The underlying mechanism behind the different outcomes of COVID-19 in children and adults

Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, has affected hundreds of millions of people globally, resulting in millions of deaths. During this pandemic, children have demonstrated greater resistance than adults, exhibiting lower infection rates, reduced mortality, and milder symptoms. Summarizing the differences in resistance between children and adults during COVID-19 can provide insights into protective mechanisms and potential implications for future treatments. In this review, we focused on summarizing and discussing the mechanisms for better protection of children in COVID-19. These protective mechanisms encompass several factors: the baseline expression of cell surface receptor ACE2 and hydrolase TMPRSS2, the impact of complications on COVID-19, and age-related cytokine profiles. Additionally, differences in local and systemic immune responses between children and adults also contribute significantly, particularly interferon responses, heterologous protection from non-COVID-19 vaccinations, and immune status variations influenced by micronutrient levels. The advantageous protection mechanisms of these children may provide insights into the prevention and treatment of COVID-19. Importantly, while age-related metabolic profiles and differential COVID-19 vaccine responses may contribute to protection in children, current comparative research remains limited and requires further investigation.

Travel-related sepsis with colitis and necrotizing skin and soft tissue infection after oysters consumption

We describe in this article a case of a 55-year-old woman admitted to our hospital in France, for oedema and paraesthesia of the lower limbs after returning from a trip to Florida. In only four hours, the patient's condition evolved into a multiple organs failure, leading the physicians to carry out a TAP scan and a CT angiogram of the lower limb, which showed acute pan-colitis and diffuse infiltration of the skin and soft legs tissues. Leg fasciotomy was performed and revealed necrotizing fasciitis and myonecrosis. The evolution was unfavorable, leading to shock and death 12 h after hospital admission. Culture revealed Vibrio vulnificus and rapid genome sequencing led to identification of MO6-24/O genotype. V. vulnificus is a bacterium commonly found in warm coastal water and responsible for necrosis SSTI after exposure to seawater through skin lesions and gastroenteritis after ingestion of contaminated seafood. Strain MO6-24/O found in our patient is associated with very poor prognosis. This case is uncommon in Europe but the modification of geographic distribution due to warming coastal waters in Pacific and Atlantic coastal regions of the northern hemisphere lead to consider V. vulnificus in travellers from coastal and estuarine regions, with history of exposure to water or seafood consumption, especially during the summer.

Utilising intraoperative hand-held cryoneurolysis for enhanced post-thoracotomy pain control

Post-thoracotomy pain (PTP) is a challenging complication following thoracic surgery, often leading to chronic, debilitating symptoms. However, little is known about the potential of intraoperative cryoneurolysis (IC) as a solution for managing PTP. This retrospective case series reports the application of IC in three patients undergoing thoracic surgery for chest wall tumors. Under direct visualisation of the intercostal nerves, temporary inhibition of nerve signalling was achieved without disrupting the surrounding tissue using a handheld device. All three patients experienced decreased pain and reduced reliance on opioids during the 6 week postoperative period. These outcomes highlight the potential of IC to improve post-thoracotomy pain management.

Gut-directed therapeutics in inflammatory bowel disease

PURPOSE OF REVIEW

Tissue-directed therapies (TDTs) provide potential advantages, including improved tolerance, safety, and efficacy. This review provides a conceptual framework for understanding intestinal TDT and summarizes the current landscape of TDT in inflammatory bowel disease (IBD).

RECENT FINDINGS

Vedolizumab, a mAb targeting the gut homing α4β7 integrin, served as revolutionary proof-of-principle for the power of advanced TDT in IBD. The development of other monoclonal antibodies targeting cell adhesion molecules followed including abrilumab (α4β7), etrolizumab (β7), and ontamalimab (MAdCAM-1). MORF-057, an oral small molecule inhibitor of α4β7, is now in development for ulcerative colitis. Efforts have also been made toward gut specific JAK inhibitors. Microbiome-based therapies, including engineered probiotics, bacteriophages, and postbiotics, are gaining interest. There are also a number of innovative drug delivery methods, including engineered yeast, hydrogels, and nanoparticles, and viral-based gene therapy.

SUMMARY

Gut-targeted therapies range from novel variations on traditional drugs (i.e., mAbs and small molecules) to microbiome-based therapeutics and engineered delivery systems. They can be used alone or in combination with currently available therapies. Future directions should focus on the development of tried-and-true modalities (mAbs, small molecules) as well as the microbiome and more innovative delivery systems.

Predictors of sepsis, intensive care unit admission, and death in patients hospitalized for complicated skin and soft tissue infections: Retrospective study at a large tertiary-care center

Background

Complicated skin and soft tissue infections often lead to poor health outcomes, with necrotizing skin and soft tissue infections occurring in 70%-80% of hospitalized patients and a mortality rate typically exceeding 20%. The current study's main objective was to identify early predictors of sepsis, intensive care unit admission, and mortality in hospitalized complicated skin and soft tissue infection patients.

Methods

A retrospective review of records from 235 adult complicated skin and soft tissue infection patients admitted from 2012 to 2022 was conducted. Collected data included demographics, medical history, clinical presentation, treatment, and outcomes. Laboratory results were used to calculate the Laboratory Risk Indicator for Necrotizing Fasciitis score for diagnosing necrotizing fasciitis. Predictors of sepsis, intensive care unit admission, and death were identified using logistic regression analysis.

Results

Of the 235 patients, 42.1% were wheelchair-bound or bedridden; 93.2% had diabetes, 76.2% had cardiovascular disease, and 33.6% had kidney disease. Necrotizing fasciitis criteria were met by 75% of patients. Sepsis was diagnosed in 27.7% of patients, while 30.6% required intensive care unit admission, and 20.4% did not survive hospital discharge. Low mean arterial pressure and vasopressor use were significant predictors of all three severe outcomes, with pre-existing kidney disease also a predictor of in-hospital death. The Glasgow Coma Scale predicted both intensive care unit admission and sepsis, but not death.

Conclusions

Low mean arterial pressure, vasopressor use, and pre-existing kidney disease are key predictors of in-hospital death in patients hospitalized for complicated skin and soft tissue infection. The former two, and the patient's Glasgow Coma Scale, also appear to predict both intensive care unit admission and sepsis.

Left bundle branch area pacing compared with biventricular pacing for cardiac resynchronization therapy in patients with left ventricular ejection fraction ≤50%: Results from the International Collaborative LBBAP Study (I-CLAS)

BACKGROUND

Cardiac resynchronization therapy (CRT) with biventricular pacing (BVP) is an established treatment of heart failure with reduced ejection fraction and wide QRS. Left bundle branch area pacing (LBBAP) has emerged as a physiologic alternative by directly engaging the His-Purkinje system, potentially improving electrical resynchronization and clinical outcomes.

OBJECTIVE

The aim of the study was to compare the clinical outcomes between BVP and LBBAP in patients with left ventricular ejection fraction (LVEF) ≤50% undergoing CRT.

METHODS

This multicenter observational study included patients with LVEF ≤50% receiving CRT with either LBBAP or BVP at 18 centers from January 2018 to June 2023. The primary outcome was a composite of all-cause mortality or first heart failure hospitalization (HFH). Secondary outcomes included separate analyses of HFH and all-cause mortality. Propensity score matching was used to balance baseline characteristics. Kaplan-Meier curves, Cox proportional hazards models, and competing risk analyses were performed.

RESULTS

A total of 2579 patients were included (BVP, 1118; LBBAP, 1461). In the propensity score-matched cohort (BVP, 780; LBBAP, 780), LBBAP demonstrated shorter paced QRS duration (129 ± 19 ms vs 143 ± 22 ms; P < .001). LBBAP was associated with a significantly lower risk of the composite primary outcome (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.66-0.98; P = .048) and reduced HFH (HR, 0.63; 95% CI, 0.49-0.82; P < .001). No significant difference in all-cause mortality was observed (HR, 0.82; 95% CI, 0.63-1.07; P = .156). Procedural complications were lower with LBBAP (3.5% vs 6.5%, P = .004).

CONCLUSION

LBBAP was associated with superior electrical resynchronization, fewer HFHs, and lower procedural complications compared with BVP in patients with LVEF <50% requiring CRT. Randomized trials are needed to confirm long-term benefits.

A Quantitative Analysis of Work System Factors and Well-Being Among Nurses and Physicians in Rural and Urban Settings During Covid-19 Pandemic

BACKGROUND

The aim of this study was to assess work system factors and nurse and physician well-being across professionals (nurse vs. physician) and geographic locations (rural vs. urban) during COVID-19 pandemic.

METHODS

This study invited nurses and physicians within four hospitals from one large healthcare system to participate: one urban academic medical center and three rural hospitals. We measured work systems factors using the National Academy of Medicine (NAM) framework and the National Institute for Occupational Safety and Health (NIOSH) survey. Wellbeing was measured using the 2-question summative burnout score, Patient Health Questionnaire (PHQ-9) to measure depression, and post-traumatic stress disorder (PTSD) checklist (PCL) to measure PTSD symptoms. Statistical analyses were conducted using Chi-square (for Likert-scale items) and t-tests (for continuous scales) as appropriate. Statistical significance was set at the .05 level, two-tailed.

RESULTS

Overall, our results suggested that nurses and physicians working in the urban settings experience more impeding work system factors and are more burned out, depressed, exhibit more PTSD symptoms, and face greater overall well-being issues, when compared to nurses and physicians working in the rural settings.Conclusions/Applications to Practice:This study examined a comprehensive set of work system factors and well-being measures to better understand differences between rural and urban settings, and nurses compared to physicians. By examining this entire set of measures, we were able to provide a greater insight into the key differences, highlighting opportunities for policy-level contributions to prevent work related impairments from reaching the healthcare workforce.

Mediating factors associated with alcohol intake and periodontal condition

Background

Alcohol consumption has been reported to increase the risk of periodontal disease and various health abnormalities such as obesity, hyperglycemia, and liver abnormalities. While the link between these health abnormalities and periodontal disease has been established, their potential mediating role in the association between alcohol consumption and periodontal disease remains unclear. Therefore, this study aims to investigate the multiple mediating roles of obesity, hyperglycemia, and liver abnormalities in this association.

Methods

A cross-sectional study was conducted on 6,529 individuals aged 35-64 years who underwent workplace health check-ups in 2003 (mean age: 45.7 ± 8.7 years). The periodontal condition was evaluated using the mean pocket depth (PD), and participants were classified into no, light/moderate (alcohol consumption 0.1-29.9 g/day), and heavy (≥30 g/day) drinking groups. Causal mediation analysis was performed.

Results

Heavy drinking had a direct effect on the mean PD. Light/moderate drinking had a indirect effect on the mean PD through the body mass index (BMI), glucose level, alanine aminotransferase level (ALT), with proportion mediated of 25.1%, 8.9%, and 18.9%, respectively. The mediating role of glucose level was found in the association between heavy drinking and the mean PD with proportion mediated of 32.7%.

Conclusion

This study confirmed that alcohol consumption was associated with worse periodontal condition among Japanese adults who received workplace health check-ups. This association was partially contributed by several factors such as BMI, glucose level, and ALT.

Knowledge, attitudes, and practices of physicians regarding multidisciplinary treatment of obstructive sleep apnea: a cross-sectional study

To investigate physicians' knowledge, attitudes, and practices (KAP) regarding the multidisciplinary treatment of Obstructive Sleep Apnea (OSA). A multicenter cross-sectional study was conducted in May 2024, enrolling physicians from southwestern China. The study collected demographic data and assessed KAP through self-administered questionnaires, with the respiratory and otolaryngology departments defined as relevant departments. A total of 329 valid questionnaires were collected. Of these respondents, 173 (52.6%) were female, and 114 (34.7%) had participated in multidisciplinary OSA-related training. The mean scores for knowledge and attitudes were 24.61 ± 8.27 (possible range: 0-34) and 39.99 ± 4.34 (possible range: 10-50), respectively. Practice scores of the physicians in departments directly and indirectly involved in OSA treatment averaged 24.28 ± 4.70 and 21.28 ± 4.24 (possible range: 6-30), respectively. Structural equation modeling results indicated that in departments directly related to OSA, knowledge had a significant positive effect on both attitudes (β = 5.53, P < 0.001) and practices (β = 5.8, P < 0.001). For departments indirectly related to OSA, knowledge had a significant positive effect on attitudes (β = 5.41, P < 0.001). Physicians showed adequate knowledge and attitudes toward OSA treatment; targeted education is recommended to enhance consistency in practices across departments.

Optimization of Postoperative Opioids Use Following Spine Surgery

PURPOSE OF REVIEW

The present investigation evaluated the use of opioids for postoperative pain relief in spinal surgery patients.

RECENT FINDINGS

Pain management is a crucial component of postoperative care that greatly impacts patient outcomes. Postoperative pain management has been shown to allow for earlier mobility, discharge, and return to normal life. Opioids are the standard treatment for postoperative pharmacologic pain relief, but they are associated with the same adverse effects that pain management strives to mitigate. Opioids are associated with a large side effect profile, including a higher risk of various postoperative complications. Opioids are potentially highly addictive and postoperative use is associated with dependence, tolerance, and the current opioid epidemic. Some studies indicate that there are similar surgical outcomes amongst patients independent of whether opioids were prescribed opioids for pain relief.

CONCLUSION

Opioids should only be recommended for postoperative pain management under strict guidance and supervision from physicians. All 50 states have acute pain guidelines in place limiting opioid prescribing. One of the strategies of reducing postoperative opioid consumption is the emphasis on opioid alternatives that should be actively considered and explored prior to resorting to opioids. There are pharmacological and non-pharmacological options available for pain relief that can provide similar levels of analgesia as prescription opioid without unwanted effects such as tolerance and dependency. Proper assessment of patient history and risk factors can aid physicians in tailoring a pain management regimen that is appropriate for each individual patient. More research into efficacy and safety of alternative treatments to opioids is warranted.

The Mediating Role of Negative Mood Affect in the Relationship Between Perceived Stress and Vulnerability to Insomnia Among Student Pharmacist Shift Workers

Background

Perceived stress and vulnerability to develop insomnia are closely linked, with negative mood affect playing a key role. Shift workers, particularly student pharmacists juggling academic demands and irregular work schedules, are at heightened risk for stress-related sleep disturbances. While previous studies have explored their direct relationships, limited evidence exists on the dual role of negative mood affect as both a mediator and a non-mediator in these pathways. This study investigates the mediating role of negative mood affect in the relationship between perceived stress and vulnerability to develop insomnia and assesses whether negative mood affect mediates the reverse relationship.

Methods

A cross-sectional study was conducted on 86 student pharmacist shift workers at Notre Dame of Maryland University. Participants completed validated self-report measures, including the Perceived Stress Scale (PSS), the Ford Insomnia Response to Stress Test (FIRST), and the Positive and Negative Affect Schedule (PANAS). Mediation analysis using Hayes' PROCESS macro (Model 4) examined the mediating role of negative mood affect in both pathways. Bias-corrected bootstrapping with 5000 iterations calculated confidence intervals for indirect effects, with significance set at p < 0.05.

Results

Negative mood affect partially mediated the relationship between perceived stress and vulnerability to develop insomnia. Higher stress levels were associated with increased negative mood affect (b = 0.49, SE = 0.05, p < 0.01), which, in turn, was linked to greater insomnia vulnerability (b = 0.39, SE = 0.04, p < 0.01). The indirect effect was significant (b = 0.19, 95% CI [0.06, 0.33]). In contrast, negative mood affect did not mediate the reverse pathway (p = 0.15).

Conclusion

Negative mood affect significantly mediates the relationship between perceived stress and insomnia vulnerability but not the reverse pathway. Interventions targeting emotional regulation may help reduce stress-related sleep disturbances. Longitudinal studies are needed to confirm these findings and refine interventions.

Development of explainable artificial intelligence based machine learning model for predicting 30-day hospital readmission after renal transplantation

BACKGROUND

Hospital readmission following renal transplantation significantly impacts patient outcomes and healthcare resources. While machine learning approaches offer promising solutions for risk prediction, their clinical application often lacks interpretability. We developed an explainable artificial intelligence (XAI) based supervised learning model to predict 30-day hospital readmission risk following renal transplantation.

METHODS

We conducted a retrospective analysis of 588 renal transplant recipients at King Abdullah International Medical Research Center, with a predominance of living donor transplants (85.2%, n = 500). Our methodology included a four-stage machine learning pipeline: data processing, feature preparation, model development using stratified 5-fold cross-validation, and clinical validation. Multiple algorithms were evaluated, with gradient boosting demonstrating superior performance. Model interpretability was achieved through dual-approach analysis using SHAP (SHapley Additive exPlanations) and LIME (Local Interpretable Model-agnostic Explanations).

RESULTS

The gradient boosting model demonstrated strong performance (AUC 0.837, 95% CI: 0.802-0.872) with accuracy of 0.796 ± 0.050 and sensitivity of 0.388 ± 0.129. Length of hospital stay (38.0% contribution) and post-transplant systolic blood pressure (30.0% contribution) emerged as primary predictors, with differences between living and deceased donor subgroups. Pre-transplant BMI showed a higher importance in deceased donor recipients (12.6% vs. 2.6%), while HbA1c and eGFR were more impacting in living donor outcomes. The readmission rate in our cohort (88.9%, n = 523) was higher than previously reported ranges (18-47%), likely reflecting center-specific practices.

CONCLUSIONS

Our XAI-based machine learning model combines strong predictive performance with clinical interpretability, offering transplant physicians donor-specific risk stratification capabilities. The web-based implementation facilitates practical integration into clinical workflows. Given our single-center experience and high proportion of living donors, external validation across diverse transplant centers is essential before widespread implementation. Our approach establishes a framework for developing center-specific risk prediction tools in transplant medicine.

Primary Neuroendocrine Tumor of the Breast: A Rare Case

Primary neuroendocrine tumors (NETs) predominantly affect postmenopausal women. This case study focused on a 54-year-old woman who presented with a painless right breast lump. While the lump exhibited estrogen and progesterone receptor (PR) positivity, it lacked human epidermal growth factor receptor 2 expression. Further evaluation revealed positivity for the neuroendocrine markers chromogranin A (CGA) and synaptophysin (SYN). It also revealed a 3% positive Ki-67 proliferation index. Treatment for neuroendocrine breast cancer (NEBC) mirrors that of standard invasive breast cancer: breast conservation or mastectomy combined with sentinel lymph node biopsy or axillary dissection. The patient underwent a right mastectomy with sentinel lymph node biopsy, followed by hormonal therapy based on her tumor's immunohistochemical profile. Due to the low incidence and limited research on primary NETs, their exact origin remains shrouded in mystery. Accurate diagnosis, specific treatment options, and long-term prognosis remain significant challenges in managing this rare form of breast cancer.

An Update on IL-22 Therapies in Alcohol-Associated Liver Disease and Beyond

Excessive alcohol consumption drives the development of alcohol-associated liver disease (ALD), including steatohepatitis, cirrhosis, and hepatocellular carcinoma, and its associated complications, such as hepatorenal syndrome. Hepatocyte death, inflammation, and impaired liver regeneration are key processes implicated in the pathogenesis and progression of ALD. Despite extensive research, therapeutic options for ALD remain limited. IL-22 has emerged as a promising therapeutic target because of its hepatoprotective properties mediated through the activation of the STAT3 signaling pathway. IL-22 enhances hepatocyte survival by mitigating apoptosis, oxidative stress, and inflammation while simultaneously promoting liver regeneration through the proliferation of hepatocytes and hepatic progenitor cells and the up-regulation of growth factors. Additionally, IL-22 exerts protective effects on epithelial cells in various organs affected by ALD and its associated complications. Studies from preclinical models and early-phase clinical trials of IL-22 agonists, such as F-652 and UTTR1147A, have shown favorable safety profiles, good tolerability, and encouraging efficacy in reducing liver injury and promoting regeneration. However, the heterogeneity and multifactorial nature of ALD present ongoing challenges. Further research is needed to optimize IL-22-based therapies and clarify their roles within a comprehensive approach to ALD management. This review summarizes the current understanding of IL-22 biology and its role in ALD pathophysiology and ALD-associated complications along with therapeutic application of IL-22, potential benefits, and limitations.

Habitat Radiomics and Deep Learning Features Based on CT for Predicting Lymphovascular Invasion in T1-stage Lung Adenocarcinoma: A Multicenter Study

RATIONALE AND OBJECTIVES

The research aims to examine how CT-derived habitat radiomics can be used to predict lymphovascular invasion (LVI) in patients with T1-stage lung adenocarcinoma (LUAD), and compare its effectiveness to traditional radiomics and deep learning (DL) models.

MATERIALS AND METHODS

We retrospectively analyzed 349 T1-stage LUAD patients from three centers from January 2021 to March 2024. The K-means algorithm was utilized to cluster CT images and apparent diffusion coefficient maps. Following features selection, we constructed three types of models, namely radiomics, habitat, and DL to identify patients with LVI. The evaluation of all models was conducted by employing the area under the receiver operating characteristic curve (AUC), calibration curves and decision curve analysis.

RESULTS

349 eligible patients were divided into an internal training set of 210 and an external test set of 139. We identified four distinct habitats, with the AUC for the overall habitat area outperforming that of the four sub-areas. Within the test set, the habitat model reached a higher AUC of 0.941 in contrast to the radiomics model at 0.918 and the deep learning model at 0.896.

CONCLUSION

CT-based habitat radiomics shows promise in predicting LVI in T1-stage LUAD patients, with the habitat signature demonstrating superior performance and significant advantages in identifying patients who are LVI-positive.

Technical Considerations for Optimizing Flow in Superficial Temporal Artery to Middle Cerebral Artery Bypass: Case Series

BACKGROUND AND OBJECTIVES

Cerebral bypass can provide flow augmentation for select patients with moyamoya disease (MMD) and steno-occlusive cerebrovascular disease (SOCD). Earlier work has suggested that sacrificing the nondonor branch of the superficial temporal artery (STA) can optimize direct flow, which we assessed in real time.

METHODS

This was a single-institution observational study of consecutive patients undergoing direct STA-middle cerebral artery (MCA) bypass with indirect encephalo-duro-myo-synangiosis for MMD and SOCD over 1 year. Excluding patients with significant STA-intracranial collateralization, the intraoperative effect of nondonor STA branch temporary occlusion on direct STA-MCA bypass flow was assessed using a Charbel flow probe. Patient characteristics and perioperative and postoperative data were reviewed.

RESULTS

Eleven patients (5 MMD, 6 SOCD; mean age 53.5 ± 15.3 years) underwent combined revascularization (4 left, 7 right). The mean donor STA branch flow increased from 4.91 ± 2.79 (baseline) to 16.63 ± 11.92 mL/min after anastomosis (95% CI 1.25-17.50; P = .015), and to 20.94 ± 10.63 mL/min after nondonor STA branch test occlusion (95% CI 1.71-6.90; P = .002). The parietal STA branch was used as the donor in 8 cases (72%). In 9 patients, the nondonor STA branch was sacrificed. Perioperatively, 1 patient experienced transient dysarthria/paresthesias (9.1%); there were no strokes or other major complications. The median hospital stay was 5.0 (IQR 4.0, 7.0) days, with 81% of patients discharged home. Over a mean follow-up of 6.2 ± 3.0 months, no patients had significant wound-healing issues, and the median modified Rankin Scale score improved from 2 (IQR 1.0, 2.5) preoperatively to 0 (IQR 0.0, 0.0) (95% CI 0.11-1.69; P < .015). Six-month angiography (available in 9 patients) demonstrated 100% direct bypass patency and a median direct bypass flow grade of 2.0 (IQR 2.0, 3.0).

CONCLUSION

In patients without STA-intracranial anastomoses, STA-MCA direct bypass flow may be optimized safely by nondonor STA branch sacrifice.

Management of Paediatric Obstructive Sleep Apnoea: From a Multidisciplinary to an Interdisciplinary Care Model

The objective of this study is to offer a comprehensive overview of paediatric obstructive sleep apnoea (OSA), a prevalent condition characterised by intermittent upper airway obstruction that impairs both ventilation and sleep. The design of the study was a literature review using an electronic search. The study extensively reviews the pathophysiology, epidemiology, sequelae and diagnostic approaches of paediatric OSA. It highlights the role of various healthcare professionals in the management of this disorder, with each specialist providing unique contributions to the diagnosis, treatment and ongoing management of OSA. The current state of sleep teams managing OSA is multidisciplinary, including sleep physicians, pulmonologists and otolaryngologists (ENT surgeons), each contributing distinct expertise. This review contrasts a multidisciplinary approach, which relies on separate expert contributions, with an interdisciplinary model that emphasises integrated, collaborative decision-making for comprehensive, patient-centred care. This review focuses on the interactions between dental and medical professionals, as other papers will provide more detailed insights into the roles of other specialists, such as myofunctional therapists, nutritionists and others. In conclusion, the evolution from a multidisciplinary to an interdisciplinary care model marks a significant development in clinical practice, enhancing cooperation and shared decision-making among healthcare professionals, thereby improving the quality of life for paediatric patients with OSA.

The rolling stone: migration of an intrauterine device leading to bladder stone formation nine years after insertion: a case report

BACKGROUND

Intrauterine devices are safe, affordable, convenient, and the most common form of contraception used by females of childbearing age in Palestine. A rare complication of intrauterine devices is migration to nearby structures, rarely the urinary bladder, leading to bladder stone formation.

CASE PRESENTATION

A 34-year-old female patient presented due to repeated urinary tract infections and flank pain associated with lower urinary tract symptoms, including dysuria, frequency, and gross hematuria. Subsequent laboratory tests revealed a past medical history of iron-deficiency anemia. Urinalysis revealed hematuria and pyuria, and the urine culture confirmed colonization of Escherichia coli. Computed tomography revealed an irregularly shaped 5.5 cm hyperdense calculus in the urinary bladder. Open cystolithotomy was done to extract the calculus, which was later incidentally revealed to be encrusting a migrated intrauterine device.

CONCLUSIONS

This case highlights the rare potential for intrauterine devices to migrate to the urinary bladder, leading to calculus formation, which, in this case, was discovered in this patient nine years post-insertion. The intrauterine device perforation into the urinary bladder was due to delayed inflammatory migration. This case underscores the critical need for both patient and physician education in low-resource settings on the warning signs of intrauterine device migration, including new-onset irritative lower urinary tract symptoms, hematuria, and missing intrauterine device threads, ensuring routine scheduled follow-ups, patient self-checks, and timely imaging can aid in early detection and prevent complications associated with intrauterine device migration.

Common bile duct exploration with choledochotomy and primary repair during pregnancy: Case Report

We present a case of a woman in the second trimester of pregnancy who was admitted due to symptomatic common bile duct stones and gallstones. The patient underwent ultrasonography (US) and magnetic resonance cholangiopancreatography (MRCP) imaging, as well as a series of relevant blood tests, to establish a diagnosis. After a comprehensive assessment, simultaneous T-tube-free laparoscopic transcholedochal stone extraction and cholecystectomy were performed safely in the pregnant patient with common bile duct stones and gallstones. Postoperatively, the patient had an uneventful recovery. This case report aims to provide detailed information on the selection of treatment options for symptomatic choledocholithiasis combined with gallstones during pregnancy and to explore the feasibility and safety of performing concurrent T-tube-free laparoscopic choledochotomy for stone extraction in pregnant patients.

Determination of reference intervals for common liver function tests among healthy adults

Reference intervals (RIs) are significant means for health evaluation, prognosis, diagnosis, and monitoring of adverse events. The RIs are affected by ethnicity, age, gender, geographic area, diet, socioeconomic, and physical situation. This study aimed to determine RIs of commonly used liver function tests (LFT) for healthy adults in Ibb City, middle of Yemen. A total of 390 participants aged between 18 and 70 were selected and administered a questionnaire. Blood specimens were assembled after an overnight fast, and the sera were separated for analysis of common LFT (DBIL, TBIL, ALB, TP, ALP, AST, and ALT) using Mindray BS-240 Automatic Clinical Chemistry Analyzer. The data were computed by GraphPad Prism 8.0.1. This study revealed that RIs for males and females of DBIL, TBIL, ALB, ALP, and ALT were significantly higher in males than females. Although RIs for TP and AST were higher in males than females, the difference was non-significance. Notably, most of the RIs in our study were different than those from other countries, either higher or lower. In conclusion, this study has established a panel of locally relevant RIs for commonly used LFT in adults, Ibb City, which may help interpret laboratory results for healthy adults and patients.

First Report of a Fatal Septicemia Case Caused by Vibrio metoecus: A Comprehensive Functional and Genomic Study

BACKGROUND

In recent years, we have witnessed an unprecedented increase in the incidence of vibriosis due to global warming. Vibrio metoecus is a recently described Vibrio cholerae-like species that has not been associated with septicemia death in humans. During follow-up of human vibriosis, we received a blood isolate from a patient with secondary septicemia who died a few hours after admission.

METHODS

Phenotypic and genotypic methods failed to identify the isolate, which could only be identified by average nucleotide identity after genome sequencing. The isolate was subjected to in vitro and ex vivo assays, complemented by comparative genomics focused on the identification of unique genetic traits. Strains and genomes from the same and related species (V. cholerae and Vibrio mimicus) were used for analyses.

RESULTS

The isolate was the only one able to resist and multiply in human serum. Its genome contained virulence genes shared with V. mimicus and/or V. cholerae, with those associated with sialic acid degradation within pathogenicity island 2 standing out. However, it also presented a unique gene cluster, flanked by a transposase gene, putatively related to surface polysaccharide pseudosialyzation.

CONCLUSIONS

We document the first case of death caused by septicemia due to V. metoecus and propose that the acquisition of surface pseudosialyzation genes explains the ability of certain isolates of this species to survive in blood. Our discovery underscores the urgent need to monitor and study newly emerging pathogenic species, as climate change may be facilitating their spread and increasing the risk of serious infections in humans.

Effect of high-altitude hypoxia on function and cytoarchitecture of rats' liver

The liver is central to metabolic, detoxification, and homeostatic functions. Exposure to hypobaric hypoxia at high altitudes causes detrimental effects on the liver, leading to injury. This study evaluated the effect of hypoxia-induced at high altitudes on liver function, oxidative stress, and histopathological changes in rats. This study used 24 male Wistar rats (aged 8-10 weeks). The hypoxia (hypobaric hypoxia) was inducted at a high altitude of 2,100 m above sea level. Normoxia is defined as 40 m above the sea level. The rats were randomly divided into two groups: a control group maintained at low altitudes and an experimental group exposed to high altitudes for eight weeks. Blood samples were collected from all rats through a cardiac puncture, and liver samples were taken through an abdominal approach. All samples were processed through standard methods and evaluated for liver function tests and histopathological assessment. Serum aspartate aminotransferase and alanine transaminase levels significantly increased by 25% and 30%, respectively, in the high-altitude group compared to controls (p < 0.01), indicating mild hepatocellular damage. Oxidative stress assessment indicated a significant elevation in malondialdehyde by 42% in the liver homogenates of high-altitude rats compared to controls (p < 0.001). Moreover, Superoxide dismutase activity and glutathione content decreased by 18% and 22% in the high-altitude group (p < 0.01), confirming the increased oxidative stress. Histologically, minimal inflammatory infiltration was observed in the rat livers at high altitudes, with no signs of necrosis or severe structural changes. Subclinical liver dysfunction, as evidenced by altered serum enzyme levels and increased oxidative stress with mild histological changes, is induced by high-altitude hypoxia in rats. This study's results support that a hypobaric hypoxic environment physiologically stresses the liver. Further research into the long-term implications of hypobaric hypoxia and the adaptive responses of the liver is warranted.

Unmasking vestibular schwannoma: A series of unusual cases

INTRODUCTION

Vestibular schwannoma (VS) is a benign, slow-growing tumor that accounts for 80-90 % of cerebellopontine angle (CPA) tumors. While classic symptoms like hearing loss, tinnitus, and vertigo are well-recognized, atypical presentations can delay diagnosis.

CASE PRESENTATION

We present four unusual cases of VS. The first patient, a 33-year-old woman, initially presented with transient tinnitus and later developed peripheral vertigo. The second case involved a 52-year-old man with sudden hearing loss, vertigo, and aural fullness. The third case was a 17-year-old female with unilateral auditory neuropathy. The fourth patient, a 39-year-old woman, presented with intermittent tinnitus, balance disturbances, and facial stiffness.

DISCUSSION

Detailed history, physical examination, and audiological evaluation are crucial for identifying patients at risk for vestibular schwannoma, especially with atypical audiological findings, to avoid misdiagnosis.

CONCLUSION

This case series emphasizes the significance of considering VS as a differential diagnosis for atypical symptoms. Early recognition and proper practice can lead to optimal outcomes for patients and contribute valuable insights to the scientific field by broadening the understanding of the diverse spectrum of VS symptoms.

Vibrio MARTX toxin binding of biantennary N-glycans at host cell surfaces

Multifunctional autoprocessing repeats-in-toxin (MARTX) toxins are a diverse effector delivery platform of many Gram-negative bacteria that infect mammals, insects, and aquatic animal hosts. The mechanisms by which these toxins recognize host cell surfaces have remained elusive. Here, we map a surface interaction domain of a MARTX toxin from the highly lethal foodborne pathogen Vibrio vulnificus. This domain corresponds to a 273-amino acid sequence with predicted symmetrical immunoglobulin-like folds. We demonstrate that this domain binds internal N-acetylglucosamine on complex biantennary N-glycans with select preference for L1CAM and other N-glycoproteins with multiple N-glycans on host cell surfaces. This domain is also essential for V. vulnificus pathogenesis during intestinal infection. The identification of a highly conserved motif universally present as part of all N-glycans correlates with the V. vulnificus MARTX toxin having broad specificity and targeting nearly all cell types.

A Foundation Model for Sleep-Based Risk Stratification and Clinical Outcomes

Clinical diagnosis of sleep disorders, which are recognized contributors to morbidity and mortality, often relies on polysomnography (PSG) data. However, the vast physiologic data collected during PSG is underutilized, presenting a key opportunity to enhance characterization of sleep dysfunction and predict clinical outcomes. We introduce a sleep foundation model that uniquely integrates PSG time-series signals and electronic medical record data. Using a diverse dataset (n=10,000; mean observation period 14.5±7.1 years), our transformer-based model generates data-driven representations of latent physiological patterns. When clustered, we identified subpopulations with differential health trajectories. The highest risk-group exhibited strong correlations with all-cause mortality (unadjusted hazard ratio [HR] 4.83, 95% confidence interval [CI] 3.60-6.50, p<0.001) as well as cardiovascular outcomes and neurological outcomes, even after accounting for traditional measures. External validation in a National Sleep Research Resource cohort confirmed findings. We created a novel, clinically applicable framework leveraging information-dense PSG data to inform risk stratification and predict health outcomes beyond traditional methods.

Health effects associated with exposure of children to physical violence, psychological violence and neglect: a Burden of Proof study

The health toll of child maltreatment or violence against children (VAC) has not yet been comprehensively evaluated. Here, in our systematic review and meta-analyses, we focused on the health impacts of physical violence, psychological violence and neglect during childhood. Utilizing the Burden of Proof methodology, which generates conservative measures of association while accounting for heterogeneity between input studies, we evaluated 35 associations between VAC and adverse health outcomes, identifying 27 statistically significant links. The associations between physical violence and major depressive disorder, ischaemic heart disease, alcohol use disorder, eating disorders and drug use disorders were rated as moderately weak, reflecting a small effect size and/or inconsistent evidence. The minimum increased risk ranged from 16% for depression to 2% for drug use disorders. Psychological violence showed similar moderately weak associations with drug use disorders (8% minimum risk increase), migraine (7%) and gynaecological diseases (2%). Neglect was linked to at least a 15% increased risk for anxiety disorders. The other 18 associations were weaker due to smaller effect sizes and/or less consistent evidence. Despite the limitations of the existing evidence, our analysis highlights substantial health impacts for VAC survivors, underscoring the need for health system prioritization and continued efforts to eliminate all forms of VAC.

Lessons learned from the lived experiences of people living with obesity during the first COVID-19 lockdown in the United Kingdom

BACKGROUND

Quantitative studies have shown that people living with obesity experienced deteriorations in mental health and health-related behaviours during the first UK's Coronavirus Disease-2019 (COVID-19) lockdown. However, there is a lack of qualitative research exploring their lived experiences during this period.

METHODS

Thematic analysis of large-scale free-text survey data was conducted to understand the challenges faced by adults with obesity during the first UK's COVID-19 lockdown.

RESULTS

Among 543 participants, 467 (86%) responded to the free text questions. The majority were female (87.8%), with a mean age of 51.6 (SD 9.9) years. Of these, 65.3% has a body mass index ≥40 kg/m2, and 57.7% were not enroled in weight management services. Five overarching themes and 10 sub-themes were identified with the five key themes being (1) increased fear and anxiety, (2) the impact of obesity being classified as 'high risk', (3) disruption in weight management services, (4) the impact on health-related behaviours, and (5) the adverse impact on mental health. Participants expressed fear of contracting COVID-19 and concerns about weight gain. UK Government messages linking obesity with severe COVID-19 complications exacerbated feelings of shame and stigma. The reduced provision of weight management services caused further health concerns, highlighting the need for digital health technologies for continued support. Participants reported changes in shopping, diet, physical activity, and sleep patterns, leading to deteriorated mental health.

CONCLUSION

People living with obesity experienced distinct challenges during the first COVID-19 lockdown, affecting their ability to practice and maintain health-related behaviours.

Gut Microbiota in Heart Failure-The Role of Inflammation

Heart failure (HF) has become an immense health concern affecting almost 1-2% of the population globally. It is a complex syndrome characterized by activation of the sympathetic nervous system and the Renin-Angiotensin-Aldosterone (RAAS) axis as well as endothelial dysfunction, oxidative stress, and inflammation. The recent literature points towards the interaction between the intestinal flora and the heart, also called the gut-heart axis. The human gastrointestinal tract is naturally inhabited by various microbes, which are distinct for each patient, regulating the functions of many organs. Alterations of the gut microbiome, a process called dysbiosis, may result in systemic diseases and have been associated with heart failure through inflammatory and autoimmune mechanisms. The disorder of intestinal permeability favors the translocation of microbes and many metabolites capable of inducing inflammation, thus further contributing to the deterioration of normal cardiac function. Besides diet modifications and exercise training, many studies have revealed possible gut microbiota targeted treatments for managing heart failure. The aim of this review is to demonstrate the impact of the inflammatory environment induced by the gut microbiome and its metabolites on heart failure and the elucidation of these novel therapeutic approaches.

Improving ultrasound image classification accuracy of liver tumors using deep learning model with hepatitis virus infection information

PURPOSE

In recent years, computer-aided diagnosis (CAD) using deep learning methods for medical images has been studied. Although studies have been conducted to classify ultrasound images of tumors of the liver into four categories (liver cysts (Cyst), liver hemangiomas (Hemangioma), hepatocellular carcinoma (HCC), and metastatic liver cancer (Meta)), no studies with additional information for deep learning have been reported. Therefore, we attempted to improve the classification accuracy of ultrasound images of hepatic tumors by adding hepatitis virus infection information to deep learning.

METHODS

Four combinations of hepatitis virus infection information were assigned to each image, plus or minus HBs antigen and plus or minus HCV antibody, and the classification accuracy was compared before and after the information was input and weighted to fully connected layers.

RESULTS

With the addition of hepatitis virus infection information, accuracy changed from 0.574 to 0.643. The F1-Score for Cyst, Hemangioma, HCC, and Meta changed from 0.87 to 0.88, 0.55 to 0.57, 0.46 to 0.59, and 0.54 to 0.62, respectively, remaining the same for Hemangioma but increasing for the rest.

CONCLUSION

Learning hepatitis virus infection information showed the highest increase in the F1-Score for HCC, resulting in improved classification accuracy of ultrasound images of hepatic tumors.

Incidental appendiceal mucocele discovery: A case series and literature review

INTRODUCTION

Low-grade appendiceal mucinous neoplasms (LAMNs) are rare entities that can present significant challenges when discovered incidentally by general surgeons during surgery or through postoperative pathology. These lesions may mimic common abdominal conditions and are often not suspected preoperatively.

METHODS

We present a case series of five patients in whom appendiceal mucoceles were incidentally identified either intraoperatively or on postoperative pathological examination. The patients ranged from 36 to 79 years old and presented with symptoms such as right lower quadrant pain, initially attributed to appendicitis, ovarian torsion, or other gynecological conditions. Intraoperative findings varied from dilated appendices with mucinous content to large cystic masses involving adjacent structures.

RESULTS

In each case, the general surgeon had to make immediate decisions regarding management. Surgical interventions included laparoscopic appendectomy and open right hemicolectomy, with an emphasis on careful handling to prevent rupture and spillage of mucin. Postoperative pathology confirmed LAMNs, with tumor stages ranging from pTis to pT4a. Some patients required additional procedures, such as cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC), due to the presence of acellular mucin or peritoneal involvement. The discussion focuses on practical guidance for general surgeons when faced with an incidental appendiceal mucocele. Key recommendations include avoiding intraoperative rupture by gentle handling, assessing the need for extended resection based on intraoperative findings, and ensuring thorough communication with pathology for accurate staging. Postoperative management should involve reviewing pathology reports carefully, considering referral to a multidisciplinary team for higher-stage tumors, and implementing long-term surveillance protocols due to the risk of recurrence.

CONCLUSION

General surgeons play a critical role in the initial management of incidentally discovered appendiceal mucoceles. Prompt recognition and appropriate intraoperative decision-making are essential to optimize patient outcomes. By adhering to careful surgical techniques and collaborating with multidisciplinary teams, surgeons can effectively manage these unexpected findings and mitigate potential complications associated with LAMNs.

Progression From Andrology Fellowship to the Workforce: Lessons Learned and Tactical Points for Consideration

The transition from urology training to the workforce presents many challenges for trainees. This is especially true for andrology fellow graduates aiming to initiate a men's health practice, as the needs of their practice will differ greatly from that of a general urologist. While trainees garner strong mentorship from their fellowship program, they often enter practices without the same resources and clinical support. This offers unique opportunities for business growth and development, which, if handled appropriately, can greatly benefit a urology practice. These tactical points for consideration also have relevance for application to all graduating urologic trainees and young urologists.

Association between long-term exposure to PM2.5 and thyroid nodules in school-aged children and adolescents: a cross-sectional study in Eastern China

BACKGROUND

Long-term exposure to particulate matter with aerodynamic diameter ≤ 2.5 μm (PM2.5) are linked to thyroid nodules in adults, but epidemiological evidence in children and adolescents and adjustments for key confounders are lacking. This study aimed to explore the association between long-term exposure to PM2.5 and the prevalence of thyroid nodules in school-aged children and adolescents.

METHODS

A cross-sectional study including 10,739 primary and junior high school students was conducted in Jiangsu Province, China, in 2021. Annual PM2.5 concentrations were estimated by a satellite based space-time model based on machine learning. Individual exposure concentrations were assigned according to the school addresses of the participants. High-resolution diagnostic ultrasound imaging was used to detect the thyroid nodules. After adjustment for covariates, the link between the two-year (2019-2020) average PM2.5 concentrations and thyroid nodules was estimated using a generalized linear mixed-effects model. The concentration-response (C-R) curves were smoothed using a restricted cubic spline function. Stratified analyses were performed to evaluate the modification effects of covariates on associations.

RESULTS

The average age of the 10,067 participants (51.9% boys) was 11 years, with a thyroid nodule prevalence of 30.5%. A non-linear positive correlation was found between the increase in prevalence of thyroid nodules and two-year average exposure concentration of PM2.5. The C-R relationship curve between thyroid nodules and PM2.5 had a J-shaped structure with a threshold value of 39.7 µg/m3. Following covariates adjustment, the odds ratio (OR) and 95% confidence interval (CI) linked to thyroid nodules were 1.515 (1.199, 1.915) for per standard deviation (SD) increase in two-year average PM2.5 concentrations (> 39.7 µg/m3). The sex-specific associations found among adults were not observed in our stratified analyses.

CONCLUSIONS

Our findings demonstrated that long-term exposure to PM2.5 was associated with a higher prevalence of thyroid nodules in children and adolescents. Strategies that consistently reduce PM2.5 pollution levels to ease the burden of non-communicable diseases have important public health implications.

Biosimilars versus biological therapy in inflammatory bowel disease: challenges and targeting strategies using drug delivery systems

Inflammatory bowel disease (IBD) is a multifactorial illness with a climbing prevalence worldwide. While biologics are commonly prescribed especially for severe cases, they may worsen patients' outcomes due to financial burden. Consequently, there has been an increased focus on biosimilars to improve overall disease outcomes by maintaining similar efficacy and safety while minimizing the cost of therapy. Infliximab-dyyb was the first biosimilar approved by US-FDA for IBD. Since that, the US-FDA approved 14 biosimilars with different mechanisms of action and different routes of administration for IBD patients (four infliximab biosimilars, nine adalimumab biosimilars, and most recently one ustekinumab biosimilar). It should be noted that more biologics are in the pipeline as golimumab and natalizumab patents are set to expire in the near future, and biosimilars are now in pre-clinical to phase 3 trials. Different studies have evaluated biologics' effectiveness and safety and concluded that the majority of available biosimilars are efficacious and have similar adverse effect profiles compared to their reference biologics. It is worth mentioningthat post-marketing surveillance reports revealed some risks associated with biosimilars which should be taken into consideration in future research and clinical trials to avoid health hazards. Most biologics and biosimilars are administered parenterally which results in several drawbacks such as raised risk of infections, hypersensitivity, autoimmunity, development of malignancies, liver toxicity as well as worsening of heart failure. Several drug delivery systems based on passive and active targeting mechanisms are under active investigation to overcome these limitations. This review sheds light on the emergence of biologics and biosimilars as alternatives in IBD management, the differences between them, challenges and risks, and future perspectives in IBD therapy and new trends in drug delivery systems.

Hypermetabolic pulmonary lesions detection and diagnosis based on PET/CT imaging and deep learning models

PURPOSE

This study aims to develop and evaluate deep learning models for the detection and classification of hypermetabolic lung lesions into four categories: benign, lung cancer, pulmonary lymphoma, and metastasis. These categories are defined by their pathological origin, clinical relevance, and therapeutic implications.

METHODS

A lesion localisation model was first developed using manually annotated PET/CT images. For classification, a multi-dimensional joint network was employed, incorporating both image patches and two-dimensional projections. Classification performance was quantified by metrics like accuracy, and compared to that of a radiomics model. Additionally, false-positive segmentations were manually reviewed and analysed for clinical evaluation.

RESULTS

The study retrospectively included 647 cases (409 males/238 females) over more than 8 years from five centres, divided into an internal dataset (426 cases from Shanghai Ruijin Hospital), an external test set I (151 cases from four other institutions), and an external test set II (70 cases from a new imaging device). The localisation model achieved detection rates of 81.19%, 75.48%, and 77.59% on the internal, external test set I, and external test set II, respectively. The classification model outperformed the radiomics approach, with area-under-curves of 88.4%, 80.7%, and 66.6%, respectively. Most false-positive segmentations were clinically acceptable, corresponding to suspicious lesions in adjacent regions, particularly lymph nodes.

CONCLUSION

Deep learning models based on PET/CT imaging can effectively detect, segment, and classify hypermetabolic lung lesions, and identify suspicious adjacent lesions. These results highlight the potential of artificial intelligence in clinical decision-making and lung disease diagnosis.

Delayed-Onset Hemothorax Following Cough-Induced Rib Fracture

Hemothorax, the accumulation of blood in the pleural space, is most frequently linked to chest trauma but can occasionally result from nontraumatic causes such as persistent or forceful coughing. Cough-induced rib fractures are rare, with an even less frequent association with hemothorax. We describe a case involving a 57-year-old male who presented with a worsening cough and left-sided pleuritic chest pain despite prior antibiotic and symptomatic treatment. Initial imaging revealed a minimally displaced 10th rib fracture, left-sided atelectasis, and trace pleural effusion. During his hospital stay, he developed acute respiratory distress and increased chest pain, with repeat imaging revealing a large left-sided hemothorax. Chest tube placement drained 1100 mL of blood, supporting the diagnosis of hemothorax, as evidenced by clinical presentation and imaging, despite the absence of fluid analysis. The patient's condition improved following the intervention, and he was discharged in stable condition without recurrence of hemothorax on follow-up imaging. This case highlights the rare association between cough-induced traumatic rib fractures and delayed development of hemothorax. While rib fractures typically result from blunt trauma, they can also occur from stress or repetitive coughing. Complications such as hemothorax are uncommon but potentially life-threatening. The interval development of hemothorax, as seen in this patient, underscores the importance of serial monitoring in cases of rib fractures with ongoing symptoms. Clinicians should maintain a high index of suspicion for hemothorax in patients presenting with rib fractures and persistent cough, particularly in the context of worsening respiratory symptoms or pleuritic chest pain. Early recognition and timely intervention are critical to optimizing outcomes and mitigating the risks of rapid clinical deterioration.

Synchronous management of urethral stricture disease and penile prosthesis implantation: a case series

There is currently limited data to describe managing a urethral stricture identified while attempting penile prosthesis placement. This study reports our management of urethral strictures during penile prosthesis placement and proposes a guideline for this event. A retrospective analysis was performed on patients who underwent penile prosthesis implantation and had incidentally found urethral stricture disease from 2009 to 2023. Cases that proceeded to the placement of penile implant were classified as "completed," while cases that could not proceed were classified as "aborted." Successful management was defined as the absence of complications requiring explantation within 90 days of the procedure. Twenty-four cases were identified. Of these twenty-four patients, eighteen had completed procedures, while six had their procedures aborted. Within 90 days after the procedure, one patient presented with urinary retention. No patients had penile prosthesis infections within 90 days. Of the six "aborted" patients, five had strictures greater than 2 cm in length with urethral lumens between 8-10F. One patient had an obliterated urethra; three patients underwent urethroplasty; one patient underwent urethral dilation and suprapubic tube placement; and two patients underwent a direct vision internal urethrotomy. This retrospective study surrounding synchronous penile prosthesis implantation and urethral stricture disease management yielded high success and low complication rates.

Yellow enhance mode is useful for distinguishing tissues in endoscopic transnasal surgery: case series with preliminary results

Precise tissue differentiation is vital in neurosurgery, especially during endoscopic endonasal surgery (ETS), where visual information is critical. The Yellow Enhance (YE) mode, a novel image-enhanced endoscopy technology, emphasizes yellow pigments to potentially improve tissue differentiation. This study retrospectively evaluated the efficacy of YE mode in five cases (two primary pituitary neuroendocrine tumors, one recurrent skull base-invasive pituitary neuroendocrine tumor, one pituitary apoplexy, and one recurrent craniopharyngioma) using the Olympus VISERA ELITE III endoscope. Eight experienced neurosurgeons reviewed surgical videos and provided 40 structured evaluations. Statistical analyses (Kruskal-Wallis and Mann-Whitney U tests) compared scores among cases. Gross or near-total resection was achieved in all cases without neurological complications. YE mode improved differentiation between normal pituitary tissue and tumors in 80% of cases, but was less effective in cases like pituitary apoplexy with degenerative changes. Across 40 evaluations, 68% rated YE mode as "useful" or "somewhat useful," while 20% noted limited utility in complex cases, such as recurrent craniopharyngiomas. YE mode shows promise in enhancing visual differentiation during ETS, particularly for normal pituitary tissue, but its utility depends on tissue characteristics. Larger prospective studies are needed to validate these findings and explore broader applications in neurosurgery.

Presence and characterization of the human pathogenic Vibrio species in the microbiota of Manila clams using cultural and molecular methods

The North Adriatic lagoons and the Po River Delta are important areas for farming Manila clams (Ruditapes philippinarum). These areas have been heavily impacted by climate change, reducing livestock numbers and increasing pathogen spread. Shellfish, particularly clams, are primary vectors for Vibrio pathogens affecting humans. In this study, the occurrence of human pathogenic Vibrio species on Manila clams was investigated using an integrated approach that combined culture-dependent and culture-independent techniques. Samples were collected over three years from farming areas in the northeastern Adriatic lagoons and the Po River Delta, regions seriously impacted by climate change and pollution. In this study, species of the human pathogen Vibrio were analyzed in the clam microbiota and characterized using recA-pyrH metabarcoding and shotgun metagenomics. Human pathogenic Vibrio species were widespread in the clam microbiota, especially in summer, demonstrating that the environmental conditions on the northern Adriatic coasts allowed the growth of these bacteria. V. parahaemolyticus and V. vulnificus were also quantified using qPCR in <50 % of summer samples Shotgun metagenomics revealed the similarity of V. parahaemolyticus strains to other worldwide genomes, enabling improved pathogen identification and tracking. In the future, climate change could cause these conditions to become even more favorable to these bacteria, potentially increasing pathogen spread. Consequently, enhanced monitoring and control of both the environment and seafood products should be planned to ensure food safety.

Hemothorax: When Hemosuccus Pancreaticus Takes an Unexpected Detour to the Chest

This case highlights an unusual presentation of bilateral pleural effusion associated with chronic pancreatitis, emphasizing that although pleural effusions are typically unilateral and left-sided, they can occasionally be bilateral. In acute or chronic pancreatitis, pleural effusions are generally transient and resolve once the underlying condition is appropriately managed. While most effusions are left-sided, they may rarely occur on the right side or present bilaterally, as observed in this patient. These effusions are typically exudative, with elevated pleural fluid amylase as a key diagnostic indicator of pancreatic origin. A 37-year-old male with a history of chronic alcohol consumption initially presented with evidence of a right-sided pleural effusion. Elevated amylase levels in the pleural fluid strongly suggested a pancreatic etiology. After a week of hospitalization, the patient developed a left-sided pleural effusion, further complicating the diagnosis. This is a rare and severe complication of hemosuccus pancreaticus (HP), which can result from hemorrhage through the ampulla of Vater or the pancreatic duct, often due to the rupture of surrounding structures such as the splenic artery. Although HP is a challenging diagnosis, computed tomography angiography (CTA) remains the gold standard for identifying the bleeding source and confirming the diagnosis. Pancreatitis should be strongly considered when a pleural effusion exhibits elevated amylase levels. Prompt identification and treatment of the underlying pancreatic condition and management of complications such as HP are crucial for resolving the effusion and improving the patient's prognosis. Early diagnosis and intervention generally lead to a favorable outcome, as these effusions are typically transient and resolve with appropriate treatment of the underlying pancreatic disorder.

Trauma-induced tetanus: case series and an up-to-date pharmacoeconomic overview in Nepal

Introduction and significance

Tetanus is an acute, fatal, and vaccine-preventable infectious disease which is caused by anaerobic bacteria Clostridium tetani. This case series emphasizes on the importance of vaccine, and impact of financial status in the recovery of the patient and pharmacotherapeutic review of tetanus.

Methods

This case series was performed at the Department of Internal Medicine at a Tertiary Teaching Hospital. The authors here report two cases of rare and fatal tetanus that were diagnosed clinically, their treatment modality, and impact of socioeconomic status on the prognosis. The authors also review different pharmacotherapeutic modalities of tetanus.

Discussion

Tetanus is a fatal disease, which requires antitoxin measures, spasm control, and airway management. The treatment of this disease requires prolonged; intensive care unit stay which also increases the incidences of other comorbid fatal conditions like pneumonia. This case series presents cases of 39-years-old male and 41-years-old male who presented to the hospital after cut injury, however financial constraints of 41 years old male made him withdraw from ventilator support whereas 39-years-old male had good recovery due to his better financial status and immunoglobulin access in time.

Conclusion

In this study, we describe the clinical history of a rare and fatal but vaccine-preventable condition, tetanus associated with comorbidities, in an adult male who was successfully treated and another who chose to discontinue treatment due to financial constraints, resulting in death.

Cutaneous metastasis from gastrointestinal cancer: A rare presentation: Case series

INTRODUCTION

Cutaneous metastases (CM) from Gastro intestinal (GI)malignancies are rare. It usually occurs lately in cancer evolution. The treatment is mostly palliative.

METHODS

This was a retrospective review of the available clinical and histological records of all patients with CMs from GI malignancies treated at our institute during 17 years (2000-2016).

RESULTS

Eight cases of CMs were recorded: (5males and 3 females. Meanage was 59 years (45-90 years). CM revealed gastro intestinal (GI) malignancy in fourcases. The metastasis was unique in 5 cases and multiple in Three cases. It was located in the thorax, the abdomen the face,the axillary region and in the trunk. The primary site was gastric (3 cases), colorectal in two cases, biliary in one pancreatic case and undetermined in one case. Treatment was palliative in all cases and overall survival after diagnosis ranged from one month to three months.

CONCLUSION

Cutaneous metastasis can be the presenting symptom of cancer or may occur in the evolution. It can mimic benign skin lesions. Treatment is often palliative based on chemotherapy the role of surgical excision is not clear. The prognosis is poor.

Transurethral migration of vesical gossypiboma following open prostatectomy: a case report and review of the literature

Gossypiboma refers to a retained surgical sponge within the body after a surgical procedure. It is commonly reported in the abdominal cavity and is rare in the urinary bladder (vesical gossypiboma). There are only a few reports of vesical gossypiboma in the literature, and patients often present long after the initial surgery. Features of recurrent urinary tract infections (UTIs) are common symptoms of vesical gossypiboma, but transurethral migration is a rare manifestation. We present a case of vesical gossypiboma with transurethral migration in a 64-year-old patient who underwent an open trans-vesical prostatectomy 3 months before visiting our hospital. He was repeatedly treated for recurrent UTIs until the diagnosis of vesical gossypiboma was finally confirmed using cystourethroscopy. We successfully removed the retained gauze via open bladder exploration. Gossypiboma can easily be overlooked, and we urge urologists to maintain a high index of suspicion to diagnose similar cases promptly.

Liver Transplant Provider Perspectives on Posttransplant Management of Alcohol Use Disorder

Background

Liver transplantation (LT) is the standard treatment for liver failure secondary to alcohol-associated liver disease, but limited literature and best practices exist for post-LT treatment of alcohol use disorder (AUD). This study explores current AUD management practices and providers' perceived barriers to effective post-LT AUD management.

Methods

A 45-item survey on post-LT AUD treatment practices was distributed to members of the American Society of Transplant Surgeons, the Association of Consult/Liaison Psychiatry Transplant Special Interest Group, and both the American Society of Transplantation's Liver and Intestine Community of Practice and Psychosocial and Ethics Community of Practice discussion boards, between December 2021 and April 2022. Univariate analysis of categorical variables was performed using the chi-square test. Data were analyzed using center volume tertiles, country region, and provider professional activity.

Results

Two hundred thirty-two respondents from 70 LT centers across all 11 United Network for Organ Sharing regions completed the survey. Half of the them were attending physicians and 16.4% were nurse coordinators. Most centers (84%) aimed for alcohol abstinence for all post-LT patients. Perceived barriers to AUD treatment efficacy included ongoing desire to drink (18%), denial about alcohol misuse (14.9%), and lack of posttransplant support (14%). Additionally, 62.1% of centers had no policy for prescribing medication-assisted therapy to treat AUD, and 32.7% of centers reported no center-level changes in AUD care. Providers identified primary needs as hiring additional mental health professionals (30.8%), dedicating specific staff to AUD care (24.7%), and standardizing psychiatric/psychological care in transplant clinics (17.2%).

Conclusions

Despite the increasing volume of LT for alcohol-associated liver disease, significant perceived barriers to effective AUD treatment remain.

The Role of Artificial Intelligence and Big Data for Gastrointestinal Disease

Artificial intelligence (AI) is a rapidly evolving presence in all fields and industries, with the ability to both improve quality and reduce the burden of human effort. Gastroenterology is a field with a focus on diagnostic techniques and procedures, and AI and big data have established and growing roles to play. Alongside these opportunities are challenges, which will evolve in parallel.

Oral delivery of ultra-small zwitterionic nanoparticles to overcome mucus and epithelial barriers for macrophage modulation and colitis therapy

Ulcerative colitis (UC) is a chronic inflammatory disease of the colon that poses significant therapeutic challenges due to the intestinal mucus and epithelial barriers. In this study, ultra-small zwitterionic nanoparticles (HC-CB NPs) is developed based on glutathione (GSH)-responsive hyperbranched polycarbonate to enhance the oral delivery of drugs and overcome these physiological barriers. HC-CB NPs demonstrate high colloidal stability across a wide range of pH environments and physiological fluids, preventing premature drug release within the gastrointestinal tract. The ultra-small sized HC-CB NPs demonstrate minimal mucin adsorption and effectively penetrate through the mucus layer, and the zwitterion surface further facilitate epithelial barrier crossing via the proton-assisted amino acid transporter 1 (PAT1) pathway. HC-CB NPs mediate enhanced macrophage uptake via monocarboxylate transporters (MCTs) pathway and ultimately improved therapy efficacy on colitis. The in vivo results reveal that FK506-loaded HC-CB NPs (HC-CB NPs@FK506) significantly reduce inflammatory markers (TNF-α, IL-6) and myeloperoxidase (MPO) levels, while promoting epithelial integrity by increasing E-cadherin expression. This study offers a promising approach to overcoming intestinal barriers in oral UC treatment, offering biocompatibility and potential for clinical translation. STATEMENT OF SIGNIFICANCE: Ulcerative colitis (UC) is a chronic inflammatory disease of the colon that poses significant therapeutic challenges due to the intestinal mucus and epithelial barriers. This study explores an oral UC therapy using ultra-small zwitterionic nanoparticles (HC-CB NPs) constructed from GSH-responsive hyperbranched polycarbonate. Compared to existing strategies, HC-CB NPs demonstrate minimal mucin adsorption and effectively penetrate through the mucus layer, and the zwitterion surface further facilitate epithelial barrier crossing via the proton-assisted amino acid transporter 1 (PAT1) pathway. Additionally, HC-CB NPs mediate enhanced macrophage uptake via monocarboxylate transporters (MCTs) pathway, resulting in improved therapeutic efficacy. These findings underscore the potential of HC-CB NPs as a transformative platform for overcoming intestinal barriers in UC treatment.

Workplace Verbal Violence Toward Romanian Doctors and Nurses: Prevalence, Contributing Factors, and Psychological Correlates

Background/Objectives: Workplace violence is a critical issue in the healthcare sector, with verbal violence being the most common form. This study is the first of its kind in Romania aiming to analyze the prevalence, characteristics, contributing factors, and psychological correlates of verbal workplace violence on doctors and nurses. Methods: A cross-sectional study was conducted using a questionnaire distributed online between February and April 2022 to doctors and nurses across Romania. Data were analyzed using descriptive statistics, the chi-squared test, and multivariate logistic regression to evaluate contributing factors and response patterns. Results: Out of 7951 participants, 56% of doctors and 9.2% of nurses reported experiencing verbal violence in the past 12 months (p = 0.001). Shift work and night shifts significantly increased the risk of verbal violence for both groups. Women were more vulnerable, with higher exposure among nurses (OR = 1.687; p = 0.001) and doctors (OR = 1.940; p = 0.001). The main aggressors were patients and patients' relatives in both groups of participants, while vertical violence was more common among doctors. Formal reporting was low, although active reactions were more common. In terms of psychological correlates, doctors reported greater psychological strain than nurses (p = 0.001). Conclusions: This study highlights a critical need for system-wide interventions to address verbal violence in the Romanian healthcare system. Measures such as reporting protocols, staff training on conflict management, and organizational support systems are essential to prevent verbal violence and combat its contributing factors. Implementing these strategies could significantly improve the safety and well-being of healthcare professionals.

Impact of weight loss and lifestyle intervention on vitamin D in men with obstructive sleep apnea: The INTERAPNEA trial

INTRODUCTION

Vitamin D deficiency is commonly found among patients with obstructive sleep apnea (OSA). We aimed to determine the effect of an eight-week interdisciplinary weight loss and lifestyle intervention on circulating vitamin D levels in patients with moderate-to-severe OSA.

METHODS

89 men were assigned to a usual-care group (n = 49) or an 8-week interdisciplinary weight loss and lifestyle intervention combined with usual-care (n = 40). Evaluations were conducted at baseline, intervention endpoint (i.e., 8 weeks), and 6 months post-intervention. Serum 25-hydroxyvitamin D (25(OH)D) was determined using a chemiluminescence immunoassay. Sleep (i.e., sleep efficiency, apnea-hypopnea index [AHI], and oxygen desaturation index) and body weight and composition (i.e., fat mass, and visceral adipose tissue) variables were also determined.

RESULTS

Serum 25(OH)D concentrations showed an insufficient vitamin D status at baseline, which significantly increased (all p ≤ 0.034) at intervention endpoint (19 %) and at 6 months after intervention (45 %) in the intervention group to the point of potentially resolving vitamin D deficiency. Higher serum 25(OH)D concentrations were related to increased sleep efficiency and reduced AHI, oxygen desaturation index, and body weight and composition variables (all p < 0.001) from baseline to 6 months and from 8 weeks to 6 months after intervention. These results were also noted from baseline to 8 weeks, except for body composition (all p ≤ 0.007).

CONCLUSION

The intervention improved and potentially resolved vitamin D deficiency. Together with the improvement of adverse sleep patterns and body composition parameters, it may be considered as a promising approach in the treatment of OSA.

CLINICAL TRIAL REGISTRATION

(ClinicalTrials.gov NCT03851653).

High-Flow Oxygen Therapy to Support Inpatient Pulmonary Rehabilitation During Very Severe Hepatopulmonary Syndrome Recovery Post Liver Transplant: A Case Report

This case study reports the novel use of inpatient pulmonary rehabilitation (PR) with near-maximal high-flow oxygen therapy in a patient recovering from very severe hepatopulmonary syndrome (HPS) following liver transplantation. HPS is a rare condition where advanced liver disease alters lung microvasculature through intrapulmonary vascular dilatation (IPVD) and angiogenesis. Platypnoea-orthodeoxia (postural dyspnoea with concurrent blood oxygen desaturation) is characteristic of HPS due to redirection of blood flow to the basal lung where IPVDs are more prominent, secondary to gravity. Currently, the only definitive treatment is liver transplantation, which allows normalization of oxygenation over an extended period, typically within 1 year. Pulmonary rehabilitation is an effective intervention for improving dyspnoea, health-related quality of life (HRQoL), and exercise capacity in people with chronic respiratory disease. Despite this, little is known of the effect PR has on individuals recovering from HPS post liver transplant. The aim is to describe an inpatient PR program for a patient recovering from HPS. This case study describes a 27-year-old male with "very severe" HPS who undertook inpatient PR 5 months posttransplant. The patient completed an 8-week program of twice-weekly PR supported by high-flow oxygen therapy (fraction of inspired oxygen of 90%). He performed aerobic and resistance exercises for the upper and lower limbs in recumbent, seated, and standing positions. The patient improved in exercise capacity on the 1-min sit-to-stand test (+4 repetitions), lower limb strength on the 5-repetition sit-to-stand test (-3.4 s) and in HRQoL outcomes assessed. Following rehabilitation, the patient still had a high burden of respiratory symptoms and required continuous high-flow oxygen therapy. This case study demonstrates that inpatient PR, modified for HPS-associated platypnoea-orthodeoxia and supported by high-flow oxygen therapy, is safe and effective and therefore feasible for other HPS patients.

Trans-nasal dental implants: indication and the report of 10 cases

Background

The rehabilitation of the atrophic maxillae with dental implants represents a challenge that can be addressed with zygomatic dental implants and traditional axial implants. In the event of a severely atrophic pre-maxilla, a quad-zygoma approach may be necessary to provide anchorage for the fixed restoration. The proximity of anatomical features can increase the possible morbidity of the quad-zygoma approach and instead, trans-nasal implants may serve as a viable anterior anchorage alternative in the atrophic pre-maxilla region.

Methods

A total of 10 patients diagnosed from a class 2B edentulism received a combined treatment with trans-nasal implants paired with a single zygomatic implant were included in this study. Trans-nasal implant marginal bone level changes were evaluated on CBCT (Cone Bean Computed Tomographic) images taken immediately after trans-nasal implant placement and 1 year of follow-up post loading. The reference point for the CBCT measurement of mesial and distal bone loss after 1 year was the horizontal interface between the implant and the abutment. Secondary measurements taken at the 1 year follow up measured the amount of bone available in the sub-nasal, lateral and apical areas of the dental implant in contact with bone.

Results

The retrospective CBCT analysis of 18 trans-nasal implants (size ranging from 22 to 25 mm with an average of 24.1 mm) placed in 10 patients (all 10 patients were female ranging from 38 to 67 years old with an average age of 59.1 years old) shows an average marginal bone loss of 0.70 mm over a time period of 1 year following restorative loading, P < 0.0001. While the sub-nasal, lateral and apical engagement shown respectively 5.46, 12.92, and 2.70 mm of radiographical bone contact with the implant.

Conclusion

The marginal bone loss observed in trans-nasal implants 1 year post loading is comparable to the marginal bone loss of conventional implants under similar conditions. The cumulative radiographical bone to implant contact between the subnasal and the apical bone seems to be of a value of 8.16 mm which seems to correspond to the size of a conventional dental implant. Therefore, it is believed that trans-nasal implants can be considered as an acceptable anterior anchorage alternative to the superior/ anterior zygomatic dental implant in the atrophic pre-maxilla region when paired with a single posterior zygomatic implant.