Retinal imaging and supervised learning predict hospitalizations and kidney and heart-lung damage in sickle cell disease.

Acute proximal junctional fracture (APJFx) is a severe form of proximal junctional kyphosis after adult spinal deformity surgery and is often associated with revision surgery. However, the clinical course of APJFx is heterogeneous, and not all patients require revision. The aim of this study was to identify independent risk factors of revision surgery after APJFx to guide the timing and necessity of revision surgery. This retrospective study included patients who developed APJFx within 6 months after undergoing multilevel (≥5 levels) fusion surgery. Demographic, surgical, and radiographic variables were analyzed. Initial postoperative alignment was evaluated using the sagittal age-adjusted score and the Global Alignment Proportion score. Radiographic parameters at the time of APJFx detection were also assessed. Revision-free survival was analyzed using Kaplan-Meier analysis. Independent predictors of revision surgery were identified through multivariate logistic regression, and optimal cutoff values were determined using receiver operating characteristic analysis. Patients were stratified into 4 subgroups based on identified risk factors. Eighty patients met the inclusion criteria, and 35 patients (43.8%) underwent revision surgery during a mean follow-up of 24.6 months. Most revision surgeries (82.9%) were performed within 24 months after APJFx detection. Multivariate analysis identified 2 independent predictors of revision surgery: a higher sagittal age-adjusted score pelvic incidence minus lumbar lordosis (PI-LL) modifier score (odds ratio = 1.76; cutoff = 0.5 point, indicating PI-LL overcorrection) and a greater proximal junctional angle at APJFx detection (odds ratio = 1.10, cutoff = 22.5°). Patients with both risk factors exhibited the highest revision rate (71.4%), whereas those with neither risk factor had the lowest rate (17.6%). Revision surgery after APJFx is common, particularly in patients with PI-LL overcorrection and increased proximal junctional angle at fracture detection. Risk-based stratification using these parameters may aid in guiding early surgical decision making and surveillance strategies.

The management and clinical course of patients admitted to the intensive care unit with leptospirosis in a referral hospital in Far North Queensland, Tropical Australia.

We aimed to evaluate the clinical and genetic characteristics and clinical course of children with persistent proteinuria associated with CUBN variants. Forty-eight children with CUBN variants from 15 pediatric nephrology centers were included. Patients' characteristics, serum creatinine, albumin, hemoglobin, vitamin B12 levels, urinalysis, spot urine protein/creatinine (uPCR), microalbumin/creatinine (uACR), beta-2 microglobulin/creatinine (uBMCR) ratios, estimated glomerular filtration rates (eGFRs), treatments, kidney biopsies, and genetic findings were evaluated. All patients had normal serum albumin and creatinine and preserved eGFR. There was no significant change in eGFR between the first and last visits (p = 0.15), whereas uPCR was lower at the last visit (p = 0.001). Kidney biopsy was performed in 13 (27%); light microscopy was normal in all except one patient with focal segmental glomerulosclerosis (FSGS). Thirty-five patients (72.9%) had ACEi/ARB therapy, which was discontinued in 21 patients without subsequent worsening of proteinuria. Overall, 26 distinct CUBN variants were identified, predominantly in the C-terminal region. The most frequent variant was c.10102A > G (p.Met3368Val). Variant types included 15 (57.7%) missense, 7 (27%) nonsense, 3 (11.5%) splicing, and 1 (3.8%) frameshift variants. In this multicenter, large pediatric cohort, proteinuria associated with CUBN variants generally followed a benign course over short to mid-term follow-up even without sustained ACEi/ARB therapy. Embedding targeted CUBN testing into the evaluation of children with asymptomatic proteinuria and normal kidney function may reduce unnecessary kidney biopsies and prolonged medication, while improving family counseling. We outline a stepwise care pathway → early genetic screening → conservative monitoring with periodic eGFR and proteinuria assessment → consideration of ACEi/ARB discontinuation and recommend prospective validation and cost-effectiveness studies.

Mycosis fungoides (MF) is the most common primary cutaneous T-cell lymphoma and typically presents with erythematous or scaly patches in older adults with a CD4 + immunophenotype. In Sri Lanka, however, a hypopigmented variant with CD8 + predominance and an apparently indolent clinical course is frequently encountered. A retrospective descriptive study was conducted on 243 patients with histologically confirmed MF diagnosed at the National Hospital, Kandy, between 2018 and 2024. Clinical, histopathologic, and immunophenotypic features were reviewed in all cases. A subset of 27 patients with a minimum follow-up of 2 years was analyzed for treatment modalities and clinical outcomes. Diagnoses were established according to WHO-EORTC 2018 criteria. Patients predominantly presented with hypopigmented patch-stage disease involving sun-protected sites. Histology showed subtle epidermotropism with small Pautrier microabscesses and a characteristic "eyeliner" pattern. Immunohistochemistry demonstrated a CD8 + -predominant infiltrate in 95.9% of cases, with absent or reduced CD4 expression. Most patients achieved complete or partial remission with topical therapy or phototherapy, and no progression to plaque or tumor stage was observed. Hypopigmented CD8 + MF in Sri Lanka represents an indolent clinicopathologic variant within the MF spectrum, recognition of which is essential to avoid misdiagnosis and overtreatment.

Bronchopulmonary dysplasia (BPD) remains a major complication of extreme prematurity, but diagnosis and severity classification have become increasingly challenging in contemporary neonatal respiratory care. Changing respiratory support practices and survival patterns have exposed limitations in older oxygen-centric definitions, while prognostic tools have emerged to estimate BPD severity or BPD or death risk earlier in the clinical course. To map post-2016 evidence on BPD definitions, severity classifications, and severity/risk prediction tools in preterm infants, and to summarise differences in construction, classifiability, healthcare-context transportability, and prediction of clinically relevant outcomes. This scoping review followed PRISMA-ScR reporting guidance and the JBI Population-Concept-Context framework. PubMed/MEDLINE, Embase, Web of Science, and Google Scholar were searched from January 1, 2017 to February 28, 2026, with citation chaining of eligible articles. No language restriction was planned at search level, but only English full-text articles were included because of feasibility. Two reviewers independently screened titles/abstracts and full texts; disagreements were resolved by consensus with a third author. Data were charted using a standardised framework and synthesised descriptively. Formal risk-of-bias appraisal was not performed because this was a scoping review. The review protocol was not registered, and no external funding was received. Eighteen studies met inclusion criteria after screening. Evidence clustered into conceptual revision of BPD definitions, comparative validation studies of newer definitions against short- and long-term outcomes, and severity/risk prediction tools including online estimators, machine-learning adaptations, and nomogram-based models. Newer support-mode-based definitions generally improved classifiability compared with oxygen-centric definitions and showed outcome gradients in representative cohorts; for example, one NRN definition correctly predicted death or serious respiratory morbidity in 81% of infants, while estimator performance varied by timing and cohort, with reported C-statistic/AUC values ranging from approximately 0.67 to 0.91 in key prediction-tool studies. Post-2016 BPD research shows a shift from oxygen-centred criteria toward contemporary support-based classification and dynamic risk estimation. Current evidence supports careful use-case-specific selection of definitions and cautious local validation of prognostic tools rather than a universal single best definition or estimator. Future work should harmonise outcome targets, strengthen external validation and calibration, and develop multidimensional, phenotype-informed classification systems.

Comparative Effectiveness of Intravenous Immunoglobulin vs Steroids in the Treatment of Pediatric Acute (Non-COVID) Myocarditis: A Pediatric Health Information Systems Database Study.

Characterize the additive value of endoscopic ultrasound (EUS) and fine needle aspiration (FNA) when applying specific surgical thresholds for pancreatic cystic neoplasms (PCNs). When characterizing PCNs, MRI assesses lesion morphology, while EUS can confirm morphology and assess malignant risk through cyst fluid aspiration. Currently there is limited understanding of the additive benefit of sequential testing. An institutional registry was queried for patients with an MRI and EUS for a PCN. Morphologic high-risk features (MHRF): mural nodule, pancreatic duct dilation, thickened/enhanced wall were assessed on both modalities. Clinical courses were assessed for development of high-grade dysplasia/cancer on surgical pathology or surveillance. Diagnostic accuracy was established on surgical pathology. Receiver operating curves and decision-curve analysis were conducted to qualify the benefit afforded by each modality. Of 3,702 registry patients, 1,674 met inclusion criteria. MRI detected MHRF in 462(28%) and EUS in 400(24%), with discordance in 436(26%). Morphologically negative MRI and EUS yielded a +FNA in 5%. MHRF on EUS but not MRI occurred in 187, with a confirmed upgrade rate of 66%. MHRF on MRI but not EUS occurred in 249, with 92% remaining cancer-free on surveillance (median:49 [23-78] months). In 215 surgical patients, EUS following normal MRI improved specificity by 14%, with MRI+EUS+FNA improving specificity to 38%. MRI+EUS+FNA demonstrated superior AUC versus MRI (P=0.022). Decision-curve analysis demonstrated EUS provides greatest clinical benefit in MRIs without MHRF when combined with FNA. EUS and FNA provide a considerable contribution to clinical decision-making in MRIs without MHRF. Retrospective registry cohort study.

Insomnia is common in the clinical course of schizophrenia, including in individuals at clinical high risk for psychosis (CHR-P). We previously found associations between insomnia and psychosis-risk symptoms in CHR-P. We attempted to replicate findings in an independent cohort. We explored associations between insomnia and psychosis-risk symptoms in CHR-P individuals in the Accelerating Medicines Partnership Schizophrenia (AMP SCZ) program (n = 269). We investigated relationships between insomnia and psychosis-risk symptoms (Brief Psychiatric Rating Scale [BPRS]). The prevalence of any terminal and initial insomnia at AMP SCZ baseline was 28% and 38%, respectively. After controlling for potential confounders, insomnia was a significant indicator of higher BPRS total (β = 0.33) and positive (β = 0.22), affect (β = 0.34), and activation (β = 0.13) subscale scores. Insomnia is prevalent and associated with psychosis-risk symptoms in CHR-P individuals. Findings are clinically relevant and highlight the need for more rigorous assessment and treatment of insomnia in this population.

Obesity has reached epidemic proportions globally, with its prevalence nearly tripling since 1975. It is now recognized as a chronic, relapsing disease associated with increased morbidity and mortality due to its strong relationship with several cardio-renal-metabolic conditions. This narrative review aims to explore the major obesity-related complications - namely obstructive sleep apnea syndrome (OSAS), metabolic dysfunction-associated steatotic liver disease (MASLD), dyslipidemia, and chronic kidney disease (CKD) - highlighting their pathophysiological mechanisms, clinical consequences, and current therapeutic strategies. Obesity contributes to OSAS by increasing upper airway collapsibility and to MASLD through ectopic fat accumulation, insulin resistance, and inflammatory responses. Dyslipidemia in obesity is characterized by elevated triglycerides, small dense LDL particles, and low HDL-C, driven by chronic inflammation and insulin resistance. CKD progression, particularly obesity-related glomerulopathy (ORG), is also mediated by metabolic and hemodynamic derangements, including renin-angiotensin-aldosterone system activation and glomerular hyperfiltration. Therapeutic interventions such as lifestyle modification, pharmacological therapy - including glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT-2is) - and bariatric surgery have shown efficacy not only in promoting weight loss but also in improving the clinical course of these obesity-related conditions. In particular, Very Low Energy Ketogenic Therapy (VLEKT) is emerging as a promising approach in improving metabolic parameters, hepatic steatosis, and cardiovascular risk factors. A comprehensive and multidisciplinary approach to obesity is essential, focusing not only on weight loss but also on mitigating associated complications. Effective management can significantly improve patients' quality of life and reduce the long-term burden of obesity on healthcare systems.

Mantle cell lymphoma (MCL) is a heterogeneous disease with variable clinical presentations, pathological types, and molecular characteristics. Survival rates have improved with the emergence of novel therapies, but rates of relapsed and refractory disease remain high in developing countries due to lack of easy availability of newer therapeutic agents due to financial and logistical constraints. In this manuscript, we present a single-center retrospective data from an Egyptian tertiary care hospital and discuss our experience with managing MCL patients and factors affecting their outcomes. This was a retrospective study that has been conducted on 69 cases of newly diagnosed MCL patients who attended the Oncology Centre Mansoura University (OCMU) from April 2011 to April 2023. Detailed history, clinical examination, basic and advanced laboratory and radiological investigations were performed at diagnosis. Patients received treatment according to the institutional protocols in the form of RCHOP [rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone] and RDHAP [rituximab, dexamethasone, high dose cytarabine and cisplatin] as induction therapy and ICE [ifosfamide, carboplatin, etoposide], ESHAP [etoposide, methylprednisolone, high dose cytarabine and cisplatin], gemcitabine-based protocols, and others as second line therapies. Some patients received metronomic therapies or received the best supportive care (BSC). The response was evaluated based on Lugano response criteria. The primary end point is to evaluate characteristics of MCL patients in Egyptian center with determination of some prognostic factors and secondary end point is evaluation of the overall survival (OS) and the factors influencing it. In our study, we demonstrated many factors that had an impact on the OS, they were categorized into factors related to the patient, factors related to the clinical course of the disease, factors related to laboratory markers and treatment related factors. Old age (≥ 65 years) was associated with an inferior survival rate with a median of 29 months (95% CI;16-45.2) with p-value = 0.044 The patients who received R-CHOP ± R-DHAP had a superior OS with a median of 64mo (95% CI; 64-75.3) and 22mo (95% CI; 16-55) respectively than the patients who received other protocols, mainly the COP [cyclophosphamide, vincristine and prednisone]and best supportive care (BSC) who experienced the most inferior OS with a p-value = 0.0016. The relapse was associated also with an inferior median OS of 22mo (95% CI; 16-60) with a significant p-value = 0.025. The patients who received only one line of chemotherapy showed a superior OS with a median of 55mo (95% CI; 35-75.3) in comparison to patients who received more than one line of chemotherapy with a median OS of 22mo (95% CI; 16-43.2) with a significant p-value = 0.0012. SOX11 expression was associated with inferior OS with a median OS of 10mo (95% CI; 5-25.3) with p-value = 0.0052 . Cyclin D1 expression was associated with better OS than the patients associated with t(11:14) with a median OS of 55mo (95% CI; 34-75) and of p-value = 0.00063 . Lower hemoglobin levels ( p -value of 0.036) , lower platelet levels ( p -value of 0.0096) , and higher levels of lactate dehydrogenase (LDH) ( p -value of 0.012) were associated with dismal prognosis. We concluded that multiple clinical, laboratory, and molecular factors can affect the survival of MCL such as old age, low hemoglobin, platelets levels, high LDH levels, SOX11 expression and lack of CyclinD1 expression. Other important factors are the type of induction chemotherapy, the response to treatment, and relapse status. To overcome the limitations in our study, larger cohorts are needed to be studied with the evaluation of the novel therapies when feasible. Enhancing financial support is crucial to improve MCL patients' care in our country.

Clinical Course and Determinants of Remission in Children and Adolescents with Prediabetes.

Depression in old age often has a poor clinical course, although there is substantial variability in depressive symptom trajectories. We aimed to characterise old-age depressive symptom trajectories, assess their multifactorial correlates, and their impact on mortality. We used cohort data from 2118 dementia-free community-dwelling adults aged ≥60years participating in the Swedish National study on Aging and Care in Kungsholmen (SNAC-K). Depressive symptoms were evaluated using the Montgomery-Åsberg Depression Rating Scale at baseline and 1-3 follow-ups over 9years. Sociodemographic (age, sex, marital status, socioeconomic status), psychosocial (social connections and support), clinical (multimorbidity), and functional (gait speed; cognitive impairment) factors at baseline were considered as trajectory correlates. Generalised growth mixture models and multinomial logit models estimated depression trajectories and their correlates. Cox proportional hazard models estimated all-cause mortality risk. Three trajectory classes emerged: low, increasing, and U-shaped trajectories of depressive symptoms. Compared to the low trajectory, socioeconomic status involving high financial strain and poor social support was more common in the increasing and U-shaped trajectories. Slow gait speed was linked to higher odds of increasing depressive symptoms, while greater multimorbidity was associated with the U-shaped trajectory. The increasing and U-shaped trajectories were associated with higher mortality risk, and the association for increasing was robust to the adjustment of covariates. Depressive symptom trajectories in late life are heterogeneous and linked to diverse socio-economic, clinical, and functional factors, some of which are trajectory-specific. Given its association with mortality, older people should be carefully monitored for depressive symptomatology.

Prospective Assessment of Cognitive Outcomes in Pediatric Self-Limited Epilepsy With Centrotemporal Spikes.

Macro-thyrotropin (TSH) is a high molecular weight complex of TSH associated with apparently elevated levels of serum TSH, which can lead to an incorrect diagnosis of subclinical hypothyroidism. Given that levothyroxine (LT4) replacement is unnecessary in such cases, the accurate identification of macro-TSH based on clinical and laboratory findings is of particular importance. We aimed to determine the prevalence and clinical features of macro-TSH in patients with subclinical hypothyroidism evaluated after the introduction of TSH harmonization. Between August and November 2023, we included 1599 consecutive patients with subclinical hypothyroidism (TSH > 4.23 mIU/L with normal fT4 levels) who were either untreated or receiving LT4 replacement monotherapy. Polyethylene glycol (PEG) precipitation was performed in all cases. Patients with TSH recovery of <20% underwent further evaluation, including gel filtration chromatography under neutral and acidic conditions, protein G and Jacalin precipitation assays, and a comprehensive battery of interference tests. Four patients (0.25%) showed high molecular-weight TSH peaks (>150 kDa) under neutral conditions that disappeared under acidic conditions, with a shift to the native molecular weight (approximately 28 kDa), indicating the initial presence of macro-TSH. The TSH complex was detected in peaks corresponding to IgG, IgA, and IgM. These findings were verified using Protein G and Jacalin precipitation assays, with no evidence of assay interference. Reevaluation of TSH recovery following PEG precipitation showed substantial variation in two patients who had abundant monomeric TSH compared with the high-molecular complex. All four patients with macro-TSH had previously received LT4 therapy, which resulted in a modest reduction in TSH levels, with three of these patients testing positive for TgAb and/or TPOAb. Macro-TSH complexes comprise several immunoglobulin isotypes. In cases with low antibody-TSH binding affinity and positive antithyroid autoantibodies, TSH levels may fluctuate during the clinical course, thereby complicating diagnosis and management.

Mitochondrial carbonic anhydrase VA (CA-VA) deficiency is a rare inherited metabolic disorder caused by biallelic variants of the CA5A gene. It presents with hyperammonemia, lactic acidosis, and ketonuria, with or without hypoglycemia. We report the long-term follow-up of the first two reported cases of CA-VA deficiency: a 16-year-old female (case 1) and her 14-year-old brother (case 2), both of whom presented with neonatal hyperammonemic encephalopathy, hypoglycemia, elevated lactate, ketonuria, and compensated metabolic acidosis. The diagnosis was made in both cases through the TIDEX study, which identified a homozygous pathogenic variant in the CA5A gene (c.697T>C, (p.Ser233Pro)). The clinical course of the index patient revealed three additional metabolic decompensation episodes (MDEs) triggered by intercurrent illnesses, with the last episode occurring at 8 years of age, highlighting the unusual timing of her MDEs compared to previously reported cases. Case 2 remained metabolically stable without any additional MDEs. These episodes were successfully treated with parenteral dextrose, a single dose of enteral carglumic acid, and occasionally parenteral lipids. Management of intercurrent illness included a sick-day formula high in carbohydrates and fats. Currently, both cases show normal growth, development, and neurological outcomes, suggesting a favorable prognosis, and in keeping with previously reported cases. Early diagnosis of CA-VA deficiency allows prompt treatment and prevents severe complications. With proper management, long-term outcomes are favorable, although severe and fatal outcomes have been reported. The impact on longevity needs to be assessed over longer durations. The development of consensus management for CA-VA deficiency is warranted.

Herd-level occurrence and spread of Theileria equi and its associated ticks on an Austrian horse farm.

Epilepsia partialis continua beyond status epilepticus: a generator-based neurophysiological framework for clinical decision-making.

Incidence of spinal-epidural haematoma after neuraxial anaesthesia for total hip and knee arthroplasty: a single-centre analysis of 96 103 consecutive cases from 2013 to 2023.

Atypical fibroxanthoma (AFX) is an uncommon cutaneous neoplasm predominantly affecting elderly individuals in sun-exposed areas. Despite its alarming histopathological features, AFX typically exhibits an indolent clinical course. Diagnosis remains challenging due to overlapping features with other aggressive cutaneous malignancies, especially malignant melanoma. We retrospectively analyzed 15 cases of AFX diagnosed between 2009 and 2024. Comprehensive immunohistochemical profiling was performed, including CD10, CD68, S100, Melan-A, HMB45, CD31, CD34, ERG, cytokeratins, P40, P63, SMA, Desmin, and newly, PRAME (clone EPR20330). Clinical and follow-up data were collected from medical records. The cohort had a mean age of 72.9 years, with a male predominance (66.7%). The scalp was the most frequent tumor site (40.0%). All cases demonstrated diffuse block-type CD10 positivity and were uniformly negative for PRAME. Occasional weak staining for melanocytic markers was observed in a minority of cases. After a mean follow-up of 84.0 months, all patients were alive. A comprehensive immunohistochemical panel is essential for the accurate diagnosis of AFX. The absence of PRAME expression, together with block-type CD10 positivity, supports the distinction of AFX from malignant melanoma and other histological mimics, facilitating appropriate clinical management.