Clinical Considerations Research Articles

Design and Pilot Implementation of an ECHO Module to Facilitate Treatment of Hepatitis C Virus Infection During Pregnancy

Abstract Background Pregnant patients are largely excluded from Hepatitis C virus (HCV) research and treatment. Studies show that pregnant patients want to discuss treatment while providers feel they lack the knowledge and training for these discussions. To bridge this gap, we designed an ECHO module about management of HCV in pregnancy and infancy. Methods Content experts from pediatric infectious diseases, hepatology, maternal-fetal medicine, bioethics and members of ECHO-Chicago discussed: prior data, potential topics, target audience and scheduling of sessions. We held 8 one-hour sessions with 20-30 minutes of didactics and 30-40 minutes of solicited case discussion. Participants included those who participated in prior ECHO training and prenatal providers in local and regional practices. A 7-point Likert scale pre- and post-training survey was administered to assess metrics of self-efficacy for management of HCV in pregnancy and childhood. Results The sessions were conducted from May to June 2023 on the following topics: HCV screening; HCV pathophysiology/clinical presentations; staging fibrosis in HCV; HCV Treatment in non-pregnant patients; harm reduction; clinical considerations of HCV in pregnancy; shared decision-making for HCV treatment in pregnancy; and HCV screening in infants & treatment for children. Fourteen participants completed pre- and post-surveys. In the pre-survey, participants had low ratings of self-efficacy (average 3.0). In the post-survey (Table 1), participants reported dramatic increases in all areas (average 5.2, increase of 2.2) with the largest in the following areas: “Ability to discuss and manage timing of hepatitis C treatment in a pregnant person”, average 5.1, increase of 3; “Ability to identify suitable pregnant candidates for treatment for Hepatitis C”, average 5.2, increase of 2.7. For context, a 1-point increase in self-efficacy is considered meaningful. All respondents reported increased ability to address HCV in a preconception, pregnant, postpartum, or neonatal population. Conclusion As pivotal studies of pan-genotypic antivirals indicate efficacy and safety during pregnancy, this ECHO module could be distributed to support providers who are discussing therapy initiation. Table 1: Average Change in Self-Efficacy between Pre- & Post-Series Surveys

Pediatric Obesity Pharmacotherapy: State of the Science, Research Gaps, and Opportunities.

Pediatric obesity is a major public health problem, affecting nearly 20% of children and adolescents living in the United States. In 2023, the American Academy of Pediatrics released its first clinical practice guideline for the evaluation and management of child and adolescent obesity and recommended integrating health behavior and lifestyle interventions with pharmacological treatment when medically indicated. However, there is a limited evidence base to guide antiobesity medication treatment decisions in clinical practice and limited data on long-term safety during this critical period of growth and development in youth. Thus, in November of 2023, the National Institute of Diabetes and Digestive and Kidney Diseases sponsored a workshop to identify knowledge gaps and opportunities for research on the use of pharmacotherapy for obesity in children and adolescents. Leading scientific and clinical experts in obesity pathophysiology and treatment, pharmacotherapy, clinical trial design, and health equity and disparities, among others, identified gaps in clinical trial design, guidance for clinical use of medications in children and adolescents, additional treatment outcomes beyond body fat or weight, and improvement in care delivery. Adolescent patients and caregivers with lived experience of obesity and weight management were also invited to participate in a panel discussion, providing personal perspectives on living with obesity, clinical care considerations, and research needs. This article summarizes the workshop proceedings on the state of the science and identifies gaps and opportunities for future research to inform optimal and equitable medical management of children and adolescents with obesity.

Major clinical relevance and considerations of zygomatic implants in elderly patients: a systematic review

For decades, zygomatic implants (ZI) have been used to rehabilitate atrophic maxillae and reconstruct maxillary defects, demonstrating significant survival rates, and have emerged as an alternative to extensive bone grafting. Despite their efficacy, surgical techniques for ZI placement have consistently been associated with perioperative complications, with additional problems arising later, especially in elderly patients. Objective: The present study developed a systematic review to address the main clinical relevance and considerations of zygomatic implants in elderly patients. Methods: The present study followed a concise systematic review model. The search was carried out in the PubMed, Embase, Ovid, Cochrane Library, Web of Science, and Scopus databases. The quality of the studies was based on the GRADE instrument and the risk of bias was analyzed according to the Cochrane instrument. Results and Conclusion: A total of 220 articles were found. In total, 77 articles were fully evaluated and 57 were included and evaluated in this study, and of the total of 57 articles, only 42 articles were developed in the item results of the systematic review. Of the initial total of articles, 108 articles were excluded because they did not meet the GRADE and AMSTAR-2 classification, and 20 were excluded because they presented a risk of bias that could compromise the credibility of the studies. The symmetric funnel plot does not suggest a risk of bias. According to the GRADE instrument, most studies presented homogeneity in their results, with X2=85.6%>50%. It was concluded the ZI has a high rate of survival accumulated in 12 years, with the majority of failures occurring in the early stages of the postoperative period. The main complication observed related to zygomatic implants in elderly patients was sinusitis, which can appear several years after implantation surgery. The presence of increased maxillary sinus pneumatization with advanced resorption of the posterior alveolus may result in insufficient bone to anchor the implant. Bone augmentation is generally necessary under these conditions to allow the placement of a sufficient number and length of implants. Another more serious condition would be defects of maxillectomy, aplasia of the maxillary sinus, and cleft deformities. Zygomatic implants appear to be a consolidated therapeutic option for a significantly atrophic maxilla in elderly patients, offering a promising alternative to costly heavy bone graft techniques, fewer complications, less time for rehabilitation, less required prosthodontic work, and significantly higher survival rates.

Ninth Version of the AJCC and UICC Nasopharyngeal Cancer TNM Staging Classification

Accurate staging is a fundamental step in treating patients with nasopharyngeal carcinoma (NPC) worldwide; this is crucial not only for prognostication, but also for guiding treatment decisions. The American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) tumor-node-metastasis (TNM) system is the global language for clinicians, researchers, and cancer registries. Continual improvement that aligns with contemporary pattern of care is essential. To improve the prognostic accuracy and clinical applicability of the eighth edition (TNM-8) for NPC. This multicenter study analyzed patients with NPC with detailed tumor features during January 2014 and December 2015 and was reviewed by experienced radiologists. The data analysis was completed in December 2023. The findings were further confirmed with internal and external validation. Statistical analyses and clinical considerations were reviewed by the AJCC/UICC multidisciplinary head and neck panels and attained consensus. The recommendations were evaluated by the AJCC Evidence-Based Medicine Committee before final endorsement as the ninth version (TNM-9). The primary end point was overall survival. Adjusted hazard ratios of different subgroups were then assessed for confirmation of optimal stage grouping. Of the 4914 patients analyzed, 1264 (25.7%) were female and 3650 (74.3%) were male; the median (SD) age was 48.1 (12.0) years. Advanced radiological extranodal extension (with involvement of adjacent muscles, skin, and/or neurovascular bundles) was identified as an independent adverse factor for all end points: this was added as a criterion for N3. Patients with nonmetastatic disease were regrouped into stages I to III instead of TNM-8 stages I to IVA. Significant hazard discrimination was achieved by grouping T1-2N0-1 as stage I, T3/N2 as stage II, and T4/N3 as stage III. Although the T1-2N0-1 subgroups had comparable 5-year overall survival, subdivisions into IA (T1-T2N0) and IB (T1-T2N1) were recommended due to the distinction in adjusted hazard ratios following adjustment for chemotherapy use. Metastatic disease was exclusively classified as stage IV, and prognostication was further refined by subdivision into IVA (M1a, ≤3 lesions) and IVB (M1b, >3 lesions). TNM-9 demonstrated superiority compared with TNM-8 in major statistical aspects. The results of this diagnostic study suggest that the ninth version of TNM staging for NPC, based on robust analyses and a comprehensive review by the AJCC/UICC staging committees, provides an improved staging system for global application and a framework for future incorporation of nonanatomical factors. This will be launched for global application in January 2025.

The Design Features, Quality by Design Approach, Characterization, Therapeutic Applications, and Clinical Considerations of Transdermal Drug Delivery Systems—A Comprehensive Review

Transdermal drug delivery systems (TDDSs) are designed to administer a consistent and effective dose of an active pharmaceutical ingredient (API) through the patient’s skin. These pharmaceutical preparations are self-contained, discrete dosage forms designed to be placed topically on intact skin to release the active component at a controlled rate by penetrating the skin barriers. The API provides the continuous and prolonged administration of a substance at a consistent rate. TDDSs, or transdermal drug delivery systems, have gained significant attention as a non-invasive method of administering APIs to vulnerable patient populations, such as pediatric and geriatric patients. This approach is considered easy to administer and helps overcome the bioavailability issues associated with conventional drug delivery, which can be hindered by poor absorption and metabolism. A TDDS has various advantages compared to conventional methods of drug administration. It is less intrusive, more patient-friendly, and can circumvent first pass metabolism, as well as the corrosive acidic environment of the stomach, that happens when drugs are taken orally. Various approaches have been developed to enhance the transdermal permeability of different medicinal compounds. Recent improvements in TDDSs have enabled the accurate administration of APIs to their target sites by enhancing their penetration through the stratum corneum (SC), hence boosting the bioavailability of drugs throughout the body. Popular physical penetration augmentation methods covered in this review article include thermophoresis, iontophoresis, magnetophoresis, sonophoresis, needle-free injections, and microneedles. This review seeks to provide a concise overview of several methods employed in the production of TDDSs, as well as their evaluation, therapeutic uses, clinical considerations, and the current advancements intended to enhance the transdermal administration of drugs. These advancements have resulted in the development of intelligent, biodegradable, and highly efficient TDDSs.

Emerging Role of Natriuretic Peptides in Diabetes Care: A Brief Review of Pertinent Recent Literature

Diabetes markedly increases susceptibility to adverse cardiovascular events, including heart failure (HF), leading to heightened morbidity and mortality rates. Elevated levels of natriuretic peptides (NPs), notably B-type natriuretic peptide (BNP) and N-terminal-proBNP (NT-proBNP), correlate with cardiac structural and functional abnormalities, aiding in risk stratification and treatment strategies in individuals with diabetes. This article reviews the intricate relationship between diabetes and HF, emphasizing the role of NPs in risk assessment and guiding therapeutic strategies, particularly in individuals with type 2 diabetes mellitus (T2DM). We also explore the analytical and clinical considerations in the use of natriuretic peptide testing and the challenges and prospects of natriuretic-peptide-guided therapy in managing cardiovascular risk in patients with diabetes. We conclude with some reflections on future prospects for NPs.

Current landscape of cystic fibrosis gene therapy.

Cystic fibrosis is a life-threatening disease that is caused by mutations in CFTR, a gene which encodes an ion channel that supports proper function of several epithelial tissues, most critically the lung. Without CFTR, airway barrier mechanisms are impaired, allowing for chronic, recurrent infections that result in airway remodeling and deterioration of lung structure and function. Small molecule modulators can rescue existing, defective CFTR protein; however, they still leave a subset of people with CF with no current disease modifying treatments, aside from lung transplantation. Gene therapy directed to the lung is a promising strategy to modify CF disease in the organ most associated with morbidity and mortality. It is accomplished through delivery of a CFTR transgene with an airway permissive vector. Despite more than threedecades of research in this area, a lung directed gene therapy has yet to be realized. There is hope that with improved delivery vectors, sufficient transduction of airway cells can achieve therapeutic levels of functional CFTR. In order to do this, preclinical programs need to meet a certain level of CFTR protein expression in vitro and in vivo through improved transduction, particularly in relevant airway cell types. Furthermore, clinical programs must be designed with sensitive methods to detect CFTR expression and function as well as methods to measure meaningful endpoints for lung structure, function and disease. Here, we discuss the current understanding of how much and where CFTR needs to be expressed, the most advanced vectors for CFTR delivery and clinical considerations for detecting CFTR protein and function in different patient subsets.

Prevalence and characteristics of lumbar ribs: a meta-analysis with anatomical and clinical considerations.

Lumbar ribs (LR) are a rare and relatively unknown anatomical abnormality of the lumbar spine. The literature provides better understanding regarding other spinal congenital variations like cervical ribs or lumbosacral transitional vertebrae, which are rather commonly recognised conditions. Thus, this meta-analysis aimed to provide data on prevalence and key characteristics of LR. Relevant databases were systematically searched for studies reporting the prevalence, laterality and geographic distribution of LR. No exclusion criteria based on language and date of original articles were employed. The pooled prevalence estimates (PPE) were calculated using a random-effects model. To assess the between-study heterogeneity, the I2 statistic and Chi-square test were utilized. Throughout the investigation, the PRISMA guidelines were adhered to scrupulously. Evaluation of the included studies' reliability was made with the AQUA tool. In total, 9 studies were included in this meta-analysis. The pooled prevalence estimate (PPE) of LR was 2.1% (95%CI: 1.0-4.6). In studies based on CT imaging, LR were found in 1.6% (95%CI: 0.6-4.3) of patients and in Xray based studies in 2.1% (95%CI: 0.4-11.1) of patients. Lumbar ribs were bilateral in majority of individuals (65.4%, 95%CI: 39.4-84.6) and could be most frequently encountered in Europe with PPE of 2.8% (95%CI: 3.0-20.0), then in East Asia with PPE of 1.5% (95%CI: 1.0-19.2) and Middle East with PPE of 1.1% (95%CI: 0.6-20.0). The findings of our study indicate that LR are a common anatomical variation of lumbar spine, contrary to previous beliefs. In a clinical practice, when a patient presents with a non-specific low back pain, a possible occurrence of LR should be taken into consideration. The presence of LR may be misleading for surgeons and result in wrong-level spine surgeries.

Animal models in neuroscience with alternative approaches: Evolutionary, biomedical, and ethical perspectives.

Animal models have been a crucial tool in neuroscience research for decades, providing insights into the biomedical and evolutionary mechanisms of the nervous system, disease, and behavior. However, their use has raised concerns on several ethical, clinical, and scientific considerations. The welfare of animals and the 3R principles (replacement, reduction, refinement) are the focus of the ethical concerns, targeting the importance of reducing the stress and suffering of these models. Several laws and guidelines are applied and developed to protect animal rights during experimenting. Concurrently, in the clinic and biomedical fields, discussions on the relevance of animal model findings on human organisms have increased. Latest data suggest that in a considerable amount of time the animal model results are not translatable in humans, costing time and money. Alternative methods, such as invitro (cell culture, microscopy, organoids, and micro physiological systems) techniques and in silico (computational) modeling, have emerged as potential replacements for animal models, providing more accurate data in a minimized cost. By adopting alternative methods and promoting ethical considerations in research practices, we can achieve the 3R goals while upholding our responsibility to both humans and other animals. Our goal is to present a thorough review of animal models used in neuroscience from the biomedical, evolutionary, and ethical perspectives. The novelty of this research lies in integrating diverse points of views to provide an understanding of the advantages and disadvantages of animal models in neuroscience and in discussing potential alternative methods.

Early intervention of unerupted maxillary central incisor: A case series

Early intervention of an impacted maxillary central incisor is crucial to avoid space loss with tipping of the adjacent teeth and allows normal root development. This case series demonstrates the clinical considerations of a surgical-orthodontic approach in managing this eruption anomaly and its challenges. All three cases involved young patients aged 7–9 years with an impacted upper left central incisor and a positive history of dental trauma. An upper sectional fixed appliance was bonded to facilitate the closed eruption of the impacted central incisor. The treatment duration increases when more space is required for the impacted tooth. There was a marginal gingival discrepancy of all the treated central incisors with vertical relapse seen upon review, indicating the need for a careful surgical approach with good hygiene maintenance and a bonded retainer as retention. Early referral for the management of an impacted maxillary central incisor through a surgical-orthodontic approach is often successful, but treatment risks, duration, and retention regimen should be discussed with the parents for informed consent.

Program evaluation of a specialized treatment home for adults with severe challenging behavior

AbstractIndividuals with intellectual and developmental disabilities who engage in severe challenging behavior may comprise 5%–10% of the clinical population. Unfortunately, challenging behavior literature tends to underrepresent adult participants and emphasize efficacy (Does the intervention work?) more often than effectiveness (Does the intervention work in real world settings?). We conducted a systematic program evaluation to examine the effectiveness of a comprehensive behavioral treatment package using a hybrid quasi‐experimental consecutive case series design featuring eight adults who experienced the treatment package. The results depicted a substantial decrease in challenging behavior and increase in adaptive behavior across sessions for most participants. Impressive treatment integrity outcomes (M = 84%, range, 82%–90%) showcased that the intervention was implemented as intended. Social validity surveys administered to participants, caregivers, and case managers provide support for the acceptability of the treatment package. Project limitations, clinical considerations, and future directions are discussed.

2024 Systematic Review of Evidence-Based Guidelines for Prehospital Care

ABSTRACT Objectives Evidence-based guidelines (EBGs) are widely recognized as valuable tools to aggregate and translate scientific knowledge into clinical care. High-quality EBGs can also serve as important components of dissemination and implementation efforts focused on educating emergency medical services (EMS) clinicians about current evidence-based prehospital clinical care practices and operations. We aimed to perform the third biennial systematic review of prehospital EBGs to identify and assess the quality of prehospital EBGs published since 2021. Methods We systematically searched Ovid Medline and EMBASE from January 1, 2021, to June 6, 2023, for publications relevant to prehospital care, based on an organized review of the literature, and focused on providing recommendations for clinical care or operations. Included guidelines were appraised using the National Academy of Medicine (NAM) criteria for high-quality guidelines and scored using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Tool. Results We identified 33 new guidelines addressing clinical and operational topics of EMS medicine. The most addressed EMS core content areas were time-life critical conditions (n = 17, 51.5%), special clinical considerations (n = 15, 45%), and injury (n = 12, 36%). Seven (21%) guidelines included all elements of the National Academy of Medicine (NAM) criteria for high-quality guidelines, including the full reporting of a systematic review of the evidence. Guideline appraisals by the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool demonstrated modest compliance to reporting recommendations and similar overall quality compared to previously identified guidelines (mean overall domain score 67%, SD 12%), with Domain 5 (“Applicability”) scoring the lowest of the six AGREE II domains (mean score of 53%, SD 13%). Conclusions This updated systematic review identified and appraised recent guidelines addressing prehospital care and identifies important targets for education of EMS personnel. Continued opportunities exist for prehospital guideline developers to include comprehensive evidence-based reporting into guideline development to facilitate widespread implementation of high-quality EBGs in EMS systems and incorporate the best available scientific evidence into initial education and continued competency activities.

Embracing a different outlook: Strengths and goals of individuals currently in treatment for anorexia nervosa

PurposeDeveloping personal goals beyond weight and shape, and promoting the agency to pursue those goals, could aid in treatment and recovery from anorexia nervosa (AN). This research explores the strengths, interests and goals of individuals currently receiving treatment for AN and evaluates how treatment services are supporting them to work towards personal goals across all areas of everyday life.MethodA total of 58 community-dwelling adults currently receiving treatment for anorexia nervosa at any stage of recovery completed the Client Assessment of Strengths, Interests and Goals Self-Report (CASIG-SR). Participants reported their goals for accommodation, work and study, interpersonal relationships, recreational activities, spirituality, religion or life purpose, physical health and mental health, and the personal strengths and supports needed to achieve those goals. Concordance scores were calculated between importance of personal goals and level of support from current services regarding these goals.ResultsThemes identified across goals, strengths and supports were Connection, Independence & Confidence, Meaning & Self: The Real Me, and Stability & Balance. Work and study goals and strengths were identified strongly. The key support needed was stability from the current treatment team to provide a stable base for change. Concordance scores indicate support provided for personal goals was less than the importance of the goal to the individual.ConclusionResults suggest goals for everyday living are critical to recovery in anorexia nervosa. Specific clinical considerations to increase motivation and hope are increased access to peer support, a focus on increasing positive affect, supporting safe exercise and promoting outdoor experiences and connection with nature.Level IIIEvidence obtained from well-designed cohort or case–control analytic studies.

Quantifying the frequency modulation in electrograms during simulated atrial fibrillation in 2D domains

Atrial fibrillation (AF) affects millions of people in the world, causing increased morbidity and mortality. Treatment involves antiarrhythmic drugs and catheter ablation, showing high success for paroxysmal AF but challenges for persistent AF. Experimental evidence suggests reentrant waves and rotors contribute to AF substrates. Ablation procedures rely on electroanatomical maps and electrogram (EGM) signals; however, current methods used in clinical practice lack consideration for time–frequency varying EGM components. The fractional Fourier transform (FrFT) can be adopted to capture time-varying frequency components, thereby enhancing the comprehension of arrhythmogenic substrates during AF for improved ablation strategies. To this end, a FrFT-based algorithm is developed to characterize non-stationary components in EGM signals from simulated AF episodes. The proposed algorithm comprises a pre-processing step to enhance the coarser features of the EGM waveform, a windowing process for dynamic assessment of the EGM, and a FrFT order optimization stage that seeks compact signal representations in fractional Fourier domains. The resulting order is related to the rate of frequency change in the signal, making it a useful indicator for frequency-modulated components. The FrFT-based algorithm is implemented on EGM signals from AF simulations in 2D domains representing a region of the atrial tissue. Consequently, the computed optimum FrFT orders are used to build maps that are spatially correlated to the underlying propagation dynamics of the simulated AF episode. The results evince that the extreme values in the optimum orders map pinpoint the localization of fibrillatory mechanisms, generating EGM activation waveforms with varying frequency content over time.

Pneumatosis cystoides intestinalis in granulomatosis with polyangiitis: a case report.

This study aims to investigate the clinical manifestations, imaging features, and treatment considerations in the rare occurrence of pneumatosis cystoides intestinalis (PCI) within the context of granulomatosis with polyangiitis (GPA). We present the case of a 71-year-old Chinese woman diagnosed with GPA, who, despite exhibiting fatigue, knee pain, and nasosinusitis, remained asymptomatic for PCI. Regular follow-up revealed laboratory and imaging evidence indicative of clinical relapse. The patient received GPA treatment but was not specifically managed for PCI. Serial abdominal CT scans were performed to monitor the progression of PCI. Radiological diagnosis confirmed the presence of gas within the colon wall, indicating pneumatosis cystoides intestinalis. Notably, the patient remained asymptomatic for abdominal complaints. Despite ongoing GPA treatment, a follow-up CT scan 2months later revealed persistent gas within the colon wall, suggesting a persistent state of PCI. Patient consent was obtained for the publication of this case report, and ethical approval was not obtained as this study constitutes a retrospective review. This case underscores the importance of recognizing pneumatosis cystoides intestinalis as a potential complication in GPA patients, even in the absence of typical abdominal symptoms. Further research is warranted to elucidate the underlying mechanisms and optimal management strategies for this rare association. Key points • Rare association: This case report sheds light on the uncommon occurrence of pneumatosis cystoides intestinalis (PCI) within the context of granulomatosis with polyangiitis (GPA), adding to the understanding of the spectrum of manifestations of GPA. • Clinical manifestations: Despite being diagnosed with GPA and experiencing symptoms such as fatigue, knee pain, and nasosinusitis, the patient remained asymptomatic for PCI, emphasizing the importance of vigilant clinical monitoring in GPA patients. • Imaging features: Radiological imaging, including serial abdominal CT scans, played a crucial role in diagnosing and monitoring the progression of PCI in the absence of typical abdominal complaints, highlighting the utility of imaging modalities in detecting silent manifestations of gastrointestinal complications in GPA. • Treatment considerations: The case highlights the challenge of managing PCI in GPA patients, especially when asymptomatic, and raises questions about the optimal management strategies for such rare associations, underscoring the need for further research in this area.

Assessment of Genetic Variants Linked to Susceptibility to Mechanical Prosthetic Valve Thrombosis

Prosthetic valve thrombosis (PVT) is a critical and life-threatening condition, driven by multifactorial etiologies including genetic predispositions. The study was designed as a single-center retrospective manner. Echocardiographic features and genetic test including Factor II Prothrombin G20210A, Factor V Leiden G1691A, Factor V R2 A4070G, ApoB-100 G10708A, ApoE C112R, ApoE R158C, MTHFR C677T, MTHFR A1298C, Factor XIII G103T (V34L), Beta fibrinogen G-455A, PAI-1 4G/5G, and HPA-1 (GPIIIa) T196C genotyping variations were assessed. We performed genetic tests in 175 patients with PVT [biologically women (n=124, 70.9%) with a mean age of 49.8 ± 13.1 years], and in 101 patients [biologically women (n=57, 56.4%) with a mean age of 54.7 ± 13.6 years] without thrombus formation. The thrombosis group was significantly younger compared to controls (p=0.004). The percentage of patients with mechanical aortic valves was significantly lower in the thrombosis group compared to controls (22.3 vs 34.7%, p=0.025). A significant difference was observed between the thrombosis and control groups regarding the genotype ratios of Factor II/Prothrombin (G20210A) (heterozygous, 6.8 vs 1%, p =0.043) and HPA-1 GPIIIa (T196C) (homozygous mutant, 7.8 vs, 0%, p=0.034) In addition, there was a significant association of heterozygous MTHFR (A1298C) variation with obstructive thrombosis compared to non-obstructive thrombosis (46.9 vs 29.2%, p=0.046). In conclusion, this is the first study to report a potential association between genetic variants including HPA-1 GPIIIa (T196C), Factor II/Prothrombin (G20210A), MTHFR (A1298C) and PVT, necessitating extensive further research and additional clinical consideration.

The Clinical Considerations of Interscalene Brachial Plexus Block in the Treatment of Post-Hepatectomy Shoulder Pain [Response to Letter

The Clinical Considerations of Interscalene Brachial Plexus Block in the Treatment of Post-Hepatectomy Shoulder Pain [Response to Letter

Society of Family Planning Committee Statement: Contraception and body weight

Understanding the relationship between contraception and body weight is an important clinical consideration. Body weight and size has the potential to affect fertility and the effectiveness of some contraceptive methods, although historically this association has not been applied within a person-centered context that would allow individuals to select their preferred contraceptive method. Further, individuals with higher body weights and larger sizes have unmet contraceptive care and counseling needs. This document aims to provide evidence-based, person-centered, and equity-driven recommendations that destigmatize contraceptive care across all body weights. Clinicians should: provide person-centered, unbiased contraceptive care, including counseling pregnant-capable individuals on their risk of pregnancy based on sexual practices and contraceptive use regardless of body weight or size; utilize evidence-based and person-centered contraceptive counseling to offer the full range of contraceptive methods regardless of body weight or size; counsel patients about any risks and benefits associated with body weight and size to assist in their selection of contraceptive methods, including emergency contraception; counsel individuals about the potential for weight change, particularly weight gain, associated with contraceptive methods as a possible factor in decision-making; and counsel individuals regarding the potential impact of weight management approaches, such as bariatric surgery and glucagon-like peptide 1 (GLP-1) agonists, on contraceptive efficacy.

Resolving Tongue Entrapment: A Comprehensive Review with Case Report

AbstractObjectiveTo report a case of oral tongue entrapment due to a metal water bottle and review clinical considerations for managing this rare pathology.Study DesignCase report and literature review.SettingTertiary care hospital.MethodsA 6‐year‐old female presented with her tongue trapped in a threaded aluminum water bottle. Upon admission, her tongue was edematous and actively bleeding, though she was spontaneously breathing. A systematic review was then performed to document similar case studies found in the literature.ResultsEmergency removal of the foreign body was performed in the operating room using drill cutting burrs and metal shears. The bottle was successfully removed with minimal injury to the oral tongue. The patient required nasal intubation for seven days to allow the tongue edema to subside. Subsequent literature review identified 14 similar cases, with the vast majority occurring with similar brand of aluminum water bottle.ConclusionThe increasing use of reusable bottles may lead to a higher incidence of tongue entrapment cases. Awareness of this complication and appropriate management strategies are crucial to prevent severe outcomes in pediatric patients.

Objetivos del tratamiento de la diabetes mellitus tipo 1

There are three ways to assess blood glucose control in type 1 diabetes (DM1): glycated hemoglobin (HbA1c, general target less than or equal to 7%), time in the 70–180mg/dl range (general target 70% or higher), and capillary blood glucose. Diabetes education is a fundamental element in achieving self-management of the disease. It is based on three fundamental pillars: nutrition, insulin therapy, and management of diabetes technology (sensors, insulin pumps, smart insulin pens, and mobile applications). Drug treatment for DM1 consists of intensive insulin therapy using multiple dose injection (MDI) or continuous subcutaneous insulin infusion (CSII). The choice of treatment regimen should be based on patient characteristics and other clinical considerations (e.g., pregnancy, presence of undetected hypoglycemia, or variable insulin requirements). There are currently no other insulin adjuvant therapies approved for use in DM1, although DM2 drugs such as GLP-1 analogs or SGLT2 inhibitors that may provide benefits in blood glucose control or weight loss have been used. Kidney-pancreas or pancreatic islet transplantation is considered a final option in patients with end-stage chronic kidney disease together with or following renal transplantation or in individuals with undetected or severe recurrent hypoglycemia that does not respond to optimized management.