Uncontrolled bleeding after trauma is the main preventable cause of death and often requires rapid fluid resuscitation and massive blood transfusion. Accurately predicting the need for massive transfusion is critical to improving outcomes in patients with trauma. To systematically assess and quantify the effectiveness of machine learning (ML) models in predicting massive transfusion needs in patients with trauma. A comprehensive search of 7 databases was conducted from inception to March 2024. Studies were screened based on prespecified inclusion criteria. Data were extracted using a standardized checklist and evaluated using the Prediction Model Risk of Bias Assessment Tool (PROBAST). Pooled performance metrics were calculated using a random-effects model, including area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, and diagnostic odds ratio (DOR). Heterogeneity was assessed using Cochran Q and I2 statistics, and potential sources of variation were identified through meta-regression. After screening, 12 studies were included in the final analysis. The pooled AUC for ML models predicting transfusion needs was 0.89, with sensitivity and specificity values of 0.83[95% CI: 0.84-0.83] and 0.84(95% CI: 0.83-0.85), respectively. Despite overall strong predictive performance, the included models showed considerable methodological heterogeneity, particularly in feature selection, handling of missing data, and model validation. Although the ML models assessed across the included studies demonstrated robust performance in predicting massive transfusion needs in patients with trauma, the studies showed methodological inconsistencies. To ensure reliable clinical implementation, future research should focus on developing standardized protocols for model development and validation. PROSPERO #CRD42024565253.
Massive pulmonary embolism (PE) is a life-threatening emergency with high mortality. Systemic thrombolysis is the standard reperfusion therapy for patients with hemodynamic instability. However, when initial thrombolysis fails, therapeutic options are limited and evidence supporting subsequent interventions is scarce. We describe a 45-year-old man with hyperlipidemia and depression who presented with dyspnea, hypoxemia, and cardiogenic shock. Echocardiography revealed right ventricular dilatation and dysfunction, consistent with massive PE. Initial therapy with full-dose alteplase (100 mg) and anticoagulation achieved only transient hemodynamic stabilization. The patient remained severely hypoxemic with persistent right ventricle (RV) dysfunction. As catheter-directed therapy and surgical embolectomy were unavailable, repeat systemic thrombolysis was pursued. A second full dose of alteplase (100 mg) was administered on hospital day four. Within 24 h, oxygen saturation improved from 65% to 92% on room air, and echocardiography confirmed substantial recovery of RV size and function. No major bleeding or other complications occurred during hospitalization. Current guidelines do not recommend repeat thrombolysis for massive PE unresponsive to initial fibrinolysis, and available evidence is confined to case reports. This case demonstrates that, in carefully selected patients without contraindications, repeat systemic thrombolysis may represent a feasible and potentially lifesaving rescue option, particularly in resource-limited settings where other reperfusion strategies are not available. Further studies are needed to define safety, patient selection, and long-term outcomes.
Massive rotator cuff (RC) tears often require advanced reconstructive procedures, with graft selection playing a critical role in determining surgical success. Autografts offer excellent biocompatibility but are limited by donor site morbidity and inconsistent mechanical strength. Acellular dermal matrix grafts support host integration but are prone to elongation and variable resorption. Tendon allografts provide superior tensile strength but may integrate slowly depending on processing methods. Synthetic and xenografts offer alternative options, yet long-term durability and immune response remain concerns. Recent improvements in graft processing, including decellularization and ready-to-use technologies, have enhanced clinical efficiency but introduced new questions about long-term performance. Given the lack of standardized guidelines, graft selection should be tailored to patient-specific factors such as age, activity level, and tissue quality. This review evaluates current graft options for reconstruction of massive RC tears, providing evidence-based insights to support personalized surgical decision-making.
Respiratory syncytial virus (RSV) bronchiolitis is one of the leading causes of hospitalization in infants, typically presenting with mild-to-moderate respiratory distress. Severe complications such as apnea, respiratory failure, and pneumothorax are known, but massive pleural effusions remain an exceptionally rare manifestation. We report a case of an eight-week-old previously healthy Saudi female infant presenting with severe RSV bronchiolitis. The patient developed progressive respiratory failure requiring mechanical ventilation, re-intubation, and circulatory support. Notably, she developed bilateral massive pleural effusions necessitating urgent bilateral pigtail catheter insertion. Pleural fluid was sterile and transudative in nature. The infant showed significant clinical improvement following drainage and supportive care, with eventual full recovery. This case highlights an unusual but severe complication of RSV bronchiolitis. It underscores the need for clinicians to consider pleural effusion in infants with RSV who deteriorate despite supportive measures, even in the absence of bacterial infection.
Purpose: To describe a case of massive retinal pigment epithelium (RPE) tear following a hypertensive crisis superimposed on chronic central serous chorioretinopathy (CSCR). Methods: A case report with a focused literature review was performed. Results: A 55-year-old man with a history of chronic CSCR presented with acute vision loss in the setting of a hypertensive emergency (blood pressure, 215/130 mm Hg). Multimodal imaging and clinical examination revealed a massive RPE tear in the right eye extending from the temporal periphery through the macula. The left eye demonstrated smaller RPE tears associated with macular scarring and intraretinal fluid. The right eye was managed conservatively and showed progression of the RPE tear over 1 month. The left eye was treated with an intravitreal faricimab injection, resulting in improvement of the intraretinal fluid. Conclusions: This case supports a potential 2-hit mechanism in which chronic CSCR-related RPE vulnerability, combined with acute hypertensive choroidopathy, leads to extensive and progressive RPE tearing. Patients with chronic pachychoroid spectrum disease and systemic hypertension may be at increased risk for severe RPE complications.
This study aims to evaluate the outcomes of arthroscopically assisted latissimus dorsi (LD) transfer for massive rotator cuff tears involving irreparable subscapularis tendon tears. This retrospective cohort study was conducted at a specialized Shoulder Unit in Paris from June 2014 to January 2023 to evaluate outcomes of LD transfer for irreparable subscapularis tendon tears. The primary outcome was the Constant score; secondary outcomes included VAS, SSV, and satisfaction levels. A subgroup analysis was performed to compare postoperative outcomes between patients with reparable versus irreparable supraspinatus tendons. Additionally, all complications were recorded. Twenty-one patients, predominantly male (90.5%) with a mean age of 58.6 years (SD 8.2), were included. Most had the right shoulder affected (85.7%), with a mean follow-up of 15.3 months (SD 11.9). The mean Constant score significantly increased from 37.4 ± 9.7 pre-operatively to 70.5 ± 11 post-operatively (gain of 31.5 ± 20, p < .001). The mean VAS score decreased from 4.4 ± 1.9 to 1.5 ± 1.5 (reduction of -2.7 ± 2.6, p < .001). The mean SSV improved from 49.5 ± 14.3 to 76 ± 11.4 (gain of 25.2 ± 25, p < .001). Satisfaction levels were high, with 16 patients very satisfied, 4 satisfied, and 1 disappointed. Subgroup analysis showed a trend toward better outcomes in the reparable supraspinatus group, although these differences were not statistically significant. Three complications (14.3%) occurred: one surgical failure requiring revision to reverse shoulder arthroplasty, one persistent painful shoulder without functional improvement, and one infection that was resolved with treatment. The Gerber test remained positive in 9 patients (42.9%), and the Belly Press test remained positive in 3 patients (14.3%). LD transfer for irreparable subscapularis tendon tears leads to significant improvements in shoulder function, pain reduction, and patient satisfaction. While it offers a viable option, residual subscapularis insufficiency persists in a subset of patients.
A 71-year-old woman was found to have pancytopenia during a routine health check-up and was referred to a local hospital. Bone marrow examination did not yield a definitive diagnosis, and the cytopenia gradually progressed over the following two years. She was subsequently referred to our institution for further evaluation, including assessment of eligibility for hematopoietic stem cell transplantation. 18F-Fluorodeoxyglucose positron emission tomography (18F-FDG PET/CT) revealed massive splenomegaly without abnormal FDG uptake. Given the concurrent infection suspected to be fungal pneumonia, a splenectomy was performed for diagnostic and therapeutic purposes. Histopathological examination of the resected spleen, together with T-cell receptor gene rearrangement analysis, led to a diagnosis of hepatosplenic T-cell lymphoma (HSTCL). Following splenectomy, hematologic recovery was achieved rapidly, and CHOP chemotherapy was administered. The patient has remained in remission for approximately one year without evidence of relapse. Although HSTCL generally has a poor prognosis, this case is notable in that splenectomy both established the diagnosis and led to marked improvement in pancytopenia.
Enhancers are cis-regulatory elements that drive context-specific gene expression, yet their target genes and modes of action remain largely unresolved. Because most disease-associated variants lie in non-coding regulatory DNA, accurate, cell type-specific enhancer-gene (E-G) mapping is essential for understanding genetic risk. However, current E-G prediction frameworks lack the resolution to capture such context-specific interactions. Massively parallel reporter assays (MPRAs) provide measurements of cis-regulatory activity, but their integration into genome-scale E-G models has been limited. Here, we introduce MPRabc, an MPRA-informed model that improves E-G interaction prediction. MPRabc integrates predicted MPRA activity, sequence-derived regulatory features, epigenomic signals, and three-dimensional chromatin contact maps with clustered regularly interspaced short palindromic repeats-based perturbation training data. Benchmarking against validated regulatory interactions shows that MPRabc outperforms state-of-the-art models. We generated high-resolution E-G networks for K562, HepG2, and human induced pluripotent stem cell (hiPSC) cell lines and applied a graph-based framework to identify regulatory architecture, map trait-associated variants and expression quantitative trait loci, and resolve transcription factor drivers of enhancer activity. Across contexts, we accurately recovered lineage-defining regulatory programs, including GATA1::TAL1 in K562, HNF1A/B in HepG2, and POU factor circuits in hiPSCs. Together, these results establish MPRA-informed modeling as a scalable strategy for decoding enhancer function and linking non-coding variants to gene regulatory mechanisms across cellular contexts.
To evaluate clinical outcomes and revision surgery rates in primary arthroscopic repair for posterosuperior massive rotator cuff tears (MRCTs) at midterm follow-up and to identify prognostic factors associated with outcomes. A retrospective study of patients with posterosuperior MRCT treated with primary arthroscopic repair between 2006 and 2023 with a minimum of 2-year follow-up. MRCT was defined as complete detachment of >2 tendons or a diameter >5 cm. Baseline characteristics, surgical technique, range of motion, and patient-reported outcomes, including American Shoulder and Elbow Surgeons, Constant score, Simple Shoulder Test, satisfaction, and visual analog scale pain, were recorded. Retear, revision surgery, and survival rates were also evaluated. Univariate and multivariate analyses identified independent predictors of outcomes. Fifty-seven patients with 5.4 ± 3.6 years mean follow-up were evaluated. All patient-reported outcomes significantly improved from pre-operative to post-operative (P < .001): Constant +32.7 points (95% confidence interval [CI]: 27.2-38.2), American Shoulder and Elbow Surgeons +51.2 points (95% CI: 43.4-59.1), Simple Shoulder Test +5.5 points (95% CI: 4.6-6.5), and visual analog scale +6.2 points (95% CI: 5.1-7.3). Range of motion significantly improved (P < .001) only for flexion and abduction. Multivariate analysis showed that only revision surgery independently affected outcomes. Among 23 (40.4%) patients with post-operative magnetic resonance imaging, the retear rate was 69.6%, with no clinical differences between retear and intact repairs. A total of 12.3% had a revision surgery, with an 87.2% (95% CI: 77.1-96.3) 5 year survival rate to revision. Arthroscopic repair of posterosuperior MRCT provides significant pain and function improvement. Despite a high retear rate, midterm clinical results remain favorable, with low complication and revision rates.
Massive open online courses (MOOCs) are increasingly used in nursing education, attracting learners with diverse participation modes. Social learners (self-directed) enroll voluntarily based on personal interests, while academic learners (institution-directed) are mandated by nursing schools, with performance linked to grades. Existing literature shows that academic learners outperform social learners in MOOCs, but evidence is scarce on whether this performance gap stems from distinct participation patterns shaped by institutional requirements. We sought to compare participation typologies between social and academic learners using latent class analysis (LCA) and assess their association with learning outcomes. A retrospective analysis was conducted of 8222 students enrolled in a rehabilitation nursing MOOC from 2021 to 2022. Learners were classified by topic test participation frequency via LCA, and their distributions and scores were statistically compared. The cohort comprised 7683 (93.4%) academic and 539 (6.6%) social learners. LCA identified 3 participation types: participation-declining (93/8222, 1.1%), high-participation (6959/8222, 84.6%), and lowest-participation (1170/8222, 14.2%). The distributions of participation types differed significantly between groups (χ2=2745.1; df=2; P<.001). Most social learners belonged to the lowest-participation group (482/539, 89.4%), whereas most academic learners belonged to the high-participation group (6923/7683, 90.1%). Among high-participation learners, academic learners significantly outperformed social learners (all P<.05; r=0.06-0.10). No significant between-group differences were observed for the other participation types (all P>.05). Distinct participation patterns were associated with the performance advantage of academic learners. Our findings highlight the importance of sustained participation, suggesting that MOOC instructors should provide enhanced support for voluntary learners.
Massive transfusion (MT) during lung transplantation (LTx) is associated with primary graft dysfunction and increased risk of post-LTx mortality and morbidity. To date, predictive factors for MT during LTx are unknown. This study aimed to establish a predictive model for intraoperative MT in patients undergoing LTx to provide personalized risk prediction. This retrospective cohort study included adult patients who underwent LTx at the Second Affiliated Hospital of the Zhejiang University School of Medicine between 2020 and 2023. MT was defined as an intraoperative transfusion of > 5 units of packed red blood cells. The dataset was randomly split into a training cohort (70%) and a test cohort (30%). Three algorithms were applied for variable selection in the training cohort and logistic models were used to establish a predictive model. Model accuracy was assessed using goodness-of-fit tests, receiver operating characteristic analyses, and bootstrap resampling. In total, 390 patients were included. The MT incidence was 25.9% in the training cohort (n = 274) and 25.0% in the test cohort (n = 116). The multivariable model for predicting MT incorporated primary diagnosis, hemoglobin level, patient entry route, surgical type, and approach, activated partial thromboplastin time (APTT), and cold ischemia time (CIT). The model demonstrated an AUC of 0.830 (95% CI: 0.775-0.884) in the training cohort and 0.759 (95% CI: 0.657-0.861) in the test set for predicting MT. A nomogram combining seven predictive factors may help predict the need for intraoperative MT in patients undergoing LTx to optimize individual transfusion strategies.
DNA methylation at CpG sites has emerged as a powerful epigenetic biomarker for predicting forensically relevant traits, including chronological age, the biological origin of forensic samples encompassing body fluid and tissue sources, and lifestyle-associated factors such as smoking. Existing models for age estimation, body fluid and tissue of origin identification, and smoking inference have demonstrated robust performance, but their reliance on separate assays limits practical application. To address this gap, we developed COSA (a Consolidated prediction panel for Origin, Smoking, and Age), an integrated methylation-based assay implemented through amplicon-based massively parallel sequencing (MPS). COSA consolidates 126 previously reported CpG markers from multiple validated models into 67 amplicons, thereby enabling the simultaneous prediction of body fluid and tissue of origin, smoking status, and chronological age from a single analysis. By unifying these established markers, COSA provides a scalable and streamlined solution for comprehensive forensic epigenetic profiling. The panel comprises three functional modules. First, body fluid identification incorporates 9 CpG markers specific to blood, semen, saliva, menstrual blood, and vaginal fluid, supporting accurate determination of sample origin in forensic framework. Additionally, body fluid and tissue of origin inference extends to internal organs through 18 CpGs targeting blood, liver, skeletal muscle, heart, brain, epidermis, dermis, kidney, and lung. Second, lifestyle inference is supported by 13 CpGs, including the well-characterized cg05575921 locus in the AHRR gene for smoking prediction. Third, age estimation is incorporated through three fluid-specific models optimized for blood, saliva, and semen, which are the fluids most frequently encountered in forensic investigations. Methodological refinements were essential to achieve balanced multiplex amplification. Multiplex PCR for bisulfite-converted DNA is challenged by issues related to primer compatibility and GC-content variation. To overcome this, we implemented a touchdown PCR strategy that improved amplification balance and coverage uniformity across multiple loci. Several primer sets were newly designed or modified to optimize amplicon length and annealing temperature, ensuring robust co-amplification within the 67-amplicon panel. Importantly, using as little as 20 ng of bisulfite-converted DNA, the COSA panel supported inference of biological origin, smoking status, and chronological age. Overall, COSA integrates three major forensic prediction modules, including origin classifiers for body fluids and organ tissues, fluid-specific age estimators, and a smoking-status predictor within a single DNA workflow. This panel represents a practical and scalable tool for forensic laboratories seeking to maximize information yield from limited DNA, advancing the application of epigenetics in human identification and investigative intelligence.
Puerperal hematomas are rare but potentially life-threatening complications of vaginal delivery. They may expand rapidly, causing significant blood loss and hemodynamic instability. We report a case of a massive vulvovaginal hematoma occurring shortly after an apparently uncomplicated vaginal delivery in a 30-year-old multipara, presenting with severe perineal pain and signs of hypovolemia. Prompt surgical exploration with incision, drainage, and ligation of bleeding vessels resulted in complete recovery. This case highlights the importance of early clinical recognition and timely surgical management of puerperal vulvovaginal hematomas, even in the absence of classic risk factors.
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Superior mesenteric artery syndrome (SMAS) is an uncommon cause of proximal intestinal obstruction caused by compression of the third portion of the duodenum between the SMA and the abdominal aorta. We report the case of a 17-year-old boy with a 2-year history of recurrent nausea, vomiting, epigastric pain, early satiety, postprandial fullness, and progressive abdominal distension, followed by recent clinical deterioration. Despite repeated non-diagnostic investigations and empirical dietary and pharmacological treatment, symptoms persisted. Contrast-enhanced computed tomography established the diagnosis by demonstrating a markedly reduced aortomesenteric angle of approximately 10° and an aortomesenteric distance of 5.5 mm, associated with severe gastric and proximal duodenal dilatation. The patient was treated conservatively with nasogastric decompression and nutritional support. Nasogastric tube placement resulted in marked gastric decompression, with substantial improvement in abdominal distension, epigastric discomfort, early satiety, and vomiting, allowing surgical intervention to be deferred during the acute phase. Follow-up showed no further acute obstructive deterioration; however, the absence of meaningful weight gain over the subsequent six months indicated persistence of the chronic nutritional component of SMAS and the need for continued dietary rehabilitation and close monitoring. This case highlights the diagnostic difficulty of SMAS in adolescents with chronic, treatment-refractory upper gastrointestinal symptoms and emphasizes that resolution of acute obstruction should not be equated with definitive correction of the underlying disease process. Early recognition, conservative stabilization, nutritional optimization, and longitudinal reassessment are essential to prevent delayed diagnosis and guide timely escalation to surgery when conservative treatment is insufficient.
Irreparable rotator cuff tears without advanced arthritis are difficult to manage. Superior capsular reconstruction (SCR) preserves the native joint, while reverse total shoulder arthroplasty (rTSA) offers reliable function but with higher implant-related risks, especially in younger patients. This study compared outcomes and complications between SCR and rTSA. This study was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. PubMed, Scopus, and Ovid Medline were searched from inception to May 2, 2025, for studies directly comparing SCR and rTSA in patients with irreparable rotator cuff tears without advanced arthritis. Eligible studies were required to report at least 1 of the following outcomes: patient-reported outcome scores, shoulder range of motion, or postoperative complications. Outcomes of interest included patient-reported outcomes, shoulder range of motion, and postoperative complications. Seven level III studies involving 257 patients in the SCR group (age, 54.2-73.6 years; follow-up, 2.1-51.6 months) and 173 in the rTSA group (age, 63-77 years; follow-up, 24-48.3 months) met inclusion criteria. Meta-analysis showed no statistically significant differences between SCR and rTSA in American Shoulder and Elbow Surgeons scores (mean difference [MD] = 1.66; 95% CI, -3.44 to 6.77; p = 0.520), pain visual analog scale (MD = 0.16; 95% CI, -0.63 to 0.95; p = 0.690), or any range of motion parameters, including abduction, forward flexion, external rotation, and internal rotation. However, SCR demonstrated a statistically significantly lower overall complication rate compared to rTSA (3.5% vs. 10.8%; odds ratio, 0.32; p = 0.020). Complications following SCR were mainly graft- or tendon-related, whereas those after rTSA were typically mechanical or bone-related, including scapular notching, acromial fracture, and implant loosening. At short- to midterm follow-up, SCR provides similar clinical outcomes to rTSA in patients with irreparable rotator cuff tears without advanced arthritis. However, the complication rate was higher in the rTSA group. Complications following SCR were primarily graft- or tendon-related, whereas rTSA complications were more often mechanical or bone-related.
Data on the manifestation and progression of neurological and psychiatric symptoms in adult patients with late-onset Tay-Sachs (LOTS) disease after the age of 2 years are scarce and not available for Germany. In this cross-sectional study data from the "8 in 1" register study for gangliosidoses of 16 adult patients with LOTS were retrospectively evaluated with respect to the manifestation and the occurrence of neurological and psychiatric symptoms. The LOTS can be manifested in preschool age with a neurodevelopmental disorder, in school age and adolescence with cerebellar symptoms or in adolescence and adulthood with leg dominant muscle weakness and muscle atrophy in the sense of a motor neuron disease (MND). The initial symptoms of LOTS begin insidiously, are variable and often go unrecognized. Severe psychiatric disorders regularly occur in the course of the disease, particularly in those patients who have neurological developmental disorders and manifestation of cerebellar symptoms. The prevalence of psychiatric disorders is 62.5%. In 10 of the 16 adult patients, psychoses occurred that were diagnosed as severe depression, bipolar affective disorder, as polymorphic psychotic disorder or as schizoaffective disorder. The patients were treated in particular with atypical antipsychotic drugs, benzodiazepines and mood stabilizers. Neuropsychiatric symptoms in LOTS were explained with the concept of a cerebellar cognitive affective syndrome (CCAS) as an organic brain disease of the cerebellum; however, symptoms such as massive psychomotor agitation, anxiety, rapid mood swings, confusion, formal and content-related thought disorder as well as hallucinations cannot be completely explained by CCAS and are consistent with concepts that describe a role of cerebellar network dysfunctions in psychoses. Our data can help to include LOTS as a differential diagnosis in patients with psychiatric and neurological symptoms. Daten zur Manifestation und zum Verlauf neurologischer und psychiatrischer Krankheitsausprägungen bei erwachsenen Patienten mit der Spätmanifestation des Morbus Tay-Sachs ab dem 2. Lebensjahr („late onset Tay-Sachs“, LOTS) sind rar und liegen für Deutschland nicht vor. Retrospektiv wurden in dieser Querschnittserhebung Daten der „8 in 1“-Registerstudie für Gangliosidosen bei 16 erwachsenen Patienten mit LOTS hinsichtlich der Manifestation sowie des Auftretens neurologischer und psychiatrischer Symptome ausgewertet. LOTS kann sich im Vorschulalter mit einer neurologischen Entwicklungsstörung, im Schul- und Jugendalter mit zerebellärer Symptomatik oder im Jugend- und Erwachsenalter mit beinbetonter Muskelschwäche und Muskelatrophie im Sinne einer Motoneuronerkrankung (MNE) manifestieren. Erste Symptome bei LOTS beginnen schleichend, sind variabel und werden häufig verkannt. Insbesondere bei neurologischen Entwicklungsstörungen und Manifestation zerebellärer Symptomatik treten schwerwiegende psychiatrische Erkrankungen im Verlauf auf. Die Prävalenz psychiatrischer Krankheiten liegt bei 62,5 %. Bei 10 der 16 Patienten wurden Psychosen beschrieben, die als schwere Depression, bipolar-affektive Störung, als polymorph-psychotische Störung oder schizoaffektive Störung diagnostiziert wurden. Behandelt wurden die Patienten vor allem mit atypischen Antipsychotika, Benzodiazepinen und Stimmungsstabilisierern. Neuropsychiatrische Befunde bei LOTS wurden mit dem Konzept eines „cerebellar-cognitive-affective syndrome“ (CCAS) als hirnorganische Erkrankung des Kleinhirns erklärt. Symptome wie massive psychomotorische Erregung, Angst, rasche Stimmungsschwankungen, Verwirrtheit, formale und inhaltliche Denkstörung sowie Halluzinationen gehen jedoch darüber hinaus und sind konsistent mit Konzepten, die eine Rolle für zerebelläre Netzwerkstörungen bei Psychosen beschreiben. Unsere Daten können helfen, LOTS als Differenzialdiagnose bei Patienten mit psychiatrischen Symptomen und neurologischen Symptomen mit einzubeziehen.
Rectal angiodysplasia is a vascular malformation typically associated with the elderly. It is an exceedingly rare cause of acute lower gastrointestinal bleeding (LGIB) in young adults. We present a unique case of massive hematochezia in a 33-year-old, potentially accelerated by long-standing vascular stress. A 33-year-old male with a history of chronic alcohol use and poorly controlled hypertension presented with acute, massive hematochezia and symptomatic anemia. Physical examination and initial labs may indicate significant blood loss. Urgent colonoscopy revealed multiple punctate, actively bleeding angiodysplastic lesions localized strictly to the rectum. Given the focal nature of the lesions, hemostasis was achieved using mechanical endoscopic titanium clips. No recurrent bleeding occurred during 6 months of follow-up. This single-case observation suggests that angiodysplasia may be considered in differential diagnosis for LGIB even in younger patients, particularly those with systemic vascular risk factors like hypertension and chronic alcohol consumption. Furthermore, it may indicate that mechanical clipping is a highly effective, targeted alternative to thermal ablation for localized rectal vascular lesions.
Persistent spinal pain syndrome type 2 (PSPS-T2), historically referred to as failed back surgery syndrome (FBSS), is a complex, debilitating chronic pain condition following spinal surgery. This nomenclature transition reflects a paradigm shift from viewing the condition as a singular surgical "failure" to a primary neuro-inflammatory and centrally sensitized disease state. While advancements in interventional techniques and neuromodulation have improved numerical pain scores, their impact on functional metrics, long-term opioid consumption, and systemic health remains heavily debated. This systematic review and network meta-analysis aim to evaluate the efficacy of current pharmacological, rehabilitative, and interventional management strategies for PSPS-T2, integrating historical functional paradigms with cutting-edge 2024-2026 neuromodulatory, investigational molecular, and massive real-world cohort evidence. Following PRISMA guidelines, a systematic search was conducted across MEDLINE, Embase, and Cochrane databases up to April 15, 2026. Screening and extraction were performed independently by two reviewers with a third-party tie-breaker. A total of 1,452 records were screened. After rigorous selection, 100 studies were included in the qualitative synthesis, and 24 randomized controlled trials (RCTs) and high-quality cohort studies were utilized for design-adjusted quantitative meta-analysis. Primary outcomes included pain intensity (using the Numerical Rating Scale (NRS) or Visual Analog Scale (VAS)) and functional disability (using the Oswestry Disability Index (ODI)). Secondary outcomes assessed long-term opioid therapy (LOT) reduction and psychological morbidity. Network meta-analysis data confirmed that spinal cord stimulation (SCS) combined with conventional medical management (CMM) is significantly superior to CMM alone (OR: 10.32, 95% CI 6.10-15.45, I2 = 68%) for achieving > 50% pain reduction. However, massive real-world cohort data encompassing 12,632 patients demonstrated that SCS implantation was not associated with a significant decrease in LOT compared to matched non-SCS cohorts (OR 1.05), establishing a critical "Opioid Paradox." Rehabilitative adjuncts, including high-intensity laser therapy (HILT) and spinal manipulative therapy (SMT), showed statistically significant improvements in ODI at 12 months. Longitudinal data further indicated a strong correlation between PSPS-T2 and an increased risk of psychiatric disorders, dementia, and all-cause mortality; these associations are likely mediated by long-term polypharmacy and physical inactivity. The management of PSPS-T2 must transition from a purely mechanical surgical model to a systemic, multidisciplinary framework. While advanced neuromodulation provides substantial pain relief in controlled environments, it fails to spontaneously resolve the long-term opioid burden in real-world populations. We conclude that successful outcomes require decoupling biological pain relief from opioid dependency behavior through early functional restoration and the integration of interventions within a holistic, biopsychosocial care pathway.