ratio <1.5) rKtrans range 1.7 (0.2-29.6) 0.4 (0.4-0.5) rVP range 2.1 (0.4-7.5) 0.7 (0.2-1.5)
Copyright (c) 2025 Adebola Ademola https://creativecommons.org/licenses/by/4.0
How is Hypertension Associated with the Risk of Dementia among Adults living in High-Income Countries: A Systematic Literature Review
Background: Dementia is a major public health challenge in high-income countries (HICs). Hypertension is a modifiable risk factor for dementia, yet the timing of exposure and dementia subtype-specific associations remain uncertain. This meta-analysis quantifies the association between hypertension and dementia risk in HICs and examines life-course timing (midlife and late-life) and dementia subtypes. Methods: Systematic searches on OVID Medline, Embase, PsycINFO, Scopus and Web of Science (from inception to July 2025) identified 21 cohort studies. Four studies were meta- analyzed to quantify the association of midlife hypertension and all-cause dementia risk. The remaining studies were narratively synthesized using the SWiM guidelines. Screening and data extraction and analysis were done in accordance with PRISMA guidelines. Study quality was appraised with the JBI checklist; risk of bias was assessed with ROBINS-E and visualized using ROBVIS. Additionally, a Directed Acyclic Graph was constructed to map hypothesized causal pathways between hypertension and dementia, and to identify key confounders, particularly given the complex life-course interactions between these conditions. Results: Twenty-one cohort studies, with sample size ranging from 1,462 to 848,505, follow-up between 8 to 37 years, and participant mean ages from 30-95 years. Study populations were largely homogeneous, consisting predominantly of white participants in Europe, the USA, and Australia, and Asian participants from Japan and Korea. Ethnic minority and socioeconomic status were not reported in the included studies. Single-country studies were conducted in the United Kingdom, USA, Finland, Norway, Sweden, Japan, South Korea, Included2-16 and Australia. One multi-cohort study included seven cohorts across five countries (United States, Sweden, Germany, Netherlands, and Spain), and another study included two cohorts from two countries (Netherlands and Sweden). Meta-analysis of four studies showed midlife hypertension increases the risk of dementia by 63% (HR 1.63, 95%CI:1.37-1.89; I²=0%). Narrative synthesis of the remaining 17 studies revealed that midlife hypertension is associated with dementia risk especially with vascular dementia (VaD). Heterogeneous findings were reported for late-life hypertension and dementia risk (null, inverse and U-shaped). Reverse nocturnal BP dipping increased dementia risk. Genetically elevated BP was found to be causal through Mendelian randomization. Evidence on antihypertensive therapy were mixed, with BP decline preceding dementia onset. Most studies had a moderate-to-serious the risk of bias due to confounding and exposure misclassification. Conclusion: Midlife hypertension consistently increases dementia risk, making it a critical public health priority for reducing dementia burden in HICs. In contrast, late life hypertension-dementia associations are heterogeneous, reflecting complex life-course dynamics and highlighting evidence gaps that require further
Copyright (c) 2025 Feyi Ayanlowo, Dr. Daniel https://creativecommons.org/licenses/by/4.0
Prevalence and prognostic significance of sodium levels in adults with traumatic brain injury: A meta-analysis
Background: Traumatic Brain Injury (TBI) is one of the leading causes of morbidity and mortality worldwide. Sodium disturbances occur commonly after traumatic brain injury and causes many complications. This study is aimed at determining prevalence and prognosis of sodium levels in adult with traumatic brain injury. Methods: A meta-analysis was performed following PRISMA guidelines. A systematic search was conducted at PubMed and Google Scholar from 2009 to 2025 for studies reporting sodium disturbances in adults with traumatic brain injury. Risk of bias was assessed using Newcastle-Ottawa Scale (NOS). Results: A total of 8 studies with 94,874 patients were involved. Data was analyzed using R software (version 4.5.1). The studies suggest that hypernatremia was associated with increased risk of mortality (OR 2.9 [95% CI 1.939-4.332] p-value <0.0001, I^2 = 85.05%) and worsened outcomes. Limited data on hyponatremia is not sufficient to make pooled analysis but few studies suggests that it is associated with increased severity and worsened outcomes. Conclusion: Hypernatremia is associated with increased risk of mortality and poorer outcomes. This study emphasizes the importance of incorporating sodium monitoring into standardized management protocols.
NagaVenkata Priya Sri Harshitha Somarouthu
Copyright (c) 2025 NagaVenkata Priya Sri Harshitha Somarouthu https://creativecommons.org/licenses/by/4.0
Polypharmacy and Outcomes in Elderly Patients with Heart Failure: A Meta-Analysis
Background: Polypharmacy, commonly defined as the use of five or more medications, is highly prevalent among elderly patients with heart failure. While guideline-directed therapy improves survival, excessive or inappropriate medication use may increase mortality, hospitalization, and treatment burden. Aim: This study aimed to evaluate the association between polypharmacy and clinical outcomes in elderly patients with heart failure, including mortality, hospitalization, and quality of life. Methods: We conducted a systematic literature search in PubMed, Cochrane, and Scopus to identify observational studies assessing the impact of polypharmacy (defined as ≥5 medications) on elderly patients (≥65 years) with heart failure. Search strategies combined keywords (e.g., "heart failure", "polypharmacy") and subject headings (e.g., MeSH). The initial search yielded a total of 1,082 records. Studies were excluded if they were narrative reviews, case reports, or did not report quantitative outcomes of interest, such as mortality or hospitalization rates. After removing duplicates, titles and abstracts were screened based on predefined inclusion criteria. Following a full-text review of potentially eligible articles, 38 studies were included in the final systematic review, representing a pooled population of >250,000 participants. Of these, 11 studies provided sufficient quantitative data as Hazard Ratios with 95% Confidence Intervals and were included in the final meta-analysis for mortality and hospitalization. Findings from the remaining studies were synthesized narratively. Two reviewers independently screened, extracted data, and assessed study quality. A random-effects model was used to pool hazard ratios (HRs) and 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I2 statistic. Subgroup analyses were performed by medication type (heart failure–specific vs. non-cardiovascular), setting (community vs. hospital), and frailty status. Results: Polypharmacy was present in >70% of elderly patients with heart failure, with hyper-polypharmacy affecting 20–30%. Our pooled analysis, visualized in the accompanying forest plot (Figure 1), demonstrated increased all-cause mortality with polypharmacy (HR 1.38, 95% CI 1.25–1.60) and greater risk with hyper-polypharmacy (HR 2.29, 95% CI 1.80–2.70). Hospitalization risk was also elevated (HR 1.22, 95% CI 1.05–1.41; P=0.009), particularly when non-cardiovascular medications predominated. In contrast, studies examining guideline-directed medical therapy (GDMT) showed that appropriate polypharmacy could mitigate risk and improve survival, especially in HFpEF and HFmrEF populations. Quality of life outcomes were inconsistent, with most studies reporting no significant association; modest improvements were observed when inappropriate medications were discontinued. Frailty amplified risks of mortality and functional decline. Conclusion: Polypharmacy in elderly heart failure patients is associated with higher mortality and hospitalization, particularly in the presence of frailty or inappropriate prescribing. However, polypharmacy driven by GDMT may confer survival benefits, underscoring the importance of medication appropriateness. Targeted deprescribing interventions and phenotype-specific management may reduce harm and improve outcomes in this vulnerable population.
Copyright (c) 2025 Minahil Akbar, Sandi Assaf https://creativecommons.org/licenses/by/4.0
Meta Analytic Review on The Effect of Repetitive Transcranial Magnetic Stimulation on Post-COVID 19 Memory Impairment and Related Cognitive Disorders
Background: After the emergence of SARS-CoV-2 (covid-19) there have been reported cases of cognitive impairment in patients after recovering. The symptoms may persist for months and significantly impair quality of life. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive procedure that has shown promise in improving cognitive function in existing psychiatric and neurologic conditions. It is hypothesised that by stimulating targeted regions of the brain, rTMS may improve memory by enhancing synaptic plasticity, modulating cortical excitability, and promoting neurogenesis. Due to its non-invasive nature and its potential for improving quality of life, rTMS could be a neofrontier in treating memory impairment following covid-19 but remains underexplored. Objective: To evaluate the effect of rTMS on memory outcomes in individuals with cognitive impairment after SARS-CoV-2 infection and related neurological conditions. Methods: Two meta analytic studies were identified by searching reputable electronic databases using predefined keywords: “rTMS”, “memory impairment”, “COVID-19”, “MCI”. All searches were conducted on September 10, 2025. The included meta analyses had performed a comprehensive search from eight databases (PubMed, Embase, Cochrane library, Web of Science, CNKI, Wanfang, Sinomed, and VIP). Inclusion criteria: (1) randomised controlled trials (RCTs), (2) studies using rTMS intervention, regardless of wave type (Theta, beta, etc), (3) studies which had standardised memory outcomes reported, (4) cases with memory/cognitive impairment after infection with COVID-19 or patients with mild cognitive impairment (MCI). A qualitative inclusion was made for a case report of rTMS in a post covid patient. The data extracted included sample size, stimulation parameters, memory outcome measures, standardized mean differences, and reported adverse effects. Data synthesis involved no new statistics and was purely descriptive based on the pooled effect sizes. Risk of bias assessment relied on the original meta analyses. Both applied Cochrane risk of bias assessment tools and reported low to moderate risk across studies. Heterogeneity was assessed using I² statistics and was low to moderate for memory outcomes. Results: Two meta analyses included a combined 23 randomised controlled trials on rTMS in mild cognitive impairment showed significant improvement in memory outcomes (Table 1). Zhang et al. reported a standardized mean difference (SMD) of 0.73 (95% CI: 0.48-0.97), while Hu et al. reported a SMD of 0.61 (95% CI: 0.41-0.82, I² = 22%). Subgroup analysis revealed stronger memory improvements with >10 sessions (SMD = 0.84) at 10 Hz stimulation (SMD = 0.86), with multisite targeting. Follow up data revealed sustained benefits (SMD = 0.93). Adverse effects were minimal and transient. A case report in a post-COVID patient showed improvement in memory after 10 sessions of bilateral theta burst rTMS, supporting possible translatability to post-COVID cognitive impairment. Conclusion: rTMS significantly improves memory in patients with MCI, particularly with optimized stimulation protocols. Although no randomised studies currently exist in post-COVID patients, one case report demonstrated similar benefits. Similarities in cognitive profiles, along with a promising case report marks rTMS as a potential treatment option for post-COVID memory impairment. However, further research is needed to directly evaluate its efficacy in this population.
Copyright (c) 2025 Hassan Khalid https://creativecommons.org/licenses/by/4.0
Ekterly (Sebetralstat): A First in Class Oral On Demand Treatment for Hereditary Angioedema
Background: Hereditary angioedema (HAE) is a rare, potentially life-threatening genetic disorder characterized by recurrent episodes of edema affecting the skin, gastrointestinal tract, and airway. With a prevalence of only about 0.0012% globally (range 0.0007–0.01%), its rarity contributes to frequent delays in diagnosis and treatment, increasing risk of severe complications. Until recently, on-demand therapies for HAE required intravenous or subcutaneous administration, limiting accessibility and adherence. Objective: This study evaluates the clinical significance, therapeutic efficacy, and potential impact of Sebetralstat (Ekterly), the first FDA-approved oral on-demand therapy for HAE. Methodology: A review of recent clinical trials was conducted, assessing efficacy and safety with key parameters including symptom relief time and bradykinin levels. Discussion: Sebetralstat is a selective plasma kallikrein inhibitor that blocks bradykinin production, the central mediator of swelling in HAE. By reducing bradykinin, it prevents excessive vascular leakage responsible for symptoms. Clinical trials demonstrated rapid relief, with a median improvement time of 1.6 hours and some patients responding within 10 minutes. In laryngeal attacks, pooled analysis showed symptom relief within a median of 1.07 hours and complete resolution within 24 hours in 64.3% of cases, especially critical outcome to prevent airway obstruction. The oral formulation provides a practical alternative to injectables, enabling timely, unobtrusive treatment and improved quality of life. Conclusion: Sebetralstat marks a breakthrough in HAE therapy, combining convenience, rapid action, and favorable safety. Its availability is expected to enhance compliance, empower patients, and redefine standards of care.
Copyright (c) 2025 Hitanshi Nareshkumar Panchal, Srijamya https://creativecommons.org/licenses/by/4.0
The Impact Of Nightshifts On Doctors’ Cognitive Performance At Kosti Teaching Hospital During War, Sudan, 2024
Background: Nightshifts are an integral part of healthcare delivery but are strongly associated with disrupted circadian rhythms, sleep deprivation, and cognitive decline. These challenges may be exacerbated in conflict-affected regions such as Sudan, where physicians face increased workload and stress. This study aimed to evaluate the impact of nightshifts on doctors’ cognitive performance at Kosti Teaching Hospital during the ongoing war in Sudan. Methods: A hospital-based cross-sectional analytic study was conducted at Kosti Teaching Hospital between September 2024 and January 2025. A total of 54 doctors from medicine, pediatrics, surgery, and obstetrics and gynecology departments were enrolled. Data were collected using a self-administered structured questionnaire incorporating the Fatigue Assessment Scale (FAS), Perceived Stress Scale (PSS), and a cognitive performance assessment tool. Analysis was performed using SPSS v22 . Results: Most participants were males (63%), single (91%), and house officers (63%), with the predominant age group being 25–29 years (69%). The majority reported no regular sleep schedule (70%) and attended fewer than two nightshifts per week (66%), sleeping less than 6 hours during shifts (96%). Overall, 59.3% of doctors demonstrated cognitive impairment. Moderate stress was reported by 77.8% and mild to moderate fatigue by 37%. No significant association was found between cognitive performance and number of nightshifts per week (p=0.106), stress level (p=0.381), or fatigue level (p=0.284). Most doctors coped with nightshifts by consuming caffeine (72.2%) and taking short breaks (57.4%), while structured sleep schedules were the most common long-term coping strategy (57.4%). Conclusion: The majority of doctors reported cognitive impairment, moderate stress, and fatigue during nightshifts, though no significant associations were observed between cognitive outcomes and workload, stress, or fatigue levels. Coping strategies such as structured sleep schedules and caffeine consumption were widely adopted. These findings highlight the urgent need for interventions, including optimized shift scheduling and supportive workplace policies, to safeguard physician well-being and patient safety in resource-limited, conflict-affected settings.
Copyright (c) 2025 Sarah Yousif, Tebyan Suliman, Reem Hatim Gaafar, Rayan Nasir Almogera, Shahd Babekir Ibrahim https://creativecommons.org/licenses/by/4.0
Psychiatric Comorbidities and Mortality After Heart Failure Hospitalization: Evidence of a Survival Paradox From a Nationwide Cohort
Introduction: Psychiatric comorbidities may influence survival outcomes among patients hospitalized for heart failure (HF), yet their individual effects on short- and long-term mortality remain underexplored. Conditions such as depression, bipolar disorder, PTSD, and schizophrenia often coexist with HF and may affect outcomes through mechanisms like poor self-care, reduced treatment adherence, and neurohormonal dysregulation. Psychiatric illness is also associated with increased healthcare utilization, delayed care-seeking, and fragmented follow-up, factors that may compound cardiovascular risk. These comorbidities are frequently underdiagnosed or undertreated in cardiovascular populations, making it critical to understand their prognostic significance. Despite the high prevalence of these comorbidities, limited research has evaluated their direct contribution to mortality following HF hospitalization at a national level. Clarifying how specific psychiatric diagnoses impact mortality may guide risk stratification and inform more tailored post-discharge interventions. Methods: We conducted a retrospective cohort study using the Nationwide Readmissions Database (NRD), spanning 2016 to 2022. Adult patients (≥18 years) hospitalized with a primary diagnosis of HF were included. Psychiatric comorbidities were identified via ICD-10 codes for depression, anxiety, bipolar disorder, schizophrenia/psychotic disorders, PTSD, and substance abuse disorder. Outcomes included 30-day and 1-year mortality, evaluated using multivariable logistic regression models adjusted for demographic, socioeconomic, and hospital-level characteristics. Among 31,886,859 weighted hospitalizations, several psychiatric comorbidities were significantly associated with lower mortality. Results: Compared to patients without these conditions, those with bipolar disorder had reduced odds of 30-day mortality (OR 0.70, 95% CI: 0.67–0.73, p<0.001) and 1-year mortality (OR 0.72, 95% CI: 0.69–0.74, p<0.001). Similar reductions were observed for schizophrenia/psychotic disorders (30-day OR 0.79; 1-year OR 0.83, both p<0.001), PTSD (30-day OR 0.71; 1-year OR 0.75, both p<0.001), and substance abuse disorder (30-day OR 0.81; 1-year OR 0.86, both p<0.001). Depression was also associated with decreased mortality (30-day OR 0.88; 1-year OR 0.88, both p<0.001). Anxiety showed no significant impact on mortality at either time point. Conclusion: In this large, nationally representative cohort of hospitalized heart failure patients, most psychiatric comorbidities, including bipolar disorder, schizophrenia/psychotic disorders, PTSD, depression, and substance use disorder, were independently associated with significantly lower 30-day and 1-year mortality. Only anxiety showed no significant association with mortality. These findings challenge conventional assumptions about the uniformly negative prognostic impact of psychiatric illness in cardiovascular populations. Instead, they suggest a complex interplay between mental health conditions, healthcare engagement, and survival outcomes, possibly reflecting enhanced monitoring, increased resource utilization, or competing risks. This paradoxical survival benefit underscores the importance of diagnosis-specific analysis in psychiatric-cardiovascular research and calls for further investigation into the mechanisms driving these associations. Tailoring post-discharge strategies to reflect the nuanced prognostic profiles of psychiatric subgroups may improve both clinical outcomes and healthcare delivery.
Copyright (c) 2025 Joseph Dantin, Kyle Thurman, Trisha Mukherjee, Dr. Paul Kang, Dr. Michael White https://creativecommons.org/licenses/by/4.0
Cardiovascular Readmissions After Heart Failure: Substance Use Disorder as a Potential Risk Factor Among Psychiatric Comorbidities
Background. Psychiatric comorbidities are known to adversely affect cardiovascular (CV) outcomes, but their specific influence on CV-related hospital readmissions remains unclear. While prior research has focused on all-cause 30-day readmissions, few studies have evaluated psychiatric conditions in relation to CV-specific readmissions over both short- and long-term periods. This study aims to assess how individual psychiatric diagnoses impact 30-day and 1-year CV-specific readmission risk in patients initially hospitalized for heart failure (HF). Methods. We conducted a retrospective cohort analysis using the Nationwide Readmissions Database (NRD) from 2016 to 2022. A total of 31,886,859 weighted hospitalizations were included. Adult patients (≥18 years) hospitalized for HF were stratified by psychiatric comorbidity, including depression, anxiety, bipolar disorder, post-traumatic stress disorder (PTSD), schizophrenia/psychotic disorders, and substance use disorder (SUD). The primary outcomes were CV-specific readmissions within 30-days and 1-year, identified using ICD-10 codes. Multivariable Cox regression models adjusted for age, sex, Charlson Comorbidity Index, income quartile, hospital characteristics, and discharge disposition were used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). Results. SUD was the only condition associated with a clinically significant increased risk of CV-specific readmission at both 30-days (HR 1.03, 95% CI 1.02-1.03, p < 0.001) and 1-year (HR 1.02, 95% CI 1.02-1.03, p < 0.001). In contrast, statistically significant but clinically modest reductions in CV-specific readmission at both were observed at both time points for depression (30-day HR 0.85, 95% CI 0.84-0.85, p < 0.001; 1-year HR 0.85, 95% CI 0.84-0.85, p < 0.001), bipolar disorder (30-day HR 0.82, 95% CI 0.81-0.84, p < 0.001; 1-year HR 0.81, 95% CI 0.80-0.82, p < 0.001), PTSD (30-day HR 0.84, 95% CI 0.82-0.86, p < 0.001; 1-year HR 0.84, 95% CI 0.83-0.86, p < 0.001), and schizophrenia/psychotic disorders (30-day HR 0.90, 95% CI 0.89-0.92, p < 0.001; 1-year HR 0.90, 95% CI 0.88-0.91, p < 0.001). Anxiety was associated with the smallest reduction in CV-specific readmission at 30-days (HR 0.94, 95% CI 0.90-0.98, p = 0.002) and 1-year (HR 0.96, 0.93-0.98, p = 0.001). Conclusion. SUD emerged as the only psychiatric comorbidity independently associated with a clinically significant increase in CV-specific readmissions at both 30-days and 1-year following HF hospitalization. In contrast, other psychiatric conditions, including depression, bipolar disorder, PTSD, schizophrenia/psychotic disorders, and anxiety, were associated with modest reductions in readmission risk. This counterintuitive pattern may reflect increased clinical monitoring and psychosocial support in patients with these established psychiatric diagnoses, which could help prevent CV decompensation. Additionally, these patients may be more frequently rehospitalized for non-CV reasons, leading to an underestimation of CV-specific readmissions in administrative data. Altogether, these findings highlight SUD as a uniquely high-risk diagnosis in the context of post-discharge CV outcomes and reinforce the critical need for structured discharge planning and timely follow-up that incorporates addiction treatment alongside CV care. Targeted interventions during and after HF hospitalization may help reduce preventable readmissions and improve long-term prognoses for this patient population.
Copyright (c) 2025 Trisha Mukherjee, Kyle E. Thurmann, MS, Joe G. Dantin, JD, MS, Paul T. Kang, PhD, Michael D. White, MD https://creativecommons.org/licenses/by/4.0
Tuberculous Aortitis Masquerading as Takayasu Arteritis: A Diagnostic Tightrope in a TB-Endemic Region
Background: Tuberculous aortitis is an exceptionally rare extrapulmonary manifestation of Mycobacterium tuberculosis, most often seen in TB-endemic areas. It typically presents with nonspecific symptoms and may closely mimic primary large-vessel vasculitis, particularly Takayasu arteritis. Differentiating between infectious and autoimmune causes of aortitis is critical, as the management pathways diverge significantly namely, anti-tubercular therapy (ATT) versus immunosuppression. This case illustrates the diagnostic complexity and clinical decision-making involved in distinguishing between the two in a high-risk patient. Case Presentation: A 50-year-old woman with a background of hypertension, type 2 diabetes mellitus, chronic atherosclerotic disease, and bilateral renal artery stenosis presented with a two-day history of vomiting and blurring of vision. She had no history of fever, claudication, stroke, postprandial pain, or chest discomfort. On examination, she had a striking discrepancy in blood pressure: 160/80 mmHg in the upper limbs and 80/50 mmHg in the lower limbs. Neurological and systemic examinations were otherwise unremarkable. Initial investigations revealed serum sodium of 119 mmol/L, creatinine of 1.5 mg/dL, and CRP of 21.6 mg/L. ANA was positive, while cANCA and pANCA were negative. CT brain showed chronic right parietal lacunar infarct. A CT aortogram revealed severe narrowing of the descending thoracic and abdominal aorta with >90% stenosis of the coeliac artery, moderate superior mesenteric artery stenosis, and one-third occlusion of the left posterior tibial artery. These findings raised strong suspicion for Takayasu arteritis. However, PET-CT demonstrated metabolically active supraclavicular lymphadenopathy, and Mantoux testing was strongly positive. ESR and CRP showed a rising trend. While a lymph node biopsy was planned, general surgery deemed it inaccessible for sampling at the time. The patient had no systemic features suggestive of autoimmune vasculitis but did meet multiple criteria for large-vessel involvement with TB-related inflammatory markers and imaging findings. Given the constellation of features and the TB-endemic context, a presumptive diagnosis of tuberculous aortitis was made. Conclusion: This case highlights the diagnostic challenge of differentiating tuberculous aortitis from Takayasu arteritis, particularly in regions where tuberculosis is endemic. Radiological findings alone may be insufficient, as both conditions can involve extensive aortic and branch vessel narrowing. In such cases, adjunctive investigations—such as Mantoux testing, PET-CT imaging, inflammatory markers, and careful exclusion of systemic autoimmune features—are critical in guiding diagnosis and therapy. Timely recognition of tuberculous aortitis is vital to prevent inappropriate immunosuppression and its complications. Empirical initiation of ATT in clinically suggestive cases, even in the absence of histopathological confirmation, may be justified in high-burden settings when biopsy is not feasible. Clinicians must maintain a high index of suspicion and adopt a multidisciplinary approach to navigate such diagnostic tightropes. Timely recognition of tuberculous aortitis is vital to prevent inappropriate immunosuppression and its complications. Empirical initiation of ATT in clinically suggestive cases, even in the absence of histopathological confirmation, may be justified in high-burden settings when biopsy is not feasible. Clinicians must maintain a high index of suspicion and adopt a multidisciplinary approach to navigate such diagnostic tightropes.
Copyright (c) 2025 Tooba Fatima Iram, Yusra Fatima Anam, Haroon Abdullah Shaheed https://creativecommons.org/licenses/by/4.0
Pregnancy Outcomes Following Elective Fetal Reduction from Dichorionic Twins to Singleton: Analysis of 30 Consecutive Cases Performed at 11-14 Weeks
Background: Requests for reduction from twins to singleton are being faced more frequently in the recent times. This study aims to assess the outcomes of fetal reduction from DCDA twins to singleton where both fetuses looked anatomically normal for gestation. Methods: This is a case series carried out in a single fetal medicine unit in Kolkata over a period of 36 months. Internal ethics committee approval was obtained for this retrospective review. Women carrying dichorionic diamniotic twins where there were no obvious medical indications were included in the study. The only reason for performing these procedures was maternal request. All cases were performed trans-abdominally at 11-14 weeks gestation by a single operator with considerable experience. The primary objective of this study was to assess the risk of procedure related pregnancy loss. The secondary objective was to assess the overall pregnancy outcome for these cases. Results: 31 cases were performed in this study period but one was lost to follow up. Hence 30 cases were analysed retrospectively. We did not have any pregnancy loss before 24 weeks in this series. Three underwent premature delivery before 34 weeks but all other pregnancies could be continued till term and delivered after 37 weeks with good perinatal outcome. Conclusion: Our study results, when compared with published literature appeared comparable in terms of the risk of miscarriage, gestational age at delivery and birth weight. Fetal reduction remains an effective option in cases to DCDA twins to those who prefer to give birth to one child only.
Copyright (c) 2025 Brojesh Rishi Mukherjee https://creativecommons.org/licenses/by/4.0
Successful Microsurgical Replantation After Multiple Traumatic Amputations Caused by an Electric Grinder: A Case Report
Traumatic digital amputations are uncommon but carry significant functional, aesthetic, and occupational consequences, particularly in young adults. Microsurgical replantation has been shown to restore hand function and improve quality of life; however, success depends on factors such as ischemia time, injury mechanism, tissue viability, and surgical technique. Machinery-related injuries are especially challenging due to extensive crush and avulsion damage, often limiting replantation possibilities. Recent evidence suggests that even in the absence of suitable veins for anastomosis, venous congestion techniques can sustain digital viability, with reported survival rates up to 78.5%. We report the case of a 24-year-old woman who suffered total traumatic amputation of the second (D2) and third (D3) digits, and partial amputation of the fourth (D4) digit of her right hand after an accident with an electric mill. She arrived at the emergency unit 1.5 hours post-injury. D3 was deemed non-replantable and underwent stump remodeling. Successful microvascular replantation of D2 was achieved, including bone fixation with Kirschner wires, terminal-to-terminal arterial anastomosis, nerve repair, and tenorrhaphy. Postoperative management included anticoagulation and antiplatelet therapy. At six weeks, fixation material was removed, and the patient continues rehabilitation with favorable outcomes and no major complications. This case demonstrates that meticulous microvascular reconstruction of digits, integrating bone, vascular, nerve, and tendon repair, can restore function and aesthetics in complex traumatic amputations. Early intervention, careful patient selection, technical precision, and comprehensive rehabilitative care are critical for success. Multidisciplinary management is essential, providing clinical evidence to guide surgical decision-making in similar high-complexity cases.
Copyright (c) 2025 Martin Rodriguez Alvarado, Mariana Fraga Duarte, Sofia Rubiralta Adame, Alba Mayra Padilla, Celina Veronica Kishi Sutto, Jorge Luis Perez Ruiz https://creativecommons.org/licenses/by/4.0
Challenging the Paradigm: Emphysematous Pyelonephritis in a Culture-Negative, Non-Diabetic Patient
Background: Emphysematous pyelonephritis (EPN) is a necrotizing infection characterized by gas within the renal parenchyma and perirenal tissues. It is highly fatal, particularly in patients with diabetes mellitus or ureteral obstruction and has predilection for the left kidney. The Huang and Tseng classification is most typically applied to stratify severity. This case is remarkable because of the extremely rare reports of EPN in non-diabetic patients with negative urine cultures, occurring in up to 30% of reported cases. The Case: A 41-year-old female with history of bilateral nephrolithiasis, presented with severe left flank pain, radiating to the lumbar and inguinal regions, in association with dysuria, oliguria, and vesical tenesmus. Physical examination revealed significant tenderness of the left flank. Laboratory findings indicated profound leukocytosis, and urinalysis showed signs of infection but no urine culture growth. Non-contrast uro-Computed Tomography demonstrated bilateral nephrolithiasis, left-sided hydronephrosis, emphysematous changes in the renal parenchyma, and inflammatory involvement of Gerota’s, Lateroconal, and Zuckerkandl’s fascia. Based on radiological criteria, the case was classified as Huang and Tseng grade IIIB. The patient was managed with broad-spectrum intravenous antibiotics and supportive measures, with subsequent clinical improvement and no symptoms recurrence at 6 months-follow-up. Conclusion: Emphysematous pyelonephritis is a life-threatening infection most commonly associated with diabetes, yet it may also occur in non-diabetic patients with obstructive uropathy. Negative urine cultures do not exclude the diagnosis. Radiologic findings play a fundamental role in classification and management decisions. Early diagnosis and prompt treatment are critical for a favorable outcome.
Early Recognition of Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss Syndrome): a Case Report of Successful Diagnosis and Treatment
Background: EGPA is a rare, multi-system, autoimmune disease characterized by vasculitis along with asthma and elevated eosinophils in the blood and tissues, affecting 1 to 3 in 1 million people annually, primarily middle-aged population [1]. It is well known that a large proportion of EGPA patients have had asthma and/or have had or currently have nasal polyps [2]. EGPA is associated with increased mortality compared to the general population. Due to variable clinical presentations, diagnosis is often delayed, leading to various physical deficits and life-threatening conditions. Therefore, it is important to detect and treat the syndrome in a timely manner. The Case: We present a case of successful diagnosis and treatment Churg-Strauss syndrome, emphasizing the importance of early recognition and intervention. A 56-year-old man with bronchial asthma and a history of sinus surgery presented with rhinitis, cough, low-grade fever, wrist pain and digital paresthesia. Initial imaging revealed sinusitis and right lung infiltrates and treatment for presumed pneumonia was started. During hospitalisation he developed anaemia, respiratory failure, haemoptysis, persistent inflammation and urinary problems. Further evaluation revealed a haemorrhagic rash, eosinophilic leukocytosis, haematuria, proteinuria and positive p-ANCA antibodies. Renal biopsy confirmed focal necrotizing and crescentic glomerulonephritis with eosinophilic infiltration consistent with EGPA. The patient's clinical condition improved rapidly with the introduction of high-dose methylprednisolone pulse therapy. Conclusion: This case demonstrates the complexity of diagnosing EGPA, which can be diverse and similar to more common diseases such as asthma, sinusitis and pneumonia. A multidisciplinary approach, including histological confirmation, was necessary to establish an accurate diagnosis. Early recognition and prompt initiation of corticosteroid treatment led to favourable short-term outcomes. Given the risk of relapse and chronic organ damage, long-term follow-up and consideration of biological therapy are warranted to improve disease control and prognosis.
Copyright (c) 2025 Viktorija Domrina, Beatričė Linkauskaitė, Liucija Mazaliauskaitė https://creativecommons.org/licenses/by/4.0
Bilateral Fasciocutaneous V-Y Advancement Flaps for Reconstruction of a Stage IV Sacral Pressure Injury in a Burn Patient: A Case Report and Literature Review
Background: Pressure injuries (PIs) in the sacral region are a major reconstructive challenge, particularly in critically ill patients or those with a history of extensive burns. Healing capacity is often impaired, and the availability of healthy tissue is limited. Surgical coverage using fasciocutaneous flaps, such as the V-Y advancement design, provides durable reconstruction and effective redistribution of tension. This case illustrates the effectiveness of bilateral V-Y fasciocutaneous flaps in managing a large sacral PI in a burn patient. The Case A 47-year-old male with a history of extensive burns developed a stage IV sacral pressure injury during a prolonged stay in the intensive care unit. Clinical evaluation confirmed deep tissue involvement. After nutritional optimization, infection control, and wound bed preparation, surgical coverage was planned. Reconstruction was achieved with bilateral V-Y fasciocutaneous advancement flaps, which allowed tension-free closure and adequate vascularized coverage. The postoperative course was uneventful. At twelve-month follow-up, the wound remained fully closed, with no recurrence, dehiscence, or functional compromise. Recent evidence suggests fasciocutaneous flaps may provide superior resistance to pressure compared with muscle flaps, while minimizing donor-site morbidity. Bilateral V-Y advancement flaps allow tension-free closure and remain reliable even in patients with challenging comorbidities, as illustrated in this case. Conclusion: Bilateral V-Y fasciocutaneous flaps represent a safe, reliable, and effective strategy for reconstructing extensive sacral pressure injuries in patients with complex backgrounds such as burns. Integration of surgical treatment into a multidisciplinary and preventive care plan is critical to optimize outcomes and reduce recurrence risk.
Copyright (c) 2025 Sebastian Colina, Wilson Sebastian Peñafiel-Pallares, Javier Campoverde-Sanchez, Jonathan Velasco-Bustamante https://creativecommons.org/licenses/by/4.0
Reversible Hypocalcaemic Dilated Cardiomyopathy causing Decompensated Heart Failure- A Case Report
Background: Hypocalcaemia induced heart failure, commonly seen in children due to Vitamin D deficiency, is a rare clinical syndrome in adults. These patients are refractory to routine treatment, but the timely diagnosis of the underlying etiology and correction of calcium promptly restores myocardial function. The Case A 55-year-old non-alcoholic and non-smoker female, previously diagnosed as a case of dilated cardiomyopathy, presented with complaints of progressive dyspnoea on exertion from NYHA-II to NYHA-IV over a span of 1 week. At admission the patient was conscious, afebrile; having respiratory distress, peripheral oxygen saturation of 93% at room air, blood pressure of 92/56 mmHg equal in both arms, regular pulse rate of 100 beats per minute, audible left ventricular S3, mild peripheral edema, and bilateral basal crepitations. She was diagnosed to have decompensated heart failure. Chest X-Ray revealed cardiomegaly. Electrocardiogram showed sinus tachycardia (90 beats/minute), QRS axis of -20o, prolonged QTc of 574 milliseconds. Laboratory analysis at admission revealed minimally deranged liver and renal functions, and highly elevated BNP. Relevant biochemical parameters are shown in the given table. Transthoracic echocardiogram revealed dilated left chambers (left ventricle end-diastolic diameter: 61 mm, left ventricle end-systolic diameter: 52 mm), left ventricle (LV) severe global systolic dysfunction (LVEF=22%) due to diffuse hypokinesia, restrictive type of diastolic dysfunction with elevated filling pressure indexes (E/E’=19), mild functional mitral regurgitation, mild tricuspid regurgitation, moderate pulmonary hypertension (systolic pulmonary artery pressure of 50 mmHg). Normal coronary angiography ruled out underlying ischemia. Patient was initially started on furosemide as decongestive therapy. Subsequent investigations conducted due to prolonged QTc revealed severe hypocalcaemia (corrected calcium of 4.38 mg/dL), inappropriately normal PTH, and presence of basal ganglia calcification on CT head was highly suggestive of primary hypoparathyroidism. Parenteral treatment with Gluconic Calcium was started: 950 mg of calcium (1 ampoule) at 6 hours, followed by oral treatment- high dose of calcium (1g TDS) and alfacalcidol (0.25µg TDS) along with management of heart failure. The patient had progressive clinical improvement and was discharged in NYHA class II on Day 10. Patient’s serum calcium progressively improved during course of stay and was within normal limits at the time of discharge. Treatment at discharge included loop diuretic, ACE inhibitor, Calcium, alfacalcidol. Patient was followed up regularly; and NYHA class, renal functions, serum calcium level, and ECG were assessed. At follow up after 3 months, patients had significant improvement in LV function and normalised LV function after 6 months. Conclusion: Considering the rarity of hypocalcemia induced dilated cardiomyopathy in adults, this etiology must be suspected in a cardiac patient with ECG changes suggestive of hypocalcaemia (as in our case). Early calcium supplementation, usually along with vitamin D, reduces and even reverses ventricular hypertrophy and dilatation as well as conduction abnormalities, as it was in our case.
Copyright (c) 2025 Shlok Bhardwaj, Prof. Dr. Bhupinder Singh https://creativecommons.org/licenses/by/4.0
When Antibiotics Leave a Mark: Understanding Minocycline-Related Pigmentation
Background: Minocycline, a broad-spectrum tetracycline antibiotic, is frequently prescribed for chronic dermatologic or infectious conditions. While generally well-tolerated, long-term or high-dose use can lead to a rare side effect: minocycline-induced hyperpigmentation (MIH). MIH is categorized into four types based on clinical presentation and histopathology, with Type I causing blue-black macules affecting sites of inflammation, Type II causing blue-gray pigmentation on areas of normal skin, Type III involving diffuse muddy-brown discoloration in sun-exposed areas, and Type IV affecting scars on the back. With the growing use of minocycline for resistant infections, recognition of this side effect is important. The Case: A 68-year-old male with a medical history of hypertension, congestive heart failure, type II diabetes, dyslipidemia, colon cancer, and prior aortic valve replacement was admitted to the hospital following a syncopal event. He was found to be febrile (104°F), delirious, and diagnosed with sepsis caused by Acinetobacter baumannii with no clear infection source. He was prescribed oral minocycline 100 mg twice daily for long-term suppression for approximately 5 years. Approximately 12 months after initiation, the patient developed bilateral hyperpigmentation on the dorsal surfaces of his feet, which gradually spread up to his bilateral lower extremities, forearms, cheeks, and sclera. The pigmentation persists and continues to expand at a slow rate. The clinical features suggest Type III MIH. Conclusion: The case illustrates a severe and unusually widespread manifestation of Type III MIH resulting from long-term minocycline use. While some pigmentation cases resolve after drug discontinuation, Type III often persists indefinitely and with increasing total cumulative dose. This disfiguring adverse effect highlights the importance of ongoing skin assessments in patients on long-term, high-dose minocycline regimens. Early recognition and timely intervention may help prevent irreversible cosmetic changes and improve long-term patient outcomes.
Copyright (c) 2025 Roma Desai, Jacqueline Leon, Alicia Fields , Jarrod Plank https://creativecommons.org/licenses/by/4.0
Beyond Genetics: Clinico-Pathological Recognition of Ullrich Muscular Dystrophy in a Resource-Limited Setting
Background: Ullrich congenital muscular dystrophy (UCMD) is a rare collagen VI–related myopathy caused by mutations in COL6A1, COL6A2, or COL6A3 genes. Although traditionally considered an autosomal recessive disorder, recent reports have identified autosomal dominant variants that cause the UCMD phenotype. Clinically, it is characterized by early‐onset muscle weakness, proximal joint contractures, and distal joint hyperlaxity. This condition frequently progresses to restrictive respiratory involvement, while typically sparing cognitive, sensory, and autonomic functions. Given this predictable trajectory, early integration of palliative care is increasingly emphasised to optimize quality of life and reduce crisis-driven interventions. UCMD is extremely rare, with an estimated prevalence of fewer than 1 in 1,000,000 births worldwide, though the exact frequency remains unknown. A definitive diagnosis requires genetic confirmation and immunohistochemistry, but such resources are often limited in low- and middle-income countries. Case summary: A 15-year-old male, born of a third-degree consanguineous marriage, presented to the internal medicine department with recurrent lower respiratory tract infections and respiratory distress. He was first evaluated at age 4 for progressive motor regression, difficulty ambulating, and multiple joint contractures. Over the next decade, he had progressive motor decline and restrictive pulmonary disease, while cognitive, sensory, autonomic, and cardiac functions remained preserved. Physical examination revealed proximal muscle weakness, contractures of elbows and ankles, lumbar lordosis, café-au-lait spots, and a waddling gait. Muscle biopsy demonstrated features consistent with a dystrophic process and mild non-specific myopathic changes. A clinical diagnosis of UCMD was established based on characteristic clinical findings and histopathological correlation due to the unavailability of genetic testing and collagen VI immunohistochemistry. The internal medicine team integrated palliative care principles in his management through holistic assessment, symptom management, caregiver support, advanced care planning, and multidisciplinary coordination. This case illustrates UCMD’s diagnostic challenges, natural history marked by progressive musculoskeletal and respiratory decline, and the imperative for early integration of palliative care principles in management. Conclusion: UCMD is a rare genetic disorder that is often underdiagnosed due to limited awareness and diagnostic challenges, particularly in resource-limited settings. Early diagnosis is essential to initiate supportive care, which can significantly improve quality of life. This case highlights the diagnostic value of comprehensive clinical evaluation and muscle biopsy in identifying UCMD. Increased awareness and expanded diagnostic testing programs are key to uncovering additional cases. Wider access to genetic testing is critical for diagnostic confirmation. Continued research into the molecular and genetic basis of UCMD will help to improve diagnosis and develop novel therapies. Owing to its rare occurrence, comprehensive epidemiological studies are needed to get more knowledge about its global incidence and natural history. Early palliative care integration is recommended to optimize patient and family well-being.
Copyright (c) 2025 PARVATHI SUDHA HARI, Dr Ranjit Sanu Watson, Dr Sudha P https://creativecommons.org/licenses/by/4.0
Circulating Tumor DNA as a Tool of Surveillance and Early Indicator of Relapse in Sarcoma Patients
Background: The use of circulating tumor DNA (ctDNA) has been increasingly explored to monitor treatment response and recurrence surveillance in sarcoma patients. Given the minimally invasive method of measurement via blood samples, and its accuracy and early prediction compared to traditional imaging studies, this method holds promise for implementation as part of patient monitoring following primary treatment. We report our experience in a retrospective series of sarcoma patients where ctDNA was measured in the context of clinical care. Methods: Retrospective review of five sarcoma patients who were monitored with a tumor-informed ctDNA assay and conventional imaging studies after completing primary treatment was completed. Results: Patient A: A 36-year-old female was diagnosed with left breast angiosarcoma with liver metastasis. Patient was on pazopanib after initial successful treatment with surgery and chemotherapy. Patient was followed with ctDNA, and 37 days later, ctDNA measurements yielded a positive result (1.25 MTM/mL). Abdomen MRI two months later revealed liver metastasis. Patient B: A 43-year-old female was diagnosed with metastatic undifferentiated pleomorphic sarcoma. Patient was disease-free for one year after lung metastasectomy but then became positive on ctDNA surveillance (1.31 MTM/mL plasma). Patient had CT imaging two weeks later which showed no disease recurrence. Positive ctDNA levels with negative CT scans led to an additional PET study, confirming recurrence and enabling earlier redirection. Patient C: A 49-year-old female in remission after treatment for left breast angiosarcoma was followed with ctDNA assays, which yielded a positive result (1.69 MTM/mL). Imaging studies were normal. Subsequent ctDNA showed further ctDNA increase (8.9 MTM/mL). CtDNA increase and negative CT scans led us to order a PET scan, revealing new lesions in the sternum, right sacrum/ilium, and left femur, resulting in early detection of metastatic disease. Patient D: A 34-year-old male was diagnosed with dedifferentiated chondrosarcoma of the right fibula. The patient completed treatment with surgery and chemotherapy, and ctDNA measurements were negative. Subsequently, a right knee MRI revealed a lesion in the resection bed; core biopsy revealed dedifferentiated chondrosarcoma. Subsequently, ctDNA assay was performed and found to be positive, and radiation was implemented. Follow-up ctDNA subsequently became negative, confirming treatment response. Patient E: An 81-year-old male was diagnosed with pleomorphic sarcoma of the chest wall and treated with chemotherapy and resection. Patient developed a recurrence five years later and underwent repeat resection. Repeat recurrence one year later coincided with a positive ctDNA result. Patient received systemic chemotherapy with which ctDNA became negative, confirming treatment response. Conclusion: CtDNA testing demonstrates promising use compared to traditional imaging studies, appearing to indicate early evidence of disease recurrence/progression. In three of five patients, positive ctDNA results revealed signs of recurrence before imaging studies. Three patient’s ctDNA levels declined with treatment, correlating ctDNA as a precise indicator of treatment response. Early recurrence detection made possible through ctDNA assay may ultimately improve patient outcomes.
Copyright (c) 2025 Esha Sankhala, Earl Brien, Jaya Gill, Leo Mascarenhas https://creativecommons.org/licenses/by/4.0
From Thirst to Hormonal Collapse: A Case of Pituitary Stalk Enlargement Presenting with Central Diabetes Insipidus and Panhypopituitarism
Background: Pathologies involving the pituitary stalk (PS) are typically identified by the presence of central diabetes insipidus. The prevalence of central diabetes insipidus (CDI) is less than 1 per 25,000 population. Up to 25% of individuals affected by CDI have cranial neoplasms or have undergone post-pituitary surgery, highlighting its association with these conditions. However, CDI rarely manifests because of pituitary stalk enlargement. We share the case of a 51-year-old female patient with pituitary stalk enlargement presenting as CDI with panhypopituitarism. The Case: A 51-year-old female with a history of cervical cancer with lung metastasis, chronic myeloid leukemia (CML) and type 2 diabetes mellitus presented with septic shock from Clostridium difficle colitis. During hospitalization, she developed symptoms of polyuria, polydipsia. On examination her urine appeared clear in color and her output was 4.2 l/day. Laboratory tests showed elevated serum osmolality (325 mosm/kg) and low urine osmolality (82 mosm/kg), with high serum sodium (156 mEq/L) and urine specific gravity at 1.003.MRI findings revealed pituitary stalk enlargement (5 mm) with diffuse enhancement of the pituitary gland and lack of T1 hyperintensity in the posterior pituitary, suggesting a pituitary pathology. Hypernatremia was managed with intravenous Dextrose 5% in water fluid. Treatment with subcutaneous desmopressin (2 mcg), resulted in significant improvement in urine output (1.2 l/day) serum osmolality (287 mosm/kg) , urine osmolality (420 mosm/kg) and urine osmolality (1.013). This confirmed the diagnosis of Secondary CDI. Concomitantly, the finding of panhypopituitarism was made, necessitating hormone replacement therapy to address deficiencies in TSH, LH, FSH, and ACTH. However, the decision to transfer the patient to hospice care was made considering her overall prognosis and quality of life given her advanced malignancies and poor hospital course. Conclusion: In this case, clinical, hormonal, and radiologic features of pituitary stalk enlargement presenting as CDI with panhypopituitarism are reported. It is a rare condition with vast possible underlying pathologies. However, diagnosing the cause of an enlarged pituitary stalk can be challenging, particularly given the difficulty, risk, and limited utility associated with obtaining a stalk biopsy. stalk. In this patient, the history of multiple malignancies raises the possibility of metastatic involvement of the pituitary. With the existing lack of literature and evidence-based guidelines on both the management and follow-up of this uncommon condition, both repeated imaging and hormonal evaluation are often necessary. In many cases, the underlying pathology will remain unknown.
Copyright (c) 2025 Tyler Ohler, Jacqueline, Kusuma Ravulapali, Rakesh Inturi https://creativecommons.org/licenses/by/4.0
Kratom Khaos: Tracing the Medical and Societal Toll of Kratom Use in Kentucky
Background: Kratom, derived from a tree species native to Southeast Asia and used in traditional medicine, is gaining popularity within the United States. While at low doses it is intended for stimulant use, higher doses of kratom can achieve analgesic effects similar to opiates. It’s use and misuse continues to be an area of interest given its unregulated status and propensity for addiction and abuse. Here we present four cases of kratom abuse observed in the inpatient and outpatient settings in southcentral Kentucky. The Case: First, 20-year-old female with medical history of anxiety and major depressive disorder presented to the emergency department due to symptoms of restlessness, body aches, chills, nausea, palpitations and loose stools. Patient revealed she has been taking 7-8 kratom tablets daily and had attempted immediate cessation but relapsed due to her symptoms. In clinic follow up, she was started on Atarax and methyl salicylate patches for symptom control and is currently in process of tapering off Kratom. Next, 49-year-old male with history of hypertension, chronic kidney disease, hyperlipidemia, and chronic pain presented to clinic with recurrent hypertensive episodes. He disclosed chronic use of kratom following MVC 5 years prior, currently taking 10 g every 4-5 hours. With a desire to cut back, the patient and his physician through shared-decision making created a tapering plan. With a slow taper, he has not reported any withdrawal symptoms. As his kratom use trends down, he will be referred to pain management specialist for chronic pain. Additionally, 18-year-old male with no significant medical history was brought to the ED being found unresponsive and foaming at the mouth. He was tachypneic, tachycardic, and hypotensive with a mildly elevated troponin. After receiving Narcan and IV fluids, the patient became responsive. Patient disclosed he was taking two 50 mg packages of kratom alongside marijuana and alcohol for recreation. After returning to baseline, the patient was discharged with close outpatient follow up. Lastly, 38-year-old female with medical history of anxiety/depression, seizures, and thyroidectomy complicated by vocal cord dysfunction presented to the ED after being found minimally responsive by family. Family explained the patient took up to 60 kratom tablets daily and she was found to have urine mitragynine level > 2500. Patient initially displayed nonsensical speech, paranoia, and hallucinations, but progressed to hypersomnolence with subsequent seizure and catatonia necessitating ICU admission. Ultimately transferred to tertiary center for benzodiazepine challenge and possible ECT. Conclusion: Presently, the United States does not regulate the manufacturing or distribution of kratom. In fact, very little is known about the long-term effects safety profile. Due to the demonstrated potential for abuse and harm, six states have made the drug illegal. From our patient interactions, the common theme is one of surreptitious addiction, monetary strain, and little understanding of the risks inherent to what was marketed as a natural supplement. Further research is warranted appropriately counsel our patients to the potential dangers recreational kratom use poses and improve the understanding the medical and socioeconomic impact of its wide availability.
Copyright (c) 2025 Jacqueline Leon, Tyler Ohler, Joseph Beckman, Mallory Vaughn https://creativecommons.org/licenses/by/4.0
Subacute Sclerosing Panencephalitis Presenting as a Stroke Mimic: A Case Report
Background: Subacute sclerosing panencephalitis (SSPE) is a rare, progressive neurodegenerative disorder caused by persistent measles virus infection in the central nervous system. In SSPE, mutant forms of measles virus persist within neurons and glial cells, evading immune clearance. This results in chronic inflammation and progressive neuronal degeneration. The condition typically presents 6–8 years after the initial measles infection with cognitive decline, behavioral changes, and myoclonus, and later progresses to motor decline, seizures, and a vegetative state. The estimated incidence of SSPE is 4–11 cases per 100,000 measles infections, though higher rates have been reported in lower- and middle-income regions, particularly when measles occurs at a young age. Although the global incidence has decreased with vaccination, SSPE continues to occur in areas with suboptimal measles immunization. We present a case of SSPE in an unvaccinated young adult, initially suspected to have ischemic stroke. The Case: A 22-year-old male, unvaccinated against measles, presented with acute neurological deficits, characterized by sudden-onset Right-sided Hemiplegia. Initial MRI showed acute cortical infarcts in the left fronto-parietal region. He received stroke-directed therapy, but there was no neurological improvement. Over the following days, the patient developed progressive behavioral disturbances, irritability, and memory impairment, followed by myoclonic jerks. A repeat MRI one month later revealed diffuse T2/FLAIR hyperintensities involving the bilateral posterior parietal lobes, left frontal and temporal lobes, and left centrum semiovale, extending beyond the initial infarct-like lesions. These findings were more suggestive of an evolving encephalitic process rather than a vascular event. Electroencephalography (EEG) demonstrated periodic epileptiform discharges (Figure 1). Cerebrospinal fluid (CSF) analysis showed markedly elevated measles-specific IgG antibodies (29.51 NTU; positive >11.0) with negative IgM, consistent with measles-related encephalitis. The diagnosis of SSPE was established in accordance with Dyken’s criteria, fulfilling two major (clinical progression and elevated CSF anti-measles antibody titres) and one minor (EEG showing periodic epileptiform discharges) criterion. The patient was given supportive treatment along with Isoprinosine, but despite these efforts, his condition continued to deteriorate, and he eventually succumbed. Conclusion: This case highlights the rare presentation of SSPE with acute neurological deficits initially suspected as stroke in a young, unvaccinated male. The progression from an apparent vascular event to features of encephalitis shows the diagnostic complexity of SSPE and the need for clinicians to maintain a broad differential diagnosis in young patients with evolving neurological symptoms. Despite supportive measures and trial therapies, the prognosis remains poor, and strengthening measles vaccination coverage remains the only effective strategy to prevent this devastating disease.
Copyright (c) 2025 Nandita Jali, Dr. Avinash Alashetty https://creativecommons.org/licenses/by/4.0
From Anatomy to Intervention: Coil Embolization of a Post-Cholecystectomy Hepatic Artery Pseudo aneurysm: A Case Report and Anatomical Insights for Medical Student
Background: Post-cholecystectomy vascular complications are rare, but serious. The surgical anatomy of the hepatic arteries is notoriously variable and increases the potential risk of injury during hepatobiliary surgery. Normally the hepatic artery proper bifurcates into right and left hepatic arteries. But, in one third of cases the aberrant right hepatic aretery (aRHA) may originate from the superior mesenteric, gastroduodenal, right gastric artery or the coeliac trunk. Trauma from surgical clips or electrocautry can damage the aRHA during dissection at the Calot's triangle, with subsequent formation of pseudoaneurysm. This presents late after surgery, mostly as GI bleed, right upper quadrant pain and jaundice—the Quincke's triad. This case report presents pseudoaneurysm formation after injury to aRHA during cholecystectomy which was subsequently managed with coil embolization. The Case: A 65-years-old gentleman presented with right hypochondrial pain of 5-months duration which was confirmed to be due to gallstones on ultrasonography. He was admitted for cholecystectomy. Intraoperatively, during laparoscopiccholecystectomy Calot's triangle was identified and cystic artery and duct were clipped under vision and cut. While removing the gallbladder massive bleeding was observed for which the procedure had to be converted to open cholecystectomy. Upon inspection an aberrant right hepatic artery was found which was ligated, while 02 pints of blood were transfused. After hemostatic control, bile leak was observed, for which T-tube was placed in the common bile duct. Postoperatively, there was a gradual decrease of his t-tube output. On the 10th post-operative day, patient became apprehensive and there was massive bleeding from T-tube site and in the sub hepatic drain. He developed shock, for which he was resuscitated. Over next week bleeding progressively decreased. Meanwhile, ultrasound showed no intra-abdominal collection but a hypo-echoic area at the porta hepatis. CT angiogram showed a pseudo-aneurysm of RHA and it was aberrantly arising directly from the celiac trunk. The case was discussed in multi-disciplinary meeting, and it was decided that patient needed coil embolization of the pseudo-aneurysm. Procedure was performed by interventional radiologist through right femoral access with 4 Fr C2 catheter. Wire was advanced into the distal right hepatic artery and embolization done with a long 6 mm coils. Coiling was done distal and proximal to the neck of the pseudo-aneurysm. No complications were observed. Post embolization patient remained stable with no bleeding episode. Hemoglobin and liver functions showed improving trend after the intervention. T-tube was removed after an unremarkable cholangiogram. Patient was discharged and follow-up after 2 and 4 weeks showed clinical improvement and no further episode of bleeding. Post-embolization angiogram at 2-week follow-up showed no filling of the pseudo-aneurysm with filling of the distal right hepatic artery branches via collaterals. Conclusion: This case underscores the importance of knowledge of hepatobiliary vascular anatomy in clinical practice, which enables a surgeon to anticipate challenges and tailor operative strategies accordingly. When an unexplained hemorrhage occurs in the post-cholecystectomy period, CT angiography should be used promptly to detect the causeincluding pseudo-aneurysm of aRHA and endovascular coil embolization is an effective minimally invasive intervention with good results.
Copyright (c) 2025 Shahan Ahmed, Faizan Ahmed, Ehsan Masud Kiani, Mahnoor Ahmed, Anis Ahmed, Syeda Qumreen Ahmad, Fatima Nazir, Kamil Ahmad Kamil https://creativecommons.org/licenses/by/4.0
Genetically Confirmed Schwartz–Jampel Syndrome: An Ultra-Rare Case of Congenital Myotonia with Osteochondrodysplasia from India
Background: Schwartz–Jampel syndrome is a rare autosomal recessive disorder caused by mutations in the HSPG2 gene, leading to perlecan deficiency. Perlecan is a heparan sulfate proteoglycan critical for cartilage integrity, basement membrane stability, and neuromuscular transmission. The disorder manifests with skeletal dysplasia and persistent myotonia, while cognition and lifespan are usually preserved. Only about 150 cases have been reported worldwide. We report a four year old child with severe osteochondrodysplasia and generalized myotonia, highlighting the therapeutic benefit of botulinum toxin A in managing both blepharospasm and perioral myotonia. The Case: A male neonate, born full term to consanguineous parents, was referred on day one of life with suspected skeletal dysplasia. Birth weight was 3.0 kg (−0 to +1 SD), with macrocephaly (>+2 SD) and short length (<−3 SD). Dysmorphic features included a narrow thorax, bent femora and tibiae, retrognathia, long philtrum, and ichthyosis. Infantogram revealed rhizomesomelia with irregular metaphyses of long bones. At four years, he presented with gross motor delay due to sustained skeletal muscle contractions, failure to thrive, and gait difficulty. Anthropometry remained <−3 SD for height, weight, and head circumference. Examination showed generalized myotonia of facial and skeletal muscles, pursed lips, micrognathia, thoracic kyphosis, hip abduction deformities, and hypertrophied muscles. Neurological assessment revealed hypertonia with areflexia, while speech and cognition were preserved. The differential diagnosis includes muscular dystrophies, skeletal dysplasias, myotonic disorders, congenital myopathies, and cramp–stiffness syndromes such as stiff person syndrome and Isaac’s syndrome. However, the coexistence of osteochondrodysplasia with persistent myotonia, supported by whole exome sequencing which revealed a homozygous likely pathogenic variant in the HSPG2 gene (c.5014+2T>C), confirmed the diagnosis. Parental carrier testing showed that both parents were heterozygous carriers of the mutation. Management included carbamazepine and regular physiotherapy, which provided partial benefit. To address disabling blepharospasm and perioral myotonia that impaired feeding, botulinum toxin A injections were administered to the orbicularis oculi and orbicularis oris. This improved both vision and feeding ability, demonstrating an effective extension of botulinum toxin use in this condition. Parents were counseled regarding malignant hyperthermia risk with anesthesia and advised genetic counseling for future pregnancies. Conclusion: Schwartz–Jampel syndrome should be suspected when skeletal dysplasia coexists with generalized myotonia, particularly in children of consanguineous unions. Supportive management includes physiotherapy and anticonvulsants, and botulinum toxin A, though primarily used for blepharospasm, can also enhance feeding through perioral muscle relaxation. Prognosis is generally favorable, as symptoms stabilize after adolescence and cognition remains intact. However, morbidity arises from progressive contractures and skeletal dysplasia, speech and feeding difficulties from facial and oropharyngeal myotonia, restrictive lung disease due to a narrow thorax, and the psychosocial burden of visible deformities with reduced mobility. Early recognition, multidisciplinary care, and family counseling, including genetic counseling for future pregnancies, are essential to optimize outcomes in this rare disorder.
Copyright (c) 2025 Nandita Vivekanand Jali, Suvarna Magar, Tanya Trikha, Varsha Vaidya, Viranchi Vaidya https://creativecommons.org/licenses/by/4.0
Critical Role of Multiplex PCR in Diagnosing Legionella–SARS-CoV-2 Co-infection in a Severely Immunosuppressed Pregnant Patient: A Case Report
Background: The pregnancy period is characterized by significant immunological shifts, creating a window of vulnerability to severe infections. This susceptibility is profoundly amplified in patients with iatrogenic immunosuppression, such as those receiving biologic therapy for inflammatory bowel disease. Sepsis in these patients presents important diagnostic and therapeutic challenges, as both common pathogens and atypical co-infections must be considered. Co-infection with Legionella pneumophila, a potent intracellular bacterium, and SARS-CoV-2, a virus known for inducing immune dysregulation, is exceptionally rare and can precipitate a life-threatening hyperinflammatory state. The Case: We present a case of severe septic shock and acute respiratory failure resulting from this unusual dual infection in a uniquely compromised host. A 31-year-old female, 35 weeks pregnant, presented in ER with fever, dyspnea and altered general state, rapidly progressing to septic shock despite the broad spectrum antibiotic therapy initiated at admission. Her medical history was significant for ulcerative colitis treated with biologic therapy (Adalimumab) for the past two years. The investigations revealed septic shock, respiratory failure due to severe pneumonia. The obstetrical risk assessment conducted to emergency C section delivery due to high risk of complications and even death for both mother and child. A healthy premature baby was admitted to neonatal unit and the next day, the mother was transferred to infectious diseases intensive care unit. On admission to the intensive care unit, she was tachypneic (24 breaths/min) with an oxygen saturation of 88% on room air, desaturating on minimal exertion. Laboratory investigations revealed a systemic inflammatory response, with a procalcitonin of 33.9 ng/mL (ref: <0.5), C-reactive protein 21.15 mg/dL (ref: <0.5) and marked neutrophilic leukocytosis. Arterial blood gas analysis confirmed severe acute hypoxemic respiratory failure. A chest radiograph showed a left upper lobe consolidation. While blood cultures remained negative, the urinary antigen test for Legionella was positive. The definitive diagnosis was established via a multiplex PCR respiratory panel, which simultaneously detected Legionella pneumophila and SARS-CoV-2. The patient was managed with a multi-modal strategy including targeted antimicrobial therapy (Levofloxacin), antiviral treatment (Remdesivir) and immunomodulation with Dexamethasone, alongside supportive care. This approach led to a rapid clinical and biochemical recovery. Inflammatory markers normalized, oxygen requirements decreased significantly, and she was discharged in an improved condition after an 8-day hospitalization. At the 3 weeks follow up evaluation, both mother and child were in healthy condition. Conclusion: This case highlights a rare and severe presentation of sepsis caused by a co-infection with Legionella pneumophila and SARS-CoV-2 virus. The patient's profound vulnerability stemmed from the convergence of the pregnancy condition and immunosuppressive therapy for ulcerative colitis, creating an unfavorable risk alignment for fulminant disease. The key learning points include the critical importance of maintaining a broad differential for atypical and multiple pathogens in immunocompromised hosts and the pivotal role of multiplex molecular diagnostics in achieving rapid and accurate diagnosis. This case demonstrates that despite extreme initial severity, a tailored therapeutic strategy combining targeted antimicrobial, antiviral, and judicious immunomodulatory agents can lead to a successful outcome.
Copyright (c) 2025 Anda Lup https://creativecommons.org/licenses/by/4.0
Pituitary Carcinoma with Secondary Intracranial Involvement: A Case Report
Background: Pituitary carcinoma is an exceptionally rare and aggressive malignancy, accounting for less than 0.5% of all pituitary tumors. Diagnosis requires evidence of cerebrospinal or systemic metastases, as histological features alone cannot reliably distinguish carcinoma from aggressive adenomas. Malignant prolactinomas are particularly uncommon and associated with poor prognosis, with most patients surviving less than one year after diagnosis. The Case: We present a 28-year-old male with metastatic lactotroph pituitary carcinoma. His initial pituitary mass was resected in 2002 after presenting with neurological symptoms. He subsequently developed multiple recurrences requiring additional surgeries and Gamma Knife radiosurgery. In 2022, a posterior fossa lesion resection confirmed metastatic pituitary carcinoma, lactotroph subtype, with immunopositivity for PIT-1 and prolactin. By 2024, imaging revealed stable lesions in the sella turcica, frontal horn, and cerebellum without new metastases. The patient developed hypopituitarism and epileptic seizures requiring a vagus nerve stimulator. He is currently on cycle 5 of Temozolomide chemotherapy with dose adjustment for thrombocytopenia. Despite the typical poor prognosis of pituitary carcinoma, this patient remains clinically stable over 12 years since the appearance of intracranial spread and over 20 years since the initial diagnosis. Conclusion: This case highlights the unpredictable clinical course of malignant prolactinomas and the potential for long-term survival with consistent multimodal therapy. The patient’s unusually prolonged survival suggests that aggressive surveillance combined with repeated surgical interventions, radiotherapy, and Temozolomide chemotherapy may improve outcomes in select cases. Further study of such rare presentations may help inform future management strategies for pituitary carcinoma.
Copyright (c) 2025 Mashoor Al Ahammed, Haifa Haris, Ryan Brownlee, Raniya Ahmed, Aditya Birla, Gerald Wallace https://creativecommons.org/licenses/by/4.0
The Lupus You Didn't See Coming: Secondary Evans Syndrome with Fulminant Autoimmune Myocarditis in a Young Woman
Background: Some cases in medicine feel like a thriller, where every test, every symptom, and every intervention builds suspense. We present a young woman whose illness unfolded like a high-stakes medical drama: chest pain, cardiogenic shock, hemolysis, and mystery antibodies all converging in a race against time. The Case: A 25-year-old female arrived at the emergency room with seven days of dragging left-sided chest pain radiating to the neck, back, and arms, accompanied by shortness of breath (NYHA II–III), palpitations, sweating, orthopnea, and facial puffiness. One day prior, she developed black stools and non-bilious vomiting. On arrival, she was in cardiogenic shock, requiring noradrenaline infusion. ECG revealed ST-elevation in aVR with global ST-depression, and echocardiography demonstrated global hypokinesia with moderate left ventricular dysfunction. Labs were dramatic: hemoglobin 6 g/dL, highly elevated troponin I, deranged liver function tests, unconjugated hyperbilirubinemia, positive direct Coombs test, and low complement levels (C3 and C4). Immediate management included intravenous steroids, multiple blood transfusions, and plasma exchange. Serology revealed strong anti-histone antibody positivity with a completely negative ANA profile (anti-dsDNA, anti-Sm, anti-RNP). Coronary angiography was normal, confirming myocarditis as the source of troponin elevation. Ultrasound showed hepatosplenomegaly, and history uncovered a recent mismatched blood transfusion, complicating the hemolytic picture. Through rapid multidisciplinary coordination including critical care, cardiology, hematology, rheumatology, and nephrology, the patient stabilized, hemoglobin improved, and she was discharged on a carefully tailored immunosuppressive regimen. Conclusion: This case is a diagnostic rollercoaster. Anti-histone positivity initially suggested drug-induced lupus, yet hypocomplementemia, secondary Evans syndrome, and fulminant myocarditis pointed toward an atypical or early-onset SLE. The presentation mimicked acute coronary syndrome, adding urgency and tension. It underscores that anti-histone antibodies should never be interpreted in isolation, and highlights the importance of integrating clinical, serological, and imaging data in complex autoimmune syndromes. Some patients turn the ER into a thriller. Fulminant autoimmune disorders can masquerade as common emergencies, putting lives at immediate risk. Early recognition, rapid multidisciplinary intervention, and careful interpretation of serology are the keys to survival and successful outcomes. This is an incredibly rare presentation of anti-histone positive lupus, with ours being the second reported case in literature.
Copyright (c) 2025 Tooba Fatima Iram, Yusra Fatima Anam, Haroon Abdullah Shaheed, Rahul Kumar Agarwal, Raksha Kapali https://creativecommons.org/licenses/by/4.0
An Uncommon Presentation of Systemic Sclerosis with Pulmonary Hypertension: A Case Report
Ba Background: Systemic sclerosis is a rare autoimmune condition that carries high mortality rates due to its varied and often hidden presentations. It is broadly classified into limited and diffuse systemic sclerosis, with the latter associated with a poorer prognosis because of its pulmonary, cardiac, and renal complications. Pulmonary hypertension and interstitial lung disease in diffuse systemic sclerosis (dcSSc) are serious complications that are difficult to diagnose due to their occult and insidious course. These manifestations not only increase morbidity and mortality but also result in significant out-of-pocket healthcare expenditure, especially among individuals with limited access to specialized care. We present a rare case of dcSSc complicated by pulmonary hypertension and interstitial lung disease, emphasizing the need for screening, early detection, and multidisciplinary treatment, especially among high-risk individuals. The Case: A 53-year-old Caucasian female presented with a six-month history of progressive dyspnea, dysphagia, Raynaud’s phenomenon, and fatigue. She also had proximal interphalangeal joint swelling, unintentional weight loss, and cutaneous changes such as sclerodactyly, calcinosis cutis, and telangiectasias. The skin thickening was diffuse, extending to the trunk, suggesting a diagnosis of diffuse cutaneous systemic sclerosis (dcSSc). Nailfold capillaroscopy revealed dilated capillaries, further supporting the diagnosis of dcSSc. Laboratory findings were significant for positive ANA with centromere patterns with elevated anti-Scl-70 antibodies. Persistent and progressive dyspnea prompted imaging, which revealed mild interstitial lung disease (ILD) on high-resolution CT and pulmonary hypertension (PH) on echocardiogram, with right ventricular hypertrophy. Pulmonary function tests confirmed reduced diffusing capacity (DLCO). This constellation of findings met the ACR/EULAR 2013 criteria for dcSSc with pulmonary involvement. A multidisciplinary approach was taken to initiate management in order to address the various systemic manifestations observed. This included immunosuppression with cyclophosphamide (15 mg/kg every 3 weeks) for ILD and bosentan, an endothelin receptor antagonist, for PH. Gastroesophageal reflux and dysphagia were treated with proton pump inhibitors and speech therapy. A common complication of systemic sclerosis is the development of joint contractures, for which physical therapy was initiated. Conclusion: This case exemplifies the complexity and vigilance required in managing dcSSc complicated by pulmonary hypertension and interstitial lung disease. The insidious onset of symptoms such as fatigue and dysphagia initially suggested gastrointestinal involvement, while pulmonary and cardiac complications remained hidden. Such varied presentations often delay diagnosis, underscoring the importance of heightened clinical suspicion and regular screening in patients at risk. Furthermore, the presence of anti-Scl-70 antibodies signaled a more aggressive disease course. Early recognition of cardiopulmonary complications is thus pivotal, enabling timely initiation of targeted therapies, including endothelin receptor antagonists for pulmonary hypertension and immunosuppressive agents for interstitial lung disease, both of which are critical for improving survival and quality of life. Effective management of dcSSc necessitates a multidisciplinary approach involving rheumatologists, pulmonologists, gastroenterologists, and physical therapists to address its multisystem involvement. A proactive diagnostic and therapeutic strategy, supported by coordinated care, as illustrated in this case, can meaningfully alter the otherwise poor trajectory of diffuse systemic sclerosis.
Copyright (c) 2025 Kedar Kulkarni https://creativecommons.org/licenses/by/4.0
Cat Scratch Disease in a Low-Prevalence Region: A Case Report from Bangladesh
Background: Cat Scratch Disease (CSD), caused by gram-negative bacillus Bartonella henselae, is transmitted through cat scratches or bites, leading to regional lymphadenopathy, fever, and malaise. It is self-limiting but can result in severe complications in immunocompromised patients, including bacillary angiomatosis or encephalitis. In South Asia, including Bangladesh, the prevalence of CSD is not well-understood due to scarce data, and it is often misdiagnosed because of its similarities to other illnesses, such as tuberculosis. Diagnostic tools like fine-needle aspiration cytology (FNAC), serologic tests (IFA and ELISA), and imaging are essential for accurate identification. A study in Bangladesh between 2018 and 2020 revealed that 15.1% of healthy cats carry Bartonella spp., confirming the risk of CSD in the area. This report discusses a previously healthy 38-year-old female with persistent axillary swelling following a recent cat scratch. The Case: A 38-year-old female with no significant past medical history and no prior history of tuberculosis or malignancies presented to the medicine outpatient department (OPD) with complaints of swelling in the left axillary region. The swelling was accompanied by mild pain localized to the left axilla, malaise, and a low-grade fever persisting intermittently for about one week, ranging from 101 to 102°F. Upon history taking, the patient reported an incident of being scratched by a cat on her left wrist and forearm six weeks back. The cat was non vaccinated, and showed features of diminished appetite before and after the scratching episode. Two weeks after the scratch, she began to notice swelling in her left axilla, which progressively increased in size over the next four weeks. The patient denied any complaints of cough, shortness of breath, or weight loss. She reported maintaining a good appetite throughout the illness. Primary care physician made a differential diagnosis of lymphoma and tuberculosis and carried out relevant investigations except FNAC. Notable physical examination findings were localized tenderness and swelling of the left axillary lymph nodes. No signs of organomegaly were noted, and laboratory investigations showed no abnormalities that would suggest any of the differentials set by the primary care physician. Ultrasonogram of lymph nodes showed hypoechoic, oval, asymmetric masses with central hyperemia and possibly fluid collection and hyperechoic hilum (Figure 1). FNAC revealed granulomas with palisading epithelioid histiocytes and central neutrophils, along with a polymorphic cell population. Although confirmatory molecular (PCR) or serological (ELISA/IFA) testing for Bartonella henselae was not performed due to limited availability in the region, the diagnosis of Cat Scratch Disease was made based on clinical history, FNAC findings, and exclusion of other differential diagnoses. Azithromycin was started in oral form and her recovery was uneventful. Informed consent was obtained from the patient for publication this case report. Conclusion: This case emphasizes the need for clinical suspicion of CSD in patients presenting with regional lymphadenopathy, particularly those with a history of cat exposure. The lack of advanced diagnostic tools resource-limited settings, such as Bangladesh and India, contributes to substantial underdiagnosis. Early recognition and appropriate antibiotic therapy can prevent misdiagnosis and unnecessary investigations and interventions.
Copyright (c) 2025 Mahnoor Fatima, Forhad Hossain, Karma Dicky Sherpa, Ahmed Al Montasir, Md. Zakir Hossain https://creativecommons.org/licenses/by/4.0
A Diagnostic Gray Zone: Isolated Left Oculomotor Nerve Palsy in the Setting of Hyperhomocysteinemia, Sphenoid Sinusitis, and Rathke’s Cleft Cyst
Rathke’s Cleft Cyst (RCC) is a benign, epithelium-lined cyst arising from remnants of Rathke’s pouch, typically located in the sellar or suprasellar region, and is a documented cause of oculomotor nerve palsy via compressive mechanisms. The sphenoid sinus lies adjacent to the cavernous sinus, through which the oculomotor nerve passes, making inflammatory spread from sphenoidal sinusitis a potential but uncommon cause of cranial nerve involvement. Hyperhomocysteinemia, defined as elevated plasma homocysteine levels, is an established independent risk factor for endothelial dysfunction, prothrombotic states, and small-vessel ischemia, and has been implicated in cranial neuropathies. We report a case involving all three of these factors contributing to isolated oculomotor nerve palsy. A 26-year-old right-handed woman presented with progressive left-eye diplopia for two months, worse on near and right gaze, along with recurrent headaches and blurring of vision in the right eye. She denied trauma, slurred speech, limb weakness, or dysphagia. Neurological examination revealed isolated left oculomotor nerve palsy: restricted adduction, elevation, and depression, with ptosis and pupil sparing. Visual acuity was 5/6 bilaterally; other cranial nerves, motor, and sensory systems were normal. Labs showed elevated homocysteine (83.9 µmol/L) and low vitamin B12 (205 pg/mL). MRI revealed a Rathke’s cleft cyst in the sellar region and left sphenoidal sinusitis. The patient responded well to a short course of corticosteroids, with resolution of diplopia and ptosis. This improvement supports an inflammatory or microvascular ischemic etiology rather than a purely compressive one. Previous studies associate hyperhomocysteinemia with microvascular cranial neuropathies, RCCs with compressive oculomotor palsy, and sphenoidal sinusitis with inflammatory extension to cranial nerves. Our case is unique in presenting all three concurrently, contributing to a diagnostic grey zone. Steroid responsiveness highlights a probable inflammatory and ischemic mechanism.
Copyright (c) 2025 Shaun Nevil, Umesh G, S Anton Charles, Sofia Mondal, Chaitra C S https://creativecommons.org/licenses/by/4.0
Acute Myeloid Leukemia in A Young Adult: Diagnostic Insights from a Case Report
Background: Acute myeloid leukemia (AML) is a clonal hematopoietic stem cell disorder. It predominantly affects older adults and is characterized by the proliferation of immature myeloid cells and bone marrow failure. Diagnosis can be made using peripheral smear, cytochemistry, immunophenotyping, and cytogenetics, as early recognition is crucial for management and prognosis. The Case: 21 year old male presented with fever, leukocytosis, mild anemia, and 75% of the blasts were medium-to-large size, with an irregular nuclear membrane, finely granular chromatin, nucleoli in peripheral blood smear with the presence of Auer rods, normocytic normochromic RBCs, and reduced platelets. Special stains such as myeloperoxidase (MPO) positivity, Sudan Black stain positivity, Periodic Acid-Schiff (PAS) negativity, and multicolor flow cytometry using CD45 vs. side scatter gating confirmed the diagnosis of Acute Myeloid Leukemia. Moreover, cytogenetic and molecular studies are recommended to improve prognosis and guide targeted therapy. Conclusion: This case demonstrates how a thorough morphological evaluation and specific cytochemical tests can swiftly guide the diagnostic considerations for AML. Multicolor flow cytometry confirms lineage and facilitates the classification necessary for treatment planning. In young adults, where early intervention can significantly impact outcomes, combining traditional and modern diagnostic methods reduces the time to diagnosis and expedites referrals to the hematology/oncology department. This case underscores the ongoing educational and practical importance of peripheral smears and cytochemistry, especially in environments where immediate access to cytogenetic or molecular testing is limited. Table 1. Immunophenotyping showing Myeloid Monocytic Markers Maturation Markers CD34 Bright Positive CD13 Bright Positive CD33 Moderate Positive CD117 Moderate Positive CD64 Dim Positive HLA-DR Dim Positive CD45 Dim Positive
Copyright (c) 2025 Jainishkumar Morker, Dr. Pinal Shah, Dr. Mubin Patel, Dr. Rahul Modi, Dr. Deepshikha Dave, Dr. Krutika Patel https://creativecommons.org/licenses/by/4.0
Guillain–Barré Syndrome in the Setting of Acute Biliary Pancreatitis: A Rare Clinical Association
Guillain–Barré syndrome (GBS) is an acute polyneuropathy often triggered by an antecedent infection. Common etiologies of GBS include C. jejuni, cytomegalovirus, HIV, influenza, and SARS-CoV-2. Antibodies to these infections can cross-react with shared epitopes on peripheral nerves, causing demyelination or axonal loss. Patients with GBS typically present with bilateral ascending flaccid paralysis, distal paraesthesias, and hyporeflexia. Acute pancreatitis is an inflammatory condition of the pancreas, often caused by gallstones. Patients classically present with epigastric pain radiating to the back with nausea and vomiting. Pancreatitis is associated with a wide range of systemic complications. Shock, disseminated intravascular coagulation (DIC), sepsis, acute respiratory distress syndrome (ARDS), and renal failure are extensively described in the literature and commonly encountered in critical care settings. Despite the substantial body of work done on pancreatitis complications, one that remains absent from the literature GBS. The Case: We report the case of a 67-year-old female with ischemic heart disease, hypertension, and megaloblastic anemia. She presented to the ER of local hospital with epigastric pain radiating to the back and multiple episodes of vomiting. Ultrasound revealed a bulky pancreas and gallbladder mucocele. She was diagnosed with acute biliary pancreatitis (BISAP score 4) and admitted to the surgical ward. After developing persistent increased work of breathing, she was shifted to the ICU, where she was intubated. Contrast-enhanced CT abdomen demonstrated pancreatic swelling, peripancreatic fat stranding, inflammatory extension to the transverse colon, and a 4.2 × 2.3 cm hypoperfused area suggestive of early necrosis. Her clinical course was further complicated by the development of ARDS and acute kidney injury requiring hemodialysis. She remained on mechanical ventilation for 8 days. After extubation, it was noted that she was unable to lift her upper and lower limbs against resistance. Reflexes were absent in all limbs, but sensations were intact. The CT brain was unremarkable. Cerebrospinal fluid analysis showed a normal protein count (24.3 mg/dl) and a raised glucose level (111 mg/dl). Suspecting critical illness polyneuropathy, nerve conduction studies and electromyography were done. However, the results were consistent with the AMSAN variant of GBS. Plasma exchange (PLEX) with albumin replacement was started. A total of 5 sessions were done over the course 2 weeks. Despite treatment, the patient’s respiratory effort continued to decline, developing type II respiratory failure. She was managed on BiPAP as she did not consent to reintubation. After 2 weeks, the patient succumbed to her illness. Conclusion This case demonstrates a rarely reported association between acute pancreatitis and GBS. In the ICU setting, new-onset neuromuscular weakness is often attributed to critical illness polyneuropathy. However, this case shows the importance of considering GBS in the differentials and performing electrophysiological studies to achieve an accurate diagnosis. Early recognition is crucial: studies show that PLEX is most effective when started within 7 days of symptom onset. Timely initiation of therapy can lead to improved functional outcomes. Further research required to determine any potential shared immune-related mechanisms between acute pancreatitis and GBS and to better define management strategies in these patients.
Copyright (c) 2025 Dr. Shaehzeen Arshad, Dr. Haider Iftikhar, Maidah Ilyas https://creativecommons.org/licenses/by/4.0
Diagnostic Challenges in Maxillary Telangiectatic Osteosarcoma: A Rare Case
Histologically, telangiectatic osteosarcoma is defined by blood-filled cystic spaces lined by high-grade malignant cells. This appearance leads to frequent diagnostic confusion with an aneurysmal bone cyst on both imaging and pathological examination. Owing to its infrequency, aggressive behavior, and nonspecific clinical features, this variant poses significant diagnostic difficulties. The Case: A 37-year-old woman presented with a rapidly enlarging right cheek swelling of 1 month's duration. It is associated with fresh blood coming out of the mouth. Later she reported a further increase in the swelling size, eventually impairing eating and speech. There is no history of trauma, systemic diseases, prior malignancies, or previous surgeries apart from dental prosthetic implants. On physical examination, there was a large, firm, right cheek swelling, non-pulsatile, non-compressible, without skin changes. Computed Tomography (CT) scan showed a heterogeneously enhancing mass lesion occupying most of the right maxillary sinus, measuring about 7x5 cm, showing few foci of calcifications compatible with detached teeth, demonstrating aggressive features such as adjacent bone erosions and destruction of the alveolar maxillary ridge inferiorly and maxillary sinus wall posteriorly. In addition to exerting mass effect upon masticator muscles, it also has medial extension into the nasal and oral cavities, displacing the tongue into the contralateral side, causing airway narrowing. The patient was assessed by the maxillo-facial surgeons, who recommended tracheostomy to secure the airways. An initial biopsy result revealed an inconclusive, poorly differentiated malignant neoplasm, given the aggressive clinical course and inconclusive results; repeat histopathological examination and immunohistochemistry was done and revealed a highly cellular malignant neoplasm predominantly composed of atypical spindle cells, with prominent vascularity and scattered areas of lace-like osteoid matrix production by the neoplastic cells. These features, along with the immunohistochemistry test, were suggestive of a poorly differentiated malignant neoplasm showing spindle and epithelioid features, consistent with telangiectatic osteosarcoma. The diagnosis and treatment options were discussed with a multidisciplinary team and the patient, and the plan involved chemotherapy with MAP protocol (Methotrexate + Doxorubicin + Cisplatin) followed by surgical resection. Conclusion: Very few cases exist regarding telangiectatic osteosarcoma, which is a unique type of osteosarcoma, and its occurrence in the maxillary sinus is even rarer. The diagnostic challenge arose during clinical judgement, histopathological, and radiological examinations, and the rapid progression of our patient's neoplasm during one month, causing profound impairment in swallowing and speech function and airway compromise, emphasizes the tumor's aggressive potential and necessitates early recognition of such complex craniofacial cancers that require a multidisciplinary approach involving airway management, oncology assessment, and function restoration and preservation, which shapes a framework for similar scenarios, especially in resource-limited healthcare settings.
Copyright (c) 2025 Malak R. Hroub, Mohanad Abuzahra, Alhareth M. Amro, Mohammed A. Barakat, Maha Ramzi, Basheer Babaa https://creativecommons.org/licenses/by/4.0
Surviving The Odds: A Rare Case of Untreated Transposition Of The Great Arteries In Adulthood With Neurological Manifestations
Background: Dextro- transposition of the great arteries (dTGA) is a very rare congenital cardiac anomaly with an incidence of 0.02-0.05% that usually results in 90% infantile mortality, without surgical correction. Simultaneous interposition with other anomalies like atrial septal defect (ASD), ventricular septal defect (VSD), can enable survival beyond infancy, in some instances. However, long-term survival into adulthood remains exceptionally uncommon, especially when complicated with brain abscess- a known but serious complication of cyanotic CHD. The Case: We present a case of Cyanotic congenital heart disease with d-TGA, VSD, ASD, dextro-cardia, complicated by a cerebral abscess. A 28-year-old male presented with two episodes of focal seizures and one episode of loss of consciousness. The patient was previously diagnosed with cyanotic congenital heart disease at age 7 months, but chose not to opt for surgical intervention as there was no delay in developmental & intellectual milestones. Since then, he had multiple episodes of deepening of cyanosis with palpitations & giddiness, which were subsequently managed by blood letting & incomplete staged surgery. Upon arrival at our hospital, he developed weakness over left-half of his body, which resolved spontaneously. On examination he was conscious and oriented. He also had, prominent bilateral EJV with central cyanosis and Grade 2 clubbing. CVS examination revealed Grade III mid-systolic murmur all over the precordium and apex beat at right sixth intercostal space along mid-clavicular line. CNS examination revealed no focal neurological deficit. All other systems were unremarkable. Echocardiography and cardiac catheterization confirmed: Situs solitus with dextrocardia Large ASD and VSD with common atrium Pulmonary artery & aorta arising parallelly (dTGA) Severe valvular and infundibular pulmonary stenosis (PS) Hypoplastic right ventricle and normal left ventricular function MRI brain revealed a right parietal lobe cerebral abscess. Blood and urine cultures were sterile. The patient was deemed unfit for neurosurgical drainage due to high cardiac risk. He was treated with IV vancomycin, ceftriaxone, and metronidazole for 6 weeks. He showed significant clinical improvement and was discharged hemodynamically stable. Two years later, he successfully underwent Bidirectional Glenn → Fontan procedure with PA banding and atrial septectomy. The patient remains alive & clinically stable till date and continues to come for periodic cardiology follow-up and has had no recurrence of cardiovascular or neurological complications. Conclusion: In the present case, the VSD and atrial septal defect served as effective admixture lesions, permitting intermixing of systemic and pulmonary circulation, thereby maintaining some degree of oxygen saturation. Severe pulmonary limited pulmonary overcirculation, protecting the pulmonary vasculature and enabled long-term survival. However, long-standing right-to-left shunting predisposes to cerebral abscess and stroke, due to paradoxical embolization and impaired immune function. This case underscores the interplay of admixture lesions (VSD, ASD), protective pulmonary stenosis, leading to survival into adulthood in unoperated d-TGA.
Copyright (c) 2025 Sristi Chakraborty, Monika P Jawanjal https://creativecommons.org/licenses/by/4.0
Giant Left Diaphragmatic Hernia Complicated With Intrathoracic Gastric Volvulus and Total Gastric Necrosis: An Uncommon Case Report
Background: Diaphragmatic hernia in adults is an uncommon but potentially fatal condition. Diagnosis is often delayed because of nonspecific symptoms, predisposing patients to severe complications. Among these, intrathoracic gastric volvulus with necrosis is one of the most catastrophic, carrying a high risk of septic shock, multiorgan failure, and postoperative mortality exceeding 30–50% in critical settings. This case is notable for the size of the hernia, the extent of gastric necrosis, and the complexity of reconstruction required, while also underscoring the need for access to specialized critical care. The Case: A 66-year-old male with cirrhosis, hypertension, and diabetes presented in extremis with severe abdominal pain, distension, and acute dyspnea progressing to refractory shock. He required mechanical ventilation and vasopressor support. Examination revealed abdominal distension, tracheal deviation, and absent left breath sounds. Chest radiography showed a massively distended stomach in the left hemithorax, with mediastinal shift and contralateral lung collapse. Emergency laparotomy demonstrated a 10 × 5 cm diaphragmatic defect containing a volvulated stomach with complete necrosis. Procedures included adhesiolysis, hernia reduction, diaphragmatic repair, total gastrectomy, and Roux-en-Y reconstruction with esophagojejunal and jejunojejunal anastomoses. A left chest tube and drains were placed. The surgery lasted nine hours with blood loss of 1500 mL. Postoperatively, the patient remained critically ill with hypovolemic and septic shock requiring dual vasopressors and ventilatory support. Conclusion: Giant diaphragmatic hernia with intrathoracic gastric volvulus and total gastric necrosis is an exceptional, life-threatening condition. Successful management requires rapid diagnosis, immediate surgical intervention, multidisciplinary collaboration, and advanced critical care infrastructure.
Copyright (c) 2025 Sofia Rubiralta Adame, Martin Rodriguez Alvarado, Mariana Fraga Duarte, Jack Abadi Chiriti, Jair Ariel Nava Vazquez, Emanuel Osmar Diaz Vega https://creativecommons.org/licenses/by/4.0
The Hidden Rhythm: A Rare Case of Isoarrhythmic Sick Sinus Syndrome Defying Chronotropic Expectations
Background: Isoarrhythmic sick sinus syndrome (SSS) is a rare and often under-recognized variant of sinus node dysfunction, where the sinus and junctional rates are nearly identical, masquerading as a normal rhythm. Typically, SSS is associated with chronotropic incompetence (the inability of the heart to appropriately increase its rate during exertion), leading to symptoms such as fatigue, syncope, or exercise intolerance. It remains a common indication for permanent pacemaker implantation. However, cases demonstrating preserved chronotropic response are extremely uncommon, and recognizing these can directly influence management strategies. The Case: We present a 72-year-old male with longstanding hypertension and chronic tobacco use, who presented with progressive dyspnea over one month, bilateral leg swelling, palpitations, and productive cough. On examination, he was in sinus bradycardia (57 bpm), hypertensive (200/100 mmHg), and had signs of fluid overload. Initial ECG suggested second-degree AV block; however, careful analysis revealed junctional rhythm with intermittent sinus capture, consistent with isoarrhythmic AV dissociation, confirming SSS. A 24-hour Holter monitor demonstrated a maximum sinus pause of 1.8 seconds, confirming sinus node dysfunction. To evaluate SA node function under physiological stress, a treadmill exercise test using the Bruce protocol was performed. Surprisingly, the patient exhibited a robust chronotropic response, with heart rate rising from 52 bpm to 133 bpm, without ischaemic changes or arrhythmias. Management focused on controlling hypertensive emergency with intravenous antihypertensives and alleviating heart failure symptoms with diuretics. Given the preserved chronotropic competence, absence of syncope, and no severe bradycardia, permanent pacemaker implantation was deemed unnecessary. The patient was discharged in stable condition with close cardiology follow-up. Conclusion: This case highlights isoarrhythmic SSS as a subtle but clinically significant variant of sinus node dysfunction, which can easily be misdiagnosed as AV block or overlooked due to near-identical sinus and junctional rates. It underscores the essential role of detailed ECG analysis, Holter monitoring, and exercise testing in evaluating sinus node function. Importantly, preserved chronotropic response challenges the conventional indication for pacemaker implantation, supporting a conservative, individualized approach in selected patients. Clinicians should maintain a high index of suspicion for isoarrhythmic SSS in elderly patients presenting with bradyarrhythmias, heart failure, or hypertensive crises. This case emphasizes that accurate diagnosis and functional assessment of the sinus node can prevent unnecessary interventions, optimize patient outcomes, and provide insight into the nuanced spectrum of sinus node disorders.
Copyright (c) 2025 Tooba Fatima Iram, Haroon Abdullah Shaheed, Yusra Fatima Anam, Rahul Kumar Agarwal, Naazira Begum https://creativecommons.org/licenses/by/4.0
When RASopathies Collide: A Case Highlighting the Continuum between Noonan and LEOPARD Syndromes
LEOPARD syndrome and Noonan syndrome are clinically overlapping RASopathies, both frequently associated with pathogenic variants in the PTPN11 gene, which encodes the SHP-2 tyrosine phosphatase. Typically, Noonan syndrome arises from gain-of-function variants, while LEOPARD syndrome results from loss-of-function alterations, most often distinguished by the presence of lentigines and cardiac anomalies. We report a diagnostically challenging case of a 17-year-old male who presented with behavioural disturbances, seizure disorder, visual and auditory hallucinations, and history of right orchidectomy and left-eye cataract. Physical examination revealed hypertelorism, low-set ears, high-arched palate, and dental overcrowding, but notably lacked lentigines or cardiac findings. Genetic analysis identified a heterozygous PTPN11 variant, p.Phe285Ser in exon 8, previously described in both LEOPARD syndrome 1 and Noonan syndrome 1. Ancillary investigations confirmed seizure activity on EEG but showed no abnormalities on ECG or MRI. This case highlights the diagnostic ambiguity inherent to RASopathies, where identical PTPN11 variants may underlie divergent phenotypes. The absence of cutaneous and cardiac manifestations traditionally considered pathognomonic for LEOPARD syndrome underscores the limitations of relying solely on phenotype for classification. Instead, this case supports a genotype-first diagnostic framework, where molecular findings refine and sometimes challenge clinical labels. Recognition of such overlap is critical for genetic counselling, prognostic assessment, and surveillance planning, as patients may deviate from usually documented syndrome descriptions. Our report adds to the growing body of evidence that PTPN11 p.Phe285Ser represents a mutational hotspot bridging Noonan and LEOPARD syndromes, reinforcing the continuum model of RASopathies.
Copyright (c) 2025 Umesh G, Sofia Mondal, Shaun Nevil, S Anton Charles, Mansi Kumarswamy https://creativecommons.org/licenses/by/4.0
Management Challenges Encountered in a Borderline Personality Disorder with Multiple Somatic Diagnosis: A Case Report
Background: Borderline personality disorder (BPD) is a complex psychiatric condition characterized by pervasive instability in affect regulation, impulse control, interpersonal relationships, and self-image. Patients often present with comorbidities such as mood disorders, substance use, or somatic illnesses, which complicate diagnosis and treatment. The Case: We present the case of a 26-year-old female with a history of major depression, known with borderline personality disorder, and multiple prior suicide attempts. The aim of this case report is to underline the therapeutic challenges in managing severe psychiatric illness in the context of complex somatic comorbidities. Psychiatric evaluation of the patient revealed depressive symptomatology with anhedonia, suicidal ideation, fatigability and social withdrawal. Somatically, the patient had a recent diagnosis of Child-Pugh A liver cirrhosis, ulcerative colitis, and primary sclerosing cholangitis, requiring careful therapeutic adjustments. The extent of hepatic damage suggested the potential need for future liver transplantation. Pharmacological management included antidepressants, antipsychotics, and benzodiazepines. Conclusion: This case underscores the ethical and clinical challenges of considering liver transplantation in a patient with a personality disorder. Although prior suicide attempts complicate prognostic assessment, the patient remained adherent to both pharmacological treatment and medical rehabilitation, underscoring that psychiatric illness alone should not preclude access to life-saving interventions, which must be considered through individualized, multidisciplinary evaluation.
Copyright (c) 2025 Alexandra Zirbo, Maria Palfi, Cristina Maria Simian, Bianca Crecan-Suciu https://creativecommons.org/licenses/by/4.0
Atypical presentation of a hypopharyngeal leiomyoma: Case Report
Leiomyomas are benign tumors of smooth muscle origin, most frequently located in the uterus and gastrointestinal tract. Their presence in the hypopharynx is extremely rare due to the limited amount of smooth muscle in this region, and clinical manifestations are often nonspecific, including dysphagia, globus sensation, and pharyngeal discomfort, which may mimic malignant disease. We report the case of a 63-year-old male with a history of gastroesophageal reflux disease (GERD) and Barrett’s esophagus who presented with a one-year history of dyspepsia, globus sensation, and progressive dysphagia. Endoscopic evaluation revealed a small lesion on the posterior hypopharyngeal wall, further confirmed by contrast-enhanced computed tomography as a 7 × 6 × 4 mm homogeneous, hypervascular, pedunculated mass without cervical lymphadenopathy. The patient underwent endoscopic cold-cut resection, which led to complete symptom resolution. Histopathological analysis demonstrated a well-circumscribed neoplasm composed of spindle-shaped cells arranged in fascicles, with no atypia, necrosis, or abnormal mitoses. Immunohistochemistry revealed diffuse positivity for smooth muscle actin, confirming the diagnosis of hypopharyngeal leiomyoma. The postoperative course was uneventful, with continued GERD management. This case illustrates an exceptionally rare benign tumor of the hypopharynx, emphasizing the importance of including such entities in the differential diagnosis of patients with nonspecific pharyngeal symptoms. Accurate diagnosis requires thorough endoscopic and radiological evaluation combined with histopathological confirmation. Complete surgical excision remains curative, providing excellent prognosis with minimal risk of recurrence. This report contributes to the limited literature on hypopharyngeal leiomyomas and highlights the value of a multidisciplinary approach in their management.
Copyright (c) 2025 Jair Ariel Nava Vazquez, Martin Rodriguez Alvarado, Alessandro Nava Torres, David Rui-Jing Guo , Neil Parikh, Ramon Adrian Magaña Davalos https://creativecommons.org/licenses/by/4.0
When Bone Forms in the Endometrium: A Case of Osseous Metaplasia Presenting with Chronic Pelvic Pain and Abnormal Uterine Bleeding
Background: Endometrial osseous metaplasia is a rare condition characterized by the transformation of endometrial stromal cells into osteoblast-like cells. Its etiology remains uncertain, but proposed risk factors include a history of abortion and chronic intrauterine inflammation. This condition is clinically relevant because it can cause infertility, abnormal uterine bleeding, and pelvic pain, particularly in young women. Early recognition and management are crucial to avoid long-term sequelae. Case: A 20-year-old woman with past medical history of spontaneous abortion six months ago, presented with pelvic pain and abnormal uterine bleeding. Transvaginal ultrasonography revealed echogenic structures suggestive of intrauterine calcifications. Hysteroscopy confirmed the presence of osseous tissue within the endometrial cavity, which was completely resected. Histopathology confirmed the diagnosis of endometrial osseous metaplasia. The postoperative course was uneventful, and symptoms resolved following treatment. Conclusion: Endometrial osseous metaplasia, though rare, should be considered in young women with recent abortions presenting with abnormal uterine bleeding, pelvic pain, or infertility. Ultrasonography serves as a valuable initial diagnostic tool, while hysteroscopy remains the gold standard for both diagnosis and treatment. This case highlights the importance of clinical awareness to ensure timely recognition and management of this uncommon entity.
Copyright (c) 2025 Camila Brito-Balanzategui, Wilson Sebastian Peñafiel-Pallares, Oscar Venegas-Baca https://creativecommons.org/licenses/by/4.0
Early Detection of alpha-synuclein deposition within Two Years Diagnosis of REM Sleep Behavior Disorder and Consequential Prevention of Parkinson’s
Background: Early diagnosis of REM sleep behavior disorder (RBD) offers a valuable prognostic indicator for individuals at risk of neurodegeneration through their progression into Parkinson's disease. The prognosis of RBD in relation to worsening symptoms can be determined using epidermal nerve punch biopsies and immunohistochemistry to assess the degree of alpha-synuclein aggregation. The Case: A 72-year-old white woman with a two-year history of REM sleep behavior disorder (RBD) is present with the neurologist for a follow-up appointment for evaluation of Parkinson’s disease. She was diagnosed with RBD through an evaluation in the ER for her injured hip from falling out of bed after acting out her dreams. She has a familial connection to Parkinson’s disease through her sister. She has been educated on RBD and its correlation to the risk of Parkinson’s disease. Being educated on upcoming research to prevent progression of synucleinopathy, she agreed to be a part of this study; therefore, we decided to obtain epidermal nerve biopsies to look for possible alpha-synuclein proteins. The posterior cervical epidermal nerve biopsy was found to be positive for alpha-synuclein proteins. The patient is told of the prognosis, that research suggests she could present with PD symptoms with dysautonomia a decade from now. Clonazepam is effectively managing her RBD symptoms; however, she is aware of research being conducted for preventing synucleinopathy progression. Conclusion: Investigating the underlying causes of Parkinson’s disease is essential for both advancing preventive strategies and providing patients with clearer expectations regarding disease progression. Epidermal nerve biopsies have been found to have a high sensitivity rate of detecting the relationship between Parkinson’s disease and RBD. Progression of synucleinopathy is suggested to cause neurodegeneration in those with RBD who later progress to PD.
Copyright (c) 2025 Hiba Khan https://creativecommons.org/licenses/by/4.0
Abstracts of the Student's Scientific Society of Tbilisi State Medical University
Copyright (c) 2025 Executive Committee of the IJMS https://creativecommons.org/licenses/by/4.0
Abstracts of the 10th International Academic Medical Congress of Maranhão (X COIMAMA) 2025
The 10th International Congress of Maranhão (X COIMAMA) brought together medical students, early-career researchers, and academic mentors to present and discuss emerging scientific contributions across the biomedical and clinical sciences. This conference book compiles the accepted abstracts from a diverse range of disciplines, including basic science, clinical research, public health, and medical innovation. The event aimed to promote scientific inquiry, strengthen research competencies among trainees, and encourage interdisciplinary dialogue within the global medical student community. The abstracts contained herein represent the collective academic output of participants and serve as a reference for ongoing research development and future collaborative opportunities.
Copyright (c) 2025 Daniela Collazos https://creativecommons.org/licenses/by/4.0
Abstracts of the International Students’ Congress of Bucharest (2024)
Copyright (c) 2025 Executive Committee of IJMS https://creativecommons.org/licenses/by/4.0
Abstracts of the Medical Academical Conferece of Piauí (COMAPI) 2023
Copyright (c) 2025 https://creativecommons.org/licenses/by/4.0