Functional assessment of myocardial ischemia is essential and can be evaluated noninvasively using coronary computed tomography angiography (CCTA) and magnetocardiography (MCG). However, the diagnostic value of integrating CCTA and MCG has not been investigated. This retrospective, single-center cohort study included 275 patients with suspected coronary artery disease (CAD) who underwent both CCTA and MCG examinations from December 2023 to June 2025. Functionally significant ischemia was defined by invasive fractional flow reserve (FFR) or CT-derived FFR (CT-FFR). Quantitative features from both modalities were extracted and normalized. Machine learning (ML) models based on MCG alone, CCTA alone, and combined MCG-CCTA were constructed and evaluated using five-fold cross-validation. Model performance was assessed using the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity; model interpretability was examined using Shapley additive explanations (SHAP). Of the 275 patients, 98 (35.6%) were classified as being ischemic. The MCG model achieved an AUC of 0.769 (95% confidence interval (CI): 0.708-0.829), and the CCTA model yielded an AUC of 0.755 (95% CI: 0.692-0.818). In contrast, the combined MCG-CCTA model developed using ML demonstrated superior performance, with an AUC of 0.829 (95% CI: 0.773-0.885), an accuracy of 0.800, a sensitivity of 0.704, and a specificity of 0.853. A combined MCG-CCTA model developed with ML outperforms models based on either modality alone for detecting functionally significant myocardial ischemia. In clinical practice, this integrated approach may enhance ischemia assessment and inform downstream testing decisions.
Autoantibodies (ABs) against intracellular proteins, including glutamate-decarboxylase 65 (anti-GAD65), are increasingly recognized in autoimmune and limbic encephalitis (AE/LE). Anti-GAD65 LE frequently progresses to severe temporal lobe epilepsy (TLE), neuropathologically characterized by hippocampal sclerosis (HS) and variable infiltration of cytotoxic T lymphocytes (CTLs). Recently, we have identified Drebrin (DBN) as a new intracellular target protein of ABs in index patients with suspected AE. Here, we aim to characterize key molecular and cellular signatures of hippocampal tissue from anti-GAD65- (GAD65-TLE) versus anti-DBN-positive TLE (DBN-TLE) patients correlated to clinical parameters. We examined hippocampal neuropathology and performed exploratory single-nucleus RNA sequencing (snRNA-seq) of hippocampal tissue from DBN- and GAD65-TLE patients, integrated with key clinical data from a large patient cohort. Although the hippocampi of the two patient groups were neuropathologically virtually indistinguishable, exploratory snRNA-seq revealed distinct transcriptional programs. DBN-TLE patients (n = 2) showed transcriptional signatures enriched for forkhead box (Fox) transcription factor family, whereas GAD65-TLE patients (n = 2) displayed transcriptional signatures enriched for transcripts related to NF-κB- signaling. In a larger cohort, DBN-TLE patients (n = 22) showed significantly more favorable pharmacological responsiveness than GAD65-TLE patients (n = 35), who were largely pharmacoresistant. Notably, in a T cell-mediated mouse model for LE, similar inflammatory programs were dynamically regulated. These findings provide a discovery-based transcriptomic signatures of rare autoimmune hippocampal tissue, revealing distinct immune-associated transcriptional states in anti-DBN- versus anti-GAD65-positive AE/TLE patients despite virtually indistinguishable hippocampal pathology in both groups and support further investigations of disease-specific therapeutic strategies.
Toxicology testing is frequently performed on newborns with known or suspected prenatal substance exposure, even though research shows that these tests often add no new clinically relevant information to that gathered during pregnancy and are rarely clinically actionable. Yale New Haven Children's Hospital lacked a protocol for newborn toxicology testing. The authors suspected that test-ordering patterns demonstrated clinically inappropriate overuse and racial and socioeconomic discrimination, leading to harm to newborns and families, including unnecessary involvement of child protective services. Their hypothesis was that reduced testing, with continued social support, would lead to no change in newborn outcomes or safety. Prior to implementation, they identified wide disproportionality in testing by race and insurance status as a marker of poverty. Compared with all babies born at Yale New Haven Children's Hospital, Black non-Hispanic newborns and newborns with Medicaid insurance were tested at 2 times and 2.6 times the average frequency, respectively. After implementation, the authors evaluated the protocol's impact on the testing volume and racial and socioeconomic distribution of tests ordered, and tracked outcomes in the institution's newborn population. By the time the protocol went live in January 2022, after extensive discussion and education among staff, testing rates had already decreased from 3.2% to 0.3%. The absolute decrease in testing rates for Black newborns was 6.7% to 0.6%, while that for white newborns was 2.5% to 0.2%. The testing rate for newborns with Medicaid insurance decreased from 8.2% to 0.5%, while the rate for newborns with commercial insurance decreased from 0.4% to 0.1%. There were so few tests ordered after the protocol was in place that differences in testing frequency by race and type of insurance could not be statistically evaluated. These reduced testing rates have persisted since that time, with no further interventions. Importantly, there were no identified hospital readmissions for withdrawal symptoms or adverse events for newborns who had no previously identified prenatal substance exposure before or after the protocol was adopted. This work succeeded due to a close evaluation of the clinical utility of newborn toxicology testing, institutional support, interdisciplinary collaboration, a culture accepting of change, and recognition of quality improvement as a health equity tool.
Acute intestinal obstruction is a common surgical emergency, most often caused by postoperative adhesions, strangulated external hernias, or tumors. Internal hernias are rare (0.6-5.8% of cases) but carry a high risk of strangulation and intestinal ischemia. Transmesocolic hernias, arising from small bowel loops herniating through congenital or acquired mesocolic defects, are an uncommon subtype, with paraduodenal hernias being more frequent. Preoperative diagnosis is challenging due to nonspecific symptoms, but contrast-enhanced abdominal CT is the gold standard for detecting abnormal bowel positioning, mesenteric mass effect, and signs of wall compromise. We report a case of transmesocolic internal hernia causing bowel obstruction in a young patient and review the literature regarding its epidemiology, diagnosis, and management. A 20-year-old male smoker presented with a 4-day history of occlusive syndrome and epigastric gurgling. Examination revealed a slightly distended abdomen with peri-umbilical tenderness, and laboratory tests showed an elevated C-reactive protein level. Contrast-enhanced CT demonstrated small bowel obstruction due to strangulation by a pseudo-sac on the right side, suggestive of a transmesenteric internal hernia, with early signs of bowel compromise, including parietal thickening and moderate fluid effusion. Intraoperative findings revealed approximately 2.9 m of ileal loops herniated through the transverse mesocolon, with a 50-cm segment inflamed and nonviable. An extended ileocecal resection of the affected segment was performed, preserving 2.9 m of healthy small intestine, followed by repositioning of the bowel and a manual end-to-end ileocolonic anastomosis. Internal hernias are a rare cause of small bowel obstruction, with transmesocolic hernias being less frequent than paraduodenal hernias. They result from small bowel loops herniating through congenital or acquired mesocolic defects, carrying a high risk of vascular compromise. Clinical presentation is often nonspecific, with intermittent pain and subocclusive episodes preceding acute obstruction. Contrast-enhanced CT is the diagnostic modality of choice, identifying abnormal bowel loops, mesenteric vessel displacement, and signs of bowel wall compromise. Definitive treatment is surgical, including reduction of herniated bowel, assessment of viability, and closure of the defect; bowel resection is required if ischemia or necrosis is present. Early diagnosis and prompt intervention are critical, as morbidity and mortality correlate with delay and the extent of necrosis. Transmesocolic hernias, although rare, should be suspected in cases of obstruction without prior abdominal surgery, and timely imaging and surgery can reduce the need for extensive resections. Internal transmesocolic hernias are rare but potentially serious causes of intestinal obstruction, often challenging to diagnose preoperatively due to nonspecific symptoms. Contrast-enhanced abdominal CT is essential for detecting suggestive features and guiding timely surgical intervention. Definitive treatment is surgical, involving reduction of herniated loops and closure of the mesocolic defect; segmental resection, such as ileocecal resection, is required in cases of irreversible intestinal injury to prevent septic complications and optimize prognosis.
Posterior epidural migration of disc fragments (PEMDF) is a rare condition that can mimic spinal tumors on imaging, particularly neurogenic lesions, thereby posing a diagnostic challenge preoperatively. Owing to its atypical posterior extradural location and characteristic contrast enhancement patterns, it is frequently misinterpreted as a neoplastic process. Previous studies have reported that such lesions are commonly managed with open posterior decompression or conventional laminectomy to establish a definitive diagnosis and relieve neural compression. However, reports describing minimally invasive management, particularly the Quadrant approach, remains sacrce. Herein, we present this case to emphasize the diagnostic pitfalls and to demonstrate the feasibility of minimally invasive surgical treatment. A 67-year-old man presented with a 6-month history of intermittent low back pain, accompanied by progressively worsening bilateral lower-extremity numbness and weakness. Magnetic resonance imaging demonstrated a posterior extradural mass at the L2/3 level, characterized by heterogeneous hyperintensity on T2-weighted images and peripheral rim enhancement following contrast administration. A neurogenic tumor was initially suspected based on these findings. Given the progressive neurological deterioration and diagnostic uncertainty, the patient underwent surgical intervention via a minimally invasive Quadrant approach, achieving complete excision of the lesion. Histopathological examination revealed findings consistent with degenerative intervertebral disc tissue. Postoperatively, the patient showed marked symptomatic improvement, with complete recovery of lower-extremity muscle strength. No neurological deficits or radiological recurrence were observed during the 6-month follow-up period. PEMDF can closely mimic spinal tumors on magnetic resonance imaging, particularly when peripheral rim enhancement and posterior extradural localization are observed. Awareness of this entity is essential to prevent misdiagnosis. While surgical treatment has traditionally relied on open decompression for both diagnostic confirmation and symptom relief, minimally invasive approaches such as the Quadrant technique, may provide an effective alternative in selected cases. Surgical exploration remains a reliable approach for establishing a definitive diagnosis and providing treatment when imaging findings are inconclusive.
Multicystic peritoneal mesothelioma (MCPM) is a borderline variant of peritoneal mesothelioma with indolent behaviour but a significant recurrence rate without radical treatment. Due to its rarity, risk factors and optimal treatment are still to clarify. The present clinical case is a report of MCPM developed after laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (Lap CRS-HIPEC) for pseudomyxoma peritonei (PMP) of appendiceal origin. The patient was treated for PMP with Lap CRS-HIPEC. One year later a recurrence was suspected at the thorax-abdomen computed tomography scan. After multidisciplinary discussion, she underwent iterative Lap CRS-HIPEC. Pathological examinations revealed MCPM. After 3 years of follow-up the patient is disease-free for both tumours. This is a unique case of MCPM mimicking recurrent PMP. Lap CRS-HIPEC is an effective approach for both conditions.
Endometriosis and interstitial cystitis/bladder pain syndrome (IC/BPS) frequently coexist; however, diagnostic delays and non-standardized criteria limit accurate identification of these conditions. To assess the feasibility, safety, and clinical characterization of coexisting endometriosis and IC/BPS using a standardized surgical evaluation approach. In this prospective single-center study, approximately 100 women with presumed endometriosis and bladder symptoms undergoing laparoscopy for staging and/or treatment will simultaneously undergo diagnostic cystoscopy for IC/BPS. Optical confirmation and phenotype characterization of IC/BPS will be assessed. In cases with cystoscopic signs of IC/BPS, a standardized therapeutic protocol will be initiated to address bladder-centric symptoms alongside endometriosis treatment. The study will evaluate whether systematic surgical assessment enables reliable detection of coexisting endometriosis and IC/BPS and facilitates the identification of bladder-centric and non-bladder-centric IC/BPS phenotypes. Early recognition of IC/BPS in women with endometriosis may reduce unnecessary interventions and inform individualized management strategies. The combination of standardized laparoscopy and cystoscopy may improve diagnostic precision in patients with suspected coexisting endometriosis and IC/BPS. The study is expected to provide insights that support phenotype-driven, multidisciplinary care and inform future research and the development of integrated diagnostic algorithms.
Abdominopelvic actinomycosis is a rare chronic suppurative granulomatous infection that often mimics malignant tumors on imaging, leading to preoperative misdiagnosis and unnecessary radical surgery. This report aims to highlight key clinical and imaging features that can aid in differentiating this entity from malignancy. We retrospectively reviewed two cases of abdominopelvic actinomycosis confirmed by surgical pathology. Clinical presentations, laboratory findings, imaging characteristics (ultrasound, MRI, and CT), and pathological results were analyzed. Both patients presented with non-specific symptoms (abdominal dull pain/distension). Imaging revealed ill-defined, irregular heterogeneous masses with moderate-to-high resistance flow on ultrasound (RI 0.63-0.70) and no ascites. One case had a history of cesarean section; the other long-term intrauterine device (IUD) use (20 years). Preoperative imaging suggested malignancy, but postoperative pathology confirmed actinomycosis with inflammatory adhesions, microabscess formation, and reactive lymph nodes. Both patients underwent surgical resection with good outcomes and no recurrence during follow-up. Abdominopelvic actinomycosis should be considered in the differential diagnosis of pelvic masses, especially in women with IUD use or abdominal surgery history. Key differentiating features include moderate-to-high resistance flow, absence of ascites, internal cystic changes (microabscesses), and infiltrative changes due to adhesions rather than destructive invasion. In selected diagnostically challenging cases, preoperative core needle biopsy may help avoid unnecessary extensive surgery; however, surgery remains indicated when malignancy is strongly suspected or complications are present.
Elder abuse affects approximately 15% of adults aged 60 years and older worldwide each year, most often within the family setting. This study aimed to explore physicians' responses to suspected cases of intrafamilial elder abuse. A qualitative study informed by grounded theory was conducted, based on ten semi-structured interviews with physicians from various specialties. Physicians evaluated suspected abuse situations and implemented medico-social interventions while preserving the therapeutic alliance. Legal authorities were involved when there was an immediate risk to the older person or when alternative measures had failed. Physicians sought collegial discussion, although the relevant stakeholders were not always clearly identified. The reported situations frequently involved cognitive impairment and concerns that caregiver burden could contribute to abusive behaviours. Intrafamilial elder abuse is a complex clinical situation. Recent French guidelines (2024) emphasize geriatric vulnerabilities and identify the key professionals and resources that should be mobilized.
Endometriosis and interstitial cystitis/bladder pain syndrome (IC/BPS) frequently coexist in women with chronic pelvic pain, yet overlapping symptoms and non-standardized diagnostic pathways often delay recognition of dual pathology. We propose that a structured surgical approach combining laparoscopy and diagnostic cystoscopy may improve identification and clinical characterization of this overlap. On the basis of prospective surgical experience in women with suspected endometriosis and concomitant bladder symptoms, optical assessment enables phenotypic differentiation of bladder-centric and non-bladder-centric IC/BPS. When cystoscopic features are present, initiation of a standardized bladder-directed therapeutic strategy alongside endometriosis treatment may enhance symptom control and reduce persistent pain. Systematic evaluation during a single surgical setting has the potential to increase diagnostic precision, minimize incomplete interventions, and support individualized, mechanism-based management. This opinion highlights the importance of integrated diagnostic algorithms and multidisciplinary care models to address the complex interplay between endometriosis and IC/BPS.
Paediatric adrenocortical tumours (pACTs) are rare but potentially life-threatening neoplasms, most of which are hormonally active and frequently present with androgen excess. Although a comprehensive evaluation is recommended, no consensus exists on the optimal diagnostic work-up. The goal of this document is to provide evidence-based recommendations to standardize the diagnostic evaluation of children with suspected pACTs. We applied a modified three-step Delphi process with an international panel of pACT experts to develop consensus on the initial diagnostic work-up. Following a literature review, the steering committee formulated statements, which were distributed electronically to 28 experts from Europe, the Americas, and Asia. Agreement was rated on a six-point Likert scale; ≥70% agreement was defined as consensus. Between rounds, results and feedback were reviewed within the ENS@T-KIDS group. In round one, 33 statements achieved consensus; 12 were revised and re-voted in round 2, with 7 reaching consensus. Five statements were further modified and one reached consensus in round three. Response rates were 86% (n = 24) in round 1, 82% (n = 23) in round 2, and 86% (n = 24) in round 3. Forty-one statements received consensus covering 4 domains: (I) General Aspects and Clinical Assessment (17), (II) Endocrine Work-up (15), (III) Imaging (4), and (IV) Genetics (6). The diagnostic evaluation of pACTs varies widely between centres and countries, influenced by resources and local expertise. This work delivers the first expert-derived, international consensus statements outlining a practical and standardized diagnostic pathway to support timely and consistent evaluation of children with suspected pACTs.
Traditional disease surveillance, such as manual case investigation, was the primary method for identifying disease clusters during the COVID-19 pandemic. However, the pandemic also provides an opportunity to explore how genomic data can be used to improve cluster detection and response. While genomic data can complement traditional methods, guidelines are needed to integrate genomic data into real-time outbreak response. Using binomial and multinomial logistic regression, we compared two methods of disease surveillance in Utah: genomic sequencing of COVID-19 cases and manual case investigation. We evaluated whether these two methods reached the same populations geographically and demographically. Next, we performed genomic clustering using SNP distance thresholds and a logit regression model to identify potential transmission clusters. We compared genomic clusters with epi-identified clusters, defined by manual case investigation, using cluster validation metrics (Adjusted Rand Index, VI), and by assessing biological plausibility (monophyly). The odds of a case being sequenced varied significantly by jurisdiction and race/ethnicity, with patients in several non-White groups being less likely to undergo sequencing. The genomic clustering methods produced clusters that were notably different from epi-identified clusters. Genomic methods, particularly the logit model, resulted in strong clusters based on metrics of cluster validation and biological plausibility. Analysis of specific epi-defined clusters revealed significant discordance with genomic data. Many large clusters were likely composed of multiple distinct genomic introductions, or contained cases that were not genomically linked. Genomic data provides an advanced level of resolution for defining disease clusters compared to traditional epidemiological data. The disparities in sequencing coverage necessitate demographically and geographically diverse sampling strategies. Furthermore, it is essential to prioritize sequencing cases in a suspected cluster to maximize the impact of genomic surveillance. Integrating genomic data into epidemiologic investigation enables more precise cluster definitions, strengthening outbreak investigation and public health mitigation.
Diagnosing optic neuritis can be challenging, particularly in atypical cases where conventional MRI may be inconclusive. This study evaluates whether adding CE FS 3D FLAIR to standard orbital MRI improves diagnostic performance. This retrospective single-center diagnostic accuracy study included 48 patients (mean age, 60 years ± 18; 30 women) clinically suspected of acute optic neuritis who underwent orbital MRI between September 2016 and July 2024. All underwent FS 2D T2WI, CE FS 3D T1WI, and CE FS 3D FLAIR. Definite optic neuritis was defined by combined clinical and paraclinical findings. Segment-, nerve-, and patient-based analyses were performed using confidence scores (≥ 4.0 = abnormal). Diagnostic performance of the standard protocol (FS 2D T2WI + CE FS 3D T1WI) and advanced protocol (FS 2D T2WI + CE FS 3D T1WI + CE FS 3D FLAIR) was compared. For nerve-level analyses, including ROC analysis, patient-level cluster bootstrap resampling was applied to account for within-patient correlation between paired optic nerves, yielding cluster-corrected 95% confidence intervals and p values. Patient-level comparisons were evaluated using McNemar's test. CE FS 3D FLAIR detected optic disc abnormalities in 18 of 55 symptomatic nerves (32.7%) compared with 11 of 55 (20.0%) on CE FS 3D T1WI. The advanced protocol yielded higher AUC (0.93 vs. 0.88, bootstrap p value = 0.003), accuracy (90.6% vs. 80.2%), sensitivity (89.1% vs. 69.1%), and NPV (86.4% vs. 69.6%) than the standard protocol. In atypical presentations, sensitivity for definite optic neuritis improved from 50.0% (13/26) to 76.9% (20/26). Adding CE FS 3D FLAIR to conventional orbital MRI significantly improves diagnostic accuracy for optic neuritis, especially in atypical clinical presentations.
Severe cutaneous adverse reactions (SCARs), including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and related conditions, are rare but potentially life-threatening adverse drug reactions. Antiseizure medications (ASMs) are among the most commonly implicated drug classes; however, comparative pharmacovigilance evidence across different ASMs and SCAR phenotypes as well as their time-to-onset (TTO) patterns remain limited. This study aimed to evaluate ASM-associated SCARs using the FDA Adverse Event Reporting System (FAERS) and characterize their TTO patterns. Reports of ASM-associated SCARs were extracted from the FAERS database (Q1 2004-Q2 2024). Reports in which ASMs were coded as primary or secondary suspect drugs were included. Disproportionality analysis was performed using the reporting odds ratio (ROR) and Bayesian confidence propagation neural network (BCPNN). A positive signal was defined as a drug-event pair that met both ROR and BCPNN criteria. Descriptive analyses and TTO analyses were conducted for the positive signal cases. Differences in TTO across SCAR phenotypes and individual ASMs were assessed using the chi-squared test. A total of 6,212 positive-signal cases associated with ASMs were identified after data cleaning and deduplication, from which 47 positive drug-event associations were detected across 15 ASMs and five SCAR phenotypes. Signals were primarily concentrated in SJS and TEN, with phenytoin-SJS showing the strongest disproportionality signal. Phenytoin, lamotrigine, carbamazepine, zonisamide, and phenobarbital showed relatively strong disproportionality signals, whereas levetiracetam and valproate exhibited comparatively weaker overall signals but were associated with multiple SCAR phenotypes. Lamotrigine and carbamazepine showed positive signals across several phenotypes, indicating broader reporting patterns across SCAR phenotypes. TTO analysis revealed marked early clustering, with 44.3% of cases occurring within 14 days, 71.6% within 30 days, and 85.0% within 60 days; peak onset occurred between 15 and 30 days. TTO differed significantly across the SCAR phenotypes and ASMs (P < 0.001). ASM-associated SCARs are predominantly concentrated in SJS and TEN and show substantial heterogeneity across individual drugs. Most events occur early after treatment initiation, particularly within the first month, indicating an early period of reporting concentration after ASM initiation. These findings provide hypothesis-generating pharmacovigilance evidence regarding the reporting patterns and time-to-onset characteristics of ASM-associated SCARs and may help inform future risk evaluation and monitoring strategies.
Pressure injuries among critically ill patients are complications that may lead to increased morbidity, prolonged hospital stays, and higher healthcare costs. Despite this fact, there is limited national data on the prevalence of pressure injuries in Norwegian intensive care units (ICUs). This study describes the prevalence, characteristics of, and associated risk factors for ICU-acquired pressure injuries in Norway. A secondary analysis of the Norwegian data from the international one-day prevalence study, DecubICUs, conducted on 15 May 2018. Data on pressure injuries, patient characteristics, and exposure to potential risk factors were analyzed. Prevalence was calculated based on the presence of one or more ICU-acquired pressure injuries on the study day. This multicenter cross-sectional study included 119 patients from 25 Norwegian ICUs. The prevalence of ICU-acquired pressure injury was 24% (28/119). These 28 patients had 52 ICU-acquired pressure injuries. Of these, the majority were stage I (71%), followed by stage II (27%), and one was categorized as suspected deep tissue injury (2%). The most common locations were the heels (23%), buttocks (23%), ears (17%), nose (12%) and mouth (10%). The risk factor associated with ICU-acquired pressure injuries was LOS-ICU (OR = 1.06/day increase, 95% CI: 1.02-1.11, p = < 0.001). The prevalence of ICU-acquired pressure injury was surprisingly high considering Norway is a high-income country, with a high nurse-to-patient ratio and well-educated critical care nurses. These findings highlight the need for continued focus on early prevention strategies, such as thorough skin assessments, "floating heels" and repositioning of medical devices. This subgroup analysis for Norwegian cases reported in a point-prevalence study presents intensive care unit patients with pressure injuries along with selected case factors. Pressure injuries are complications that appear to remain an intensive care unit challenge, even in units with high nurse to patient ratios.
Testosterone declines by 0.4%-2% annually after the age of 30 and is potentially linked with muscle mass and strength. This study examined how testosterone levels are associated with handgrip strength (HGS) and appendicular lean soft tissue index (ALSTI) in men aged 40-49 and 50-59 years. Data were sourced from the National Health and Nutrition Examination Survey (NHANES) cycles (2011-2014). The median values of each cohort (378.2 and 378.6 ng/dL for those aged 40-49 and 50-59 years of age, respectively) and the European Association of Urology guidelines were used to define higher serum testosterone, HGS and ALSTI. Linear and logistic regressions assessed associations between higher/lower serum testosterone with higher/lower HGS and ALSTI for each age group. In 1001 men aged 40-59 years, higher total testosterone levels were positively associated with higher HGS, with stronger links in the 50- to 59-year-olds (b = 1.35, 95% confidence interval [CI] 0.08-2.62, p < 0.01). In this group, higher testosterone was linked to increased odds ratio (OR) of having higher HGS (OR: 1.73, 95% CI 1.17-2.55, p < 0.01). Per European Association of Urology guidelines, men with testosterone levels above deficiency (≥ 230 ng/dL) had higher odds of increased ALSTI versus those with deficiency (OR: 3.31, 95% CI 1.42-7.74, p < 0.01), while normal testosterone (> 346 ng/dL) versus deficiency showed a significant albeit weaker association (OR: 2.48, 95% CI 1.35-4.57, p < 0.01). Linear regression confirmed an ALSTI increase above deficiency (b = 0.20, 95% CI 0.05-0.34, p < 0.01); however, normal versus suspected deficiency for total testosterone was linked to a small but potentially minor clinically significant difference with ALSTI in the whole cohort (b = 0.10, 95% CI 0.00-0.19, p = 0.049). Normal testosterone was linked to higher HGS overall (OR: 1.37, 95% CI 1.05-1.80, p = 0.02) and in men aged 50-59 years (OR: 1.53, 95% CI 1.03-2.28, p = 0.03). Normal and higher than deficiency testosterone levels in men aged 40-59, particularly 50- to 59-year-olds, are associated with higher HGS and ALSTI compared with those with deficient testosterone concentrations.
Providing reasonable accommodations for persons with intellectual disabilities (ID) is increasingly recognized as an essential competency for pharmacists. However, pharmacy education in Japan often lacks training that reflects real-world interactions with this population. To explore practicing pharmacists' experiences and educational needs regarding support for persons with intellectual disabilities, and to identify implications for pharmacy communication education. Semi-structured interviews were conducted with 11 pharmacists working in community pharmacies and hospitals in Japan. Interviews focused on their experiences supporting persons with suspected ID and their perspectives on education. Transcripts were analyzed thematically using Braun and Clarke's six-phase approach. Two overarching themes-"Educational Gaps" and "From Practice to Pedagogy"-and six subthemes were identified: (1) Experiential Learning and Educational Gaps, (2) On-the-Job Learning Through Imitation, (3) Personalized Communication Adaptation, (4) Removing Prejudice and Respecting Individuality, (5) Building Trust Through Repeated Interaction, and (6) Setting Boundaries and Staying Resilient. Participants emphasized the importance of adjusting communication to patient needs, reducing stigma, and learning through direct experience. Many reported a lack of educational exposure to ID during pharmacy school and developed their skills through informal, workplace-based learning. Pharmacists' narratives highlight the need for communication education that goes beyond standardized assessment to foster empathy, adaptability, and patient-centered care. Pharmacy curricula should incorporate experiential learning opportunities with persons with disabilities and promote collaboration with practicing pharmacists.
Heatstroke (HS) encompasses acute multi-organ dysfunction and increases susceptibility to subsequent heat-related conditions, making timely diagnosis and intervention critical. This systematic review aimed to identify risk factors and long-term health consequences, evaluate cooling methods for field interventions, and assess the accuracy of predictive technologies. A comprehensive search of five major databases (MEDLINE/PubMed, Embase, Web of Science, Scopus, and CINAHL) was conducted in May 2024 for peer-reviewed English studies published between January 2014 and May 2024. Eligibility criteria included populations diagnosed with classic or exertional heatstroke (EHS) and reports on clinical outcomes. Methodological quality was assessed using the JBI critical appraisal tools, and the certainty of the evidence was determined using the GRADE system. Results were synthesized narratively due to study heterogeneity. Out of 1346 identified records, 39 studies were included. Risk of Bias (RoB) assessment categorized 66.7% of studies as low RoB, 20.5% as moderate, and 12.8% as low/moderate. High-precision data confirm a bimodal age risk distribution: runners younger than 30 have a 5.5-fold higher incidence of EHS, while classic heatstroke peaks at ≥ 65; at ≥ 80 years, it is 4.45 per 100,000 (moderate certainty). Among comorbidities, neuropsychiatric disorders carried the highest independent risk (aOR 7.69; 95% CI 4.06-14.54; P < 0.01) (high certainty). Survivors face significant chronic risks, with strong associations found for acute myocardial infarction (aHR 7.43) and chronic kidney disease (aHR 4.35) (low certainty due to serious inconsistency/imprecision). Cold-water immersion (CWI) is the definitive gold standard (0.14-0.22 °C/min), achieving cooling rates that are mathematically five times faster than cold IV saline (0.039 °C/min; P < 0.01) (moderate certainty). Emerging machine learning models utilizing wearable sensors achieved a predictive AUC of 0.99, though clinical certainty is low due to small event samples and suspected publication bias. CWI is the gold standard treatment for rapidly reducing core temperature to prevent permanent organ damage. "Cool first, transport second" should be prioritized, with prevention targeted at young athletes and elderly populations with neuropsychiatric conditions. Future research is needed on predictive models in large clinical cohorts to translate laboratory validation into real-time prevention.
A method for examining the female genital organs using complete pelvic exenteration in forensic cases is described, facilitating documentation of injuries in suspected sexual assault. This systematic dissection approach takes place during the routine post-mortem examination. This technique does not require sectioning of the pelvic bones and allows the pelvic organs to be returned intact after examination, with only biopsy-sized samples retained when necessary. Trace evidence should be collected prior to cleaning the body and dissection of the genital organs, in accordance with approved departmental procedures. The procedure is composed of eight steps, each described in detail and supported by anatomical diagrams.
Transurethral laser enucleation of the prostate for benign prostatic hyperplasia (BPH) is considered a first-line surgical treatment for patients with prostate volume > 80 cm. However, a significant proportion of patients undergo prostate biopsy prior to surgery due to suspected prostate cancer (PCa), which may potentially affect surgical outcomes. To evaluate the impact of prior prostate biopsy on perioperative and functional outcomes, complications of transurethral thulium fiber laser enucleation of the prostate (ThuFLEP), and the detection rate of incidental prostate cancer. A retrospective analysis was performed on 1555 patients who underwent ThuFLEP between 2020 and 2024 at the Institute of Urology and Human Reproductive Health (Sechenov University). Patients were divided into three groups: no prior biopsy (n=1265), prior transrectal biopsy (n=197), and prior combined (mpMRI/US fusion and saturation) transperineal biopsy (n=93). The analysis included perioperative parameters, functional outcomes at 6 months, incidental prostate cancer detection rate, and complication rates. The groups differed significantly in PSA level (p<0.001), PSA density (p<0.001), age (p=0.018), and IPSS score (p<0.001). There were no statistically significant differences in operative time (p=0.189) or enucleated tissue weight (p=0.141). However, catheterization and hospitalization time were significantly longer in patients with prior biopsy (p<0.001). Functional outcomes at 6 months - including IPSS (p=0.397), QoL (p=0.115), Qmax (p=0.274), and post-void residual volume (p=0.248) - did not significantly differ among groups. Overall complication rates were similar, except for urethral strictures, which were more frequent in patients with prior biopsy (6.1% and 6.5% vs. 1.2%; p<0.001). Incidental PCa was more commonly detected after transrectal biopsy (11.1% vs. 5.5%; p=0.01), although most cases were clinically insignificant (ISUP grade 1). Prior prostate biopsy is associated with a higher risk of urethral stricture and longer catheterization and hospitalization durations, without significantly affecting functional outcomes or the rate of other complications. Incidental prostate cancer was more frequently detected after transrectal biopsy, though most cases were clinically insignificant.