Sturge-Weber syndrome (SWS) is a rare neurocutaneous syndrome characterized by facial port-wine birthmarks and associated eye and meningeal angiomatosis. Its neurological manifestations include intellectual disability, seizures, and stroke-like episodes (SLEs), often misdiagnosed as stroke. We report a case of SWS presenting with left-sided weakness. Cranial computerized tomography revealed SWS-related venous anomalies, while digital cerebral angiogram confirmed proliferative angiopathy of the distal middle cerebral artery (MCA) with proximal MCA spasm, resolved by intra-arterial verapamil. Despite initial symptom resolution, electroencephalography (EEG) revealed electroclinical seizures. The patient was treated with anti-seizure medications (ASMs) and aspirin, achieving full recovery. SLEs in SWS can result from vascular malformations or postictal phenomena, with ischemia-related events often complicated by vasospasm and altered hemodynamics. Our case highlights the importance of multimodal imaging and video EEG in distinguishing SLE etiologies in SWS, which can guide timely intervention with ASMs and aspirin to reduce recurrence and improve prognosis.
Objective: To evaluate histopathological markers of inflammation and tissue repair in esophageal specimens obtained during substitution surgery and determine their association with postoperative anastomotic stenosis.Design: Retrospective cross-sectional study.Setting: Tertiary care referral center (Clínica de Tracto Digestivo Superior, Hospital General de México "Dr. Eduardo Liceaga").Participants: Sixteen adults undergoing esophageal substitution for benign disease between January 2012 and January 2022. Inclusion required complete clinical records and native esophageal histology; cases with malignancy or missing histology were excluded.Methods: Archived slides from the proximal esophageal margin were reviewed with hematoxylin and eosin and Masson's trichrome. A semi-quantitative score assessed neutrophilic infiltration, lymphocytic infiltration, collagen deposition, and granulation tissue across mucosa, submucosa, and muscularis (range 0-18), classifying profiles as low risk (≤15) or high risk (≥16). Patients were grouped by presence (CEA) or absence (SEA) of postoperative stenosis. Statistical comparisons used Fisher's exact test and Mann-Whitney U, with medians (IQR) and exact p-values.Results: Median total histological scores were higher in CEA than SEA (18 [17-18] vs 12 [9-15]; P=0.014). All stenosis cases were high-risk, whereas 92.3% of non-stenosis cases were low-risk (P=0.007). Individual inflammatory markers were not statistically different between groups; however, collagen deposition and granulation tissue appeared more severe among CEA patients. No meaningful differences in demographic or operative variables were observed.Conclusion: In this exploratory study, a composite histopathological score identified patients at increased risk of postoperative anastomotic stenosis. The approach may support risk stratification and surveillance in gastrointestinal reconstructive surgery and warrants external validation.
Purpose: We explored the association between metastatic cancer, chemotherapy, and the risk for suicide attempts (suicide injuries) in adult trauma patients.Methods: We conducted a retrospective analysis of the Trauma Quality Program Participant Use File (2017-2019), comprising 27,474 patients from 700 U.S. Trauma Centers. Self-harm/suicide injury (compared to controls) was the dependent variable; presence of metastatic cancer and current chemotherapy were the key independent variables. We adjusted for age, sex, race/ethnicity, method of payment, facility levels, and discharge year (Model 1), and Model 1 plus trauma type, injury location, stay length, comorbidities, Injury Severity Score, and Glasgow Coma Scale (Model 2). We employed chi-square analysis, Fisher's exact test, and unadjusted and adjusted logistic regression using Stata v18, setting statistical significance at P≤0.05.Results: Of 27,474 patients, 249 (0.91%) reported suicide injuries. Significantly higher attempts were noted among patients with metastatic cancer (201 out of 249; 80.72%) and those not receiving chemotherapy (184 out of 249; 73.90%), P<0.001. Metastatic cancer was associated with higher odds of suicide injuries (unadjusted OR:2.252, 95%CI: 1.642-3.089; adjusted OR in Model 1:1.925, 95%CI:1.302-2.848). Chemotherapy was associated with lower odds of suicide injuries (unadjusted OR:0.408, 95%CI:0.307-0.541; adjusted OR in Model 1:0.444, 95%CI:0.311-0.636). However, neither metastatic cancer nor chemotherapy was significantly associated with suicide injuries in adjusted Model 2, suggesting the crucial role of other factors in influencing this risk.Conclusion: Patients with metastatic cancer exhibited notable prevalence of suicide injuries. Findings suggested metastatic cancer was associated with higher odds, and chemotherapy with lower odds, of suicide injuries. Multifaceted factors were associated with suicide risk beyond the presence of metastatic cancer or chemotherapy status, underscoring the importance of mental health assessments and interventions in oncology care, particularly for those with advanced cancer.
To evaluate the symptoms improvement of major depressive disorder (MDD) by transcranial magnetic stimulation (TMS) the PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), and SinoMed (a biomedical literature service system managed by the Institute of Medical Information [IMI] and Library of the Chinese Academy of Medical Sciences [CAMS]) library databases were searched. A total of 12 studies involving 1318 patients were included. It was found that the Hamilton Depression rating scale (HAMD) score decreased after TMS (-4.47, 95% CI: -7.10 to -1.84, P < 0.00001). It showed a decreased grade of Montgomery-Asberg Depression Rating Scale (MADRS) after TMS treatment (-2.72, 95% CI: -4.75 to -0.70, P=0.0004) compared to the control. The difference in the Involvement-Detachment scale (IDS) score was not statistically significant between the groups (-2.40, 95% CI: -7.42 to 2.62, P=0.05). The Clinical Global Impression (CGI) score decreased after TMS treatment (-1.12, 95% CI: -2.43 to -0.20, P < 0.00001) compared to the control group. The HAMD, MADRS, and CGI scores showed an improvement trend after TMS treatment, indicating TMS has a therapeutic effect on major depression.
Phenomenon: In academic medicine and healthcare, individuals may encounter peers or superiors who obstruct, hinder, or undermine their professional advancement. This phenomenon, termed Career Sabotaging (CS), reflects a form of malicious envy that occurs regardless of a subject's efforts toward career growth or promotion. Prompted by real-world experiences, this paper examines the conceptual understanding and defining components of CS. Approach: An open-source online survey was conducted over 2 months with 109 anonymous respondents. The 18-item questionnaire observed whether CS was a recognized phenomenon in academia and medicine. Descriptive statistics were used to summarize the data. Findings: Of the respondents, 87 (79.8%) were familiar with CS; 81 (74.3%) had personally experienced it, and 92 (84.4%) had observed it in peers. Most reported incidents occurred in nonacademic professional workplaces (43.3% and 37%, respectively). The observations corroborated the description of the phenomenon of Career Sabotage. Insights: The findings provide preliminary support that many professionals recognize and label a pattern of career obstruction as CS. The survey did not investigate whether those who reportedly experienced CS were disproportionately targeted by ethnicity, gender, age, ability, or sexual orientation. These questions and more should form part of future inquiry in understanding CS.
Background: Long COVID presents with a variety of symptoms, some of which could be related to autonomic dysfunction. Our aim was to evaluate the prevalence of autonomic dysfunction in long COVID patients.Methods: We conducted a cross-sectional study and included all consecutive patients enrolled in several clinical research studies. We performed the following autonomic dysfunction markers: heart rate variability, heart rate, systolic and diastolic blood pressure changes during NASA Lean Test, cardiopulmonary exercise testing and a Composite-Autonomic-Symptom-Score (COMPASS)-31 scale. We used linear regression to calculate the contribution of each dysautonomia measure on symptom burden as measured by the modified COVID-19 Yorkshire scale.Results: We included 100 patients for this study. Our sample population had a mean age of 56+/-11 years, included 53% minorities, and 32% were women. Dysautonomia, as defined by an abnormal COMPASS-31, was seen in 82% (95% confidence interval [CI] 72-89) of our study population, while cardiovascular resting dysautonomia, as represented by an abnormal heart rate variability, was seen in 60% (95% CI 48-70) of our study population. Orthostatic hypotension was observed in 12% of our study population, and postural orthostatic tachycardia syndrome (POTS) was found in 10% of our study population. In our adjusted analysis, we found that the beta coefficient for the COMPASS-31 score (0.37) was significant on changes in a self-reported long COVID symptom burden. The orthostatic intolerance and gastrointestinal domains of the COMPASS-31 were associated with the highest long COVID symptom burden.Conclusion: Dysautonomia is common in long COVID patients and contributes to the overall symptoms seen in long COVID. Identifying dysautonomia has important diagnostic and therapeutic implications.
Background/Purpose: We explored the complex relationship between the presence of metastatic cancer and undergoing cancer chemotherapy in adults with moderate to severe trauma and risk of reported physical abuse/assault-related trauma as defined in the American College of Surgeons Trauma Quality Programs Participant (ACS-TQP) dataset. We analyzed how these specific health conditions are associated with vulnerability to assault-related trauma, addressing a significant knowledge gap in existing literature.Methods: We utilized retrospective data from the ACS-TQP from 2017-2019 (N=27,531). The outcome was the report of physical abuse/assault-related trauma (no/yes). We focused on adults (aged ≥ 18 years) diagnosed with moderate to severe physical trauma (Injury Severity Scale: 9-75) who either had metastatic cancer (exposure) or were currently receiving chemotherapy (intervention), adjusting for predisposing factors and need for care factors based on Anderson's Model of Health Service Utilization. We used descriptive statistics, Fisher's exact test, chi-square analysis, and logistic regression using Stata.v18, with a statistical significance of P≤0.05.Results: We found 0.19% of 27,531 overall patients reported assault-related trauma, with 16,261 (0.16%) among those with moderate to severe trauma. Among these, a substantial majority with metastatic cancer reported assault-related trauma compared to those without metastatic cancer (84.62% vs. 15.38%; P value: 0.040). Patients receiving chemotherapy reported less frequent assault-related trauma than those not receiving it (26.92% vs. 73.08%; P value = 0.045). In the adjusted model, patients with metastatic cancer had significantly higher odds of reporting assault-related trauma than those without metastatic cancer (OR:7.847; 95% CI: 1.021-60.337; P<0.05). Chemotherapy was associated with a lower adjusted odds of assault-related trauma (OR 0.31, 95% CI: 0.08-1.14), but this did not reach statistical significance.Conclusion: In this large trauma cohort, metastatic cancer was associated with higher odds of assault-related trauma, while chemotherapy showed a reduced risk only in unadjusted analyses. Our findings highlight the higher vulnerability of patients with metastatic cancer and support further investigation into potential protective associations with active treatment.
Voriconazole-induced hypoglycemia in non-diabetic patients has rarely been reported. We describe a non-diabetic man, aged 50 years, without hepatic or renal dysfunction who developed severe prolonged hypoglycemia about 28 hours after initiating therapeutic dose of intravenous (IV) voriconazole therapy for invasive pulmonary aspergillosis. He required continuous IV infusion of dextrose solutions to maintain euglycemia. He recovered from hypoglycemia after discontinuation of voriconazole. Higher than normal plasma insulin (30.4 μU/mL) as well as C-peptide (10.04 ng/mL) levels were observed, which reached normal levels after he recovered from hypoglycemia. The temporal association between voriconazole administration and hypoglycemia occurrence led to probability that it was voriconazole-induced. The voriconazole trough level (8.9 μg/mL) checked during the hypoglycemia episode was elevated. The mechanism of hypoglycemia may be strongly attributed to insulinemia resulting from high voriconazole concentration. There is a possibility of genetic polymorphisms in the hepatic cytochrome P450 2C19 isoenzyme in this patient, which altered the voriconazole metabolism, causing high trough levels associated with hypoglycemia. This case suggests that voriconazole has a propensity to alter glucose homeostasis in the absence of liver and kidney dysfunction, and it may induce hypoglycemia without drug over dosage or drug interaction that clinicians should be vigilant about.
Objective: To determine whether serum squamous cell carcinoma antigen (SCC-Ag) is predictive of treatment response in patients with squamous cell cervical carcinoma (SCC) undergoing chemoradiation therapy, and to establish the mean normal serum SCC-Ag level in age-matched, apparently healthy female controls.Methods: Patients with histologically confirmed cervical SCC scheduled for concurrent chemoradiation were recruited (75 cases, alongside 75 age-matched apparently healthy controls, N = 150). Blood samples were collected before treatment and 6 weeks post-external beam radiotherapy to assess serum SCC-Ag levels, which were correlated with tumor stage and grade. Age-matched apparently healthy controls were also phlebotomized at baseline and 12 weeks later to determine normal SCC-Ag levels. Serum SCC-Ag was analyzed using Alinity i SCC reagent and analyzer (Abbott Laboratories, Chicago, IL, USA). The manufacturer's reference value for SCC-Ag is ≤1.5 ng/ml. Treatment response was assessed via pre- and post-treatment abdominopelvic computed tomography scans and classified as either complete or partial response. Data analysis was performed using SPSS v22.0, and logistic regression was used to evaluate predictors of treatment response. A P value <0.05 was considered statistically significant.Results: The mean age was 55.1 ± 11.6 years for cases and 55.5 ± 11.4 years for controls. Among cervical cancer patients, the median pre-treatment SCC-Ag level was 7.4 ng/ml, and post-treatment was 1.2 ng/ml, both significantly higher than in controls (0.4 ng/ml and 0.5 ng/ml, respectively). Vaginal bleeding was the most common symptom (94.7%), and 68% presented with locally advanced disease. SCC histology was confirmed in 94.7% of cases, and 61% showed either complete or partial treatment response. Median SCC-Ag levels were significantly associated with disease stage (P<0.001) but not with tumor grade (P=0.159). Logistic regression identified tumor size as a significant predictor of treatment response, while pre-treatment SCC-Ag and SCC-Ag reduction rate were not.Conclusion: Serum SCC-Ag levels were normal among all healthy controls and some patients with prior treatment. SCC-Ag correlated with disease stage but was not predictive of treatment response in patients undergoing chemoradiation. Tumor size was the only significant predictor of treatment response.
Acephalgic migraine (AM), or migraine aura without headache, is a subtype of migraine, characterized by transient neurological symptoms without the accompanying headache phase. Its diagnosis remains challenging due to varied clinical presentation and the tendency to misattribute symptoms to other neurological, psychiatric, or systemic disorders. This case report describes a female patient, age 38 years, presenting with episodic, incapacitating fatigue, nausea, and cognitive dysfunction, initially leading to an extensive but inconclusive diagnostic workup. Partial symptom relief with ondansetron, but not with metoclopramide, suggested involvement of migraine-associated pathways. A detailed history revealed a family history of migraine and specific triggers, including dietary and hormonal factors. A therapeutic trial with triptans led to dramatic symptom resolution, supporting an AM diagnosis. Retrospectively, the patient was able to identify additional aura symptoms, reinforcing the diagnosis. This case underscores the diagnostic challenge of AM and migraine aura variants. It also highlights the pivotal role of careful history-taking, patient-physician communication, and clinical reasoning in the evaluation of atypical symptom presentations. Clinician awareness of migraine spectrum disorders is essential to prevent misdiagnosis, reduce unnecessary testing, and improve patient outcomes. Further research is needed to refine diagnostic criteria and optimize management strategies.
Hypopharyngeal carcinoma (HPC) has one of the poorest prognoses among all types of head and neck squamous cell carcinoma (HNSCC). Artificial intelligence (AI) is a scientific field that is in the spotlight, especially in the last decade, and AI has also been widely used in the research field of HPC. This scoping review aimed to describe the improvement of HPC clinical cares brought by AI. Literatures utilizing AI and machine learning in HPC were searched in PubMed, EMBASE, and Web of Science, and 116 articles from 1987 to 2024 were retrieved. After removing duplicate and irrelevant articles, 85 were further selected for detailed review. AI helps analyze large amounts of data from HPC patients and develop models to facilitate clinical practice. The emergence of AI improves the endoscopic, radiologic, and pathologic diagnosis accuracy of HPC and guides personalized treatment and prognosis prediction. However, there are certain unmet challenges that need to be further elucidated, like interpreting the AI algorithms into features that can be observed by humans and promoting the AI models in larger and multi-centered cohorts.
Objective: The purpose of this study was to determine and interpret the results of surgical intervention, namely, preservation of hearing and facial nerve functionality and reduction of the risk of recurrence and mortality from the disease.Methods: The study conducted a retrospective analysis of the clinical records of 26 patients treated at the state-owned public utility enterprise on the right of economic ownership "Multi-speciality City Hospital No. 1" of Astana (Kazakhstan) during the period from January 1, 2016 to December 31. 2023.Results: The mean age of patients was 49.5 years, of whom 69.1% were female. The most common complaints were throbbing tinnitus, hearing impairment, and dizziness. Regional metastases were observed in 15.4% of cases, and one case (3.8%) had a malignant form of paraganglioma with distant metastases to the liver. Most patients (84.6%) underwent surgery with transmastoidal access. Preoperatively, most patients had hearing impairment, both conductive and sensorineural types, as well as mixed. After treatment, deafness on the tumor side was diagnosed in six patients (23%). In the immediate postoperative period, the facial nerve function (I-II degree) was preserved in more than one-third of patients, and significant dysfunction (V-VI degree) was observed in 17.4% of patients. Early postoperative complications were observed in 13% of patients. Recurrence of tumor growth was detected in two patients (7.7%).Conclusion: This study demonstrates that surgical treatment, complemented by preoperative embolization, is an effective approach for managing middle ear paragangliomas, significantly reducing the risk of bleeding and improving postoperative outcomes.
Background: Cancer and heart failure (HF) are significant causes of morbidity and mortality worldwide. Moreover, there is increasing evidence of a relationship between HF and cancer. Although oncology has experienced significant advancements in cancer therapies, patients with a combination of these conditions represent an important clinical challenge due to varying outcomes among different demographic populations. Therefore, understanding these trends is crucial for targeted interventions.Aims: This study analyzed two decades of mortality data to examine the trends, patterns, and disparities in cancer-related and cancer with HF-related deaths across the United States (US).Methods: Mortality data from 1999 to 2020 were obtained using CDC WONDER, identifying cancer and cancer with HF-related deaths in adults age ≥25 years via ICD-10 codes. Demographic and regional distributions of mortality were analyzed utilizing statistical methods. Joinpoint regression analysis was used to determine trends in age-adjusted mortality rates (AAMR) and annual percentage changes (APC).Results: Between 1999 and 2020, there were 13,880,876 cancer-related deaths in the US, including 567,657 with HF listed as a cause of death. The AAMR for cancer-related deaths decreased from 343.7 to 252.4 per 100,000 (APC: -1.61% [95% CI: -1.70, -1.57] from 1999 to 2018, then -0.62% to 2020). Cancer with HF-related deaths initially declined (AAMR: 15.0 to 10.2 from 1999-2013) but increased from 2013 to 2020 (APC: +6.03%). Males had higher mortality rates than females for both conditions. Cancer-related mortality was highest among non-Hispanic (NH) Whites and Hispanics, while cancer with HF-related mortality was highest among NH Whites and NH American Indians/Alaska Natives. Geographically, the South had the most cancer-related deaths (37.3%), while the Midwest led in cancer with HF-related deaths (4.5%).Conclusions: Cancer-related mortality has declined overall, whereas mortality for cancer with co-existing heart failure has risen since 2013 after an initial decline. Disparities persist, with the highest burden in NH Whites, males, and those in rural or underserved areas. The findings underscore the need for focused interventions aimed at reducing mortality related to cancer and cancer with heart failure, particularly among the vulnerable population.
Introduction: Leiomyomatosis peritonealis disseminate (LPD) is an entity with uncertain biological behavior, characterized by multiple smooth muscle intra-abdominal and pelvic nodules that may recur after apparently complete resection. LPD has been predominantly described in childbearing age females. Most case reports with short term follow-up describe this as a benign entity. Only isolated case reports indicate the malignant potential of the disease. A comprehensive collation of cases is lacking in literature.Methods: We present a case of malignant transformation of LPD, confirmed by histology and imaging, occurring over two decades. This patient was originally diagnosed with uterine atypical smooth muscle tumor but developed frank malignancy during follow-up. An increasingly malignant aggressive disease course resulted in ultimate development of liver and lung metastases almost 23 years after original diagnoses, resulting in her demise. A comprehensive literature review was performed, and 213 cases of LPD were described, including the present case. Patients were divided into G1 (reportedly benign), G2 (malignant at presentation), and G3 (malignant transformation).Results: Compared to G1, G2 at presentation were more likely to be symptomatic (73%/88%), larger sized (4.1/8.4 cm), and older aged (38/44). In G1, G2, and G3, the average age was 38.5, 44.3, and 37.5 years, respectively; while the disease specific survival was 100%, 71%, and 40%, respectively. The mean number of surgeries performed in G1, G2, and G3 was 1.6, 1.8, and 3.8, respectively. Hormone receptors were found in 24.4% of cases. The mean reported follow-up time in G1, G2, and G3, respectively, was 44.9, 13.1, and 70.5 months. This suggests with longer follow-up, even apparently benign tumors may develop malignancy. The transformation time to malignancy in G3 was 77.8 months, which is more than the average reported follow-up in G1 (44.9 months).Conclusions: LPD is a potentially malignant condition with long latency prior to transformation. Lifelong surveillance should be considered even in cases originally presumed to be benign. Loss of hormone receptor expression may serve as a marker for this transformation. Circulating Tumor DNA (ctDNA) levels may be associated with development of hematogenous metastases and may be a useful biomarker.
Pelvic floor dysfunction is commonly observed in individuals with spinal cord injury, often resulting in urinary, gastrointestinal, and sexual disturbances. Although pelvic floor rehabilitation is a widely accepted treatment for pelvic floor dysfunction in the general population, its application in spinal cord injury remains insufficiently explored. This study presents clinical experiences with pelvic floor rehabilitation in patients with incomplete motor spinal cord injury, aiming to contribute to the growing body of literature.This case series includes three patients with incomplete spinal cord injury, American Spinal Injury Association Impairment Scale, Grade-D, who underwent individualized multimodal pelvic floor rehabilitation programs. Interventions targeted urinary, bowel, and sexual dysfunctions using pelvic floor muscle training, biofeedback, electrical stimulation, tibial nerve stimulation, and sensory retraining strategies. All three patients demonstrated notable improvements in bladder and bowel continence, voluntary voiding, and sexual function. Subjective reports indicated enhanced functional independence and quality of life. Pelvic floor rehabilitation shows promise as an effective therapeutic option for managing neurogenic pelvic floor dysfunction in patients with incomplete spinal cord injury. Further randomized controlled trials are warranted to establish its efficacy and define optimal intervention protocols.
Behçet's disease (BD) is a multi-systemic, chronic inflammatory disease of unknown etiology, with a multisystemic recurrent course and variable vasculitis. Although the disease onset is usually between the second and fourth decades of life, the preliminary symptoms and signs may appear under the age of 16 years. The prevalence of BD in children is unknown, but it is probably very low. The most common ocular manifestations of pediatric BD include anterior and posterior uveitis, panuveitis, retinal vasculitis, and retinitis. The pathogenesis, treatment, and future directions for pediatric BD are also briefly discussed.
Chromoblastomycosis (CBM) is a rare chronic, granulomatous mycosis affecting the skin and subcutaneous tissue. It is a deep, slow growing, fungal infection that most often presents with epidermal changes that clinically appear as a hypertrophic and verrucous plaque. We describe an atypical presentation of an immunocompromised male patient, age 76 years, who presented with a 4-month history of painless subcutaneous firm nodules of the left fifth finger. The fungal culture grew Exophiala bergeri, and histopathology showed medlar bodies with lack of pseuodepitheliomatous hyperplasia or epidermal changes commonly seen in CBM. To our knowledge, this is the first case of Exophiala bergeri CBM in the United States, highlighting its unique clinical presentation and expanding the differentials for a subcutaneous nodule.
Eosinophilic fasciitis (EF) is a rare fibrosing disorder caused by an autoimmune response to an unknown trigger. Many possible triggers have been suggested including strenuous exercise, drug or chemical exposure, and preceding infection. We present a case of a female patient, age 69 years, who developed EF following SARS-CoV-2 infection. There have been several advances in the diagnosis and management of EF since it was first described 50 years ago. EF is a mimic of scleroderma, but key clinical features can be used to differentiate between the two diagnoses. Laboratory abnormalities include eosinophilia, elevated inflammatory markers, and hypergammaglobulinemia. A full thickness biopsy of the skin including muscle and fascia is recommended to confirm the diagnosis. Imaging modalities such as ultrasound and magnetic resonance imaging have been increasingly used in the diagnosis and follow-up of EF. Corticosteroids remain the first line in treatment of EF. Combination of steroids and methotrexate have shown the best possible outcome. Early diagnosis is important for better treatment response.
The main function of high-density lipoprotein (HDL) is to remove low-density lipoprotein (LDL) from blood vessels through reverse cholesterol transport. In addition, HDL has anti-inflammatory and antioxidant properties. Low HDL level is an independent risk factor for development of coronary artery disease. To manage patients with low HDL levels, general measures such as lifestyle modification, controlling acute metabolic syndrome, and participating in regular endurance exercise are essential. Smoking cessation is a must, and it will often improve HDL levels by 5% to 10%. While statin therapy is the backbone therapy for controlling LDL levels, it also results in elevation of HDL levels by at least 5%. Specific pharmacologic interventions to improve HDL level and function have been disappointing. Cholesteryl ester transfer protein (CETP) is the key metabolic pathway to transfer HDL to LDL; thus, CETP inhibitors result in elevation of HDL levels. Several products were tested in large controlled studies, such as dalcetrapib and evacetrapib; neither resulted in any clinical benefit. Anacetrapib only resulted in very limited benefit and is no longer under active development. The most recent study utilized apolipoprotein A1 infusion in high-risk patients shortly after acute myocardial infarction. There was no benefit in the primary end point of myocardial infarction, stroke, or death. In patients with low HDL, a strategy of having LDL as low as can be possibly achieved may be the most appropriate approach.
Management of humeral head fractures presents numerous challenges, particularly in cases of separation fractures, which are relatively rare and often caused by high-energy trauma. Due to the complexity of these fractures and the absence of a standardized treatment algorithm, surgical intervention can be technically intricate and fraught with postoperative complications. In young patients, the decision to pursue open reduction and internal fixation must be meticulously made to achieve optimal outcomes while minimizing long-term sequelae. We present a rare case of a man, age 25 years, sustaining a complex proximal humerus fracture. The patient presented with a proximal humerus fracture involving a head-splitting pattern comprising five fragmented pieces, necessitating careful anatomical reduction and fixation. Despite the technical challenges encountered during surgery, including the meticulous reconstruction of the humeral head "puzzle" using headless screws, the postoperative recovery was relatively uneventful. While some restrictions in range of motion were noted postoperatively, the absence of early complications like osteonecrosis bodes well for the patient's long-term functional prognosis. This is a thought-provoking case accentuating that by apposite surgical techniques and tailored treatment strategy to individual young patients, successful management of humeral head fractures can be achieved while minimizing potential complications and optimizing functional recovery in this challenging patient population.
