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In the injection molding industry, the shift toward small-batch production has led to a greater variety of products and smaller batch sizes, necessitating frequent mold changes and efficient quality control, which still largely relies on human operators. This study proposes a comprehensive methodology for evaluating and comparing deep learning-based automatic optical inspection (AOI) strategies to detect complex surface defects in injection-molded parts. Three inspection setups were assessed: static frontal imaging, belt conveyor inspection, and robotic-assisted inspection. The findings reveal clear differences in defect detection capabilities among the methods, with the robotic-assisted approach demonstrating superior performance, achieving higher defect detection accuracy due to its flexibility in optimizing camera angles and positions. The proposed methodology serves as a workflow to systematically evaluate and optimize inspection setups across different parameters, enabling informed decisions about AOI systems design. This research contributes to narrowing the gap between the development of advanced detection algorithms and their industrial application, offering insights into the strategic implementation of AI technologies in quality control processes and enhancing the automatic detection of challenging defects.

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by thunderclap headache and reversible segmental cerebral arterial constriction. Although neurological complications are well recognized, concurrent extracerebral vasoconstriction remains under appreciated. A 53-year-old woman presented with sudden chest tightness immediately followed by a thunderclap headache. Initial brain computed tomography and magnetic resonance imaging showed no hemorrhage or infarction; however, magnetic resonance angiography demonstrated multifocal cerebral arterial narrowing, consistent with RCVS. During hospitalization, she developed recurrent nonaneurysmal subarachnoid hemorrhages (SAHs) on days 2 and 4. No bleeding source was identified on serial angiography. Recurrent episodes of chest tightness prompted coronary angiography with acetylcholine provocation, which revealed severe coronary vasospasm, establishing the diagnosis of vasospastic angina (VSA). Treatment with benidipine and nicorandil was initiated thereafter, and no recurrence of either cardiac or neurological symptoms was observed, with complete resolution of cerebral vasoconstriction on follow-up imaging. This case highlights a rare but clinically important association between RCVS, recurrent nonaneurysmal SAH, and coronary VSA confirmed by pharmacologic provocation. Although each condition is potentially reversible, their coexistence supports the concept of systemic vasoconstriction syndrome and underscores the need for vigilance regarding extracranial vascular involvement in patients with RCVS. Early recognition and targeted vasodilator therapy may be essential to prevent serious neurological and cardiovascular complications.

This study investigated the haemodynamic effects by simulating simplified cerebrovascular at different stenosis levels. To improve the understanding of haemodynamic changes due to atherosclerosis, computational fluid dynamics (CFD) simulations are employed to visualise wall shear stress (WSS), pressure distribution, and flow rate within arterial models. Three different degrees of arterial atherosclerosis, specifically 25%, 50% and 75% plaque thickness have been examined. Findings show that in the severe atherosclerosis of 75%, blood flow velocity through the plaque undergoes a significant change, leading to low pressure due to extreme narrowing and resulting turbulent flow. Moreover, WSS contours reveal extensive and severe red zones when atherosclerosis reaches 75%, especially within and beyond the severely constricted region. Although the individual parameters were visualised, the velocity-pressure correlation for each atherosclerosis level showed velocity peaks around 10 m/s for 50% plaque and sharply increasing to nearly 100 m/s for 75% plaque. In mild atherosclerosis (25% plaque), both velocity and pressure profiles remain relatively stable. This study offers deeper insights and understanding on how atherosclerosis alters cerebral circulation, potentially enhancing diagnostic accuracy and treatment strategies for stroke prevention.

Tetralogy of Fallot (TOF) with absent pulmonary valve (APV) spectrum is a rare congenital cardiac anomaly characterized by dysplastic or APV leaflets, leading to severe pulmonary regurgitation and aneurysmal dilatation of the pulmonary arteries. We report a 4-year-old male presenting with recurrent respiratory infections. Cardiac computed tomography (CT) revealed TOF with a subaortic ventricular septal defect, overriding aorta, right ventricular hypertrophy, and right ventricular outflow tract narrowing. The pulmonary valve was dysplastic, with marked aneurysmal dilatation of the main and branch pulmonary arteries, causing compression of the right main bronchus. This case highlights the role of cardiac CT in comprehensive anatomical assessment and its importance in preoperative planning. RésuméLa tétralogie de Fallot (TDF) avec spectre d’absence de valve pulmonaire (AVP) est une anomalie cardiaque congénitale rare caractérisée par des feuillets valvulaires pulmonaires dysplasiques ou absents, entraînant une régurgitation pulmonaire sévère et une dilatation anévrismale des artères pulmonaires. Nous rapportons le cas d’un garçon de 4 ans présentant des infections respiratoires récidivantes. La tomodensitométrie cardiaque (TDM) a révélé une TDF avec communication interventriculaire sous-aortique, aorte à cheval, hypertrophie ventriculaire droite et rétrécissement de la voie d’éjection du ventricule droit. La valve pulmonaire était dysplasique, avec une dilatation anévrismale marquée du tronc et des branches des artères pulmonaires, entraînant une compression de la bronche principale droite. Ce cas souligne le rôle de la TDM cardiaque dans l’évaluation anatomique complète et son importance dans la planification préopératoire.

Comparative data on vessel preparation using intravascular Shockwave lithotripsy (Johnson and Johnson, New Brunswick, NJ) or the 355-nm Auryon laser (Angiodynamics, Latham, NY) in calcified femoropopliteal arterial disease is limited. This is a retrospective, single-center study evaluating the 30-day safety and effectiveness of the 355-nm laser system versus Shockwave lithotripsy in treating calcified femoropopliteal arterial disease. Angiographic images were reviewed by core laboratory. The primary endpoint of safety is freedom from major adverse limb event (MALE) at 1 month. The primary effectiveness endpoint is acute procedural success, defined as achieving less or equal 30% mean residual narrowing postfinal treatment with no bailout stenting. A total of 29 consecutive patients were included (355-nm laser 15 patients [15 vessels] and Shockwave lithoplasty 14 patients [15 vessels]). At baseline, there were no differences between the two cohorts in demographics or clinical presentation. Also, there were no difference in total occlusions (33.3 vs. 33.3%), lesion length (median: 12.0 vs. 12.1 cm), presence of moderate to severe calcium (86.7 vs. 100%). At 30-day, there were no MALEs in both groups. There were no perforations, type D dissections, or distal embolization seen in both cohorts. Bailout stent was driven by a higher residual stenosis and was 35.7 vs. 13.3% in Shockwave versus laser, respectively ( p  = 0.215). At 30-day ankle-brachial indices were similar between the two groups (median: 0.9 vs. 1.09). Both Shockwave and 355-nm laser are effective and safe in calcified femoropopliteal lesions. A numerically higher rate of bailout stenting was seen with Shockwave lithoplasty.

A three-year-old neutered female Bernese mountain dog was referred for evaluation of multiple congenital cardiac abnormalities. Transthoracic echocardiography demonstrated features consistent with type A pulmonic stenosis, including a normal pulmonary valve annulus, an increased transvalvular pressure gradient, systolic doming of thickened and fused pulmonary valve leaflets, and concentric right ventricular hypertrophy. Additionally, a focal aneurysmal dilation arising from the intermediate pulmonary valve leaflet was identified. Furthermore, a concurrent left-to-right shunting patent ductus arteriosus was detected. Computed tomography confirmed thickening of the pulmonic valve, narrowing of the sinotubular junction, and thin-walled, contrast-enhancing saccular dilation originating of the intermediate pulmonary valve sinus. These findings supported the diagnosis of a pulmonary valve sinus aneurysm associated with severe type A pulmonic stenosis and patent ductus arteriosus.

Cerebral vasospasm is a rare but devastating complication following intracranial tumor surgery, particularly in pediatric suprasellar lesions such as craniopharyngiomas. Delayed cerebral ischemia secondary to postoperative vasospasm remains insufficiently recognized and may result in fatal neurological injury. We report the case of a 5-year-old girl who underwent gross total resection of a cystic suprasellar craniopharyngioma through a subfrontal approach without intraoperative vascular injury. The immediate postoperative course was uneventful. On postoperative day 6, the patient developed sudden refractory status epilepticus associated with rapid neurological deterioration and bilateral fixed mydriasis. Brain computed tomography (CT) revealed extensive left hemispheric ischemia with severe cerebral edema. CT angiography demonstrated marked narrowing of the A1 + M1 segment of the left middle cerebral artery, consistent with malignant cerebral vasospasm. Despite intensive care management, the patient progressed to brain death and subsequently died. Delayed malignant cerebral vasospasm following pediatric craniopharyngioma resection is an unpredictable and potentially fatal complication that may occur even in the absence of intraoperative vascular injury. Prompt recognition of delayed neurological deterioration and early vascular imaging are crucial to improve diagnostic and therapeutic management.

Polyarteritis nodosa (PAN) is a rare vasculitis affecting predominately medium-sized vessels. Our evolving understanding of PAN, including the role of HBV and discovery of monogenic variants such as deficiency of adenosine deaminase 2 (DADA2), has resulted in idiopathic PAN becoming a very rare condition with an annual incidence of 0.6-19.9/million. The investigative approach is to assess organ involvement and confirm the diagnosis either by imaging or biopsy. Conventional catheter angiography is being replaced by CT or MR angiography, which provide increasingly good resolution of the typical fusiform narrowing and aneurysm. ANCA-associated vasculitis (AAV) should be excluded. DADA2 is being more frequently identified as causing a PAN-like illness, especially in children; cases presenting in adulthood are now recognised. In children and most adults, genotyping for DADA2 should be undertaken. There are no high-quality randomised controlled trials of treatment in idiopathic PAN. Current approaches have been adapted from those used to treat other types of vasculitis. The five-factor score may be used to stratify patients to identify those needing intensive therapy with glucocorticoids combined with CYC. In order to reduce the burden of glucocorticoid toxicity, the ACR has advocated the use of immunosuppressive drugs in addition to steroids in those not initially receiving CYC. Unlike AAV, there appears to be little role for rituximab in the treatment of idiopathic PAN, although it is occasionally used as salvage therapy. HBV-associated PAN is treated with immunosuppression and antiviral therapy. There is reasonably good evidence to support the use of anti-TNF to treat DADA2.

Metastatic involvement of the biliary tract and gastrointestinal (GI) system secondary to breast carcinoma is exceedingly rare. We hereby report a case of a 57-year-old woman with a past history of Human Epidermal Growth Factor Receptor 2-positive, estrogen and progesterone receptor-negative breast carcinoma treated 4 years earlier, who presented with jaundice, vomiting, early satiety, and significant weight loss. Biochemical evaluation revealed a cholestatic pattern of jaundice. Magnetic resonance cholangiopancreatography and contrast-enhanced computed tomography revealed intrahepatic biliary dilatation secondary to a mass at the porta hepatis compressing the distal common bile duct, along with significant narrowing of the D1-D2 segment of duodenum. Endoscopic ultrasound-guided biopsy confirmed metastatic adenocarcinoma consistent with a breast primary. Due to anatomical constraints precluding endoscopic biliary stenting, the patient underwent palliative double bypass surgery of cholecystojejunostomy and gastrojejunostomy. Postoperatively, the patient demonstrated resolution of jaundice and restoration of normal oral intake, with marked symptomatic improvement. This case highlights a rare metastatic presentation of breast carcinoma closely mimicking primary hepato-pancreato-biliary malignancies, posing a significant diagnostic challenge. A high index of suspicion is thus essential in patients with a prior history of breast cancer presenting with biliary or upper GI symptoms. In cases where endoscopic interventions are not feasible, surgical double bypass proves to be an effective palliative strategy for symptom relief. RésuméL’atteinte métastatique des voies biliaires et du tractus gastro-intestinal secondaire à un carcinome mammaire est exceptionnelle. Nous rapportons le cas d’une patiente de 57 ans, ayant des antécédents de carcinome mammaire HER2 positif, négatif pour les récepteurs hormonaux, traité quatre ans auparavant, admise pour ictère, vomissements, satiété précoce et amaigrissement. Le bilan biologique objectivait un syndrome cholestatique. La cholangiopancréatographie par résonance magnétique et la tomodensitométrie abdominale avec contraste ont révélé une dilatation des voies biliaires intra-hépatiques secondaire à une masse du hile hépatique comprimant le cholédoque distal, associée à un rétrécissement du duodénum (D1–D2). La biopsie guidée par échoendoscopie a confirmé un adénocarcinome métastatique compatible avec une origine mammaire. En raison de contraintes anatomiques rendant impossible le drainage biliaire endoscopique, une dérivation palliative par double court-circuit (cholécystojéjunostomie et gastrojéjunostomie) a été réalisée. L’évolution postopératoire a été favorable, avec régression de l’ictère et reprise de l’alimentation orale. Ce cas illustre une présentation métastatique rare mimant une néoplasie hépato-pancréato-biliaire primitive, posant un défi diagnostique. Un haut niveau de suspicion est essentiel, et en l’absence d’alternative endoscopique, le double court-circuit chirurgical constitue une option palliative efficace.

Peripheral artery disease (PAD) is a prevalent and disabling vascular condition characterized by progressive atherosclerotic narrowing and stiffening of peripheral arteries. Arterial stiffness, most accurately measured by pulse wave velocity (PWV), has gained prominence as a critical biomarker in the assessment and management of PAD. Unlike traditional diagnostic tools that focus primarily on anatomical lesions, PWV offers dynamic insights into vascular function, elasticity, and systemic cardiovascular risk. Elevated PWV has been consistently associated with adverse outcomes in PAD patients, including critical limb ischemia, restenosis following angioplasty, amputation, and cardiovascular mortality. It not only reflects disease severity but also facilitates early risk stratification, informs treatment selection, and enables monitoring of therapeutic efficacy. Studies have shown that reductions in arterial stiffness following angioplasty, pharmacological therapy, or lifestyle interventions correlate with improved limb perfusion and long-term clinical outcomes. Moreover, in elderly PAD patients, arterial stiffness often coexists with frailty-another key predictor of poor prognosis. Emerging evidence suggests that both conditions may share pathophysiological pathways related to vascular aging and sarcopenia. The integration of PWV into routine PAD evaluation may thus offer a more holistic understanding of patient risk and resilience. Given its diagnostic, prognostic, and therapeutic utility, arterial stiffness-particularly as assessed by PWV-should be considered an essential parameter in PAD management. Incorporating this measurement into clinical practice holds significant potential to improve individualized care, reduce complications, and enhance overall patient outcomes.

Despite well-established childhood immunization programs in many high-income countries, vaccination series are often delayed or not completed. Gaps in vaccination coverage are more common among children from socioeconomically disadvantaged households, among whom they are associated with higher rates of related hospitalizations. We aimed to assess the extent of these gaps in Germany, as well as the presence of socioeconomic inequality and the factors accounting for it. Using health insurance claims data from Techniker Krankenkasse for 2016-2019, we examined vaccination coverage for a comprehensive set of STIKO-recommended childhood vaccinations in six birth-year cohorts (2011-2018; approximately 430,000 children; 2.5 million recommended vaccinations). Coverage was defined as completion of the recommended series with all doses administered within the recommended age window. Socioeconomic inequality was quantified using the Erreygers-corrected concentration index and decomposed into contributions from factors such as parental education and travel time to the treating physician. Approximately 80% of vaccination series in the sample were complete and administered within the recommended age window. Vaccination coverage showed a small but statistically significant socioeconomic gradient (concentration index = 0.024, 95% confidence interval: 0.023 to 0.025) favoring children from higher socioeconomic households. In the decomposition analysis, provider type accounted for the largest share of this gradient, with lower completion rates and timeliness among children whose outpatient care was mainly delivered by general practitioners compared with pediatricians. Parental education contributed to a lesser extent, and travel time contributed little to the observed inequality. Childhood vaccination coverage in Germany remains below national targets and shows a small socioeconomic gradient. The gradient appears to be less strongly related to logistical access barriers than to differences in how vaccinations are delivered in outpatient care outside pediatric settings. These provider-type differences in vaccination delivery may therefore be more relevant for narrowing the observed gradient than further reductions in travel time.

Global glycemic control in diabetes is suboptimal, with persistent gaps between guideline recommendations and clinical practice. To evaluate the effectiveness of a role-playing-based intensive training program for physicians in improving glycemic control among patients with type 2 diabetes. This was an open-label, 2-arm parallel, cluster randomized clinical trial conducted at 205 centers in China, with enrollment from February 13 to September 19, 2023, and 12-month follow-up completed on October 25, 2024. In phase 1, 205 physicians from qualified diabetes centers across China were enrolled from February 13 to April 29, 2023, and randomly assigned to the intensive training group (n&#x2009;=&#x2009;103) and the regular training group (n&#x2009;=&#x2009;102). In phase 2, 2017 patients with type 2 diabetes were enrolled from February 28 to September 19, 2023. Data were analyzed from January 1 to June 1, 2025. One-week on-site role-playing-based intensive training (involving simulating patient roles in experiencing diabetes-related health examinations, complication scenarios, lifestyle intervention, and face-to-face conversations) vs regular training. The proportion of patients achieving a hemoglobin A1c (HbA1c) level of less than 7.0% at 6 months. The primary analysis was based on the intention-to-treat principle. A total of 205 physicians (mean [SD] age, 36.2 [5.1] years; 155 women [75.6%]) and 2017 patients (mean [SD] age, 53.0 [7.0] years; 713 women [35.3%] and 1304 men [64.7%]) were enrolled, with 1009 patients in the intensive training group and 1008 patients in the regular training group. At 6 months, a significantly greater proportion of patients in the intensive training group achieved an HbA1c level less than 7.0% compared with the regular training group (58.0% [476 of 820] vs 42.9% [351 of 818]), with an adjusted between-group difference of 16.6% (95% CI, 7.2%-25.7%; P&#x2009;<&#x2009;.001). At 12 months, the difference between the intensive training group and the regular training group remained significant (60.9% [502 of 824] vs 44.6% [371 of 832]; adjusted between-group difference, 17.0% [95% CI, 7.0%-26.8%]; P&#x2009;<&#x2009;.001). The intensive group had greater reductions in body mass index (adjusted between-group difference, -0.3 [95% CI, -0.5 to -0.1]), waist circumference (adjusted between-group difference, -1.4 cm [95% CI, -2.1 to -0.8 cm]), fasting glucose (adjusted between-group difference, -6.3 mg/dL [95% CI, -10.7 to -1.9 mg/dL]), and systolic blood pressure (adjusted between-group difference, -1.5 mm Hg [95% CI, -2.9 to -0.1 mm Hg]). Serious adverse events were comparable between groups (intensive group, 2.6% [26 of 1009]; regular group, 2.4% [24 of 1008]). In this cluster randomized clinical trial of role-playing-based intensive training for physicians managing type 2 diabetes, the intervention significantly improved patient glycemic control. These findings suggest a feasible strategy to narrow the guideline-implementation gap in diabetes care. ClinicalTrials.gov Identifier: NCT05715307.

Lung stereotactic body radiotherapy (SBRT) requires highly reproducible workflow execution because of steep dose gradients, respiratory motion, and narrow treatment margins. This study evaluated the workflow effectiveness and process-safety impact of an FMEA-guided quality-improvement workflow for lung SBRT. This single-center historical-control study included 128 patients treated with lung SBRT. Sixty-three patients treated under conventional quality-control procedures served as the control group, and 65 patients managed after implementation of an FMEA-guided quality-improvement workflow served as the FMEA-guided group. The workflow included risk identification, targeted corrective measures, respiratory coaching, dual verification, immobilization optimization, and enhanced equipment quality control. RPN changes were analyzed using the Wilcoxon signed-rank test. CBCT-derived setup deviations were assessed using patient-level median absolute couch correction values and fraction-level linear mixed-effects models. Workflow-related adverse events were compared using Fisher's exact test. Eleven high-risk failure modes were identified. The overall median residual RPN was lower than the initial RPN [39.0 (IQR, 26.0-46.5) vs 177.5 (IQR, 165.0-209.0); p&#xa0;=&#xa0;0.003]. The setup-error analysis included 374 CBCT registrations from 63 control patients and 388 registrations from 65 patients in the FMEA-guided group. Patient-level median absolute couch correction values were smaller in the FMEA-guided group, and fraction-level mixed-effects models confirmed significantly smaller deviations across all six translational and rotational dimensions. Workflow-related adverse events decreased from 11.11% to 3.08%, but the difference was not statistically significant (RR&#xa0;=&#xa0;0.277, 95% CI, 0.060-1.282; p&#xa0;=&#xa0;0.093). Implementation of an FMEA-guided quality-improvement workflow was associated with reduced residual RPN scores and smaller CBCT-derived setup deviations in lung SBRT. Workflow-related adverse events decreased numerically but did not reach statistical significance. These findings support the value of proactive, closed-loop workflow risk management, while further prospective multicenter validation is warranted.

As the population continues to age, the scientific selection and rational layout of older adult(s) care facilities are increasingly becoming key issues in urban planning. Yet, traditional planning methods have clear limitations in terms of spatial precision and practicality. This study focuses on Shanghai, a megacity experiencing rapid population aging. It explores a three-tiered, progressive framework for predicting the location of older adult(s) care facilities that integrates POI data, machine learning algorithms, and space syntax. Shanghai was divided into 33,010 500 &#xd7; 500-m grid cells, and a training dataset was constructed using POI data. The C5.0 decision tree algorithm was employed, and a multi-algorithm benchmark comparison was conducted with logistic regression and random forests. Through a three-tiered progressive screening process-comprising citywide grid prediction, secondary screening based on aging data, and space syntax-based local choice verification-the study sequentially identifies preliminary suitable grids, priority deployment grids, and key planning grids. The study found that: (1) The C5.0 decision tree model achieved a prediction accuracy of 83.36%, outperforming logistic regression (82.05%) and random forests (80.96%), indicating that the method is robust and reliable. The model identified 940 preliminarily suitable grid cells, with a spatial match rate of 89% compared to existing older adult(s) care facilities (&#x3c7;2 = 30,517, p < 0.001). Catering, real estate, and company facilities were identified as key influencing factors, indicating that existing older adult(s) care facilities tend to cluster in areas with convenient daily services, high residential density, and accessible employment opportunities. (2) Based on the aging rates and older adult population sizes of each subdistrict, a secondary screening was conducted to identify 519 priority deployment grids. These areas exhibit a center-to-periphery decreasing distribution, with the highest density in the central urban area and few in outer suburban areas such as Chongming. (3) A citywide space syntax analysis was conducted using the complete Shanghai road network, identifying 104 key planning grids from among 519 priority deployment grids. Taking Jiading District-which has the highest number of priority deployment grids (168)-as a case study, the space syntax analysis was used to narrow the selection down to 34 key planning grids. The three-tiered, progressive site selection framework developed in this study integrates macro-level predictions of functional suitability with micro-level assessments of road network accessibility. It provides urban planning authorities with actionable spatial decision-making references for identifying priority deployment areas for older adult(s) care facilities, and offers a replicable methodological approach for the planning of public service facilities in other high-density cities.

Lithium remains a cornerstone in the treatment of bipolar I disorder because of its well-established efficacy in reducing mood episode recurrence and suicide risk. However, its narrow therapeutic index makes patients particularly susceptible to clinically significant toxicity, especially following medication changes or drug-drug interactions. Nonsteroidal anti-inflammatory drugs (NSAIDs) are recognized to increase serum lithium concentrations by reducing renal lithium clearance, although reports involving nabumetone remain limited.&#xa0;We report the case of a 50-year-old woman with bipolar I disorder who had remained psychiatrically stable on chronic lithium therapy for approximately seven years before developing severe lithium toxicity following recent escalation of both lithium and nabumetone dosages. The patient presented with progressive confusion, lethargy, recurrent falls, tremor, myoclonic jerks, gait instability, generalized weakness, and altered mental status. Initial serum lithium concentration exceeded 2.9 mmol/L despite preserved renal function. Lithium and nabumetone were discontinued, aggressive intravenous fluid administration was initiated, and serial lithium concentrations were monitored. Given preserved renal function, declining serum lithium concentrations, and rapid neurologic improvement with supportive management, hemodialysis was deferred. The patient experienced progressive clinical recovery with normalization of lithium concentrations and resolution of neurologic symptoms. Lithium was cautiously reintroduced at a reduced dosage without recurrence of toxicity. Application of the Naranjo Adverse Drug Reaction Probability Scale yielded a score of 9, supporting a definite adverse drug reaction.&#xa0;This case highlights that severe lithium toxicity may occur despite preserved renal function following concurrent escalation of lithium and nabumetone therapy. The report emphasizes the importance of comprehensive medication reconciliation, recognition of clinically significant drug-drug interactions, close serum lithium monitoring following medication changes, and early recognition of neurologic manifestations suggestive of lithium toxicity.

The use of de-epithelialized oral vestibular flap (boot flap) for treating free border deformity in unilateral cleft lip and for the correction of whistling lip deformity in bilateral cleft lip is reported. A 22-year-old patient with a Tessier no. 0 median cleft was referred after having undergone median lip repair, facial bipartition for correction of orbital hypertelorism, and nasal reconstruction using a scalping forehead flap at a different hospital. The patient presented with vermilion notching and a reverse V-shaped deformity of the upper lip. The standard bilateral cleft lip repair technique was modified, and satisfactory results were obtained. Specifically, a bilateral boot flap procedure was performed on the oral vestibule along the central suture line of the primary repair. The boot flap was designed to be shorter than that used in standard cases of bilateral cleft lip. The surface mucosa was de-epithelialized before flap elevation, and a subcutaneous pedicle was created beneath the flap, which was then connected to the orbicularis oris muscle. Bilateral subcutaneous pockets were dissected, into which the boot flap was inserted and fixed using absorbable sutures. The donor site was closed by advancing the bilateral mucosal flaps. Full-thickness skin from the nasal dorsum was grafted onto the pigmented forehead donor area of the scalping flap, and direct suturing was performed to narrow the nasal dorsum. The postoperative course was uneventful, and vermilion notching did not recur during a 7-year follow-up.

Monochromator phototesting is a specialist investigation to assess abnormal skin response to defined ultraviolet and visible wavebands in patients with suspected photodermatoses. Monochromator phototesting spans ultraviolet B (UVB), ultraviolet A (UVA) and visible light (VL) and is used in specialist UK photodiagnostic centres. Abnormal-response yield varies between individuals and diagnostic groups. However, the procedure is time- and resource-intensive and limited to specialist centres. To identify the wavebands and waveband combinations that captured the greatest proportion of abnormal monochromator responses, and to explore whether these findings could inform future evaluation of limited-waveband approaches within specialist phototesting pathways. This retrospective single-centre analysis included 668 phototesting results from 552 individuals collected between 2020 and 2025 at the Scottish Photobiology Service, NHS Tayside, Dundee, UK. Records prior to 2020 were reviewed in some selected patients to distinguish persistently negative monochromator tests from previously documented abnormal responses that had resolved before the study period. Assessed wavebands were 305&#x2009;&#xb1;&#x2009;5&#xa0;nm (UVB), 335&#x2009;&#xb1;&#x2009;27&#xa0;nm (UVB&#x2009;+&#x2009;UVA), 365&#x2009;&#xb1;&#x2009;27&#xa0;nm (UVA), 400&#x2009;&#xb1;&#x2009;27&#xa0;nm (UVA&#x2009;+&#x2009;VL) and 430&#x2009;&#xb1;&#x2009;27&#xa0;nm (VL). Of 552 individuals, 353 received a final clinical diagnosis of photodermatosis and 199 did not. Across individuals with photodermatoses, 335&#xa0;nm showed the highest single-wavelength abnormal-response yield (203/353, 57.5%), followed by 365&#xa0;nm (194/353, 55.0%), 305&#xa0;nm (169/353, 47.9%), 400&#xa0;nm (108/353, 30.6%) and 430&#xa0;nm (46/353, 13.0%). Selected two- and three-waveband combinations increased abnormal-response yield, with 305&#x2009;+&#x2009;365&#xa0;nm showing the highest two-waveband yield (239/353, 67.7%) and 305&#x2009;+&#x2009;365+400&#xa0;nm showing the highest selected three-waveband yield (259/353, 73.4%). In complete-case paired analysis, abnormal-response rates differed significantly across wavelengths (Cochran's Q&#x2009;=&#x2009;200.4, df&#x2009;=&#x2009;4, p&#x2009;<&#x2009;0.001). Exploratory subgroup analyses showed distinct wavelength-response profiles across CAD, PLE and SU: CAD showed high yields at 305 and 335&#xa0;nm, PLE showed lower monochromator abnormal-response yields across selected wavelengths and combinations, and SU showed greater longer-wavelength involvement. In this exploratory single-centre study, around one quarter of individuals with a final photodermatosis diagnosis in our service did not demonstrate abnormal responses on narrow-waveband monochromator phototesting. Limited waveband monochromator combinations showed differing abnormal response yields across photodermatoses, capturing most abnormal responses in chronic actinic dermatitis and many in solar urticaria, but under-detecting polymorphic light eruption. These findings support waveband phototesting across the ultraviolet and visible spectrum in specialist phototesting services. Broadband and provocation-based photodiagnostic approaches remain important, particularly for conditions such as polymorphic light eruption.

Posterior rectus sheath hernia is an exceptionally rare interparietal abdominal wall hernia in which abdominal contents herniate through the posterior rectus sheath into the retrorectus space while the anterior rectus sheath remains intact. Clinical diagnosis may be difficult because the hernia remains confined within the abdominal wall, and delayed recognition may result in bowel strangulation. We report a rare case of spontaneous posterior rectus sheath hernia complicated by bowel necrosis requiring staged operative management. A 73-year-old woman with no history of previous abdominal surgery presented with a 48-h history of progressively worsening epigastric abdominal pain, nausea, and emesis. Computed tomography demonstrated a narrow-neck posterior rectus sheath hernia containing incarcerated small bowel with decreased bowel wall enhancement, proximal small bowel dilatation, and findings concerning for strangulation. Emergency exploratory laparotomy confirmed an approximately 1-cm posterior rectus sheath defect with incarcerated mid-jejunum within the retrorectus space. Following reduction, a 10-cm segment of necrotic jejunum with pinpoint perforation required resection. Because adjacent bowel viability remained uncertain, temporary abdominal closure with negative-pressure therapy was performed followed by a planned second-look laparotomy 24&#x2009;h later. Re-exploration demonstrated complete recovery of the remaining bowel, allowing stapled side-to-side functional end-to-end small bowel anastomosis and primary repair of the posterior rectus sheath without mesh because of contamination. The patient experienced an uncomplicated postoperative recovery, was discharged home on postoperative day five, and remained free of recurrent posterior rectus sheath hernia or incisional hernia at 1-month clinical follow-up and 1-year computed tomography surveillance. Posterior rectus sheath hernia should be considered in patients presenting with small bowel obstruction and an interparietal abdominal wall defect on computed tomography, even in the absence of previous abdominal surgery. Careful recognition of the characteristic retrorectus anatomy and prompt operative intervention are essential when strangulation is suspected. This case demonstrates successful staged management with bowel resection, planned second-look laparotomy, and durable primary repair with no recurrence at 1 year.

In type 1 autoimmune pancreatitis (AIP), serum immunoglobulin G4 (IgG4) has a complex correlation with pathology. In this study, clinical/histopathological traits of serum IgG4-negative/positive (N/P) patients were compared, and serum IgG4-tissue IgG4 correlations were explored to aid accurate diagnosis/typing. A retrospective analysis was performed on 78 type 1 AIP patients (screened from 160 eligible cases through inclusion/exclusion criteria, International Consensus Diagnostic Criteria-confirmed at Changhai Hospital (December 2019-2023). At diagnosis, patients with serum IgG4 <135 mg/dL (n = 19) were assigned to the serum IgG4-N group, and those with serum IgG4 &#x2265;135 mg/dL (n = 59) were assigned to the serum IgG4-P group. Clinical baseline data, laboratory indicators, imaging features (computed tomography/magnetic resonance imaging/endoscopic ultrasound guided [EUS]), and histopathological findings (from EUS fine-needle aspiration/fine-needle biopsy [EUS-FNA/FNB] or surgery) were compared. Statistical analysis (R 4.4.0) was conducted with Chi-square/Fisher's exact tests (categorical data) and Mann&#x2012;Whitney U tests (continuous data); Spearman correlation was used to assess serum IgG4-tissue IgG4 links. A Bonferroni-corrected P <0.050 was considered to indicate statistical significance. No significant differences in sex, age, most comorbidities (e.g., hypertension), or symptoms (e.g., abdominal discomfort) were observed between the serum IgG4-N and serum IgG4-P groups (all P > 0.050). The rate of bile duct stenosis was higher in the serum IgG4-P group than in the serum IgG4-N group (55.93% vs. 26.32%, P = 0.047), as were the rates of EUS examination (84.75% vs. 52.63%, P = 0.010), EUS-FNA/FNB (84.75% vs. 52.63%, P = 0.010). The 84.75% vs 52.63% (P = 0.010) represents the EUS examination receiving rate between serum IgG4-P and serum IgG4-N groups, rather than the diagnostic positive rate of FNA/FNB subtypes. The serum IgG4-P group also had a higher histopathological confirmation rate (71.19% vs. 36.84%, P = 0.015) and a greater median number of tissue IgG4-P cells (36 vs. 8 cells per high-power field (HPF), P = 0.035). In contrast, the serum IgG4-N group had a higher median carbohydrate antigen 19-9 (CA19-9) level (32.14 vs. 5.97 U/mL, P = 0.035), a higher rate of long/multiple pancreatic duct narrow sections (30% vs. 2%, P = 0.013), and a higher surgical rate (47.37% vs. 15.25%, P = 0.010). Across both groups, no significant correlation was detected between serum IgG4 levels and tissue IgG4-P plasma cell counts (Spearman's rho = 0.113, P = 0.322; linear regression coefficient = 0.004, P = 0.538). Serum IgG4 typing is associated with the clinical-pathological features of type 1 AIP. The serum IgG4-P group often shows biliary duct stenosis and diffuse pancreatic enlargement, with a reliance on EUS puncture. The serum IgG4-N group has higher CA19-9 and a higher surgical rate. Pathological examination remains critical (no serum-tissue IgG4 association). This study supports optimized, accurate diagnosis and stratified management of type 1 AIP.