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Adverse drug reactions (ADRs) are an important cause of morbidity, prolonged hospital stay, and increased healthcare costs. Monitoring and reporting ADRs through pharmacovigilance systems help identify drug-related risks and improve patient safety. This study aimed to describe the pattern, characteristics, and outcomes of ADRs reported at a tertiary care teaching hospital under the Pharmacovigilance Programme of India (PvPI). A retrospective, observational, cross-sectional study was conducted at the ADR Monitoring Center of a tertiary care teaching hospital. Individual Case Safety Reports submitted to the Vigiflow database between January 2023 and December 2024 were analyzed. This study got approval by ethics committee. Data were evaluated for patient demographics, suspected drugs, system organ class involvement, seriousness, outcomes, and causality using the World Health Organization-Uppsala (WHO-UMC) scale. Descriptive statistics were used to summarize the data. A total of 299 ADRs were described and analyzed. Adults accounted for the majority of cases, with a slight male predominance. Antimicrobials (29%) were the most commonly implicated drug class. Most ADRs were non-serious. On causality assessment, the majority of reactions were classified as "probable (90.63%)". The most common adverse event was headache (8.6%). The ADR outcome was recovered/resolved in 64.6%. ADRs are commonly encountered in tertiary care settings, with antimicrobials being the most frequent contributors. Describing and analyzing reported ADR data, increasing awareness among medical students, healthcare professionals, and encouraging regular ADR reporting are essential steps to enhance patient safety and promote rational drug use.

The American Board of Internal Medicine (ABIM) Pilot Pathway E introduces a competency-based certification model designed for international medical graduates (IMGs) who have completed prior internal medicine training outside the USA. Amid persistent physician workforce shortages and growing reliance on IMGs within internal medicine, innovative certification pathways are increasingly necessary. National Match data demonstrate both the substantial contribution of IMGs to internal medicine and the large pool of highly trained physicians navigating prolonged or duplicative training routes. Pilot Pathway E allows eligible IMGs, those who have completed at least 3 years of internal medicine training abroad and an ACGME-accredited ABIM subspecialty fellowship, to pursue eligibility for the Internal Medicine Certification Examination without repeating full US residency training. Competency is validated through accredited fellowship oversight and standardized clinical competence evaluations prior to examination approval. ABIM Pilot Pathway E establishes a 5-year pilot program integrating prior international internal medicine training with performance in US ACGME-accredited subspecialty fellowships. Drawing on lessons from alternative certification models in other specialties, this pathway reflects a broader shift from time-based requirements toward outcomes-based assessment. While implementation considerations include licensure, visa policy, and longitudinal outcome monitoring, Pathway E represents a structured effort to align global physician training with US certification standards while preserving rigor, safety, and educational quality.

Orthotopic liver transplantation (OLT) remains the gold standard treatment for end-stage liver disease but is severely limited by donor scarcity and immune rejection. Consequently, bioartificial liver (BAL) systems and hepatocyte transplantation have emerged as promising alternatives, yet their clinical efficacy hinges on the unresolved challenge of generating functional hepatocytes at scale. This review systematically examines the molecular landscape governing hepatocyte proliferation, dissecting the key regulatory roles of Wnt/β-catenin, Hippo-YAP, Notch, and TGF-β signaling pathways in balancing proliferation and differentiation. We critically evaluate current in vitro expansion strategies, contrasting viral-mediated genetic modification approaches with emerging non-genome-editing strategies. Particular emphasis is placed on "next-generation" methodologies, including chemically defined media, bioreactor-based dynamic cultures, and multicellular co-culture systems that recapitulate the native hepatic niche. Furthermore, we highlight recent breakthroughs in liver organoid technology-such as the construction of multi-zonal and vascularized architectures-that bridge the gap between in vitro expansion and in vivo physiological relevance. Finally, we summarize the translational progress of these expanded hepatocytes in BAL devices, cell transplantation trials, and high-fidelity pharmacotoxicological models. We further discuss how emerging technologies, including CRISPR-Cas9-mediated gene correction and bioengineering innovations, may help address current limitations, while acknowledging that substantial preclinical validation remains necessary.

We conducted a systematic review on the epidemiology, clinical presentation, pathophysiology, treatment, and prognosis of clinically amyopathic dermatomyositis (CADM). A qualitative systematic review was performed from October 1988 to January 2026 according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines, using seven electronic databases: PubMed, Web of Science, EMBASE, Virtual Health Library, PsycInfo, Scopus, and the Cochrane Library. Studies were eligible if at least one combination of search terms appeared in the title, were written in English, Portuguese, or Spanish, and addressed the epidemiology, pathogenesis, diagnosis, or treatment of CADM. Systematic reviews, theses, dissertations, letters, editorials, studies with unclear methodology, and articles addressing classic or paraneoplastic dermatomyositis were excluded. A total of 106 studies comprising 816 patients were included. CADM is more frequent among females and most prevalent in the fifth and sixth decades of life. The most common cutaneous findings were Gottron's signs, heliotrope rash, and the V-neck sign. Interstitial lung disease (ILD) was the most frequent extracutaneous, extramuscular manifestation. Elevated ferritin, lactate dehydrogenase (LDH), and C-reactive protein (CRP) levels were common. The most frequent autoantibodies were anti-MDA-5 (Anti-Melanoma Differentiation-Associated gene 5) and anti-Ro-52. Treatment most often combined pulse glucocorticoids with human immunoglobulin, cyclophosphamide, rituximab, or cyclosporine. Poorer prognosis was associated with higher ferritin, CRP, and LDH levels, and with the presence of ILD. CADM is a serious, complex disease with a distinct clinical and serological profile, requiring further conceptual refinement and multicenter studies to better characterize this DM phenotype.

Ischemic stroke is a major cause of mortality globally, but single-target therapies often fail due to the complex "ischemic cascade". This study investigated the neuroprotective effects and multitarget mechanisms of Curcumae Rhizoma (CR) using an integrated network pharmacology approach and in vivo validation. The active compounds of CR were screened through ADME filtering, and their potential targets were identified using the TCMSP, TTD, and UniProt databases. Molecular docking was used to validate the structural binding stability between CR ligands and core targets. In vivo efficacy was evaluated using a mouse model of middle cerebral artery occlusion, followed by histological analysis of infarct volume, neurological scores, and markers of reactive astrogliosis (GFAP) and neuroinflammation (COX-2). Network analysis identified 20 active compounds and 49 core targets, including F2 (thrombin) and PTGS2 (COX-2). Molecular docking revealed that alexandrin and hederagenin exhibited potent binding affinities for COX-2 and thrombin. In vivo, CR extract (CRex; 100 mg/kg) significantly reduced infarct volume and cerebral edema, while facilitating functional motor recovery. Mechanistically, CRex suppressed the overactivation of GFAP-positive reactive astrocytes (an intermediate filament marker of reactive astrogliosis) and downregulated COX-2 expression in the peri-infarct cortex. These findings demonstrate that CRex exerts synergistic neuroprotective effects primarily by attenuating COX-2-driven neuroinflammation, while network pharmacology predicts its secondary potential to interact with thrombin networks. By shifting the focus toward computationally predicted high-affinity candidates, such as alexandrin and hederagenin, our findings establish a valuable molecular hypothesis for CR as a promising multi-target therapeutics for ischemic stroke management.

Breast cancer is one of the leading causes of cancer related mortality in women. Triple negative breast cancer (TNBC), characterized by the absence of ER, PR and HER2 receptors, is particularly challenging to target owing to its highly aggressive nature. Conventional chemotherapeutic agents cause drug resistance, cancer remission and high toxicity even to normal cells. Tupistra nutans (TN) is a flowering plant of the Asparagaceae family and is widely consumed in the Northeastern Himalayan regions. This is the first study exploring the anti-tumorigenic effect of TN on triple-negative breast cancer (TNBC) subtype. We perform ICP-MS and GC-MS analysis to provide comprehensive insights into the phytochemical composition of TN. Using the PASS online tool, we predict that compounds identified in GC-MS such as diosgenin, rhodopin and 1,2-cyclopentanedione, act as apoptosis agonist, MMP9 inhibitor and myc inhibitor respectively. In vitro studies demonstrated IC₅₀ values of 15.2, 28.2, and 70.1 µg/mL at 48 hours in the TNBC cells MDA-MB-231 and HCC1937 and in the normal epithelial-like HEK-293T cell line, respectively, suggesting selective cytotoxicity toward cancer cells. TN shows an anti-migratory effect in MDA-MB-231 cells and was not found to cause apoptosis. Through immunofluorescence for γ-H2A.X, and neutral comet assay we also demonstrate that TN does not induce genotoxicity, rather it upregulates NBR2, indicating possible metabolic stress signalling, and downregulates BRCA1 transcript. TN likely has a cytostatic effect selectively in TNBC cells, indicating functional suppression of tumorigenic properties. Further studies are required to elucidate the underlying mechanisms, and its potential use in combinatorial therapies.

Efficient bacterial production of recombinant antibody fragments is critical for structural characterization and subsequent functional studies. In this study, a systematically optimized workflow was developed for the expression, extraction, and purification of soluble T-cell receptor (TCR)-like antibody fragments in Escherichia coli (E. coli). Two expression hosts, the K-12-derived HB2151 strain and the B-lineage BL21(DE3) pLysS strain, were comparatively evaluated. Although both strains supported recombinant expression, BL21(DE3) pLysS produced higher levels of soluble protein. However, conventional osmotic shock extraction resulted in limited protein recovery. To improve extraction efficiency, a combined lysis approach incorporating freeze-thaw cycles, lysozyme treatment, and sonication was applied, increasing total protein recovery in cell lysates to 149.2-178.4 mg/L of culture. Purification was carried out using Protein A affinity chromatography, and the purification conditions were further optimized to enhance protein recovery. Optimal binding was achieved using 20 mM sodium phosphate buffer (pH 6.8), while elution with 100 mM citric acid (pH 2.9) improved protein yield while maintaining protein stability during purification. Under these conditions, purified soluble TCR-like antibody fragments were obtained at final yields of 6.16-7.08 mg/L of culture. The purified proteins migrated at the expected molecular weight (~ 15 kDa) on SDS-PAGE and were specifically detected by dot blot analysis. Overall, this study provides a reproducible and scalable workflow for improving the expression, extraction, and purification of recombinant soluble TCR-like antibody fragments in E. coli.

Collagen remodeling is an emerging hallmark of breast cancer progression, offering profound insights into tumor biology and therapeutic vulnerability. While breast cancer has long been understood through the lens of genetic mutations and cellular deregulation, recent advances have emphasized the crucial role of the tumor microenvironment (TME), particularly the extracellular matrix (ECM), in directing cancer progression. As the most prevalent structural protein within the ECM, collagen plays a key role in tissue mechanics, cell signaling, and immune regulation. This review examines the current understanding of the molecular configuration and diversity of collagen types found in breast tissue, with an emphasis on the pathological alterations that occur during malignant transformation. We explore how enzymes, such as matrix metalloproteinases (MMPs) and lysyl oxidase (LOX), regulate collagen degradation and crosslinking. These processes drive ECM stiffening and the formation of aligned collagen fibers, which promote tumor invasion, angiogenesis, and immune evasion. This article also highlights tumor-associated collagen signatures (TACS) as potential diagnostic biomarkers and evaluates advanced imaging modalities, including techniques like second harmonic generation (SHG) microscopy and magnetic resonance elastography (MRE), which enable in vivo assessment of collagen remodeling. Furthermore, we review therapeutic approaches targeting collagen-modifying enzymes and emerging nanoparticle-based delivery systems designed to disrupt the fibrotic ECM and improve drug penetration. Ultimately, collagen is now recognized not merely as a structural scaffold, but as an influential factor actively involved in the progression of breast cancer. Understanding the mechanisms and clinical implications of collagen remodeling may open novel paths for personalized diagnostics and targeted therapies, offering new hope for the management of aggressive and treatment-resistant breast cancers.

Gestational duration is influenced by multiple factors, with placental function being one of the key determinants. First-trimester serum biomarkers reflect the quality of placentation and may be associated with the duration of pregnancy. To investigate the association between first-trimester serum placental biomarkers and gestational duration, and to evaluate the independent effects of nulliparity and fetal sex on gestational length. This retrospective, single-center study included 346 singleton pregnancies delivered between 34&#x2009;+&#x2009;0 and 41&#x2009;+&#x2009;0 weeks of gestation following spontaneous labor. First-trimester PAPP-A and free &#x3b2;-hCG multiples of the median (MoM) values were measured. Gestational length was calculated as the interval between the estimated last menstrual period and the date of delivery. Spearman correlation analysis and multiple linear regression were used to assess associations with gestational duration. The mean gestational duration was 271&#x2009;&#xb1;&#x2009;10.5 days. Pregnancy duration was significantly longer in the PAPP-A MoM&#x2009;&#x2265;&#x2009;0.6 group compared to the <&#x2009;0.6 group (273 vs. 269 days, p&#x2009;=&#x2009;0.001). In multiple linear regression analysis, PAPP-A MoM (B&#x2009;=&#x2009;2.08, p&#x2009;=&#x2009;0.034), nulliparity (B&#x2009;=&#x2009;2.96, p&#x2009;=&#x2009;0.013), and fetal sex (B&#x2009;=&#x2009;2.63, p&#x2009;=&#x2009;0.022) were identified as independent predictors of gestational duration. No significant association was observed between free &#x3b2;-hCG MoM and gestational duration. Higher first-trimester PAPP-A MoM levels are independently associated with longer gestational duration, even after adjustment for parity and fetal sex, suggesting that early placental function may play a role in regulating the timing of parturition with modest effect.

Schizophrenia is a chronic psychiatric disorder characterized by substantial biological and clinical heterogeneity. Beyond classical neurotransmitter-based models, increasing evidence suggests that systemic metabolic alterations may contribute to its pathophysiology. This study aimed to characterize urinary organic acid profiles in patients with schizophrenia and investigate their associations with clinical characteristics and pathway-level metabolic alterations. In this cross-sectional study, urinary organic acids were quantified using liquid chromatography-tandem mass spectrometry (LC-MS/MS) in 55 patients with schizophrenia and 30 age- and sex-matched healthy controls. Organic acid concentrations were normalized to urinary creatinine levels. Clinical severity was evaluated using the Positive and Negative Syndrome Scale and the Clinical Global Impressions-Severity scale. Differential metabolite analysis, subgroup comparisons, principal component analysis, correlation analyses, and pathway enrichment analyses were performed. Patients with schizophrenia demonstrated widespread alterations in urinary organic acid profiles compared with healthy controls, with 40 metabolites remaining significantly different after false discovery rate correction. Subgroup analyses identified additional metabolomic variation according to symptom severity, treatment adherence, family history, and current treatment status. Principal component analysis demonstrated partial separation between patients and controls, whereas subgroup distributions showed substantial overlap. Correlation analyses revealed predominantly weak-to-moderate associations between clinical variables and urinary metabolite concentrations. Pathway enrichment analysis identified propanoate metabolism as the only pathway that remained statistically significant after multiple testing correction, while several additional pathways demonstrated nominal enrichment. These findings suggest that schizophrenia is associated with broad alterations in urinary metabolomic profiles and support the possibility that intermediary metabolic pathways may contribute to the biological complexity and heterogeneity of the disorder. Further longitudinal and validation studies are needed to clarify the biological and clinical relevance of these observations.

The healthcare cost crisis in the USA has become unsustainable, with patients facing rising premiums and deductibles and providers unable to meet their bottom lines, forcing practice mergers and buyouts that further exacerbate gaps in care access. Promoting high value care has been a stated priority of health systems for nearly two decades, but practical implementation within a largely fee-for-service system has remained limited. Practicing clinicians must be at the forefront of health system transformation in order to promote value, but medical trainees and early career physicians-who have an increasing interest and knowledge in high value care-often lack a structured career path to lead change in this space. Trainees and early career faculty would benefit from practical and concrete guidance throughout their training to ensure they can sustain their passion and leadership in this space as they transition to faculty/independent practice. We outline four career pathways-Education, Care Delivery Research, Quality/Operations Leadership, and Commercial Innovation-that can help trainees translate early interest in high-value care into sustainable professional roles. Creating visible, supported pathways for these careers is essential if health systems hope to retain and empower the next generation of clinicians committed to advancing value.

Endophthalmitis is a severe intraocular infection associated with potentially devastating visual outcomes. Shinella, a Gram-negative bacillus commonly found in water and soil, has never been reported as a cause of human disease. A 49-year-old female farmer presented with a 7-day history of vision loss, ocular irritation, and ophthalmalgia in her right eye. She had been previously misdiagnosed and treated with high-dose systemic corticosteroids at another institution. She underwent emergent pars plana vitrectomy. Vitreous samples were analyzed using conventional culture and metagenomic next-generation sequencing (mNGS), which identified Shinella species as the predominant pathogen. Intravitreal amikacin and systemic ceftazidime were initiated on postoperative day 3 after culture confirmed Gram-negative bacilli. Two weeks of targeted antibiotic therapy resulted in complete resolution of intraocular inflammation and near-full visual recovery. To our knowledge, this is the first reported case of intraocular infection caused by Shinella species. This case highlights Shinella as a potential ocular pathogen and demonstrates the utility of pars plana vitrectomy combined with mNGS for diagnosing atypical intraocular infections.

Health-related quality-of-life (HRQOL) assessment provides insight into patient's subjective experiences that complement traditional clinical and radiological indicators. This study aims to characterize individual variability in long-term HRQOL recovery trajectories after spinal fusion for severe adolescent idiopathic scoliosis (AIS) and to identify preoperative and surgical factors associated with baseline HRQOL and the rate of improvement. This retrospective longitudinal cohort study included 388 patients with severe AIS (Cobb angle&#x2009;&#x2265;&#x2009;45&#xb0;) who underwent spinal fusion (mean age at surgery 15.3&#x2009;&#xb1;&#x2009;2.1&#xa0;years). A total of 1,539 longitudinal SRS-22r and Spinal Appearance Questionnaire (SAQ) records with up to&#x2009;>&#x2009;20&#xa0;years of follow-up were analyzed. Hierarchical multilevel growth models with random intercepts and random slopes (cubic time polynomial) were used to model recovery trajectories. Preoperative patient-reported outcome measures (PROM) level, age at surgery (continuous), sex, and curve magnitude were evaluated as trajectory moderators. "Good recovery" was defined as final-visit SRS-22r composite score&#x2009;&#x2265;&#x2009;4.0 or SAQ mean score&#x2009;&#x2264;&#x2009;4.2. Marginal and conditional R2 quantified explained variance; partial-effects plots illustrated predicted probabilities. Substantial individual variability existed; the population-average trajectory explained only 18% of variance in SRS-22r and 23% in SAQ scores. Preoperative PROM level was the strongest moderator (additional 54-58% variance explained), with patients having moderate baseline disability showing the greatest and most rapid gains. Younger age at surgery significantly hastened&#xa0;recovery (p&#x2009;<&#x2009;0.01). Most postoperative HRQOL improvement occurred within the first 4&#xa0;years (SRS-22r) and 6&#xa0;years (SAQ), after which scores plateaued at normative levels with no significant long-term decline. Preoperative PROM levels and younger age at surgery are dominant, modifiable moderators of both baseline HRQOL and subsequent postoperative recovery speed. These trajectory-based findings support individualized, patient-centered surgical timing discussions rather than rigid chronological thresholds and facilitate shared decision-making that aligns postoperative HRQOL gains with key psychosocial and educational milestones.

Hypoparathyroidism (HypoPT) is a rare endocrine disorder frequently associated with impaired quality of life. Disease-specific patient-reported outcome measures may help to better characterize symptom burden in Hypoparathyroid patients. The Hypoparathyroidism Patient Questionnaire-28 (HPQ-28) was originally developed in German and subsequently validated French. The aim of this study was to validate the Italian version of the HPQ-28 in a multicenter cohort. In this cross-sectional study, adult participants were recruited from two tertiary referral centres in Italy. The study population were divided in three groups: patients with chronic postsurgical HypoPT (Group 1), patients with hypothyroidism without HypoPT (Group 2), and healthy controls (Group 3). Structural validity was assessed using confirmatory factor analysis with a weighted least squares mean- and varianceadjusted estimator. Internal consistency was evaluated using Cronbach's alpha and McDonald's omega coefficients. Test-retest reliability was assessed using intraclass correlation coefficients in a subgroup of patients. Construct validity was examined by comparing HPQ-28 scores across clinical groups. A total of 163 participants were included (69 HypoPT patients, 60 hypothyroid patients, and 34 controls). Confirmatory factor analysis supported the original six-factor structure of the HPQ-28, with acceptable goodness-of-fit indices (CFI = 0.933, TLI = 0.924, RMSEA = 0.075, SRMR = 0.081). Internal consistency was satisfactory across domains, with Cronbach's alpha ranging from 0.70 to 0.89 and McDonald's omega from 0.75 to 0.93. Test-retest reliability demonstrated good temporal stability. Patients with HypoPT reported significantly higher symptom burden compared with both hypothyroid patients and healthy controls across several domains. The Italian version of the HPQ-28 demonstrates good psychometric properties and represents a reliable disease-specific instrument for assessing symptom burden in patients with hypoparathyroidism in both clinical practice and research settings.

Colorectal cancer (CRC) progression and metastasis are primarily driven by dynamic changes within the tumor microenvironment (TME). Cancer-associated fibroblasts (CAFs) exhibit significant heterogeneity within the TME and play a crucial role in regulating ferroptosis. Therefore, identifying novel ferroptosis-related biomarkers associated with CAFs could contribute to the development of personalized therapeutic strategies for cancer. This study integrates single-cell sequencing data from 64 CRC samples and uses hierarchical clustering to identify cancer-associated fibroblast (CAF) subpopulations. We then combined spatial transcriptomics, hdWGCNA, CellChat, and Monocle analyses to characterize CAF subgroups. Single-cell and spatial transcriptomic data were integrated with Seurat to build a comprehensive spatial atlas. Multiplex immunohistochemical staining was used to analyze the spatial relationships of key genes with CAFs. Functional validation of these genes was performed with molecular docking, qPCR, Western blot, and both cellular and animal experiments. Single-cell data analysis identified five distinct CAF subpopulations, among which inflammatory cancer-associated fibroblasts (iCAFs) were significantly associated with the ferroptosis pathway and closely correlated with the proliferation and metastasis of malignant epithelial cells (p&#x2009;=&#x2009;0.87). WGCNA revealed that the iCAFs-M10 module exhibited the strongest correlation with the expression of ferroptosis-related genes (cor&#x2009;=&#x2009;0.6796). Further investigation identified ATG13 as a key hub gene, highly expressed in tumor tissues and significantly associated with poor patient prognosis. Spatial transcriptomics and multiplex immunohistochemistry (mIHC) results demonstrated that ATG13 was highly expressed in CAFs and co-localized with CAFs markers, such as &#x3b1;-SMA and Vimentin. In vitro and in vivo functional assays confirmed that ATG13 knockdown effectively inhibited the proliferation, migration, and invasion of colorectal cancer cells. Additionally, ferroptosis was induced upon ATG13 silencing, as evidenced by increased levels of GPX4, SLC7A11, ACSL4, MDA, Fe2&#x207a;, GSH, and lipid peroxidation. In conclusion, this study reveals that ATG13, highly expressed in iCAFs, is associated with ferroptosis suppression in CRC, suggesting a potential CAF-tumor cell crosstalk axis that warrants further mechanistic investigation, thereby promoting the malignant progression of colorectal cancer. These findings provide potential targets for therapeutic strategies aimed at targeting the CAFs-ferroptosis axis. This study identifies the iCAFs subpopulation as playing a key role in regulating ferroptosis in CRC, with ATG13 acting as a negative regulator of ferroptosis that promotes tumor progression. These findings provide new insights and potential targets for understanding the mechanisms of ferroptosis in CRC and for the development of targeted therapies.

We describe a case of refractory chylous ascites (RCA) successfully managed with a Denver shunt (DS) after conversion surgery for unresectable locally advanced pancreatic cancer. A 55-year-old woman developed RCA 6 months after distal pancreatectomy with celiac axis and portal vein resection. Conservative therapy, lymphangiography, and repeated paracentesis were ineffective. After confirming negative cytology, culture, and endotoxin tests, DS placement on postoperative day 425 resulted in rapid resolution of ascites, accompanied by improvement in body weight and hypoalbuminemia. No early major complications were observed after DS placement, and she was discharged safely. Although the shunt was removed 29 months later because of internal jugular vein thrombosis, no reaccumulation of ascites was observed thereafter. The patient remains alive without reaccumulation of ascites or tumor recurrence 60 months after curative resection. Although careful patient selection is essential because of potential complications, DS may serve as an effective salvage option for postoperative RCA when conservative approaches fail.

Dermatological delusional disorders, such as delusional infestation (DI), are a unique type of psychosis in which the patient experiences specific delusions, such as parasites or inorganic materials that come out of their skin. Originally, this type of "encapsulated psychosis" was thought to be unresponsive to antipsychotic agents. However, over the past half a century, several medications with antipsychotic properties have been found to be effective in the treatment of these conditions in the USA, especially pimozide and risperidone. Despite effective treatments, several challenges may arise for clinicians in successfully treating patients with these conditions. These challenges include selecting an efficacious medication and skillfully practicing diplomacy and empathy while guiding patients toward effective management. Navigating interactions with patients with DI and their frequent denial of a psychiatric component to their condition often poses additional challenges to patient-provider rapport and proper and timely management. In the USA, many patients with DI are opposed to trying the conventional approach of psychiatric care and immediate trial of antipsychotic medications. This manuscript represents a single-center psychodermatology perspective on managing dermatologic delusional disorders. This article synthesizes clinical experience from a US clinic and situates that experience within the available evidence. High-quality comparative data are limited. Therefore, this paper highlights pragmatic engagement strategies, pharmacotherapy principles, essential safety monitoring, and research priorities. Experience-based recommendations are clearly labeled as such.

Circadian rhythm sleep disorders (CRSDs) are common among healthcare workers (HCWs) and may impair alertness and cognitive performance during night shifts. This study examined CRSDs associations with cognitive function and sleepiness during overnight duty. Seventy-six hospital employees (80.3% female; mean age 31.8&#x2009;&#xb1;&#x2009;7.5 years) participated in this cross-sectional study. Based on clinical evaluation, participants were classified as normal circadian rhythm, delayed sleep phase syndrome (DSPS), and shift work sleep disorder (SWSD). Sleepiness was measured using Karolinska Sleepiness Scale (KSS) and Epworth Sleepiness Scale (ESS). Cognitive and psychomotor performance were assessed at the start and end of an 8-hour night shift using reaction time, minor lapses, memory span, and digit span tests. Statistical analyses included ANOVA, paired t-tests, Wilcoxon, and Kruskal-Wallis tests. The prevalence of DSPS and SWSD was 13.2% and 15.7%. Total sleep duration did not differ significantly between CRSDs (P&#x2009;>&#x2009;0.05). Reaction times and minor lapses increased significantly after the night shift (P&#x2009;<&#x2009;0.05). Memory span, forward and reverse digit recall, and total correct responses all declined post-shift (P&#x2009;<&#x2009;0.01). KSS scores increased significantly (P&#x2009;=&#x2009;0.001). Reaction times and minor lapses differed significantly between CRSD subgroups, with SWSD participants demonstrating the greatest decline in performance. HCWs with SWSD, exhibited greater cognitive deterioration and sleepiness during night shifts compared with normal circadian rhythms, whereas individuals with DSPS show relatively preserved performance. These findings highlight the importance of early recognition and occupational strategies to mitigate cognitive fatigue and associated risks in shift-working HCWs.

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