Delirium superimposed on dementia: clinical implications, challenges, and management strategies

Background: Mucormycosis is a rare but aggressive opportunistic fungal infection that predominantly affects immunocompromised individuals, particularly patients with diabetes mellitus. Poor glycemic control creates a favorable environment for fungal proliferation, leading to rapid disease progression and high mortality. The rising incidence of mucormycosis among diabetic patients highlights the need for a detailed evaluation of its clinical presentation, management strategies, and outcomes. Objective: To assess the clinical features, diagnostic approaches, management strategies, and treatment outcomes of mucormycosis among diabetic patients presenting to the Department of ENT, Hayatabad Medical Complex, Peshawar. Methodology: A retrospective observational cohort study was conducted involving 250 diabetic patients diagnosed with mucormycosis between June 2023 and June 2024. Data were collected from medical records, including demographic characteristics, clinical presentation, diagnostic modalities, treatment strategies, and outcomes. A prospective follow-up of six months was performed to evaluate recovery and mortality. Statistical analysis was carried out using SPSS version 25.0, with significance set at p < 0.05. Results: The rhino-orbital-cerebral form was the most common clinical presentation, affecting 72% of patients. Pulmonary, cutaneous, and disseminated forms were less frequent. Complete recovery was observed in 40%, partial recovery in 36%, while 24% of patients died. Uncontrolled diabetes showed a statistically significant association with increased disease severity and mortality. Conclusion: Mucormycosis represents a serious and often fatal complication among diabetic patients, particularly those with poor glycemic control. Early diagnosis, aggressive antifungal therapy, timely surgical intervention, and stringent diabetes management are critical to improving patient outcomes. These findings provide valuable insight for optimizing clinical management strategies in resource-limited settings. Keywords: Diabetes Mellitus, Glycemic Control, Mucormycosis, Rhino-Orbital-Cerebral, Treatment Outcomes.

Hearing loss is often caused by genetic and environmental factors, with inherited mutations responsible for 50–60% of cases. The GJB2 gene, encoding connexin 26, is a major contributor to nonsyndromic sensorineural hearing loss (NSHL) due to its role in cellular communication critical for auditory function. In Taiwan, common deafness-associated genes include GJB2, SLC26A4, OTOF, MYO15A, and MTRNR1, which were similar to those found in other populations. The most common pathogenic genes is GJB2 mutations and the hearing level in children with GJB2 p.V37I/p.V37I or p.V37I/c.235delC was estimated to deteriorate at approximately 1 decibel hearing level (dB HL)/year. We found another common mutation in Taiwan Biobank, GJB2 p.I203T, which were identified in our data and individuals carrying this mutation experienced more severe hearing loss, suggesting a synergistic effect of these mutations on auditory impairment. We suggest GJB2 whole genetic screening is recommended for clinical management and prevention strategies in Taiwan. This study used data from the Taiwan Biobank to analyze allele frequencies of GJB2 gene variants. Predictive software (PolyPhen-2 version 2.2, SIFT for missense variants 6.2.1, MutationTaster Ensembl 112 and Alphamissense CC BY-NC-SA 4.0) assessed the pathogenicity of specific mutations. Additionally, 82 unrelated NSHL patients were screened for mutations in these genes using PCR and DNA sequencing. The study explored the correlation between genetic mutations and the severity of hearing loss in patients. Several common GJB2 mutation sites were identified from the Taiwan Biobank, including GJB2 p.V37I (7.7%), GJB2 p.I203T (6%), GJB2 p.V27I (31%), and GJB2 p.E114G (22%). Bioinformatics analysis classified GJB2 p.I203T as pathogenic, while GJB2 p.V27I and GJB2 p.E114G were considered polymorphisms. Patients with GJB2 p.I203T mutation experienced more severe hearing loss, emphasizing the potential interaction between the gene in auditory impairment. The mutation patterns of GJB2 in the Taiwanese population are similar to other East Asian regions. Although GJB2 mutations represent the predominant genetic cause of hereditary hearing loss, the corresponding mutant proteins exhibit detectable aggregation, particularly at cell–cell junctions, suggesting at least partial trafficking to the plasma membrane. Genetic screening for these mutations—especially GJB2 p.I203T (6%), GJB2 p.V27I (31%), and GJB2 p.E114G (22%)—is essential for the effective diagnosis and management of non-syndromic hearing loss (NSHL) in Taiwan. We found GJB2 p.I203T which were identified in our data and individuals carrying this mutation experienced more severe hearing loss, suggesting a synergistic effect of these mutations on auditory impairment. We suggest whole GJB2 gene sequencing in genetic screening is recommended for clinical management and prevention strategies in Taiwan. These findings have significant clinical and public health implications for the development of preventive and therapeutic strategies.

Australian and New Zealand Journal of Obstetrics and GynaecologyVolume 36, Issue 4 p. 424-429 Clinical Implications and Management Strategies When Depression Occurs During Pregnancy John H. Coverdale MB Ch B, Corresponding Author John H. Coverdale MB Ch B Senior lecturer in the Department of Psychiatry and Behavioural Science at The University of Auckland, New Zealand5 Department of Psychiatry and Behavioural Science. Faculty of Medicine and Health Science, The University of Auckland, Private Bag 92019, Auckland, New Zealand.Search for more papers by this authorLaurence B. McCullough PhD, Laurence B. McCullough PhD Professor of medicine, community medicine, and medical ethics at Baylor College of Medicine, Houston, Texas and adjunct professor of ethics in Obstetrics and Gynecology at Cornell University Medical College, New YorkSearch for more papers by this authorFrank A. Chervenak MD, Frank A. Chervenak MD Professor in the Department of Obstetrics and Gynecology at Cornell University Medical College, New YorkSearch for more papers by this authorTimothy Bayer MD, Timothy Bayer MD Assistant professor in the Department of Psychiatry and Behavioural Sciences at Baylor College of Medicine, Houston, TexasSearch for more papers by this author John H. Coverdale MB Ch B, Corresponding Author John H. Coverdale MB Ch B Senior lecturer in the Department of Psychiatry and Behavioural Science at The University of Auckland, New Zealand5 Department of Psychiatry and Behavioural Science. Faculty of Medicine and Health Science, The University of Auckland, Private Bag 92019, Auckland, New Zealand.Search for more papers by this authorLaurence B. McCullough PhD, Laurence B. McCullough PhD Professor of medicine, community medicine, and medical ethics at Baylor College of Medicine, Houston, Texas and adjunct professor of ethics in Obstetrics and Gynecology at Cornell University Medical College, New YorkSearch for more papers by this authorFrank A. Chervenak MD, Frank A. Chervenak MD Professor in the Department of Obstetrics and Gynecology at Cornell University Medical College, New YorkSearch for more papers by this authorTimothy Bayer MD, Timothy Bayer MD Assistant professor in the Department of Psychiatry and Behavioural Sciences at Baylor College of Medicine, Houston, TexasSearch for more papers by this author First published: November 1996 https://doi.org/10.1111/j.1479-828X.1996.tb02185.xCitations: 10AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume36, Issue4November 1996Pages 424-429 RelatedInformation

Cardiovascular diseases (CVD) and thyroid dysfunction are two of the most prevailing disorders in the world that are closely interlinked. Actions of thyroid hormones are mediated via thyroid receptors present in the myocardium and the vascular tissue. Primary mechanism that links thyroid dysfunction with CVD is the modification of cardiovascular risk factors (dyslipidemia, blood pressure, coagulation parameters, etc.) resulting in endothelial and left ventricular systolic and diastolic dysfunction. Both overt and subclinical hyperthyroidism and hypothyroidism may cause adverse alterations in cardiac function. Hyperthyroidism gives rise to palpitation, atrial fibrillation, systolic hypertension, and heart failure, whereas hypothyroidism increases diastolic hypertension, pericardial effusion, and the risk of ischemic heart disease via altering lipid and coagulation parameters. Early recognition and treatment of thyroid dysfunction may prevent adverse cardiovascular events in patients with or without pre-existing CVD. Certain cardiac conditions and medications can cause alterations in thyroid function that may predispose an individual to higher morbidity and mortality. In certain situations, thyroid dysfunction treatment may have cardiovascular benefits. This study deals with the interplay between cardiovascular and thyroid dysfunctions associated with clinical implications and management strategies.

Immune checkpoint inhibitors, including cytotoxic T-lymphocyte antigen 4 (CTLA-4) and programmed cell death-1 (PD-1) inhibitors, represent an effective treatment modality for multiple malignancies. Despite the exciting clinical benefits, checkpoint inhibition is associated with a series of immune-related adverse events (irAEs), many of which can be life-threatening and result in significant treatment delays. Pneumonitis is an adverse event of special interest as it led to treatment-related deaths in early clinical trials. This review summarizes the incidence of pneumonitis during treatment with the different checkpoint inhibitors and discusses the prognostic significance of tumor type. The wide range of clinical, radiographic, and histologic characteristics of checkpoint inhibitor-related pneumonitis is reviewed and followed by guidance on the different management strategies.

Heterogeneous mutations in dentin sialophosphoprotein (DSPP) gene, which is located on autosome 4, are associated with hereditary dentin developmental disorders. According to the new classification proposed by de La Dure-Molla et al, diseases caused by DSPP gene mutations mainly manifested as abnormal dentin development are collectively referred to as dentinogenesis imperfecta (DI), including dentin dysplasia type Ⅱ (DD-Ⅱ), dentinogenesis imperfecta type Ⅱ (DGI-Ⅱ) and dentinogenesis imperfecta type Ⅲ (DGI-Ⅲ) in Shields classification. And dentin dysplasia type Ⅰ (DD-Ⅰ) in Shields classification is redesignated as radicular dentin dysplasia. In this paper, progress in the classification, clinical characteristics and genetic mechanisms of DI are reviewed. This paper also provides clinical management and treatment strategies for patients suffering DI.

Soybeans and peanuts belong to the leguminous family and are common causes of food anaphylaxis. Symptoms range from oral allergy syndrome to severe breathing difficulties, anaphylactic shock, and even death. But the allergens causing allergies are different, and the severity of symptoms are different. Precise diagnosis at the molecular level or component-resolved diagnosis (CRD) is necessary. CRD is a technology that accurately identifies allergen proteins to help physicians personalize clinical treatment and management strategies for allergy patients. In this article, according to the European Academy of Allergy and Clinical Immunology (EAACI) issued the "Allergen Component Diagnostic Guidance Recommendation 2.0 (MAUG 2.0)", it introduces the soy and peanut allergenic components, clinical diagnosis, treatment and management, aimed at improving the accurate diagnosis and personalized treatment of soy and peanut allergy.

The optimal approach for identification and evaluation of the sexual problems in men and women in primary care or general medicine practice has not been consensed. To provide recommendations/guidelines concerning state-of-the-art knowledge for clinical evaluation and management strategies in the evaluation and treatment of sexual dysfunction in men and women, emphasizing evidence-based medicine and a patient-centered framework. An International Consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five continents developed in a process over a 2-year period. Concerning the Clinical Evaluation and Management Strategies Committee, there were 12 experts from five countries. Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation and debate. Three concepts underlie sexual medicine management: (i) adoption of a patient-centered framework for evaluation and treatment; (ii) application of the principles of evidence-based medicine in diagnostic and treatment planning; and (iii) use of a unified management approach in men and women. When taken together, these three principles provide a balanced and integrated approach to sexual dysfunction management. Common algorithms for diagnosis and management of men and women with sexual dysfunction, brief sexual symptom checklists, basics in history and physical examination, indications for specialized referral and development of a follow-up strategy are presented. More research is needed in understanding the role of evidence-based and patient-centered medicine in the clinical evaluation and management strategies of men and women with sexual dysfunction.

There are no comprehensive management guidelines for pediatric blunt renal injury; therefore, we hypothesized that wide variation in care exists. We sought to describe contemporary management of pediatric blunt renal trauma and explore associations between clinical management strategies and adverse outcomes. We retrospectively evaluated blunt renal injury patients (younger than 18 years) treated at 11 pediatric level I trauma centers from 2020 to 2022. We categorized patients by the American Association for the Surgery of Trauma renal injury grade (low, grades 1-3; high, grades 4-5) and isolated renal injury versus polytrauma. Clinical management strategies included bedrest, urinary catheter use, antibiotic use, urology consult, intensive care unit (ICU) admission, and serial laboratory/imaging. We determined site-specific clinical management strategy frequencies and compared composite intervention outcomes (operations, interventional radiology procedures, blood transfusions) and composite adverse outcomes (mortality, infection, readmission, hypertension, deep venous thrombosis) between patients who did and did not undergo given clinical management strategies. We analyzed 276 patients stratified by low-grade isolated (15.2%), low-grade polytrauma (51.1%), high-grade isolated (12%), and high-grade polytrauma (21.7%). Compared with other clinical management strategies, antibiotic use, ICU admission, and urinary catheter placement were less universally implemented across sites. Composite adverse and intervention outcomes did not vary significantly based on use of bedrest, antibiotics, and postdischarge serial renal imaging (all p > 0.05). Composite adverse outcomes varied significantly among high-grade polytrauma patients with and without ICU admission (55.6% vs. 18.2%, p = 0.003) and among low-grade polytrauma patients with and without serial hemoglobin laboratories (20.8% vs. 0%, p = 0.04), serial renal laboratories (26.3% vs. 10.1%, p = 0.02), and serial inpatient renal imaging (28.6% vs. 13%, p = 0.04). Pediatric blunt renal injury management varied across institutions. Patients with isolated renal injuries had minimal differences in interventions or adverse outcomes despite variable clinical management. This population would benefit from a consensus-based algorithm to minimize clinical management strategy variation. Therapeutic/Care Management; Level IV.

Background/Introduction Pulmonary embolism (PE) is caused by blockage of pulmonary arteries by thrombus. The sources of thrombus are thought to be mostly veins in lower extremities, whereas deep vein thrombosis (DVT) in upper extremities rarely occurs spontaneously. Recent studies reported that DVT in upper extremities might have significant complications, and DVT in upper extremities could be increasing. However, there is a paucity of data on patients with DVT in upper extremities, leading to uncertainty in optimal treatment strategies including anticoagulation therapy. Purpose We sought to evaluate the clinical characteristics, management strategies, and long-term outcomes of patients with DVT in upper extremities in a large observational database in Japan. Methods The COMMAND VTE Registry is a multicenter registry enrolling 3027 consecutive patients with acute symptomatic venous thromboembolism (VTE) objectively confirmed by imaging examination or by autopsy among 29 centers in Japan between January 2010 and August 2014. The current study population consisted of 2498 patients with DVT in upper or lower extremities, after excluding 381 patients with PE only, 144 patients who had thrombus in locations other than upper or lower extremities, and 4 patients with DVT in both upper and lower extremities. The study patients were divided into 2 groups: patients with DVT in upper extremities and patients with DVT in lower extremities. We compared the clinical characteristics, management strategies and long-term outcomes between the 2 groups. Results There were 74 patients (3.0%) with upper extremities DVT and 2498 patients (97%) with lower extremities DVT. Patients with upper extremities DVT more often had active cancer at diagnosis (58%) and central venous catheter use (22%). The proportion of concomitant PE at diagnosis was lower in patients with upper extremities DVT than in those with lower extremities DVT (14% and 51%, P<0.001). Discontinuation of anticoagulation therapy was more frequent in patients with upper extremities DVT (63.8% and 29.8% at 1-year, P<0.001). The cumulative 3-year incidence of recurrent VTE was not different between the 2 groups (9.8% and 7.4%, P=0.43) (Figure). After adjusting confounders, the risks of upper extremities DVT relative to lower extremities DVT for recurrent VTE remained insignificant (HR 0.94, 95% CI 0.36–2.01, P=0.89). Kaplan-Meier event curves for recurrence Conclusions The prevalence of patients with DVT in upper extremities was 3.0% in the current large-scale real-world registry. Patients with DVT in upper extremities more often had active cancer at diagnosis and central venous catheter use as a transient risk factor for VTE, and less often had concomitant PE. Patients with DVT in upper extremities had similar long-term risk for recurrent VTE as those with DVT in lower extremities despite shorter duration of anticoagulation. Acknowledgement/Funding Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

Background:Coronary artery disease is the leading cause of mortality in India. There is scarcity of data on demographic profile and outcomes of acute coronary syndrome (ACS) in low socioeconomic status (SES) population of India.Objectives:This study was undertaken to determine the clinical presentation, management strategies, and in-hospital outcomes of ACS in low SES population.Methods:We conducted 1-year prospective observational cohort study of ACS patients admitted at Employees State Insurance Corporation unit of our tertiary care cardiac center. Clinical parameters, management strategies, and in-hospital outcomes of 621 patients enrolled during the study period from February 2015 to January 2016 were studied.Results:Mean age of patients was 56.06 ± 11.29 years. Majority (62%) of the patients had ST elevation myocardial infarction (STEMI), whereas Non-ST elevation acute coronary syndrome (NSTE-ACS) was seen in 38% of the patients. Median time from symptom onset to hospital admission was 285 min with wide range from 105 to 1765 min. Coronary angiography was performed in 81% of patient population. Single-vessel disease (SVD) was the most common pattern (seen in 43.3%) of coronary artery involvement with left anterior descending coronary artery (LAD) being the most frequently involved vessel (62.8%). Pharmaco-invasive approach was the preferred strategy. Overall percutaneous coronary intervention (PCI) rates were 59.1% (62.1% in STEMI and 54.2% in NSTE-ACS). Overall in-hospital mortality was 3.2%, being significantly higher in STEMI (4.2%) as compared with NSTE-ACS (1.7%).Conclusions:With implementation of evidence-based pharmacotherapy and interventions, outcomes comparable with developed countries can be achieved even in low SES populations of developing world.

Background and Objective:Pneumothorax presents the significant clinical and public health challenge in the Kashmir region due to the unique geographical, demographic, and socioeconomic factors. This study analyses the clinical patterns, etiological factors, management strategies, and outcomes of 650 pneumothorax cases treated at a tertiary care centre in Kashmir. This study aims to evaluate the clinical patterns, etiological factors, diagnostic approaches, management strategies, and outcomes of pneumothorax cases in the Kashmir region. By analysing a large dataset from a tertiary care centre, the study seeks to highlight region-specific challenges and propose improvements in diagnostic and therapeutic strategies to enhance patient care.Materials and Methods:An ambispective analysis of 650 cases of pneumothorax from January 2020 to July 2024 was conducted. Patients were classified as having traumatic, spontaneous, or iatrogenic pneumothorax. Data on demographic distribution, clinical presentation, associated injuries, management approaches, complications and outcomes were analysed using descriptive statistics.Results:Traumatic pneumothorax was the most common type (61.5%, n = 400), with unilateral presentation in 67.5% of cases. Spontaneous pneumothorax accounted for 21.5% (n = 140), of which secondary causes predominated (54.3%). Iatrogenic pneumothorax comprised 16.9% (n = 110). Chest radiography (CxR) was the primary diagnostic tool (100%), with CT scanning required in 28.5% of cases. Ultrasound showed 89.2% sensitivity in emergency settings. Intercostal tube drainage (ICTD) was the mainstay of treatment in 78.5% of cases, yielding a success rate of 94.5%. Complications included persistent air leak (12%), empyema (3.7%), and recurrence (6.3%).Conclusion:Our study provides a comprehensive analysis of pneumothorax in the Kashmir region, highlighting its unique etiological and clinical patterns. The findings emphasize the need for improved trauma care systems, standardized treatment protocols, and widespread training in emergency procedures, particularly in rural and resource-limited settings, to optimize patient outcomes and reduce complications.

Sarcopenia, characterized by progressive loss of skeletal muscle mass and strength, is a prevalent but often overlooked condition in patients with cancer who are terminally ill. It contributes to functional decline, increased symptom burden, and reduced quality of life, yet remains underrecognized in palliative care. Diagnosing sarcopenia in this population is challenging because conventional imaging techniques are often impractical. Instead, alternative assessments, such as the Strength, Assistance with walking, Rise from a chair, Climb stairs, and Falls questionnaire (SARC-F), anthropometric measurements, and bioelectrical impedance analysis offer feasible options. Management should focus on symptom relief, functional preservation, and patient comfort, rather than on muscle mass restoration. Nutritional support must be tailored to prognosis, with aggressive interventions generally avoided during end-of-life care. Although exercise may help to maintain mobility and alleviate symptoms, its feasibility is often limited. Pharmacological interventions, including appetite stimulants and anti-cachexia agents, remain largely investigational, with insufficient evidence for routine use in palliative care. Future research should refine sarcopenia assessment methods and develop patient-centered interventions that align with palliative care principles, emphasizing quality of life and individualized needs.

BackgroundPhysicians often select clinical management strategies not strongly supported by evidence or guidelines. Our objective was to examine the likelihood of selecting, and rationale for pursuing, clinical management strategies with more or less guideline support among physicians using clinical vignettes of eight common medical admissions.MethodsWe conducted a cross-sectional survey using clinical vignettes of attending physicians and housestaff at one internal medicine program in New York City. Each clinical vignette included a brief clinical scenario and a varying number of clinical management strategies: diagnostic tests, consultations, and treatments, some of which had strong evidence or guideline support (Level 1 strategies) while others had limited evidence or guideline support (Level 3 strategies). Likelihood of selecting a given management strategy was assessed using Likert scales and multiple response options were used to indicate rationale(s) for selections.ResultsOur sample included 79 physicians; 68 (86%) were younger than 40 years of age, 34 (43%) were female. There were 31 attending physicians (39%) and 48 housestaff (61%) and 39 (49%) had or planned to have primarily primary care internal medicine clinical responsibilities. Overall, physicians were more likely to select Level 1 strategies “always” or “most of the time” when compared with Level 3 strategies (82% vs. 43%; p < 0.001), with wide variation across the eight medical admissions. There were no differences between attending and housestaff physician likelihood of selecting Level 3 strategies (47% vs. 45%, p = 0.36). Supportive evidence and local practice patterns were the two most common rationales behind selections; supportive evidence was cited as the most common rationale for selecting Level 1 when compared with Level 3 strategies (63% versus 30%; p < 0.001), whereas ruling out other severe conditions was cited most often for Level 3 strategies.ConclusionsFor eight common medical admissions, physicians selected more than 80% of management strategies with strong evidence or guideline support, but also selected more than 40% of strategies for which there was limited evidence or guideline support. The promotion of evidence-based care, including the avoidance of care that is not strongly supported by evidence or guidelines, may require better evidence dissemination and educational outreach to physicians.

HER2-positive breast cancers are complex tumors that are clinically and biologically heterogeneous. Even within HER2+ breast cancer, there are different molecular subtypes, mutational profiles, levels of HER2 protein, and immune infiltration. Additionally, HER2 may not be expressed homogeneously among all the cancer cells in the same tumor, some tumors may have low HER2 expression, while other tumors evolve during treatment. These molecular differences help explain why patients do not benefit to the same extent to HER2-directed therapies. We will review data regarding outcomes for tumors with known tumor heterogeneity, hormone receptor positivity, HER2-low positivity, and cases where brain metastases may be present. We will discuss optimal clinical management in the modern era with multiple HER2-directed therapies, including next-generation antibody-drug conjugates. Future strategies to tailor therapy to the individual patient will need to not just factor in anatomic tumor burden, but also key molecular features. Citation Format: S Tolaney. Heterogeneity in treatment outcomes for HER2+ breast cancer - Clinical management strategies [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr TF2-2.