Inflammatory indices as independent predictors of in-hospital mortality in acute upper gastrointestinal bleeding.

Blue Rubber Bleb Nevus Syndrome (BRBNS) is a rare congenital disorder characterized by multiple venous malformations, most frequently affecting the skin and gastrointestinal tract, but occasionally involving the central nervous system and other visceral organs. Fatal outcomes are exceedingly rare and usually result from acute hemorrhage or airway compromise. This report describes a fatal case of BRBNS in a 31-year-old woman who developed uncontrollable bleeding from vascular malformations following an emergent tracheostomy performed for anaphylaxis secondary to lidocaine administration during dental treatment. Despite aggressive resuscitative measures, the patient succumbed to hemorrhagic shock. External examination revealed bluish subcutaneous lesions in the perioral region, periorbital ecchymosis, and multiple bluish, compressible subcutaneous vascular "blebs" on the right upper extremity, extending to the right hemithorax. Internally, multiple submucosal, hemorrhagic-appearing lesions were identified on the base of the tongue, hypopharynx, larynx, and aryepiglottic folds, with additional vascular malformations in the posterior mediastinum and right temporalis muscle. Histologic examination confirmed cavernous hemangiomas at the tracheostomy site. A review of the English-language literature revealed only a small number of fatal cases associated with BRBNS. This case highlights the potential for fatal airway hemorrhage in BRBNS, particularly during emergent procedures involving the upper airway. Awareness of possible laryngeal and tracheal involvement is crucial to avoid iatrogenic complications. Comprehensive autopsy remains essential to determine the cause of death, document lesion distribution, and distinguish disease-related hemorrhage from procedural injury.

The hybrid marbled goby (Oxyeleotris marmoratus ♀ × Oxyeleotris lineolatus ♂) is a high-value aquaculture species in China, with rapidly increasing production in recent years. While Streptococcus agalactiae is a well-known pathogen in various fish species, its association with marbled goby has not been previously reported. Here, we present the first confirmed case of S. agalactiae infection in farmed hybrid marbled goby. Infected fish exhibited typical signs of streptococcosis, including erratic swimming, hemorrhages at fin bases, skin ulcers, and cloudy or hemorrhagic eyes. A Gram-positive bacterial strain, designated ZH2208, was isolated from diseased fish. Morphological, biochemical, 16S rRNA sequencing, and phylogenetic analyses identified the isolate as S. agalactiae, serotype Ia-a dominant serotype previously associated with tilapia infections in Guangdong, China. Challenge experiments using doses of 1 × 10⁴ and 1 × 10⁷ CFU/fish confirmed the high virulence of ZH2208, resulting in 50% and 100% mortality, respectively. Eleven virulence genes involved in host invasion, hemolysis, immune evasion, and blood-brain barrier penetration were detected by PCR. Histopathology revealed typical lesions in gills, liver, spleen, kidney, and brain, including acute inflammation, hemorrhage, and neuronal degeneration. Notably, pronounced swim bladder swelling with distinct hemorrhagic spots was observed. Antibiotic susceptibility testing showed that ZH2208 was sensitive to enrofloxacin and doxycycline but resistant to several common aquaculture antibiotics, highlighting its multidrug-resistant profile. In conclusion, this study provides the first comprehensive characterization of S. agalactiae infection in hybrid marbled goby. These findings support the development of effective prevention and control strategies, including vaccination and rational antibiotic use, to manage streptococcal disease in goby aquaculture.

Screening and management for portal hypertension in hepatocellular carcinoma: A nationwide survey in China.

PurposeThis study compares the anatomical and functional outcomes of two treatments for acute submacular haemorrhage (SMH): pars plana vitrectomy with subretinal recombinant tissue plasminogen activator (tPA) and gas tamponade versus intravitreal tPA and gas injection.MethodsA retrospective single-centre study was conducted of patients treated for acute SMH at Buckinghamshire Healthcare NHS Trust between January 2016 and December 2022. Patients received either intravitreal tPA and gas ± anti-VEGF (Group A) or pars plana vitrectomy with subretinal tPA and gas tamponade ± anti-VEGF (Group B). The primary outcome was anatomical success, defined as displacement of haemorrhage from the fovea. Secondary outcomes were visual acuity (VA) improvement, central foveal thickness (CFT) reduction, and complication rates.ResultsEighty eyes from 73 patients (mean age: 79.8 ± 11.5 years; 57.5% female) were analysed, with 53 eyes in Group A and 27 in Group B. Anatomical success was achieved in 71.6% of Group A and 77.8% of Group B. VA improved in 66% of Group A and 63% of Group B. CFT decreased by over 50% in both groups. No statistically significant differences were found between the two treatment groups and in anatomical or functional improvement.ConclusionIn this real-world study, both approaches effectively displaced SMH and improved vision with comparable outcomes, suggesting that treatment selection may be best determined by patient-specific and logistical factors.

IntroductionPituitary apoplexy is a rare but potentially life-threatening endocrine emergency characterized by acute hemorrhage or infarction of the pituitary gland. While often associated with pre-existing adenomas, it may also occur in previously normal glands. Risk factors include surgery, pregnancy, and medications such as gonadotropin-releasing hormone (GnRH) agonists, which are rarely implicated in pituitary apoplexy.Clinical CaseWe present the case of a 59-year-old male with a history of type 2 diabetes mellitus, hypertension, hyperlipidemia, and prostate cancer who developed intractable headache, nausea, vomiting, photophobia, and blurred vision shortly after receiving a leuprolide, GnRH agonist injection, for the treatment of prostate cancer. Brain imaging revealed a sellar and suprasellar pituitary tumor with hemorrhage. He was treated with intravenous fluids and steroids. The patient underwent emergent transsphenoidal hypophysectomy surgery, and pathology confirmed a gonadotroph adenoma with necrosis. The patient was discharged in stable condition.Pituitary apoplexy following GnRH agonist therapy is exceedingly rare, with fewer than 30 cases reported in the public domain. Proposed mechanisms include sudden cell shrinkage and metabolic hyperactivity within the pituitary gland. This case underscores the importance of recognizing the clinical presentation of pituitary apoplexy, as timely diagnosis and treatment are crucial for preventing severe neurological and endocrine sequelae.ConclusionClinicians should maintain a high index of suspicion for pituitary apoplexy in patients presenting with acute neurological or endocrine symptoms following GnRH agonist therapy. Increased awareness and vigilance in at-risk populations are essential, as routine pre-screening for pituitary adenomas is not currently standard practice.Figure 1:Magnetic resonance imaging of the brainMagnetic resonance imaging of the brain revealed a large heterogeneous enhancing mass expanding the sella, extending inferiorly into and expanding the left sphenoid sinus, and extending superiorly into the suprasellar cistern causing mild mass effect on the optic chiasm, measuring 2.8 x 3.4 x 3.4 cm. There was no definite cavernous sinus invasion. There was mild patchy intrinsic T1 hyperintensity throughout the mass, with small central areas of susceptibility artifact particularly within the left sphenoid sinus. Table 1:Laboratory test results

IntroductionPaget's disease of bone is a metabolic bone disorder characterized by abnormal bone remodeling and is often detected incidentally through elevated alkaline phosphatase (ALP) or pathological fractures. Presentation with severe hypocalcemia is unusual. Here, we describe a rare case of Paget's disease admitted to the emergency department with profound hypocalcemia and extensive cranial bone involvement.Clinical CaseA 64-year-old woman presented with progressive somnolence and speech difficulties. Neurological evaluation revealed disorientation with a Glasgow Coma Scale score of 11, frontal and temporal bone prominence, and increased head size. Cranial changes had gradually progressed over the previous four years, with hearing loss and recurrent headaches emerging during the last two years. Her vital signs were stable. Chvostek’s and Trousseau’s signs were positive. Arterial blood gas analysis revealed pH 7.39, bicarbonate (HCO₃⁻) 30 mmol/L, and ionized calcium 2.3 mg/dL. Brain CT and diffusion MRI excluded acute stroke and intracranial hemorrhage. ECG demonstrated a prolonged QT interval of 490 ms. Laboratory tests showed severe hypocalcemia (Ca: 4.1 mg/dL), low phosphorus (2.1 mg/dL), markedly elevated ALP (1550 U/L), low vitamin D (<5 ng/mL), elevated parathyroid hormone (PTH: 125 pg/mL), and reduced 24-hour urinary calcium excretion (32 mg/day). She was treated with intravenous calcium infusion together with magnesium, requiring 8–10 ampoules of calcium gluconate daily (≈0.74–0.93 g elemental calcium) to maintain normocalcemia. She also received 150,000 IU/week intramuscular cholecalciferol, and oral calcitriol was initiated at 0.5 mcg/day. Electrolytes and clinical status were monitored daily. Skull X-ray revealed mixed lytic and sclerotic lesions consistent with the classic “cotton wool” appearance. Bone scintigraphy showed diffuse cranial uptake, suggesting active-phase Paget’s disease. The maximal skull thickness measured 6 cm. Given the extensive cranial involvement and unusual biochemical presentation, clinical exome sequencing was performed, which did not reveal any germline variant to explain this presentation. By the 10th day of hospitalization, her oral intake had improved, and intravenous treatment was tapered. She was discharged after stabilization with a prescription including 40,000 IU/week of cholecalciferol, 3 g/day of oral calcium carbonate, and 365 mg/day of oral magnesium supplementation. At her 3-month follow-up, laboratory results were: PTH 40.7 pg/mL, creatinine 0.9 mg/dL, calcium 9.7 mg/dL, phosphorus 3.8 mg/dL, albumin 4.0 g/dL, magnesium 2.0 mg/dL, and ALP 1000 U/L. She received 5 mg intravenous zoledronic acid at that visit.ConclusionThis case illustrates a rare presentation of Paget’s disease with severe hypocalcemia and massive skull involvement. Although radiological findings were consistent with Paget’s disease of bone, other causes of cranial bone thickening, such as osteopetrosis, should be excluded.Figure 1:Lateral skull X-ray of a patient with Paget’s disease of bone, showing massive cranial involvement with mixed lytic and sclerotic changes, giving the classic “cotton wool” appearance. Table 1:Laboratory Findings and Treatment Timeline in Paget’s DiseaseLaboratory parameters at admission and after treatment in a patient with Paget’s disease presenting with profound hypocalcemia and massive skull involvement. The table also summarizes the therapeutic interventions administered during hospitalization and follow-up.

Eagle syndrome as a rare cause of acute pharyngeal hemorrhage

Introduction:Common complications after endoscopic retrograde cholangiopancreatography (ERCP) include acute pancreatitis, gastrointestinal perforation or bleeding, while splenic artery rupture and bleeding is a very rare complication.Main symptoms:This study reports a case of splenic artery rupture and bleeding after ERCP, providing reference experience for clinicians. This article describes the case of a 67-year-old patient who underwent ERCP to alleviate jaundice associated with pancreatic head cancer. During the procedure, the patient experienced unexpected hemorrhagic shock.Diagnoses, interventions, and outcome:The shock was later confirmed as distal splenic artery (short gastric artery) bleeding by digital subtraction angiography, without splenic capsule tearing or subcapsular hematoma. Distal splenic artery branch embolization was performed immediately to avoid splenectomy, and satisfactory results were achieved.Conclusion:Splenic artery bleeding is an unexpected and extremely rare complication after ERCP and distal splenic artery branch embolization with digital subtraction angiography is a possible treatment approach. This case provides physicians with valuable experience, highlighting the importance of being highly suspicious of such rare complications, and discussing the possible causes and treatment methods for splenic injury following ERCP.

This study evaluated the efficacy and safety of N-butyl-2-cyanoacrylate (NBCA)-based middle meningeal artery embolization (MMAE) in preventing recurrence of chronic subdural hematoma (CSDH) in elderly patients. We retrospectively analyzed 221 patients aged ≥ 65 years who underwent burr hole surgery (BHS) with or without adjunctive MMAE between April 2023 and March 2025. Clinical, radiological, and perioperative variables were assessed, with the primary outcome being 90-day recurrence requiring retreatment. Among the cohort, 92 patients received BHS with MMAE and 129 underwent BHS alone. The median age was 82.0 years (IQR 77.0-86.0), and 64.3% were male. The overall recurrence rate was 12.7% (n = 28). Multivariate analysis identified male sex as an independent risk factor for recurrence (OR 4.95, 95% CI 1.61-21.7, P = 0.004), while acute hemorrhage within the hematoma (OR 0.19, 95% CI 0.01-0.99, P = 0.048) and BHS combined with MMAE (OR 0.37, 95% CI 0.13-0.94, P = 0.04) were associated with reduced recurrence risk. Subgroup analyses suggested that MMAE was particularly effective in male patients and in those with septated hematomas. Additionally, the BHS with MMAE group experienced fewer symptomatic complications (0% vs. 4.6%, P = 0.044) and required postoperative Goreisan far less frequently (16.5% vs. 92.3%, P < 0.001). These findings support that NBCA-based MMAE is associated with lower odds of recurrence and fewer symptomatic complications in elderly patients with CSDH, especially in anatomically and clinically favorable subgroups.

Uterine artery embolization (UAE) has become widely used in clinical practice and plays an important role in the treatment of uterine fibroids, adenomyosis, and the treatment or prevention of acute uterine hemorrhage (e.g., scarred pregnancies, placental implantation disorders, and postpartum or post-abortion hemorrhage). However, UAE is not without complications and may affect subsequent pregnancies. This article provides a summary of the more frequent and clinically significant complications, along with an analysis of their effects on subsequent fertility and pregnancy outcomes. The objective is to support the current body of knowledge on the clinical management of UAE and its implications for reproductive health.

Repetitive mild traumatic brain injury (rmTBI) is a major contributor to long-term neurological dysfunction, yet many preclinical models lack precise control and quantification of biomechanical forces across impacts. We developed a reproducible, closed-skull mouse model of rmTBI using a custom-built weight–drop apparatus featuring a solenoid-based rebound arrest system, integrated high-speed videography, and accelerometry to track head kinematics during impact. Adult male and female mice received either a single impact or nine daily impacts. Linear and angular acceleration data were analyzed alongside behavioral and histological outcomes. Our apparatus delivered consistent impact and velocity forces with minimal intersubject variability. Additionally, the animals experienced consistent linear and angular acceleration as measured using high-speed video capture. These impacts did not cause skull fracture or acute vascular hemorrhage, but impacted animals had increased return of righting reflex time, consistent with mild, concussion-like symptoms. Behavioral testing revealed reduced performance of rmTBI-affected mice in an olfaction-mediated foraging task (buried food task), particularly at later timepoints, consistent with progressive olfactory impairment. Immunohistochemical analysis of Iba1 and CD68 in the brain demonstrated sex-dependent microglial activation, with males showing higher expression levels in both single- and nine-impact models. Among the brain regions investigated, microglial activation was most pronounced in the corpus callosum, neocortex, and olfactory tubercle. These findings underscore the importance of including sex as a biological variable in rmTBI research and support the utility of this model for probing injury thresholds, regional vulnerability, and potential therapeutic interventions in repetitive head trauma.

Management of intracranial aneurysms: a 2024 nationwide study from China.

A Case Series of Ruptured Fungal Mycotic Pseudoaneurysms in Renal Transplant Patients.

Clinical laboratory testing of blood from patients presenting to the emergency department with acute bleeding due to factor Xa inhibitors: An unmet medical need.

Despite the involvement of the thalamus in the auditory pathway, hearing loss is not commonly recognized as a sequela of thalamic hemorrhage. Interestingly, only a few case reports in the literature describe thalamic hemorrhage as a cause of sudden sensorineural hearing loss (SSHL). The use of brainstem evoked potentials (BAEPs) to evaluate hearing loss in these patients has not been reported in the literature. A 56-year-old man presented to the emergency room for an acute onset of hearing loss and left perioral and foot numbness. On neurological examination, he was found to have mild left hemiparesis, sensory deficit, ataxia, and complete hearing loss. His National Institutes of Health Stroke Scale was 6. Initial noncontrast head computed tomography (CT) showed a focal acute parenchymal hemorrhage in the right thalamus and posterior limb of the internal capsule. Magnetic resonance imaging (MRI) of the brain confirmed the presence of the right thalamocapsular hematoma, and the gradient echo sequence demonstrated remote hematoma in the left lentiform nucleus. Otolaryngology was consulted and diagnosed the patient with idiopathic sudden sensorineural hearing loss. Given the unclear etiology, BAEPs were pursued and revealed an intact brainstem auditory pathway and suggested reduced activity in thalamic auditory regions. He was discharged on prednisone taper and referred for formal outpatient audiometry testing. This case highlights sensorineural hearing loss as a potential thalamic syndrome and the utilization of BAEPs as diagnostic tools in suspected central origin of hearing impairment.

We highlight the complex management considerations in a patient with cerebral amyloid angiopathy who developed venous thromboembolism, explicitly navigating the balance between risks of thromboembolism and bleeding with anticoagulation therapy. This case highlights a man in his 70s who presented to the emergency department with an acute right frontal intracerebral haemorrhage secondary to cerebral amyloid angiopathy with an acute segmental pulmonary embolism managed with an inferior vena cava (IVC) filter. During hospitalisation, the patient developed a large expansile thrombus extending inferior from the IVC filter to the right popliteal vein. This necessitated the initiation of anticoagulation therapy, beginning with unfractionated heparin, transitioning to enoxaparin and ultimately to apixaban. He was treated with 3 months of anticoagulation with no haemorrhagic complications. The patient's successful outcome underscored the potential for safe and effective anticoagulation management in this complex clinical scenario.

Ultrasound-guided mini-midline catheter technique in patients with acute gastrointestinal bleeding

Key scientific gaps and unmet needs in wired magnetic-assisted capsule endoscopy for acute upper gastrointestinal bleeding

Preemptive TIPS in patients with cirrhosis and acute variceal bleeding related to gastric varices: The GAVAPROSEC trial.