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Ambient artificial intelligence (AI) scribes for chart documentation have seen rapid adoption in clinical practice, but their educational impact on medical students has not been described. The purpose of this study is to determine the impact of an AI scribe on pre-clerkship medical student note writing. In this prospective non-randomized pre/post design study, all first-year medical students (n=104) at a single U.S. medical school submitted "human-only" notes based on a summative observed structured clinical examination (OSCE) station in May 2025. An AI scribe generated independent AI notes post-OSCE from recorded audio. A sub-group of students (n=47) consented to complete a second "hybrid" note by revisiting their human-only note and incorporating AI notes as perceived necessary, followed by a brief survey about the AI notes. Trained, blinded fourth-year medical student raters were randomly assigned to score all notes on 10 elements using QNOTE acceptability criteria (0=Unacceptable, 50=Partially, 100=Fully). A post-hoc, exploratory element-level review was then conducted. Across all elements, median evaluation scores of human-only notes were high (range 81.3 - 100) and were similar between students who participated in "hybrid" notes and those who did not. In paired analyses between "human-only" and "hybrid" notes, the only notable element-level change was a decline in Chief Complaint scores (P=.05). Symptom duration was omitted in the Chief Complaint section in 8 of 47 (17%) AI notes. No score differences were observed in QNOTE elements requiring documentation of pertinent findings and prioritized lists. Participants agreed that the AI note "was more concise than my note" (37/47, 79%) and would be "helpful as a first draft" (31/47, 66%); 26 out of 47 (55%) agreed that the AI note "left out important details", and 10 out of 47 (21%) agreed that the AI note "may reduce my ability to learn how to write a good note." Interaction with AI notes among pre-clerkship medical students had little impact on quality of "hybrid" notes. Chief Complaint scores likely declined due to conciseness in AI notes that often omitted symptom duration. Our findings suggest that among students who predominantly write close to fully acceptable "human-only" notes, there was no detriment to clinical reasoning, and students were discerning in balancing AI's conciseness and its omissions. The lack of impact on note quality may have been due to the workflow employed in this study, in which students were required to generate independent judgments before exposure to AI-generated content. Future work must explore longitudinal use of such tools using standard workflows seen in clinical settings, where AI notes serve as true first drafts. Especially for lower-performing students, AI scribes could enhance students' own note writing, though educational safeguards are necessary given the potential for harm due to overreliance on automated systems. The study was granted approval by the Yale School of Medicine Committee to Review Student Participation in Research on January 14, 2025, and an exemption from full review due to the minimal-risk educational nature of the project by the Yale Human Research Protection Program on January 23, 2025 (IRB Protocol ID 2000039478).
The aim of this study was to analyse the disinfection of root canals contaminated with Enterococcus faecalis (E. faecalis) using different complementary activation devices post instrumentation. Sixty-two one-root human mandibular premolars were filled with a culture of E. faecalis, for 21 days. The specimens were prepared with Reciproc R25 files to a working length of 1 mm short of the apical foramen. Microbiological samples were collected with absorbent paper cones before and after preparation (S0 and S1, respectively). Afterward, the specimens were randomly divided into 3 experimental groups: Ultrasonics (US), XP-Endo Finisher (XP), and Easy Clean (EC). Each complementary device was kept at working length and was activated for 1 minute, followed by irrigation with 12 mL of saline. Microbiological samples (S2) were collected after activation with the devices US, XP, and EC. Data from the microbial reductions (in CFU × mL0-1) were submitted to the Kruskal-Wallis and 5% Dunn tests. The root canal preparation with R25 instruments promoted a large microbial reduction in all groups (P < .05). The use of activation devices significantly reduced the amount of microorganisms (P < .05); however, there was no significant difference among activation devices. It was concluded that the use of complementary activation devices US, XP, and EC significantly improved the disinfection of the root canals when compared to conventional irrigation.
Following a request from the European Commission, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was asked to deliver an opinion on the safety of an oil derived from the microalga-like organism Schizochytrium sp. A2 as a novel food (NF) pursuant to Regulation (EU) 2015/2283. The oil is a mixture of triglycerides in which docosahexaenoic acid (DHA) represents around 40% of total fatty acids. The applicant proposes the use of the NF as an ingredient in infant formula and follow-on formula and in food supplements for adults (excluding pregnant and lactating women), at a maximum intake of 3 g DHA per day. The evidence provided by the applicant does not allow the determination of the species to which Schizochytrium sp. A2 belongs. Although batch analyses showed that tested marine biotoxins were below their respective limits of quantification, since it is unknown to which species the production strain belongs, the concern that the strain Schizochytrium sp. A2 has the potential to produce other toxins than those tested remains. Due to the unresolved taxonomic identity of the production strain, the qualified presumption of safety qualification of the production strain cannot be used in the safety assessment of this NF. Furthermore, no toxicological studies conducted with the NF itself were submitted. While toxicological data exist for DHA-rich algal oils derived from other Schizochytrium strains, these cannot be used to establish the safety of the oil produced from strain A2. The Panel concludes that, based on the available data, the safety of the NF (oil produced from Schizochytrium sp. A2) cannot be established.
A deterioration in K CO or T LCO by ∼5% pred per year or any rise in BNP in patients with fibrotic ILD should prompt echocardiography and thereafter referral for invasive assessment by RHC in a PH centre, as appropriate https://bit.ly/4ozSdbb.
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Bipolar-spectrum illness emerging after traumatic brain injury (TBI) can be difficult to treat and may present with mixed or agitated depressive features that appear sensitive to glutamatergic modulation. In post-TBI cases, diagnostic certainty is often limited because irritability, impulsivity, sleep disturbance, affective lability, and cognitive change may overlap with frontal-limbic injury syndromes. This case is, therefore, framed as probable bipolar-spectrum disorder secondary to TBI rather than definitive idiopathic bipolar disorder. The Cheung Glutamatergic Regimen (CGR)--low-dose dextromethorphan with CYP2D6 inhibition plus piracetam--is used here only as a shorthand for an open-source, free-to-use, non-proprietary combination of off-patent components, not as a branded product. This report describes a woman in her mid-thirties with right frontal atrophy after a 2009 subdural hematoma who later developed probable bipolar-spectrum illness. On 21 October 2025, she presented with severe depressive relapse, insomnia, persistent rumination, irritability, and hypnagogic phenomena, with a Patient Health Questionnaire-9 (PHQ-9) score of 22. After partial improvement on valproate, risperidone, and Deanxit, dextromethorphan 30 mg nightly and piracetam 600 mg nightly were added on 5 November 2025. Within weeks, rumination decreased and mental flexibility improved, but transient mild hypomanic or frontal-disinhibition-like symptoms emerged, especially inappropriate laughter with a moria-like quality. She self-reduced dextromethorphan to 22.5 mg, piracetam was increased, and euthymia returned. Over the next six months, PHQ-9 scores improved to 10-12 and Generalized Anxiety Disorder-7 (GAD-7) scores to 8-13, with functional gains including exercise and motorcycle riding lessons. Later medications included aripiprazole, paroxetine-controlled release, pregabalin, and low-dose quetiapine. By April 2026, dextromethorphan and piracetam were used as needed during stress-related or premenstrual dips. No further psychotic symptoms were reported, and later mild dissociative or cognitive complaints became manageable after dose adjustment. This single-patient course suggests a three-phase pattern: induction with a narrow therapeutic window and brief activation/overshoot, stabilization after titration, and later PRN maintenance. Dextromethorphan appeared temporally most linked to both clinical benefit and transient activation, while piracetam may have acted as a modulator. However, causal inference is limited by the uncontrolled design, early PHQ-9 improvement before CGR initiation, later polypharmacy, unmeasured pharmacokinetics, absence of standardized mania/cognitive measures, and incomplete PRN-frequency documentation. The case is also only hypothesis-generating in relation to transcriptomic findings implicating bipolar-specific plasticity-related biology. Low-dose oral glutamatergic augmentation may warrant study as a closely monitored induction and consolidation strategy in post-TBI bipolar-spectrum illness, but prospective controlled trials are needed before broader recommendations can be made.
Realistic online 3D reconstruction from endoscopic video is essential for intraoperative inspection and navigation. However, existing approaches often neglect realistic light modeling, rely on offline optimization, or depend on fragile photometric tracking, thereby limiting physically plausible rendering and stable tracking. This study addresses these limitations through an online framework enabling stable tracking and photorealistic endoscopic rendering. We propose LumenGSLAM, an online RGB-D Gaussian Splatting framework for highly texturized dense reconstruction of endoscopic scenes. The method leverages dense depth input to enable stable geometry estimation and photorealistic appearance modeling through per-Gaussian physically based rendering (PBR). Surface-aligned Gaussian initialization and per-parameter gradient scaling are introduced to enhance anatomical fidelity and geometric consistency. Robust camera pose estimation is achieved via a Gaussian-coupled feature-based tracking module using SuperPoint/LightGlue and Perspective-n-Point (PnP), ensuring reliable localization under rapid motion and challenging illumination conditions. Evaluated on C3VD and SCARED datasets, LumenGSLAM achieves superior online reconstruction and tracking performance. It attains PSNR = 30.6, SSIM = 0.89, and LPIPS = 0.23 on C3VD, outperforming all online baselines and approaching state-of-the-art offline PR-ENDO quality. In tracking, it delivers the lowest Absolute Trajectory Error (ATE = 0.93 mm) and Rotational Error (ARE = 0.98 ∘ ), demonstrating robustness even under large inter-frame motions. LumenGSLAM establishes a new benchmark for online RGB-D endoscopic reconstruction, achieving photometrically consistent and anatomically accurate mapping through explicit light modeling and geometry-aware Gaussian optimization. Its robustness makes it a promising candidate for intraoperative navigation and future extensions toward dynamic tissue modeling. Project page: https://github.com/FrancescoLeni/LumenGSLAM .
Introduction Antiretroviral therapy (ART) compliance is essential for successful treatment outcomes of children living with human immunodeficiency virus (HIV) infection. The factors affecting adherence to ART, which have not yet been explored in Oman for children living with HIV infection, must thus be investigated. Methods A cross-sectional study was conducted that included all children living with HIV who were receiving care at the pediatric infectious disease clinics of Royal Hospital, a tertiary care center, and who had been on pediatric antiretroviral therapy (ART) formulations for more than one year. After receiving informed consent, 43 caregivers of HIV-positive children were interviewed using a questionnaire. Patients' characteristics, socioeconomic, pharmacological, and health care system factors were analyzed in correlation with adherence to ART using SPSS version 26 (IBM Corp., Armonk, USA). Results Thirty percent of patients (n=13) had high HIV viral loads, and among those, 19% (n=8) had suboptimal adherence. Young and non-educated caregivers, low income, and lack of transportation were significant factors for poor adherence to ART therapy, with a significant p-value. Other important factors noticed were medication not available at home, missed medication refills, and a child's busy schedule at school, and patients' caregivers did not always administer the prescribed medications. Conclusion The study results support the recommendation to provide a pediatric formulation of ART and supply it to peripheral secondary care hospitals for easy access to medications. Psychological assessments and counselling at the adolescent medicine clinic in the same centre would aid caretakers psychologically and gauge children with HIV's preparedness for disease disclosure.
Postpartum depression (PPD) is a common yet underdiagnosed mental health condition affecting a substantial proportion of new mothers in the United States. Its consequences can be severe, impacting maternal well-being, infant development, and family dynamics. PPD is particularly prevalent in underserved communities, where socioeconomic hardship, limited access to healthcare, cultural stigma, and systemic inequities intensify the risk. Addressing these disparities requires interventions that move beyond traditional clinical approaches and focus on the social, emotional, and environmental determinants of maternal mental health. This narrative review explores a wide range of community-based interventions developed and implemented in the United States to support women experiencing or at risk for postpartum depression. These interventions include nurse-led home visits, telehealth platforms, digital cognitive-behavioral therapy programs, peer-support networks, and culturally grounded co-parenting strategies. Other approaches, such as the use of ergonomic infant carriers and increased exposure to green spaces, have also emerged as innovative means of enhancing maternal-infant bonding and reducing depressive symptoms. Each intervention targets different aspects of the postpartum experience, from improving health literacy and social support to reducing intimate partner violence and enhancing accessibility to mental health resources. By synthesizing findings from diverse settings and populations, this review provides family physicians and community health practitioners with evidence-based tools for identifying, supporting, and treating mothers affected by PPD. Integrating these interventions into primary care and community settings can help mitigate health disparities, strengthen maternal-child relationships, and promote long-term wellness. A focus on culturally sensitive, flexible, and accessible models of care is essential for expanding the reach and impact of PPD prevention and treatment efforts across vulnerable populations.
Introduction Adherence to post-bariatric supplement intake may be affected by tolerability issues. This study aimed to characterize nausea associated with supplement intake and explore the patient-reported symptom course following structured intake instructions in a real-world customer-support context. Methods This retrospective observational study with prospectively collected data consisted of two parts. Part one: a cross-sectional survey of 540 FitForMe customers after bariatric surgery who reported nausea, assessing the timing of supplement intake, the onset and triggers of nausea, and the impact on daily functioning. Part two: a single-arm, uncontrolled follow-up of a separate sample of 75 French FitForMe customers experiencing nausea, who received structured intake instructions during standardized telephone interviews. Recommendations included switching from capsules to chewable tablets, taking supplements with meals, dividing doses, and allowing slower dissolution. The presence of nausea (yes/no) was reassessed by telephone one week later. Results Part one indicated that a large percentage of individuals did not take the supplement according to intake instructions; 256 (47.4%) took it on an empty stomach. Nausea occurred in 93 patients (17.2%) before the actual intake of the supplement. Overall, 365 patients (67.6%) reported a score of 5 or higher on a 0-10 scale measuring the impact on daily life, where 0 indicated no restriction, and 10 indicated being unable to do anything. In part two, at the one-week follow-up, 55 of 75 patients (73.3%) reported resolution of nausea (within-patient comparison, p<0.001). The recommendation most frequently endorsed by patients as perceived to have contributed to their symptom course was switching from capsule to chewable tablet, reported as helpful by 41 of 44 patients who made this switch (93.2%; 54.7% of the total follow-up cohort, n=75; p<0.001). Taking supplements with lunch or dinner was also commonly endorsed (n=42, 56.0%). Additional complaints were common, including potentially dumping-related symptoms (n=30, 40.0%), food intolerance (n=28, 37.3%), and altered taste or smell (n=31, 41.3%). Conclusion In a selected sample of bariatric patients who reported nausea during multivitamin use, incorrect intake practices and multifactorial symptom patterns were common. In a follow-up cohort, structured intake advice was associated with patient-reported resolution of nausea in many participants. While these observational findings do not establish causality, the recommendations are simple, low-cost, and easy to implement, and may be considered as a pragmatic first step in routine post-bariatric care.
To advance minimally invasive surgical techniques, we developed the sutureless ELANA® End-to-End anastomotic technique. This preclinical study aimed to evaluate the technical feasibility, hemostatic performance, and short-term patency of the new approach in a porcine model. Six pigs underwent implantation of the ELANA End-to-End device in a divided in situ right internal mammary artery (RIMA) via partial sternotomy. The pigs were followed-up for either 35 days (N=3) or 90 (N=3) days. Feasibility was evaluated based on technical success, achievement of hemostasis, and anastomotic construction time. Patency was assessed at the end of follow-up through angiography and histological analysis. The anastomosis was successfully constructed in four of six animals. Among these, hemostasis was achieved in three cases without additional intervention; one required a single hemostatic stitch. The median anastomotic construction time was 18 (15-45) minutes. Technical failure in two animals was due to difficulty maintaining vessel alignment during deployment. All four successfully constructed anastomoses were patent at the end of follow-up (N=2, 35 days; N=2, 90 days), with no evidence of stenosis on angiography or histology. The ELANA End-to-End technique demonstrated promising patency outcomes. However, the current procedure is technically demanding. Design improvements aimed at stabilizing vessel positioning are warranted to enhance feasibility and reduce construction time.
Small bowel obstruction (SBO) is a surgical emergency commonly caused by adhesions from prior abdominal surgeries or hernias. In contrast, SBO caused by omental bands with no history of trauma or abdominal surgeries is rare, and only a few cases have been reported. We present a case of a previously healthy 44-year-old male who presented with sudden, severe generalized colicky abdominal pain after eating, associated with nausea, vomiting, and abdominal tenderness, without distension. Initial lab results and X-ray findings were unremarkable. Intravenous contrast computed tomography (CT) scan revealed closed-loop jejunal obstruction with irreversible ischemic changes. Emergency intra-operative findings indicated mechanical obstruction caused by an omental band, which led to bowel necrosis. Laparoscopic necrotic bowel resection and anastomosis were performed, and the patient recovered uneventfully. The lack of specific signs and symptoms associated with internal hernias (IHs) poses a tremendous diagnostic challenge, with CT scans playing a pivotal role in guiding management.
Thrombocytopenia is a common hematologic abnormality with a broad differential diagnosis, often requiring careful evaluation to identify overlapping and potentially reversible etiologies. Medication-induced thrombocytopenia is well recognized, particularly with valproic acid, while substance use such as cocaine may further exacerbate bleeding through platelet dysfunction and vascular effects. We present the case of a 39-year-old woman with a history of seizure disorder treated with valproic acid and comorbid psychiatric illness, including a prior suicide attempt, who presented with acute heavy vaginal bleeding. Laboratory evaluation revealed thrombocytopenia without evidence of hemolysis or coagulopathy. Peripheral smear was unremarkable aside from nonspecific red blood cell changes, and imaging studies did not demonstrate hepatosplenomegaly or structural abnormalities. Further history revealed recent cocaine use, raising concern for a multifactorial process. Valproic acid was discontinued due to suspected drug-induced thrombocytopenia, and the patient was transitioned to an alternative antiepileptic regimen. With supportive care and cessation of the offending agents, the patient demonstrated stabilization of platelet counts and resolution of bleeding. This case highlights the importance of recognizing multifactorial thrombocytopenia, particularly in patients with concurrent medication exposure and substance use. Early identification of reversible contributors is critical, as prompt discontinuation of offending agents can lead to rapid clinical improvement and prevent unnecessary invasive evaluation. Additionally, this case underscores the need for a multidisciplinary approach that integrates hematologic, neurologic, and psychiatric considerations in complex presentations while comparing the case with the current literature.
Flat-detector computed tomography (FDCT) is increasingly used for periinterventional cerebral imaging. The recently introduced Sine Spin FDCT (S-FDCT) aims to improve cerebral soft tissue contrast compared with conventional FDCT (C-FDCT). Reliable visualization of healthy brain parenchyma is essential for detecting pathological changes. This study compared gray-white matter differentiation between intraindividually acquired S-FDCT and C-FDCT. A retrospective analysis of a prospectively maintained database included patients with ischemic stroke treated by mechanical thrombectomy who underwent both S-FDCT and C-FDCT within the same interventional session on a latest-generation angiography system. Quantitative image quality was assessed using the contrast-to-noise ratio (CNR). Qualitative image quality was evaluated using a five-point scale at basal ganglia and supratentorial cortex. Analyses focused on healthy brain parenchyma contralateral to infarction. Radiation dose was assessed using entrance-skin dose and dose-area product (DAP). Forty patients (74.2 ± 15.3 years) were analyzed. S-FDCT demonstrated a higher CNR than C-FDCT (mean CNR ± SD: 2.62 ± 1.36 versus 1.03 ± 0.38; p < 0.001). Qualitative ratings were higher for S-FDCT at the basal ganglia (2.45 ± 0.71 versus 1.54 ± 0.53; p < 0.001) and supratentorial cortex (3.01 ± 0.80 versus 1.71 ± 0.60; p < 0.001). Inter-reader agreement was good (κ = 0.798). S-FDCT showed a moderately higher radiation dose than C-FDCT (DAP: 50.6 ± 3.10 versus 46.89 ± 2.86 Gy·cm², p < 0.001). S-FDCT improves cerebral soft tissue visualization compared with C-FDCT in periinterventional imaging. These findings highlight the potential of Sine Spin technology to enhance FDCT image quality and support its role in advanced angiography-suite-based neuroimaging.
Human metapneumovirus (hMPV) is an under-recognized cause of severe respiratory illness in high-risk adults. We conducted a systematic review and meta-analysis to quantify hMPV prevalence and clinical outcomes in adults with chronic underlying conditions predisposing them to severe respiratory illness, including the immunocompromised. We searched MEDLINE, Embase, and BioRelate (January 2010 to February 2025) for studies of laboratory-confirmed hMPV in adults (≥ 18 years) with high-risk chronic or immunocompromising conditions. We extracted data on hMPV positivity and key outcomes (hospitalization, intensive care unit [ICU] admission, respiratory support, length of stay, and mortality). We performed random-effects meta-analyses for outcomes reported in ≥ 3 studies and assessed study quality using an adapted Joanna Briggs Institute checklist. We included 72 studies. Among immunocompromised adults with hMPV infection, 55.2% (95% confidence interval [CI], 42.0-67.7%) required hospital admission. Among immunocompromised patients hospitalized with respiratory illness, hMPV was detected in 5.4% (95% CI, 2.7-10.8%). Among patients with cardiovascular disease, 11.4% (95% CI, 8.0-16.1%) tested positive for hMPV. Regarding patients with chronic respiratory conditions, 3.4% (95% CI, 2.4-5.0%) of patients with chronic obstructive pulmonary disease exacerbations and 7.6% (95% CI, 2.5-20.5%) of patients with asthma exacerbations were hMPV-positive. Among hospitalized hMPV-positive high-risk patients, 13.0% (95% CI, 8.8-18.9%) required ICU admission, 43.6% (95% CI, 34.9-52.7%) required supplemental oxygen, and 7.3% (95% CI, 1.2-33.8%) required mechanical ventilation. The mean length of hospital stay was 10.4 days (95% CI, 3.4-17.4%). The pooled case fatality ratio among hospitalized adults with hMPV infection was 2.4% (95% CI, 0.1-35.1%). hMPV is a substantial cause of severe respiratory illness in high-risk adults. Enhanced detection, surveillance, and preventive strategies are needed to reduce hMPV-associated morbidity in vulnerable populations.
Despite adequate primary and secondary prevention of cardiovascular events, significant residual risk remains. Part of this risk has been attributed to lipoprotein(a) (Lp{a}). This is a genetically determined lipoprotein that has been linked to cardiovascular disease. Its variability and pathogenicity are attributed to the unique apolipoprotein(a) (apo{a}) within the molecule. This protein has been related to proatherogenic, proinflammatory, prothrombotic, and procalcific mechanisms that favor cardiovascular disease (CVD). Although it is recognized as a causal factor in disease, there are currently no approved therapeutics targeting this lipoprotein. Current management focuses on aggressive control of traditional cardiovascular risk factors. Novel therapeutics targeting Lp(a), including small interfering ribonucleic acids (siRNAs) and antisense oligonucleotides (ASOs), showed promising results in phase 2 trials. Multiple therapeutics are currently undergoing phase 3 trials, promising to bring a solution to this unsolved issue.
Contrast-associated acute kidney injury (CA-AKI) is more common in patients with heart failure (HF). Stratified by left ventricular ejection fraction (LVEF), the effect of disease severity is still unknown. There is little and inconsistent data comparing the risk of CA-AKI among the various forms of HF identified by the latest guidelines of the European Society of Cardiology (ESC). A systematic search of PubMed, Embase, Cochrane Library, and Web of Science (January 1, 2011 - December 11, 2025) for studies reporting CA-AKI outcomes stratified by LVEF phenotypes (heart failure with reduced ejection fraction (HFrEF), heart failure with mildly reduced ejection fraction (HFmrEF), and heart failure with preserved ejection fraction (HFpEF)) was performed. We planned a meta-analysis, but due to heterogeneity in adjusted models and limited study data available, we present a narrative synthesis of adjusted effect estimates. Risk of bias was assessed using Risk Of Bias In Non-randomized Studies - of Exposures (ROBINS-E). Two observational cohort studies comprising 3,499 patients with HF met the eligibility criteria. Both studies reported multivariable-adjusted odds ratios. One study found no significant association between reduced ejection fraction (EF) and CA-AKI after adjustment (HFrEF vs. HFpEF adjusted OR 1.01, 95% CI 0.69-1.74; HFmrEF vs. HFpEF adjusted OR 1.31, 95% CI 0.87-1.96). Another study reported adjusted estimates suggesting higher odds with HFrEF compared with other phenotypes (reported adjusted OR 0.85, 95% CI 0.73-0.98 for phenotype-level comparisons). Because of the differences in study design, populations, and covariate adjustment, we did not pool estimates quantitatively; instead, we describe the findings narratively. Current evidence is limited to two observational cohorts and yields inconsistent adjusted estimates. Therefore, pooled effect estimates weren't reported. The findings suggest that EF alone may not fully reflect kidney vulnerability. Due to the limited number of observational studies, these findings should be interpreted with caution, highlighting the need for larger studies in the future.
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Vascular complications following operative fixation of Lisfranc injuries are rare and may present in a delayed manner. This report describes a case of a woman in her early 60s who sustained a Lisfranc fracture-dislocation following a fall from height and was treated with open reduction and internal fixation. Initial recovery was uncomplicated. The patient re-presented two months later with recurrent pulsatile bleeding from the dorsal midfoot wound and symptomatic anaemia. CT angiography revealed a 14 × 8 mm pseudoaneurysm arising from the dorsalis pedis artery adjacent to the fixation hardware. Diagnostic angiography confirmed thrombosis of the pseudoaneurysm with preserved distal arterial runoff. The patient was managed conservatively without surgical or endovascular intervention. This case highlights a clinically important but uncommon delayed vascular complication following Lisfranc fixation. It emphasises the role of early vascular imaging in patients presenting with delayed postoperative bleeding and demonstrates that conservative management may be appropriate in selected cases. Importantly, it underscores a decision-making paradigm in which intervention can be safely avoided when spontaneous thrombosis and adequate perfusion are present.
High prevalence of smoking tobacco among people with tuberculosis (TB) contribute towards poor outcomes in low- and middle-income countries. A mobile phone-based intervention for smoking cessation among this population (mTB-Tobacco) was evaluated for its cost-effectiveness alongside a cluster randomised controlled trial in Pakistan and Bangladesh. A two-arm superiority cluster randomised controlled trial with 6 months follow up was conducted between September 2023 and January 2025 in Dhaka, Bangladesh and Punjab, Pakistan. The trial compared the mTB-Tobacco intervention with usual care as control. Participants included those older than or equal to 15 years of age, diagnosed with drug-sensitive pulmonary TB in the past 4 weeks, smoked tobacco daily but willing to quit, and had access to mobile phones. Eighteen TB health facilities (cluster) were randomised to mTB-Tobacco group (n = 720 participants) and nine to usual care (n = 360 participants). The primary analysis was an incremental cost-utility analysis from a public/voluntary sector perspective and primary outcome measure was Quality-Adjusted Life Years (QALYs). Total costs included the costs of TB treatment, costs of intervention or control, and costs of doctor visit and hospital stay. Secondary and sensitivity analyses were also conducted. Total costs were INT$ (international dollars) 36.17 (95% CI 3.65-65.81) higher and QALYs were 0.017 (95% CI 0.003-0.030) higher in mTB-Tobacco group than usual care group. Incremental cost-effectiveness ratio was calculated at INT$2127.64 per QALY gained. Estimates by country suggested mTB-Tobacco being unlikely cost-effective in Bangladesh (ICER = INT$4261.11 per QALY gained) but likely cost-effective in Pakistan (ICER = INT$1024.29 per QALY gained). If decision makers in the public/voluntary sector are willing to pay over INT$2100 for one additional QALY gained, mTB-Tobacco intervention could likely be cost-effective. The UK NIHR Global Health Research Unit on Respiratory Health (RESPIRE) (NIHR132826).