Traumatic crown-root fractures involving previously endodontically treated anterior teeth can present substantial restorative difficulties, particularly when the fracture line extends below the alveolar crest and compromises the remaining tooth structure. Preservation of the alveolar ridge following extraction is essential to facilitate future implant-supported rehabilitation and optimize aesthetic outcomes. This report describes the management of a 17-year-old male who presented with pain and mobility of the maxillary right central incisor following dental trauma. The tooth had undergone prior root canal treatment but lacked a definitive coronal restoration. Clinical and radiographic evaluation revealed a horizontal crown-root fracture extending subcrestally, accompanied by a defect in the labial cortical plate. Owing to the unfavorable restorative prognosis, limited residual tooth structure, and inability to establish a predictable ferrule, the tooth was considered nonrestorable and extracted atraumatically. Socket preservation was performed using sticky bone prepared from injectable platelet-rich fibrin, advanced platelet-rich fibrin, and xenograft particles, followed by provisional rehabilitation with a Maryland bridge. Radiographic assessment after three months demonstrated adequate preservation of ridge architecture, permitting placement of a 3.5 × 13 mm dental implant with simultaneous guided bone regeneration. Definitive prosthetic rehabilitation was subsequently completed. This case highlights the potential benefit of combining autologous platelet concentrates with xenograft material for ridge preservation after the extraction of nonrestorable traumatized teeth, thereby supporting predictable implant placement and favorable functional and aesthetic outcomes in adolescent patients.
Introduction The use of health services expanded during the pandemic and became a regular part of healthcare. There is not a lot of information about how these services are used over the long term and how patients engage with them. This study examined how patients used telemental health services at King Abdulaziz Medical City (KAMC), Riyadh, Kingdom of Saudi Arabia, from 2019 to 2025. Objectives To evaluate how telemental health services were used and how patients engaged with them during the time before the pandemic, during the pandemic, and after the pandemic. The study also compared how many appointments were completed and the characteristics of patients who had virtual appointments versus in-person appointments. Methods This was a retrospective, repeated cross-sectional census study of electronic health record data on all scheduled mental health appointments, virtual and in-person, at KAMC from January 1, 2019, to December 31, 2025. All eligible encounters and unique patients across 12 facilities were included using total enumeration rather than sampling. Data were cleaned and analyzed in Python using Google Colab. Descriptive statistics were used to summarize appointment and patient characteristics. Chi-square tests were used to compare categorical variables, including appointment completion by encounter type, and the Mann-Whitney U test was used to compare patient age between virtual and in-person appointments. A binary logistic regression model was used to identify factors associated with appointment completion, including encounter type, pandemic period, and patient demographics. Results The study included 479,643 appointments with 51,323 patients at 12 facilities. Overall, 9% of the appointments were virtual. In 2019, there were no appointments, but their use increased during the pandemic and then stayed steady at around 11% to 12% per year after 2021. Overall, 55% of appointments were completed. Virtual appointments had a higher completion rate than in-person appointments, with 60% of virtual appointments being completed compared to 54% of in-person appointments. We also found that patients who had virtual appointments were substantially older and that virtual appointments were mostly used for follow-up visits rather than new patient appointments.  Conclusion Telemental health services went from being an emergency solution during the pandemic to a part of mental health services at the facility. The study found that virtual appointments were associated with patient engagement, which means that patients were more likely to complete their appointments. These findings support the continued use of a hybrid of in-person and virtual mental health services. The findings provide information to support the planning and development of telemental health services. Telemental health services are a part of the healthcare system, and they can be an effective way to deliver the services.
Volume-targeted ventilation (VTV) is an evidence-based, lung-protective strategy demonstrated to reduce the incidence of bronchopulmonary dysplasia (BPD) and severe neurologic injury in premature infants. While variations in VTV adoption are well-documented in North America and Europe, data characterizing its utilization across the broader Middle East remains limited. To evaluate the utilization rates of VTV, the selection of tidal volume (VT) targets across various clinical scenarios, and the perceived barriers to VTV implementation among practicing neonatologists in the United Arab Emirates (UAE). A cross-sectional survey was distributed to practicing neonatologists across multiple regions in the UAE. The survey assessed clinician and unit characteristics, core ventilation practices, scenario-based VT targeting, and barriers to VTV implementation. A total of 94 responses were analyzed. VTV was the most commonly reported invasive mode, with 78 (84.8%) of respondents classified as regular VTV users. VTV was predominantly utilized across both the acute and weaning phases of ventilation, with 60 (64.5%) respondents reporting its use. The reported median VT limits ranged from 4.0 to 6.0 mL/kg. Scenario-based responses revealed a median initial VT target of 5.0 mL/kg for a 500-g, 24-week infant with respiratory distress syndrome (RDS), 5.0 mL/kg for a term infant with meconium aspiration syndrome (MAS), and 4.0 mL/kg for an infant with congenital diaphragmatic hernia (CDH). High-frequency oscillatory ventilation (HFOV) was widely used (78, 97.5%); however, the use of volume guarantee (VG) during HFOV remained uncommon (28, 36.4%). Regular VTV use was significantly associated with ≥10 years of experience (P = 0.011) and practice in an academic/training level III NICU (P = 0.021). Unlike North American cohorts, the primary reported barrier to VTV adoption in the UAE was equipment unavailability rather than a lack of clinical understanding. The UAE demonstrates a high rate of VTV adoption, aligning with the most progressive international benchmarks. However, scenario-specific VT targeting reveals a tendency to default to standard volumes regardless of the underlying lung pathophysiology. Continued efforts should focus on optimizing equipment availability and providing targeted education on individualizing VT settings to further elevate neonatal respiratory care.
Giant cell arteritis (GCA) is a large vessel vasculitis classically presenting with headache, jaw claudication, visual disturbance, and raised inflammatory markers. However, atypical presentations occur, and a delay in recognition can lead to irreversible visual loss. We report a 75-year-old male with sequential ocular involvement in whom erythrocyte sedimentation rate and C-reactive protein remained within normal limits. Carotid/vertebrobasilar imaging showed atherosclerotic change without critical stenosis, and 18F-fluorodeoxyglucose PET demonstrated vertebral arterial uptake consistent with cranial GCA. High-dose corticosteroids were commenced with rheumatology input. Normal inflammatory indices do not exclude GCA. Clinicians should maintain a high index of suspicion when visual symptoms evolve and initiate treatment without delay where clinical probability is high.
Antineutrophilic cytoplasmic antibodies glomerulonephritis (ANCA-GN) is the most common type of crescentic glomerulonephritis in the elderly. It is life-threatening, and early detection is key to facilitating complete remission with treatment. Albeit rare, more reports are implicating hydralazine use in the development of ANCA-associated vasculitis (AAV) and ANCA-GN. Classic treatment involves the use of corticosteroids with cyclophosphamide (+/- plasmapheresis) in ANCA-GN. However, a definite therapeutic approach and duration for drug-induced AAV has yet to be studied in clinical trials. In our case, we aim to provide another approach that would one day improve and structure therapy guidelines for drug-induced AAV. We present a 75-year-old female patient, with medical history of hypertension, atrial fibrillation status post ablation on anticoagulation, pulmonary hypertension, who came to the nephrology clinic with symptoms of fatigue, anorexia, nausea, weight loss, hemoptysis, and rise in serum creatinine to 2.39 mg/dL from baseline of 0.65 mg/dL, and by admission to the hospital in August 2024 was 4.6 mg/dL. Anti-MPO and anti-histone antibodies were positive; complement was normal. Renal biopsy confirmed pauci-immune necrotizing GN with crescents. Therapy included steroids, rituximab, cyclophosphamide, and plasmapheresis with clinical improvement and complete remission of extra-renal disease.
Post-acute sequelae of SARS-CoV-2 infection (PASC), commonly referred to as long COVID, is characterized by persistent symptoms, including fatigue, cognitive dysfunction, pain, and neuropsychiatric complaints, that can impair daily functioning. Proposed mechanisms are heterogeneous and may include autonomic dysregulation in a subset of patients. Stellate ganglion block (SGB) is a cervical sympathetic block used to treat symptoms of post-traumatic stress disorder (PTSD), anxiety, and, more recently, PASC. A 58-year-old man with a history of attention-deficit/hyperactivity disorder, generalized anxiety disorder, obsessive-compulsive disorder, autism spectrum disorder, PTSD, and chronic musculoskeletal pain developed persistent post-COVID symptoms following infection in March 2020, including brain fog, slowed information processing, word-finding difficulty, worsening anxiety, impaired balance, and reduced hand-eye coordination that significantly impaired occupational functioning as a chef. In January 2023, sequential left- and right-sided SGBs one week apart were performed to address cognitive dysfunction, fatigue, pain, and anxiety. Follow-up documentation described marked improvement in anxiety, frustration tolerance, and cognition lasting approximately six months. Repeat right-sided SGBs were performed in December 2024 and September 2025 for recurrence of symptoms and were again associated with symptomatic improvement. This is the first case demonstrating both longitudinal and reproducible functional improvement in cognitive symptoms, anxiety, and pain following serial SGBs in a patient with PASC complicated by psychiatric comorbidity and chronic pain. Although emerging observational literature suggests potential benefit of SGB in selected patients with PASC, prospective controlled studies are required to determine efficacy, mechanisms, and long-term outcomes.
3D printing has multiple applications in the practice of medicine, including but not limited to the construction of 3D models to facilitate training in ultrasound-guided regional anaesthesia. Such models are typically far less expensive than commercially developed "phantom" trainers, making them particularly attractive in scenarios where budget constraints may impact regional anaesthesia training opportunities. The PEricapsular Nerve Group (PENG) block is a relatively recently described regional anaesthesia technique that is particularly useful in providing post-operative analgesia to patients undergoing hip replacement. To date, there are very few commercially available phantom models that permit the practice of the PENG block ex vivo, and those that do exist are considerably costly to purchase. This report describes the process of using readily accessible home 3D printing technology to create an extremely low-cost, simple-to-assemble phantom of the hip region, suitable for practicing the needling techniques necessary to carry out the PENG block. It may be of particular interest to regional anaesthesia training centres where funding issues present an obstacle to purchasing commercial models. The report demonstrates construction feasibility and preliminary sonographic usability of such a phantom, without formal evaluation of trainee learning, expert-rated fidelity, and comparative educational value. Free, open-source software and 3D models were used to prepare an appropriate pelvic model for printing. Stereolithography (SLA) 3D printing technology was used to produce a resin-based model of the pelvis, with gelatine utilised to create a tissue layer encompassing the model. A sonographic representation of the psoas tendon (a notable landmark in the block) was created, utilising pasta strands encompassed in nitrile and embedded in the gelatine at the expected location along the pelvic brim. The ultrasound characteristics of this phantom were reasonable, and the phantom permitted multiple needling attempts. The total cost for the production of this phantom was slightly over 12 euros (excluding initial 3D printer purchase and post-processing materials), and the total preparation time was 20 hours, including print time, print pre- and post-processing time, and gelatine setting times. This 3D phantom was produced using home 3D printing technology and affordable, readily available materials, for an exceptionally low cost and relatively fast production time. The limitations of the phantom include a short shelf life if not frozen, simplified anatomy, and relatively low ultrasonographic soft-tissue fidelity. Additional strategies for improving these aspects are discussed and could be implemented if desired.
Background Muscle strength is a key factor determining metabolic health, physical performance, and morbidity. Although body mass index (BMI) is used widely to assess obesity, it does not assess body composition adequately. Percentage body fat (PBF) could provide a better estimate of adiposity and its association with muscle strength, particularly in Asian populations with higher body fat at lower BMI levels. We aimed to evaluate the associations of BMI and PBF with HGS and lower limb muscle strength among North Indian adults and to compare the independent associations of BMI and PBF with HGS. Methodology This cross-sectional study included 1,513 apparently healthy adults aged 18 to 60 years. Anthropometric measurements, BMI, and PBF were measured using bioelectrical impedance analysis. HGS was measured using a Jamar hydraulic dynamometer, and lower limb muscle strength was tested using a handheld dynamometer. Correlation and multiple regression analyses were performed to assess the association of BMI and PBF with muscle strength. Results The average age of the participants was 38.25 ± 9.76 years, and 54.5% were males. PBF showed a significant inverse association with HGS for both hands. For the right HGS, the regression coefficient B was -0.619 with an R² of 0.331, while for the left HGS, B was -0.594 with an R² of 0.336 (p < 0.001 for both). However, BMI showed a comparatively weaker association with HGS, explaining less than 2% of the variation. Higher BMI was significantly associated with greater lower limb muscle strength (p < 0.001), while no significant association was found between BMI categories and HGS. Multivariable regression analysis further showed that PBF remained independently associated with HGS (p-value < 0.001 for both hands). Conclusions According to our study, PBF demonstrated a stronger association with muscle strength than BMI. These findings show that relying on BMI alone is insufficient and suggest including body composition assessment to identify individuals at risk of reduced muscle strength and related health complications.
Granulicatella elegans (G. elegans) is a fastidious, nutritionally variant streptococcus (NVS) that represents a rare but clinically significant cause of infective endocarditis (IE), particularly in patients with congenital heart disease (CHD). Diagnosis is frequently delayed owing to its specific culture requirements and an indolent, non-specific clinical presentation. We present a case of a six-year-old male with complex CHD who presented with an 11-day history of low-grade fever, anorexia, and asthenia. Seven months prior, he had undergone dental caries repair without antibiotic prophylaxis. Transthoracic echocardiography (TTE) showed no vegetations. After 18 days of incubation in enriched culture media, blood cultures yielded the identification of G. elegans. A diagnosis of possible IE was established per the modified Duke criteria. Treatment with ceftriaxone and gentamicin was initiated per the European Society of Cardiology (ESC) 2023 guidelines, subsequently switched to vancomycin due to hematological toxicity. The patient was discharged in stable condition and remained asymptomatic at a three-year follow-up. Comparison with five previously published pediatric cases of Granulicatella IE was made. G. elegans IE should be considered in any child with CHD and prolonged unexplained fever, even in the absence of classical echocardiographic findings.
Penile fracture is a rare and underreported urological emergency, defined as traumatic rupture of the tunica albuginea of the corpus cavernosum. Most cases result from vigorous sexual intercourse or direct blunt trauma to an erect penis. While conservative management was once standard, high rates of long-term complications - including severe penile curvature, fibrotic plaques, and permanent erectile dysfunction (ED) - have led to a universal preference for immediate surgical repair. Although anatomical and physiological outcomes after surgery are well documented, the long-term psychosexual impact remains poorly characterised. Many patients report performance anxiety, fear of recurrence, and changes in sexual habits, but these experiences are often overlooked in favour of objective hemodynamic assessments. This scoping review aims to map and synthesise current evidence on functional, sexual, and psychosexual outcomes after surgical repair of penile fractures. Specifically, it examines the impact of surgical timing on erectile function, identifies independent risk factors for postoperative ED, and evaluates psychological effects on sexual satisfaction, relationship dynamics, and ejaculatory function. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) framework. Comprehensive searches were conducted in PubMed/MEDLINE, EMBASE, the Cochrane Library, SCOPUS, and Web of Science. Data charting included patient demographics, injury mechanisms, diagnostic methods, surgical timing, and validated psychometric assessments across nine core studies. Immediate surgical intervention, ideally within 24 hours, is the gold standard and is associated with lower postoperative ED rates (6.5% to 16.5%) than delayed surgery (up to 42.9%) and conservative management (up to 52.9%). Independent predictors of poor outcomes include age over 50, urethral injury, bilateral corporal involvement, and tunical defects larger than 2 centimetres. Early repair reduces scarring and penile curvature. However, psychosexual outcomes remain complex. While erectile function is usually preserved, many patients experience psychogenic issues. Up to 77.5% report persistent fear of recurrence, and nearly 69% change their sexual habits. Changes in ejaculatory latency are also observed and correlate with higher depressive scores. Broad psychiatric screening tools do not show increased rates of clinical depression or generalised anxiety, indicating that psychological distress is specific to sexual performance and relationships. Immediate surgical repair remains the standard approach for preserving erectile function and anatomical integrity after penile fracture. However, postoperative recovery should not be assessed solely by structural or hemodynamic outcomes. The available evidence suggests that some patients experience persistent fear of recurrence, avoidance behaviours, performance anxiety, and reduced sexual confidence after repair. These findings highlight the need for more consistent assessment of psychosexual outcomes in follow-up studies. Multidisciplinary postoperative support, including psychological counselling, sexual health assessment, and partner-centred care, may be considered where clinically appropriate, but further research is needed to define optimal follow-up and rehabilitation strategies.
Pulmonary lymphangitic carcinomatosis (PLC) and pulmonary tumor embolism (PTE) are rare manifestations of metastatic malignancy that may mimic more common causes of dyspnea and pulmonary hypertension, often leading to delayed diagnosis. Both conditions are associated with poor prognosis and may present with rapidly progressive right ventricular failure. A 45-year-old female lifelong non-smoker with no significant past medical history presented with a two-week history of cough, pleuritic chest pain, and worsening fatigue. CT pulmonary angiography was negative for central macrovascular pulmonary embolism but demonstrated interlobular septal thickening, ground-glass opacities, pulmonary nodules, and vertebral lesions. Initial echocardiography showed mild to moderate pulmonary hypertension with preserved right ventricular function. Despite supportive management, the patient experienced rapid clinical deterioration, progressing to severe pulmonary hypertension, right ventricular failure, cardiogenic shock, and pulseless electrical activity arrest. Post-mortem examination revealed invasive pulmonary adenocarcinoma with extensive lymphovascular invasion and metastatic disease, consistent with PLC and PTE. This case emphasizes the need to take into account PLC and PTE in patients with rapidly progressive pulmonary hypertension despite negative pulmonary embolism imaging. Recognition of subtle radiographic clues may facilitate earlier diagnosis, although prognosis remains poor once right ventricular failure develops.
The COVID-19 pandemic had profound global health and socioeconomic impacts, necessitating rapid vaccine deployment to reduce morbidity and mortality. However, perceptions regarding vaccine safety have influenced vaccine confidence and uptake in many communities. This study explored community-reported experiences of adverse events following COVID-19 vaccination and their implications for vaccine acceptance, uptake, and public perceptions in Mitooma District, Southwestern Uganda. A qualitative cross-sectional study was conducted using focus group discussions (FGDs) among community members and leaders from seven randomly selected villages in Katenga Subcounty, Mitooma District, Southwestern Uganda. Participants were purposively selected based on their involvement, influence, or knowledge of COVID-19 vaccination-related issues. Data were collected on reported experiences following vaccination, perceptions regarding vaccine safety, and factors influencing vaccine acceptance and uptake. A total of 52 participants (male-to-female ratio, 1:1) participated in the FGDs. The median age (range) of participants was 45 (23-82) years. Most participants were Banyankole (n = 45, 86.5%), married (n = 46, 88.5%), and engaged in subsistence farming (n = 26, 50%). More than half (n = 28, 53.8%) had attained primary education as their highest level of education. Participants commonly reported experiencing symptoms after COVID-19 vaccination, ranging from mild and expected local or systemic reactions to severe or unusual experiences that they perceived as vaccine-related. The most frequently reported experiences included injection-site symptoms, fever, dizziness, and gastrointestinal symptoms. Some participants also described rare and alarming events, including perceived nerve-related problems, impotence, and deaths occurring after vaccination; however, these reports were based on participant accounts and were not clinically verified or confirmed to be causally related to COVID-19 vaccination. Concerns regarding reported adverse events, amplified by misinformation and anti-vaccine messages in local media, negatively influenced willingness among some individuals to receive additional vaccine doses. Nevertheless, overall vaccine acceptance and uptake remained high, largely attributed to fear of severe COVID-19 outcomes and previous positive experiences with immunization programs. Community perceptions of vaccine safety were shaped by both personal experiences and information circulating within communities. Engagement of community leaders and participatory approaches were important in supporting vaccination efforts. Strengthening pharmacovigilance systems, improving mechanisms for reporting and evaluating adverse events following immunization, and implementing proactive risk communication strategies are essential for addressing vaccine safety concerns and maintaining public trust.
Donanemab is an immunoglobulin G1 (IgG1) monoclonal antibody that was recently approved by the United States Food and Drug Administration for the treatment of early symptomatic Alzheimer's disease (AD). The drug was approved with boxed warnings for amyloid-related imaging abnormalities (ARIA). While seizures are recognized adverse events, they are predominantly characterized in the context of ARIA and accompanied by edema (ARIA-E) or hemosiderin deposition (ARIA-H). The precise epileptogenic mechanisms of anti-amyloid immunotherapies independent of macroscopic ARIA remain poorly understood. We report the case of a 90-year-old man with mild cognitive impairment due to AD and a history of well-controlled focal epilepsy on levetiracetam, who experienced two generalized tonic-clonic seizures. Each paroxysmal event occurred within two hours of completing his fifth and sixth monthly donanemab (1,400 mg intravenous) infusions. Inter-ictal magnetic resonance imaging (MRI), including fluid-attenuated inversion recovery (FLAIR) and susceptibility-weighted imaging (SWI) sequences, demonstrated no evidence of ARIA-E or ARIA-H. Routine electroencephalography (EEG) revealed no interictal epileptiform discharges. Seizure recurrence necessitated an escalation of his levetiracetam dosage to 750 mg twice daily and the immediate discontinuation of donanemab therapy, after which he remained seizure-free. The temporal proximity of the seizures to the infusions, the positive rechallenge, and the absence of identifiable structural, metabolic, or infectious precipitants raise the possibility of an association with donanemab. However, causality cannot be established from a single case report. Several biologically plausible mechanisms may explain this temporal association, including rapid amyloid-beta (Aβ) clearance, microglial activation, neuroinflammatory responses, and transient blood-brain barrier dysfunction, which may lower the seizure threshold in a patient with pre-existing epileptogenic networks. However, these mechanisms remain hypothetical and were not directly demonstrated in this patient. Clinicians should maintain a high index of suspicion for acute post-infusion seizures in patients receiving donanemab, particularly those with a history of epilepsy, even in the absence of radiographically detectable ARIA. Clinicians should be aware of this potential safety signal in patients with pre-existing epilepsy. Additional studies are needed before specific monitoring or treatment recommendations can be established.
Disseminated fungal infection (DFI) is the presence of a fungal pathogen in the blood and/or any other deep-seated site due to vascular spread. It represents a rare but life-threatening infectious complication in immunocompromised patients. In this case report, we present a 19-year-old male with weakness of the limbs, headache, and slurred speech. He was a known case of endobronchial fungal infection with worsening neurological symptoms. Motor examination revealed reduced tone and strength, while respiratory examination revealed bilaterally decreased air entry. Fundoscopic examination revealed papilledema. Immunological evaluation demonstrated elevated IgE and IgG levels and a reduced CD16/56 natural killer cell count, indicating defective innate immunity. Radiological examination, including computed tomography (CT), positron emission tomography-computed tomography (PET-CT), and magnetic resonance imaging (MRI), demonstrated nodules with opacities and mediastinal and cervical lymphadenopathy in the chest, as well as multiple supratentorial and infratentorial lesions, extensive edema, and nodular leptomeningeal thickening on neuroimaging. The patient is hypothesized to have dysfunctional ryanodine receptors (RyR) rather than typical CGD. The patient was managed with antifungal therapy along with antiepileptic and antiedema drugs.
A 32-year-old male patient presented with symptoms of gastric outlet obstruction secondary to distal gastric adenocarcinoma. A fully covered self-expanding metal stent (SEMS) measuring 20 mm × 130 mm was placed to relieve obstruction and restore oral intake, with the aim of optimizing the patient for planned perioperative chemotherapy. The patient subsequently received neoadjuvant FLOT (fluorouracil, leucovorin, oxaliplatin, and docetaxel) chemotherapy as per recommendations of the multidisciplinary team and completed three cycles uneventfully. Before scheduled restaging imaging and completion of the fourth cycle, he developed sudden-onset abdominal pain with signs of generalized peritonitis. Imaging revealed pneumoperitoneum, and an emergency exploratory laparotomy was performed. Intraoperatively, a perforation was identified in the ascending colon near the hepatic flexure. A right hemicolectomy was carried out. Histopathological examination demonstrated a foreign body consistent with a migrated stent embedded at the perforation site, confirming complete transintestinal migration of the gastric stent as the cause of colonic perforation. This case highlights a rare but serious complication of fully covered gastric SEMS, particularly in patients receiving neoadjuvant chemotherapy, and emphasizes the need for clinical vigilance even in the absence of interim symptoms.
Definitive radiotherapy is a standard larynx-preserving treatment for early-stage glottic squamous cell carcinoma. This study evaluated recurrence patterns and freedom from recurrence after definitive radiotherapy in Panama; explored baseline clinical, pathological, and treatment-related factors associated with recurrence; and analyzed initial post-treatment response as an early marker of subsequent recurrence risk. We conducted a retrospective cohort study of adults diagnosed between 2013 and 2022 with T1-T2 N0 M0 glottic squamous cell carcinoma and treated with definitive radiotherapy at the National Oncology Institute of Panama. Time to recurrence, event-free survival, overall survival, and laryngeal preservation with oncologic control were evaluated. Freedom from recurrence was estimated using the Kaplan-Meier method, with deaths without prior recurrence censored. Survival outcomes were compared using log-rank tests and Cox proportional hazards models. Ninety-four patients were included: 79.8% had T1a, 13.8% had T1b, and 6.4% had T2 disease; 94.7% received three-dimensional conformal radiotherapy. An initial complete response was achieved in 86/93 patients (92.5%). With a median observed follow-up of 65.9 months (38.6-96.6), 17/94 patients (18.1%) developed recurrence: local recurrence occurred in 13.8% and regional recurrence in 4.3%, with no distant metastases. Freedom from recurrence at two and five years was 87.0% and 80.2%, respectively; five-year event-free survival was 70.4%, and five-year overall survival was 81.7%. Laryngeal preservation with oncologic control was achieved in 77/94 patients (81.9%). Partial response was associated with lower five-year freedom from recurrence compared with complete response (28.6% vs. 84.2%; p < 0.001). Five-year freedom from recurrence was 85.4% with hypofractionation and 78.5% with conventional fractionation (p = 0.483). In this retrospective cohort with a median observed follow-up of 65.9 months, definitive radiotherapy achieved a high initial complete response rate, predominantly local recurrence patterns, and a five-year freedom from recurrence of 80.2%, with deaths without prior recurrence censored. Partial response identified a high-risk subgroup as an early post-treatment response marker. Hypofractionation showed a non-significant numerical trend toward higher five-year freedom from recurrence, but the study did not demonstrate superiority, equivalence, or non-inferiority between fractionation schedules.
Cardiac surgery in patients with cryoglobulinemia remains challenging because perioperative hypothermia may increase the risk of cryoglobulin-related complications. We report the case of a 49-year-old man with severe bicuspid aortic valve stenosis and preoperatively confirmed cryoglobulinemia who underwent totally endoscopic minimally invasive aortic valve replacement without preoperative plasmapheresis. The patient had no clinical manifestations of cryoglobulinemic vasculitis, and extensive hematologic and immunologic evaluation demonstrated no monoclonal gammopathy, a normal serum free light chain ratio, and negative viral and autoimmune markers. Because the patient was considered low risk for cryoglobulin-related complications, surgery was successfully performed using normothermic cardiopulmonary bypass with intermittent tepid blood cardioplegia, while maintaining a lowest core temperature of 34.8 °C. The postoperative course was uneventful, with no evidence of cryoglobulin-related complications. This case suggests that, in carefully selected low-risk patients without active vasculitic manifestations, minimally invasive cardiac surgery under strict normothermic management may be feasible without routine preoperative plasmapheresis.
Introduction Diabetes is among the many known chronic diseases resulting from the inability of the body to produce insulin. The use of traditional drugs such as sulfonylurea, biguanide, and thiazolidinediones has been associated with some side effects, hence making researchers turn their attention toward herbal medicine as a treatment or prevention option for diabetes. Hence, the present study was designed to evaluate and compare the metabolic effects of allantoin (5 mg/kg and 10 mg/kg), metformin (500 mg/kg), and their combination on blood glucose and body weight in low-dose streptozotocin (STZ)-induced diabetic Wistar rats. Methods An in vivo study employed a randomized, controlled, parallel-group, preclinical experimental design consisting of a total of 36 young adult (8-10 weeks old) male Wistar rats (Rattus norvegicus) weighing 200-260 g, which were randomly assigned to six experimental groups, namely, G1 to G6. G1 and G2 served as non-diabetic and diabetic controls administered intraperitoneally (ip) with 2 ml of normal saline (NS) and STZ 45 mg/kg + 2 ml NS, respectively. G3, G4, G5, and G6 groups served as treatment groups and received STZ 45 mg/kg, concurrently administered intraperitoneally with allantoin (ALN) 5 mg/kg, ALN 10 mg/kg, metformin (MET) 500 mg/kg (oral), and ALN 5 mg/kg (ip) + MET 500 mg/kg (oral), respectively. Fasting blood sugar (FBS) estimation was done for nine days daily after STZ injection, after diagnosis of diabetes mellitus on the 9th/10th day, and on the 28th day of treatment. Body weight of experimental animals was recorded once weekly on days 0, 7, 14, 21, and 28. Results FBS levels differed significantly among groups at baseline and day 28 (p < 0.0001). Diabetic controls maintained persistently elevated glucose levels, whereas ALN treatment at 5 mg/kg (301.17 ± 11.18 vs. 218.33 ± 10.11; -82.84; p < 0.001) and ALN 10 mg/kg (302.83 ± 5.08 vs. 171.17 ± 7.88; -131.66; p < 0.001) significantly reduced FBS in a dose-dependent manner. Metformin monotherapy markedly improved glycemic control (297.00 ± 17.73 vs. 126.00 ± 10.10; -171.00; p < 0.001), while combination therapy with ALN and metformin produced the greatest reduction in glucose levels (302.50 ± 11.41 vs. 120.00 ± 9.57; -182.50; p < 0.001), suggesting additive antihyperglycemic effects. ALN 10 mg/kg significantly increased body weight (p = 0.002). Conclusion Allantoin, particularly along with metformin, offers promising therapeutic potential for the management of diabetes and associated metabolic alterations.
Background Many incoming medical students begin training using study approaches that were effective in prior academic settings but may not meet the pace and cognitive demands of medical school. Evidence-based strategies such as retrieval practice and spaced repetition improve long-term retention, yet students are rarely formally taught how to apply them. Large language models (LLMs) may offer a scalable way to develop accessible educational materials that introduce these concepts to students before matriculation. Objective The objective of this study was to evaluate the feasibility, engagement, and perceived impact of an eight-week, AI-assisted "study strategies" curriculum for incoming medical students. Methods All incoming students at a single medical school received weekly emails summarizing evidence-based study techniques, with supplementary PDF summaries and podcasts. Content was drafted using LLMs and reviewed for accuracy. Students completed a voluntary survey assessing demographics, prior instruction on study strategies, engagement with materials, and perceived impact. Descriptive statistics summarized outcomes. Group comparisons used t-tests and ANOVA, and Pearson correlations assessed relationships between engagement and perceived impact. Results A total of 65% (78/120) students completed the survey. Students read a mean of 3.58 emails (SD=2.53), reviewed 2.29 PDFs (SD=2.22), and listened to 1.03 podcasts (SD=1.76). Participants reported learning new techniques they planned to use (M=2.09, SD=0.63), moderate influence on study approach (M=2.58, SD=0.85), and moderate likelihood of applying strategies in medical school (M=3.10, SD=1.14). Greater email engagement correlated with perceived helpfulness, learning new techniques, influence on study approach, and likelihood of application (r=0.302-0.612, all p<0.01). No significant differences were observed by first-generation status, prior formal instruction, or path to medical school. Conclusion This AI-assisted pre-matriculation study strategies curriculum was feasible to implement and was perceived as useful by participating students. Higher engagement with curricular materials was associated with greater perceived impact on study approaches and planned application of evidence-based learning strategies.
Antimicrobial resistance is an important clinical challenge in patients with hematologic malignancies, who are highly susceptible to severe infections due to prolonged neutropenia, disrupted mucosal barriers, intensive chemotherapy, and hematopoietic stem-cell transplantation. This systematic review synthesizes available international evidence on pathogen distribution, antimicrobial resistance patterns, and clinical outcomes in hemato-oncology settings. This systematic review searched PubMed, Scopus, and Google Scholar for English-language studies published from January 2014 to 15 November 2025. Studies reporting microbiologically confirmed infections in patients with hematologic malignancies, with extractable antimicrobial susceptibility or resistance data, were included. Due to substantial clinical, microbiological, methodological, and epidemiological heterogeneity, findings were synthesized qualitatively. Seventeen studies met the inclusion criteria. Gram-negative bacteria predominated across most settings, although pathogen distribution varied by region, age group, infection type, and denominator unit. Extended-spectrum β-lactamase (ESBL)-producing Enterobacterales, carbapenem-resistant Gram-negative bacteria, multidrug-resistant Gram-negative organisms, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococcus were reported across included studies. Where extractable study-level data were available, ESBL-related estimates ranged from 40% to 78%, while carbapenem-resistance estimates varied widely by organism group and study setting, from low carbapenem resistance among Enterobacteriaceae in one pediatric oncology cohort to 38.2% carbapenem-resistant Gram-negative bacteria in an Indian adult febrile neutropenia cohort. Mortality outcomes were heterogeneously reported and were not pooled. In comparative studies, resistant or multidrug-resistant bloodstream infections were associated with worse outcomes, including increased mortality and ICU admission, although causality cannot be inferred from the predominantly observational evidence. Antimicrobial resistance is a clinically important problem in patients with hematologic malignancies, particularly due to resistant Gram-negative pathogens. The findings support strengthened hemato-oncology-specific surveillance, local antibiogram-guided empirical therapy, antimicrobial stewardship, and standardized reporting of resistance phenotypes and clinical outcomes.