Developing a tool for assessing and communicating the expected difficulty of performing a tracheostomy

There are no guidelines for assessing and communicating the expected difficulty of a tracheostomy, leading to difficulties planning a percutaneous approach in intensive care or referring onwards to surgical teams. A Delphi process was used to develop a tool containing metrics which are relevant for either specialty and can be universally assessed by both. Palpable tracheal rings, prior surgery or radiotherapy to the anterior neck, uncorrectable clotting or platelet dysfunction, ability to extend the neck freely, and overlying vessels visible, palpable or on imaging were all found to be relevant. It is hoped this tool will aid communication between specialties.

SleepECG-Net: Explainable Deep Learning Approach With ECG for Pediatric Sleep Apnea Diagnosis

Obstructive sleep apnea (OSA) in children is a prevalent and serious respiratory condition linked to cardiovascular morbidity. Polysomnography, the standard diagnostic approach, faces challenges in accessibility and complexity, leading to underdiagnosis. To simplify OSA diagnosis, deep learning (DL) algorithms have been developed using cardiac signals, but they often lack interpretability. Our study introduces a novel interpretable DL approach (SleepECG-Net) for directly estimating OSA severity in at-risk children. A combination of convolutional and recurrent neural networks (CNN-RNN) was trained on overnight electrocardiogram (ECG) signals. Gradient-weighted Class Activation Mapping (Grad-CAM), an eXplainable Artificial Intelligence (XAI) algorithm, was applied to explain model decisions and extract ECG patterns relevant to pediatric OSA. Accordingly, ECG signals from the semi-public Childhood Adenotonsillectomy Trial (CHAT, n = 1610) and Cleveland Family Study (CFS,n = 64), and the private University of Chicago (UofC, n = 981) databases were used. OSA diagnostic performance reached 4-class Cohen's Kappa of 0.410, 0.335, and 0.249 in CHAT, UofC, and CFS, respectively. The proposal demonstrated improved performance with increased severity along with heightened cardiovascular risk. XAI findings highlighted the detection of established ECG features linked to OSA, such as bradycardia-tachycardia events and delayed ECG patterns during apnea/hypopnea occurrences, focusing on clusters of events. Furthermore, Grad-CAM heatmaps identified potential ECG patterns indicating cardiovascular risk, such as P, T, and U waves, QT intervals, and QRS complex variations. Hence, SleepECG-Net approach may improve pediatric OSA diagnosis by also offering cardiac risk factor information, thereby increasing clinician confidence in automated systems, and promoting their effective adoption in clinical practice.

Risk factors and significance of post-operative edema in Parkinson Disease patients submitted to deep brain stimulation. A ten-year case series

BACKGROUND

Peri-electrode edema after deep brain stimulation (DBS) surgery for Parkinson Disease (PD) has been reported in up to 100% of cases. The clinical significance of this finding is unclear, with most papers suggesting a benign course. The risk factors are also poorly defined. We aimed at defining the incidence rate, the clinical significance and the predictive factors of peri-electrode edema in patients undergoing DBS for PD.

METHODS

We reviewed data of 119 patients treated with frameless stereotactic DBS for PD between 2012 and 2022 at our Institution. A mixed-technique targeting was adopted. Awake surgery was used in 64.7% cases; in most cases, microelectrode recording (MER) was adopted. The target was the subthalamic nucleus (STN) in 91.2% cases.

RESULTS

Ninety patients were included. Postoperative edema related to lead placement was noticed in 40% patients after a median time of 2 days since surgery; in 88.9% of these cases, it was limited to subcortical white matter. Symptomatic edema was registered only in one case (1.1%), confirming previous reports on the benign clinical course. The only independent predictive factor for edema onset was asleep surgery (p = 0.0451). Notably, the use of directional electrodes was not associated with an increased risk of edema at multivariable analysis. Clinical parameters including age, and timing of CT scanning, did not affect edema onset.

CONCLUSIONS

We confirmed the very low rate of symptomatic edema in DBS for PD. When feasible, awake DBS using MER is the ideal technique to reduce the risk of radiologic postoperative edema.

Percutaneous and endoscopic transpapillary cholecystoduodenal stenting in acute cholecystitis-A viable long-term option in high-risk patients?

BACKGROUND

The prolonged use of percutaneous cholecystostomy tubes (PCTs) in patients with acute cholecystitis, deemed inoperable, is fraught with complications. Transpapillary cholecystoduodenal stenting (TCDS) is an alternative technique that restores the physiologic outflow of bile, avoiding the need for an external drain. However, the long-term safety and efficacy of this approach remain unclear. We sought to prospectively assess the safety and efficacy of this procedure, performed via percutaneous or endoscopic approach, in high-risk patients presenting with acute cholecystitis.

METHODS

This prospective study included consecutive patients with acute cholecystitis and long-lasting, prohibitive surgical risk, in whom TCDS was offered at two partnering tertiary care centers between August 1, 2018, and December 31, 2022. Patients with a need for endoscopic retrograde cholangiopancreatography (ERCP) underwent ERCP-guided TCDS. In patients without a need for ERCP, a temporary PCT was followed by fluoroscopic-guided TCDS 4 weeks to 6 weeks later. Interval cholecystectomy was performed in patients who became surgical candidates later. All patients were followed up until January 1, 2023.

RESULTS

Transpapillary cholecystoduodenal stenting was successful in 67 (percutaneous in 45/50; endoscopic in 22/23) of 73 patients (92%) attempted. Over a median follow-up period of 17 months (7, 26), 10 patients (15%) developed stent blockage or migration; all but two had their stent successfully replaced. Five patients (7%) developed mild, self-limited pancreatitis. Five (7%) patients underwent interval cholecystectomy at a median time of 7 months.

CONCLUSION

Transpapillary cholecystoduodenal stenting is a safe and promising definitive alternative to chronic PCT in high-risk patients with acute cholecystitis that eliminates the discomfort and complications of long-term external drainage.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level II.

Uncommon Causes of Pulmonary Hypertension With Associated Cardiomyopathy: Computed Tomography and Magnetic Resonance Imaging of Cardiothoracic Manifestations

Pulmonary hypertension (PH) is a disease characterized by pathologically increased pressure in the pulmonary arteries, defined by a mean pulmonary arterial pressure (mPAP) >20 mmHg at rest measured with right heart catheterization (RHC). This definition encompasses pathologies with very different pathological backgrounds, ultimately resulting in PH. For this reason, the latter can be possibly (though seldom) accompanied by cardiomyopathies, pathologies characterized by a structural and functionally abnormal myocardium not secondary to coronary disease, hypertension, valvular disease, or congenital heart disease. Notable examples of these diseases are sarcoidosis (a multi-systemic inflammatory granulomatous disease, possibly involving the lung and the heart), systemic sclerosis (SSc) (a connective tissue disease [CTD], possibly causing interstitial lung disease [ILD], direct as well indirect involvement of the cardiovascular system), and chronic kidney disease (CKD) (a progressive pathological process involving the kidneys, with multi-systemic involvement and possible development of a peculiar form of cardiomyopathy, i.e., uremic cardiomyopathy [UC]). The diagnostic work-up of patients with coexistent PH and cardiomyopathies implies the use of multiple imaging techniques, with computed tomography (CT) and cardiovascular magnetic resonance (CMR) being among the most important. The knowledge of CT and MRI findings, together with a suggestive clinical picture, forms the basis for a correct diagnosis, therefore it is important for the radiologist to recognize them in complex clinical scenarios. The advent of new technologies (e.g., photon counting detectors) and the development of new artificial intelligence (AI) algorithms will further pave the way for improved diagnostic processes (also regarding this kind of pathologies) as well as allowing to perform a better prognostic evaluation.

Pediatric Asthma Impairment and Risk Questionnaire: Rationale and development of a composite control tool

BACKGROUND

Asthma in children is a leading cause of missed school days, emergency department visits, and hospitalizations. Approximately 40% of children with asthma experience uncontrolled disease and annual exacerbations. There is a need for a validated composite tool for children, such as the Asthma Impairment and Risk Questionnaire (AIRQ), which was developed to assess current control and predict exacerbations in adolescents and adults with asthma.

OBJECTIVE

To obtain feedback from children with asthma and their parents/caregivers to inform development of a version of the AIRQ for pediatric use (Peds-AIRQ).

METHODS

Children with asthma aged 5 to 11 years and their parents/caregivers participated in cognitive interviews to elicit language describing asthma symptoms and exacerbations and to assess understanding and relevance of draft Peds-AIRQ questions. Physicians and parents/caregivers provided clinical information and performed assessments relative to the children's asthma morbidity.

RESULTS

There were 60 dyads that participated: children's mean (SD) age = 7.9 (1.9) years; 68% male, 45% non-White, 32% Hispanic, and 40% with public health insurance. Overall, 53% had well-controlled, 30% partly controlled, and 17% uncontrolled asthma, based on the Global Initiative for Asthma symptom control questions. Oral or injected corticosteroids were used for asthma by 53% of the children in the previous year. Participants found draft Peds-AIRQ items understandable and relevant. Seven impairment and 3 risk questions were retained for validation, along with 5 additional items containing wording or control threshold variations.

CONCLUSION

This study supports the need for developing a composite (impairment and risk) control tool to assess children aged 5 to 11 years with asthma and identified suitable questions for the validation of a Peds-AIRQ.

Lateral Approach for Regenerative Treatment of Intrabony Defects Associated With an Edentulous Alveolar Ridge: A Prospective Case Series

OBJECTIVES

This case series evaluated the clinical efficacy of the novel "lateral approach" combined with an enamel matrix derivative (EMD) and bone grafting in the regenerative surgical treatment of intrabony defects associated with an edentulous ridge.

MATERIAL AND METHODS

The innovative flap, called the "lateral approach," is explicitly designed for regeneration of unchallenged isolated intrabony defects associated with edentulous alveolar ridges. The flap is defined by a curved vertical incision on the buccal side opposite the treated defect and a sulcular incision on the buccal and defect-associated sides, promoting uneventful healing and regeneration while minimizing complications. Seven intrabony defects (one per patient) distal to the lower second molar were treated using the "lateral approach" combined with EMD and grafting with deproteinized bovine bone mineral. The primary outcome was clinical attachment level (CAL) change. As additional parameters, pocket probing depth (PPD) reduction and complication rate were analyzed. All the outcomes were assessed 6 months post-surgery and compared with the baseline values.

RESULTS

Primary wound healing occurred in 100% of cases, and no complications were reported. At the 6-month re-evaluation, the initial median CAL of 6 mm (interquartile range 5-8 mm) was reduced to 3 mm (3-5 mm). The corresponding median PPD was reduced from 6 mm (IQR 6-8 mm) to 4 mm (IQR 3-5 mm). These differences were statistically significant (p < 0.05).

CONCLUSIONS

The "lateral approach" is a technique for the surgical treatment of intrabony defects associated with the edentulous ridge. Within the limitations of the study, this method seems to be suitable for distal intrabony defects in the lower second molars, which frequently develop after third molar extraction.

Advancing Sleep Disorder Diagnostics: A Transformer-Based EEG Model for Sleep Stage Classification and OSA Prediction

Sleep disorders, particularly Obstructive Sleep Apnea (OSA), have a considerable effect on an individual's health and quality of life. Accurate sleep stage classification and prediction of OSA are crucial for timely diagnosis and effective management of sleep disorders. In this study, we develop a sequential network that enhances sleep stage classification by incorporating self-attention mechanisms and Conditional Random Fields (CRF) into a deep learning model comprising multi-kernel Convolutional Neural Networks (CNNs) and Transformer-based encoders. The self-attention mechanism enables the model to focus on the most discriminative features extracted from single-channel electroencephalography (EEG) recordings, while the CRF module captures the temporal dependencies between sleep stages, improving the model's ability to learn more plausible sleep stage sequences. Moreover, we explore the relationship between sleep stages and OSA severity by utilizing the predicted sleep stage features to train various regression models for Apnea-Hypopnea Index (AHI) prediction. Our experiments demonstrate an improved sleep stage classification performance of 78.7%, particularly on datasets with diverse AHI values, and highlight the potential of leveraging sleep stage information for monitoring OSA. By employing advanced deep learning techniques, we thoroughly explore the intricate relationship between sleep stages and sleep apnea, laying the foundation for more precise and automated diagnostics of sleep disorders.

Complete second branchial cleft fistula in a fifteen-year-old boy: A case report

INTRODUCTION AND IMPORTANCE

The branchial or pharyngeal apparatus, crucial in embryological development, consists of clefts, arches, pouches, and membranes. Anomalies arising from this apparatus particularly involving the second branchial arch, are rare. Among these anomalies, complete second branchial cleft fistulas, with both external and internal openings, are exceptionally uncommon. This case report presents such a rarity in a fifteen-year-old boy, highlighting the clinical presentation, diagnostic approach, surgical management, and outcome.

CASE PRESENTATION

A fifteen-year-old boy presented with a history of mucoid discharge from an opening on the lateral aspect of the right neck, noticed since birth. Clinical examination revealed a pinhole opening along the anterior border of the sternocleidomastoid muscle. Imaging studies confirmed the diagnosis of a complete second branchial cleft fistula, extending from the right lateral neck to the right tonsillar fossa. Surgical excision using a stepladder approach was performed under general anesthesia, leading to complete resolution of symptoms.

CLINICAL DISCUSSION

Complete second branchial cleft fistula is a rare entity. The diagnosis requires thorough history and examination, imaging, biopsy and surgical excision along with certain period of folllow-up.

CONCLUSION

Complete second branchial cleft fistulas are exceedingly rare congenital anomalies, typically presenting with mucoid discharge from a neck opening since birth. Diagnosis involves clinical examination and imaging studies, such as sinography with water-soluble contrast. Surgical excision, often via a stepladder approach, remains the mainstay of treatment, resulting in favorable outcomes. Early recognition and prompt intervention are essential for optimal management.

Surgical outcomes from robotic-assisted adrenalectomy: a case series on experience in a large tertiary referral centre

BACKGROUND

Robotic-assisted surgery is gaining wider acceptance in most surgical specialties. However, in the United Kingdom, endocrine surgery has not fully adopted robotics. This paper aims to present the early experience and outcomes of patients who underwent robotic-assisted adrenalectomy at a tertiary referral endocrine surgery department. Outcomes were compared to national and international performance measures.

METHODS

Seventy-two elective robotic adrenalectomies were performed over a 24-month period. Data collected included patient demographics, co-morbidities, indication for surgery and tumour size. Outcomes assessed were console time, conversion rates, complications, length of stay and excision margin.

RESULTS

Seventy-two cases were included for analysis. Sixty-six percent (n = 48) of the patients were female with a median age of 60 years. Median BMI was 28. Functional tumours accounted for 76% (n = 55) of cases with the most common being phaeochromocytomas and cortisol producing adenomas. Median docking time was 5 min with a median intraoperative time on the console of 45.5 min. Tumour size ranged from 1 to 14 cm. Median length of stay postoperatively was 1 day. There was only one conversion to open procedure. Two patients reported post-op superficial surgical site infections and there were no mortalities.

CONCLUSION

This case series demonstrates robotic-assisted adrenalectomies performed in a tertiary care centre were safe and feasible in a selected cohort of patients with functional and non-functional tumours. Large randomised controlled trials with long-term follow-up are required to establish the benefits of robotic adrenal surgery over conventional laparoscopic adrenalectomy.

Memory-Enhancing and Anxiolytic Effects of the Rose of Jericho on Sleep Deprivation-Related Cognitive and Behavioral Changes

BACKGROUND

Sleep is a crucial physiological phenomenon that enables the body to engage in restoration and rejuvenation. Remarkably, even limited periods of sleep deprivation (SD) can adversely affect cognitive functions such as memory retention, emotional regulation, data processing, and concentration. The Rose of Jericho (RoJ) has been considered more than a plant and has demonstrated potential therapeutic actions in childbirth, respiratory diseases, gastrointestinal disorders, and cancer. The effect of the RoJ on memory, cognition, and behavior has not yet been well-studied.

OBJECTIVES

The present study aimed to investigate the possible therapeutic effects of the RoJ on memory, cognition, behavior, and motor coordination in a rat model of SD.

MATERIALS AND METHODS

Thirty male Wistar albino rats weighing 120-150 g were used in the present study. The rats were acclimatized and trained and then randomly divided into three groups: control (C), sleep-deprived (SD), and SD treated with RoJ (SD+RoJ). Spatial memory and learning were assessed using the Morris Water Maze (MWM) test, while anxiety-related behaviors were evaluated through the Elevated Plus Maze (EPM) test. The rotarod test was used to assess motor coordination.

RESULTS

The study revealed significant behavioral and cognitive performance improvements with the SD+RoJ group across all the tests. In the MWM test, the SD group exhibited a marked increase in test duration (29.5 ± 3.57 sec) and a reduction in average speed (1.9 ± 0.3 cm/s) when compared to the C group (13.41 ± 1.57 sec and 5.9 ± 0.34 cm/s, respectively). Interestingly, the SD+RoJ group significantly reduced test duration (19.75 ± 3.36 sec) and improved rats' speed (6.06 ± 0.27 cm/s) compared to the SD group. The EPM test demonstrated that the SD group spent significantly less time in the open arms (16.2 ± 9.44 sec) than the C group (59.8 ± 3.29 sec). Interestingly, the SD+RoJ group significantly improved the time spent in the open arms (45.8 ± 11.64 sec). Moreover, the SD+RoJ group showed notable improvement in open-arm entries (7 ± 2.39) compared to the SD group (1.6 ± 0.81). In the Rotarod test, the SD group demonstrated a significant decline in latency to fall (44.2 ± 9.5 sec) compared to the C group (228.67 ± 35.44 sec). The SD+RoJ group exhibited a significantly longer falling latency (165 ± 28.77 sec) than the SD group.

CONCLUSION

Treatment with the RoJ alleviated SD-dependent cognitive impairment, anxiety, and decline in motor coordination. Supplementation with the RoJ may offer potential therapeutic benefits, including boosting memory, improving cognition, reducing anxiety and depression, and enhancing motor coordination.

Seymour fracture management and functional outcome assessment: a case report

Seymour fracture, a rare entity whose management is complex due to the mechanism and rate of complications. We present a case to describe our management approach. A 14-year-old child with a laceration secondary to a boot crush of 1 day of evolution. The physical examination reveals a lacerated fifth digit involving skin, nail bed, and distal phalange. Radiography was performed, Salter-Harris I fracture was diagnosed. Early surgical intervention was performed, irrigation, nail bed repair, debridement, open reduction, and osteosynthesis with K-wires. The patient was referred to rehabilitation and an antibiotic scheme of amoxicillin-clavulanic plus clindamycin was given. After 8 weeks Kirschner wire was removed, and no complications were reported. A fingertip injury outcome score was performed obtaining 11 points. Early intervention is a must. The use of Fingertip Injuries Outcome Assessment Score is vital for followup in children. Collaboration across disciplines is key to improving outcomes.

Useful biomarkers for predicting poor prognosis of patients with drug-induced liver injury: A retrospective cohort study

BACKGROUND

Drug-induced liver injury (DILI) plays an important role in liver failure and causes mortality. Patients with DILI compatible with Hy's law are associated with poorer outcomes. However, the predictive accuracy of Hy's law is not good enough in clinical practice. This study aimed to investigate the optimal values of biomarkers associated with the prognosis of DILI.

METHODS

From June 1, 2014-May 30, 2022, patients with reported DILI were included. Patients' characteristics, drugs, DILI type, liver enzymes, and comorbidities were assessed. The associations with DILI-related comorbidities and survival were analyzed.

RESULTS

Ninety-five DILI patients were enrolled, 5 patients died of liver failure, and 23 patients died within 56 weeks after DILI. This study found that 15 mg/dL of total bilirubin, 1000 U/L of ALT, and 2 of PT-INR were optimal cut-off values in predicting DILI-related mortality. For the overall survival, patients with sepsis (HR:5.053, 95% CI:1.594-16.018, p = 0.006), malignancy (HR:4.371, 95% CI:1.573-12.147, p = 0.005), or end-stage renal disease (HR:7.409, 95% CI:1.404-39.103, p = 0.018) were independent poor prognostic factors in multivariate Cox regression analysis.

CONCLUSIONS

Total bilirubin >15 mg/dL, ALT >1000 U/L, and PT-INR >2 are useful biomarkers in predicting DILI-related mortality. DILI patients with sepsis, malignancy, or end-stage renal disease are associated with worse overall survival.

A, Arunachalam AS, M. A. A, Palani BP, Raveendiran B, Sundaram B, Majella CM, Perumal J, Jeemon P, Ganesan K, Balasubramani K, Kumaresan K, Perumal K, Radhakrishnan K, Srinivasan K, Ganesan M, Tamilmani M, Azhakesan M, K. N, Mohandoss NP, Jayabalan N, Mohanan N, Padmnabhan P, Mohamed RB, Sethumadhavan R, Edwin R, Kannappan S, Gnanamuthu S, Krishan SR, Satish SP, Ahamed D, Jagannathan R. Impact of telemedicine in STEMI care system: A five-year experience from Tamil Nadu, India

Background & objectives Timely reperfusion reduces mortality in ST-segment elevation myocardial infarction (STEMI). Telemedicine and social media have been shown to improve STEMI care in community settings as reported previously. We established a government-sponsored STEMI care system in the State of Tamil Nadu with a goal of enhancing guideline-directed revascularisation (GDR) in STEMI. This study aimed to improve GDR by networking non-percutaneous coronary intervention (PCI)-capable hospitals with PCI capable hospitals in a hub-and-spoke model and implementing telemedicine through social media groups. Methods Eighteen Government medical college hospitals were provided cardiac catheterisation laboratories and linked to 188 Taluk and non-PCI capable Government hospitals forming 18 STEMI clusters. Telemedicine guidance on STEMI management was provided through WhatsApp groups created for each cluster. Cumulative daily data on the number of STEMIs, the revascularisation provided, and mortality were collected through free online web forms. Annual cumulative data on STEMI volumes and GDR were analysed. Results A total of 71,907 individuals were treated for STEMI from 2019 to 2023. A 67 per cent annual increase in the total individuals treated for STEMI was observed. The proportion of individuals receiving pharmaco-invasive therapy (PIT) increased from 7.9 to 31.7 per cent. There was a 68 per cent increase in the individuals receiving primary PCI. The number of individuals without GDR decreased by 20 per cent. There was a 6.7-fold rise in the individuals referred from spoke to hub hospitals for catheter-based revascularization. Overall mortality showed a marginal decrease from 8.7 to 8.4 per cent. Interpretation & conclusions Findings of this study suggest that a government-sponsored STEMI care system in a hub-and-spoke model, guided by telemedicine through social media groups will improve GDR in STEMI care in developing nations.

3D printed customized facemask for early treatment of Class III malocclusion: a two-center case series feasibility study

BACKGROUND

This prospective two-center case series feasibility study aimed to investigate the potential of a novel maxillary protraction facemask customized to the patients' anatomy recorded with 3D face scanning and then produced by digital design and additive manufacturing.

METHODS

Ten subjects (5 females and 5 males, average age 7.7±1.0 years) with Class III malocclusion were treated with a rapid maxillary expander (RME) and a Petit-type facemask (FM), whose components were digitally designed on a 3D scan of the patient's face. Subjects' face scans were obtained either with a tablet or with face scanner. FM components were modelled with a 3D software. The pads were 3D printed in biocompatible resin, and the bar was printed in stainless steel. A questionnaire investigating the patients' experience was filled in after the first week of treatment and after 3, 6, and 9 months.

RESULTS

The customized FM showed an excellent adaptation to the anatomy of the face. No severe complications were reported during the 9 months of appliance wearing. Some reversible episodes of skin irritation were reported below the pads, mainly in the chin area. The reported time wearing ranged between 8.2±2.3 and 9.5±1.2 hours per day, mainly at night. Reported pain was overall low (maximum after 1 week with an average value of 1.9±1.7 on a visual analog scale [VAS] 0-10) and patients' satisfaction was adequate at the end of the facemask wear after 9 months (8.7±1.4 on a VAS 0-10).

CONCLUSIONS

The customized FM was overall well accepted by the patients and represents a valid alternative to conventional ones.

The risks of artificial intelligence: A narrative review and ethical reflection from an Oral Medicine group

As a relatively new tool, the use of artificial intelligence (AI) in medicine and dentistry has the potential to significantly transform the healthcare sector. AI has already demonstrated efficacy in medical diagnosis across several specialties, used successfully to detect breast, lung and skin cancer. In Oral Medicine, AI may be applied in a similar fashion, used in the detection and diagnosis of oral cancers and oral potentially malignant diseases. Despite its promise as a transformative diagnostic aid, the use of AI in healthcare presents significant safety, reliability and ethical concerns. There is no formal consensus on the safe and ethical implementation of AI systems in healthcare settings, but the literature converges on several key principles of ethical AI use including transparency, justice and fairness, non-maleficence, responsibility and privacy. This article provides a narrative review of the key ethical issues surrounding AI use in medicine, and reflects on these, providing view-points of a bioethicist and Oral Medicine clinicians from several units.

Mad (wild) honey poisoning: a case series of eleven cases

Introduction

Mad (Wild) honey, used as alternative medicine in some countries where cases of poisoning are reported, got its name due to its intoxicating effects. Poisoning due to mad honey mostly presents as bradycardia and hypotension.

Case reports

We report 11 cases involving 6 females and 5 males, of mad honey poisoning used for medicinal purposes. All patients were young adults (average age 43.9 years) except for one. Lightheadedness, dizziness and nausea were the most common complaints. All presented in bradycardia ranging from 35 to 60 beats per minute. All cases were managed conservatively while one required vasopressors support. All patients improved with a couple of days of supportive care.

Discussion

Mad honey poisoning seems to be a geographically restricted entity as the majority of cases are reported from a particular region. Because of its use as an alternative medicine for various purposes, cases of intoxication occur year around. Although the signs and symptoms of mad honey can be life threatening including nausea, dizziness, bradycardia, and hypotension, the prognosis is generally good.

Conclusion

Although the prognosis is fairly good, mad honey intoxication has significant morbidity. Lack of awareness about the potential complications of consuming mad honey seems to be the cause of cases of poisoning seen annually.

Impact of Helicobacter pylori Eradication on Clinical and Laboratory Parameters in Non-alcoholic Fatty Liver Disease Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

Helicobacter pylori (HP) infection is associated with non-alcoholic fatty liver disease (NAFLD) and insulin resistance; however, the correlation between HP eradication and NAFLD remains controversial. This systematic review and meta-analysis examined the effect of HP treatment on clinical and laboratory parameters in NAFLD patients.

METHODS

We conducted a literature search of the PubMed, Embase, Scopus, and Web of Science databases through September 2023 for randomized controlled trials (RCTs) examining the effect of HP treatment on NAFLD patients versus lifestyle changes alone. The primary outcome was the change in steatosis parameters. The secondary endpoints were changes in anthropometric parameters, inflammatory markers (TNF-α), and metabolic parameters (fasting blood glucose, homeostasis model assessment of insulin resistance, AST/ALT, and lipid profile). The random effects model was used to calculate the standardized mean difference (SMD) with associated 95% confidence intervals (CIs) for our desired outcome.

RESULTS

Four RCTs met our inclusion criteria. A total of 453 patients were included (mean age 42.8 years, 58.5% males), 228 (50.3%) of whom were in the HP eradication group and 225 (49.7%) of whom were in the lifestyle modification group. Compared with lifestyle modification alone, HP eradication had a significant effect on reducing liver steatosis and TNF-α levels (SMD: - 0.9; 95% CI - 14.67, - 3.82, I2 = 0% and SMD: - 6.3; 95% CI - 9.04, - 3.56, I2 = 0%, respectively). No significant effect on other metabolic parameters was found.

CONCLUSIONS

HP eradication significantly reduced liver steatosis and TNF-α levels in NAFLD patients. However, HP eradication did not significantly affect other metabolic indices compared to lifestyle changes alone.

The Role of Structural Empowerment in Mediating the Relationship Between Practice Environment and Quality of Care Among Emergency Nurses: A Multilevel Modeling Approach

INTRODUCTION

Strong evidence demonstrated that working in a healthy environment has been associated with high-quality patient care. However, the mechanism underlying this relationship requires further investigation. This study aimed to examine the role of structural empowerment in mediating the relationship between nursing practice environment and quality of care among emergency nurses.

METHODS

A proportional stratified clustered sampling technique was used to recruit staff nurses working in acute care hospitals in Oman. Four standardized instruments were used to assess nurses' sociodemographic characteristics, perception of the practice environment, structural empowerment, and perceived quality of care. Hayes' process for mediation analysis was used to examine whether empowerment mediates the relationship between the practice environment and quality of care.

RESULTS

A total of 160 emergency nurses participated. The majority (78.8%) perceived the quality of care as good/excellent. Having an adequate foundation for quality of care, sufficient staffing, and managerial support were significant predictors of perceived quality of care. Practice environment was directly and indirectly related to the perceived quality of care through structural empowerment.

DISCUSSION

Nurse leaders can enhance care quality in emergency departments by improving the work environment through engaging nurses in quality activities, ensuring adequate staffing and resources, and providing robust leadership support, which collectively empower nurses and improve patient outcomes.

The link between the ANPEP gene and type 2 diabetes mellitus may be mediated by the disruption of glutathione metabolism and redox homeostasis

Aminopeptidase N (ANPEP), a membrane-associated ectoenzyme, has been identified as a susceptibility gene for type 2 diabetes (T2D) by genome-wide association and transcriptome studies; however, the mechanisms by which this gene contributes to disease pathogenesis remain unclear. The aim of this study was to determine the comprehensive contribution of ANPEP polymorphisms to T2D risk and annotate the underlying mechanisms. A total of 3206 unrelated individuals including 1579 T2D patients and 1627 controls were recruited for the study. Twenty-three common functional single nucleotide polymorphisms (SNP) of ANPEP were genotyped by the MassArray-4 system. Six polymorphisms, rs11073891, rs12898828, rs12148357, rs9920421, rs7111, and rs25653, were found to be associated with type 2 diabetes (Pperm ≤ 0.05). Common haplotype rs9920421G-rs4932143G-rs7111T was strongly associated with increased risk of T2D (Pperm = 5.9 × 10-12), whereas two rare haplotypes such as rs9920421G-rs4932143C-rs7111T (Pperm = 6.5 × 10-40) and rs12442778A-rs12898828A-rs6496608T-rs11073891C (Pperm = 1.0 × 10-7) possessed strong protection against disease. We identified 38 and 109 diplotypes associated with T2D risk in males and females, respectively (FDR ≤ 0.05). ANPEP polymorphisms showed associations with plasma levels of fasting blood glucose, aspartate aminotransferase, total protein and glutathione (P < 0.05), and several haplotypes were strongly associated with the levels of reactive oxygen species and uric acid (P < 0.0001). A deep literature analysis has facilitated the formulation of a hypothesis proposing that increased plasma levels of ANPEP as well as liver enzymes such as aspartate aminotransferase, alanine aminotransferase and gammaglutamyltransferase serve as an adaptive response directed towards the restoration of glutathione deficiency in diabetics by stimulating the production of amino acid precursors for glutathione biosynthesis.

Indocyanine Green as a Marker for Tissue Ischemia in Spinal Tumor Resections and Extended Revisions: A Technical Note

Background/Objectives: The increasing complexity of spinal oncology procedures, particularly in en-bloc tumor resections, creates challenges in tissue perfusion assessment due to extended operative times and extensive surgical dissection. Real-time visualization of tissue perfusion can be achieved with ICG using commercially available handheld imaging systems, offering potential advantages in spinal oncology cases. This study assessed the utility of ICG in analyzing soft-tissue viability during complex spine procedures extending beyond 7.5 h, with a particular focus on oncologic resections. Methods: Three cases that required over 7.5 h of operative time were chosen for ICG utilization. These cases included an en-bloc malignant peripheral nerve sheath tumor resection, an en-bloc resection of a malignant epithelioid neoplasm, and a long-segment fusion revision for pseudoarthrosis. At the conclusion of the critical portion of the procedure, a handheld intraoperative fluorescence camera was utilized to visualize the tissue penetration of intravenous ICG. Results: Prior to injecting ICG, devascularized tissue was not clearly visible. Injecting ICG allowed clear separation of vascularized (fluorescing) and devascularized (non-fluorescing) tissues. One region of non-florescent tissue was later confirmed to be devascularized with MRI and experienced postoperative infection. Conclusions: As the complexity of spinal oncology procedures increases, ICG fluorescence imaging offers a novel method for real-time assessment of tissue perfusion. This technique may be particularly valuable in extensive tumor resections, post-radiation cases, and revision surgeries where tissue viability is at risk. Further investigation in the spinal oncology population could help establish whether early identification of poorly perfused tissues impacts wound healing outcomes.

Preoperative Diffusion Tensor Imaging and Neurite Dispersion and Density Imaging in Isocitrate Dehydrogenase-Mutant Grade 2 and 3 Gliomas: Definition of Tumor-Related Epilepsy and Predictive Factors of Seizure Outcomes Based on a Single-Center Retrospective Case Series

BACKGROUND AND OBJECTIVES

Understanding and managing seizure activity is crucial in neuro-oncology, especially for highly epileptogenic lesions like isocitrate dehydrogenase (IDH)-mutant gliomas. Advanced MRI techniques such as diffusion tensor imaging (DTI) and neurite orientation dispersion and density imaging (NODDI) have been used to describe microstructural changes associated with epilepsy. However, their role in tumor-related epilepsy (TRE) remains unclear. This study aims to investigate the role of DTI and NODDI tumor-derived metrics in defining TRE and predicting postoperative seizure outcomes in patients undergoing surgical resection for IDH-mutant grade 2 and 3 gliomas.

METHODS

This was a single-center retrospective study. Preoperative DTI parameters included fractional anisotropy and mean diffusivity. NODDI parameters included neurite density index (NDI), orientation dispersion index, and free-water fraction (FWF). These metrics were calculated within three volumes of interest (fluid-attenuated inversion recovery [FLAIR] tumor volume, FLAIR peripheral zone, and FLAIR central zone [Fcz]) and correlated with seizure presentation, type, and postoperative control, which was reported according to the Engel classification system.

RESULTS

Fifty-seven patients were included in this study. Increased NODDI-derived FWF-Fcz (P = .031) and NDI-Fcz (P = .046) values correlated with preoperative generalized seizure presentation, although only the FWF-Fcz confirmed its statistical significance (P = .047) in the multivariate analysis. Lower mean diffusivity-FLAIR tumor volume correlated with poor postoperative seizure control both in the univariate (P = .015, P = .026) and multivariate analyses (P = .024, P = .036), while a trend toward significance was found between higher NDI-FLAIR peripheral zone and worse seizure control (P = .055).

CONCLUSION

DTI and NODDI tumor-derived quantitative parameters may define TRE and predict postoperative seizure outcomes in patients with IDH-mutant gliomas. Notably, DTI metrics were found to be independent predictors of postoperative seizure outcomes, while preoperative NODDI parameters correlated with seizure presentation. Further research is warranted to validate our findings and to better understand the underlying mechanisms driving TRE.

Early Detection for Better Patient Outcome: A Case Report on Two Patients Presenting With Fibrodysplasia Ossificans Progressiva at Tikur Anbessa Specialized Hospital, Ethiopia

Fibrodysplasia ossificans progressiva is an ultrarare disorder of endochondral ossification. It is unfamiliar to most care providers in low-income countries such as Ethiopia. Even though the clinical presentation is typical, most cases remain misdiagnosed in our region. Moreover, we hypothesize that many such cases undergo unnecessary or harmful interventions for a painless lump. In Ethiopia, with a population of approximately 120 million, only one case has been reported in the literature so far. We present two cases that were referred to our institution for a biopsy of a mass. This report is aimed at summarizing the typical presentation of the disease and at highlighting the harmful interventions one should avoid in such patients. We also hope that this report serves as an entry point to try to find more patients with this similar condition early in their clinical course. Furthermore, we believe that in order to lessen the overall impact of the illness, it is crucial to provide caregivers with health education about the causes of disease flare-ups.

The impact of COVID-19 pandemic on sleep duration and mental health among middle school students: a 3-year cross-sectional survey

Background

Since the outbreak of COVID-19 in late 2019, and until the Chinese government downgraded the pandemic control measures to Category B management in January 2023, various epidemic prevention measures were implemented across regions based on the local spread of the virus. Correspondingly, educational formats shifted between online and offline teaching according to the pandemic situation. Changes in daily life and teaching methods, along with the high initial mortality rate of COVID-19, have had varying degrees of negative impact on the mental health (MH) of adolescents.

Purposes

This study aimed to explore the impact of the COVID-19 pandemic status on the sleep duration (SD) and MH of adolescents, investigate the relationship between SD and MH in middle school students, and evaluate the protective effect of SD on MH.

Methods

Using a convenient sampling method, 6 junior high schools and 3 senior high schools in Guiyang City, China, were selected. Random samples from two classes per grade in each school were chosen for the survey. The study was conducted annually for three consecutive years using the Mental Health Inventory of Middle-school students (MMHI-60) scale and a self-designed questionnaire. Data were analyzed using IBM SPSS version 26.0 software, employing ANOVA, cross-tabulation, and generalized linear models to examine the relationship between SD and MH scores.

Results

The SD and MH scores of middle school students in 2021, 2022, and 2023 were 436.41 ± 71.21 min/day, 423.69 ± 61.71 min/day, and 445.26 ± 65.04 min/day (F = 41.44, p < 0.001), 1.72 ± 0.63, 1.87 ± 0.73, and 1.79 ± 0.67 (F = 18.31, p < 0.001). The SD compliance rates were 34.1%, 23.9%, and 33.2%, and the MH problem detection rates were 27.9%, 36.4%, and 33.4%, respectively; there is a significant correlation between SD and MH scores among middle school students (P < 0.001); the protective effects of SD compliance on MH were 1.859 times, 2.156 times, and 1.516 times higher than those of SD non-compliance (all p < 0.001).

Conclusion

Meeting the SD standard is a protective factor for adolescent MH. The COVID-19 pandemic and its control measures have had a severe and long-term negative impact on both SD and MH in middle school students, with differences observed between genders and academic levels. The greater the severity of the pandemic and the stricter the control measures, the more significant the negative impact on SD and MH etc.

Optimizing Sedation Strategies in the Cardiac ICU: Induction, Maintenance and Weaning

PURPOSE OF REVIEW

We aim to summarize the available literature guiding tailored sedation practices for specific conditions encountered in the Cardiovascular Intensive Care Unit (CICU).

RECENT FINDINGS

Data specific for the CICU population is lacking. Preclinical data and observational studies guide sedation approaches for specific pathologies that we have used to generate a guideline for sedative choice for various scenarios. We discuss the challenges associated with extubation and highlight the importance of spontaneous breathing trials and role of non invasive ventilation. Understanding the underlying pathology and the effects of sedation and positive pressure ventilation is the base to guide induction and sedation management for patients in the CICU. There is a pressing need for further research to generate high quality clinical data to improve sedation techniques in the CICU.

Saturated fat in an evolutionary context

Evolutionary perspectives have yielded profound insights in health and medical sciences. A fundamental recognition is that modern diet and lifestyle practices are mismatched with the human physiological constitution, shaped over eons in response to environmental selective pressures. This Darwinian angle can help illuminate and resolve issues in nutrition, including the contentious issue of fat consumption. In the present paper, the intake of saturated fat in ancestral and contemporary dietary settings is discussed. It is shown that while saturated fatty acids have been consumed by human ancestors across time and space, they do not feature dominantly in the diets of hunter-gatherers or projected nutritional inputs of genetic accommodation. A higher intake of high-fat dairy and meat products produces a divergent fatty acid profile that can increase the risk of cardiovascular and inflammatory disease and decrease the overall satiating-, antioxidant-, and nutrient capacity of the diet. By prioritizing fiber-rich and micronutrient-dense foods, as well as items with a higher proportion of unsaturated fatty acids, and in particular the long-chain polyunsaturated omega-3 fatty acids, a nutritional profile that is better aligned with that of wild and natural diets is achieved. This would help prevent the burdening diseases of civilization, including heart disease, cancer, and neurodegenerative conditions. Saturated fat is a natural part of a balanced diet; however, caution is warranted in a food environment that differs markedly from the one to which we are adapted.

Description of current status of implementation and management of cardiac arrest in China

Variation in the incidence, survival rate and factors associated with survival after cardiac arrest in China is reported. Some studies have tried to fill the knowledge gap regarding the epidemiology of cardiac arrest in China but were unable to identify reasons for the reported differences. Therefore, the purpose of this study was to describe Chinese management of cardiac arrest, particularly from the perspective of compression, ventilation, monitoring, treatment, and extracorporeal cardiopulmonary resuscitation. An online questionnaire with 56 questions was designed about demographic characteristics, management of cardiac arrest, compression, ventilation, treatment and medicine, as well as advanced life support and resuscitation skill training. A total of 814 copies of questionnaire were received from 23 provinces, 4 autonomous regions and 4 municipalities of China. Results were combined with official information on population density. Throughout China, hospitals resuscitate according to the guideline, however, there are still differences varies in implement with regard to chest compression, ventilation, medicine, monitoring, as well as advanced life support and resuscitation skills training because of economical and developmental level from different regions. All the startup of chest compression is manual, whereas mechanical compression instruments are increasingly involved in sequential resuscitation. Most of clinicians rotate during resuscitation every five cycles other than the guideline recommends every 2 min or when they are tired. About half of the participants don't build the advanced airway rather than use bag valve mask to ventilate, and 75% of the rest use mechanical ventilation whether they succeed to ROSC. Most of rescuers choose endotracheal intubation which is consistent with many other clinical trials results. Various compression feedback devices play increasingly significant roles in assessment of ROSC. More and more regional hospitals have access to ECPR and implement TTM, but still lead to various divergences. Thus, more elaborate clinical trials need to be designed to verify and explore every procedure in the CPR life cycle.

Adjunctive intravascular lithotripsy for heavily calcified carotid stenosis: a dual-center experience and technical case series

BACKGROUND

Heavily calcified carotid stenosis (HCCS) is considered an exclusion for carotid angioplasty and/or stenting (CAS), amenable only to carotid endarterectomy. This study presents preliminary retrospective dual-center experience utilizing the Shockwave S4 intravascular lithotripsy (IVL) system (Shockwave Medical) as an adjunct to CAS for HCCS.

METHODS

Patients with symptomatic or asymptomatic HCCS (de novo stenosis or in-stent restenosis (ISR)) undergoing IVL+CAS were included. Charts were reviewed for demographic, imaging, procedural, and outcome data. The primary endpoint was composite major adverse event (MAE) rate: death, ipsilateral stroke, or myocardial infarction (MI) within 30 days of IVL+CAS. Secondary endpoints included technical and procedural success, residual stenosis, and ISR postprocedure.

RESULTS

Fifteen patients underwent 17 IVL+CAS procedures: de novo HCCS=13, heavily calcified ISR=4; symptomatic disease was addressed in seven cases. Procedures were performed transfemorally under conscious sedation with dual protection; flow reversal through a balloon guide catheter, and distal embolic protection system (EPS) use. Median pre-IVL+CAS stenosis was 73% (IQR 60-80%). Technical success (IVL+CAS+ EPS use) was achieved in all cases. Median post-IVL+CAS residual stenosis was 27% (IQR 12-33%), achieving <50% residual stenosis and procedural success in all. Five patients required dopamine infusion for postprocedural hypotension. No periprocedural ipsilateral strokes occurred. MAE rate was 6.7% (95% CI 0.2% to 32%), including one MI resulting in death. Additionally, one ISR (6.3%; 95% CI 0.2% to 30.2%) identified 160 days after IVL+CAS was retreated with angioplasty.

CONCLUSIONS

IVL+CAS was safe and effective for treating symptomatic and asymptomatic HCCS, achieving high rates of freedom from MAE. IVL has potential to expand the role of CAS in difficult to treat HCCS.

Multimodal treatment combining neoadjuvant therapy, laparoscopic subtotal distal pancreatectomy and adjuvant therapy for pancreatic neck-body cancer: Case series

BACKGROUND

Pancreatic cancer involving the pancreas neck and body often invades the retroperitoneal vessels, making its radical resection challenging. Multimodal treatment strategies, including neoadjuvant therapy, surgery, and postoperative adjuvant therapy, are contributing to a paradigm shift in the treatment of pancreatic cancer. This strategy is also promising in the treatment of pancreatic neck-body cancer.

AIM

To evaluate the feasibility and effectiveness of a multimodal strategy for the treatment of borderline/locally advanced pancreatic neck-body cancer.

METHODS

From January 2019 to December 2021, we reviewed the demographic characteristics, neoadjuvant and adjuvant treatment data, intraoperative and postoperative variables, and follow-up outcomes of patients who underwent multimodal treatment for pancreatic neck-body cancer in a prospectively collected database of our hospital. This investigation was reported in line with the Preferred Reporting of Case Series in Surgery criteria.

RESULTS

A total of 11 patients with pancreatic neck-body cancer were included in this study, of whom 6 patients were borderline resectable and 5 were locally advanced. Through multidisciplinary team discussion, all patients received neoadjuvant therapy, of whom 8 (73%) patients achieved a partial response and 3 patients maintained stable disease. After multidisciplinary team reassessment, all patients underwent laparoscopic subtotal distal pancreatectomy and portal vein reconstruction and achieved R0 resection. Postoperatively, two patients (18%) developed ascites, and two patients (18%) developed pancreatic fistulae. The median length of stay of the patients was 11 days (range: 10-15 days). All patients received postoperative adjuvant therapy. During the follow-up, three patients experienced tumor recurrence, with a median disease-free survival time of 13.3 months and a median overall survival time of 20.5 months.

CONCLUSION

A multimodal treatment strategy combining neoadjuvant therapy, laparoscopic subtotal distal pancreatectomy, and adjuvant therapy is safe and feasible in patients with pancreatic neck-body cancer.

Major Bleeding in the Emergency Department: A Practical Guide for Optimal Management

Major bleeding is a life-threatening condition with high morbidity and mortality. Trauma, gastrointestinal bleeding, haemoptysis, intracranial haemorrhage or other causes of bleeding represent major concerns in the Emergency Department (ED), especially when complicated by haemodynamic instability. Severity and source of bleeding, comorbidities, and prior use of anticoagulants are pivotal factors affecting both the clinical status and the patients' differential response to haemorrhage. Thus, risk stratification is fundamental in the initial assessment of patients with bleeding. Aggressive resuscitation is the principal step for achieving haemodynamic stabilization of the patient, which will further allow appropriate interventions to be made for the definite control of bleeding. Overall management of major bleeding in the ED should follow a holistic individualized approach which includes haemodynamic stabilization, repletion of volume and blood loss, and reversal of coagulopathy and identification of the source of bleeding. The aim of the present practical guide is to provide an update on recent epidemiological data about the most common etiologies of bleeding and summarize the latest evidence regarding the bundles of care for the management of patients with major bleeding of traumatic or non-traumatic etiology in the ED.

Postintubation hypotension following rapid sequence intubation with full- vs reduced-dose induction agent

PURPOSE

Rapid sequence intubation (RSI) is a common emergency department (ED) procedure with an associated complication of postintubation hypotension (PIH). It has not been clearly established whether the selection and dose of induction agent affect risk of PIH. The objective of this study was to determine the incidence of PIH in patients receiving full-dose compared to reduced-dose induction agent for RSI in the ED.

METHODS

This was a health system-wide, retrospective cohort study comparing incidence of PIH based on the induction medication and dose given for RSI in the ED. Patients were included if they underwent RSI from July 1, 2018, through December 31, 2020, were 18 years of age or older, and received etomidate or ketamine. A reduced dose was defined as a ketamine dose of 1.25 mg/kg or less and an etomidate dose of 0.2 mg/kg or less.

RESULTS

A total of 909 patients were included in the final analysis, with most receiving etomidate (n = 764; 84%) and a smaller number receiving ketamine (n = 145; 16%). Patients who received ketamine had a higher mean pre-intubation shock index (full dose, 1.08; reduced dose, 1.04) than those who received etomidate (full dose, 0.89; reduced dose, 0.92) (P ≤ 0.001). Reduced doses of induction agent were observed for 107 patients receiving etomidate (14.0%) and 60 patients receiving ketamine (41.4%). Patients who received full-dose ketamine for induction had the highest rate of PIH (n = 31; 36.5%), and the difference was statistically significant compared to patients receiving reduced-dose ketamine (16.7%; P = 0.021) and full-dose etomidate (22.8%; P = 0.010).

CONCLUSION

We observed that full-dose ketamine was associated with the highest rate of PIH; however, this group had the poorest baseline hemodynamics, confounding interpretation. Our results do not support broad use of a reduced-dose induction agent.

Emergency Department Crowding as Contributing Factor Related to Patient-Initiated Violence Against Nurses-A Literature Review

AIM

To synthesise how ED crowding contributes to patient-initiated violence against emergency nurses.

DESIGN

Framework synthesis.

DATA SOURCES

A systematic literature search was conducted in the PubMed, PsycINFO, CINAHL and Scopus databases, covering articles up to 21 March 2024.

REVIEW METHODS

A total of 25 articles were reviewed, evaluating study quality using the Crowe Critical Appraisal Tool and employing a framework synthesis approach to chart and synthesise data.

RESULTS

The review identifies key factors linking emergency department crowding to patient-initiated violence, focusing on crowding conditions, vulnerable populations and adverse outcomes. It emphasises the importance of multidimensional assessments, including input, throughput, output stages and staffing characteristics. Special attention is needed for patients with severe symptoms who are triaged into lower priority categories, as their perceptions of injustice and dissatisfaction may increase the risk of aggressive behaviour. However, limited information is available regarding the perspectives of patients' family members.

CONCLUSION

Accurate assessments of emergency department crowding and a thorough understanding of cognitive and emotional changes in high-risk patients are essential to develop strategies to manage patient-initiated violence effectively.

IMPACT

This review improves emergency nurses' understanding of the dynamics of patient-initiated violence in crowded emergency departments, equipping them with knowledge to better anticipate and respond to such incidents. It also offers insights that are crucial for enhancing nursing practices and ensuring workplace safety, thereby supporting the development of future emergency safety strategies.

NO PATIENT OR PUBLIC CONTRIBUTION

As this is a systematic review and framework synthesis, there was no direct patient or public involvement.

The diagnosis and treatment of 56 cases of breast hamartoma: a single-center analysis and a review of the literature

Introduction

To analyze and summarize the clinical and pathological features of breast hamartoma to enhance clinicians' awareness of this rare and benign lesion of the breast.

Methods

We retrospectively described the clinical data, imaging results, and pathological findings of 56 patients with breast hamartoma who underwent surgical treatment at the First Hospital of Jilin University between January 2005 and December 2020, and summarized the features. Additionally, a literature review was conducted using the PubMed database for clinical reports on breast hamartoma and analyzed them.

Results

This study included 56 female patients. Preoperative ultrasound revealed round or elliptical heterogeneous echoes with clear boundaries: hypoechoic in 35 cases (63%), iso-echoic in 8 cases (14%), hyperechoic in 1 case (2%), mixed echo in 9 cases (16%), slightly strong echo in 1 case (2%), and uneven echo of fat in 2 cases (4%). Mammography was performed in 33 cases, revealing clear and dense shadows in 20 cases (61%) and dense shadows on the outer edges in 16 cases (48%). The excised masses were solid, with light yellow and gray cut surfaces. Pathological analysis identified ducts and fibrous tissue, with intra-tumoral fat content ranging from 10 to 90%.

Conclusion

Breast hamartoma is prevalent among perimenopausal women and is characterized by ultrasound and radiography; surgical intervention remains the primary treatment with a good prognosis.

Clinical application of 3D slicer reconstruction and 3D printing localization combined with neuroendoscopy technology in VPS surgery

To explore techniques, advantages and disadvantages of 3D Slicer reconstruction and 3D printing localization technology combined with transcranial neuroendoscopy in ventriculoperitoneal shunt surgery. Retrospective analysis of clinical data of patients with hydrocephalus treated by ventriculoperitoneal shunt surgery using 3D Slicer reconstruction and 3D printing positioning technology combined with transcranial neuroendoscopy in our hospital from October 2021 to March 2023. A total of 33 patients with complete data were collected, including 19 males and 14 females, aged 10-81 years. Pre operative use of 3D Slicer reconstruction and 3D printing localization, and intraoperative use of neuroendoscopy assisted catheterization to complete ventriculoperitoneal shunt surgery. The drainage tube position was confirmed by brain CT and 3D Slicer reconstruction after operation, of which 30 cases were located in the frontal horn or center of the ipsilateral lateral ventricle, and 3 cases were located in the frontal horn or center of the contralateral lateral ventricle. All patients were successfully catheterized and well positioned. According to the unique ventricular system characteristics of each hydrocephalus patient, the 3D Slicer reconstruction technology was used to determine the individualized puncture point and direction, measure the puncture depth, accurately locate the puncture through the 3D printing guide plate, and accurately send the tip of the ventricular catheter into the frontal or central part of the lateral ventricle with the assistance of neuroendoscopic visualization, which improved the success rate of the operation and reduced the risk of tube blockage. At the same time, our team has newly developed a puncture point ("Cai's point"), which has a puncture path in a non-vascular area and can reduce the risk of puncture bleeding. However, further prospective clinical research is needed to determine its routine location.

A nested case-control study evaluating the relationship between adverse childhood experiences and immune-mediated inflammatory disease in the Canadian Longitudinal Study on Aging

OBJECTIVE

Adverse childhood experiences (ACE) have inconsistently been implicated as risk factors for immune-mediated inflammatory diseases (IMID). We evaluated whether the association of ACE with disease differs between IMID and other chronic diseases.

DESIGN

Nested retrospective case-control study.

SETTING

We used data from the Canadian Longitudinal Study on Aging (CLSA), which recruited participants aged 45-85 years between 2010 and 2015.

PARTICIPANTS

We included 12 627 CLSA participants: 2 102 who reported diagnoses of IMID (258 multiple sclerosis (MS), 1 692 rheumatoid arthritis (RA) and 160 inflammatory bowel disease (IBD)), 5 519 with diabetes, 170 with epilepsy, 3 889 with asthma and 1 125 with no chronic diseases. ACE, including childhood maltreatment (physical, emotional and sexual abuse, neglect) and household dysfunction, were queried using questions from the Childhood Experiences of Violence Questionnaire-Short Form and the National Longitudinal Study of Adolescent to Adult Health Wave III questionnaire.

PRIMARY AND SECONDARY OUTCOME MEASURES

We first evaluated whether the association of maltreatment differed across diagnoses (IMID, diabetes, asthma, epilepsy, no chronic diseases). Second, we evaluated whether the association between maltreatment differed across IMID. We repeated our analyses for different types of ACE.

RESULTS

Maltreatment or household dysfunction was experienced by 64% of participants and 30% experienced both. On multivariable analysis, history of any maltreatment, sexual abuse, any household dysfunction and having ≥3 types of ACE were all associated with increased risk of IMID compared with no chronic disease. The association between ACE and IMID did not differ across MS, RA and IBD.

CONCLUSION

ACE are common among Canadians with and without chronic diseases. History of any maltreatment or household dysfunction is associated with increased risk of chronic disease.

Hidden Partner of Immunity: Microbiome as an Innovative Companion in Immunotherapy

Recent studies have highlighted that the microbiome is the essential factor that can modulate the clinical activity of immunotherapy. However, the role of the microbiome varies significantly across different immunotherapies, suggesting that it is critical to understand the precise function of the microbiome in each type of immunotherapy. While many previous studies primarily focus on summarizing the role of the microbiome in immune checkpoint inhibitors, we seek to explore a novel aspect of the microbiome in other immunotherapies such as mesenchymal stem cell therapy, chimeric antigen receptor T cell therapy, and antibodies-based therapy (e.g., adalimumab, infliximab, bevacizumab, denosumab, etc.) which are rarely summarized in previous reviews. Moreover, we highlight innovative strategies for utilizing microbiome and microbial metabolites to enhance the clinical response of immunotherapy. Collectively, we believe that our manuscript will provide novel insights and innovative approaches to the researchers, which could drive the development of the next generation of personalized therapeutic interventions using microbiomes.

Bilateral synchronous UBE for unilateral laminotomy and bilateral decompression as a potentially effective minimally Invasive approach for two-level lumbar spinal stenosis

Currently, Unilateral biportal endoscopy is widely used in the surgical treatment of lumbar spinal stenosis. To investigate the feasibility of bilateral synchronous UBE to unilateral laminotomy and bilateral decompression(BS-UBE-ULBD) for treating two-level lumbar spinal stenosis (LSS). Sixty-four patients with two-level lumbar spinal stenosis (LSS) treated with BS-UBE-ULBD from October 2022 to January 2024 were retrospectively analyzed. All patients were treated with BS-UBE-ULBD. All 64 patients successfully underwent surgery, and the duration of surgery was 95-180 min, with an average of 119.92 ± 14.79 min. The average number of fluoroscopy was 3.02 ± 0.92. The average blood loss during the surgery was 73. 44 ± 36.70 ml. Postoperative lumbar CT showed that the spinal canal and bilateral nerve roots were fully decompressed. There were no postoperative complications, such as infection, severe nerve root injury, and lumbar instability. Complete follow-up data were obtained for all 64 cases. The VAS score of low back and leg pain and the ODI of lumbar function significantly (P < 0.05) improved at each follow-up time point. MacNab evaluation at 6 months after the surgery showed that the results were excellent in 48 cases, good in 14 cases, and fair in 2 cases. The excellent and good rate was 96. 88% (62/64). So BS-UBE-ULBD is a minimally invasive, highly effective, and safe procedure for 2-level LSS.Degenerative lumbar spinal stenosis (LSS) refers to clinical symptoms caused by the compression of the cauda equina, nerve root, and vascular complex. LSS can occur due to the abnormal shape and volume of the bony or fibrous structure after degenerative changes and the stenosis of the inner diameter of one or more lumens at a single level or multiple levels. It is a common cause of lumbago or lumbago and leg pain, which is common among middle-aged and elderly people1. LSS has become the most common cause of lumbar surgery among patients over 60 years of age2. However, traditional surgery necessitates extensive stripping of paraspinal muscles, which can easily lead to the ischemic injury of paraspinal muscles and atrophy after denervation. Therefore, traditional surgery may result in intractable back pain, stiffness, and discomfort after surgery3,4. Furthermore, as the posterior bone and soft tissue structures need to be extensively resected during the surgery, epidural scar and nerve compression are highly likely after the surgery. The high risk of general anesthesia cannot be ignored among elderly and weak patients2,5.Recently, with the rapid development of minimally invasive spine surgery, endoscopic surgery has been applied in the treatment of LSS6. Unilateral biportal endoscopy (UBE ) is more popular in treating LSS and is a more flexible operation, with small trauma, quick recovery, and a gentle learning curve. In addition, many studies have proven the good clinical efficacy of unilateral biportal endoscopy7. Multilevel spinal stenosis can be done simultaneously. Previously, the same operator decompressed multiple segments in turn8,9, but the operation lasted longer, and the corresponding problems, such as bleeding, high risk of anesthesia, and fluoroscopy frequency, increased.From October 2022 to June 2024, our hospital pioneered the use of Bilateral Synchronous UBE-unilateral Laminotomy and Bilateral Decompression (BS-UBE-ULBD) for two-level degenerative LSS. Sixty-four patients with two-segment LSS were treated with BS-UBE-ULBD, and the results were satisfactory.

Severe Diabetic Ketoacidosis in Children with Type 1 Diabetes: Ongoing Challenges in Care

Diabetic ketoacidosis is the most common acute complication in children and adolescents with type 1 diabetes, and contributes significantly to morbidity, mortality, and healthcare burden. This review aims to explore the multifaceted aspects of severe diabetic ketoacidosis in pediatric age, including its epidemiology, pathogenesis, risk factors, complications and emphasizing advances in prevention strategies. Incidence rates vary due to influences from geographic, socioeconomic, cultural and demographic factors. Pathogenesis is linked to insulin deficiency and an excess of counter-regulatory hormones, which disrupt glucose, protein, and lipid metabolism, causing hyperglycemia, ketosis, acidosis, dehydration, and electrolyte imbalances. According to the International Society for Pediatric and Adolescent Diabetes guidelines, severe diabetic ketoacidosis is characterized by a pH < 7.1 or bicarbonate < 5 mmol/L. This condition can lead to a wide range of life-threatening complications, including cerebral edema that represents the leading cause of death. Several prevention strategies, including awareness campaigns, early diagnosis of diabetes, regular monitoring and management, effective insulin therapy, education, access to healthcare and technological assistance, may contribute to reduce the risk of severe diabetic ketoacidosis episodes in children and adolescents.

Unusual-site thrombosis in patients with hazardous alcohol use: a narrative review

AIMS AND METHODS

Hazardous alcohol use poses an increasing public health issue worldwide and it manifests as excessive consumption (acute or chronic), which may lead to addiction. The risk of alcohol-related pathologies correlates with the patterns of intake and increases with the amount of alcohol consumed. While the effects of alcohol consumption on ischemic stroke and ischemic heart disease are well documented, the impact on venous thromboembolism is less clear. Conflicting studies have reported that alcohol may be a risk factor for, or have a protective role against venous thromboembolism. Our narrative review aimed to assess the risk of unusual-site venous thrombosis in individuals with hazardous alcohol use, as it may stem from alcohol-related organ damage (e.g. liver cirrhosis, pancreatitis) as well as provide some suggestions for physicians.

RESULTS

There appears to be a correlation between hazardous alcohol use and unusual-site thrombosis, though the underlying mechanisms are largely still unknown.

CONCLUSION

In subjects with hazardous alcohol use complicated by alcohol-related organ damage, physicians should be vigilant for potential thrombotic symptoms, and be prepared to diagnose and promptly initiate appropriate anticoagulation therapy.

Advancements in Obstructive Sleep Apnea Diagnosis and Screening Through Artificial Intelligence: A Systematic Review

BACKGROUND

Obstructive sleep apnea (OSA) is a prevalent yet underdiagnosed condition associated with a major healthcare burden. Current diagnostic tools, such as full-night polysomnography (PSG), pose a limited accessibility to diagnosis due to their elevated costs. Recent advances in Artificial Intelligence (AI), including Machine Learning (ML) and deep learning (DL) algorithms, offer novel potential tools for an accurate OSA screening and diagnosis. This systematic review evaluates articles employing AI-powered models for OSA screening and diagnosis in the last decade.

METHODS

A comprehensive electronic search was performed on PubMed/MEDLINE, Google Scholar, and SCOPUS databases. The included studies were original articles written in English, reporting the use of ML algorithms to diagnose and predict OSA in suspected patients. The last search was performed in June 2024. This systematic review is registered in PROSPERO (Registration ID: CRD42024563059).

RESULTS

Sixty-five articles, involving data from 109,046 patients, met the inclusion criteria. Due to the heterogeneity of the algorithms, outcomes were analyzed into six sections (anthropometric indexes, imaging, electrocardiographic signals, respiratory signals, and oximetry and miscellaneous signals). AI algorithms demonstrated significant improvements in OSA detection, with accuracy, sensitivity, and specificity often exceeding traditional tools. In particular, anthropometric indexes were most widely used, especially in logistic regression-powered algorithms.

CONCLUSIONS

The application of AI algorithms to OSA diagnosis and screening has great potential to improve patient outcomes, increase early detection, and lessen the load on healthcare systems. However, rigorous validation and standardization efforts must be made to standardize datasets.

Endoscope-assisted transcranial surgery for complex pituitary adenoma: a retrospective case series study with propensity score matching

Surgical treatment of complex pituitary adenomas (PAs) presents a significant challenge. Here in, we compared the surgical outcomes between patients undergoing endoscope-assisted transcranial surgery and microscopic regimens to assess the safety and efficacy of endoscope-assisted transcranial surgery in treating complex PA. This retrospective case-control study was conducted at the First Affiliated Hospital of Soochow University, China. Clinical data were retrospectively analysed between January 2018 and January 2023. The primary outcome was gross total resection (GTR), and the secondary outcomes included recurrence, residual tumour volume, and patient status. Propensity score matching was used to account for group differences. We enrolled 73 patients, of whom 29 underwent endoscope-assisted transcranial surgery, and 44 underwent transcranial microscopic surgery. Compared with the microscopic regimen group, the endoscope-assistedgroup had higher postoperative Karnofsky Performance Scale (KPS) scores (p = 0.031), higher GTR rates (GTR: 79.3% vs. 50%, p = 0.023), and smaller tumour residual volume (residual tumour volume: 0.15 vs. 0.94, p = 0.029). After propensity score matching, the endoscope-assistedregimen was associated with increased odds of GTR rate, compared with the microscopic regimen (odds ratio: 3.65, 95% confidence interval: 1.06-12.54, p = 0.040). KPS score improvement at discharge was more evident in the endoscope-assisted group than in non-combined group. The endoscope-assisted transcranial surgery regimen offered increased GTR rates, higher postoperative KPS score, and less residual tumour than the non-combined regimen did, highlighting endoscope-assistedtherapy as the more favourable treatment approach for patients with complex PA.

Duodenum and ascending colonal perforation due to biliary stent migration

Introduction

Bowel perforation due to migrated biliary stent is a rare complication. Here, we report a case of duodenal and ascending colonal perforation due to biliary stent migration.

Case presentation

A 35-year-old man is complaining of right upper abdominal pain presented to the gastroenterology department. Two months ago, he was diagnosed with common bile duct stone with acute cholangitis, a straight plastic biliary stent was placed in his common bile duct. Abdominal computed tomography, upper endoscopy and colonoscopy confirmed that the stent penetrated the duodenum into the ascending colon. The stent was extracted by upper endoscopy, and the defects of the duodenum and ascending colon were closed by clips endoscopically.

Discussion

Bowel perforation due to biliary stent migration is a rare but severe complication. Risk factors for dislocation of stents include stent insertion for more than one month, wide stent, benigh diseases and longer stent. Endoscopy is a minimally invasive and safe meneuver to retrieve stent.

Conclusion

Patients inserted with long, wide and straight biliary stent for more than one month are at high risk of stent dislocation. Endoscopy is a minimally invasive and safe meneuver to retrieve stent, and should be considered as the first-line treatment.

Novel triangle papilla access approach for interdental bone defect regeneration: A case study

BACKGROUND

Successful periodontal regeneration depends on primary wound closure and interdental papilla preservation. In this case study, we introduce a novel triangle papilla access approach (T-PAA) performed under a surgical microscope for treating interdental bone defects. In this novel approach, buccal incisions were used to access root surfaces and bone defects, avoiding interdental papilla incisions and preventing papillary collapse and necrosis.

METHODS

Nine patients with a mean age of 56 years were enrolled in this study. Incisions were made to create a triangular flap, which was reflected using a micro-periosteal elevator to expose the bone defect and granulation tissue. Subsequently, the granulation tissue was removed from the bone defect using a microsurgical blade, followed by root debridement using ultrasonic and micro-hand scalers and root conditioning. Thereafter, a mixture of fibroblast growth factor-2 and carbonated apatite granules was applied to the bone defect. The triangular flap was repositioned to ensure that the apex was not lifted by the graft material, and from the flap apex, 7-0 nylon sutures were used, followed by the addition of mesial and distal sutures. Adjacent teeth were splinted using wire and resin cement.

RESULTS

Postoperatively, clinical and radiographic evaluations at 6 months and 1 year showed significant improvements in periodontal parameters and bone filling. All patients achieved primary wound closure with no postoperative complications.

CONCLUSIONS

T-PAA is a promising approach for periodontal regeneration, providing adequate surgical access under a surgical microscope while preserving the papilla and potentially improving clinical outcomes in patients with interdental bone defects.

KEY POINTS

Triangle papilla access approach (T-PAA) provides adequate surgical access, preserves the interdental papillae, and improves clinical outcomes in cases of interdental bone defects. Triangular incisions made in areas with abundant blood flow and thicker gingiva at the base of the papilla are less likely to impair blood supply to the interdental papillae. T-PAA facilitates effective debridement, precise placement of regenerative materials, and accurate flap repositioning regardless of the defect morphology in localized interdental areas.

PLAIN LANGUAGE SUMMARY

Successful periodontal treatment often requires surgical procedures for bone regeneration in patients with bone defects. However, traditional surgical approaches may damage the interdental papillae, leading to esthetic concerns and compromised healing. In this study, we introduced a new surgical technique called the triangle papilla access approach, which uses a specially designed triangular incision to access and treat bone defects under a surgical microscope while preserving the interdental papillae. Our results from nine patients demonstrated that this technique effectively maintained tissue health and promoted bone regeneration. Therefore, it could become a more efficient approach for treating interdental bone defects.

Sleep Quality Among Patients and Healthcare Providers in the Primary Healthcare Setting

Background/Objectives: As adults spend about 30% of each day asleep, having a sleep disorder can negatively affect their functioning. The study objective was to determine the factors that influence sleep quality among patients and healthcare providers in the primary healthcare setting. Methods: This study included respondents of both sexes aged 18-90 years, comprising outpatients and the healthcare providers working in the General Medicine Service at the "Liman" Department of the "Novi Sad" Health Center in Novi Sad, Republic of Serbia. Demographic data along with factors related to lifestyle and sleep habits were collected using a demographic questionnaire specifically designed for this research. The standardized Pittsburgh Sleep Quality Questionnaire, Serbian version (PSQI), was used to assess sleep quality. Results: The study sample comprised 92 respondents (42 healthcare providers and 50 patients), 73.9% of whom were female, with an average age of 50.0 years. Although 50% of healthcare providers reported sleeping only 3-6 h the previous night, according to the PSQI results, patients had lower overall sleep quality (54.0% vs. 33.3%; p = 0.046) and achieved lower scores in the DISTB (sleep disturbances, p = 0.001), SLPQUAL (subjective sleep quality, p = 0.013) and MEDS (use of sleeping medication, p = 0.003) PSQI domains. Conclusions: Sleep quality is impaired in more than half of patients and more than a third of healthcare providers. By detecting and acting on the factors in the home and work environment that affect quality of sleep, and by changing lifestyle habits, sleep quality in adults can be improved.

Novel reduced heteropolyacid nanoparticles for effective treatment of drug-induced liver injury by manipulating reactive oxygen and nitrogen species and inflammatory signals

With the rapid advancements in biomedicine, the use of clinical drugs has surged sharply. However, potential hepatotoxicity limits drug exploitation and widespread usage, posing serious threats to patient health. Hepatotoxic drugs disrupt liver enzyme levels and cause refractory pathological damage, creating a challenge in the application of diverse first-line drugs. The activation and deterioration of reactive oxygen and nitrogen species (RONS) and inflammatory signals are key pathological mechanisms of drug-induced liver injury (DILI). Herein, a novel reduced heteropolyacid nanoparticle (RNP) has been developed, possessing high RONS-scavenging ability, strong anti-inflammatory activity, and excellent biosafety. These features enable it to swiftly restore the redox and immune balance of the liver. Intravenous administration of RNP effectively scavenged RONS storm, reversing liver oxidative stress and restoring normal mitochondrial membrane potential and function. Furthermore, by inhibiting c-Jun-N-terminal kinase phosphorylation, RNP facilitated the restoration of nuclear factor erythroid 2-related factor 2-mediated endogenous antioxidant signaling, ultimately rescuing the liver function and tissue morphology in acetaminophen-induced DILI mice. Crucially, the high biocompatible RNP exhibited superior efficacy in the DILI mouse model compared to the clinical antioxidant N-acetylcysteine. This targeted therapeutic approach, tailored to address the onset and progression of DILI, offers valuable new insights into controlling the condition and restoring liver structure and function.

Patients' attitudes toward artificial intelligence (AI) in cancer care: A scoping review protocol

BACKGROUND

Artificial intelligence broadly refers to computer systems that simulate intelligent behaviour with minimal human intervention. Emphasizing patient-centered care, research has explored patients' perspectives on artificial intelligence in medical care, indicating general acceptance of the technology but also concerns about supervision. However, these views have not been systematically examined from the perspective of patients with cancer, whose opinions may differ given the distinct psychosocial toll of the disease.

OBJECTIVES

This protocol describes a scoping review aimed at summarizing the existing literature on the attitudes of patients with cancer toward the use of artificial intelligence in their medical care. The primary goal is to identify knowledge gaps and highlight opportunities for future research.

METHODS

This scoping review protocol will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA-ScR). The electronic databases MEDLINE (OVID), EMBASE, PsycINFO, and CINAHL will be searched for peer-reviewed primary research articles published in academic journals. We will have two independent reviewers screen the articles retrieved from the literature search and select relevant studies based on our inclusion criteria, with a third reviewer resolving any disagreements. We will then compile the data from the included articles into a narrative summary and discuss the implications for clinical practice and future research.

DISCUSSION

To our knowledge, this will be the first scoping review to map the existing literature on the attitudes of patients with cancer regarding artificial intelligence in their medical care.

CPAP Therapy for OSA and Its Impact on Various Cardiovascular Disorders

Obstructive sleep apnea (OSA), a highly prevalent and serious disorder with significant complications, causes considerable daytime and nighttime symptoms as well as long-term consequences and is yet an underdiagnosed and inadequately treated condition. Patients with OSA undergo frequent awakenings during the sleep cycle and find it impossible to get restorative sleep. Individuals are extremely fatigued, sleepy, and irritable throughout the day. Reduced exercise performance and physical activity contribute to a decrease in energy metabolism and weight gain. Those in this population may experience decreased motivation, which could result in depressive symptoms. The abrupt drops in oxygen levels during the sleep cycle result in profound spikes in blood pressure and strain the cardiovascular system. Given its close tie with major cardiovascular risk factors, OSA is linked with various cardiovascular diseases, including coronary artery disease, cardiac arrhythmia, poorly controlled blood pressure, heart failure, and stroke. Continuous positive airway pressure is an effective and tried-trusted approach for symptom relief and improving quality of life. Despite its benefits, patients struggle with compliance and often go untreated because of physical discomfort and perceived inconvenience of using these machines. One other explanation for this could be the lack of awareness, comprehensive data, and extensive research on its effects on long-term cardiovascular and metabolic complications caused by OSA. The current standard treatment for OSA, using adequate positive airway pressure, greatly reduces cardiovascular morbidity. Nevertheless, patients with cardiovascular disorders continue to be highly susceptible to OSA and its detrimental clinical consequences, even with effective therapy available. In summary, continuous positive airway pressure has an indirect potential to affect cardiovascular outcomes, but further studies should be done to address issues with patient compliance and adherence.

The pathogenesis and management of heatstroke and heatstroke-induced lung injury

In the past two decades, record-breaking heat waves have caused an increasing number of heat-related deaths, including heatstroke, globally. Heatstroke is a life-threatening systemic condition characterized by a core body temperature >40°C and the subsequent development of multiple organ dysfunction syndrome. Lung injury is a well-documented complication of heatstroke and is usually the secondary cause of patient death. In recent years, extensive research has been conducted to investigate the underlying causes of heatstroke and heatstroke-induced lung injury. This review aims to consolidate and present the current understanding of the key pathogenic mechanisms involved in heatstroke and heatstroke-induced lung injury. In addition, systemic factors such as heat cytotoxicity, systemic inflammation, oxidative stress, endothelial cell dysfunction, and other factors are involved in the pathogenesis of lung injury in heatstroke. Furthermore, we also established current management strategies for heatstroke and heatstroke-induced lung injury. However, further investigation is required to fully understand the detailed pathogenesis of heatstroke so that potentially effective means of treating and preventing heatstroke and heatstroke-induced lung injury can be developed and studied.