Careful Review Research Articles

Defusing the legal and ethical minefield of epigenetic applications in the military, defense, and security context

Abstract Epigenetic research has brought several important technological achievements, including identifying epigenetic clocks and signatures, and developing epigenetic editing. The potential military applications of such technologies we discuss are stratifying soldiers’ health, exposure to trauma using epigenetic testing, information about biological clocks, confirming child soldiers’ minor status using epigenetic clocks, and inducing epigenetic modifications in soldiers. These uses could become a reality. This article presents a comprehensive literature review, and analysis by interdisciplinary experts of the scientific, legal, ethical, and societal issues surrounding epigenetics and the military. Notwithstanding the potential benefit from these applications, our findings indicate that the current lack of scientific validation for epigenetic technologies suggests a careful scientific review and the establishment of a robust governance framework before consideration for use in the military. In this article, we highlight general concerns about the application of epigenetic technologies in the military context, especially discrimination and data privacy issues if soldiers are used as research subjects. We also highlight the potential of epigenetic clocks to support child soldiers’ rights and ethical questions about using epigenetic engineering for soldiers’ enhancement and conclude with considerations for an ethical framework for epigenetic applications in the military, defense, and security contexts.

Azathioprine induced acute sialadenitis: A case report

Key clinical messagePatients presenting with acute sialadenitis need careful review of their medications. Azathioprine is one of such drugs, which can rarely induce acute sialadenitis. Prompt discontinuation of the medication leads to reversal of the patient condition.AbstractAcute sialadenitis is one of the rare adverse effects of azathioprine. We report a case of acute submandibular sialadenitis following initiation of azathioprine which resolved upon discontinuation of the drug.

Outcomes of a multifaceted intervention to prevent eclampsia and eclampsia-related deaths in Nigerian referral facilities.

Eclampsia causes maternal mortality in Nigeria. This study presents the effectiveness of multifaceted interventions that addressed institutional barriers in reducing the incidence and case fatality rates associated with eclampsia. The design was quasi-experimental and the activities implemented at intervention hospitals included a new strategic plan, retraining health providers on eclampsia management protocols, clinical reviews of delivery care and educating pregnant women and their partners. Prospective data were collected monthly on eclampsia and related indicators from study sites over 2y. The results were analysed by univariate, bivariate and multivariable logistic regression. The results show a higher eclampsia rate (5.88% vs 2.45%) and a lower use of partograph and antenatal care (ANC; 17.99% vs 23.42%) in control compared with intervention hospitals, but similar case fatality rates of <1%. Overall, adjusted analysis shows a 63% decrease in the odds of eclampsia at intervention compared with control hospitals. Factors associated with eclampsia were ANC, referral for care from other facilities and older maternal age. We conclude that multifaceted interventions that address challenges associated with managing pre-eclampsia and eclampsia in health facilities can reduce eclampsia occurrence in referral facilities in Nigeria and potential eclampsia death in resource-poor African countries.

Fahr disease presenting with multiple cerebral calcifications

Fahr disease, also known as idiopathic basal ganglion calcification, is a rare and genetically heterogeneous neurological disorder. Herein, we report a rare case of Fahr disease presenting with multiple cerebral calcifications. A 63-year-old woman presented with dizziness to a local clinic. Brain computed tomography performed on admission revealed multiple high-intensity lesions in both basal ganglia, both cerebellar hemispheres, and the left frontal lobe. In contrast, brain magnetic resonance imaging (MRI) showed no prominent lesions on T2- and T1-weighted images, and there was no contrast enhancement after gadolinium injection. However, multiple dark signals were detected on gradient echo MRI. The location and radiological appearance of the lesion resembled those of a physiological intracranial calcification, except for asymmetric calcification in both cerebellar hemispheres and the left frontal subcortical white matter. The patient was diagnosed with basal ganglion calcification with multiple cerebral cavernous malformations or, less likely, brain tumors. Through a careful radiological and clinical review, the calcifications were diagnosed as Fahr disease. Follow-up was planned. It is important to consider the presence of multiple intracranial calcifications in the basal ganglia, cerebellum, or deep subcortical white matter as a warning sign for Fahr disease.

Clinical audit to assess whether the current use of proton pump inhibitors in a general practice conforms to standard guidelines

Introduction: Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. The present clinical audit identifies the patients who are on Proton Pump Inhibitor (PPI) therapy and assess whether their indication for proton pump indicators is appropriate as per the standard guidelines. The data is collected by the personal interview of patients or their attenders and filled information in the questionnaires and results are analysed. Effective interventions are made and then a second phase audit is conducted. Again data is collected and results are analysed. Proton pump inhibitors (PPIs) are a group of drugs that cause pronounced and long-lasting reduction of gastric acid production. PPIs are frequently prescribed for inappropriate indications or for indications where their use offers little benefit. Inappropriate PPI use is a matter of great concern, especially in the elderly, who are often affected by multiple comorbidities and are taking multiple medications, and are thus at an increased risk of long-term PPI-related adverse outcomes as well as drug-to-drug interactions. Our audit aimed to assess whether the current use of proton pump inhibitors in a general practice conforms to standard guidelines. Results: Out of 205 patients, appropriate use was found in 176 cases, and inappropriate use of PPIs was found in 29 cases in phase I audit. After intervention, Phase II audit is conducted and results are evaluated. Out of 250 patients, appropriate use was found in 248 cases, and inappropriate use of PPIs was found in 2 cases in phase II audit. The inappropriate use of proton pump inhibitors was decreased in the Phase II by around 14.2%, when compared to the Phase I audit. Conclusion: The present clinical audit showed the usage pattern of PPIs in a wide range of indications. PPIs should be used only when there is valid documented evidence and when their use is clinically justified. This clinical audit has strongly highlighted that there is inappropriate use of PPI as add on drug for corticosteroids. Various efforts should be made to reduce the unnecessary use of PPIs to minimize drug interactions, related risks, adverse effects and health care costs.

002 National clinical audit on the management of Stevens–Johnson syndrome/toxic epidermal necrolysis in adults

Abstract UK guidelines for the management of Stevens–Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) in adults, published by the British Association of Dermatologists (BAD) in 2016, outline a set of audit standards (Creamer D, Walsh SA, Dziewulski P et al. U.K. guidelines for the management of Stevens–Johnson syndrome/toxic epidermal necrolysis in adults 2016. Br J Dermatol 2016; 174:1194–227). Our aim was to audit the current management of SJS/TEN in adults against audit standards in the BAD guidelines. BAD members were invited to submit data on five consecutive adults with SJS/TEN per department over an 8-week period in 2022. All data were obtained from respondents using a Microsoft Excel spreadsheet proforma returned to the BAD by email. No patient-identifiable data were requested. Initial data extraction was conducted using a novel and reproducible program written in the R statistical language (V3.7 and the readxl, ggplot2 and ggthemes packages). The data analysis was also performed using Microsoft Excel. Thirty-nine (29%) dermatology centres in the UK participated and data for 147 adults with SJS/TEN were collected. Within 24 h of a diagnosis being made or suspected, the following were documented: Severity-of-Illness Score for TEN (SCORTEN) for 52% (n = 76/147) of submitted cases, list of medications for 77% (n = 113) and timelines for commencement/alterations of medications for 71% (n = 104). Initial assessment was of the eyes (by an ophthalmologist) for 48% (n = 71) of cases, the mouth in 88% (n = 130), the genital skin in 70% (n = 103) and the urinary tract in 63% (n = 93). In the first 10 days after a suspected or confirmed diagnosis of SJS/TEN, daily assessments of the mouth were documented in 18% (n = 26) of cases, the eyes in 8% (n = 12) and the urinary tract and genital skin in 10% (n = 14). Documentation regarding advice on (i) avoidance of the culprit drug was present for 58% (n = 76/130) of cases and (ii) request for a medic alert bracelet/amulet in 6% (n = 9/147). In adults with SJS/TEN, drug causality assessment was documented adequately. Initial assessment of the mouth, eyes, urinary tract and genital skin was good to fair; however, daily assessments were poor. Other audit standards that require improving include documentation of SCORTEN and advice to avoid the culprit drug and request a medic alert bracelet/amulet. In adults with SJS/TEN, there are multiple points in the assessment pathway that require careful documentation and regular review. These are a challenge for many clinical inpatient environments. Care within a burns unit or similar may not be possible for all. This audit suggests that some form of assessment and clinical review checklist might enable colleagues to maintain standards outlined in the guideline. Among these, use of SCORTEN, advice to avoid the culprit drug and requests for a Medic Alert bracelet/amulet are key.

What to expect after revision shoulder arthroplasty? A comprehensive review of the literature.

The number of shoulder arthroplasties has increased tremendously over the last twenty years, creating a proportional increase in complications rates and revision. Shoulder arthroplasty surgeon should have a clear understanding of the reasons for failure based on the specific index procedure that was performed. The main challenge includes the need for component removal and managing glenoid and humeral bone defects. This manuscript aims to outline the most common indications for revision surgery and treatment options based on a careful and detailed review of the available literature. This paper should help the surgeon in patient evaluation and selection of the optimal procedure for an individual patient.

The Relationship between Thyroid Disease and Diabetes a Retrospective Descriptive Study

From January of 2017 to January of 2018, 1,683 individuals seeking Endocrinology Department services at the Hayatabad Medical Complex (HMC) in Peshawar, Pakistan were evaluated, and 350 of them were diagnosed with thyroid disease in addition to diabetes. Through analyzing the data, it was discovered that those suffering from both ailments had heightened thyroid-stimulating hormone (TSH) levels, body mass index (BMI), and age. This data unmistakably shows that there is a favorable correlation between the two conditions. Reducing morbidity and mortality in individuals with both diabetes and thyroid disease may be achievable through timely diagnosis and appropriate care, as the data indicates. Furthermore, in the field of healthcare, the findings of this investigation have the potential to guide future research and policy decisions for HMCs and comparable healthcare environments, regarding the issue of diabetes and thyroid disease. Objectives: Endocrinology Department in HMC Peshawar's patients from Jan 2017 to Jan 2018 have their correlation between thyroid disease and diabetes extensively studied by this research's aim. Methods: From January 2017 to January 2018, all patients who were 18 years or older and underwent evaluation at the Department of Endocrinology in HMC, Peshawar were included in this retrospective descriptive study. Most of the patients who had thyroid disease and diabetes were female, comprising 71.7% of the sample, with an average age of 52.7 11.6 years. The mean BMI was 28.3 6.2 kg/m2. The mean TSH level of patients with thyroid disease and diabetes was found to be 5.8-2.5 mIU/L. Demographic and clinical data were collected through careful review of patient medical records. Thyroid-stimulating hormone (TSH) level, treatment outcome, age, sex, BMI, and history of diabetes/thyroid disease were all noted in the gathered data. Results: In the department of endocrinology at HMC, 1683 patients were assessed during the study period, and among them, 350 were found to have thyroid disease and diabetes. As for gender division, most patients with both conditions were female (71.7%). Their average age was 52.7 11.6 years, and they had a mean BMI of 28.3 6.2 kg/m2. The TSH level in these patients averaged 5.8–2.5 mIU/L. On the whole, 97.1% of patients responded well to treatment, managing to either achieve remission or gain partial relief. Conclusion: The results of this study indicate that there is a positive correlation between diabetes and thyroid disease. The study also revealed that BMI, age, and TSH levels were significantly higher among those with diabetes and thyroid disease. These findings highlight the importance of early detection and effective management of both conditions to reduce morbidity and mortality in patients with diabetes and thyroid disease. The results of this study can also be used to inform future research and healthcare policies to address the issue of diabetes and thyroid disease in HMC and other healthcare settings. Keywords: diabetes, thyroid disease, correlation, HMC Peshawar, BMI, TSH, treatment, morbidity, mortality

ChatGPT У ПІДГОТОВЦІ ФІЛОЛОГІВ І ПЕРЕКЛАДАЧІВ. ВИКЛИКИ І ПЕРСПЕКТИВИ

The article deals with the challenges and perspectives of using artificial intelligence tools based on the large language models in the practice of training professionals in linguistic and translation fields of study at higher education institutions. Based on the analysis of scientific publications, the methodical principles of correct and academically integer application of the artificial intelligence tools in pedagogical and translation practice have been outlined. Founded on the example of ChatGTP, the concept of the principal compatibility of its use with the norms of academic integrity has been suggested – for the improvement of learning outcomes of students and for the forming of critical rational thinking and optimization of time and resources use as well. Based on the personal pedagogic experience of the authors in teaching non-related – informational technological and philological disciplines and on the empirical material of completed classes with the use of ChatGTP, the weak points of artificial intelligence systems in the training of philologists and translators, the risks of their uncritical use, restricted efficiency in forming of professional competencies and especially of common background knowledge has been analyzed. The conclusion has been made about the necessity of combination the use of artificial intelligence in the real time mood with the forming methods of elaborated creative teaching tasks that do not provoke the plagiarism and about the increase of the share of vivid communication in foreign languages in practice of teaching linguistic and translation disciplines to prevent the domination of the hybrid quasi-communication with the chat-bot. At the same time, the positive role of artificial intelligence in generation of the text information with the correct, academically integer reference to its source and in the practical written translation of the narrow-specialized terminologically intensive text by their careful reviewing has been stated.

New records of euglenoid algae from Surma river in Bangladesh

Eight species of Euglenophyceae from Surmariverin Bangladesh are reported in this paper. The species are: Euglena hyaline Klebs, E. robertilamii Lefèvre , Phacus gigas Da Cunha, P. pseudoplatalea Pochm., P. triqueter (Ehr.) Duj.var. oblonga Shi, Trachelomonas scabra Playf. var. labiata (Teiling) H.-P., Trachelomonas spiculifera Palmer, and T.umbili copora Conradare. After a careful review on the list of euglenoid algae of Bangladesh, all these eight species are found to be new addition, and hitherto described here for the first time in Bangladesh. Bangladesh J. Plant Taxon. 30(1): 107-110, 2023 (June)

915-P: Euglycemic Ketoacidosis in Type 1 Diabetes on an Automated Insulin Delivery System after Bariatric Surgery—A Case Series

Obesity is an increasing concern in patients with type 1 diabetes. Bariatric surgery is an effective option for weight loss and is associated with an improvement in metabolic complications. We report 2 cases of adults with type 1 diabetes using automated insulin delivery where laparoscopic sleeve gastrectomy was complicated post-operatively by euglycemic ketoacidosis. The first case was of a 28-year-old man using Control-IQ (HbA1c 7.3%, body mass index 40, and insulin requirements 0.98 Units/kg/day). His insulin requirements and carbohydrate intake decreased from 108 units and 208 grams respectively to 44 units and 8 grams during the preoperative liquid diet. His lack of carbohydrate consumption continued post-operatively. Two days after his surgery, he presented to the emergency department with nausea, where his glucose level was 12.8 mmol/L, venous pH level 7.30, venous bicarbonate concentration 20.9 mmol/L, and plasma beta-hydroxybutyrate 4.5 mmol/L. He was treated with intravenous hydration with supplementation dextrose with observation. The second case was of a 33-year-old woman using the MiniMed 770G (HbA1c 7.0%, body mass index 44, insulin requirements 0.4 units/kg/day). Post-operative day 16, she presented to the emergency department with nausea and vomiting. Her glucose level was 11.9 mmol/L venous pH was 7.31, venous bicarbonate was 17 mmol/L, and positive urinary ketones. Daily insulin requirements had reduced (from preoperatively to post-operatively) from 35.8 to 16.3 Units per day, with her carbohydrate intake from 86 to 33 grams. She was treated with intravenous insulin. Though euglycemic ketoacidosis is documented after bariatric surgery and starvation, automated insulin delivery (particularly unnoticed insulin changes) may have influenced glycemia and acidosis. Careful review of insulin administration, carbohydrate intake, and ketone monitoring is recommended in these cases. Disclosure M.Pasqua: None. M.Tsoukas: Speaker's Bureau; Novo Nordisk Canada Inc., Boehringer Ingelheim (Canada) Ltd., Eli Lilly and Company, Janssen Scientific Affairs, LLC, AstraZeneca, Sanofi. W.Hu: None.

Out with AI, in with the psychiatrist: a preference for human-derived clinical decision support in depression care

Advancements in artificial intelligence (AI) are enabling the development of clinical support tools (CSTs) in psychiatry to facilitate the review of patient data and inform clinical care. To promote their successful integration and prevent over-reliance, it is important to understand how psychiatrists will respond to information provided by AI-based CSTs, particularly if it is incorrect. We conducted an experiment to examine psychiatrists’ perceptions of AI-based CSTs for treating major depressive disorder (MDD) and to determine whether perceptions interacted with the quality of CST information. Eighty-three psychiatrists read clinical notes about a hypothetical patient with MDD and reviewed two CSTs embedded within a single dashboard: the note’s summary and a treatment recommendation. Psychiatrists were randomised to believe the source of CSTs was either AI or another psychiatrist, and across four notes, CSTs provided either correct or incorrect information. Psychiatrists rated the CSTs on various attributes. Ratings for note summaries were less favourable when psychiatrists believed the notes were generated with AI as compared to another psychiatrist, regardless of whether the notes provided correct or incorrect information. A smaller preference for psychiatrist-generated information emerged in ratings of attributes that reflected the summary’s accuracy or its inclusion of important information from the full clinical note. Ratings for treatment recommendations were also less favourable when their perceived source was AI, but only when recommendations were correct. There was little evidence that clinical expertise or familiarity with AI impacted results. These findings suggest that psychiatrists prefer human-derived CSTs. This preference was less pronounced for ratings that may have prompted a deeper review of CST information (i.e. a comparison with the full clinical note to evaluate the summary’s accuracy or completeness, assessing an incorrect treatment recommendation), suggesting a role of heuristics. Future work should explore other contributing factors and downstream implications for integrating AI into psychiatric care.

Neuroimaging of complications arising after CD19 chimeric antigen receptor T-cell therapy: A review.

Chimeric antigen receptor (CAR) T cells targeting the CD19 (cluster of differentiation 19) cell surface glycoprotein have emerged as a highly effective immunologic therapy in patients with relapsed or refractory B-cell malignancies. The engagement of CAR T cells with CD19 on the surface of neoplastic B cells causes a systemic cytokine release, which can compromise the blood-brain barrier and cause an immune effector cell-associated neurotoxicity syndrome (ICANS). In a small proportion of ICANS patients who demonstrate neuroimaging abnormalities, certain distinct patterns have been recognized, including signal changes in the thalami, external capsule, and brainstem, the subcortical and/or periventricular white matter, the splenium of the corpus callosum, and the cerebellum. On careful review of the underlying pathophysiology of ICANS, we noticed that these changes closely mirror the underlying blood-brain barrier disruption and neuroinflammatory and excitotoxic effects of the offending cytokines released during ICANS. Furthermore, other uncommon complications of CD19 CAR T-cell therapy such as posterior reversible encephalopathy syndrome, ocular complications, and opportunistic fungal infections can be catastrophic if not diagnosed in a timely manner, with neuroimaging playing a significant role in management. In this narrative review, we will summarize the current literature on the spectrum of neuroimaging findings in ICANS, list appropriate differential diagnoses, and explore the imaging features of other uncommon central nervous system complications of CD19 CAR T-cell therapy using illustrative cases from two tertiary care institutions.

A Series of 69 COVID-related Dermatoses With Biopsy, Immunohistochemistry With Anti-spike 3, in situ Hybridization and PCR: A Critical Reappraisal of Viral Involvement in COVID-19 Skin Lesions

BackgroundDespite the large number of articles published on skin lesions related to COVID-19, clinicopathological correlation has not been performed consistently and immunohistochemistry to demonstrate spike 3 protein expression has not been validated through RT-PCR. Material and methodsWe compiled 69 cases of patients with confirmed COVID-19, where skin lesions were clinically and histopathologically studied. Immunohistochemistry (IHC) and RT-PCR was performed in skin biopsies. ResultsAfter a careful review of the cases, 15 were found to be dermatosis not related to COVID-19, while the rest of the lesions could be classified according to their clinical characteristics as vesicular (4), maculopapular eruptions (41), urticariform (9), livedo and necrosis (10) and pernio-like (5). Although histopathological features were similar to previously reported results, we found two previously unreported findings, maculopapular eruptions with squamous eccrine syringometaplasia and neutrophilic epitheliotropism.IHC showed in some cases endothelial and epidermal staining but RT-PCR was negative in all the tested cases. Thus, direct viral involvement could not be demonstrated. ConclusionsDespite presenting the largest series of confirmed COVID-19 patients with histopathologically studied skin manifestations, direct viral involvement was difficult to establish. Vasculopathic and urticariform lesions seem to be those more clearly related to the viral infection, despite IHC or RT-PCR negative results failed to demonstrate viral presence. These findings, as in other dermatological areas, highlight the need of a clinico-pathological correlation to increase knowledge about viral involvement in COVID-19 skin-related lesions.

Patient-independent epileptic seizure detection by stable feature selection

The detection of epileptic seizures in EEG signals is a challenging task because it requires careful review of multi-channel EEG recordings over a lengthy time interval. In general, EEG-based seizure detection is strongly dependent on the ability to select descriptive features that are also stable in the sense that they are not sensitive to changes in the training data. This study proposes and investigates a patient-independent seizure detection model that uses stable EEG-based features obtained by comparing multiple feature selection methods. The schemes considered can be divided into five categories, often referred to as similarity, information theoretic, sparse learning, statistical, and graph centrality feature selection methods. The stability of the features these schemes produce was evaluated by random forest classification, using the intersection, frequency, correlation, and similarity measures. In experiments with Temple University Hospital’s Seizure database of EEG records of 341 patients, unsupervised graph centrality feature selection was the most effective method, with a correct classification rate of 91.5%.

Probiotics and the microbiota-gut-brain axis: focus on patients with depression. A review of current research.

This review covers recent data on the relationship between major depressive disorder (MDD) and faecal microbiome and examines the co-relations between the use of probiotics and changes in psychiatric state. We conducted a thorough search of academic databases for articles published between 2018 and 2022, using specific keywords and previously established inclusion/exclusion criteria regarding faecal microbiota, depressive disorder, and probiotics. Of 192 eligible articles (reviews, original papers, and clinical trials), we selected 10 that fully met our criteria and performed a careful review to determine any correlation between microbiome, probiotic treatment, and depression. All patients were adults (mean age, 36.8), with at least one MDD episode and onset of depression during adolescence (duration of 31.39 years of depressive episodes). We found mixed but mostly positive results regarding the influence of probiotic/prebiotic/postbiotic effects on depression. We could not identify the precise mechanism of action that led to their improvement. Antidepressants did not alter the microbiota, according to studies that evaluated this aspect. Probiotic/prebiotic/postbiotic treatments were proven to be safe, with few and mild side effects. Probiotics seemingly could be beneficial in patients with depression, as evidenced by well-established depression scales. Based on this finding and the high tolerability and safety of probiotics, no caveats against their routine use can be made. Some unmet needs in this field include determination of the dominant type of microbiota in specific patients with depression; study of microbiome-directed/driven treatment regarding dose and duration adjustments; and multiple versus single strain treatments.

Application of nonstationary extreme value analysis in the coastal environment – A systematic literature review

Coastal zones are among the most complex and dynamic areas on earth. Many marine and hydrologic processes act individually or combined in these areas and can lead to extreme events impacting coastal communities. Since coastal areas are densely populated and host many significant economic activities, understanding how these extremes are changing is crucial for integrated coastal zone management. More reliable and appropriate estimations of future extreme conditions in nearshore areas are urgently needed in light of the projected increases in the severity of future loading conditions combined with the limited residual service life of many existing coastal infrastructures. Considering the ever-growing adoption of nonstationary extreme value analysis as a reliable tool to study the evolution of extremes in coastal regions, this paper provides a systematic and comprehensive literature review on this topic. For this purpose, an automated search algorithm is used to retrieve the most relevant literature form the SCOPUS database. Then, after a careful review of the full texts, a set of articles and conference papers that fully match the purpose of the article are selected and classified based on 14 different categories. Moreover, research challenges and future research pathways regarding nonstationary extreme value analysis are highlighted and discussed.

Commissioning Children's Social Care

Government plans in the wake of the Care Review aim to tackle the challenging environment faced by commissioners, with increasing numbers of children in the system and inflation pushing up care fees

Exploring Radiation Oncology Representation on the National Board of Medical Examiners (NBME) Official Practice Material for the Undergraduate United States National Standardized Medical Board Examinations

Background The portrayal of oncology-related topics on the National Board of Medical Examiners (NBME) published practice material for undergraduate medical education (UGME) standardized examinations including the United States Medical Licensing Exams (USMLE) Step 1, Step 2 Clinical Knowledge (CK), and NBME Clinical Science Subject Examinations ('Shelf') is largely unknown. The goal of this study is to explore the presence and characterization of radiation oncology topics, including radiation therapy (RT), on these practice examinations. Methods All current and commercially accessible NBME published self-assessments and sample questions for the aforementioned examinations will be queried for content pertaining to oncology and associated treatment modalities of RT, surgery, and systemic therapy. The total volume of oncology-related questions and its distribution across all 3 major practice examination types will be recorded. The questions will be cataloged by selected attributes including context, treatment modality appearing as the correct answer for "next best step" (NBS) prompt, and answers appearing as the incorrect answer for NBS prompt. Results 1320 USMLE Step 1 practice questions are available for analysis. In preliminary analysis, minimal questions about RT were noted; all appearing to involve concepts of associated toxicity. 920 USMLE Step 2CK practice questions are available for analysis. RT-related questions appeared with higher frequency on the clinical science preparation material (n=10) compared to basic science (n=4), while also notably appearing as a listed answer choice for NBS prompt against other treatment modalities. 1325 practice questions from relevant NBME shelf examinations were available. RT appeared sparingly on the practice NBME shelf examinations of Surgery (n=5), Medicine (n=4), Ob/Gyn (n=2), and Clinical Neurology (n=2). RT questions were absent from Pediatrics, Emergency Medicine, and Family Medicine Shelf practice examination material. In the final analysis of these practice questions from all 3 major examination types, we seek to conduct a comparative analysis to other treatment modalities. Discussion This work represents the first attempt, to our knowledge, to characterize RT topic appearance within the NBME published practice questions and their accompanying explanations for the USMLE Step 1, Step 2CK, and select NBME shelf examinations. Our analysis is important in assessing the presence of RT topics on medical student board preparation material, a potential avenue of RT content exposure in UGME. Careful review and comparative analyses of all oncology-related content can provide important insight for UGME-related RT education. Our anticipated analyses and future discussion may identify areas for improvements in the important education of oncology-related topics in UGME. The portrayal of oncology-related topics on the National Board of Medical Examiners (NBME) published practice material for undergraduate medical education (UGME) standardized examinations including the United States Medical Licensing Exams (USMLE) Step 1, Step 2 Clinical Knowledge (CK), and NBME Clinical Science Subject Examinations ('Shelf') is largely unknown. The goal of this study is to explore the presence and characterization of radiation oncology topics, including radiation therapy (RT), on these practice examinations. All current and commercially accessible NBME published self-assessments and sample questions for the aforementioned examinations will be queried for content pertaining to oncology and associated treatment modalities of RT, surgery, and systemic therapy. The total volume of oncology-related questions and its distribution across all 3 major practice examination types will be recorded. The questions will be cataloged by selected attributes including context, treatment modality appearing as the correct answer for "next best step" (NBS) prompt, and answers appearing as the incorrect answer for NBS prompt. 1320 USMLE Step 1 practice questions are available for analysis. In preliminary analysis, minimal questions about RT were noted; all appearing to involve concepts of associated toxicity. 920 USMLE Step 2CK practice questions are available for analysis. RT-related questions appeared with higher frequency on the clinical science preparation material (n=10) compared to basic science (n=4), while also notably appearing as a listed answer choice for NBS prompt against other treatment modalities. 1325 practice questions from relevant NBME shelf examinations were available. RT appeared sparingly on the practice NBME shelf examinations of Surgery (n=5), Medicine (n=4), Ob/Gyn (n=2), and Clinical Neurology (n=2). RT questions were absent from Pediatrics, Emergency Medicine, and Family Medicine Shelf practice examination material. In the final analysis of these practice questions from all 3 major examination types, we seek to conduct a comparative analysis to other treatment modalities. This work represents the first attempt, to our knowledge, to characterize RT topic appearance within the NBME published practice questions and their accompanying explanations for the USMLE Step 1, Step 2CK, and select NBME shelf examinations. Our analysis is important in assessing the presence of RT topics on medical student board preparation material, a potential avenue of RT content exposure in UGME. Careful review and comparative analyses of all oncology-related content can provide important insight for UGME-related RT education. Our anticipated analyses and future discussion may identify areas for improvements in the important education of oncology-related topics in UGME.

Development of coronary artery disease in a young adult with Takayasu's arteritis: the lesser, the better

Large vessel vasculitis, such as Takayasu's arteritis (TA), is a rare inflammatory disease affecting multiple vascular districts including the coronary arteries, producing either stenosis and/or aneurysms: these lesions can be found in the same patient and also in the same vessel, with potentially devastating effects. Moreover, TA often affects young people, in the midst of their work and social activity. Ischemic heart disease is the leading cause of cardiovascular mortality in Western countries and is mainly due to coronary atherosclerosis, whose etiopathogenesis is multifactorial and is closely related to the concomitant presence of classic cardiovascular risk factors and inflammation of the vessel wall. We report the case of a young, physically active adult with multivessel coronary artery disease developed in the context of a TA bursted 7 years before and currently in clinical remission. This complex case required a careful literature review and a multidisciplinary approach, since the best treatment option for coronary lesions induced by TA has not been established: a "watchful waiting" strategy was eventually adopted, considering the poor outcome of both percutaneous and surgical revascularization in this group of patients.