Burnout of nurses is a global occupational hazard characterized by emotional exhaustion, cynicism, and reduced care quality. Often framed as a nurse resilience issue, other evidence suggests organizational and systemic contributors such as workload, staffing shortages, and toxic leadership. This article introduces a holistic, tarot-informed framework for nurse self-reflection based on the Rider-Waite process organized around the Celtic Cross card-position structure. This framework uses card positions and symbolism as prompts to explore psychological, social, professional, and structural influences that inform nurses' experiences of burnout, rather than using tarot for prediction or divination. The 10-card position spread supports meaning-making, mindfulness, and professional identity to explore nurses' work experiences; tarot cards can be added for deeper symbolic meaning. This interconnected framework provides a pathway to nurse resilience and holistic insight. Individual reflection alone is insufficient; sustainable change also requires leadership accountability and organizational commitment to healthy work environments. Nursing is based on human caring, which also includes caring for ourselves.
Gastroesophageal reflux disease can progress to reflux esophagitis and Barrett's esophagus (BE), making accurate endoscopic diagnosis important. Artificial intelligence tools like ChatGPT-5 may assist image interpretation, though data on newer large language models remains limited. This study evaluated ChatGPT-5 for BE detection and LA esophagitis severity classification. Endoscopic images from the HyperKvasir dataset were analyzed, including BE, esophagitis A, esophagitis B-D, and normal Z-line images. Four standardized prompts were assessed: (1) BE versus normal, (2) esophagitis versus normal, (3) LA-grade severity (A vs. B-D), and (4) BE versus severe esophagitis. ChatGPT-5 was evaluated in auto mode. Two investigators analyzed 640 unique images, yielding 1280 evaluations. Sensitivity, specificity, positive/negative predictive values (PPV/NPV), F1 scores, and accuracy were calculated. In binary tasks, sensitivity was highest for severe esophagitis (B-D) (0.774). Binary accuracy was similar across tasks (~0.64), with the highest for severe esophagitis (0.655). In three-class analyses, severe esophagitis performed best (sensitivity 0.506, specificity 0.761, accuracy 0.438), with performance improving alongside disease severity. PPV trended higher for severe esophagitis compared with normal mucosa (p ~ 0.03), though significance was not retained after multiple-comparison correction. In the BE-severe esophagitis-normal comparison, severe esophagitis achieved the highest sensitivity (0.590), specificity (0.790), and accuracy (0.521). PPV trended higher for severe esophagitis versus normal mucosa (p ~ 0.05), though significance was not maintained after multiplicity adjustment. NPVs exceeded PPVs across all paradigms. ChatGPT-5 demonstrated moderate performance for esophageal image interpretation, performing best for severe esophagitis and worst for mild esophagitis/BE. Binary prompting outperformed multiclass formats, and the model functioned better as a rule-out tool.
Antibiotic prescribing in simple hand trauma is variable, and poor documentation may undermine antimicrobial stewardship. This study combined a closed-loop audit with a literature review to evaluate prescribing practices and current evidence regarding prophylactic antibiotic use in hand trauma. A retrospective closed-loop audit of adult patients presenting with simple hand trauma to a tertiary plastic surgery trauma clinic was performed over two 2-week cycles. Uncomplicated lacerations and nail bed injuries were included, while bite wounds, crush injuries, and open fractures were excluded. Data collected included wound characteristics, antibiotic prescribing practices, and documentation quality. Following cycle one, a departmental teaching session on antimicrobial stewardship and a revised trauma clinic proforma with mandatory prescribing prompts were introduced prior to re-audit. A literature review of PubMed, Scopus, and Google Scholar was also conducted. Twenty-two patients were included in cycle one and 15 in cycle two. In cycle one, antibiotics were prescribed in 72% (15/22) of cases, with poor documentation of indication (6.7%), wound status (6.7%), antibiotic choice and route (40%), and duration (20%). Following intervention, prescribing reduced to 60% (9/15; p=0.099). Documentation of indication, wound status, duration, and appropriate antibiotic choice improved to 100%. The literature review demonstrated substantial variation in prescribing practices and limited evidence supporting routine prophylactic antibiotics in uncomplicated hand trauma. Antibiotic prescribing and documentation in simple hand trauma were suboptimal at baseline. Targeted education and redesign of the trauma proforma improved documentation quality and adherence to antimicrobial stewardship principles, highlighting the value of simple, low-cost interventions in supporting evidence-based prescribing.
Eosinophilic fasciitis (EF) is a rare sclerosing disorder characterized by limb edema evolving to woody induration with peau d'orange texture and the groove sign. Diagnosis typically requires a full-thickness fascial biopsy, while magnetic resonance imaging (MRI) can noninvasively demonstrate fascial thickening and guide biopsy. EF has recognized associations with hematologic conditions, including monoclonal gammopathy. A previously healthy 64-year-old woman developed progressive lower extremity hyperpigmentation, edema, and painful induration after travel. Over months, she experienced forearm induration and neuropathic hand pain; examination revealed bilateral lower leg peau d'orange and a right forearm groove sign. Laboratory evaluation showed episodic peripheral eosinophilia and an IgA-κ monoclonal gammopathy with nephrotic-range proteinuria. Electromyography confirmed bilateral median neuropathy at the wrists. Empiric prednisone produced marked symptomatic improvement. Bone marrow evaluation was consistent with monoclonal gammopathy of undetermined significance (MGUS). Kidney biopsy showed no amyloid, monoclonal immunoglobulin deposition disease (MIDD), proliferative glomerulonephritis with monoclonal deposits (PGNMID), light-chain cast nephropathy, or light-chain tubulopathy - making monoclonal gammopathy of renal significance (MGRS) unlikely. The hallmark cutaneous signs of EF (groove sign, peau d'orange) and limb-predominant involvement favored EF over mimics such as scleredema, morphea profunda, and systemic sclerosis. MRI is useful to confirm fascial involvement and guide biopsy when patients hesitate about incisional sampling. EF is classically steroid-responsive; methotrexate or mycophenolate are common steroid-sparing agents, with biologics or intravenous immunoglobulin (IVIG) reserved for refractory disease. The patient also had MGUS and carpal tunnel syndrome - both conditions that may raise concern for amyloidosis; however, amyloid was excluded histopathologically. This case highlights EF associated with IgA-κ MGUS and significant proteinuria, in which a kidney biopsy excluded MGRS lesions, illustrating the importance of multidisciplinary evaluation and targeted tissue diagnosis. Prompt recognition of EF's bedside signs can expedite treatment and functional recovery while more invasive diagnostics are considered.
Background and Clinical Significance: To report an unusual case of a bilateral low-frequency air-bone gap consistent with an apparent conductive audiometric pattern following spinal anesthesia and discuss a possible underlying mechanism; Case Presentation: A 56-year-old man underwent elective inguinal hernia repair under spinal anesthesia. On the second postoperative day, he developed a severe postural headache followed by bilateral hearing loss. Otoscopic examination was normal. Tuning fork tests and pure-tone audiometry demonstrated a bilateral low-frequency air-bone gap consistent with an apparent conductive audiometric pattern. Laboratory findings were unremarkable. The patient was managed conservatively with bed rest, hydration and systemic corticosteroids, resulting in gradual clinical improvement; Conclusions: Hearing loss after spinal anesthesia is typically sensorineural and attributed to cerebrospinal fluid pressure alterations. This case highlights a rare apparent conductive audiometric pattern in the absence of clinically evident middle-ear pathology. A possible mechanism may involve altered inner-ear pressure dynamics leading to transient mechanical restriction of stapes mobility. Awareness of this atypical presentation may facilitate prompt recognition and appropriate management.
Hypophosphatemic osteomalacia is an uncommon metabolic bone disorder that may present with nonspecific musculoskeletal symptoms, resulting in delayed diagnosis across orthopedic and emergency care pathways. We describe a 55-year-old man who presented through a National Health Service (NHS) orthopedic pathway with progressive atraumatic bilateral hip and groin pain, worsening mobility, proximal muscle weakness, and functional decline, initially managed as presumed mechanical musculoskeletal pain. Plain hip and pelvic radiographs did not identify a structural explanation for the severity of his symptoms. Initial laboratory investigations demonstrated profound hypophosphatemia (0.32 mmol/L) with markedly elevated alkaline phosphatase (428 IU/L), mildly reduced corrected calcium (2.18 mmol/L), elevated parathyroid hormone, and vitamin D insufficiency. Because the severity of hypophosphatemia appeared disproportionate to the degree of vitamin D deficiency, extended metabolic bone investigations were undertaken. Further testing demonstrated renal phosphate wasting with reduced tubular maximum phosphate reabsorption corrected for glomerular filtration rate (TmP/GFR 0.42 mmol/L) and C-terminal fibroblast growth factor 23 (FGF23) above the laboratory reference range (248 RU/mL), supporting suspected FGF23-mediated phosphate-wasting osteomalacia; localization imaging and definitive etiologic classification remained pending at the time of reporting. Severe hypophosphatemia with elevated alkaline phosphatase in patients presenting with unexplained atraumatic bilateral hip or groin pain, proximal weakness, or progressive mobility impairment should prompt consideration of metabolic bone disease and renal phosphate wasting. This case also illustrates that clinically significant osteomalacia may occur despite only mildly reduced calcium concentrations and initially nondiagnostic radiographs. Early biochemical recognition may facilitate timely specialist referral and help reduce diagnostic delay and downstream skeletal morbidity in patients with phosphate-wasting disorders.
Background and Clinical Significance: Brain metastases in non-small cell lung cancer (NSCLC) carry a poor prognosis, particularly in patients lacking targetable driver mutations or significant programmed death-ligand 1 (PD-L1) expression. Durable intracranial control exceeding five years is uncommon in this population and the factors that determine exceptional therapeutic response remain incompletely understood; Case Presentation: We report a 59-year-old male with pathological stage pT3N1 solid-type pulmonary adenocarcinoma (EGFR wild-type, ALK wild-type, PD-L1 <1%) who developed two sequential brain metastases following right upper lobectomy and adjuvant pembrolizumab plus pemetrexed-carboplatin. The first lesion was treated with single-fraction stereotactic radiosurgery (SRS, 10 Gy); a second metastasis identified 18 months later was managed with focal radiotherapy (8 Gy, single fraction) followed by whole-brain radiotherapy (24 Gy in 12 fractions). Local progression of the second metastasis in 2024 prompted successful surgical resection via right occipital craniotomy. Over a follow-up exceeding five years, the patient achieved sustained intracranial disease control, preserved neurological function, and maintained quality of life. Notably, no clinically apparent neurocognitive deterioration was documented on routine clinical follow-up, despite whole-brain irradiation without hippocampal sparing; formal neuropsychological testing was not performed; Conclusions: This case demonstrates that durable intracranial control may be achievable through carefully sequenced multimodal therapy-including stereotactic radiosurgery, whole-brain radiotherapy, and neurosurgical resection-even in biologically unfavorable NSCLC. The absence of clinically apparent neurocognitive deterioration on routine follow-up after WBRT raises hypothesis-generating questions regarding interindividual variability in radiation tolerance; this observation must be interpreted in the absence of formal neuropsychological testing and prospective hippocampal dosimetry. A multidisciplinary, individualized approach integrating radiotherapy, systemic therapy, and neurosurgery remains essential in this setting.
Uterine polypoid adenomyoma (UPA) is a rare focal form of adenomyosis that can present as an intracavitary lesion and pose a significant diagnostic challenge, often mimicking more common or concerning entities, such as endometrial polyps or uterine adenosarcoma. We describe the case of a 53-year-old woman who presented with profound anemia (hemoglobin 3.9 g/dL) secondary to acute on chronic heavy vaginal bleeding. Multimodal imaging, including ultrasound and MRI, prompted the initial diagnosis of UPA, later supported by surgical pathology. Ultrasound demonstrated diffusely heterogeneous myometrial echotexture and multifocal "venetian blind" artifact consistent with adenomyosis. MRI revealed an ovoid lesion within the endometrial cavity containing numerous T2 hyperintense cystic foci and imaging characteristics similar to the junctional zone, consistent with a submucosal UPA. Management included blood transfusions, hormone therapy, and ultimately hysterectomy. This case serves to underscore the importance of a combined approach, including both multimodal imaging and histopathology, in guiding the accurate diagnosis and optimal management of UPA. It is also intended to increase awareness of this rare lesion and encourage its consideration in the differential diagnosis of intracavitary uterine masses, as it may have implications for treatment planning.
Acute empyema refers to suppurative inflammation of the pleural cavity secondary to pulmonary infection. Prompt diagnosis and intervention are required upon identification to prevent progression to chronic empyema; hence, clinically effective biomarkers are needed to predict the development of acute empyema. To investigate the early diagnostic value of four serum markers, namely, S100 calcium-binding protein A12 (S100A12), serum amyloid A (SAA), C-reactive protein (CRP), and neutrophil-to-lymphocyte ratio (NLR), for predicting progression to acute empyema in patients with early-stage pneumonia. A retrospective analysis was performed on 60 patients diagnosed with community-acquired pneumonia complicated with acute empyema admitted to Xichang People's Hospital from January 2021 to June 2022. Another 60 patients with community-acquired pneumonia without empyema treated during the same period were enrolled as controls. Univariate analysis was used to compare differences in general clinical data, clinical manifestations, biochemical indicators, and treatment conditions between the two groups. Receiver operating characteristic (ROC) curves were adopted to evaluate differences in sensitivity and specificity of single and combined detection of S100A12, SAA, and NLR for early identification of acute empyema. Levels of S100A12, SAA, CRP, and NLR were significantly higher in patients with acute empyema than in those with community-acquired pneumonia (all P < 0.05), whereas serum albumin was markedly lower in the empyema group (P < 0.05). ROC curve analysis was performed to assess the diagnostic efficacy of individual and combined S100A12, SAA, and NLR for predicting acute empyema. The combined panel of S100A12+SAA+NLR yielded a sensitivity of 76.7% and a specificity of 96.7%, with an area under the ROC curve (AUROC) of 0.938 (95% CI: 0.900-0.977, P < 0.0001). The AUROC of the combined panel was significantly superior to those of single S100A12 (AUROC = 0.803, 95% CI: 0.722-0.884, P < 0.0001), SAA (AUROC = 0.908, 95% CI: 0.860-0.957, P < 0.0001), and NLR (AUROC = 0.694, 95% CI: 0.599-0.788, P = 0.0003), with statistically significant differences (P < 0.05). Acute empyema is mostly secondary to pulmonary infection, which is closely associated with host immunity, bacterial virulence, and invasiveness. Clinicians need reliable predictive biomarkers for early identification and prevention of acute empyema progression. Our study reveals that the combined panel of S100A12, SAA, and NLR achieves favorable sensitivity and specificity in predicting acute empyema, exhibiting superior diagnostic performance for early detection and promising clinical application prospects.
Chiral-induced spin selectivity (CISS) is caused by the interplay between the chirality of a system and electron magnetic moments in nonequilibrium. CISS manifests itself in two-terminal junctions (e.g., electrode-molecule(s)-electrode) in magnetoresistance. For a given magnetization orientation of the ferromagnetic electrode, l- and d-enantiomers show different current-voltage behavior. Reversing the magnetization reverses the current response of l and d, respectively. The fact that this happens near zero bias in the linear regime has prompted a discussion on the consequences of time-reversal symmetry for the possible mechanisms underlying CISS, which are often based on simplifying the junction to an effectively one-dimensional system or to an idealized helix with two orbitals per site. This motivates us to explore the electron transport characteristics of realistic chiral molecular junctions as typically studied in experiments. As a measure of how strongly the junctions deviate from idealized cases, we focus on the number of nonzero transmission eigenvalues. We find that all systems considered exhibit at least two transmission eigenvalues that lie clearly above the noise threshold. This is most pronounced for unsubstituted [6]-helicene, thio-[6]-helicene, [6]-carboxyhelicene, and a pentapeptide α-helix with thiolated terminal groups and less pronounced for helicenes with amine, bromine, or thiadiazole anchoring groups and for short linear peptides. We therefore propose a comparative study of molecules with differently pronounced second transmission eigenvalues, under identical experimental conditions, to assess the relevance of these transmission eigenvalues for the CISS effect.
The purpose of this study is to report a case of unilateral central retinal artery occlusion (CRAO) as a rare ophthalmic complication following bilateral cosmetic blepharoplasty in a young patient and to highlight its probable causes, management, and preventive considerations. A 31-year-old gentleman, with no known comorbidities, presented with complaints of vision loss in the left eye for 6 weeks after undergoing bilateral cosmetic blepharoplasty. At presentation, the best corrected visual acuity (BCVA) was 20/25 in the right eye (OD) and no perception of light (NPL) in the left eye (OS). Intraocular pressure (IOP) was 14 mmHg in both eyes (OU). Pupillary examination revealed a round, regular, and reactive pupil in the right eye, whereas the left pupil was mid-dilated and nonreactive, with a positive relative afferent pupillary defect (RAPD). The fellow eye remained asymptomatic following surgery. At presentation, optical coherence tomography (OCT) was performed, and it demonstrated marked thinning of the inner retinal layers, consistent with chronic CRAO in the left eye. Given the rarity of CRAO in young individuals, a comprehensive systemic workup was performed, including hematological, inflammatory, coagulation, autoimmune, and cardiac evaluations. All investigations were within normal limits. CRAO can occur as a rare postoperative complication of cosmetic blepharoplasty. Early recognition, prompt management, and careful postoperative monitoring may prevent the risk of such complications.
Japanese spotted fever (JSF) is a tick-borne infection caused by Rickettsia japonica, classically presenting with the triad of fever, rash, and eschar, and characterized by systemic vasculitis resulting from endothelial injury. Concomitant cholecystitis associated with JSF is exceedingly rare. We report the case of a 77-year-old man who presented with fever, was diagnosed with calculous cholecystitis at a referring hospital, and underwent laparoscopic cholecystectomy. Postoperatively, erythema developed on the extremities and trunk, along with an eschar on the right ankle. Polymerase chain reaction (PCR) testing subsequently detected R. japonica, confirming JSF. The ischemic injury secondary to vasculitis may have contributed to the development of cholecystitis. Even in calculous cholecystitis, JSF should be considered in endemic areas when rash or eschar is present, highlighting the importance of early PCR testing and the prompt administration of tetracyclines.
Breastfeeding is a key early-life primary prevention behavior; yet, despite consistent recommendations and recent improvements, exclusive breastfeeding rates remain well below target levels. This preregistered longitudinal randomized controlled trial (RCT) tested the effectiveness of two resource-efficient digital communication interventions. Women in the 36th week of pregnancy (N = 467) were randomly assigned to one of six conditions in a 2 × 3 between-participants design. The first intervention consisted of informational messages targeting components of the extended Theory of Planned Behavior (TPB). The second intervention was a drip communication campaign delivered via mobile phone messages: participants in the tips condition received messages aimed at increasing practical breastfeeding knowledge and skills, whereas participants in the implementation intentions condition were additionally prompted to formulate specific if-then plans. Control groups received messages related to healthy eating and physical activity. Participants were followed up until 5 months postpartum. The TPB-based intervention exerted indirect effects on both full and any breastfeeding duration by increasing breastfeeding self-efficacy and perceived behavioral control, which in turn enhanced exclusive breastfeeding intentions. For full breastfeeding only, the intention-behavior relationship-and thus the indirect effect of the TPB intervention-was strengthened by both the tips and implementation intentions interventions. Higher levels of self-objectification indirectly reduced breastfeeding duration through weaker identification as a breastfeeding mother and lower intentions. Delivering simple, resource-efficient digital communication interventions that empower mothers and support the translation of intentions into sustained behavior represents a scalable strategy to promote exclusive breastfeeding.
Both citrin deficiency (CD) and citrullinemia type I (CTLN1) may be detected by elevated citrulline through newborn screening (NBS) or present as acute liver failure in later infancy, but they differ significantly in management. This may pose therapeutic challenges in the early period after presentation while awaiting diagnostic confirmation. We report a Chinese girl (birth weight 1.98 kg at 37 weeks) who was recalled on day 5 for elevated citrulline (47 μmol/L; cutoff < 25) and citrulline/arginine ratio of 7.34 at NBS on day 2. Citrulline rose to 264 μmol/L upon retesting on day 5. Initial investigations revealed INR of 3.4 and raised alkaline phosphatase, while ammonia, conjugated bilirubin, glucose, albumin, gamma-glutamyl transferase, and transaminases were normal. Suspected CTLN1 led to halting protein intake and starting high glucose infusion. Within 17 h, INR increased to 6.5 and albumin dropped. Worsening hepatic function following high-glucose intake and her small for gestation age status suggested CD. She improved rapidly after switching to lactose-free MCT-enriched formula. Genetic analysis revealed compound heterozygous known pathogenic mutations in the SLC25A13 gene, confirming the diagnosis of CD. This is the first report of CD presenting with neonatal acute liver failure without cholestasis. It highlights the importance of prompt differentiation between CD and CTLN1 in NBS recalls for safe and effective interim treatment.
Diffuse alveolar hemorrhage (DAH) is a life-threatening pulmonary emergency that may occur as a manifestation of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). We report a rare case of perinuclear antineutrophil cytoplasmic antibody (p-ANCA)-positive vasculitis presenting with severe DAH without renal involvement, preceded by acute bilateral hearing loss. A previously healthy 21-year-old woman presented with hemoptysis, severe hypoxemia, and respiratory failure requiring mechanical ventilation. Chest imaging showed bilateral diffuse infiltrates and ground-glass opacities. Bronchoalveolar lavage findings were consistent with DAH. Serologic workup revealed positive p-ANCA with negative cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) and anti-glomerular basement membrane (anti-GBM) antibodies. Renal function and urinalysis remained normal throughout admission. The patient was treated with pulse intravenous methylprednisolone followed by oral corticosteroids, leading to rapid clinical improvement and successful extubation within five days. Further history revealed bilateral hearing loss one week before presentation, which may represent a possible early otologic manifestation of vasculitis. This case highlights that ANCA-associated vasculitis may present as isolated DAH without renal involvement, while unexplained hearing loss may provide an early clue to underlying AAV before the onset of life-threatening pulmonary manifestations. Early recognition and prompt immunosuppressive therapy are essential to improve outcomes.
Ileus is a common gastrointestinal complication in critically ill patients, posing a unique management challenge due to its multifactorial etiology and impact on clinical stability. Standard therapeutic approaches often fail in the setting of metabolic derangement and hemodynamic instability. Prucalopride, a selective 5-HT4 receptor agonist, has demonstrated efficacy in promoting colonic motility; however, its use in severe small bowel and colonic ileus or decompensated liver disease populations remains limited. We report the case of a 28-year-old man with decompensated alcoholic hepatitis who developed severe small bowel and colonic ileus refractory to standard management. Concerns for worsening illness prompted a trial of prucalopride, which was temporally associated with rapid resolution of the ileus and remarkable improvement in radiographic imaging and clinical phenotype. Prucalopride may be a potential therapeutic option for severe small bowel and colonic ileus in critically ill patients. Further studies are warranted to delineate its safety and efficacy.
ACS-like presentations may rarely be the first sign of occult lung cancer. Interval changes on coronary angiography and atypical myocardial imaging should prompt consideration of metastatic cardiac involvement and a multidisciplinary diagnostic approach. https://bit.ly/48XvNLi.
Spontaneous intracranial hypotension (SIH) is a debilitating syndrome typically characterized by orthostatic headache and classic brain MRI findings. However, brain MRI abnormalities are indirect manifestations of cerebrospinal fluid (CSF) volume depletion rather than direct evidence of the leak, and some patients may present with unrevealing or absent typical brain MRI findings, posing a considerable diagnostic challenge. A comprehensive search of PubMed/Medline, Web of Science, and Scopus was conducted to perform a systematic review, according to PRISMA guidelines, analyzing the available evidence on MRI-negative SIH (patients without typical SIH findings on their initial brain MRI), including its clinical features, advanced diagnostic strategies, and therapeutic outcomes. This analysis reveals that, in selected cohorts, brain MRI-negative SIH has been reported in a substantial minority of patients, sharing core clinical symptoms with MRI-positive SIH but often associated with longer symptom duration and higher recurrence rates. While standard qualitative brain MRI without dedicated spinal imaging or dynamic myelographic techniques is often unrevealing, advanced modalities such as CT myelography, MR myelography, and particularly digital subtraction myelography (DSM) may help to identify occult cerebrospinal fluid (CSF) leaks, including CSF-venous fistulas. Treatment with epidural blood patch may provide clinical benefit in selected patients, while targeted surgical repair of demonstrated leaks or CSF-venous fistulas may be associated with high rates of clinical improvement. In patients with a clinical presentation suggestive of SIH, the absence of typical brain MRI findings should not automatically exclude the diagnosis but should prompt further diagnostic evaluation to improve patients' outcomes. CRD420251146583. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD420251146583.
Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital anomaly associated with myocardial ischemia, ventricular arrhythmias, and sudden cardiac death. Although typically identified in younger individuals, it may present in adulthood with nonspecific or exercise-related symptoms. A 43-year-old physically active man with no prior cardiac symptoms presented with intermittent dizziness and palpitations. Exercise stress testing demonstrated frequent ventricular ectopy progressing to nonsustained ventricular tachycardia during recovery. Coronary computed tomography angiography (CCTA) revealed an anomalous right coronary artery arising from the left sinotubular junction with an interarterial and intramural course. He underwent surgical unroofing with resolution of symptoms on follow-up. AAOCA should be considered in adults presenting with exercise-related ventricular arrhythmias, particularly during stress test recovery. Prompt anatomical evaluation with CCTA enables early identification of high-risk anatomy and timely surgical intervention with favorable outcomes. AAOCA can present in adulthood with exercise-related ventricular arrhythmia despite normal cardiac structure. CCTA is essential for identifying high-risk anatomical features, while management decisions should integrate both anatomy and clinical evidence of ischemia or arrhythmia.
Peanut allergy is one of the most common and potentially life-threatening food allergies in children. It frequently persists into adulthood and imposes significant burdens on affected families, including dietary vigilance, social restrictions, and the constant risk of anaphylaxis. For many years, clinical guidelines recommended delaying the introduction of allergenic foods during infancy, based on the assumption that limiting early exposure would reduce the risk of sensitization and subsequent development of allergy. However, accumulating epidemiological observations and rigorous clinical trial data have fundamentally reversed this paradigm, demonstrating that early oral exposure to peanut protein during a critical window in infancy promotes immune tolerance rather than sensitization. This narrative review synthesizes the key evidence underpinning this paradigm shift, beginning with the epidemiological observations that prompted investigation and centering on the landmark Learning Early About Peanut Allergy randomized controlled trial, which demonstrated a substantial relative risk reduction in peanut allergy among high-risk infants who consumed peanut regularly during early infancy through early childhood. The review also examines long-term follow-up data through adolescence confirming the durability of this protective effect, supporting evidence from the Enquiring About Tolerance trial and pooled analyses, and the biological rationale for early oral tolerance induction. Finally, it provides practical, risk-stratified guidance aligned with current recommendations from the National Institute of Allergy and Infectious Diseases, the American Academy of Pediatrics, and other major medical organizations, addressing clinical implementation strategies, safety considerations, and barriers to adoption in routine pediatric care.