BACKGROUND In critical care practice, difficult airway management poses a substantial challenge, necessitating urgent intervention to ensure patient safety and optimize outcomes. Extracorporeal membrane oxygenation (ECMO) is a potential rescue tool in patients with severe airway compromise, although evidence of its efficacy and safety remains limited. AIM To review the local experience of using ECMO support in patients with difficult airway management. METHODS This retrospective case series study includes patients with difficult airway management who required ECMO support at a tertiary hospital in a Middle Eastern country. RESULTS Between 2016 and 2023, a total of 13 patients required ECMO support due to challenging airway patency in the operating room. Indications for ECMO encompassed various diagnoses, including tracheal stenosis, external tracheal compression, and subglottic stenosis. Surgical interventions such as tracheal resection and anastomosis often necessitated ECMO support to maintain adequate oxygenation and hemodynamic stability. The duration of ECMO support ranged from standby mode (ECMO implantation is readily available) to several days, with relatively infrequent complications observed. Despite the challenges encountered, most patients survived hospital discharge, highlighting the effectiveness of ECMO in managing difficult airways. CONCLUSION This study underscores the crucial role of ECMO as a life-saving intervention in selected cases of difficult airway management. Further research is warranted to refine the understanding of optimal management strategies and improve outcomes in this challenging patient population.

Technology has brought about a revolution in the management of type 1 diabetes (T1D). The adoption of continuous glucose monitoring (CGM) and insulin pump therapy in the everyday life of children and adolescents with T1D is a real innovation and the most promising choice for optimizing glycemic control in this population. The incorporation of an alarm system, including notifications, alerts and alarms and warning patients and their parents about glucose levels and upcoming events interfering with safety, is an invaluable additional tool for better targeting euglycemia. However, in parallel with the clinical benefits of alarm systems in ameliorating metabolic control parameters, alarm fatigue was recorded as a phenomenon, negatively affecting the everyday lives of patients and their caregivers, and as a cause for rejecting or abandoning CGM or pump therapy treatment. There are a few data concerning the frequency, consequences and methods of eliminating alarm fatigue among children. As a result, we have conducted a narrative review to briefly present the basic philosophy of the existing CGM alarm systems and their positive effect on glycemic management, and focus on alarm fatigue; definition, frequency, effect on quality of life and sleep, not only of T1D pediatric patients but also of their families, and methods of elimination. Efforts to achieve a more reliable and accurate alarm system and educate on adapting personalized limits and positively interpreting them may protect the T1D pediatric population from alarm fatigue and prevent rejection or incomplete use of CGM and insulin pump as the therapeutic choice, ensuring the best glycemic control.

Sepsis is a syndrome of life-threatening organ dysfunction that results from dysregulated host response to infection, with septic shock defined as persistent hypotension despite fluid resuscitation, a serum lactate > 2mmol/L and the need for a vasopressor infusion to maintain a mean arterial pressure of at least 65 mmHg. Approximately, 49 million cases of sepsis are recorded worldwide annually, with 11 million sepsis-related deaths, the majority occurring in patients with septic shock. A substantial proportion of survivors suffer from moderate to severe functional limitations including physical, cognitive and psychological disability, exacerbation of pre-existing chronic conditions and a high incidence of re-hospitalisation in the first 12 months after the initial diagnosis. Optimal management of patients with septic shock requires prompt and reliable recognition of patients with sepsis who require additional haemodynamic support. Initially, patients will need judicious intravenous fluids and consideration of the need for vasopressors such as norepinephrine. Administration of appropriate antibiotics and consideration for control of the source of infection are also required. In the optimisation phase, depending on patients' comorbidities and response to therapy, the balance of fluid therapy, vasopressors and potentially the addition of an inotropic agent will need to be adjusted, based on clinical findings and haemodynamic and biochemical parameters. For those patients who do not respond to initial therapy, more intensive monitoring may be required with consideration of adjunctive therapies such as corticosteroids, vasopressin, angiotensin II or other rescue therapies to achieve cardiovascular stability. Once stability has been achieved, clinicians need to consider strategies to ameliorate the potential long-term effects on survivors, while keeping in mind the perspective and experience of their patients.

Background Paclitaxel is a widely used chemotherapeutic agent with known vesicant properties. Extravasation is rare, but it can result in significant local tissue injury. There is no consensus on the optimal management strategy, and recommendations differ significantly. Case presentation We report the case of a 63-year-old woman with metastatic cervical cancer who experienced a large-volume paclitaxel extravasation during a peripheral infusion. Management involved immediate subcutaneous administration of hyaluronidase around the affected area, followed by repeated applications of dry warm compresses. The patient reported only mild discomfort during treatment, and the local cutaneous symptoms resolved within days. Despite effective local management, the patient developed persistent paresthesia in the extravasated limb, later diagnosed as sensory neuropathy affecting the ulnar nerve. This was accompanied by lower limb neuropathy, likely related to the systemic paclitaxel exposure. Paclitaxel was discontinued, and the patient continued palliative treatment with carboplatin monotherapy. Conclusion Based on our literature search, this appears to be the first documented case of high-volume paclitaxel extravasation successfully managed with both hyaluronidase and dry warmth. The intervention proved to be effective in preventing severe local tissue injury, although it did not mitigate neurotoxic effects. Further research is needed to establish standardized management protocols.

This study aims to analyze the influence of the value of intangible assets on the value of the company, with auditor quality as a moderating variable, in manufacturing companies listed on the Indonesia Stock Exchange during the period 2021–2024. The main problem lies in how intangible assets affect investors' perception of a company's value, as well as the role of auditor quality in strengthening those relationships. This study uses a quantitative approach based on secondary data with multiple linear regression analysis methods and moderation interaction tests. The results of the study show that the value of intangible assets has a positive and significant effect on the value of the company. In addition, the quality of auditors is proven to strengthen the relationship, where companies audited by the Big Four Public Accounting Firms (KAP) show greater influence. These findings emphasize the importance of optimal management of intangible assets and the selection of high-quality auditors in increasing the company's value in the eyes of investors.

Interventional radiology (IR) is rapidly expanding in paediatric care due to technological advancements and research, as well as its minimal invasiveness compared to surgery. New therapeutic options have been developed to manage both benign and malignant conditions refractory to medical treatments or for which surgery has failed or is not feasible, particularly regarding locally advanced liver tumours, vascular malformations and vascular tumours of the liver, lymphatic disorders, portal hypertension and complications of liver transplantation. A multidisciplinary approach is essential for the optimal management of patients, as well as for increasing the awareness of paediatricians and surgeons regarding IR. This review article will discuss the pathologies affecting both the native and the transplant liver with focus on cutting-edge devices that have significantly influenced clinical practice, gaps of knowledge, research needs and potential collaborations.

Optimal initiation and management of long-term home non-invasive ventilation (LTH-NIV) therapy requires a personalised approach that may not be possible within some healthcare systems. This survey of Italian physicians determined current practices regarding LTH-NIV initiation and follow-up in patients with chronic hypercapnic chronic obstructive pulmonary disease (COPD), areas for process improvements, and use of telemonitoring. A 35-question survey was developed then sent via e-mail for completion using computer-assisted web interviewing methodology. Respondents were Italian hospital-based physicians identified using a healthcare professional database who had 3 years' experience in pulmonology, treated/followed up at least 50 patients on NIV, and consented to participate. 60/71 physicians approached completed the online survey. Of these, 41/60 (68%) said that LTH-NIV prescription followed hospitalisation for acute COPD exacerbation. The most important clinical aspects to monitor early after discharge and during long-term follow-up were reported as mask fit and patient quality of life. Physicians reported a high workload for management of patients on LTH-NIV, but felt that many therapy management tasks could be performed by other providers, especially outpatient pulmonologists and homecare providers. Only 32% of respondents were currently using telemonitoring; reasons for non-use were lack of human resources (63%) or regulatory framework (37%), and cost/reimbursement issues (22%). These data highlight substantial differences between LTH-NIV clinical practice for chronic hypercapnic COPD in Italy and current guidelines, suggesting that guideline-mandated processes may not be achievable or sustainable in real-world settings. Involvement of homecare providers and use of telemonitoring could help improve the management of LTH-NIV therapy.

Vascular Ehlers-Danlos syndrome (vEDS) is one of the most severe heritable connective tissue disorders, caused by pathogenic variants in COL3A1 and characterized by arterial fragility, premature mortality, and a high burden of vascular events. Management remains particularly challenging, requiring careful balance between the risks of intervention and the prevention of catastrophic complications. We present three cases of genetically confirmed vEDS that exemplify the complexity of patient care in this setting. These cases underline the importance of early referral to expert centers, where multidisciplinary care, genetic counseling, and structured follow-up can be guaranteed. They also highlight the central role of therapeutic adherence and long-term surveillance, as interruption of validated medical therapy may lead to life-threatening vascular events. Pharmacological treatment with celiprolol remains the first strategy supported by randomized trial evidence, while recent data suggest that the addition of angiotensin receptor blockers may further reduce vascular risk. Nevertheless, outcomes remain poor, and the prognosis of vEDS continues to be dominated by recurrent arterial complications despite optimal management. Conservative strategies are generally preferred, with invasive interventions reserved for life-threatening circumstances and best performed in specialized centers. These cases underscore both the progress made and the unmet need for novel therapeutic options to improve outcomes in this high-risk population.

Background/Objectives: Tumors of the cerebellopontine angle (CPA) encompass a limited range of histologies, predominantly vestibular schwannomas (VSs), meningiomas, and paragangliomas (PGLs). Their growth region threatens the cranial nerves (V–XII), brainstem, and cerebellum, possibly causing functional deficits. This review aims to synthesize clinical features and multidisciplinary treatment strategies for CPA tumors with brainstem involvement, emphasizing functional preservation alongside tumor control. Methods: A systematic PubMed search identified studies on VSs, CPA meningiomas, and intradural PGLs. Eligibility criteria included studies reporting tumor management and cranial nerve outcomes. Data extraction focused on tumor size, neurological presentation, surgical approach, adjunctive therapies, and postoperative cranial nerve function. Multidisciplinary involvement and rehabilitation strategies were noted. Results: Twenty studies (3311 patients) analyzed large VSs, showing facial nerve dysfunction in 8–53%, trigeminal neuropathy in 20–77%, and cerebellar signs in up to 79%. Microsurgery (MS) achieved variable gross total resection, while stereotactic radiosurgery (SRS) preserved facial nerve function but carried trigeminal and hydrocephalus risks. CPA meningiomas demonstrated cranial nerve displacement patterns critical for surgical planning, with transient deficits common and recovery linked to baseline function. In 388 intradural PGL cases, staged surgery combined with preoperative embolization was standard; functional preservation of lower cranial nerves was often limited. Across all histologies, multidisciplinary management and targeted rehabilitation were essential. Conclusions: Optimal CPA tumor management balances tumor control with functional preservation. VSs benefit from individualized MS or SRS based on size and mass effect. Meningioma surgery prioritizes cranial nerve preservation over radical resection. Intradural PGLs require staged vascular-conscious approaches. Multidisciplinary care and structured rehabilitation are pivotal to improving outcomes and quality of life.

Abstract Placental chorangiomas are the most common benign tumors of the placenta. Although most are small and asymptomatic lesions, giant chorangiomas are associated with an increased risk of adverse maternal and fetal outcomes. Therefore, in those affected by giant placental chorangioma, early diagnosis and intensive fetal monitoring are indicated to screen for fetal compromise and intervene as indicated. In some cases, expectant management or supportive therapies may serve a role. In the setting of fetal compromise, definitive treatment aimed at devascularization of the tumor has been described to gain pregnancy latency and avoid the risks of preterm delivery. Although multiple treatment options have been described, the optimal management of giant placental chorangioma remains undetermined. This narrative review serves to review the definition, diagnosis and pathophysiology of chorangioma, associated pregnancy complications, proposed management, and possible treatment options.

Combined pulmonary fibrosis and emphysema (CPFE) is defined as a clinical-radiological-physiological syndrome characterized by upper-lobe emphysema and fibrosis predominantly in the lower lobes. The diagnosis of CPFE remains challenging due to the opposing pathophysiological effects of emphysema and fibrosis, which can mask their characteristic clinical and imaging features. Although an international committee proposed standardized terminology for CPFE in 2022, uniform diagnostic criteria and optimal management strategies have not yet been established. Patients with CPFE exhibit reduced overall survival and higher mortality compared to those with chronic obstructive pulmonary disease (COPD) or idiopathic pulmonary fibrosis (IPF). This may be due to increased disease severity, as assessed by CT findings (the extent of fibrosis and emphysema), advanced age, and associated complications such as lung cancer, acute exacerbations, and pulmonary arterial hypertension. This narrative review synthesizes the literature on CPFE from 1990 to 2024, covering its historical background, epidemiology, pathogenesis, clinical presentation, diagnostic features (imaging and pulmonary function), disease course (diagnosis, prognosis, complications), and management.

Background Adenomyosis is frequently associated with abnormal uterine bleeding (AUB) and anemia. In the setting of arterial stenosis or hypercoagulability, AUB may precipitate ischemic stroke. However, the optimal management strategy remains unclear. Methods In accordance with PRISMA 2020, we systematically searched PubMed, Web of Science, CNKI, and Wanfang from inception to November 20, 2024, without language restrictions. Eligible studies were human case reports or case series that described adenomyosis-associated ischemic stroke with extractable data on management and outcomes. Data extraction was performed independently by two reviewers, and risk of bias was assessed using the JBI tool. A descriptive synthesis was conducted, and Fisher’s exact tests were applied where appropriate. Results Eighteen studies involving 24 patients fulfilled the inclusion criteria. Among these patients, 66.7% experienced stroke onset during menstruation, 85.7% presented with anemia, and more than 95% showed elevated CA125 and D-dimer levels. Stroke recurrence occurred in 55.6% of patients who received conservative management, compared with 0% of those who underwent hysterectomy (Fisher’s exact p ≈ 0.005). In menstruation-related cases managed conservatively, the recurrence rate reached 83.3%. Conclusion Current evidence indicates that rapid uterine hemostasis may facilitate timely initiation of antithrombotic therapy and thereby reduce recurrence risk in adenomyosis-associated stroke. Surgical management, particularly hysterectomy, appears more effective than conservative therapy in carefully selected high-risk patients. Larger prospective studies are needed to confirm these findings and to refine management strategies.

The menopause transition represents a period of complex hormonal, metabolic and psychosocial change that poses unique challenges for women living with Type 1 Diabetes Mellitus (T1DM). Despite an expanding population of midlife women with T1DM, evidence to guide optimal menopause management remains limited. This narrative review synthesises current clinical and mechanistic evidence on the impact of menopause in women with T1DM. A literature search was conducted in MEDLINE (PubMed), the Cochrane Library, and professional society guidelines between January and May 2025. Across studies, women with T1DM appear to experience an earlier onset of menopause and an increased risk of osteoporosis, cardiovascular disease, psychological distress, metabolic deterioration and sexual dysfunction compared with women without diabetes. Oestrogen deficiency may exacerbate insulin resistance, dyslipidaemia, and vascular dysfunction, while glycaemic variability and altered insulin requirements are frequently reported during the menopause transition. Evidence regarding the safety and efficacy of hormone replacement therapy (HRT) in this group is sparse. In the absence of disease-specific data, clinicians should adopt an individualised approach-screening proactively for menopausal symptoms, bone loss, and cardiovascular risk, tailoring HRT decisions based on individualised risk profiles and recommending transdermal oestradiol when HRT is used. This review highlights the urgent need for dedicated research, evidence-based guidelines, and integrated clinical pathways to optimise menopause management and long-term outcomes for women living with T1DM.

This report describes a man in his late 50s who underwent donation-after-circulatory-death kidney transplantation in 2012, due to end-stage kidney disease of unknown origin. More than a decade post-transplant, he presented with a progressive decline in graft function after maintenance immunosuppression had been reduced due to multiple skin carcinomas and the prolonged time since transplantation. Kidney biopsy revealed chronic-active tubulointerstitial nephritis with positive immunohistochemical staining for SV40, initially raising suspicion for BK polyomavirus-associated nephropathy. However, quantitative PCR (qPCR) analysis for BKPyV in both plasma and tissue was negative. In contrast, qPCR for JC polyomavirus (JCPyV) was positive in both plasma and biopsy tissue, leading to the diagnosis of JC polyomavirus nephropathy. Despite the reduction of immunosuppressive therapy, the patient experienced ongoing deterioration of graft function. Our report adds to the limited but growing body of literature on JCPyV and emphasises the need for increased clinical awareness and further research into its prevalence, pathogenesis and optimal management in kidney transplant recipients.

The rise of vascular point-of-care ultrasonography (POCUS) is transforming the diagnostic approach in primary care. This promising development raises questions about the balance between generalists and angiologists. There are substantial training gaps: 300 exams are required for POCUS certification, compared to 1,250 for the angiologist qualification. This affects diagnostic accuracy, notably for the 30-50 % of distal thromboses that are missed by the two-point protocol. POCUS should be considered as a rapid orientation tool, particularly useful in emergencies or when immediate access to a specialist is not possible. In other situations, however, evaluation by an angiologist remains essential to ensure a complete diagnosis and optimal management. This complementarity between generalists and specialists is key to providing both efficient and safe care.

Total hip or knee replacement (arthroplasty) is common in aging populations as are prescribed opioids for osteoarthritis pain while awaiting such surgeries. Opioid-related harm can be minimised through pre-surgery tapering of opioids yet, the practice is uncommon. This research sought to understand general practitioners (GPs) understandings, beliefs and support needs for managing pain while waiting surgery, use of opioids and pre-surgery tapering. A qualitative study with GPs in Australia. Semi-structured interviews were conducted. Data were transcribed, deidentified and reflectively analysed inductively and thematically. Analysis of transcript data from GP interviews (n=17) revealed little knowledge of, yet support for, pre-arthroplasty opioid tapering as a further way to minimise opioid harm. Three themes described were: 1. feeling challenged by pre-surgery pain management and opioid prescribing; 2. optimal pain management and tapering prevented by patient-related and system-level barriers; and 3. sharing workload and perceived risk - pharmacists could provide opioid management support. Realisation of potential opioid tapering benefits will require addressing some personal, patient and system level barriers revealed by this study. GPs view support from pharmacists as valuable and welcomed yet the required collaborative models appear, currently, underdeveloped between these primary care professions. Implementation research is a crucial next area of inquiry.

Carotid artery dissection is a rare but significant cause of pediatric stroke, often associated with trauma or underlying collagen vascular disorders. The management of these cases, both medical and surgical, is complex, particularly in bilateral dissections where collateral circulation may be insufficient. We describe a case of bilateral internal carotid artery occlusion that developed 10 days after an initial traumatic fall. The progression of ischemic stroke burden and fluctuating neurologic status, despite therapeutic anticoagulation and optimal medical management, led to the decision for endovascular intervention involving balloon angioplasty and stenting. Following the procedure, a rapid improvement in neurologic function was observed, with the patient exhibiting only mild deficits at discharge. This case highlights the complexities in managing pediatric carotid dissections, especially in unusual presentations. Our experience underscores the necessity for tailored treatment strategies, rigorous monitoring, and a multidisciplinary approach to optimize outcomes in pediatric stroke patients.

Time-in therapeutic range (TTR) is defined as the time a drug concentration remains within the therapeutic range. To explore the optimal management of calcineurin inhibitor (CNI), we investigated how TTR percentage (TTR%) in two different CNI protocols relates to short-term outcomes after living-donor liver transplantation (LDLT). TTR% was estimated for two different protocols in 352 adult LDLT recipients over 90 days in this retrospective, single-center study. Short-term outcomes were compared among the TTR% groups in each protocol. Higher TTR% was associated with better acute rejection-free survival: 96.2%, 86.1%, 74.7%, and 38.9% for TTR% ≥ 60%, ≥ 50%-< 60%, ≥ 40%-< 50%, and < 40%, in the low-target protocol, respectively (p < 0.001, log-rank test); 73.7%, 74.3%, 63.6%, and 48.3%, in the high-target protocol, respectively (p = 0.003). The incidence of adverse events was similar among TTR% groups in each protocol. Multivariate analysis revealed higher TTR% was protective for rejection-free survival, and this trend was particularly pronounced in the low-target protocol. High TTR%, reflecting well-controlled CNI levels, was associated with better outcomes after LDLT. The outcome of high TTR% in low-target protocol seems better, but further prospective validation is warranted.

BackgroundTherapeutic inertia the failure to intensify treatment despite persistent hyperglycemia is a major barrier to optimal management of type 2 diabetes, particularly in low-resource settings.MethodsA hospital-based cross-sectional study was conducted from June 1, 2024, to August 30, 2024. A total of 299 systematically selected patients were included. Data were collected via structured questionnaires and patient medical records. Bivariable and multivariable binary logistic regression analyses were used to identify factors associated with therapeutic inertia. Variables with a p value < 0.25 in the bivariable analysis were included in the multivariable model, and those with a p value < 0.05 were considered statistically significant.ResultsOverall, 67.2% of patients experienced therapeutic inertia. Multivariable analysis identified four independent predictors: lack of health insurance reduced the likelihood of treatment intensification (AOR = 0.177; 95% CI: 0.054–0.576; p = 0.004); management by general practitioners doubled the odds of inertia compared with specialist care (AOR = 2.002; 95% CI: 1.017–3.939; p = 0.045); higher baseline fasting plasma glucose was associated with increased odds of inertia (AOR = 1.008; 95% CI: 1.003–1.013; p = 0.003); and limited availability of point-of-care HbA1c testing substantially increased the risk of inertia (AOR = 8.423; 95% CI: 1.889–37.561; p = 0.005).ConclusionTherapeutic inertia is highly prevalent, affecting 67.2% of ambulatory patients with type 2 diabetes at NEMMCSH. This study highlights critical barriers at patient, provider, and system levels. Interventions such as expanding insurance coverage, enhancing provider training and decision support, implementing prompts for elevated glycemia, and integrating point-of-care HbA1c testing are urgently needed to reduce therapeutic inertia and improve glycemic control in resource-constrained settings.

Acute type A aortic dissection(aTAAD) complicated by mesenteric malperfusion (MMP) is associated with a high mortality rate due to bowel necrosis and subsequent multiorgan failure [(Yang Bet al. inJ Thorac Cardiovasc Surg158:675-687 e674, 2019), (Wang C et al. in Rev Cardiovasc Med24:127, 2023)]. The optimal management strategy remains controversial, particularly regarding the timing and extent of bowel resection. Extensive resection can lead to short bowel syndrome, resulting in chronic intestinal failure and poor nutritional outcomes. Here, we present a case of aTAAD successfully managed with staged bowel resection guided by intraoperative indocyanine green (ICG) fluorescence angiography. A 29-year-old man presented with acute lower back pain and sensory deficits in both legs. He was diagnosed with acute type A aortic dissection and multiple malperfusions, including MMP. Emergency total aortic arch replacement with frozen elephant trunk was performed as central repair. Postoperatively, ischemic necrosis of the ascending colon was identified and resected, while the viability of the ileum remained uncertain. Intraoperative ICG fluorescence angiography confirmed adequate perfusion of the vasa recta, indicating reversible ischemia. To minimize unnecessary bowel resection, a second-look laparotomy surgery was performed 16h later, leading to additional necrotic bowel resection. Ultimately, 180cm of the ileum from the ligament of Treitz was preserved. The patient resumed oral intake approximately one month postoperatively and achieved full enteral independence by four months. This case highlights the importance of integrating ICG fluorescence angiography and staged bowel resection in the management of aTAAD with MMP. Early central repair, combined with real-time assessment of intestinal perfusion, enabled the preservation of intestinal length and improved postoperative outcomes. A strategic, stepwise approach is essential to optimizing bowel viability while maintaining hemodynamic stability in such critical situations.