Dyslipidemia is a major metabolic disorder and a key risk factor for atherosclerotic cardiovascular disease (ASCVD), particularly in the geriatric population. Elderly patients frequently present with multiple comorbidities, such as hypertension and hyperuricemia, which complicate clinical management and substantially increase cardiovascular risk. Moreover, acute conditions, including trauma-related injuries, may further disrupt metabolic control, functional capacity, and adherence to long-term therapy. This case report describes a 70-year-old male patient (RE) who presented to a primary healthcare center with swelling and intermittent pain in the right lower extremity following a fall. The patient had a known history of dyslipidemia, hypertension, and hyperuricemia. Laboratory investigations revealed elevated total cholesterol (242 mg/dL), borderline fasting plasma glucose (102 mg/dL), and uric acid level of 6.6 mg/dL. Physical examination was unremarkable except for edema and localized tenderness in the affected limb, consistent with a soft tissue injury. A holistic management approach was implemented, integrating pharmacological and non-pharmacological interventions. Statin therapy was initiated to address dyslipidemia, antihypertensive treatment was optimized, and analgesic therapy combined with limb elevation was provided to manage acute pain and edema. Non-pharmacological strategies included comprehensive lifestyle modification, encompassing dietary counseling (low saturated fat, low salt, and low purine diet), gradual resumption of physical activity following injury recovery, and structured patient–family education to improve adherence and prevent recurrent falls. Follow-up evaluation demonstrated clinical improvement, including resolution of edema, improved functional mobility, and better metabolic control. The novelty of this case lies in demonstrating how acute trauma in geriatric patients can act as a critical entry point for integrated chronic disease management within primary care settings. This case emphasizes that holistic, biopsychosocial–spiritual management not only improves lipid and blood pressure control but also enhances functional outcomes and quality of life in elderly patients with complex comorbidities.

Yield of injury testing for contacts of children evaluated for physical abuse.

To evaluate the cost-effectiveness of opportunistic CT for sarcopenia screening compared with standard-of-care clinical screening methods, using a decision-analytic model based on quality-adjusted life years (QALYs) and healthcare costs. We developed a decision-analytic model simulating a hypothetical cohort of 70-year-old male patients at risk for sarcopenia over a 3-year time horizon from a US healthcare system perspective. The model compared two screening strategies: standard-of-care clinical evaluation per EWGSOP2 guidelines (physical exam + DXA evaluation of lean mass) and opportunistic CT as measures of muscle mass and quality. Model inputs-including screening sensitivities/specificities, costs, utility values, and probabilities of cardiovascular complications-were derived from published literature. Incremental cost-effectiveness ratio (ICER) and net monetary benefit (NMB) were calculated, and sensitivity analyses were performed to assess the robustness of findings across variable inputs. Opportunistic CT was the favored strategy, with lower costs ($845 vs. $1,295), comparable effectiveness (0.87 QALYs), and higher net monetary benefit ($86,037 vs. $85,588) relative to the standard-of-care strategy. The standard-of-care strategy's ICER was $47.7 million per QALY, exceeding our willingness-to-pay threshold of $100,000. Probabilistic sensitivity analysis across 100,000 simulations demonstrated that opportunistic CT was favored across all tested willingness-to-pay thresholds up to $200,000. Opportunistic CT is a cost-effective strategy for sarcopenia screening, offering similar effectiveness at a lower cost compared to the standard-of-care approach. By leveraging existing imaging studies, opportunistic CT screening has the potential to enhance early detection and decrease the underdiagnosis of sarcopenia while also reducing the burden of additional DXA scans and clinical visits.

Typhoid fever remains a significant public health challenge in many low- and middle-income countries, including Indonesia, where inadequate sanitation, limited access to clean water, and suboptimal hygiene practices continue to facilitate disease transmission. Although typhoid fever is more commonly reported in school-aged children and adolescents, its occurrence in toddlers poses unique diagnostic and management challenges due to atypical clinical presentations and increased vulnerability to dehydration and complications. Early recognition and comprehensive management at the primary health care level are therefore critical. This study describes the holistic primary care–based management of typhoid fever in a 14-month-old boy presenting to a community health center in Bandar Lampung, Indonesia. The patient was brought with a three-day history of persistent fever and a one-week history of watery diarrhea, accompanied by decreased appetite, irritability, and generalized weakness. A holistic diagnostic approach integrating clinical symptoms, physical examination, environmental exposure, and family hygiene practices was applied. Key clinical features included a fever pattern worsening in the late afternoon to evening, prolonged diarrhea, and a coated tongue with erythematous margins, strongly suggestive of typhoid fever in the absence of other focal infections. Management combined pharmacological and non-pharmacological interventions tailored to the toddler age group and primary care setting. Pharmacological therapy consisted of first-line antibiotic treatment with cotrimoxazole, antipyretic therapy, zinc supplementation, and oral rehydration therapy to prevent dehydration. Non-pharmacological interventions emphasized continued breastfeeding, adequate fluid intake, safe food preparation, access to clean drinking water, and strict hand hygiene practices within the household. Family members were actively involved in the care process to ensure adherence to treatment and implementation of preventive measures. Clinical improvement was observed following the integrated intervention, with resolution of fever and gastrointestinal symptoms and restoration of appetite and activity levels. This approach highlights the importance of combining clinical management with family-centered hygiene education and environmental risk assessment. The findings underscore the critical role of primary health care services in early detection, effective treatment, and prevention of typhoid fever among vulnerable pediatric populations.

Symptom expectations influence symptom severity in patients with pain disorders through nocebo and placebo mechanisms. Similar associations have been suggested for patients with somatic symptom disorder (SSD). While evidence underlines the significance of expectations for symptom experience, yet little is known about the nature of these expectations in SSD or about the psychological and biological factors that shape them. Patients diagnosed with SSD participated in a structured on-site assessment at the psychosomatic outpatient clinic of the University Medical Center Hamburg-Eppendorf. The assessment included standardized questionnaires, a physical examination, and a clinical interview. Descriptive statistics and multiple regression analyses were conducted on symptom impairment expectation and symptom-specific expectation measures. A total of N=241 patients participated in this study. The majority of patients (66.8% female, mean age=44.5years) reported negative short-term symptom expectations (54%). Patients with more negative expectations also reported greater somatic symptom severity, higher depression and anxiety severity, increased symptom-related distress, and higher symptom-related disability. Symptom-related disability was found to have the largest association with symptom impairment expectations (short-term: β=0.46, p<0.001, long-term: β=0.26, p<0.001), whereas symptom severity was associated with symptom-specific expectations the most (β=0.66, p<0.001). Negative symptom expectations are associated with elevated psychological burden in patients with SSD, indicating a clinically relevant subgroup that may benefit from expectation-focused interventions.

A 3-year-old boy presented with dark-colored urine for 4months. His history was negative for infections, but he was taking oral methylcobalamin treatment for a persistent deficiency. His parents were first-degree cousins, and a female cousin had proteinuria of unknown etiology. A physical examination and laboratory examination revealed no abnormalities except for non-orthostatic nephritic proteinuria and low levels of vitamin B12. Albumin was the main protein in the urine. Kidney biopsy showed nonspecific changes. Genetic analysis identified a homozygous pathogenic AMN mutation, confirming Imerslund-Grâsbeck syndrome (IGS). Angiotensin-converting enzyme inhibitor was prescribed but discontinued due to stable protein levels. After 4years, kidney function remained stable. Imerslund-Grâsbeck syndrome is a rare autosomal recessive disorder that affects vitamin B12 and protein, particularly albumin absorption. While typically presenting with megaloblastic anemia, AMN mutations show variable phenotypes. Proteinuria is resistant to ACE inhibitors, and currently, there is no specific treatment.

Introduction: Pleural Effusion (PE) results from an imbalance between pleural fluid production and absorption. It may occur due to multiple aetiologies, including heart failure, infections, malignancies, and liver disease. While Light’s criteria remain the gold standard for classification, they misclassify up to 25% of transudates. Additional biochemical markers such as pleural fluid cholesterol, Alkaline Phosphatase (ALP), and D-dimer have shown promise in enhancing diagnostic accuracy. Aim: To compare the diagnostic efficacy of pleural fluid total cholesterol, pleural ALP, and D-dimer levels with Light’s criteria in differentiating exudative from transudative PEs. Materials and Methods: The present hospital-based crosssectional study was conducted jointly in the Departments of Respiratory Medicine and Biochemistry at Adesh Medical College and Hospital, Shahabad (M), Kurukshetra, Haryana, India, from November 2022 to October 2023. A total of 100 adult patients presenting with PE were recruited. Each patient underwent detailed clinical history, physical examination, chest radiography or Computed Tomography (CT) when indicated, and routine laboratory investigations. Pleural fluid samples were analysed for protein, Lactate Dehydrogenase (LDH), cholesterol, ALP, and D-dimer, while corresponding serum levels were also measured. Effusions were classified as transudative or exudative using Light’s criteria. Data were statistically analysed using independent t-test, Chi-square or Fisher’s exact test, binary logistic regression, and Receiver Operating Characteristic (ROC) curve analysis. A p-value &lt;0.05 was considered statistically significant. Results: In the present study, 71% of participants were male, and the mean age was comparable between the exudative and transudative groups. Pleural fluid cholesterol, pleural ALP, pleural/serum ALP ratio, pleural D-dimer, and pleural/serum D-dimer ratio were significantly higher in exudates than in transudates (p &lt;0.001). ROC analysis demonstrated that all parameters had an Area Under the Curve (AUC) of 1.0, with 100% sensitivity and specificity at the identified cut-off values. Logistic regression analysis identified serum ALP as a protective factor and the pleural/serum LDH ratio as an independent predictor of exudative effusion. Conclusion: Pleural fluid cholesterol, ALP, and D-dimer, along with their respective ratios, are highly reliable in differentiating exudative from transudative PEs and may serve as valuable adjuncts to Light’s criteria. These findings warrant validation in larger multicentric studies.

Lead is known to exert toxic effects on nearly all tissues and organ systems, with the nervous, gastrointestinal, and haematopoietic systems being particularly vulnerable. In humans, lead interferes with haemoglobin synthesis, leading to anaemia, and its disruption of porphyrin metabolism can trigger abdominal pain due to vasospasm. Cases due to lead poisoning are an uncommon presentation in healthcare facilities and often overlooked as a cause of anaemia and abdominal pain. Although occupational exposure remains a well-established source of lead poisoning, non-occupational factors, such as the use of metal cookware, are gaining importance as potential contributors in daily life. We report a case of a 48-year-old man presenting with a two-month history of crampy abdominal pain, fatigue, and constipation. After a detailed history and physical examination, other possible causes were excluded and revealed his recent use of a new cookware to ferment rice. Subsequent testing showed an elevated blood lead level of 87.2 μg/ dL. The patient recovered after chelation therapy. Lead poisoning can cause nonspecific symptoms like abdominal pain, anaemia, and neuropathy, often leading to misdiagnosis. Delayed diagnosis may result in irreversible harm. It should be considered in emergency cases of unexplained abdominal pain after ruling out common causes. This case highlights the importance of paying attention to subtle, often overlooked aspects of a patient’s daily routine. Maintaining a broad differential diagnosis and asking targeted questions can be crucial in identifying uncommon causes and achieving a timely, potentially life-saving diagnosis.

Cardiovascular and musculoskeletal health in breast cancer survivors.

Clinicians' perspectives of pain in older adults with heart failure.

Characteristics of online medication consultation from home-based patients on a tertiary hospital WeChat platform: a cross-sectional study.

Increased risks of systemic and abdominal obesity associated with long-term exposure to PM2.5 constituents.

The impact of previous head trauma and history of cranial surgery on clinical findings in acute pediatric head injury.

Telerehabilitation is an innovative, technology-supported approach that enables the delivery of rehabilitation services remotely through information and communication technologies. It serves as a modern extension of conventional face-to-face rehabilitation, aiming to provide continued care for individuals of all ages following hospital discharge or in settings where access to in-person rehabilitation is limited. Telerehabilitation has been applied across a wide range of clinical conditions, including musculoskeletal and neuromuscular disorders, cerebrovascular accidents, pulmonary diseases, dermatological conditions, and sports-related injuries. The rapid expansion of telerehabilitation during the COVID-19 pandemic highlighted its potential to overcome geographical, temporal, and financial barriers to healthcare delivery. Technological advancements such as wearable sensors, digital health platforms, virtual reality, and artificial intelligence have further strengthened the role of telerehabilitation in clinical practice, sports physiotherapy, and physiotherapy education by enabling remote assessment, monitoring, and intervention. Community-based telerehabilitation programs have demonstrated the ability to improve equity in healthcare access, particularly in densely populated and underserved regions, while supporting sustainable health systems and addressing shortages of rehabilitation professionals. Despite these advantages, several barriers limit widespread implementation, including restricted physical examination, inadequate internet infrastructure, data privacy and security concerns, evolving regulatory frameworks, and the potential risk of misdiagnosis. Addressing these challenges requires the development of robust regulatory policies, legal protections, professional training programs, and public awareness initiatives. In Pakistan, strengthening digital infrastructure, expanding internet accessibility, and establishing clear national telerehabilitation guidelines are essential to promote trust and effective adoption. Telerehabilitation should be recognized as an integral component of rehabilitation services, with significant potential to improve patient outcomes and transform the future of rehabilitation care.

Iliopsoas (IP) tendinitis is an underrecognized but important cause of anterior hip pain in active patients. Some studies have reported that a physical examination (PE) has limited reliability in making a diagnosis of IP tendinitis. Differentiating anterior hip pain due to IP tendinitis from intra-articular sources is critical to appropriately and expediently treat patients. PE techniques can detect IP tendinitis, and we sought to quantify the diagnostic utility of these techniques using responses to an ultrasound-guided anesthetic injection as the reference standard. Cohort study; Level of evidence, 3. Charts from a single surgeon's practice were reviewed. Patients with suspected IP tendinitis who received an ultrasound-guided IP bursa injection were included. A pain reduction ≥50% immediately or at first follow-up defined the positive reference standard. Recorded PE variables were absolute and relative seated hip flexion (SHF) weakness, pain with SHF, and absolute and relative tenderness to palpation (TTP) of the IP tendon. Radiographs were systematically reviewed for relevant parameters and concomitant abnormalities, and magnetic resonance imaging (MRI) scans obtained within 12 months of the diagnosis were examined for changes consistent with IP tendinitis. Diagnostic accuracy statistics were calculated. A total of 135 injections in 105 patients (mean age, 41.2 ± 15.4 years; 74.8% female) had follow-up; 77.8% had true positive results. Absolute SHF weakness showed 96.2% sensitivity and a 77.1% positive predictive value (PPV). Relative SHF weakness yielded 82.2% sensitivity, 24.1% specificity, and a 79.0% PPV. Pain with SHF demonstrated 76.1% sensitivity and a 76.9% PPV. Absolute TTP reached 92.6% sensitivity and a 74.6% PPV, whereas relative TTP showed 86.6% sensitivity, 18.5% specificity, and a 76.3% PPV. MRI abnormalities were present in 18.1% of scanned hips, producing 19.2% sensitivity and 85.0% specificity. Weakness or pain during SHF and direct TTP of the IP tendon were highly sensitive and predictive for IP tendinitis, whereas MRI was poorly sensitive and should be considered for ruling out other sources of hip pain. Ultrasound-guided injections may be helpful both diagnostically and therapeutically. A focused PE can allow for a rapid, accurate diagnosis.

Non-ambulatory tetraparesis or tetraplegia in cats may constitute a diagnostic challenge for general practitioners. Therefore, this study aimed to evaluate if clinical variables from signalment, history, clinical examination and basic ancillary tests are associated with underlying diagnoses in cats with non-ambulatory tetraparesis or tetraplegia. This was a retrospective single-centre study of cases presented between 2010 and 2023. Information on disease onset, progression, neurological and physical examination findings and ancillary tests was analysed across all diagnoses. Diagnostic categories comprising five or more cases were carried forward to univariate and/or multivariable analyses. Eighty-one cats were included, with 82.7% of cases represented by six conditions: polyneuropathy (PN; n = 26), ischaemic myelopathy (IM; n = 15), spinal cord neoplasia (n = 8), feline infectious peritonitis (n = 7), intracranial neoplasia (n = 6) and spinal cord contusion (n = 5). On multivariable analysis, an age of below 3 years, progressive presentation, normal mentation, reduced spinal reflexes in the thoracic limbs and normal blood tests were statistically associated with PN. Age between 6 and 9 years or older than 9 years and peracute onset of clinical signs were associated with IM. This was a retrospective study with limited multivariable analysis in certain diagnostic categories. Furthermore, the study included only referral cases, which may not represent the animal population seen by general practitioners. PN and IM were the most common causes for non-ambulatory tetraparesis or tetraplegia in this population of cats. Attention to the neurological examination and easy to identify clinical features can be used to determine the most likely differential diagnoses and assist general practitioners in the formulation of a diagnostic plan.

ABSTRACT The purpose of this study was to evaluate how floating toes affect baseball pitching motion. Fifteen young male baseball players pitched from a pitching mound after physical examination, including floating toes, determining if any toes are not in contact with the ground. At least 20 pitches were thrown and the 10-best pitches were selected for the analysis. Images of the ball release point for sagittal and coronal views were captured from the videos recording the pitching motion. The positions of the ball, wrist, and leading foot were measured and the variability of each position over the 10 pitches was expressed as a standard deviation (SD). Each SD between the players with and without floating toes was statistically compared. The prevalence of floating toes on the pivot and plant foot was 47% and 33%, respectively. Those with floating toes on the pivot foot showed significantly greater SD in the antero-posterior position on the ball, wrist, and leading foot at ball release (p = 0.04, 0.02, and 0.01, respectively). Those with floating toes on the plant foot showed a significantly greater SD in the antero-posterior position of the plant foot (p = 0.02). Pitching with floating toes may lead to inconsistent pitching motion.

Referrals are the primary vessel for transferring patient information between primary care clinicians and specialists, providing a snapshot of the patient's condition and the question that ought to be addressed by the consultant. Despite their importance, no guideline currently exists outlining which components should be included in a quality referral for a cutaneous complaint. This scoping review summarizes the evidence outlining which components might be included in such referral. The review was conducted in accordance with PRISMA-ScR and Joanna Briggs Institute reporting guidelines. Sources from Embase, MEDLINE, Web of Science, and CADTH Grey Matters were screened independently and in duplicate. Data from 47 sources published between 1964 to 2023 was charted and synthesized. Results suggest cutaneous referrals should include referral information (e.g., reason for referral, urgency, and consultant details), referring clinician information (e.g., name, role, contact information), patient information (e.g., demographics, contact details) and clinical information. Clinical information emphasized the importance of characterizing the lesion or eruption (e.g., anatomical location, size, duration, evolution) and ABCDE criteria for suspected melanoma. If applicable, the referring clinician's impression of the lesion, explicit clinical suspicion of malignancy, and high-quality lesion photography was also noted. Relevant medical background, medications, psychosocial history, physical examination, and prior investigations and management were also highlighted and special considerations for inpatient referrals were noted. This scoping review provides a comprehensive list of components for high-quality referrals for cutaneous complaints, addressing a significant gap in medical communication. Standardizing components of referrals can enhance the quality and efficiency of referrals, ultimately improving patient care with more efficient and accurate triage.

Diagnostic errors remain common in abdominal pain, a frequent yet challenging presentation. We sought to compare diagnostic error profiles between abdominal and non-abdominal pain and to identify abdominal pain-specific, potentially modifiable targets in physical examination, diagnostic testing, and differential diagnosis. We conducted a retrospective secondary analysis of a systematically coded database of diagnostic error case reports. Adult pain cases were categorized as abdominal or non-abdominal after excluding pediatric and non-pain cases. Errors were classified using the Diagnostic Error Evaluation and Research (DEER), Reliable Diagnosis Challenges (RDC), and Generic Diagnostic Pitfalls (GDP) taxonomies. Frequencies of codes and contributing factors were compared. Of 163 cases, 55 involved abdominal pain and 108non-abdominal pain. The abdominal pain group had more RDC codes per case (3.1±1.8 vs. 2.5±1.7; p=0.032). Misinterpretation of physical findings and diagnostic tests, particularly imaging, was more common. Presentations with non-specific features or findings that masked/mimicked other conditions were also more frequent. Most physical examination errors (78 %) and imaging errors (82 %) reflected misinterpretation rather than underordering. Diagnostic errors in abdominal pain often involve misinterpreting physical and imaging findings and difficulty distinguishing among diseases within the correct organ system. Strengthening bedside diagnostic skills, fostering structured comparison of same-organ differential diagnoses, and ensuring reliable radiology support may reduce these errors and enhance patient safety.

ACR Appropriateness Criteria® Diagnosis and Monitoring of Sarcopenia.