Abstract This case describes a 50-year-old kidney transplant recipient with subacute development of erythematous-to-violaceous skin lesions on the face, trunk, and extremities, accompanied by malaise, myalgia, and arthralgia. Histopathologic analysis of skin biopsies revealed characteristic vascular proliferation consistent with bacillary angiomatosis (BA), a rare angioproliferative disease caused by Bartonella henselae or Bartonella quintana infection, primarily affecting immunocompromised individuals. The patient was treated successfully with oral doxycycline, resulting in the resolution of symptoms and lesions. BA is typically transmitted via cats and presents variably, including cutaneous angioproliferative lesions, hepatic or splenic involvement, and endocarditis. Diagnosis relies on histopathology with specialized staining and molecular testing, as culture and serologies are often insufficient. Treatment typically involves prolonged antibiotic therapy, emphasizing the importance of early recognition in immunosuppressed patients, including solid organ transplant recipients, to prevent complications.

BackgroundVitamin D is a steroid hormone primarily produced in the skin. In Jordan, vitamin D deficiency is widespread among the population. This study aims to compare serum vitamin D levels between patients with autoimmune and non-autoimmune hypothyroidism.MethodsA retrospective observational study was conducted at the Jordanian Royal Medical Services in Jordan from January 2023 to November 2024. Data were gathered from the patient's medical records, including age, gender, vitamin D level, thyroid-stimulating hormone (TSH) value, free thyroxine (FT4) level, anti-thyroid peroxidase, and anti-thyroglobulin levels.ResultsA total of 150 patients were included, aged 5 to 76 years, with a mean age of 39.2 years. The mean vitamin D level was 17.9 ng/mL, indicating widespread deficiency. There was no significant difference in vitamin D levels between patients with autoimmune and non-autoimmune hypothyroidism (p = 0.860), suggesting that vitamin D levels are independent of autoimmune hypothyroidism status. Additionally, there was no significant relationship between vitamin D levels and TSH (ρ = −0.119,p = 0.148) or FT4 (ρ = 0.128,p = 0.123). Age showed a modest negative correlation with TSH levels (ρ = −0.067,p = 0.416) and a positive but nonsignificant correlation with FT4 levels (ρ = 0.024,p = 0.775).ConclusionSerum vitamin D levels do not significantly differ between patients with autoimmune and non-autoimmune hypothyroidism, nor do they correlate with TSH levels. Further studies are needed to evaluate vitamin D status in these patient groups.

IntroductionThere is a lack of a standardized curriculum for the appropriate use of noninvasive ventilation (NIV), which is readily accessible. Management of NIV is a core competency for physicians training in pulmonary and critical care medicine (PCCM). We present a blended model of instruction that was highly successful in our pilot program.MethodsThe curriculum targeted eight first-year PCCM fellows to assess knowledge and confidence in key competencies of NIV management. After a baseline assessment, fellows engaged in both hands-on instruction and traditional didactics in NIV. Following, fellows were encouraged to use the e-learning modules for enhanced instruction. The modules were designed to cover all major aspects of NIV management and with unique interactive patient cases for both inpatient and outpatient uses of NIV.ResultsEight first-year PCCM fellows completed the training and responded to the posttest assessment 4 weeks later. The average multiple-choice questions (MCQs) score increased from 13.5 ± 3.2 (54.0%) to 18.4 ± 1.6 (73.6%) and was significant (p = 0.004). A Likert assessment of learner confidence also showed significant improvement across several key competency domains.ConclusionThis curriculum represents a successful and novel approach to NIV education, a critical but challenging core competency in pulmonary medicine for physicians training in PCCM.

BackgroundMore than a decade of armed conflict has devastated Syria's healthcare system, severely disrupting graduate medical education (GME) across the country. Damage to teaching hospitals, displacement of faculty, and fragmented oversight have contributed to deteriorating educational standards and a growing physician shortage. As Syria transitions into a post-conflict recovery phase, reforming its GME system is a national and global priority.ObjectiveThis white paper aims to evaluate the current state of GME in Syria and propose a strategic framework for rebuilding a standardized, sustainable, and internationally aligned system through stakeholder engagement, data collection, and comparative analysis.MethodsIn February 2025, the Syrian American Medical Society (SAMS) conducted workshops in Damascus and Aleppo involving over 45 stakeholders, including teaching hospital directors, medical educators, and diaspora physicians. A pre-workshop survey assessed program structure, oversight, curricula, evaluation methods, and infrastructure across 21 institutions. Workshop discussions were informed by a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis and global best practices from countries including Jordan, Saudi Arabia, and the United States.ResultsFindings revealed wide variability in program oversight, clinical training quality, evaluation standards, and faculty support. Only 57% of institutions reported having formal curricula, while 81% conducted some form of trainee evaluation. Common challenges included inadequate financial support, lack of standardized accreditation, insufficient faculty development, and limited research access. Recommendations from the workshops included the creation of a national accreditation council, modernization of curricula, investment in faculty training, development of centers of excellence, and integration of online education and 25 continuing medical education.ConclusionReforming Syria's GME system requires coordinated, multilevel efforts to implement competency-based education, establish independent regulatory bodies, and align training programs with global standards. The phased framework presented here offers actionable steps to rebuild Syria's medical education infrastructure and train a resilient health workforce capable of addressing both national and regional healthcare needs.

Sickle cell disease (SCD) is a hereditary hemoglobin disorder characterized by vaso-occlusion and chronic hemolysis, leading to severe complications. Finding cost-effective and reliable biomarkers for predicting disease severity and identifying high-risk patients remains challenging, especially in resource-limited settings. This systematic review evaluates the association between lactate dehydrogenase (LDH) levels measured during clinical steady-state and various complications of SCD to assess its prognostic value. A systematic literature search, adhering to PRISMA guidelines, was conducted across Medline/PubMed, Web of Science, Embase, and ScienceDirect. Eligible studies included all observational studies examining the relationship between LDH levels and subsequent SCD complications. The statistical analyses were performed to calculate the pooled standardized mean difference (SMD) and its 95% confidence interval (CI). A total of 34 studies were included, highlighting significant associations between elevated LDH levels and various SCD-related complications. These included pulmonary arterial hypertension (SMD = 0.454, 95% CI: 0.032–0.875,p = 0.035), stroke risk through transcranial Doppler velocities (SMD = 0.651, 95% CI: 0.459–0.843,p < 0.001), and kidney involvement (SMD = 0.399, 95% CI: 0.014–0.785,p = 0.042). This systematic review reveals a consistent association between elevated steady-state LDH levels and major complications of SCD. The findings suggest a potential role for LDH as a readily available biomarker for SCD severity, underlining its potential for inclusion in clinical assessments of SCD severity, risk stratification, and tailored interventions for high-risk patients.

Artificial intelligence (AI) has great potential in diagnosing, managing, and predicting cardiovascular diseases through imaging, clinical decision support, remote monitoring, and optimizing treatment strategies. AI in cardiology brings unique ethical issues that need careful examination and resolution. There are several ethical concerns, including privacy, bias, trust, accountability, and responsibility. AI systems handle large quantities of data, which can present privacy and security risks if hacked or exploited illegally. AI models may exhibit biases due to limited or nonrepresentative training data sets, impacting their reliability. ChatGPT shows potential in cardiology for patient education, clinician support, and research facilitation. However, its use in direct patient care is limited due to concerns regarding accuracy, ethical issues, and the necessity for human oversight. AI's responsible development and application in cardiology hinges on thorough evaluation, regulatory compliance, and ethical oversight to ensure safety and effectiveness. The collaboration of health care professionals, data scientists, ethicists, researchers, and policymakers is essential for the advancement of AI in cardiology and the resolution of its associated challenges. Collaboration is mandatory to ensure AI tools improve patient care while upholding the highest medical standards. The incorporation of AI into cardiology offers significant potential for the coming years. With its extensive data sets and strong evidence-based guidelines, cardiology is ideally suited to using this technology.

BackgroundAcute poisoning is a significant public health concern, leading to numerous emergency admissions globally. In northwestern Syria, understanding poisoning epidemiology is essential for targeted prevention efforts. This study examines the causes and demographic characteristics of poisoning cases in the region.MethodsThe study was conducted over 1 year (July 1, 2022–July 1, 2023) at six northwestern Syrian hospitals supported by humanitarian organizations. The study gathered information from patients aged 14 years and above who suffered from poisoning during the study period.ResultsPoisoning cases totaled 172 throughout the study period. Majority of patients were females aged between 14 and 24 (76.7 and 55.2%, respectively), most of them were married (65.1%). Most of the patients identified as housewives among the total patient population (52.9%) and had primary or middle school education. A large majority of the population (77.3%) were smokers while most poisoning incidents (77.3%) were reported in rural camps and villages. The study found oral ingestion as the most common route of poisoning at 88.4% and intentional poisonings made up 86% of all cases. The most prevalent toxic agents causing poisoning cases were drugs, 61.6%, with organophosphorus compounds ranking second, 14.5%. The symptom of vomiting appeared most often during acute poisoning cases (48.8%). The administration of specific antidotes took place in 11.6% of patients who needed hospital admission for 94.8% of these cases. The patients stayed in the hospital for an average duration of 33.1 hours. A total of 76.7% of patients achieved full recovery and 7.6% succumbed to their injuries.ConclusionAcute poisoning presents as a major health problem across northwestern Syria mostly affecting young married females who live in rural regions. The unusually high number of cases of purposeful poisoning emphasizes the requirement for both psychiatric support and educational programs for the public.

In this study, we analyzed various clinical and imaging factors of patients with isolated tricuspid valve infective endocarditis (TVIE) who have undergone surgical intervention, and assessed short- and long-term outcomes after surgery. We retrospectively enrolled 26 patients diagnosed with definite isolated TVIE and underwent surgical intervention between February 2004 and August 2019. We collected patients' demographics, preoperative and postoperative data. The primary outcomes were death and a composite of the following: death, readmission with right-sided heart failure, or recurrent endocarditis. A total of 29 isolated tricuspid valve surgical interventions were performed on 26 patients. The mean age was 38.6 ± 12.3 years. In total, 22/29 (75.8%) of TVIE were related to Staphylococcus aureus and 4/29 (13.8%) were secondary to fungal infection. During a follow-up of 5.4 ± 3.7 years, there were 9 (34.6%) deaths and 15 (57.7%) composite outcomes. Multivariable Cox regression analysis showed that male sex (hazard ratio [HR]: 16.68, 95% confidence interval [CI]: 1.63-170.34, p = 0.018) and intravenous drug users (IVDU) (HR: 25.66, 95% CI: 1.87-352.79, p = 0.015) are significantly associated with increase death; on the other hand, higher level of preoperative hemoglobin and preoperative left ventricular ejection fraction (LVEF) was found to have decreased hazard of death: HR: 0.90, 95% CI: 0.82-0.99, p = 0.033 and HR: 0.92, 95% CI: 0.86-0.98, p = 0.013, respectively. In our institution, surgical intervention for isolated TVIE has a mortality rate of 34.6%. Men, a history of IVDU, lower preoperative hemoglobin levels, and reduced LVEF were significant predictors of postsurgical mortality. Earlier surgical intervention for TVIE before the development of anemia or impaired LV systolic function may have a potential survival benefit.

The Enhanced Recovery After Surgery (ERAS) protocols are a set of steps taken before, during, and after surgery to improve patient care and outcomes. While ERAS is well known for its benefits in various surgeries, its application in pediatric cardiac surgery is relatively new. With the recent emergence of studies on its implementation in pediatric cardiac surgery, this study is the first to systematically review the current evidence on the efficacy of ERAS in the field. A meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two reviewers independently searched PubMed, Cochrane, Google Scholar, Web of Science, Embase, and Scopus databases for comparative studies with control groups that described the use of ERAS in all types of pediatric cardiac surgeries from 2000 to 2024. The data collected included study design, patient demographics, elements of the ERAS protocols, and postoperative outcomes. The random-effects model was used to calculate the pooled odds ratios (ORs) and mean differences (MDs) with the corresponding confidence intervals (CIs) for proportional and continuous variables, respectively. Five studies, involving 1,008 patients, were included in the final analysis: three randomized controlled trials (RCTs), one retrospective cohort, and one case-control study. The ERAS protocols were applied in 430 (43%) patients, and standard perioperative care was applied in 578 (57%) patients. The analysis revealed that implementing the ERAS protocol significantly reduced ICU length of stay ( I 2 = 98.26%; MD = -1.441; 95% CI: -2.610 to -0.273; p = 0.016). The ERAS group had a comparable rate of postoperative complications to the standard care group ( I 2 = 15.3%; OR: 0.889; 95% CI: 0.622-1.269; p = 0.516). The ERAS protocols in pediatric cardiac surgery appear to be safe and effective in improving certain short-term outcomes. However, evidence is limited due to the small number of studies. Further multicenter RCTs that fully incorporate the ERAS protocol elements and assess both immediate and long-term outcomes are needed.